- (1.) (The Appellant as Complainant filed a complaint before the District Forum against the opposite parties, praying for a direction to the opposite parties to pay a sum of Rs.21582/- being the cost of medical bill, alogwith compensation of Rs.1 lakh. The District Forum dismissed the complaint. Against the said order, this appeal is preferred praying to set aside the order of the District Forum dt.30.12.2010 in CC.No.391/2009. This petition coming before us for hearing finally on 19.01.2012. Upon hearing the arguments of the counsel on both sides, perusing the material papers on record, lower court records, as well as the order passed by the District Forum, this commission made the following order) M. THANIKACHALAM J, PRESIDENT 1. The complainant is the appellant.
(2.) The complainant/ appellant, being the beneficiary under a health insurance policy, covering the period 12.2.2008 to 11.2.2009, had taken treatment, for which he incurred an expenses of Rs.41,582/-, for which claim was made, the opposite parties have paid only a sum of Rs.20000/-, denying the balance of Rs.21,582/-, which should be construed as deficiency in service, has filed a case for the recovery of the said amount, with compensation of Rs.1 lakh.
(3.) The opposite party, not questioning the policy, under which right is claimed, resisted the case, contending that the consumer complaint is filed, under misconception as if he is entitled to full sum assured, irrespective of the actual expenses incurred, and limitation, that under the terms and conditions of the policy, for the disease, for which he had taken treatment, the limit is restricted to 15% of the sum assured, or maximum of Rs.30000/-, and accordingly amount paid, which cannot be termed as deficiency in service, praying to reject the claim, questioning the other averments also.;