CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE MS. BIMLA KUMARI, MEMBER (FEMALE)

Present: Ms. Binny Sethi, counsel for the Appellant.

Mr. Shripal, counsel for the Respondent

PER :HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT

JUDGMENT

1. The facts of the case as per the District Commission record are as under:

“2. Briefly stated facts of the case are that the complainant had taken a Health Medical Claim Policy bearing No.OG-1101-8430-00002563 dated 15.02.2020 from OP No. 1 with effect from 15.02.2020 to 14.02.2021 for the sum insured of Rs.3,00,000/- (Three Lacs only).

3. It is further alleged that on 23.03.2000, the Complainant got admitted in the hospital of OP No.2 due to fever, vomiting, Abdomen pain and on 30.03.2020 and was discharged from OP No. 2. It is also alleged that the OP No. 2 generated the medical treatment bill of Rs.64,257/- (Rupees Sixty Four Thousand Two Hundred Fifty Seven only) which was paid by Complainant to OP No. 2. The complainant thereafter claimed the aforesaid bill from OP No.1 but the same was repudiated by OP No. 1 vide letter dated 17.08.2020. It is also alleged that the medical documents submitted by the Complainant to OP No. 1 were issued by the OP No. 2.

4. It was also stated that the present complaint has been filed within the period of limitation. The complainant is resident of at "Kakrola" New Delhi and OP No. 1 works for gain within the jurisdiction of this Commission, hence this Commission has jurisdiction to try and decide the case.

5. It is prayed that OP be directed to pay a sum of Rs.64,257/- (Rupees Sixty Four Thousand Two Hundred Fifty Seven only) to complainant with pendent elite and future interest @ 18% p.a. from the date of repudiation of the claim i.e. 17.08.2020 till its realization. OP No. 2 be directed to verify and produce the medical treatment record and bills of complainant OP be also directed to pay w.e.f. 23.03.2020 to 30.03.2020. compensation and cost of litigation.

6. Notice of the complaint was issued to both OPs, upon which OP No.-1 appearance entered and filed reply/written statement contesting the complaint on various grounds, inter alia that complaint was not maintainable as it was filed on false and frivolous facts. It was also stated that there was no deficiency in service on part of the OP. It was further stated that the admission of the complainant to the OP No. 2 hospital for fever and weakness for four days was without any basis since the pathologist, Dr. R.S. Kushwaha had written a letter to the OP No. 1 stating that the reports of the complainant were fake and had not been verified by him. Dr. R.S. Kushwaha had further stated that he does not visit the OP No. 2/ hospital. It was alleged that complainant and the OP No. 2 were hand in glove to deceive OP No.1 with the intention of getting insurance money from the OP No. 1 by fabricating documents of a medical claim.

7. It was alleged that the standard medical protocols have not been followed during the alleged hospitalization. The complainant claimed that she was admitted for eight days and yet no tests were done on the complainant for notifiable diseases which is the standard medical protocol.

8. It was further alleged that the OP No. 2 had refused to provide records of the Complainant to the OP No.1. The OP No. 2 did not cooperate with the OP No. 1 and no record of alleged treatment was shown despite requests. It was also alleged the clause D of the terms and conditions of the policy on the basis of which the claim was repudiated is as under:

"Where this Policy requires you to do or not to do something, then the complete satisfaction of that requirement by you or someone claiming on your behalf is a precondition to any obligation We have under this Policy. If you or someone claiming on your behalf fails to completely satisfy that requirement, then we may refuse to consider your claim."

9. It was also alleged that the complaint is not maintainable as the same has been