Mr. Jawahar Lal Gupta,
S/o Sh. D.P. Gupta,
R/o E-26, 1st Floor, Satyawati Nagar,
Ashok Vihar, Phase-III, New Delhi-52.
Also at:
E-13, Johri Niwas, Benglow Road,
Kamla Nagar, Delhi-110007. …….. Complainant
VERSUS
The Branch Manager,
National Insurance Co. Ltd.,
1, Jeewan Vikas Building,
30-31 A, Asaf Ali Road,
New Delhi-110002. ..…. Opposite Party
O R D E R
SUBHASH GUPTA, MEMBER
The complainant has filed the present complaint against the O.P u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that complainant had taken mediclaim policy No.350304/48/05/850000/1791 from O.P, covering himself, his wife and son. The policy was renewed by the O.P on the basis of his previous policy No.2004/350304/48/04/8500001389. It is alleged that during the period of Mediclaim policy, complainant suffered with Inguinal Hernia, therefore he contacted M/s Cosmos Hospital Pvt. Ltd., F-1, Kalindi Ring Road, New Delhi. It is further alleged that on the basis of diagnosis/ prescription of Dr. Ashok the complainant applied for cashless benefit against the said policy. It is alleged that along with application for cashless facility the complainant submitted all policies, medical diagnosis/ prescription. It is further alleged that after considering all the record the O.P issued cashless certificate contended the estimated expenditures of Rs.40,000/- approved maximum duration of stay for three days and authorized the limit to Rs.25,000/- vide approval certificate No.EMSL/PAC/NI/44752/07 dated 14/02/2007. It is alleged that the complainant remained under treatment in M/s Cosmos Hospital Pvt. Ltd. under Dr. Ashok from 15/2/2007 to 17/2/2007. It is further alleged that on 11.07.2009 complainant received a notice from the said hospital vide which the hospital demanded Rs.45,340/- from the complainant as the O.P failed to pay the treatment bill of the complainant. It is alleged that the O.P illegally closed the claim. The complainant filed a consumer complaint No.384/2010. The said complaint was decided by this forum vide orders dated 03.10.2012 with directions to O.Ps to decide the claim of the complainant one way or the other within a period of 30 days. The O.Ps later on repudiated the claim, therefore, the complainant was compelled to file the present complaint. It is further alleged that as the O.P failed to reimburse the medical bills despite it had given pre approval of the same vide approval certificate No.EMSL/PAC/NI/44752/07 dated 14.02.2007, therefore, on these facts the complainant prays that O.P be directed to pay Rs.45,340/- with interest @ 24% p.a. apart from cost and compensation as claimed.
2. O.P appeared and filed its written statement. It has not been disputed that complainant had taken mediclaim policy No. 350304/48/05/850000/1791. It has also not been disputed that complainant had been treated in the Cosmos Hospitals, Kalindi, Ring Road, New Delhi. However, its case is that the complainant was suffering from a disease which was pre-existing in nature and the same was excluded as per the terms and conditions of the insurance policy. It is alleged that as per the discharge summary the complainant was having history of illness for 5-6 years prior to the date of hospitalization i.e. 16.02.2007. It is further alleged that the patient got admitted in hospital for pre-existing disease in second year of the policy which is not payable as there is waiting period of two years for Inguinal Hernia and if the disease is pre-existing for previous claim free policy period is mandatory. It is alleged that complainant is not entitled for any relief claimed. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit in evidence testifying all the facts as alleged in the complaint. He has also filed on record documents exhibited as Ex. CW-1/1 to CW-1/7. On the other hand Shri Dinesh Kumar Nigam, Admn. Officer has filed his affidavit on behalf of O.P and documents have been exhibited as Ex. OPW-1/1 to OPW-1/2. Written arguments have also been filed by the parties.
4. We have carefully gone through the records of the case and heard submissions of Ld. Counsels for the parties. A close scrutiny of the documents filed by the complainant reveals that no documentary evidence has been filed to prove that the complainant has incurred expenses for the treatment taken by him from the hospital. Although it has been pleaded in the complaint that the complainant had received a notice on 11.07.2009 from the hospital vide which the hospital demanded a sum of Rs.45,340/- from the complainant as the O.P failed to pay the treatment bill of the complainant but neither the copy of the demand notice of the hospital received by the complainant nor any receipt in token of payment made by the complainant to the hospital have been filed on record. In absence of any proof of payment to the hospital the reimbursement as claimed by the complainant vide the present complaint cannot be allowed. As such the complaint fails and is accordingly dismissed. Ordered accordingly.
Copy of this order be sent to the parties as per rules.
Announced this 24th day of May, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
