CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)x
New Delhi – 110 016
Case No. 497/2009
SH. SHEEL CHANDRA
S/O LATE SHRI ADISHWAR LAL
R/O FLAT NO. 101,
ADISHWAR APARTMENTS,
34 FEROZ SHAH ROAD,
NEW DELHI-110001
………. COMPLAINANT
Vs.
- RAKSHA TPA PVT. LTD.
PLOT NO. 202, FIRST FLOOR,
PHASE- III
OKHLA INDUSTRIAL ESTATE
NEW DELHI-110029
- NEW INDIA ASSURANCE CO. LTD.
BOMBAY LIFE BUILDING,
N-34, CONNAUGHT CIRCUS
NEW DELHI-110010
………….RESPONDENTS
Date of Order: 10/08/2018
O R D E R
Ritu Garodia-Member
The complainant purchased a medical policy from OP vide policy no. 310300/31/07/11/00002796 which covered a period from 30/03/2008 to 29/03/2009.
It is stated that the wife of the complainant was hospitalised in Mulchand Hospital from 20/08/2008 to 28/08/2008 and from 5/09/2008 to 12/09/2008. It is alleged that expenses incurred one month prior to hospitalisation and two months post hospitalisation is covered under the insurance policy. The complainant submitted the claim form with receipts from the chemist, lab report and charges for ambulance and emergency room with OP. It is stated that a summarised account of expenses amounting to Rs. 53,151/- was given to OP.
It is further stated that the wife of complainant was readmitted in Mulchand Hospital on 12/12/2008. She expired on 17/12/2008 and OP was informed of the same. A letter dated 8/12/2008 was received from OP asking for prescriptions for medicine and lab test bills.
It is stated by the complainant that all consultations from doctor was done telephonically as personal visits to doctor would have been very expensive and no prescriptions were given. It is further stated that OP asked for the discharge summary of the hospital which was already submitted. The claim was closed vide letter dated 12/2/2009. It is stated that the expenses during the hospitalisation had been paid by OP. The complainant prays for settlement of claim along with compensation. The complainant has filed letter dated 12/02/2009, 29/01/2009,17/01/2009, 24/12/2008, 8/12/2008, 22/11/2008, bills of the chemist, bills for investigation and photocopy of insurance policy.
Notice was issued to OP1 who was proceeded ex-parte on 13/06/2011.
OP 2 in its reply has admitted the insurance policy which was subject to terms and conditions. It is also admitted that the claim was lodged for reimbursement of the expenses on account of pre and post hospitalisation of complainant’s wife. OP 2 has vide letter dated 8/12/2008, 24/12/2008 and 17/01/2009 had requested for submission for information along with relevant documents as per the terms and conditions of the policy. As no compliance was made the claim was closed. It is further explained that no written prescription of treating doctor has been filed.
We have perused the pleadings filed by both the parties. Letter dated 24/12/2008 by OP2 to the complainant clearly states that “kindly provide prescription in support of consultation fees, medicine and lab test bills provided”. Same was reiterated in other letters by OP2.
It is clear that the complainant was not able to file prescriptions for the medicine and the lab test as being duly prescribed by the doctor. The complainant has also admitted that she had taken these consultations telephonically from the doctor. No certificate or verification from the doctor has been filed. No evidence has been adduced by the complainant as to whether these bills where in support of pre and post hospitalisation. The complainant has also not placed any discharge summary/report of the hospital from where it could be corroborated that the said medicines or the lab investigations were in continuation of the hospital treatment. No verification can be made regarding medicines as being prescribed for the insured. Hence we find no merits in this complaint. The complaint is dismissed.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(RITU GARODIA) (H.C SURI) (A.S YADAV)
MEMBER MEMBER PRESIDENT
