ORDER                                 Dated:  20.01.2017

Manju Bala Sharma, Member

1. Instant complaint has been filed by complainant stating there in that the complainant took a policy namely ‘Reliance Life Care for you plan’ from OP vide application no. U258103 and policy no. 50247584 dated 12.07.2012 for a term of three years with cashless hospitalization up to Rs. 2,00,000/-  all over India.  After purchase of the above policy the complainant fell medically sick and get paralyzed on 02.07.2013 and admitted in ‘Hemant Hospital’ at Mohindergarh road, Narnaul Haryana and after that he contacted 

OP but  OP asked him to change his hospital to ‘Batra Nursing Home and heart Care Centre’ at Sonepat (Haryana) because ‘Hemant Hospital’ is not covered under the said policy.  Complainant was discharged from ‘Batra Nursing Home and Heart Care Centre’ on 10.07.2013 and paid all medical  bills of Rs. 26,700/- beside other expenses.  Complainant had approached OP and submitted all medical bills  and papers but he could not get his medical expenses at that time.  Despite repeated requests of the complainant ,  OP neither  make payment to  ‘Batra Nursing Home and Heart Care Centre, Sonepat (Haryana) nor paid back medical expenses to complainant till date.  Hence there is deficiency in service on the part of OPs due to which he suffered immense pain and mental agony and prayed that OPs be directed to return or refund the whole amount of medical expenses along with upto date interest @ 18% p.a. and to  pay Rs. 50,000/-  as compensation towards mental pain and agony, Rs. 40,000/- towards the  medical  and traveling expenses incurred by him and  Rs. 8500/- as litigation cost. 

2. Notice was issued and OP filed its reply and took preliminary objections that the complainant has no of cause of action regarding lack in services on the  part of OP and the complaint is liable to be dismissed on account of non-joinder  of necessary  and proper party viz. Mr. Nirmal Kumar Jha advisor of M/s Medicare i.e. the insurance  executive/ advisor.  In para wise reply the complainant admitted that the claim of the complainant was registered on 11.09.2013  initially and it was repudiated on 16-09-2013 as in the claim form it was mentioned that the hospital was not registered.  As the hospital was empanelled with Medicare they had taken a clarification from authorised representative and subsequently the claim was re-opened and was finally closed due to  non-receipt of additional documents for which reminders were sent on 19-10-2013,31-10-2013,11-11-2013 and 22-01-2013.
3. In rejoinder the complainant reiterated the facts stated in the complaint and denied  the contentions  made by the OP by way of its written statement.  Affidavit of evidence has been filed by both the parties in support of their respective case.   In support of his complaint complainant has filed  policy (Ex. CW1/1) (colly), copy of driving license (Ex. CW1/2)  , copy of card issued against policy (Ex.CW1/3) , copy of cash memo (Ex. CW1/4) , copy of  diagnosed slip issued by Hemant Hospital  (Ex. CW1/5), copy of report dated 09-07-2013   (Ex. CW1/6),  copy of receipt dated 10.07.2013 (Ex. CW1/7) (colly), copy of cash receipt dated 10-07-2013 (Ex CW1/8), copy of receipt dated 02-07-2013 (Ex CW1/9) , copy of report dated 09-07-2013 (Ex CW1/10) , copy of cash memos(Ex. CW1/11) (Colly),  copy of diagnosed slips issued by Batra Nursing Home (Ex. CW1/12) (colly).
4. Before the arguments learned counsel for the OP stated that the claim of the complainant for a sum of Rs. 25,859/-  has already been paid and a cheque dated 29-03-2016 has already been issued in favour of complainant which  has also been got encashed by him.  Learned  counsel for the complainant states that the  complainant is satisfied with the claim amount passed in his favour but he wants to argue on the point of compensation as well as litigation charges.  
5. Counsel for the complainant has argued that the complainant fell sick on 02.07.2013 and got admitted at ‘Hemant Hospital’ at Mahindergarh road,  Narnaul Haryana and after that  he contacted with  the OP who directed him to change hospital to the Batra Nursing Home and Heart Care Center at Sonepat , Haryana  as ‘Hemant Hospital’ is not covered in the said policy.  The complainant was  discharged from the Batra Nursing Home and Heart Care Center at Sonepat , Haryana on 10-07-2013. Thereafter the complainant approached OP  who assured him that the  company  will pay all the medical and other expenses within 15 days and after 15 days complainant approached OP  but he did not get any satisfactory reply though he submitted all the medical bills and papers and despite repeated  requests complainant did not get  proper response from the OP and was compelled to file the present complaint in this forum.
6. On the contrary to this OP has relied upon  the letters and the reminders sent to the complainant (Ex. OP1/1 to Ex. OP1/5) asking him to submit the documents  as mentioned in those letters but complainant failed to comply with the same. This contention of the OP has been averred  in the written statement which has been denied by the complainant by way of his rejoinder in which he has stated that he has not received any such letter from the official of OP.  Instant complaint has been filed by the complainant on 16-01-2014 whereas complainant fell sick and got admitted in the hospital on 02-07-2013. The complainant has no where stated in his complaint that the claim of the complainant was repudiated or closed though OP has averred in the written statement that the claim of  complainant was closed for non receipt of the additional documents which were asked to be submitted vide letters dated 19.10.2013,31.10.2013,11.11.2013 and 22.11.2013.  This shows that the OP has not intimated the  complainant about the closure of his claim and that as claim of the complainant was not settled by the OP the complainant was constrained to file the present complaint in this forum. 
7. In view of the above facts and circumstances we are of the opinion that there is deficiency in service on the part of OP. We therefore direct that OP is  liable to pay Rs. 3,000/- as compensation and Rs. 2,000/- as cost of litigation to the complainant.
8. This order shall be complied with by the OPs within a period of 30 days from the date of receipt of this order failing which interest @ 10% shall be payable on the entire above mentioned amount from the date of this order till realization.  Copy of this order be sent to all the parties free of cost.   File be consigned to Record Room. 

Announced on this   ………..