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Hon'ble Sri Mahesh Chand, Member.

Sri Alok Kumar Singh, Advocate for the Appellant.

Smt. Shuchita Singhfor the  Respondent.

Date:  18.07.2016                                                                              Judgment Sri Mahesh Chand,Member-This Appeal has been filed by National Insurance Company Ltd. through its Manager, Regional Office, Hazaratganj, Lucknow, against the order dated 9.9.2014, passed by learned District Consumer Dispute Redressal Forum-I,Ghaziabad, in complaint case No 52/2011, Vinod Kumar Singh& OrsVs.National Insurance Company Ltd.In brief the facts of the case are in connection with the dispute regarding the payment of compensation to the complainant who got the insurance cover for medical treatment for himself and the family members under group insurance policy. This policy No 501600/46/09/8500000052 was purchased by complainant's company where he was employed through the opposite party no. 2 of the complaint/Family Health Plan Limited, TPA through Competent Authority. This policy was valid through the period from  1 July 2009 to 30 June 2010. The complainant's wife Smt. Beena Singh was pregnant and at the time of delivery on the advice of consulting doctor, she was admitted in the Hospital, opposite party no.3 on dated 14.4.2010 wherein she delivered a female child through surgical operation under supervision of Dr Monica Agarwal. Smt Beena Singh was discharged from the hospital on 20.4.2010. The complainant paid the bill of Rs 46991/- to the hospital in two installments i.e. Rs23000/- on dated 16.4.2010 and Rs23991/- on dated 20.4.2010.

The District Forum has erred in not considering the fact that the Group Insurance Policy was obtained by Areva T & D (I) Ltd. but in the instant case the company has not filed any claim before the appellant insurance company but by the complainant.

The complainant's bills were false and fabricated and highly inflated.

The patient was diagnosed as a case of LSCS with Bilateral Tubual Ligation and as per policy condition No 4.8 Bilateral Tubual Ligation charges are not payable.

The independent investigator appointed by TPA found several discrepancies in the bills. The hospital was not registered. Hence the bills were rejected.

           The respondent/complainant filed the written statement. The respondent/complainant has denied all the allegations made in the appeal. The respondent has stated that all the grounds of the appeal are false and against the record. It has been stated in the reply that the Group Insurance policy was obtained by Areva T & D (India) Ltd for its employees all over India. It covers the family members of the employee also. Appellant has not given any proof regarding fabrication and falseness of the bills. The respondent has also stated that Bilateral Tubual Ligation was done immediately after delivery and no extra charges were paid for this. More over the hospital was duly registered and its renewal was regularly done. The allegations made in the appeal are frivolous and the appeal is liable to be dismissed.

             We have heard the arguments of the learned counsels of both the parties and perused the record on file. The contention of the learned counsel of the appellant  that the claim should have been filed by Areva T & D (I) Ltd. only then it would have been considered,  is not tenable. The complainant  has categorically stated that he was paying the premium of the policy through the company. He is the beneficiary of the scheme and not the company. Company is the mediator/facilitator. It is a Group Insurance Policy. Under the policy family members of the subscriber-staffare covered. In the instant case the spouse of the employee/complainant have undergone the surgical operation. The claim was submitted by the insured through the company. He is entitled to file the claim. So far as the condition No 4.8 is concerned that the claim for Bilateral Tubual Ligation is not payable. The Respondent -Complainant has stated that no extra charges have been paid for Bilateral Tubual Ligation. In the instant case surgery was performed for delivery of a child to save the life of the mother and child otherwise normal delivery would have been performed.In the policy surgical delivery of a child is not mentioned in the exclusion list.  Hence there is no occasion for declining the claim of LSCS (Lower segment Cesarian section: A Cesarian section in which the surgical incision (cut) is made in the lower segment of the uterus). So far as the inflation of the bills is concerned the appellant has not given any proof of it. Similarly no proof for fabrication of bills or their being false, has been given. In these circumstances the contentions of the appellant are not tenable. There is no force in the  appeal and is liable to be dismissed Order           In the light of above discussion and observation the Appeal is dismissed. Parties will bear own costs. Hence No order to the costs.