Complainant Ravinder Aggarwal 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 Rs.11,550/- alongwith interest for which he is legally entitled being insured under the Health Insurance Policy. Opposite parties be further directed to pay Rs.10,000/- as litigation expenses and Rs.15,000/- on account of mental torture, in the interest of justice.
2. The case of the complainant in brief is that he got a Medical Insurance Policy bearing No.401501/48/13/3500000413 which was valid from 29.12.2013 to 28.12.2014 and his risk was covered upto the amount of Rs.6,00,000/- by paying total premium of Rs.11,358/- to opposite party. It has further pleaded that unfortunately he fell ill and treated by the Doctors and Rs.34,691/- was incurred upon his treatment and all medical bills has been supplied by him to the opposite party but the opposite party paid only Rs.23,142/- which was credited in his account through NEFT dated 14.11.2017 but up till today the opposite party has failed to make the payment of reimbursement remaining amount of Rs.11,550/- 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 cause of action and locus standi to file the present complaint; the complainant has concealed the material facts from this Ld.Commission and as such not entitled for any discretionary relief; the complaint is pre-matured. Actually the claim has been filed by the complainant and the amount has been duly paid worth Rs.23,142/- and after that there is no other liability of the opposite party. Mr.Ravinder Kumar is covered under Sampuran Suraksha Mediclaim Policy with sum assured of Rs.3,00,000/- + Rs.1,15,000/- cumulative bonus since 29.12.2012. Mr.Ravinder Kumar was hospitalized at Dr.Om Parkash Eye Institute Pathankot from 20.03.2017 to 20.3.2017 with diagnosis of Right Eye Cataract for which the procedure Right Eye Phaco with IOL was done. The amount of Rs.34,191/- has been claimed but the amount of Rs.11,050/- has been disallowed. The reason for disallow amount of Rs.11,050/- is due to the fact that Phaco is a widely acceptable procedure for Cataract Surgery and the cost of this procedure in the best hospital is Rs.22,000/- only. Hence under reasonable and necessary customary clause the balance amount is being disallowed. The Policy Condition No.3.11 reasonable and customary expenses means Reasonable and Customary Surgical/medical treatment expenses within the scope of cover of this policy to treat the condition for which the insured person was hospitalized. So, the amount of Rs.23,141/- has been duly paid. On merits, it was submitted that the claim has been filed by the complainant and an amount of Rs.23,142/- has been duly paid and the claim has been paid as per the terms and conditions of the policy. Thus, there is no deficiency in services on the part of the opposite party. 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-7.
6. Alongwith the written statement ld.counsel for the opposite parties filed affidavit of Sh.Kulbhushan Kumar, Authorized Signatory Ex.OP-1/1/A alongwith document Ex.OP-1/2.
7. Written arguments have not been filed by the parties.
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. Present complaint is filed by the complainant against opposite parties for payment of balance unpaid amount deducted by opposite parties from the medical claim under Policy No.401501/48/13/3500000413. It is alleged by complainant that an amount of Rs.11,550/- has been deducted by opposite parties from the claim amount of Rs.34,691/- and denied its reimbursement.
10. Opposite party no.1 in their written reply quoted the reason that deductions are made as per Clause 3.11 of the terms and conditions of the Policy under reasonable and customary expenses.
It is further stated by opposite party that it is case of eye surgery of right eye cataract of the complainant and its charges are approximately Rs.22,000/- in the best hospitals for such type of treatment. Opposite party also submitted the details of deductions at Ex.OP1/2 which is shown as deductions from cost of medicines and consumables whereas other charges are fully reimbursed.
11. In view of the aforesaid facts and details of the case, we are of the considered view that opposite party has already reasonably reimbursed the claim of the complainant as per terms and conditions of the policy which is binding on both the parties. We find no merit in the complaint of the complainant. Hence present complaint is hereby dismissed with no order as to costs.
12. 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.
13. 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 20, 2022 Member
*MK*
