Jharkhand

Bokaro

CC/18/42

Sukumar Mahanti - Complainant(s)

Versus

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

Sanjeev Ojha

07 Jan 2022

ORDER

1.     Complainant has filed this case with prayer for direction to O.Ps. to pay insurance claim of Rs. 14,463/- and for payment of Rs. 10,000/- and Rs. 5,000/- as compensation and litigation cost respectively to him.
2. Complainant’s case in brief is that the complainant being      

retired B.S.L. employee obtained mediclaim scheme from O.Ps. for the sum insured Rs. 2,00,000/- each for himself and his wife, which was renewed time to time for the year 2015-16. Further case is that on 08.11.2015 complainant consulted the Doctor at Purulia where he was advised for operation of cataract for which he was admitted in Rotary Club of Purulia Service Centre Eye Clinic on 07.03.2016 and discharged on 08.03.2016  who paid Rs. 14,000/- and at that very time his policy was operational. Further case is that in spite of repeated requests his claim for re-imbursement for Rs. 14,463/- was not settled then a Legal Notice was served to the O.Ps. having no response hence this case has been filed.

3. O.P. No.1 and 2 have filed their reply mentioning there in that    

they have not charged any premium rather they are Third Party Administrator (in short TPA) hence they are not liable for the claim.

4. O.P. No.4 being SAIL Administration has also filed reply admitting the fact regarding employee of the complainant and facility provided to the Ex-employees.
5.     O.P. No.3 being Insurance Company has filed separate reply admitting the fact of para 1 to 4 and 7 of the complaint petition.  There is no specific denial of contents of paras No. 5,6, 8 to 13 of the complaint petition. It is stated that the claim of the complainant as made in the complaint petition has been denied because it was neither satisfactory nor as per the terms and conditions of the policy. Further it is stated that the complainant has not furnished the sticker of the lense as required for re-imbursement of hospitalization bill, hence claim has been denied.
6.       It is admitted fact that the complainant and his wife were fully covered under the medical insurance scheme and on the relevant date policy was enforced. No any paper regarding term and condition related to deposit of sticker of the lense with the O.P. has been shown to the Commission by the O.Ps.
7.     Papers annexed with the complaint petition are showing that claim for re-imbursement of medical expense has already been made in time and there is no denial about it. Photo copy of money receipt shows that complainant has paid Rs. 14,000/- to the hospital concerned towards expenses incurred during his treatment. Other money receipts are dt. 24.02.2016, 03.03.2016 & 08.03.2016 by which it is said that complainant has purchased medicines etc.
8.     On careful perusal of the pleadings of the parties and photo copy of the papers submitted by the parties, we are of the opinion that refusal of claim mere on the basis of non submission of sticker of the lense is unjustified because there may not be a practice of a particular hospital to furnish such sticker to the patients, however, patient was also not aware about it. No such terms and conditions have been brought on the record by the O.Ps. to justify their refusal of the claim. Therefore, we are of the opinion that prayer of the complainant is liable to be accepted.
9. Accordingly claim of the complainant is being allowed in the following manner :-

O.P. No. 3 is directed to pay Rs. 14,000/- (Rs. Fourteen thousand)as insurance claim amount to the complainant within 45 days from today, failing which he will pay interest @ 8% P.A. on the above amount from filing of the case i.e. 28.02.2018.

O.P. No. 3 is further directed to pay Rs. 5,000/- compensation and Rs. 5,000/- as litigation cost to the complainant within 45 days from today.