Final Order / Judgement

 Passed by Shri Atul D. Alsi, Hon’ble President.

1. The complainant has filed complaint case against non disbursement of part insurance claim of Rs.11,700/- for Cataract eye surgery and thereby claiming compensation of Rs.31,700/- along with cost of litigation.

2. The complainant insured himself alongwith his family with O.P. for the period from 26.2.2019 to 25.2.2020 bearing policy No.16030934182800000193 name as New India Floater Policy. The complainant has undergone cataract surgery on 27.12.2019. The O.P. has paid part of insurance claim of Rs.20,000/- against the claim of Rs.31,700/- as 10% for the sum assured of Rs.2,00,000/- under the policy. The O.P. has not supplied the terms and conditions of the policy at the time of issuance of policy certificate.  The non disbursement of balance of Rs.11,700/- towards medical expenses for cataract operation does amount to deficiency of service therefore the present complaint has been filed.
3. The O.P. filed reply and denied allegation and submitted that the complainant has not narrated any allegations for the deficiency in-service and Unfair Trade Practice of O.P. in the complaint. The O.P. has paid medical expenses against the full and final settlement of insurance claim of complainant under the policy bearing no. 16030934182800000193 for the cataract operation as per terms and condition of policy which is 10% of the sum assured of Rs.2,00,000/- is to be payable for cataract operation of one eye or Rs.50,000/- whichever is less. Therefore the demand of balance amount of Rs.11,700/- towards expenses for cataract operation of complainant eye is denied by O.P. which is not Unfair Trade Practice. Therefore complaint is liable to be dismissed with cost.

REASONING

4.  The O.P. has paid Rs.20,000/- towards cataract eye surgery of complainant insurance claim as 10% of sum assured or Rs.50,000/- whichever is less as per terms and conditions of policy clause 5-F and denial of claim of Rs.11,700/- for balance amount of cataract surgery is not Unfair Trade Practices on the part of O.P.  The terms and conditions which has not been supplied by the O.P. as claimed by the complainant at the time of disbursement of claim is not acceptable and therefore the denial of balance amount of claim of Rs.11,700 by O.P. as per terms and conditions of policy does not amount to Unfair Trade Practice and there is no deficiency on the part of O.P.Therefore complaint is liable to be dismissed.Therefore compliant is dismissed as per following order.

ORDER

1. Complaint is dismissed.
2. No order as to costs.
3. Copy of order be furnished to both the parties, free of cost.