Date: 29-09-2016 Mohd. Anwar Alam, President
1. The complainant filed this complaint on 04-06-2015and alleged that he took mediclaim insurance policy from OP1 for him and his family members namely Mrs. Mala Lamba (wife), Mrs Muskan Lamba (daughter ) and Mr. Anmol Krishna (son). It was renewed after 16.04.2015 and due insurance premium paid to OP1. As per medical consultant Mrs. Mala Lamba had got two surgeries at Bhatia Global Hospital and Endosurgery Institute on 11.12.2014. Despite cash less mediclaim insurance policy with OP1 he paid Rs. 20,000/- to the hospital. OP1 denied cash less payment to hospital. OP1 sanctioned only Rs. 27,700/- and denied the balance payment for the unknown reasons. The complainant approached to the Ops for the settlement of claim but no response from OP hence this complaint wherein it was prayed that OPs be directed to pay a sum of Rs. 144643/- along with the interest , compensation for mental pain and agony and cost of litigation.
2. OP2 did not appear despite service of notice to it on 01/07/2015. Hence Ex-parte proceeded against him.
3. In reply OP1 admitted their policies which was renewed upto 16.04.2015 and further admitted that amount of Rs.27,700/- passed by TPA. OP1 denied rest of the allegations made in the complaint. OP1 also objected that present complaint was premature. Complainant did not file original bills required for the settlement of the claim for which requests on 08.01.2015 , 24.01.2015 and again on 19.12.2015 were made but complainant did not supply required documents and approached to this forum.
4. The complainant filed his rejoinder and evidence on 03-11-2015 and supplied 18 documents to the OP1 and opposed the reply. In support of complaint complainant filed his affidavit along with documents Ex. CW1/1 to Ex. CW1/28 in support of the claim but he did not deny the letters dated 8.1.2015 , 24.1.2015 and 09.02.2015 written by OP1 him to prove its claim. Hence such denial is invasive.
5. We have heard the arguments and considered the evidence led by the complainant and OP1 and their written and oral arguments. In this case points to be considered are as under:- (a) Whether complainant is a consumer? (b) Whether there is any deficiency in service on the part of the OP? ( c) Relief?
6. It is admitted by the OP1 that complainant took a mediclaim policy which was valid upto 16.04.2015. Hence complainant is a consumer.
7. Perusal of the complainants affidavit and his claim form Ex. CW1/24 which was prepared on 18.12.2014 shows that date of filing of claim with OP is missing in it. It is pertinent to mention here that in legal notice to the OP Ex. CW1/26 date of filing of the claim form is also missing. Even in Ex. CW1/25 (schedule of expenses) no date of submission of claim is mentioned. Therefore, it is presumed that complainant supplied 18 documents in original relating to policies and prescription slips on 03.11.2015 in the court. Therefore, in these circumstances after receiving the required documents OP shall submit the claim which is reasonable time to submit the claim. On 01.03.2016 complainant filed application that he has received a settlement memo dated 28.01.2016 and amount of Rs. 88,413/- was paid to him against his claim of Rs. 141015/- out of which an amount of Rs. 51,842/- was to be paid by the hospital on account of over and above of GIPSA PPN PKG charges. Therefore, he prayed for compensation for mental agony and cost of litigation. OP in reply to the application filed by the complainant stated that the claim of the complainant already settled on 28.01.2016. The permissible amount within 3 months under the policy was duly paid to him on receipt of the documents , therefore, application filed by the complainant be dismissed. On 30.06.2016 amount of Rs. 51,842/-was refunded by hospital against full and final settlement which was received on behalf of Mrs. Mala Lamba.
8. Therefore, looking to the above facts and circumstances we are of the opinion that there is no deficiency on the part of OP and complaint is not entitled for any compensation for mental agony and litigation charges. Hence, complainant has filed this complaint prior to the repudiation of the claim by the OP. Hence, complaint is dismissed as settled accordingly. File be consigned to record room. Announced on .. [HON'BLE MR. MOHD. ANWAR ALAM] PRESIDENT [HON'BLE MR. VIKRAM KUMAR DABAS] MEMBER [HON'BLE MRS. MRS. MANJU BALA SHARMA] MEMBER