ORDER
                         Date:  29-09-2016



    Mohd. Anwar Alam, President

1.     The complainant filed this complaint on 04-06-2015and alleged
that he took mediclaim insurance policy from OP1 for him and his
family members  namely Mrs. Mala Lamba (wife), Mrs Muskan Lamba
(daughter ) and  Mr. Anmol Krishna (son). It was renewed after
16.04.2015 and due insurance premium paid to OP1.  As per medical
consultant Mrs. Mala Lamba had got  two surgeries at Bhatia Global
Hospital and Endosurgery Institute  on 11.12.2014. Despite cash less
mediclaim insurance policy with OP1 he paid Rs. 20,000/- to the
hospital.  OP1 denied cash less payment to hospital. OP1 sanctioned
only Rs. 27,700/- and denied the balance payment for the unknown
reasons.  The complainant approached to the Ops for the settlement of
claim but no response from OP hence this complaint wherein it was
prayed that OPs be directed to pay a sum of Rs. 144643/- along with
the interest , compensation for mental pain and agony and cost of
litigation.

2.     OP2 did not appear despite service of notice to it on
01/07/2015. Hence Ex-parte proceeded against him.

3.     In reply OP1 admitted their policies which was renewed upto
16.04.2015 and further admitted that amount of Rs.27,700/- passed by
TPA.  OP1 denied  rest of the allegations made in the complaint. OP1
also objected that present complaint was premature.  Complainant did
not file original bills required for the settlement of the claim for
which requests on 08.01.2015 , 24.01.2015 and again on 19.12.2015 were
made but complainant did not supply required documents and approached
to this forum.

4.     The complainant filed his rejoinder and  evidence on 03-11-2015
and supplied 18 documents  to the OP1 and opposed the reply.  In
support of complaint complainant filed his affidavit along with
documents Ex. CW1/1 to Ex. CW1/28   in support of  the claim but he
did not deny the letters dated 8.1.2015 , 24.1.2015 and 09.02.2015
written by OP1 him to prove its claim.  Hence such denial is invasive.

5.     We have heard the arguments and considered the evidence led by
the complainant and OP1 and their written and oral arguments.  In this
case points to be considered are as under:-

(a) Whether complainant is a consumer?

(b) Whether there is any deficiency in service on the part of the OP?

( c) Relief?

6.     It is admitted by the OP1 that complainant took a mediclaim
policy which was valid upto 16.04.2015. Hence complainant is a
consumer.

7.     Perusal of the complainant’s affidavit and his claim form Ex.
CW1/24 which was prepared  on 18.12.2014 shows that date of filing of
claim with OP is missing in it. It is pertinent to mention here that
in legal notice to the OP Ex. CW1/26 date of filing of the claim form
is also missing. Even in Ex. CW1/25 (schedule of expenses) no date of
submission of claim is mentioned. Therefore, it is presumed that
complainant supplied 18 documents in original relating to policies and
prescription slips on 03.11.2015 in the court.  Therefore, in these
circumstances after  receiving the required documents OP shall  submit
the claim within 3 months which is reasonable time to submit the
claim.  On 01.03.2016 complainant filed application that he has
received a settlement memo dated 28.01.2016 and amount of Rs. 88,413/-
was paid to him against his claim of Rs. 141015/- out of which an
amount of Rs. 51,842/- was to be paid by the hospital on account of
over and above of GIPSA PPN PKG charges. Therefore, he prayed for
compensation for mental agony and cost of litigation. OP in reply to
the application filed by the complainant stated that the claim of the
complainant already settled on 28.01.2016.  The permissible amount
under the policy was duly paid to him on receipt of the documents ,
therefore, application filed by the complainant be dismissed. On
30.06.2016 amount of Rs. 51,842/-was refunded by  hospital against
full and final settlement which was received on behalf of Mrs. Mala
Lamba.

8.     Therefore, looking to the above facts and circumstances we are
of the opinion that there is no deficiency on the part of OP and
complaint is not entitled for  any compensation for mental agony and
litigation charges. Hence, complainant has filed this complaint prior
to the repudiation of the claim by the OP. Hence, complaint is
dismissed as settled accordingly. File be consigned to record room.



Announced on ………………..