Complainant Ashok Mahajan has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to make payment of reimbursement amount of treatment alongwith interest for which he is legally entitled being insured under the Health Insurance Policy. Opposite parties be further directed to pay Rs.3,000/- as litigation expenses and Rs.3,000/- on account of mental harassment and  torture, in the interest of justice.

2.       The case of the complainant in brief is that he got a Medical Insurance Policy bearing No.401501/48/16/3500000257 which was valid from 26.08.2016 to 25.08.2017 and his risk was covered upto the amount of Rs.9,00,000/- by paying total premium of Rs.15,459/- to opposite party. It has further pleaded that unfortunately he fell ill and was got admitted in Max Super Specialty Hospital Mohali on 10.04.2017 for treatment of Bilateral Hip Joint Replacement. At the time of discharging he paid total bill amounting to Rs.5,48,456/- to the Hospital, but the opposite party no.2 only approved Rs.3,55,000/- but up till today the opposite party has failed to make the payment of reimbursement for remaining amount of treatment to which he is legally entitled as such there is clear cut deficiency in services on the part of opposite party. Hence this complaint.

 3.          Notice of the complaint was issued to the opposite parties. Opposite party no.1 appeared through their counsel and filed their written reply taking the preliminary objections that the complainant has no locus standi to file the present complaint; the complainant has no cause of action to file the present complaint and the present complaint is not maintainable and the complainant not entitled to any of the relief claimed in the complaint. On merit, it was submitted that the complainant took the medical insurance policy under 'SAMPOORNA SURAKSHA BIMA' vide policy No.401501/48/16/3500000257. The complainant lodge the claim for Rs.5,48,456/- under the said policy. The company after considering the claim of the complainant in the light of the terms and conditions of the policy and observed that the claimant is not entitled to the whole amount claimed by him and the deductions in the same were liable to be made which are as under:-

                   i) The amount over & above PPN

                       package as per Patient Room Rent

                       Entitlement                                             Rs.  31,500/-

                   ii) Excess cost of implant                           Rs.1,93,250/-+                                                                                   Rs.       200/-

                   iii) Discount given by the hospital                Rs.  18,256/-

However, the company after considering the deductions as per the terms and conditions of the policy as contained in exclusion clauses of the policy, deducted the amount and paid the claim to the complainant.  The company has settled the claim and paid the amount to the complainant as full and final payment of the claim which was accepted by the complainant as full and final payment of his claim. Now the complainant is not entitled to any further amount as claimed by him in the complaint.

 All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       R.C. of opposite party no.2 has not been received back. Period of 30 days had already been elapsed. Presumption could be drawn that opposite parties had been served but was intentionally evading the service of the notice. Case called several times, but none had appeared on behalf of opposite party no.2. Hence, opposite party was ordered to be proceeded against exparte vide order 24.9.2019.   

5.       Alongwith the complaint, complainant has filed his own affidavit Ex.C-1 alongwith other documents Ex.C-2 to Ex.C-4.

6.      Alongwith the written statement opposite party has filed affidavit of Sh.Janak Raj son of Sh.Inder Ram, Officer Ex.OPW-1/A alongwith documents Ex.OP-1 and Ex.OP-2.

7.      Written arguments have not been filed by the parties. Oral arguments of both the parties heard.

8.    We have carefully gone through the pleadings of counsel for the complainant; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the parties for the purposes of adjudication of the present complaint.

9.     As detailed above present complaint is filed by the complainant against opposite parties for payment of deductions made from the medical claim.

          It is alleged by complainant that medical claim for Rs.5,48,456/- was submitted to opposite parties against his policy No.401501/48/16/3500000257 (Ex.C2), but opposite parties have approved only Rs.3,55,000/- and balance amount has not been paid to him. It is mentioned by complainant that his sum assured was upto Rs.9,00,000/-.

10.     Opposite party no.1 in their written statement stated that certain deductions as per terms and conditions of the policy on account of over and above PPN package for room rent entitlement, excess amount of implant and discount given by hospital are made from the claim amount of complainant. Opposite party has further stated that admissible amount has already been paid to the complainant as per policy. Detailed terms and conditions of policy are placed at Ex.OP-2 by opposite parties.

11.     From the above, we can see that it is the admitted fact by complainant that he has received Rs.3,55,000/- from the claim amount of Rs. 5,48,456/-. Admissibility of claim is detailed in the terms and conditions at Ex.OP-2.

     There does not seems to  be any infirmity in deductions  made by opposite party as it has been  deducted legally and categorically explained in their reply on the basis of terms and conditions of the policy. It is understood that terms and conditions of policy are binding on both the parties.

12.     From the aforesaid discussion by considering the facts and circumstances of the case we find no merit in the complaint. Hence, present complaint is dismissed with no order as to costs. 

13.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

14.    Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.                                                                                                                                                         

            (Naveen Puri)

                                                                            President   

Announced:                                                   (B.S.Matharu)

July 13, 2022                                                       Member

*MK*