Sh.Anoop Sharma, Presiding Member

1.       Sh.Navneet Kumar Gupta has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, on the allegations that the complainant got Health Benefit mediclaim insurance for himself, his wife and two children from Opposite Party by virtue of the Punjab Government employee and pensioner Health Insurance Scheme for Punjab government employees covering the risk period 1.1.2016 to 31.12.2016. The wife of the complainant Dr.Sonia Gupta unfortunately fell ill and was to be hospitalized at Sir Ganga Ram Hospital, New Delhi on 30.3.2016 till 31.3.2016 and the treatment cost of the said hospitalization came to Rs.1,26,353/-. The Opposite Party was immediately informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashless basis and is worth mentioning over here that the sum insured for the medical benefit is for Rs.5 lacs. The Opposite Party instead of making the payment of the said amount of Rs.1,26,353/- made the payment of Rs.21,036/- only to the complainant and the rest of the payment of Rs.1,05,317/- has not been made till the filing of the present complaint. The complainant is making futile calls and visits to the Opposite Party till the filing of the present complaint to settle the genuine claim of the complainant completely, but the Opposite Party has not completely settled the genuine claim of the complainant. It is worth mentioning over  here that even the policy terms and conditions were never supplied to the complainant. The aforesaid acts of the Opposite Party in not completely settling the genuine claim of the complainant is an act of the deficiency in service, mal practices, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant for which the Opposite Party is liable to pay compensation of Rs.50,000/- to the complainant. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Party  may be directed to pay Rs.1,05,317/- alongwith interest @ 12% per annum from 31.3.2016 till realisation.

b)      Compensation to the tune of Rs.50,000/- may also be awarded to the complainant.

c)       Opposite Party be directed to pay the adequate cost of the litigation.

d)      Any other consequential relief to which the complainant is entitled to under the law, equity, justice and fairplay be also awarded.   

Hence, this complaint.

2.       Upon notice, none appeared on behalf of Opposite Party despite due service, hence Opposite Party was  ordered to be proceeded against exparte vide order of this Forum.

3.       In his bid  to prove the case, complainant tendered  his duly sworn affidavit Ex.C1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C4 and closed the exparte evidence.

4.       We have heard the ld.counsel for the complainant and have carefully gone through the evidence on record.

5.       From the perusal of the evidence on record, it becomes evident that the complainant got Health Benefit mediclaim insurance for himself, his wife and two children from Opposite Party by virtue of the Punjab Government employee and pensioner Health Insurance Scheme for Punjab government employees covering the risk period 1.1.2016 to 31.12.2016. The wife of the complainant Dr.Sonia Gupta unfortunately fell ill and was to be hospitalized at Sir Ganga Ram Hospital, New Delhi on 30.3.2016 till 31.3.2016 and the treatment cost of the said hospitalization came to Rs.1,26,353/-. The Opposite Party was immediately informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashless basis and is worth mentioning over here that the sum insured for the medical benefit is for Rs.5 lacs. The Opposite Party instead of making the payment of the said amount of Rs.1,26,353/- made the payment of Rs.21,036/- only to the complainant and the rest of the payment of Rs.1,05,317/- has not been made till the filing of the present complaint. The complainant is making futile calls and visits to the Opposite Party till the filing of the present complaint to settle the genuine claim of the complainant completely, but the Opposite Party has not completely settled the genuine claim of the complainant. It is worth mentioning over  here that even the policy terms and conditions were never supplied to the complainant. The aforesaid acts of the Opposite Party in not completely settling the genuine claim of the complainant is an act of the deficiency in service, mal practices, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant for which the Opposite Party is liable to pay compensation of Rs.50,000/- to the complainant. The evidence produced by the complainant has gone unrebutted on record as  the Opposite Party,  despite due service, did not opt to appear and contest the proceedings. In this way, the Opposite Party has impliedly admitted the correctness of the allegations made in the complaint. It also shows that Opposite Party has no defence to offer or defend the complaint. The complainant has sought for refund of amount of Rs.1,05,317/- alongwith interest besides compensation to the tune of Rs.50,000/-.

6.       Consequently, the instant complaint succeeds  and Opposite Party is directed to settle the claim of the complainant within one month from the date of receipt of copy of this order. Opposite Party is also directed to pay Rs.2,000/- on account of compensation for causing mental tension and harassment, besides Rs.2,000/- as costs of litigation. The complaint stands allowed exparte accordingly. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Forum