Sh.Anoop Sharma, Presiding Member.

1.       Sh.Sushen Kakkar  has brought the instant complaint under the Consumer Protection Act, on the allegations that  complainant and his family got medically insured their life with Opposite Party No.1 through Opposite Party No.2 under Silver Plan having policy name Happy Family Floater-2015 Policy Schedule vide policy bearing No. 235301/48/2017/1710 dated 12.10.2016 and paid the premium as mentioned in the policy cover note. Opposite Party No.3 is paneled hospital of Opposite Party No.1 and as such, the complainant is a consumer of the Opposite Parties under the Act. Unfortunately, the complainant suffered jaundice i.e. Acute Viral Hepatitis etc. and after getting requisite approval from Opposite Party No.2, the complainant took treatment from Opposite Party No.3 where he spent Rs.47,434/-. As per the policy plan, the Opposite Party No.3 had to receive the said amount directly from 2, but at the time of discharge, the complainant was pressurized to make the payment of the bill as Opposite Parties No.1 and 2 did not pass the claim of the complainant vide letter dated 15.11.2016 regarding denial of the cashless facility on the reason that the claim within 30 days  from policy inception date can not be claimed, but there is no mentioning of such clause in the policy document issued t o the complainant. The aforesaid act of Opposite Parties  clearly amounts to committing gross negligence and utter deficiency in providing services.             Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Parties No.1 and 2  may be directed to refund the amount covered under the bill regarding treatment of complainant covered under said policy alongwith interest.

b)      To direct Opposite Parties No.1 and 2  to pay Rs.1 lac towards compensation for causing mental harassment, agony etc to the complainant.

c)       To direct Opposite Party to pay a sum of Rs.11000/- towards litigation expenses.

Hence, this complaint.

2.       Upon notice, opposite parties No.1  appeared, but however, none appeared on behalf of Opposite Party No.2 and 3, hence Opposite Parties  No.2 and 3 were  proceeded against exparte.

3.       Opposite Party No.1 contested the complaint by filing  written statement taking preliminary objections therein inter alia that the present complaint is not maintainable under the law being pre mature complaint; that the complainant is estopped by his own act and conduct from filing the present complaint. On merits it is submitted that due intimation has been given by complainant to Opposite Party No.2 with regard to his hospitalisation and thereafter treatment taken by the complainant. However, Opposite Party No.2 has denied the cashless facility to the patient concerned keeping in view the terms and conditions of the policy in question. Moreover, no reimbursement claim has been lodged by the complainant uptil now which clearly manifests  that present complaint is a pre mature complaint.   Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

4.       No evidence on behalf of the complainant is produced. But however, at this stage, ld.counsel for Opposite Party No.1 has made statement that the Opposite Party is ready to decide the claim case of the complainant as per the terms and conditions of the policy in question if the complainant lodged reimbursement claim with regard to medical treatment taken by the complainant alongwith relevant medical record to be submitted for the processing of the claim of the complainant within 15 days from the date of receipt of copy of order and the Opposite Party shall decide the claim case of the complainant within a period of 2 months from the date when the complainant supplies the relevant documents alongwith reimbursement of the claim form to the Opposite Party.

5.       On the other hand, ld.counsel for the complainant also made statement that the complainant accepts the offer  made by Opposite Party and the case may be disposed of accordingly.

6.       In view of the aforesaid statement made by both the parties separately before this Forum, the complaint is disposed of accordingly and the complainant is directed to lodge the  reimbursement claim with regard to medical treatment taken by the complainant alongwith relevant medical record to be submitted for the processing of the claim of the complainant within 15 days from the date of receipt of copy of order and the Opposite Party shall decide the claim case of the complainant within a period of 2 months from the date when the complainant supplies the relevant documents alongwith reimbursement of the claim form to the Opposite Party. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room.

Announced in Open Forum