Ex-P A R T E O R D E R
PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding deficiency in service on the part of Opposite Party by not paying full mediclaim to the Complainant.
2) The Complainant had taken a Family Health Insurance Policy from the Opposite Party for the period from 14/02/2008 to 13/02/2009 vide Protection Note No.MH/M-102 Renewal Protection No.MH/M-1428 for protection value of Rs.2 Lakh. The wife of the Complainant who was covered under the Protection Note as mentioned above was hospitalized during the validity of the mediclaim policy. The Complainant then submitted her mediclaim for reimbursement for Rs.2,48,237/- with all necessary documents vide letter dtd.04/04/2008. The Complainant received the claim discharge voucher of approved amount of Rs.1,20,000/- only instead of Rs.2 Lakh as per the Protection Note mentioned above.
3) The Complainant sent reminders to Opposite Party for the reimbursement for the full insured amount but the Opposite Party did not respond and did not reimburse Rs.2,00,000/- as per the mediclaim policy and thereby the Opposite Party is deficient in its service.
4) Therefore the Complainant prayed for the balance of his mediclaim of Rs.78,670/- and Rs.12,600/- as the interest on this amount as the claim was not settled within the period of 60 days as per rule, plus interest on Rs.78,670/- @ 18 % from the date of submission of the claim to Opposite Party, Rs.1 Lakh compensation for mental and physical harassment and the Opposite Party be directed not to refuse the renewal of the protection note in future.
5) The Complainant also submitted the relevant documents in support of his complaint and affidavit in evidence. The complaint was admitted and the Opposite Party was served with the notice by R.P.A.D. Inspite of service of the notice on the Opposite Party by R.P.A.D., the Opposite Party did not appear before this Forum. The acknowledgment due receipt duly signed by the Opposite Party is on record. The Forum passed the order ex-parte against the Opposite Party vide Roznama dtd.31/12/2009. The Complainant then filed his affidavit-in-evidence and argued orally in person. We heard the Complainant and perused the complaint and documents submitted by the Complainant. Our findings are as follows.
6) The Complainant had taken mediclaim cover from the Opposite Party for his family for the period from 14/02/08 to 13/02/09 for the sum of Rs.2 Lakh. During the validity of this protection note the Insured Smt.Anjali Kirtane, was hospitalized at Hinduja Hospital for the heart ailment and the mediclaim of Rs.2,48,237/- was submitted to Opposite Party for reimbursement. As the sum assured was only 2 Lakh, the Opposite Party was supposed to reimburse Rs.1,98,670/- as per the terms and conditions of the policy. However, the Opposite Party reimbursed only Rs.1,20,000/-. Thus, the Opposite Party failed to reimburse the mediclaim amount of Complainant of Rs.78,670/-. The explaination given by the Opposite Party in this connection is not correct. The Opposite Party has assumed the sum insured as only Rs.1,50,000/-where as actually the sum insured was Rs.2 Lakh for the relevant year. Thus, there is deficiency in the service of the Opposite Party as it calculated the reimbursement amount incorrectly, therefore, the Opposite Party is liable for reimbursement of Rs.78,670/- with an interest @ 9 % from 04/06/2008. The Opposite Party is also liable for the compensation for mental and physical harassment caused to the insured. Therefore, we pass the following order -
O R D E R
i. Complaint No.298/2009 is partly allowed.
ii.Opposite Party is directed to pay Rs.78,670/- (Rs.Seventy Eight Thousand Six Hundred Seventy Only) to the
Complainant alongwith interest @ 9 % p.a. from 04/06/2008 till the realization of entire amount.
iii.Opposite Party is also directed to pay Rs.5,000/-(Rs.Five Thousand Only) to the Complainant as a
compensation for the mental and physical harassment.
iv.Opposite Party is directed to pay Rs.1,000/-(Rs.One Thousand Only) to the Complainant towards the cost of
this complaint.
v. Opposite Party is directed to comply with the above order within 30 days from the date of receipt of this
order.
vi.Certified copies of this order be furnished to the parties.
