Haryana

Yamunanagar

CC/167/2024

Sushil Verma S/o Atma Ram Verma - Complainant(s)

Versus

Care Health Insurance Ltd. - Opp.Party(s)

Samsher Singh

07 May 2024

ORDER

CC No.167 of 2024.

Sushil Verma        Vs.     Care Health Insurance Ltd.

 

Present:       Sh. Samsher Singh, Adv. for the complainant.

                    

                  Complaint presented before the registry of this Commission on 02.05.2024 and put up before this Commission on today itself.  It is hereby ordered to be registered against the registration number already allotted by the registry of this Commission.                

                   Complainant attached documents Ex.C1 to Ex.C14 with the complaint.

                 Heard.  The opponent issued medi-claim policy Ex.C8 in favour of the complainant covering his risk as well as his two sons and his spouse and the policy Ex.C8 is valid for the period 28^th February, 2024 to 27^th February, 2025 and sum assured is Rs.10,00,000/-. As per the version of the complainant, during the validity period of insurance policy Ex.C8, he was hospitalized in Satyam Super Specialty Hospital, Near Kanhaiya Chowk, Yamuna Nagar, w.e.f. 11.03.2024 to 13.03.2024 and diagnosed for SARS-Cov-2 and referred to Paras Hospital, Panchkula, where he remained admitted w.e.f. 13.03.2024 to 17.03.2024 and incurred an expenditure of Rs.1,80,000/- on his treatment and he submitted the medical bills with the opponent for reimbursement under the policy Ex.C8, but the opponent repudiated the same. The complainant has not attached repudiation letter with the complaint and during the course of arguments, Ld. Counsel for the complainant conceded, the claim of the complainant was verbally declined by the opponent. The claim of the complainant has not been accepted or repudiated in writing. However, in order to maintain the balance, and to avoid any sort of prejudice to the parties, if appropriate directions are given to the parties, it will suffice the purpose. At this stage, no notice is required to the opponent affording an opportunity, of being heard, because no adverse order, at this stage, is likely to be passed against the opponent.

                 The complaint of the complainant is rejected, at this stage, it being pre-mature, leaving to bear his own costs of litigation and he is directed to submit his medical bills including fulfillment of claim form, if already not submitted, with the opponents, within the period of 10 days from today, against proper receipt. Thereafter, the opponent insurance company will decide the claim case of the complainant, in either way as per its own wisdom, within the period of one month from the date of receipt of documents from the complainant, if already not submitted, if already received document, then, the opponent will decide the claim case of the complainant, within the period of one month from the date of certified copy of this order, or whatever is earlier. Thereafter, in case, the claim case of the complainant is not settled by the opponent within stipulated period as ordered hereinbefore or repudiated and the complainant is not satisfied with the decision of the opponent, then the complainant will be at liberty to file afresh complaint against the opponent before this Commission and in the fresh complaint, the complainant will disclose the particulars of this case and its fate and will attach certified copy of this order.

                 Certified copy of this order be supplied to the complainant, free of costs and he will deliver the same upon the opponent either by hand or through registered post, at his own responsibility.   File be consigned to the records.

 

                                                                                                                        President

                                L. Member                     Member                                   DCDRC, YNR,

07.05.2024.

           

Typed by: Jitender Sharma, Steno-typist