ORDER

14.02.2024

Ms. Nipur Chandna, Member

1. In brief facts of the present case are that complainant is a senior citizen. It is stated that complainant is insured by the OP for the purpose of medical insurance. The complainant due to her age had problem of urine and admitted for treatment with RG Urology Laproscopy Hospital, B-12, Derawal Nagar, Model Town- II New Delhi through its RG Stone clinic. It is further stated that complainant incurred medical expenses to the tune of Rs. 27,830/- and submitted the claim with OP. It is stated that OP disallowed the payment of the bill by stating that the treatment is not covered under the policy.
2. It is stated that complainant was also having stomach problem for which she was treated and bill of Rs.10,746/- was charged. The complainant filed the claim with OP but again not allowed on the ground that this is not a treatment but a test. The complainant filed photocopies of treatment documents and claim form in support of her claim.
3. Being aggrieved by the conduct of the OP present complaint was filed seeking suitable orders for recovery of Rs.27,830/- and Rs.10,846/- with 12% interest and damages of Rs.50,000/- for suffering lot of pain, anguish, discomfort and mental agony and cost of the present proceedings.
4. Notice of the complaint was sent to OP. OP filed written statement wherein it denied any deficiency in service on its part. It is stated that the contract of insurance is based on utmost good faith and each party after contract are bound to follow terms and conditions of the contract of insurance. It is further stated that complainant is bound by the terms and conditions of the contract of insurance and as per clause no.2.3 of the insurance policy the claim of the complainant is maintainable only when there is hospitalization of minimum period of 24 hours, which in this case is not present, therefore, the claim does not fall under the terms and conditions of the policy accordingly, claim was rightly rejected.
5. It is stated that complainant has not filed the discharge summary. The complainant also not supplied the previous policy details, therefore, claim was closed as no claim on 29.11.2014 and same was informed to husband of complainant sh. Pawan Kumar. It is stated that the bill dated 28.07.2014 is of Rs.20,000/- only. It is further stated that as per policy terms and conditions the bills for treatment for one month prior to hospitalization and after hospitalization are payable only and no other bill is payable. It is further stated that no claim of Rs.10,746/- lodged with the OP and no copy of such bill supplied to OP. It is stated that present complaint is liable to be dismissed.
6. As per record rejoinder not filed by complainant to the WS.
7. Complainant filed evidence by the affidavit of Pawan Kumar her husband. In the affidavit contents of complaint reiterated. The complainant relied on copy of insurance card Ex.CW1/A, copies of treatment and bills Ex.CW1/B (colly) and copy of bill of Rs.27,830/- Ex.CW1/C.
8. OP filed evidence by way of affidavit of Deepak Sarin Assistant Manager. In the affidavit contents of WS reiterated. OP relied on copy of policy Ex.RW1/1.
9. Complainant filed written arguments. OP also filed written arguments.
10. We have heard Sh. Amit Kumar alongwith Sh. Sadanane counsel for complainant and Sh. Raghav proxy counsel for Sh. R.K Gupta counsel for OP and perused the record.
11. Admittedly, the complainant has not placed on record the copy of policy documents pertaining to the year 2013-14, 2014-. The complainant has placed on record the copy of medical bill pertaining to the treatment in the year November, 2013, however she failed to place on record any documentary evidence in respect to the submission of the reimbursement claim to OP Ins. Co. As per the insurance policy the insured is required to submit the requisite documents for reimbursement of the claim. Admittedly the complainant failed to complete requisite formalities as such she is not entitled for medical expenses to the tune of Rs. 10,846/- pertaining to the year 2013.
12. Complainant has placed on record the medical bills for the  treatment undergone in the year April, 2014. She has failed to place on record the copy of the discharge summary pertaining to the treatment undergone and the hospitalization in respect to the claim in question. As per the written version of OP Ins. Co. complainant was admitted at 11:06 AM in the hospital and was discharged on the same day at about 07:09 AM, complainant has neither filed rejoinder to the written statement of OP nor had placed on record any documentary evidence rebutting the allegation of OP in respect to the hospitalization. She has also failed to place on record any documentary proof justifying the hospitalization for less than 24 hours. Having no other option we have to rely upon the contention of the OP company that the hospitalization of complainant in the present complaint case is less than 24 hours. As per clause 2.3 of the policy terms and conditions the ins. Co. is liable to reimburse the claim only if there is a hospitalization for a minimum period of 24 hours.
13. In view of the above discussion, we are of the considered opinion that while repudiating the claim in question the OP Ins. Co. has acted within the four corners of the policy terms and conditions. We therefore, hold repudiation justified. We find no merits in the present complaint, same is hereby dismissed being devoid of merit. File be consigned to record room.
14. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  14.02.2024.

SANJAY KUMAR                   NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER