Jharkhand

Bokaro

CC/17/155

Narmowala Devi - Complainant(s)

Versus

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

Santosh Kumar Mahto

02 Jun 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 155/2017

  Date of Filing-23-11-2017

 Date of Order-02-06-2022

Narmowala Devi W/o- Sri Bhagwan Das Mahto

R/o Jainamore, Tola- Tandmohanpur, District- Bokaro.

                                      Vr.

1.Director, E-Meditek, Plot No.- 577, Udoyog Vihar, Phase-5, Gurgaon, Haryana

2.The E- Meditek (TPA), Service Pvt. Ltd. Plot No.- HD-11, Sector-04, Bokaro Steel City, District- Bokaro

3. The Director United India Insurance Co. Ltd., D.O. 11 E-85, Himalaya Hause, 8^th floor, K.G. Marg, New Delhi

 4. Managing director United India Insurance Co. Ltd., Plot No. GB-28, City Centre, Sector-04, Bokaro Steel City, District Bokaro

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. 1,73,194/- on account of medical expense incurred during treatment of complainant  and to pay Rs. 1,25,000/- & Rs. 15,000/- as compensation and litigation cost respectively to her.
2. Complainant’s case in brief is that her husband  is retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy vide MIN No. 4731505 for himself and his wife Smt. Narmobala Devi. During the enforcement of the insurance policy the complainant became ill and she was admitted in the CMC Vellore on 30.03.2016 and discharged on 27.04.2016 during which Rs. 1,73,194/- was paid to the Hospital. Complainant applied for reimbursement of the said 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.1&2 appeared and have filed W.S. mentioning therein that these O.Ps. are only processing the claim on behalf of insurance co. as per their guidelines and claim is being reimbursed by the insurance co. hence these O.Ps. are having no financial liability in the case.
4.  O.P. No.3 & 4 appeared and have filed W.S. mentioning therein that the complainant has not provided necessary documents for processing of the claim hence claim has not been processed and case is liable to be dismissed.
5.  As documentary evidence the photo copy of discharge summary of the patient Narmobala Devi issued from CMC Vellore,  photo copy of claim form, photo copy of Medical book of SAIL/ BSL, photo copy of Medical card related to mediclaim scheme, photo copy of receipts related to payment of the bill to the CMC Vellore, and photo copy of the legal notice have been filed. 
6.  Point for consideration is whether complainant is entitled to get relief as claimed ?
7.   Following facts are admitted facts in this case:-

i). That Narmobala Devi was wife of the Ex-SAIL employee Sri Bhagwan Das Mahto.

ii) That being wife of Ex-employee of the SAIL, Bokaro complainant is entitled to opt mediclaim policy for her treatment and treatment of her husband on payment of premium.

iii) That husband of the complainant obtained mediclaim policy from O.P. vide MIN No.4731505 for his treatment and for the treatment of his wife.

iv) That at the time of treatment i.e. from 30.03.2016 to 27.04.2016 O.P. No.3 & 4  United India Insurance Co. were liable to pay the medical expense of the Ex-employees and their wife of the SAIL, Bokaro.

V) That complainant has submitted claim form to the O.Ps. for reimbursement of the expense incurred during treatment at CMC Vellore.

vi) That till date no payment has been made to the complainant by the O.Ps.  

10.  On perusal of photo copy of the claim form it appears that    complainant has  made claim for reimbursement of Rs. 1,73,194/- as it was paid to the Hospital for her treatment and said claim form was received by O.Ps. along with all relevant documents such as discharge summary, payment receipts etc.

10   It reveals from the record that on 16.05.2016 claim form was dispatched by the complainant to the O.Ps. but since then O.Ps. have not given any response on it. Though in the W.S. it is mentioned that claimant has not provided documents but it has not been specified that which of the documents were required and have not been submitted by the claimant. Therefore said reply is not specific rather it is evasive reply. Therefore, we are of the opinion that the claim of the complainant is liable to be accepted accordingly above point is being decided in favour of the complainant.

9   Accordingly the claim of the complainant is being allowed in the manner indicated here in below:-

O.P. No. 3 & 4   (United India Insurance Co.)  are directed to pay Rs. 1,73,194/- (Rs one lac seventy three thousand one hundred and ninety four) only to the complainant within 60 days from today otherwise they will pay interest thereon @ 9% per annum from 23.11.2017 (the date of filing of the case). Further O.P. No.3 & 4  are directed to pay Rs. 10,000/- as compensation related to various type of harassment and Rs. 5,000/- as litigation cost within 60 days from today.