The case of the complainant is that he is a retired teacher having various ailments including prostate cancer took mediclaim policy from opposite party no.1 since 2006 and renewed it every year without any interruptions. During the period of mediclaim policy from 29.05.2020 midnight to 29.05.2021 midnight. The complainant under advised of his Doctor admitted in North City Hospital on 10.08.2020 and discharged there from on 12.08.2020. He prayed for cashless treatment which was refused by the opposite parties. After discharge from North City Hospital, on 08.09.2020 he submitted a claim for Rs.64,910/- (Rupees sixty four thousand nine hundred ten) only for the amount he spent for his treatment. All bills, invoice and other necessary documents in original were submitted by the complainant along with his claim application with the opposite party no.1.
According to the complainant, on 12.10.2020, the opposite parties approved Rs.23,000/- (Rupees twenty three thousand) only and paid the same through online to the complainant on the same date in respect of the claim submitted on 09.09.2020 for the treatment in ‘Day Care Centre’ in Apollo Hospital. Thereafter, the complainant wrote two successive letters dated 06.06.2022 and 05.07.2022 to opposite party no.2 referring to the mistake committed by the opposite parties in settlement of his claim but to no effect. Hence this case.
Notices have been served upon opposite parties but the opposite parties deliberately not appeared in the case to contest the same. So, the case was heard ex-parte against both opposite parties.
The complainant submitted affidavit in chief along with photo copies of documents.
The photo copy of mediclaim policy for the period of 29.05.2020 to 29.05.2021 midnight is marked document - 1; the photo copy of discharge summery of the complainant issued by North City Hospital & Neuro Institute Pvt. Ltd. is marked document - 2; the photo copy of denial letter for cashless treatment issued by Heritage Health Insurance TPA Pvt. Ltd. is marked document - 3; the photo copy of the letter dated 06.06.2022 is marked document - 4 and photo copy of the letter dated 07.06.2022 is marked document - 4/1.
The complainant on affidavit stated that he has been suffering from various ailments and prostate cancer. He had mediclaim policy for the period on and from 29.05.2020 to 29.05.2021(document - 1). During the validity of period of said medicalim policy, he was admitted at North City Hospital & Neuro Institute Pvt. Ltd. on 10.08.2020 under the advice of his Doctor and discharged there from on 12.08.2020 (document - 2). He spent Rs.64,910/- (Rupees sixty four thousand nine hundred ten) only for his treatment. Thereafter, on 08.09.2020 he submitted all papers of hospital including treatment papers, bills, invoice etc. along with his claim form with the opposite parties. Till date the said claim has not been settled by the opposite parties. On the other hand on 12.10.2020 the opposite parties approved and paid Rs.23,000/- (Rupees twenty three thousand) only through online to the complainant regarding a claim submitted on 09.09.2020 of Apollo Hospital which has no connections with the claim of this case. Document -3 reveals that cashless facilities was refused to the complainant. Document - 4 and document - 4/1 reveal that the complainant has sent letters to opposite party no.2 on 06.06.2022 and 07.06.2022 stating the above referred fact and claimed Rs.41,919/- (Rupees forty one thousand nine hundred nineteen) only out of his total claim of Rs.64,910/- (Rupees sixty four thousand nine hundred ten) only as he already received Rs.23,000/- (Rupees twenty three thousand) only in his Bank account from the opposite parties.
In spite of service of the aforementioned letters, the opposite parties did not pay any heed to it. The complainant submits that being a cancer patient he has been subjected to harassment by the opposite parties which is clearly deficiency in service. Hence this case.
The complainant has proved his case by his un-rebutted and unchallenged testimony.
Therefore, the case of the complainant succeeds.
Hence, it is
O R D E R E D
That the complaint case be and the same is allowed ex-parte against the opposite parties with cost.
The opposite party no.1 shall pay a sum of Rs. 41,910/- (Rupees forty one thousand nine hundred and ten) only to the complainant within thirty days from the date hereof failing which shall be liable to pay 9% simple interest from the date of filing of the case till the date of actual payment.
The opposite party no.1 shall pay a sum of Rs.20,000/- (Rupees twenty thousand) only as compensation to the complainant within one month from the date hereof failing which shall be liable to pay 9% simple interest on the compensation amount till the date of actual payment.
The opposite party no.1 shall pay a sum of Rs.20,000/- (Rupees twenty thousand) only as litigation cost within one month from the date hereof failing which shall be liable to pay 9% simple interest till the date of actual payment.
