Jharkhand

Bokaro

CC/17/136

Bachcha Singh died during pendency hence sunil kumar singh - Complainant(s)

Versus

CEO, Rakhsa TPA Pvt. Ltd. - Opp.Party(s)

Ajay Kumar Jha

30 Nov 2022

ORDER

          District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-25-09-2017

Date of final hearing-30-11-2022

 Date of Order-30-11-2022

Case No. 136/2017

Bachcha Singh, died during pendency hence.

Sunil Kumar Singh S/o Late Bachcha Singh

R/o Sector-3/B, Qr.No. 260, Bokaro Steel City, District- Bokaro

Vs.

1. C.E.O. Raksha TPA Pvt. Ltd.

    C/o- Escort Corporate Centre, 15/5, Mathura Road,

     Faridabad, Haryana

 2. Iffco Tokio General Insurance Co. Ltd.

      Unit Nos. 52-63, Mezzaine Floor, Ansal Fortune Arcade,

       Sec 18, Noida, Uttar Pradesh

3. Sail, Bokaro Steel Plant, Represented by Chief Executive Officer,

     Ispat Bhawan, Administrative Building, Bokaro Steel City,

     District- Bokaro, Jharkhand

 

                             Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

 

PER- J.P.N Pandey, President

-Judgment-

 

1. Complainant has filed this case with prayer to direct the O.Ps. to pay Rs. 2,16,375.49/- with interest @ 12%  P.A. on account of amount paid to the hospital for treatment of his father and to pay Rs. 20,000/- as compensation and Rs. 10,000/- as litigation cost. It is important to note here that original complainant was Ex-employee of the SAIL/BSL but during pendency of the case he died hence his son has been replaced against original complainant.
2. Case of the original complainant is that he being retired SAIL, BSL employee was entitled to get medical facilities for himself and his wife as per norms of the company, on making payment of the premium to the insurance co. ( O.P.). Further case is that complainant has paid premium of his share to the Insurance co. as per norms and being covered by mediclaim policy of O.Ps. covering OPD treatment as well as indoor treatment in the hospitals for which MIN No. 4702468 was allotted to him by the O.P. Insurance Co. Further case is that due to some illness as mentioned in the complaint petition he was admitted in CMC, Vellore on 10.02.2017 whose request for cashless facility was refused.  and discharged on 25.02.2017 and paid the amount Rs. 2,16,375.49 related to medical expense to the Hospital, for which he submitted duly filled up claim form in the office of the O.Ps. but his claim has been closed on the ground that original papers have not been filed inspite of repeated demand. Further case is that inspite of issuance of legal notice grievance of the complainant has not been redressed, hence this case has been filed with prayer for re-imbursement of the amount Rs. 2,16,375.49 paid to the Hospital and further for payment of compensation Rs.20,000/- and litigation cost Rs. 10,000/-as mentioned in the complaint petition.
3. Inspite of due service of notice O.P. No.1 TPA has not appeared and filed W.S. in this case.
4. O.P. No.2 Insurance co. has filed W.S. in this case mentioning therein that case is not maintainable. Further reply is that only cashless facility was denied against the treatment but claim for reimbursement was not denied. Further reply is that inspite of issuance of letter and reminder letters to provide/submit documents to process the claim, no reply was given hence claim of the complainant has been closed as no claim.
5. W.S. has also been filed by the O.P. No.3 by which claim of the complainant has been admitted.
6. Only point consideration is that whether complainant is entitled to get relief as claimed or not?
7. On careful perusal of the pleadings of the parties it is apparent that either following facts have been admitted or have not been controverted/disputed or specifically denied by the parties of this case.

1. That original complainant was earlier employee of SAIL, BSL, Bokaro and he retired from the service of SAIL, BSL, Bokaro.
2. That as per policy of the SAIL, BSL, Bokaro all retired employees of the SAIL,BSL, Bokaro are entitled for medical insurance coverage to the some extent on contributing premium  towards it.
3. That as per norms of the SAIL, BSL, Bokaro original complainant has deposited the required premium and was being covered by the mediclaim policy of the O.P. No2.
4. That said mediclaim policy of the complainant was effective for the period for which claim has been made.
5. That original complainant was allotted MIN number by the insurance co. as mentioned in the complaint petition.
6. That the original complainant suffered with illness as mentioned in the complaint petition and he got himself  admitted in CMC, Vellore Hospital for the period as mentioned in the complaint petition.
7.  That the original complainant has made payment of the amount to the CMC, Vellore Hospital as mentioned in the complaint petition on account of medical expense incurred on his treatment.
8. That the claim of the complainant has been closed by the O.Ps.

 

8.     It is apparent from the papers annexed with the complaint petition as well as the papers annexed with the W.S. of O.P. No.2. It appears that as per terms and conditions of the policy at point 6 (6.4.3) there is capping in mediclaim policy in respect to room rent @ Rs. 3000/- per day and maximum ceiling for Hip implant is Rs. 75000/- only. As per photo copy of discharge summary of the patient it appears that there was total Hip replacement of the patient. In this way it appears that patient was admitted in the hospital on 10.02.2017 and discharged on 25.02.2017 (total for 16 days) for which Rs. 15,900/- has been paid to the hospital. Learned Counsel for the Insurance co. has already received original papers as demanded earlier and he admits that all those original papers have also been send to the O.P. No.2 through curriers service dt. 08.09.2022 and it has been delivered to O.P. No.2 on 10.09.2022.
9. Since earlier original papers were not provided to the O.P. No.2 hence there was no decision by the O.P. No.2 but now all original papers have already been provided to O.P. No.2 hence it was expected from O.P. No.2 to take final decision towards payment of the medical expense as per terms and conditions of the Insurance policy.
10. Accordingly prayer of the complainant named above is being allowed in the following manner :-

O.P. No.2 (IFFCO TOKIO General Insurance Co. Ltd.) is directed to take final decision in respect to admissible amount as per terms and conditions of the Insurance policy and make payment to the complainant within 3 months from receipt/production of the copy of this judgment. In case decision is not taken by the Insurance Co. (O.P. No.2) within stipulated period then complainant will have liberty to take proper recourse of law for which fresh cause of action will arose from final decision of the Insurance Co.

 

 

(J.P.N. Pandey)

                                                                                President

 

                                                                                               

                                                                              (Baby Kumari)

                                                                                  Member