A-31/2017

19-2-2024

O R D E R

BY SRI RAVI SHANKAR, JUDICIAL MEMBER

Heard from appellant/OP. Notes of arguments also filed by the respondent/complainant.

2. The crux of the case is that, the respondent clamed for medical reimbursement by virtue of the policy and tendered a claim of Rs.43,962/-. After scrutiny, this appellant suggested to pay an amount of Rs.37,992/-, but the complainant not accepted the said amount, instead of that approached the District Commission alleging deficiency in service.

3. The District Commission after trial allowed the complaint and directed this appellant to pay the amount claimed in the claim form to the tune of RS.43,962.19. In fact the complainant is not entitled to get any such amount, they have offered to pay an amount of Rs.37,992/- which is an eligible amount, some medicines are not reimbursable, hence after scrutiny only they have suggested to pay the said amount, but the complainant without any reason approached the District Commission, even the District Commission also without any valid reasons directed this appellant to pay the entire amount paid towards medical treatment. Hence, prays to set aside the order passed by the District Consumer Commission.

4. On perusal of the certified copy of the order, we noticed this appellant offered to pay Rs.37,992/- after scrutiny. It is an admitted fact, the entire medical bills are not payable, the said medical bills are subjected to eligibility as per the terms and conditions of the policy. We do not find any deficiency in service on the part of this appellant in offering to pay an amount of Rs.37,992/-. Though there is no any deficiency in service on the part of this appellant. The District Commission directed to pay the entire medical expense which according to us is not in accordance with law.  The order passed by the District Commission requires to be set aside. The complaint is entitled to get an amount of Rs.37,992/- round off to Rs.38,000/- towards the claim along with 6% interest per annum on the said amount from the date of disposal of the complaint. Accordingly, the order passed by the District Commission is hereby set aside and a direction is given to the appellant to pay Rs.38,000/- to the complainant towards the medical claim along with 6% interest per annum within 30 days from the date of this order. Accordingly, the appeal is disposed off. Hence, we proceed to pass the following:-

O R D E R

The appeal is hereby disposed off.     

          The Opposite Party/appellant is directed to pay an amount of Rs.38,000/- to the complainant towards the medical claim along with 6% interest per annum on the said amount from the date disposal of the complaint till the date of realization.

Further the Opposite Party/appellant is further directed to comply the above order within 30 days from the date of receipt of this order. 

The amount in deposit shall be transmitted to the concerned District Consumer Commission to pay the same to the complainant.

Send a copy of this order to both parties as well as Concerned District Commission.

Member                                             Judicial Member