CC:227/2022

Dated:08.08.2022

ORDERS ON MAINTAINABILITY OF THE COMPLAINT

1.     Heard the counsel for the complainant regarding the maintainability of the complaint before this commission. Complainant has sought refund of Rs.51,450/- being the balance amount spent for his hospitalization expenses. On perusing the complaint, it is mentioned therein that he had obtained a health insurance policy from OP and due to COVID, he was admitted to the hospital for which he had to spent Rs.2,23,920/- and made a claim with OP who refused to pay the amount on the ground that the treatment was not required hospitalization and could have been treated on OPD basis against which he made a complaint to the insurance ombudsman who ordered the OP to pay Rs.1,69,153/- and that he has spent more money then what was ordered by ombudsman and hence for direction to OP to pay the balance of the amount spent i.e. Rs.51,450/- .

2.     The copy of the order passed by the ombudsman for insurance had been produced wherein, it is stated that:

“The complaint emanated from denial of health (Covid 19) claim of Rs.2,23,920/- under policy number 2890/00033106/000/00 by the Respondent Insurer (RI) stating that hospitalization was not required. Complainant’s representation to the RI for reconsideration of his claim did not result in any resolution. Hence the complainant approached this Forum for relief. The complaint was registered on 30.12.2021.

Upon intervention of the Forum, the RI vide their email dated 17.03.2022 agreed to pay Rs.1,69,153/- as per policy’s terms and conditions.

The  Complainant vide his email dated 17.03.2022 accepted the above settlement offer as full and final settlement of the said claim.

AWARD

Taking into account the facts and circumstances of the case and based on the records made available to this forum, the complaint was resolved amicably upon mediation by the Forum wherein both the parties have agreed to the payment of Rs.1,69,153/- as full and final settlement of the lciam. Hence, the complaint is treated as closed and disposed of accordingly.

Compliance of Award:

Attention of the complainant and the insurer  is hereby invited to the following:

a. The Complainant shall submit all requirements/Documents required for compliance of award within 15 days of receipt of the award to the Respondent Insurer.

b.  As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and update compliance of the same in the CMS module provided for complaints registered at the Forum.”

3.     When the said award is taken in to consideration, the said award has been passed amicably upon the mediation between the parties and complainant has agreed to get the matter settled for Rs.1,69,153/- against the claim of Rs.2,23,920/- as full and final settlement of the claim and as a result the ombudsman closed the complaint of the complainant as fully settled and closed.  When the complainant himself has unequivocally admitted that he has agreed to receive Rs.1,69,153/- towards the full and final settlement of the claim of Rs.2,23,920/-, this complaint on the same cause of action is not maintainable as matter has been settled and there is also direction by the ombudsman to the insurance company to pay the said amount within 30 days. When such being the case, it is for the complainant to file the Execution petition or the course open to him to recover the said amount for having agreed for the said amount.  Hence in our view this complaint is not maintainable on the same cause of action and hence the COMPLAINT IS HEREBY DISMISSED.

  MEMBER       MEMBER         PRESIDENT