Jharkhand

Bokaro

CC/18/51

Arjun Prasad Keshri - Complainant(s)

Versus

Branch Manager, M.D. India Health Insurance TPA Pvt Ltd. - Opp.Party(s)

MD. Anwar Ali

21 Jun 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 51/2018

  Date of Filing-13-04-2018

 Date of Order-21-06-2022

Arjun Prasad Keshri S/o Late Mahadeo Prasad Keshri

R/o Plot No 10, S.S.P. Market Sector-1/B, 

District Bokaro Jharkhand   

Vr.

 

1. Branch Manager, M/s, M.D. India Health Insruance T.P.A. Pvt. Ltd. Plot No. 19A, city Centre Sector-4, Bokaro Steel City

 2. United India Insurance Co. Ltd. D.O. XI E-85, Himalaya House 8^th floor, K.G. marg New Delhi

3. C.E.O. Sail/ Bokaro Steel Plant, A.D.M. building, Bokaro Steel City, Bokaro

4. Branch Manager United India Insurance Co. Ltd. Plot No. A-17, City Centre, Sector-4, District- Bokaro, 827004

Present:-

          Shri Jai Prakash Narayan Pandey, President

           Smt. Baby Kumari, Member

                                                -Order-

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 10,250/- with 18% per annum interest on account of medical expense incurred during treatment of complainant  and to pay Rs. 25,000/-  as compensation and Rs. 10,000/- as litigation cost.
2. Complainant’s case in brief is that he is retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy vide MIN No. 4708827 for himself and his wife which was valid at the relevant time. During the enforcement of the insurance policy the complainant got operated cataract of his right eye in the month of Sept. 2017 for which Rs. 13,000/- was paid by the Insurance Co. instead of Rs. 19,250/-. Again in the Month of Nov. 2017 complainant got operated cataract of his left eye for which Insurance Co. has paid Rs. 19,250/- to the hospital under cashless policy. Further case is that for purchase of medicine only Rs. 559/- and Rs. 1820/- respectively for both  operations was paid by the Insurance Co. Complainant applied for reimbursement of the rest of the amount but inspite of repeated requests no action was taken by the O.Ps.  Thereafter legal notice was served having no impact. Hence this case has been filed with above mentioned prayer.  

 

3.   O.P. No.3 SAIL/ BSL Bokaro appeared and has filed W.S. in which there is no comment on the claim of the complainant and it has been admitted that complainant has obtained mediclaim policy valid from 11.04.2017 to 10.04.2018.

 

4. On behalf of O.P. No.2 & 4 W.S. has been filed in which there is no denial in respect to facts mentioned in paras 1 to 11 of the complaint petition. However, it is mentioned at para 13 that complainant has to provide all original papers related to treatment. It has also been mentioned that as cashless treatment Rs. 13000/- and Rs. 19,250/- were sanctioned for two subsequent cataract operation and Rs. 559/- and Rs. 1820/- were sanctioned for purchase of medicines of the operation.

 

5.  On the basis of above pleadings we have to see whether complainant is entitled to get relief as claimed or not?

 

6. It is admitted fact that complainant was fully covered with the insurance policy and for the operation of the cataract the same package was opted by him in the same hospital on two occasions firstly in the month of Sept. 2017 and secondly in the month of Nov. 2017 . Another admitted fact is that the package for the operation for each eye was Rs. 25,000/- each amongst which cashless facility was also approved by the O.P. Insurance Co. on both occasions. Another admitted fact is that during post operative care for the purchase of medicines Insurance Co. has also made payments. In this way most of the facts of the case are admitted facts. Only dispute is that for the same package on both occasions different payments have been made.

 

7. On calculation it is apparent that on second occasion O.P. Insurance Co.  has paid Rs. 19,250/-  + 1820/-  total Rs. 21,070/-. On first occasion Rs. 13,000/-+ Rs. 559/- total Rs. 13,559/- has been paid. In this way for the same purpose at first time there is less payment of Rs. 7511/- to the complainant for which he is entitled to get recovered from the Insurance Co. Therefore, we are of the view that complainant has prima facie established his case and he is entitled to get relief.

8   Accordingly prayer of the complainant is being allowed in  the manner indicated here in below:-

O.P. No. 2 & 4  ( the United India Insurance Co. Ltd.) are directed to pay Rs. 7511/- to the complainant within 60 days from today otherwise these O.Ps. shall pay interest @ 10% per annum from 13.04.2018 (the date on which complaint was filed). Further these O.Ps. are directed to pay Rs. 2000/- as compensation for various type of harassment and also to pay Rs. 1000/- as litigation cost within 60 days from today.