09.12.2022

Present: Sh. S. K. Singla, Advocate counsel for complainant.

Sh. P. K. Singla, Advocate counsel for opposite party.

1. Brief Facts : The Complainant has been buying health insurance from the OP annually since 2015 with a policy cycle commencing from 15th of October of every year to the 14th of October of succeeding year. Complainant submitted that due to some illness, he, firstly from 21.01.2020 to 25.01.2020 and then secondly from 09.11.2020 to 14.11.2020, was hospitalized in DMC Ludhiana, wherein he incurred Rs. 35,660/- and Rs. 46,082/- upon his first and second treatment respectively. Complainant submitted that for both of these treatment expenditures, he filed insurance claims to the OP and sought reimbursement but the OP till date has not completely settled the ibid claims and aggrieved with that the complainant has preferred the present complaint praying that OP be directed to pay the insurance claim amount of Rs. 35,692/- i.e. amount pending under both of the ibid claims alongwith interest @18% p.a. and Rs. 20,000/- as compensation and Rs. 25,000/- as Litigation expenses.

2. In reply, interalia to various other objections, the OP mainly has asserted that the 1st claim of the complainant was for Rs. 35,660/- out of which after deducting the TDS & other non payable expenses, Rs. 23,648/- was approved and duly paid on 11.02.2020 vide NEFT/Cheque No. 2119526924 and the 2nd claim of the complainant was for Rs. 46,081/- out of which after deducting the TDS & other non payable expenses, Rs. 30,708/- was approved and duly paid on 09.12.2020 vide NEFT/Cheque No.

12094555320. First and Second claim settlement vouchers are Ex. OP-3 and Ex. OP-4 respectively. So, claiming no deficiency in service the OP has prayed for dismissal of the present complaint.                                      (1)

3. Complainant has tendered into evidence his Self-Declaration and documents Ex.C-1 to C-39 and closed the evidence. OP tendered into evidence the Self-Declaration of Mr. Ashwani Kumar, Senior Divisional Manager and some documents Ex. OP-1 to Ex. OP-6 and closed the evidence. Written Arguments submitted by the parties are also on the record.

4. We have heard the learned counsels of the parties and gone through the oral & documentary evidence placed on record, with their kind assistance.

5. Claim settlement vouchers i.e. Ex. OP-3 and Ex. OP-4 are the clear and undisputed evidence of the fact that the amounts spent by the complainant upon his first and second treatment have been duly reimbursed by the OP as per the policy terms and conditions. There was no cause of action against the OP, therefore the OP is not guilty of any deficiency in service on his part.

6. Resultantly, in view of the above, the present complaint is dismissed and parties are left to bear their own costs.

7. Applications pending, if any, stand disposed of in terms of the aforesaid judgement. 

8. The complaint could not be decided within the statutory limits, due to Covid restrictions, unavailability of quorum and pendency of other cases.

9. Copy of the order be sent to the parties concerned free of cost and file be consigned to the record room. 

Pronounced:

09.12.2022

                                                                                 Sharda Attri, R. L. Mittal,

                                                                                     Member President

 

With utmost respect I am unable to concur with the findings/decision of the case.

 

                                                                                                         Suraj Goyal

(2)                                                                                                           Member