NATIONAL INSURANCE COMPANY LIMITED Vs. RAJAN KUMAR

JUDGEMENT

(1.) THIS appeal has been preferred against the order dated 4.5.2010 passed by District Consumer Forum, Jind in complaint No. 405/2009 which relates to medi -claim compensation in respect of the Medi -claim Insurance obtained by the complainant (respondent No. 1 herein).

(2.) THE brief facts of the present case as can be gathered from the record are that the complainant had obtained a Mediclaim Insurance Policy No. 420605/48/088500000113 dated 13.8.2008 valid w.e.f. 13.8.2008 to 12.8.2009 by way of which the complainant, his wife and children were insured. In the month of December, 2008 wife of the complainant Smt.Rajani suffered urine problem, she was taken to Bhatia Global Hospital and Endosurgery Hospital, Delhi for treatment on 20.12.2008 and remained admitted there w.e.f. 23.12.2008 to 26.12.2008. She was diagnosed as a case of Gastritis and Duodentitis. According to the complainant he spent Rs. 22,236 as treatment charges. Again she was admitted in the above said hospital on 28.12.2008 and discharged on 3.1.2009 with a diagnosis of Calculus of Kidney and Ureter. As per complainant he spent Rs. 50,976 for this treatment. Complainant lodged a claim of Rs. 68,163 with the opposite party No.1. The opposite parties offered payment of Rs.18,721 to the complainant which the complainant did not accept and for that reason the claim of the complainant was closed. Alleging it as a deficiency in service and unfair trade practice, the complainant invoked the jurisdiction of the District Consumer Forum seeking direction to the opposite parties to pay Rs. 68,143 as amount of claim; Rs. 30,000 as compensation for mental agony and harassment along with interest @ 18% per annum from the date of claim till realization.

(3.) UPON notice, the opposite parties appeared and contested the complaint. In the written statement it was stated that the disease of Smt. Rajni was pre -existing as per medical record submitted by the complainant to the opposite parties the bill of Rs. 22,236 was payable to the complainant to the extent of Rs. 18,721 only as per details given in the discharge voucher No. NAD09030901 dated 9.3.2009 sent by the opposite party No. 2 to the complainant and out of this a sum of Rs. 3515 was disallowed being not payable. As the complainant failed to submit the duly discharged voucher with the opposite parties, the compensation could not be paid to the complainant. The second bill for Rs. 50,976 was not payable as the patient was treated for Calculus of Kidney and Ureter and as per Discharge Summary, she was a known case of Renal Calculus for the last one and half year and for that reason the disease suffered by Rajni was not contracted on the date of commencement of the Insurance Policy. Thus, denying any kind of deficiency in service on their part, the opposite parties prayed for dismissal of the complaint.