Per Shri  Bhaskar B. Yogi – Hon’ble President.

1.       The present complaint is filed against the insurance company for repudiating partial claim.

Brief facts of the complaint are as under:-

2.       The complainant herein has purchased the medical policy from the opposite party. The opposite party has accepted the premium of Rs.27,035/- and insured complainant and his family for a sum of Rs.5,00,000/- (Rs. Five Lac).

3.       The opposite party accordingly issued mediclaim policy to complainant bearing policy no 281301502010000628 which commence on dated 25/01/2021 and it is valid till 24/01/2022.

4.       The wife of the complainant namely Kavita Sureshkumar Batheja got hospitalized for her treatment. At the time of Hospitalization, complainant has forwarded the documents of Hospitalization to the opposite party. And also provided all documents as and when demanded by OP. Therefore, the complainant has provided all the necessary documents for the heed of hospitalization to opposite party.

5.       It is case of complainant that later on the complainant submitted the bills of entire treatment and submitted all the claims duly filled in the claim form. Total expenses done by complainant at Hospital is Rs. 1,27,004/-. The complainant claimed total amount of Rs. 1,27,004/- (Rupees One lac Twenty Seven Thousand Four Only) from the opposite party. The opposite party despite receipt of all the relevant documents from complainant partially allowed the claim of only Rs.76,100/- (Rupees Seventy Six Thousand One Hundred Only) which is against the law.

6.       Having unsuccessfully exhausting all the remedies available with the complainant, the complainant had issued legal notice to the opposite party on dated 20/12/2021 to call the opposite party to settle the entire claim of complainant by releasing the amount within 15 days from the date of receipt of notice. But, opposite party fails to pay the amount to the complainant. Hence present Complaint filed Praying :-

a) It be declared that the opposite party are indulge in unfair trade practices.

b) To direct the opposite party to pay the remaining pending claim amount of Rs.50,904/-

c) To direct the opposite party to pay interest on the claim amount at the rate of 24% per annum over the claim amount from the date of complaint till its realization.

d) To award compensation for mental harassment of Rs. 1,00,000/- which is caused to the complainant due to illegal acts of the opposite party.

e) To award cost of maintaining this complaint of Rs.20,000/-

 f) Grant any other relief as the Honb'le commission deems fit under the facts and circumstances of the present complaint in the interest of justice and trial.

7.       Opposite-party appeared and filed their written version on 06/05/2022 and admitted the policy and partially payment of Rs. 76,100/-and contented that they rightly and legally deducted the payment as per terms and conditions of insurance policy, but fail to explain on what grounds they deducted the amount. Therefore, Limited issue to be decided in present complaint is- whether partial deduction is rightly deducted or without sufficient reasons?

8.       Heard arguments advance by ld. advocates for the parties and on perusal of written version as well as rejoinder affidavit of Opposite-party and written arguments it is crystal clear that no plausible reasons given for said deduction and mere denial in absence of sufficient reasons Coupled with partial admission of claim deduction of certain amount without any sufficient grounds amounts to unfair trade practice. Therefore, the complaint must be allowed with some compensation, but we are not inclined to grant any cost due to failure to carry out continuous pagination as directed time and again to the ld advocates. On perusal of bills at pg. no. 19, 22, 27-34, 37 the amount mentioned by complainant at pg. no. 90 for Rs. 1,27,004/- is not established with supporting bills. Therefore Rs.16,582/- only  (92,682-76100) is allowed.

          Hence following order.

-:FINAL ORDER:-

1.       Complaint allowed with compensation of Rs. 5,000/- to be paid to complainant by the opposite-party and further directed to pay Rs. 6,582/- to the complainant within 15 days. In default, the aforesaid amount shall carry interest @9% P.A. from today till           realization.          

2.         Certified free copy of this order be provided to the parties as per Regulation 21.

3.       Additional sets of complaint be returned to the complainant and original complaint along with documents be confined to record         room