ORDER                                   Dated:  06-10-2016

Mohd. Anwar Alam, President



1.      The complainant has filed this complaint on 30-11-2015 and
alleged that he is mediclaim policy holder since 1999   till today for
insured sum of Rs. 1,25,000/- with OP. He fell ill on 03.04.2015 and
treated at Metro Hospital Najafgarh and he was admitted in the
hospital from 02.04.2015 to 04.04.2015 for acute problem  of
gastritis. He submitted his bills for reimbursement  to  TPA of the
insurance company who has paid the hospital bill after the deduction
of Rs. 13,600/- arbitrary. He made complaint against OP in the office
of insurance ombudsman Delhi but did not get any relief, hence  this
complaint was filed for the deficiency in service on the part of the
OP. Therefore, complainant prayed for the payment of the  Rs. 13,600/-
with interest @ 18% along with compensation of Rs.50,000/-

2.      In reply, OP did not deny mediclaim policy of the complainant
and admitted the repudiation of the claim amount of Rs. 13,600/-  of
the complainant and denied rest of the allegations made in the
complaint. It was further stated by OP that claim of the complainant
was rejected for violation of terms and conditions of the policy.

3.     The complainant   has filed rejoinder to the reply and
explained that the objections filed by OP are baseless.

4.     In support of his complaint complainant filed his own affidavit
   along with documents OPD prescription dated 03.04.2015 to
30.04.2015 (Ex. CW1/A ), discharge slip (Ex. CW1/B)  ,  details issued
by TPA (Ex. CW1/C), complaint dated 23.06.2015 (Ex. CW1/D) , complaint
before insurance ombudsman (Ex. CW1/E) , certificate dated 27.11.2015
(Ex. CW1/ F) ,  prescription of doctors (Ex. CW1/G) ,  MRI report (Ex.
CW1/H) , copy of complaint for recovery (Ex. CW1/I) , affidavit (Ex.
CW1/X) and details of bill (Annexure A) and policy (Annexure B) .

5.      In support of reply OP filed affidavit of Smt. Kavita Jain
(Attorney) along with true copy of  mediclaim policy 2012  (Ex. OP1).

6.     Both the parties filed their written arguments.

7.     We have heard the arguments and considered the evidence led by
the parties and their written and oral arguments.  In this case points
to be considered are as under:-

   (a) Whether complainant is a consumer?

   (b) Whether there is any deficiency in service on the part of the OP?

   (c) Relief?

8.     OP admitted that  mediclaim policy of the complainant hence
complainant is   a consumer.

9.     It is admitted in the reply of OP that OP has repudiate the
claim of Rs. 13,600/- for violation of the terms and conditions of the
policy but OP did not assign any specific reasons or grounds for the
repudiation of the claim of the complainant. While complainant file
mediclaim 2012 policy (Annexure B)  which explained the pre
hospitalization and post hospitalization period. Under his policy pre
hospitalization under  condition 2.19 is as under:-

“2.19 Pre-hospitalization means relevant medical expenses incurred for
any    one illness during period upto 30 days prior to hospitalization
admissible under the policy.”

Similarly under his policy (Annexure B)  Post Hospitalization  under
condition no. 2.20 is as under:-

“ 2.20 Post Hospitalization means relevant medical expenses incurred
for   any one illness during period upto 60 days after hospitalization
admissible under the policy.”

It is pertinent to mention herein that mediclaim policy 2012 (Ex. OP1)
submitted by OP  is a subsequent policy for the year 2013-2014 , and
it is not  signed by the OP, hence cannot be relied in this matter.

10.                         Looking to these facts and circumstances,
deduction of Rs. 13,600/- from the details of bill (Annexure A)   by
the complainant is unjustified which is suffice to prove the
deficiency on the part of the OP.

11.                         Looking to the above facts and
circumstances, we are of the considered     opinion that deduction
from claim of Rs. 13,600/-  (Annexure A) of the complainant and its
repudiation by the OP is deficiency in service on the part of OP
,therefore, we direct OP as under:-

           1.  To pay the complainant a sum of Rs. 13,600/- to the complainant.

2. To pay the complainant a sum of Rs. 10,000/- as compensation for
mental agony.

           3. To pay the complainant a sum of Rs. 3000/- as cost of litigation.

12. Above  amount will be paid within a period of 60 days from the
date of order failing which an interest  of 18% p.a. will be payable
on this entire amount.

13. Copy of the order be made available to the parties as per law.
File be consigned to record room.

Announced on ……….