Jharkhand

Bokaro

CC/38/2022

Amarendra Kumar - Complainant(s)

Versus

. The Branch Head MD India Health Insurace, TPA Pvt. Ltd. - Opp.Party(s)

Rakesh Kumar Ray

20 Apr 2023

ORDER

                District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-09-03-2022

Date of final hearing-20-04-2023

 Date of Order-20-04-2023

Case No. 38/2022

Amarendra Kumar S/o Garib Prasad Verma,

R/o Plot No. 14 near Naya More,

Co-Operative Colony, B.S.City,

 District- Bokaro, Jharkhand 827001

Vs.

1. The Branch Head MD India Health Insurance, TPA Pvt. Ltd.

Office at- MDINDIA HEALTH INSURANCE,

near Railway Booking Counter, Sector-1,

Bokaro Steel City, Jharkhand Pin 827001

2. The Director Cum C.E.O.

MD INDIA HEALTH INSURANCE , TPA Pvt. Ltd.

Head Office at- MDINDIA HEALTH INSURANCE,

S.NO.- 46/1, E- Space Building A2, 3^rd Floor,

Vadgaon Sheri, Pune-411014, Maharashtra

3. The Competent Authority of

Untied India Insurance Company Ltd.

Head Office at 19, Nungambakkam High Road,

IV Lane, Chennai-600034

4. Final Settlement Cell

Personnel Department IISCO Steel Plant,

Burnpur, Asansol, W.B. PIN No. 713325

 

 Present:-

                             Shri Jai Prakash Narayan Pandey, President

Shri Bhawani Prasad Lal Das, Sr.Member

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant has filed this case with prayer for direction to O.Ps. to pay him  Rs. 2,39,065/-  with interest @ 9% per annum on account of medical expense incurred during his treatment and compensation of Rs. 50,000/- and also to pay Rs. 20,000/- as litigation cost.
2. Complainant’s case in brief is that he being ex-employee of the SAIL/BSL opted for Mediclaim policy for himself. He was provided MIN No. 5717264 which was valid at the relevant time. Further case is that he was suffering with ailments for which he was admitted in the CMC, Vellore on 01.03.2019 and discharged on 22.03.2019 during which he paid Rs. 2,39,065/- to the hospital but Inspite of filing of claim for re-imbursement of aforesaid amount  and repeated requests O.Ps. have not paid  claim. Later on legal notice dt. 14.02.2022 was issued having no impact. Hence this case has been filed with above mentioned prayer. 

 

3.   Inspite of due service of notice O.Ps. No. 1 & 2 have not appeared hence vide order dt. 14.07.2022 case is being proceeded ex-parte against these O.Ps.

 

4. O.P. No.3 United India Insurance Co. Ltd. appeared and has filed W.S. mentioning therein that complainant has not furnished intimation proof, discharge summary, bifurcated and consolidated bill, investigation reports, detailed information of hospital and doctor on it, proof of treatment as, of the complainant as hospitalization proof have not been provided by the complainant and claim has been filed after two and half months delay without any proper explanation. Further reply is that hospitalization was diagnosis and investigation purpose which was not followed by the treatment. Further reply is that moreover no claim is repudiated by the O.P. No.3.

 

5. Point for consideration is whether prayer of the complainant is liable to be accepted or not?

 

6. On perusal of the papers annexed  with the complaint  petition it appears that complainant has filed photo copy of his Adhar Card (Annexure-1), photo copy of legal notice (Annexure-2), photo copy of his Medical Card (Annexure-3), photo copy of his discharge summary (Annexure-4), photo copy of payment receipts (Annexure-5), photo copy of his claim form (Annexure-6) and  photo copy of proof regarding payment of premium for renewal of the policy of the complainant (Annexure-7) have been filed. Except above papers no any other paper or evidence has been filed by the complainant.

 

7. It is very much clear that as per O.P.  No.3 Insurance Co. complainant has not provided so many papers to this O.P. for settlement of the claim and till date claim has not been repudiated. In this way we are of the view that this case is liable to be disposed off with direction to both the parties in the following manner:-

 

8.   Accordingly prayer of the complainant is being disposed off with following direction:-

 

Complainant is directed to provide all the papers to the O.P. No.3 as indicated at para 14 of the W.S. and on furnishing the papers O.P. No.3 will provide its receipt to the complainant. Further complainant will have liberty to produce photo copy of those papers about which originals have already been furnished to O.P. No.3 or his agency. Complainant shall comply this order within 60 days from receipt/production of the copy of this order.

         On receipt of required documents O.P. No. 3 United India Insurance  Co. Ltd. is directed to decide and pay all genuine claims to the complainant within further 60 days from receipt/production of the papers provided by the complainant.  

 

(J.P.N. Pandey)

                                                                                      President

 

 

(B.P.L Das)

   Sr. Member

                                                                            

                  

                                                                               (Baby Kumari)

                                                                                       Member