CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi-110016.

Case No.391/2009

Shyam Singh,

331, Chattar Pur Village,                                           

New Delhi -30.                                                      ……Complainant 

Versus

1.       The Oriental Insurance Co. Ltd.

          Through its Divisional Manager,

          D.O. 25, G-8, Hauz Khas Market

          New Delhi.

2.       Raksha Third Party Administrator Pvt. Ltd.

          15/5, Mathura Road, Faridabad, Haryana-121003.

3.       Fortis Flt. Lt. Rajan Dhall Hospital,

          Sector B, Pocket 1, Aruna Asaf Ali Marg,

          Vasant Kunj, New Delhi – 70.                     ……Opposite parties

                                             Date of Institution          : 11.05.2009  

                                     Date of Order                 : 29.09.2015

Coram:

Sh. N.K. Goel, President

Ms. Naina Bakshi, Member

O R D E R

The case of the complainant is that in continuation of earlier policy he took mediclaim policy bearing No.215200/487/08/2330 effective from 19.12.2007 to 18.12.2008 for himself and his three family members of Rs. 2 Lakhs each from the OP and paid Rs. 10,461/- as premium amount.  However, on 18.9.2007 (sic) he felt giddiness/ghabrahat etc. and went to Apex Hospital, Chattarpur Mandir Raod, New Delhi where he was given first aid and advised to go to hospital as he was suffering from high blood pressure.  He went to OP-3 Hospital where he was advised to get himself admitted in the hospital as he was suffering from acute hypertension and vertigo.  The OP-3 sought policy details from him and submitted the same to OP-2 for cashless claim but, however, vide letter dated 20.9.08 OP-2 denied the claim of the complainant.  Hence, complainant filed the present complaint with the following prayers for directing the OP:

1. to reimburse Rs. 17,842.00 along with interest @ 18% p.a.
2. to reimburse Rs. 5,000.00 as post hospitalization treatment expenses.
3. to reimburse Rs. 200/- as the charges paid to Apex Hospital
4. to direct impose interest on the above-said amount @ 18%
5. to impose cost of Rs. 75,000.00 due to mental agony faces and suffered by the complainant.

     In the written statement OP-1 has stated that the complainant was suffering from Accelerated Hypertension and the previous claim history and his claim fell under the first two years of the policy and, therefore, his claim was rejected under exclusion clause 4.3 of the insurance policy in question.  It is prayed that the complaint be dismissed.

     Reply filed on behalf of OP-3 is of no much use.

          Complainant has filed rejoinder to the reply of OP-1 wherein he has inter-alia stated that the copy of the terms and conditions of the insurance policy was not supplied to him at any point of time and that he was having no history of such disease and, therefore, the rejection of the claim was not justified.

     Affidavits in evidence filed.

     Written arguments have been filed on behalf of the parties.

 We have heard the arguments advanced on behalf of the complainant, OP-1 and OP-3 and have also gone through the file very carefully.

According to the complainant, Ex. CW1/1 is the copy of prescription slip dated 18.9.08 issued by Appex Hospital where his disease was diagnosed as Vertigo and Ghabarahat.  He had been provided some medicines.   However, nowhere in the said prescription the complainant had been advised for hospitalization.  Ex. CW1/2 is the copy of discharge slip issued by OP-3 Hospital where his disease was diagnosed as Acute hypertension with Vertigo and he remained admitted in the hospital from 18.9.2008 to 20.9.2008.  Some tests etc. were conducted and he was issued a final bill for Rs. 17,842/- which included  Rent  charges of Rs. 11,000/- and Doctor charges as Rs. 3000/-.  The judgment delivered in case No.FA-08/531 – Mrs. Sushil Mohini Gupta Vs. Bikram & Ors. relied on behalf of the complainant is of no help to him because in that case the complainant had to undergo medical examination or check up at a Hospital in Canada.  She did not require any hospitalization.  In Para 8 of the said judgment, it has been held that the Hypertension is not a disease but normal wear and tear of human life, which is controllable with medication and does not involve such a treatment that needs hospitalization or operation to cure it.  However, in the present case, the complainant had got himself admitted to OP-3 Hospital for his treatment.  Therefore, his claim fell under exclusion clause 4.3 of the terms and conditions of the policy in question, copy of which has been placed on record.  Since the complainant has not stated in his complaint that copy of terms and conditions governing the policy in question was not supplied to him at any point of time, his said version made in the rejoinder cannot be accepted.  Therefore, we hold that the complainant has failed to prove deficiency in service on the part of OP-1 & OP-2.

          In view of the above discussion, we dismiss the complaint with no order as to costs.

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.

Announced on 29.09.15.

(NAINA BAKSHI)                                                         (N.K. GOEL)  

MEMBER                                                                     PRESIDENT   

  .09.2015

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