Order by:

Smt.Priti Malhotra, President

1.           The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant purchased one policy namely Arogya Plus Policy bearing policy no.000000001367511-03 from Opposite Party on 10.07.2019. Thereafter the said policy was renewed for the period from 10.07.2022 to 09.07.2023 for sum assured of Rs.3,00,000/- and entire family of the complainant was covered under the said policy. During the policy period, on 04.09.2022 complainant got admitted at Rajiv Hospital, Ferozepur Road, Moga for total Hip Replacement of Left Hip Joint and his surgery took place on 05.09.2022 and thereafter he discharged from Rajiv Hospital on 10.09.2022. The complainant spent Rs.2,12,552/- approximately on his treatment for Hip replacement and thereafter lodged the claim with Opposite Party and submitted all the relevant record with them, but they did not pay any amount to complainant. Thereafter, complainant made number of visits to Opposite Party, but to no effect. The Opposite Party has harassed the complainant unnecessarily and refused to provide any medical claim under the policy. The complainant also served a legal notice dated 01.11.2022 to Opposite Party, but all in vain. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite party may be directed to make the payment of Rs.2,12,552/- approximately alongwith interest.

b)      To pay an amount of R.1,00,000/- as compensation on account of mental tension, harassment and agony.

c)       And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is premature as the complainant has not lodged any claim with the Opposite Party nor any documentary proof regarding lodging of any claim has been placed on file, as such the present complaint is liable to be dismissed. The intricate questions of law and facts are involved in the present complaint, which require voluminous documents and evidence for determination which is not possible in the summary procedure under Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has concealed the material facts and documents from this Commission as well as from the Opposite Party, thereof the complainant is not entitled to any relief. The complainant has not lodged any claim with the Opposite Party regarding the alleged claim. The Opposite Party reserves its right to decide the claim as per terms and conditions of the policy as and when the complainant lodges the claim with them alongwith documents. The complainant is not the consumer of Opposite Party. The complainant has no locus standi or cause of action to file the present complaint against Opposite Party. The complaint is not maintainable in the present form. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7 and copies of other documents Ex.C4A to Ex.C4K.

4.       To rebut the evidence of the complainant, Opposite party tendered in evidence affidavit of Sh.Nishant Gera, Assistant Manager Legal and Authorized Signatory, SBI General Insurance Co. Ltd. Ex.OP1/1 along with copy of policy-cum-terms and conditions Ex.OP1/2.

5.       We have heard the counsel for the complainant and gone through the documents placed on record.

6.       Perusal of the record shows that complainant has not produced on record any document, which shows that he ever lodged any claim with Opposite Party for the expenses incurred by him on his treatment. Even in the written reply, the objection raised by the Opposite Party is that complaint is pre-mature, as till date the complainant has not lodged any claim with them and there is no repudiation letter on record. However, the complainant has served a legal notice to Opposite Party, for which, the Opposite Party has not given any reply nor informed the complainant regarding lodging of the claim.

7.       In view of the above, we are of the concerted view that as the complaint is premature, so it stands disposed of with a direction to complainant to lodge his claim alongwith necessary documents with Opposite Party and Opposite Party is directed to decide the claim of the complainant next within 30 days after lodging of the claim alongwith relevant documents by the complainant. However, complainant is at liberty to file a fresh complaint, if he is not satisfied with decision of the Opposite Party regarding settling of the claim. Keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.

Announced on Open Commission