H.N. ARORA Vs. FAMILY HEALTH PLAN LIMITED

JUDGEMENT

(1.) Being aggrieved by order dated 18.5.2011 passed by State Consumer Disputes Redressal Commission, Delhi (for short, 'State Commission'), Petitioner /Complainant has filed the present petition.

(2.) Brief facts are "that Petitioner/ Complainant obtained for himself and for his wife. Smt. Krisha Arora a Hospitalization and Domiciliary. Hospitalization Benefit Policy for a period commencing from 30.4.2005 to 29.4.2006, the insured sum for each being Rs. 1 lac and bonus amount of Rs. 5,000. Earlier also they had a similar policy. In the month of January, 2005, with complaint of back pain, petitioner went to three hospital from 8.1.2005 to 24.2.2006 for physiotherapy and was subsequently diagnosed Multiple Myeloma with UTI and was advised to get three phase bone scan, which was performed at Dr. Diwan Chand Diagnostic Centre, Delhi. Even thereafter, the pain persisted. On 28.5.2005, petitioner was taken to Rockland Hospital for the treatment and the hospital asked him to give details of his mediclaim number so that the hospital could get approval from Respondent No. 1/O.P.No. 1 to provide the cashless facility. Petitioner's grouse is that the Respondent did not provide him mediclaim number. The petitioner was referred to oncologist who advised him for thorough investigation Thereafter petitioner was referred to Shanti Mukund Hospital on 1.6.2005 where he was admitted and after much trouble, respondents agreed for the cashless facility for the treatment for five days wherefrom he was discharged on 6.6.2005. It is further alleged that he was again admitted to Sir Ganga Ram Hospital under the treatment of an Oncologist as he was suffering from pain and was treated there. Thereafter, chemotherapy was given to him in two different hospitals but he did not improve and then he was admitted to Anand Hospital and Cancer Centre on 3.6.2006 and was discharged on 10.6.2006. Petitioner's further grouse is that despite his requests, respondent-Insurance Company did not provide him cashless facility barring the one as noted above for treatment in different hospitals. He, therefore, lodged a claim before the respondent- Insurance Company for a sum of Rs. 1,43,439 on 15.12.2006 annexing with it summary of his hospitalization and details of post hospitalization bill and also claimed Rs. 61,000 towards medical charges paid by him to Anand Hospital but in vain. The petitioner therefore filed a complaint before District Forum alleging deficiency in service on the part of the respondents claiming Rs. 2,50,000 towards medical insurance claim and Rs. 61,000 paid by him to Anand Hospital along with pendente lite and future interest @ 24% totalling to Rs. 4,53,439

(3.) Respondent No . 1 was proceeded ex parte.