PRESIDENT 

1)        The Complainant has prayed to grant an amount of Rs.86,636/- to the Complainant alongwith interest @ 24 % from 06/03/2006 and cost of Rs.10,000/- towards this complaint.  

2)        According to the Complainant, he had obtained Medical Insurance Policy of Opposite Party No.2 bearing No.112500/48/05/83962 on 31/10/05 by paying premium of Rs.1,444/- including service tax. The copy of the said premium receipt is at Exh.‘A’.  The said policy was valid for the period 31/10/05 to 30/10/06.  It is alleged that the Complainant was admitted at Shah Surgical and Maternity Home Pvt. Ltd., Kandivali (W), Mumbai, on 27/02/06 and discharged on 08/03/06 due to enteric fever and the said hospital had charged bill of Rs.33,600/-.  The Complainant during the said treatment was required to purchase medicines of Rs.7,826/-.  It is submitted that he had spent Rs.1,710/- as fair of Autoriksha, foods and other miscellaneous requirements.  It is alleged that the Complainant had totally incurred an amount of Rs.43,136/- for the above purposes during the time of his illness.   

3)        It is submitted that the Complainant then submitted his claim to the Opposite Party No.1 alongwith the expenditure bills.  The Opposite Party, however, by letter dtd.03/08/06 informed the Complainant that in view of notification from the Insurance Company instructing to de-panel the hospital where the Complainant had taken the treatment i.e. Shah Surgical and Maternity Home Pvt. Ltd. for both cashless as well as reimbursement claim and therefore, the claim of the Complainant stands non-payable.  The copy of the said letter of the Opposite Party No.1 is at Exh.‘D’.  It is alleged that at the time of issuance of policy the Opposite Parties did not give any guidelines or guided that which hospital’s claim will be approved and which hospital’s claim will not be approved.  The Opposite Party No.1, however, denied the claim by its letter dtd.03/08/06.  The Complainant therefore, issued notice to the Opposite Party No.1 on 07/09/2006.  The copy of which is at Exh.‘E’ and the copy of the acknowledgment RPAD receipt is at Exh.‘F’.  It is submitted that the Opposite Party No.1 did not reply to the notice of the advocate or paid the amount of medical expenditure incurred by the Complainant.  The Complainant has therefore, claimed the reliefs as mentioned in para 1 of this order.   

4)        The Opposite Party No.2 contested the complaint by filing written statement.  It is contended that Complainant’s claim does not fall within the purview of the policy as the hospital in which the Complainant was admitted was de-paneled for cashless and reimbursement claims as the said hospital was blacklisted for its immoral and unethical behaviour.  It is contended that the Complainant has failed to prove his admission and treatment in Shah Surgical and Maternity Home Pvt. Ltd.  It is contended that it is difficult to believe that the person suffering from enteric fever being admitted in a maternity hospital which cast doubt upon genuineness of the claim.  The copy of the policy terms and condition and the list of de-paneled hospital as is marked as Exh.‘A’. It is contended that the Opposite Parties had already informed the Complainant by letter dtd.03/08/2006 that his claim is not tenable due to de-paneled of hospital.  It is submitted that the Opposite Party would like to place on record various investigation report and various communication regarding activities of Shah Surgical Hospital and Maternity Home Pvt. Ltd. to prove the fact of bogus bills and record created by it.   It is alleged that the hospital staff was not ready to show any record of the Complainant to the Opposite Parties Investigator.  Dr. K.M. Shah being a Gynecologist is not qualified to treat enteric fever.  It is contended that the time at which injections were given to the patients is not mentioned in the indoor case paper of the hospital.  The hospital laboratories were not having the Complainant’s record in it’s computer which proves that the claim lodged by the Complainant is false and frivolous. It is submitted that the Opposite Parties representative contacted the Complainant but he was not ready to talk.  It is contended that various investigations in relation to the hospital where the Complainant alleged to have taken treatment prove that the said hospital have been indulging in many fraudulent malpractices.  The copy of the detail investigation report dtd.04/05/06 is marked as Exh.‘B’ and copies of the various investigation reports in respect of the Shah Surgical and Maternity Home Pvt. Ltd. are marked as Exh.‘C’.  It is contended that the Opposite Parties are not guilty of any deficiency in service and are not liable to pay any amount as claimed in the complaint.  It is therefore, prayed that the complaint be dismissed with cost.  

5)        The Complainant has filed affidavit of evidence.  The Sr. Divisional Manager of Opposite Party No.2 Dilip Sonawane has filed his affidavit of evidence. Both the parties filed their written arguments.  We heard the oral argument of Dinesh Kumar Shukla, Ld.Advocate for the Complainant.  The Advocate for the Opposite Party No.2 R. Bhargawan & Associates, in spite of notice remained absent. However, the advocate for the Opposite Party No.2 filed pursis that the written argument filed on record may be treated as oral argument of Opposite Party No.2.  The Opposite Party No.1 though served remained absent.  Hence, complaint against Opposite Party No.1 proceeded ex-parte.   

6)        We have perused the documents filed by both sides.  The Opposite Party has filed the copy of the terms and conditions of the policy obtained by the Complainant and also the copy of the list of de-paneled hospitals which was attached to the policy issued to the Complainant at Exh.‘A’ in the said list Shah Surgical and Maternity Home Pvt. Ltd. is shown as de-paneled and debarred hospital for both cashless and reimbursement claims.  The Complainant by his affidavit of evidence has though denied the said fact and also denied the report of Investigator – Santosh Muthukutty.  However, we are of the view that the report of the investigator filed at Exh.‘3’ with the affidavit of evidence of the Opposite Party No.2 Shri. Dilip Sonawane can be relied upon.  The Opposite Party No.2 has also placed on record various reports of the Investigators – Mahendra Choksi, Dr. I.V. Bandukwala, showing that Shah Surgical Hospital, Kandivali did not maintain the proper record of the patients and the case papers maintained by the said hospital are totally fabricated.  The letter relied by the Complainant dtd.18/04/07 Shah Surgical Hospital that no person has visited to Shah Surgical Hospital also cannot be believed as the same is vague letter.  In view of the details mentioned in the investigation report of Santosh Muthukutty at Exh.‘3’ with the affidavit of Dillip Sonawane, the Sr. Divisional Manager of the Opposite Party No.2 the report filed at Exh.‘3’ can be relied upon.  As per the terms and conditions of the policy the Company shall not be liable to pay any payment under the policy in respect of such claim be in any manner fraudulent or supported by any fraudulent means or deceive whether by the Insured person or by any other person acting on his behalf.  In the present case in our view the Opposite Party has rightly informed to the Complainant as per letter at Exh.‘D’ that the claim made by the Complainant stands non payable for obtaining the treatment from the hospital which is de-paneled as well as from the hospital which is surgical and maternity hospital for the disease of enteric fever.  We therefore, hold that the Complainant is not entitled for the claim made in the complaint and Opposite Parties have rightly repudiated the claim of the Complainant. In our view the Complainant has lodged fraudulent claim to the Opposite Parties and as such, it cannot be held that the Complainant has proved deficiency of service and unfair trade practice on the part of the Opposite Parties. In the result the following order is passed – 

O R D E R 

i.                    Complaint No.489/2006 is dismissed with no order as to cost.

ii.                 Certified copies of this order be furnished to the parties.