MS. NIPUR CHANDNA, MEMBER

ORDER

11.07.2024

1.       A complaint under Section 12 of Consumer Protection Act filed. In brief the facts are that complainant is the mediclaim policy holder of OP Ins. Co. vide policy bearing no. 221903/48/10/06/00001058 w.e.f. 13.01.2011 to 12.01.2012 covering complainant and all his family members .

2.       On 27.10.2011, complainant’s wife Mrs. Rakesh was admitted to Ekansh Nursing Home for the treatment of Dengue Fever with Thrombocytopenia and discharge from the said nursing home on 03.11.2011. The intimation of the hospitalization was given to OP2 on 27.10.2011. It is alleged by the complainant that he submitted his claim of Rs. 51,359/- along with all the original medical documents to OP2 through speed post dated 08.11.2011. On 16.11.2011, the employee of OP2 namely Mr. Atul Sharma visited at the residence of complainant and took the statement of his wife and also collected the copy of photo Id. It is further submitted by the complainant that he received a query letter dated 19.11.2011 for submitting the photo ID proof of his wife although the same has been collected by the employee of OP2 on 16.11.2011.

 3.      On 10.12.2011, complainant checked his wife’s claim status on the website of OP2 and found that claim was repudiated by OP Insurance Co. On 20.01.2012, the complainant again submitted his hospitalization claim and requested for further renewal of the policy but OP stuck up on his grounds of repudiation. Complainant also sent legal notice to the OP thereby requesting it to consider the claim and renewed the policy, but all in vain.  Being aggrieved by the conduct of OP complainant approached this Commission for redressal of his grievance.

4.       Notice of the complaint was sent to OP-1 & 2. OP1 & 2 filed their joint written statement wherein they denied any deficiency in service on their part. The OP1&2 has taken the preliminary objection in respect to the maintainability of the present complaint on the ground of territorial jurisdiction. It is further stated that the insured under this policy is subject to condition, clause, warranties, endorsement as per the form attached. It is further stated that as per the policy terms and conditions the nursing homes should have at least 15 beds and on perusal of the registration certificate of Ekansh Nursing Home where the complainant was admitted and under gone treatment it was found that the said nursing home is having only ten beds and as such the claim of the complainant is not tenable. It is further stated that the IPD papers were prepared by single person in the same handwriting and as per the nursing sheets there is no signature of the nurses present during investigation and it was found that there was no qualifying nursing staff and nursing registration certificate was also not provided  and as such the claim of the complainant was not tenable and is being repudiated. It is stated in the written statement that the insured and the hospital authority has not cooperated with the investigator to show the treatment papers of the patient.  It is further submitted by OP that the treatment of the complainant’s wife does not require hospitalization as category of dengue is following under the low risk category as the platelets count had not reached 40000 or below which may be considered as one of the basic ground for hospitalization. It is further stated by OP that the present complaint is abuse of the process of law, hence, be dismissed with cost.

5.       Rejoinder to the WS of OP1 & 2 filed. Complainant filed his evidence by way of affidavit wherein he has corroborated the contents of his complaint.

6.       Complainant has placed on record the copy of letter dated 27.10.2011 and 08.11.2011 vide which he lodged the claim with OP, copy of policy documents, copy of claim form, copy of medical bills and record, copy of legal notice dated 26.03.2012 served upon OP in support of his contention.

7.       Sh. Deepak Sarin Administrative Officer filed his evidence by way of affidavit on behalf of OP. OP has placed on record the copy of repudiation letter dated 06.12.2011 in support of its contention.

8.       Written arguments filed by the parties.

9.       We have heard  the arguments advance at the bar by Sh. Sachin  on behalf of complainant and Sh. Gurmeet Singh Ahuja counsel for OP and  have perused the record.

10.     During the course of arguments OP has strongly challenged the issue of territorial jurisdiction. On merit it is argued on behalf of OP counsel that the wife of the complainant undergone the treatment in Ekansh Nursing Home. She was admitted in the hospital on 27.10.2011 and was discharged on 03.11.2011. It is further submitted that the hospital is having only ten beds and as per the policy terms and conditions clause 2.1 the nursing home has at least ten inpatient beds in town having a population less than 10 Lakhs and 15 inpatient beds in all other places. As the wife of the complainant has taken the treatment in the nursing home having ten patient beds the claim of the complainant was rightly repudiated by referring clause 2.1 of the policy terms and conditions. To support its contention counsel for OP has drawn out attention towards the copy of the registration certificate dated 24.09.2014 of Ekansh Nursing Home issued by Directorate Of Health Services  Shahdara, Delhi where by the Nursing home was authorized to carry on nursing home activities with ten beds. It is further argued on behalf of OP counsel that the treatment of the complainant’s wife does not require hospitalization as category of dengue is following under the low risk category as the platelets count had not reached 40000 or below which may be considered as one of the basic ground for hospitalization. It is further stated by OP that the present complaint is abuse of the process of law, hence, be dismissed with cost.

11.     OP has strongly challenged the issue of territorial jurisdiction, hence, needs to be decided first.

12.     Before adverting to the disposal of the present complaint case let us peruse the relevant provision of CP Act 1986 which are reproduced as under:-

          Section 11 Jurisdiction of the District Forum

(1) Subject to the other provisions of this Act, the District Forum shall have jurisdiction to entertain complaints where the value of the goods or services and the compensation, if any, claimed 1[does not exceed rupees five lakhs].

(2) A complaint shall be instituted in a District Forum within the local limits of whose jurisdiction- (a) the opposite party or each of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides or 1[carries on business, or has a branch office or] personally works for gain; or (b) any of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides, or 1[carries on business or has a branch office, or personally works for gain: PROVIDED that in such case either the permission of the District Forum is given, or the opposite parties who do not reside, or 1[carry on business or have a branch office, or personally work for gain, as the case may be, acquiesce in such institution; or (c) the cause of action, wholly or in part, arises.

13.     Admittedly, in the present complaint case the policy was issued from Karampura office of OP Company The claim of the complainant was repudiated (constituting the cause of action) from Gurugram office of OP company, hence, neither the OP nor the cause of action arose within the territorial jurisdiction of this Commission, hence, we are of the considered opinion that this Commission has no territorial jurisdiction to entertain and adjudicate the present complaint case.

14.     On merit, after perusal of the registration certificate we found that the claim of the complainant was hit by clause 1.2 of the policy terms and condition and as such the repudiation is justified. The OP Ins. Co. has repudiated the claim of the complainant on another ground i.e. as per the investigation report, the claim seems to be fabricated, hence, dismissed. To justify the repudiation counsel for OP has drawn our attention toward the report of Mittal Diagnostic Centre dated 24.10.2011 which clearly shows that on 24.10.2011 the platelets of complainant’s wife is 2.34 Lakhs/cumm, hence, the contention of the OP that the treatment of the complainant’s wife does not require hospitalization as category of dengue is following under the low risk category as the platelets count had not reached 40000 or below which may be considered as one of the basic ground for hospitalization is justified and legal.

15.     In view of the above discussion, we are of the considered opinion that that firstly this commission lack territorial jurisdiction to entertain and adjudicate the present complaint. On merits of the case we are of the opinion that claim of the complainant was rightly repudiated by OP Ins. Co. in the light of medical records as well as the policy terms and conditions. We, therefore, find no merits in the present complaint, same is hereby dismissed.

          File be consigned to record room.

16.   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 the application from the parties in the registry. Order be uploaded on.

Announced in open Commission on   11.07.2024.

(SANJAY KUMAR)              (NIPUR CHANDNA)                      (RAJESH)

PRESIDENT                                    MEMBER                              MEMBER