ORDER

13.02.2024

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 was admitted during the period of March, 2014 in Medanta Hospital, Global Health Pvt. Ltd. E-18, Defence colony, New delhi for treatment of Gal Bledder Tumur and undergone operation. It is further stated that complainant submitted bills with OP for clearance but same were not paid. It is stated that complainant is suffering a lot of pain, anguish, discomfort and mental agony due to acts of the OP, therefore, present complaint filed. The complainant seeking orders for recovery of Rs. 33,405/- along with 12% interest, damages of Rs. 50,000/- and cost.
2. OP filed detailed WS and taken preliminary objections that complainant is not a consumer as per CP Act and not approached the Hon’ble Consumer Forum with clean hands, therefore, present complaint is liable to be dismissed. It is stated that in the present facts detailed examination of evidences and cross examination are required, therefore, appropriate civil court of law has the jurisdiction to adjudicate the present matter.
3. 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 rejected.
4. It is stated that the present claim of complainant is not maintainable amounting to Rs. 33,405/- as same has been already settled. It is further stated that the preauthorization from the Hospital a sum of Rs. 10378/- was approved but after deducting Rs. 1038/- as TDS a sum of Rs. 9340/- was paid through NFT on 02.05.2014 to the Hospital. It is stated that after receiving the claim papers and bills of pre and post hospitalization the competent authority has approved the balance of Rs. 17645/- which was paid to the insured on 05.08.2014, therefore, present claim is liable to be dismissed. It is stated that true facts are that a policy bearing no. 221900/48/13/9700004170 valid from 15.03.2014 to 14.03.2015 was issued for covering the Hospitalization of the complainant subject to terms and conditions of the policy.
5. On merit all the allegations are denied. 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 way of affidavit . 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 & C (colly).
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 assessment sheet Ex.RW1/1.
9. Complainant filed written arguments. OP also filed written arguments.
10. We have heard Amit Kumar alongwith Sadanane counsel for complainant and Sh. Raghav proxy counsel for Sh. R.K Gupta counsel for OP and perused the record.
11. OP counsel relied on the copy of the assessment sheet placed on record along with evidence by way of affidavit of OP. The bare perusal of the assessment sheet makes it clear that out of the total claim of Rs. 33,405/- OP Ins. Co. partly paid the sum of Rs. 10,378/- on 02.05.2014 on account of preauthorization and secondly after receiving the medical record OP paid a balance sum of Rs. 17,654/- on 05.08.2014 to complainant as per the policy terms and condition.
12. Admittedly, the complainant filed the present complaint against OP on 07.12.2015 against the non reimbursement of the entire claim of Rs. 33,405/- whereas as per the written statement of OP as well as the assessment sheet placed on record by OP counsel the complainant received the claim amount of Rs. 28,032/- against the reimbursement claim of Rs. 33,405/- from OP Ins. Co. in the month of August, 2014. The complainant concealed the material facts regarding the receipt of the claim from this Commission as well as failed to place on record any documentary evidence in respect to the non receipt of the reimbursement claim in question.
13. In view of the above discussion we are of the considered opinion that due to lack of documentary evidence, the complainant failed to prove the case of deficiency in service on the part of OP. We therefore find no merits in the present complaint, same is hereby dismissed.
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  13.02.2024.

SANJAY KUMAR                 NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER