Presented by Sri B.K. Pati, Member:-<br /> The present complaint pertains to deficiency of service as provided under the Consumer Protection Act-1986 and its brief history is as follows:- <br /> <br /> The Complainant, holder of Medi-claim Policy No. 2007 /400 Dt. 26/07/2006 under the Opposite Party company, under went medical treatment for his eye trouble on Dt. 14/06/2007 at L.V. Prasad Eye Institute, Bhubaneswar, by incurring an expenditure of Rs. 8,000/-(Rupees eight thousand)only for the purpose. He filed the claim in the prescribed form along with related documents on Dt. 20/07/2007 and as the Opposite Party did not take steps to reimburse the medi-claim, the Complainant sent a reminder on Dt. 27/08/2007 followed by a Pleader's Notice Dt. 04/09/2007 calling upon the Opposite Party to reimburse the claim and pay a compensation of Rs. 50,000/-(Rupees fifty thousand)only for the harassment and mental tension suffered by the Complainant for the negligence of the Opposite Party, which amounts to deficiency of service.<br /> <br /> The Complainant claims from the Opposite Party Rs. 58,000/-(Rupees fifty eight thousand)only, that includes the medi-claim of Rs. 8,000/-(Rupees eight thousand)only.<br /> <br /> The Opposite Party, in his version, admits the medi-claim policy taken by the Complainant and contends that he came to know about the Eye treatment under-gone by the Complainant from the latter's letter Dt. 16/07/2007 and drew the attention of the Complainant that as per the terms and condition of the policy, notice of the claim should have been given to the company furnishing necessary details within 48(forty eight) hours of admission or before discharge from the Nursing home/Hospital. Though the Complainant had failed to comply with that provision of the policy, the Opposite Party supplied him with the claim form and filled-up form along with original documents was received by the Opposite Party on Dt. 23/07/2007. When the matter was under the process of investigation and was under active consideration, this Opposite Party received the notice of the present case on Dt. 24/03/2008. As such, the Opposite Party was unable to proceed with the settlement of the claim any further as the matter became sub judice in the court of law. The Complainant has filed this case before settlement of the claim and the same being premature, is not maintainable. The Complainant has also not complied with the formalities of the terms and condition of the policy, thereby not performing his part of the contract and thus he is not entitled to any indemnity for a claim under this policy. The claimant should be hospitalized for a minimum period of 24 (twenty four) hours where as the Complainant was hospitalized for one hour only. In case of claim/query the insured should contact M/s Heritage Health Pvt. Ltd , Bhubameswar, which the Complainant has not done. The Complainant having violated the term and condition of the policy is not entitled to the claim and the complaint is liable to be dismissed with cost.<br /> <br /> Perused the complaint, the version of the Opposite Party and the copies of documents filed and find as follows:-<br /> The Policy in question is admitted. The medical treatment of the eye of the Complainant is not disputed, rather corroborated and confirmed by both the copies of the documents and the report of the investigation conducted by the Opposite Party, accompanied by the expert opinion of an Eye Specialist . The only objection raised by the Opposite Party is that the Complainant has not observed certain formalities like informing the Opposite Party before discharge from the Hospital or that he is required be hospitalized for a minimum period of twenty four-hours and that the Complainant did not contact M/s Heritage Health Pvt. Ltd., Bhubaneswar as per the term and condition of the policy. In a case where the Policy is in force and the fact of having under gone treatment is established and admitted, the non observance of such formalities sans substance cannot stand in the way of the insured getting his legitimate due of being reimbursed the expenses incurred in the treatment. Otherwise, refusal of payment of the claim on such trivial grounds would strike at the very root of the principle of natural justice and equity as well as negate and frustrate the very purpose of such mediclaim policy, which, precisely, is to afford financial succour to the insured at such a juncture. Naturally, repudiation of claim on mere technicality would amount to deficiency of service. <br /> <br /> It is found that, the Policy is yet to be settled and the complaint has been filed in this Forum. Hence the Opposite Party is directed settle up the claim and make the payment of Rs. 8,000/-(Rupees eight thousand)only, the claim amount, along with a cost of Rs. 2,000/-(Rupees two thousand)only within thirty days hence, failing which both the amounts shall carry 12%(twelve percent) interest per annum till payment.<br /> <br /> Complaint allowed accordingly. <br />