DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No. 341/11
Parladh Rai,
Shop No. 1, 1st Floor,
DDA Mini Mkt,
Sriniwasuri,
New Delhi-110065. -Complainant
Vs
1. The Oriental Insurance Company Ltd.
Branch Office at 2, Central Road,
Jangpura, New Delhi – 110014.
2. Raksha TPA Pvt. Ltd.,
15/5, Mathura Road,
Faridabad, Haryana-121003
3. Mr. Jattin Charnalia,
Agent of Respondent No. 1
2, Central Road,
Jangpura, New Delhi – 110014 -Opposite Parties
Date of Institution: 14.09.2011 Date of Order: 20.05.2016
Coram:
N.K. Goel, President
Naina Bakshi, Member
O R D E R
The case of the complainant as revealed from scrutiny of the complaint and various documents is that he took mediclaim policy for himself and his dependants from the OP-1 for the period 18.2.09 to 17.2.10 vide policy No. 212702148. This was a cashless policy and the complainant was given cashless hospitalization card with the advice that at the time of admission in Hospital the complainant will not have to pay any money and the Hospital Authorities could claim from the OPs on the basis of cashless card. He felt chest heaviness and was taken to Escort Hospital wherein he deposited a fee of Rs. 100/- under cashless facility admission format with relevant information to OP-2. Subsequently, an estimate of Financial charges for Rs. 2,11,600/- was prepared by hospital and he had to deposit Rs. 5000/- as advance. At the time of admission, the complainant gave cashless card to Hospital Authority who sent the estimate to the OPs for approval but OPs declined the facility of cashless claim on the ground that it fell under “Pre-existing and two year exclusion clause”. On 22.10.10, he was discharged. In all he paid Rs. 2,28,223/- minus Rs. 45500/- (subsidy) = Rs. 1,82,723/- to the hospital. He further states that he had to spend another sum of 1328.48 on medicines and further a sum of Rs. 987/- on 24.01.2011. These medicines were towards the post hospitalization. Aggrieved with the denial of cashless policy by the OPs he has invoked jurisdiction of this Forum claiming Rs. 2,75,038/- under following breakup:
Rs. 1,82,723/- + 1,328 + 987/- = 1,85,038/-
Rs. 20,000/- legal fee and Rs. 50,000/- for mental agony.
In its reply, OP-1 has inter-alia stated that the policy was renewed and the same was valid from 18.2.10 to 17.2.11. It is further stated that the cashless benefit was declined to the complainant on the basis of exclusion clause 4.3 & 4.1 of the terms and conditions of the insurance policy in question but thereafter OP-1 or OP-2 did not receive any claim from the complainant for reimbursement of the hospitalisation charges and, hence, the complaint be dismissed.
OP-2 has also filed written statement repeating the same stand as taken by the OP-1.
The complainant has filed his own affidavit in evidence. OPs have not filed evidence. Therefore, vide order dated 3.6.14 passed by our predecessors, OPs were proceeded exparte.
The complainant has filed written arguments.
We have heard the arguments of the complainant and carefully examined the material on record.
We feel it very painful to note that the complaint is liable to be dismissed on the sole ground that before filing the present complaint the complainant did not file his claim before OP-1 & 2 for their consideration. It was possible that these OPs, after considering the claim made by the complainant, would have accepted the same in part or in toto or they would have rejected it. In any case, the claim should have been filed before OP-1 & 2 before invoking the jurisdiction of this forum. Therefore, we are constrained to hold that the complainant has failed to prove deficiency in service on the part of OP-1 & 2. OP-3 is an unnecessary party.
In view of the above discussion, we dismiss the complaint with no order as to costs. However, we grant liberty to the complainant to file his claim along with all the original medical papers before OP-1 & 2 within 60 days from the date of receipt of copy of this order and OP-1 & 2 shall consider the same without taking the plea of limitation and shall decide the claim on merits within a period of 30 days from the date of filing of the claim by the complainant before them. The complainant shall be at liberty to seek further remedy, if any, against the order of the OPs in case the need arises for doing so.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
(NAINA BAKSHI) (N. K. GOEL) MEMBER PRESIDENT
Announced on 20.5.2016
Case No. 341/11
20.05.2016
Present – None
Vide our separate order of even date pronounced, the complaint is dismissed. Let the file be consigned to record room.
(NAINA BAKSHI) (N. K. GOEL) MEMBER PRESIDENT
