ORDER

SH. RAKESH KAPOOR, PRESIDENT



       It is alleged by the complainant  that on 6.7.2013, his
daughter  Archana was admitted to Ekansh Nursing Home and was
discharged on 11.7.2013.   Intimation about the admission was given to
OP2 on 6.7.2013 itself.   The complainant had incurred a sum of Rs.
35,141/- on the aforesaid treatment and had lodged a claim which was
not settled . Hence, the complaint.

        The OP has filed a written statement in the aforesaid case
wherein it has denied any deficiency in service on its part and has
claimed that the complaint is liable to be dismissed. It has, however,
admitted that the claimant was holder of mediclaim polices issued by
it and had lodged claim which has not been settled by it.  The
relevant defence is contained in the following pras of the written
statement  :-

PRELIMINARY OBJECTIONS

3.That as   per  record,   the complainant's  previous  policy    no.
042500/48/13/06/00000520, under which the claim has been raised. That
the admission of the complainant/insured is doubtful as the antecedent
of treating Hospital is very suspicious. After investigation by the
opposite party No. 2, it is revealed that the treating Hospital does
not carry a good reputation being involved in fraudulent activity.



4.That the opposite party No. 2 has appointed a special investigator
to investigate the present claim. The investigator namely M/s PROBUS
ASSOCIATES & CONSULATATION PVT. LTD. conducted the investigation and
submitted his report. As per the report of investigator GENUINITY OF
ADMISSION APPEARS TO BE DOUBTFUL.

5.That the M/s PROBUS investigator has conducted inquiry with patients
and raised certain queries like WHY SHE HAD NOT CONSULTED AN
EMPANELLED HOSPITAL, BUT NO EXPLANATION PROVIDED BY THE PATIENT. As
per statement of neighbour of patient namely Jyoti, who has informed
the investigation , that she was admitted with hospital for treatment
prior of this hospitalization but insured has not provided details of
past hospitalization even not intimated to the OP No. 2 for past
treatment.



7.That the present claim is pending and being considered by the Third
Party Administrator who is a professional agency and engaged for a fee
or remuneration by the insurance companies for the provision of health
services under an agreement and under the provision of IRDA
Regulations (Third Party Administrator-Health Services) 2001. That
even otherwise in the insurance policies of such nature as relates to
the present case, the company relies upon professional recommendations
and decisions of TPA which requires to be followed by the company
under the provision as stated. As such, the present claim is pending
under consideration.

      We have heard arguments advanced at the bar and have perused the record.

      The learned counsel for the insurance company has contended that
the claim filed by the complainant  is doubtful.   She has contended
that a special investigator namely M/s Probus Associate and Consultant
 Private Ltd  who had been appointed to investigate the claim who had
submitted its report as per which the fact  of the  admission  of the
patient appears to doubtful. She has further contended that an
investigation was also carried out by the TPA (OP2) and it was found
that   the treating hospital does not carry a good reputation being
involved in fraudulent activity. She has , therefore, justified  the
action of the OP in not settling claim of the complainant

     We have considered the contention raised by the learned counsel
for the Ops. The Ops have not filed any document  showing the
investigation carried out or the investigation carried out by M/s
Probus Associate and Consultant  Private Ltd . No report of the
investigator has been placed on record. Merely terming that the claim
filed is  doubtful  does not help the cause of the insurance company.
In the present case, the patient was allegedly admitted in the nursing
home on 6.7.2013. The TPA was informed about the admission on the same
day. It appears to us that the TPA had failed to conduct due
investigation in this regard.  Since, the admission of the  patient
had been made known to TPA ( OP2) on the very day of admission, it
would have  easily verified about the fact on the said date or on the
date following thereto. Therefore, taking a  stand that the admission
of the patient in the hospital was doubtful is not tenable. We see no
material on record on the basis of which the claim can be said to be
doubtful or any other basis which it  could have been repudiated. The
insurance company was obliged to settle the claim within a period of 3
months from the date of lodging of the claim. In the present case, the
claim had been lodged on 18.7.2013 and already more than two years
have passed and still the insurance company has neither accepted nor
repudiated the claim. We, therefore, hold that the OP insurance
company was not justified in not settling the claim lodged by the
complainant.  We hold the OP insurance company guilty of deficiency in
service and direct it as under:



1.Pay to the complainant a sum of Rs. 35,141/-.



   The insurance company shall pay this amount within a period of 30
days from the date of this order failing which they shall be liable to
pay interest on the entire awarded amount @ 10% per annum.  IF the
insurance company fails to comply with this order, the complainant may
approach this Forum for execution of the order under Section 25/27 of
the Consumer Protection Act.



     Copy of the order be made available to the parties as per rule.

  Files be consigned to record room.

Announced in open sitting of the Forum on.....................