Jharkhand

Bokaro

CC/17/13

Dr. Abhay Pratap - Complainant(s)

Versus

E-Meditek (TPA) Service Ltd. - Opp.Party(s)

V.B. Singh

27 May 2019

ORDER

Complainant Dr. Abhay Pratap filed this case for a claim of Rs. 9,42,707/- ( Nine Lac Forty Two Thousand Seven Hundred and Seven) with 18% interest p.a. for four mediclaim bills.

2          The facts of the case is that Complainant, a retired SAIL employee, had taken mediclaim scheme of SAIL and the insurance company, having MIN No. 4715801 with his wife.

            The insurance company M/s United India Insurance company covered the policy for the period 01-01-2014 to 31-03-2015 and M/s National Insurance co. Ltd. covered the policy for the period 01-04-2015 to 31-03-2016.

            During the above periods, complainant’s wife Dr. Smt Chira Prabha was suffering from End Stage of Renal Disease and she was treated under the advice of Dr. Tarun Jeloka of Aditya Birla medical Hospital Pune. She was always being treated at home as per advice of the aforesaid doctor.

            Earlier for the period 01-08-2013 to December 2013 were cleared by the insurance company by order of this forum in CC/59/2014.

            But this time for bills of Rs. 3,02,447/- ( Three Lac Two Thousand Four Hundred Forty Seven) and Rs 73,042/- ( Seventy Three Thousand and Forty Two Only) were repudiated by M/s National Insurance company Ltd. and bills for Rs. 4,53,934/- ( Four Lac Fifty Three Thousand Nine Hundred Thirty Four) and Rs. 1,13,284/- ( One Lac Thirteen Thousand Two Hundred Eighty Four) were not cleared by M/s United India Insurance Co. Ltd. without any cogent reasons.

            All the claims were sent through TPA for clearance.

            Legal Notice was sent to O.Ps but there was no reply.

3          The following documents are filled in support:-

Anx-1 to 1/12- Copy of prescriptions from 12-04-2014 to 04-03-2015 and 07-05-2015 to 05-01-2016.

            Anx-2 to 2/47- Copies invoice medical receipts.

            Anx-3 to 3/3- Copies of claim forms

            Anx-4 to 4/8- O.P.D. pharmacy bills from 24-05-2015 to 30-06-2015

 except Anx 4/3

            Anx- 4/3 and 4/9 to 4/15- O.P.D. Pharmacy bills from 25-11-2015 to

        30-06-2015.

            Anx-5- Copy of the legal notice dt. 06-10-2016

4          O.P. No.3 M/s United India Insurance Co. Ltd. appeared and filed W.S. It is submitted that the case is time barred and the dispute is not consumer dispute and there is no cause of action and denied the claim of Rs. 1,13,284/- ( One Lac Thirteen Thousand Two Hundred Eighty Four) between 16-01-2016 to 29-03-2016 and thus there is no hospitalisation and there is no repudiation letter of this O.P. 3 and case is liable to be dismissed. The policy is not denied.

5          O.P. No.4 M/s National Insurance Co. Ltd. has also appeared and filed W.S. it is submitted that the policy is admitted and also admitted that the O.P. No.4 is concerned with claim of Rs. 3,02,447/- ( Three Lac Two Thousand Four Hundred Forty Seven) and Rs. 73,042/- ( Seventy Three Thousand and Forty Two Only). The claim is not payable for the expenses of medical equipment and for this reason TPA denied the liability of the O.P. It is admitted that as per advice of doctor the patient has to go for APD at home. (Automated Peritoneal Dialysis). There is no need for hospitalisation. Hence claim is repudiated and the case is liable for to be dismissed.

FINDINGS

6.         We perused the record. The delay, if any, is condoned as the claim is genuine.         

                        It appears that Complainant, a retired SAIL employee, had taken mediclaim scheme on payment of premium of the SAIL and the Insurance Companies on yearly basis.

Hence, being beneficiary of the scheme complainant and his wife are consumers and dispute is a consumer dispute.

7          The wife of the complainant having MIN No. 4715001 had went for APD (Automated Peritoneal Dialysis) at home under the advice of doctor at Aditya Birla Hospital, this facts are not denied by O.P. No.3 and O.P. No.4 in their W.S.

            O.P. No.3 M/s United India Insurance Co. Ltd. has taken a plea that here is no repudiation of the claim and denied the claim of Rs. 1,13,284/- ( One Lac Thirteen Thousand Two Hundred Eighty Four). There is no denial that the complainant had not entered into mediclaim scheme for the period 01-01-2014 to 31-03-2015. The Anx-1 series are the doctor’s prescription showing, APD at home. So, the reason for not allowing the claim of medicine required for APD by the O.P. no.3 cannot be accepted on the ground of natural justice and as such O.P. No.3 is liable for deficiency in service and has to reimburse the medicines bills for the period 01-01-2014 to 31-03-2015 except any part claim is already paid.

            O.P. No.4 M/s National Insurance co. Ltd. has admitted the claim is repudiated on the advice of TPA on the ground of expense of expanses on medical equipment. This Anx-2 series which are only medicine bills, required for APD, shows no equipment purchase bills are attached. Therefore, O.P.4 is also liable for deficiency in service for not allowing the claim which is only bills for medicine used in APD at home, as per doctor’s advice.

8          Thus, we allow the claim of the complainant.

            O.P. No.3 M/s United India Insurance Co. Ltd. is directed to pay Rs. 5,67,218/- ( RS 4,53,934/- and Rs 1,13,284/-) (Five Lac Sixty Seven Thousand Two Hundred Eighteen Only) minus any part claim already paid with interest of 6% p.a till realisation.

            O.P. No.4 M/s National Insurance Co. Ltd., is directed to pay Rs. 3,75,489 (Rs 3,02,447/- and Rs. 73,042/-) (Three Lac Seventy Five Thousand Four Hundred Eighty Only) Minus the amount already paid if any with interest of 6% p.a. till realisation.

            O.P. No.3 and O.P. No.4 both are further directed to pay compensation of Rs. 3,000/- (Three Thousand) each to the complainant and litigation cost of Rs. 1,000/- (One Thousand) each to the complainant.

            All the payments must be paid within 60 (Sixty) days of this order failing which the rate of interest on the main claims shall be enhanced to 10% (Ten Percent) p.a. till realisation.