Jharkhand

Bokaro

CC/3/2023

Anil Kumar Sinha - Complainant(s)

Versus

Divisional Manager, United India Insurance Co. Ltd. - Opp.Party(s)

Sanjeev Kumar Pathak

01 Jul 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-05-01-2023

Date of final hearing-01-07-2023

 Date of Order-01-07-2023

Case No. 3/2023

Anil Kumar Sinha S/o Late Bhola Prasad Sinha

R/o Ramnagar Colony Block “C”,

 P.O. and P.S. - Chas, District - Bokaro, Jharkhand

                                      Vrs.

1. Divisional Manager, United India Insurance Co. Ltd.

at Plot No. A/17, 2^nd Floor, Sector- 4, City Centre,

P.O. and P.S. - Sector- 4, B.S.City, District - Bokaro, Jharkhand 827004

2. Manager, Medi Assist Insurance TPA Pvt. Ltd.

Thapar House, 25, Brabourne Road, Kolkatta,

West Bengal- 700001

3. Branch Manager, Indian Bank,

HD-11, Sector-4, City Centre,

P.O. and P.S.- Sector-4, B.S.City,

District- Bokaro, Jharkhand 827004

4. Sr. Divisional Manager, United India Insurance Co. Ltd.

Division No. 010500 Catholic Centre (Old No. 64)

New No. 108, 1^st Floor, Armenian Street, Chennai 600001

Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

          1. Complainant Anil Kumar Sinha  has filed this case for direction to the O.Ps. United India Insurance Co. Ltd. to pay  a claim of Rs. 12,748/- with 18% interest from the date of claim  with compensation of Rs. 15000/- for various types of harassment and for legal expense Rs. 5000/- to the complainant.

2                 The case of the complainant in short is that he is having Mediclaim policy No. 0105002019484100001088638 valid from 01.11.2019 to 31.10.2020 and during that very period due to illness he was admitted in Muskan Hospital and Research Centre, Chas Bokaro on 01.05.2020 and discharged on 02.05.2020 for the treatment of Fundal Gastritis (Rut Positive) for which he paid total Rs. 12,748/- to the hospital. Further case is that complainant applied before the O.Ps. for reimbursement of aforesaid amount which was refused on the ground that the hospitalization was purely for the purpose of evaluation and not followed by any active treatment hence claim is outside of Insurance policy. Thereafter complainant served legal notice dt. 03.03.2021 upon the O.Ps. having no impact hence this case has been filed with above mentioned prayer.

3. O.P. No. 1 and 4 United India Insurance Co. Ltd. appeared and have filed W.S. mentioning there in that claim has been repudiated on the ground that hospitalization was not needed. However, there is no specific denial of the contents of para 1,2,3,4,5,6,7,8,9,10 , 13,14 of the complaint petition and para 11 has been completely admitted, however para 12, 16 of the complaint petition have been partially accepted by these O.Ps. Para 15 of the complaint petition has been denied. Hence it is prayed to dismiss the case. In respect to O.P. No. 2 & 3 case is being proceeded ex-parte because they have not appeared inspite of due service of notice.

4. Point for determination is whether complainant is entitled to get relief as prayed or not?

5. On perusal of the reply of the O.P. Insurance Co. it appears that facts related to entitlement of the complainant, his admission in the hospital, line of treatment, payment to the hospital and submission of claim for reimbursement are either admitted or have not been expressly denied by the O.Ps. Only ground for repudiation of the claim is that hospitalization of the complainant was purely for the purpose of evaluation and not followed by any active treatment. Therefore, we have to determine whether ground  for repudiation of the claim is justifiable or not?

6. Annexure-3 ,4 and 5 are prescription, Endoscopy Report and discharge summary respectively of the complainant which show that as per well qualified Gastroenterologist there was need of hospitalization because of the complain related to the complainant. As per Endoscopy report there was Fundal Gastritis RUT Positive for which patient was treated from 01.05.2020 to 02.05.2020 as indoor patient and discharged under stable condition with advice to take medicines as prescribed and to review after one month or as per requirement. In this way it is apparent that complainant has well proved the fact related to need of hospitalization as per expert’s advice. Contrary to it there is no any expert’s opinion or evidence by the O.Ps. to show that hospitalization was not required in the present case. As per Annexure-6 (photo copy of consolidated bills) total Rs. 12,748/- has been paid by the complainant to the hospital on different heads towards his treatment.

7. In light of above discussion we are of the view that complainant has well proved his case by the documentary evidence prepared by an expert doctor  and contrary to it there is no any evidence from the side of O.Ps. to disbelieve the evidence of the complainant. Hence we are of the opinion that complainant has well proved his case that repudiation of claim by the O.Ps. is not based on justifiable reasons. Accordingly above point is being decided in favour of the complainant.

8. Hence prayer of the complainant is being allowed in the following manner:-

O.P. No.1 & 4 are directed to pay Rs. 12,748/- to the complainant within 60 days from receipt/production of the copy of this order, failing which they shall pay interest on that very amount @ 10% per annum from 05.01.2023 (i.e. the date on which case was filed). Further these O.Ps. are directed to pay Rs. 3000/- as compensation and Rs. 2000/- as litigation cost to the complainant within above mentioned period.

 

S/d   

(J.P.N. Pandey)

                                                                                      President

 

                                                                            

          S/d   

                                                                               (Baby Kumari)

                                                                                       Member