MS. NIPUR CHANDNA, MEMBER

ORDER

26.06.2024

1.         A complaint under Section 12 of Consumer Protection Act filed. In brief the facts are that complainant is the mediclaim policy holder of OP Ins. Co. vide policy bearing no. 271901/48/2016/1709 w.e.f. 22.07.2015 to 21.07.2016 covering complainant and six family members .

2.       On 25.08.2015, complainant’s mother namely Smt. Nirmal Bansal was suffering from fever chills and rigor, pain abdomen and recurrent vomiting and as such she was admitted to Ekansh Nursing Home, where Dr. R. Prashar advised her for getting admitted in the hospital. The intimation of the Hospitalization was duly given to OP2 on 25.08.2015. The mother of the complainant got discharged on 01.09.2015 and the complainant incurred total expenses to the tune of Rs. 71,365/-against the hospitalization. The complainant lodged the claim with OP2 through speed post letter dated 04.09.2015. The complainant received query letter dated 18.09.2015 from OPs and vide letter dated 28.09.2015 the complainant respond to the queries raised by OPs. It is alleged by the complainant that again vide letter dated 12.10.2015 he satisfied the queries of the OPs in respect to the claim in question but thereafter no information in respect to the claim in question was given by OP Ins. Co. As such complainant filed and RTI application dated 10.12.2015. In response to the RTI application the complainant received one letter dated 07.12.2015 vide which the OP had already repudiated the claim of the complainant. It is alleged by the complainant that OP had arbitrarily rejected his claim despite the fact that the entire claim formalities as well as the requisite documents were submitted to the OPs. Being aggrieved by the repudiation of his claim complainant approached this Commission for redressal of his grievance.

3.       Notice of the complaint was sent to OP-1 & 2. OP1 & 2  filed their joint written statement wherein they denied any deficiency in service on their part. It is further stated that the insured under this policy is subject to condition, clause, warranties, endorsement as per the form attached. It is further stated that as per the policy terms and conditions the nursing homes should have at least 15 beds and on perusal of the registration certificate of Ekansh Nursing Home where the complainant mother was admitted and under gone treatment it was found that the said nursing home is having only ten beds and as such the claim of the complainant is not tenable. It is further stated that the IPD papers were prepared by single person in the same handwriting and as per the nursing sheets there is not signature of the nurses present during investigation and it was found that there was no qualifying nursing staff and nursing registration certificate was also not provided and as such the claim of the complainant was not tenable and is being repudiated. It is further stated by OP that the present complaint is abuse of the process of law, hence, be dismissed with cost.

4.       No Rejoinder to the WS of OP1 & 2 filed. Complainant filed his evidence by way of affidavit wherein he has corroborated the contents of his complaint.

5.       Complainant has placed on record the copy of letter dated 04.09.2015 vide which he lodged the claim with OP, copy of policy documents, copy of medical bills and record, copy of repudiation letter dated 07.12.2015 in support of his contention.

6.       Sh. Anil Aggarwal Divisional Manager filed his evidence by way of affidavit on behalf of OP. OP has placed on record the copy of policy document and its terms and conditions, copy of registration certificate of Ekansh Nurding Home, copy of repudiation letter dated 07.12.2015 in support of its contention.

7.       Written arguments filed by the parties.

8.       We have heard  the arguments advance at the bar by Sh. Kapil Chawla counsel for OP. Despite ample opportunity complainant’s counsel failed to address the arguments and have perused the record.

9.       The sole question for our consideration in the present complaint case is whether the repudiation of the claim of the complainant by OP Ins. Co. is justified or not.

10.     It is argued on behalf of OP counsel that the mother of the complainant undergone the treatment in Ekansh Nursing Home having only ten beds and as per the policy terms and conditions clause 2.1 the nursing home has at least ten inpatient beds in town having a population less than 10 Lakhs and 15 inpatient beds in all other places. As the mother of the complainant has taken the treatment in the nursing home having ten patient beds the claim of the complainant was rightly repudiated by referring clause 2.1 of the policy terms and conditions. To support its contention counsel for OP has drawn out attention towards the copy of the registration certificate dated 24.09.2014 of Ekansh Nursing Home issued by Directorate Of Health Services  Shahdara, Delhi where by the Nursing home was authorized to carry on nursing home activities with ten beds.

11.     The bare perusal of the registration certificate makes it clear that the claim of the complainant was hit by clause 1.2 of the policy terms and condition and as such the repudiation is justified. The OP Ins. Co. has repudiated the claim of the complainant on another ground i.e. IPD papers were prepared by single person in the same handwriting and as per the nursing sheets there is no signature of the nurses present during investigation and it was found that there was no qualifying nursing staff. The complainant has placed on record the IPD record of Ekansh Nurding Home. We have carefully gone through it and found that the entire IPD record does not bear the signature of any nursing staff. The bare perusal of the IPD record justified the ground of repudiation by Ins. Co.

12.     In view of the above discussion, we are of the considered opinion that claim of the complainant was rightly repudiated by OP Ins. Co. in the light of medical records as well as the policy terms  and conditions. We therefore find no merits in the present complaint, same is hereby dismissed.

          File be consigned to record room.

13.   Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving the application from the parties in the registry. Order be uploaded on www.confonet.nic.in.

Announced in open Commission on   26.06.2024.

(SANJAY KUMAR)                (NIPUR CHANDNA)                        (RAJESH)

PRESIDENT                                     MEMBER                               MEMBER