(Passed on 08/02/2024 )

Per Smt. Vaishali R. Gawande, Hon’ble President.

1. That the complainant had filed the present complaint under Section 35 and 38 of Consumer Protection Act, 2019 claiming compensation under the medical policy issued by the OP.
2. The brief facts of the case are as under.
3. That the complainant is the resident of address mentioned in the title cause  of the complaint and OP is the specialized health insurance company issuing health insurance policy to their customers.
4. The complainant got the information that the OP is an organization which are good in claim settlement and therefore the complainant from the web site of the OP had obtained health insurance policy namely “Family Health Optima Insurance Plan” and insured his entire family for the sum assured of Rs. 5,00,000/- and paid premium  of Rs. 11,505/-. The complainant had renewed the said policy for the period  of 26/09/2021 to 25/09/2022 and paid the premium of Rs. 12,620/- Insuring himself, his wife Rashmi and daughter Anvi vide policy bearing No. P/161111/01/2021/016567. It is further submitted by the complainant that along with policy, the complainant had not received any terms and conditions as well as exclusion under the policy and therefore the terms and conditions as well as exclusion are not binding on the complainant. During the subsistence of the policy on 10/06/2022, when  the complainant was riding his motorcycle and coming to Chandrapur from Ghugus  for getting the products of his medical business at about 5.00 pm near Datala, wild pig came in front of his vehicle and the complainant met with an accident and sustained severe injuries on his left leg.
5. That, there was no third party involvement in the accident, therefore the complainant had not filed any police report and had been to Dr. Dipak Nale’s Orthopedic clinic which is around 3 km from the spot of accident and taken initial treatment. Even after taking initial treatments, there was no improvement in the condition of complainant’s leg and therefore on 16/6/2022, he approached Dr. Sandip Wagh, Nagpur  at his hospital namely Suyog Hospital. Dr. Wagh diagnosed the complainant and asked him to immediately operate on his leg, otherwise consequences will be  very dangerous. The complainant was admitted in Suyog Hospital, Nagpur as per the advice of Dr. Wagh from 16/06/2022 to 17/06/2022 and surgery was performed on his left leg. The complainant incurred the hospital charges of Rs. 31,500/- and other medicine expenses total amounting to Rs. 65,091/-.
6. The complainant on the initial web site of OP filed his claim on email id. – claims.intimation@starhealth.biz . The complainant received response to the claim on his email that “ Expenses incurred towards treatment in any of the excluded providers” It is further submitted by the complainant that without verifying the doctors practice and documents submitted by the complainant denying the complainant’s legible claim is nothing but deficiency in service on the part of OP.
7. The complainant on 19/08/2022, filed the insurance claim in the prescribed form of OP with all the required documents for an amount of Rs. 65,091/- and sent the same by registered post on 22/06/2022. The OP repudiated the claim of complainant vide their e-mail dated 2/9/2022. The complainant with no other alternative left, sent legal notice to OP through his counsel on 14/11/2022 and filed the present claim seeking compensation as per prayer clause of the complaint.
8. The Commission was pleased to issue notice to the OP even after the service of notice, the OP failed to appear before this Commission and therefore the matter had been proceeded exparte against the OP on 12/06/2023
9. The complainant filed their rejoinder and fairly admitted that the OP had paid an amount of Rs. 57,586/- in complainant’s account on 6/1/2023 without informing to the complainant. The complainant further submitted that as the OP had paid amount of Rs. 57,586/-, therefore the claim of complainant remains for Rs. 7,508/- out of total claim of Rs. 65,091/-

REASONING

10.  As there is no rebuttal on the part of OP and the complainant fairly admits the receipt of part of claim amount, the remaining amount which the complainant is claiming cannot be granted as those were regular deductions like policy cess and other restrictions on room rent and particular surgery restrictions.
11. Heard, Mr. Nandkishor Potdukhe at length and going through the record, the Commission pass following order.

ORDER

1. The complaint is dismissed.
2. The complainant had already received the claim amount of Rs. 57,586/- and therefore there is no merit remains in the claim of complainant.
3. No order as to cost.
4. Copy of order be furnished to both parties, free of cost.