Order dictated by:

(Sh.Anoop Sharma, Presiding Member)

          The complainant has filed the present complaint under section 12 of the Consumer Protection Act on the allegations that he obtained Royal Mediclaim Policy bearing No.233300/48/2015/4760 from the Opposite Party and paid all the premiums to Opposite Party. The wife of the complainant Smt.Paramjit Kaur fell sick and she remained admitted in Dukhniwaran Multi Specialty Hospital, Amritsar as well as Nayyar Hospital and the claim was lodged with Opposite Party which was received by the Opposite Party. The complainant paid Rs.60,000/- to said hospitals vide different bills and copies of the same are enclosed herewith. The complainant provided all the requisite  documents as demanded by the Opposite Party, but till date, the Opposite Party has not paid the claim amount. The complainant has been approaching t he Opposite Party and requested to reimburse the claim amount to her, but the Opposite Party did not listen her request and even no intimation has been given to her regarding her claim case. The complainant also served legal notice through his counsel upon the Opposite Party dated 28.12.2015, but to no affect. Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Party may be directed to reimburse the medical claim amount of Rs.60,000/- to the complainant immediately.

b)      A compensation of Rs.20000/- on account of  mental pain,  agony and harassment suffered by the complainant may also be granted.

c)       Costs of the proceedings of Rs.11000/- may also be granted in favour of the complainant. 

Hence, this complaint.

2.       Upon notice, Opposite Party appeared and contested the complaint by filing  written statement taking preliminary objections therein inter alia that the complaint is pre-mature one because the claim of the complainant has not been settled due  to non cooperation of the complainant and not submitting the requisite documents required for the settlement of the claim as such, the present complaint is liable to be dismissed. The present complaint is not maintainable because after receiving the information regarding the hospitalization of the wife of the complainant, the Opposite Party has immediately informed its TPA to look out the matter and the TPA of the Opposite Party has made contact with the concerned hospital where the wife of the complainant was admitted and requested them to submit all the required documents before the discharge of the patient, but  inspite of request of the Opposite Party to the hospital, the said hospital not provided any document even otherwise the TPA of the Opposite Party has written number of letters to the complainant to submit all those documents which are necessary for the settlement of the claim, but inspite of submitting these documents, the complainant has made a concocted story that he has submitted aall the documents with the Opposite Party. The complainant is not cooperating with the Opposite Party and its TPA for  the settlement of the said claim just to harass the Opposite Party and not submitting the required documents and the said complaint is liable to be dismissed on this score only. On merits, the Opposite Party took almost same and similar pleas as taken by them in the preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

3.       In his bid  to prove the case, complainant tendered into evidence  affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2   to Ex.C13  and closed his evidence.

4.       On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.Gurdip Singh, Senior Divisonal Manager Ex.R1 alongwith copies of documents  Ex.R2 to Ex.R8 and closed the evidence on behalf of the Opposite Party.

5.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.

6.                Ld.counsel for the OP-Insurance Company has submitted that the present complaint is not maintainable as documentations required in the claiam case as alleged by the complainant  has not  been supplied/ submitted with the OP-Insurance Company and without those documents/ information, the OP-Insurance Company is unable to process/ settle the claim of the complainant.  On the other hand, ld.counsel for the complainant has repelled the aforesaid contentions of the ld.counsel for the OP-Insurance Company on the ground that the requisite documents/ information have already been submitted to the OP-Insurance Company and the copies of the same are also placed on the record.  Ld.counsel for the Opposite Party has further argued that due to non submitting of the required papers/ documents, the Opposite Party could not settle the claim case of the complainant regarding the hospitalization of his wife. So, we are of the view that although, as alleged by the complainant that he has already submitted the required documents with the Opposite Party, but to settle the claim case of the complainant, it is no hitch to the complainant, if the required  documents are again submitted with the Opposite Party.

7.       In such circumstances, we direct the OP-Insurance Company to process and settle the claim of the complainant either way, positively within 30 days from the date of receipt of required documents from the complainant. The complaint is disposed of accordingly. However, the complainant is at liberty to file the fresh complaint after the final settlement of his claim, if he still not satisfy with the decision of the OP-Insurance Company.  No order as to costs. Copies of this order be supplied to the parties free of cost and the file be consigned to record room after compliance.   Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

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rum.

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