Jharkhand

Bokaro

CC/16/52

Baidh Nath Prasad Sharma - Complainant(s)

Versus

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

31 Jan 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-07-06-2016

Date of final hearing-31-01-2023

 Date of Order-31-01-2023

Case No. 52/2016

Baidh Nath Prasad Sharma

R/o QR.No. 317, St-19, Sector-9/C, P.O.- Sector-9,

P.S.- Harla, District- Bokaro

Vs.

1. E- Meditek (TPA) Services Limited

577, Udyog Vihar, Phase V, Gurgaon, Haryana, 122016

2. National Insurance Company Limited

III rd Floor, 6/90, Padam Singh road, Karol Bagh, New Delhi 11005

 

                             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 for direction to O.Ps. for payment of Rs. 36,498/- + Rs. 38,399/- with 18% per annum interest on account of medical expense incurred during treatment of his wife.
2. Complainant’s case in brief is that he is a retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy for himself and his wife. His wife was provided MIN No. 4724129 which was valid at the relevant time. Further case is that due to illness wife of the complainant was admitted in CMC, Vellore Hospital and hospitalization charge was paid by the O.Ps. Further case is that again she was admitted in Bokaro General Hospital (in short BGH) on 10.11.2014 and discharged on 29.11.2014 thereafter she got herself treated at Max Hospital, New Delhi as OPD patient during which she incurred Rs. 26,152/- as treatment cost etc. Further case is that again she was admitted in KGN Health Centre on 01.03.2015 and discharged on 07.03.2015 for which Rs. 38,399/- was paid but inspite of repeated requests O.Ps. have not paid her claim. Hence this case has been filed with above mentioned prayer. 

 

3.   O.P. No. 1 has not appeared inspite of due service of notice.

4. On behalf of O.P. No.2 (National Insurance Co. Ltd.) W.S. has been filed in which it is mentioned that there is no proper line of treatment to the claimant. Further reply is that the KGN Hospital does not come within purview of the hospital as per rules of IRDA. Further it is mentioned that  “Hospital” means any institution established for inpatient care and day care treatment of sick-men and for injuries and which has been registered as a hospital with the local authority wherever applicable and is under the supervision of registered and qualified medical practitioner,
5.  

1. Has at least 10 inpatient bed in those towns having a population of at least 10,00,000 and 15 inpatient beds in all other places.
2. Has qualified nursing staff under its employment round the clock.
3.        Has qualified practitioners round the clock.
4. Has fully equipped operation theater of its own where surgical procedures are carried out.
5. Maintain daily records of patients and will make their accessible to the insurance authorized personal.

Further reply is that as per IRDA norms concerned hospital is not fulfilling the criteria of hospital hence claim has been rightly repudiated and case is liable to be dismissed.

 

5. On the basis of above pleadings we have to see whether complainant is entitled to get relief as claimed or not?
6. On careful perusal of the reply of the O.P. Insurance co. it is very much clear that no ground shown in the W.S. regarding rejection of the partial claim related to Rs. 26,152/- which was in respect to post hospitalization treatment at Max Hospital, New Delhi within 60 days from discharge of the patient on 29.11.2014 from BGH. As per policy terms and conditions OPD treatment in respect to same disease upto the period of 60 days from the date of discharge in respect to that very particular disease/illness for which hospitalization had taken place.  Therefore, it is very much clear that during post hospitalization the complainant has paid Rs. 26,152/- for which he is entitled to get it be reimbursed which has not been done nor it has been replied in the W.S.
7. So far, the claim related to payment to KGN hospital is concerned it has been denied on the ground of hospital criteria as per the norms of the IRDA. On this aspect there is no evidence by the complainant to show that said hospital comes within purview of the definition of the hospital or said hospital was registered with local authority as hospital. Therefore, said claim is not admissible and denial of payment to that very extend is justified.
8. In light of above discussion we are of the view that part of the prayer of the complainant only in respect to payment of Rs. 26,152/- is being substantiated for which he is entitled to get relief. However, rest part of the claim of the complainant has not been proved hence prayer is liable to be partly rejected. Accordingly there is deficiency in service to that very extent by the O.Ps.
9.   Accordingly prayer of the complainant is being partly allowed in the following manner:-

         O.P. No. 2 National Insurance Co. Ltd. Is directed to pay Rs. 26,152/- to the complainant within 60 days from receipt/production of the copy of this Judgment, failing which he will pay interest @ 10% per annum  on that very amount from 07.06.2016 (i.e. the date on which case was filed). Rest of the prayer is being partly rejected.

J.P.N. Pandey)

                                                                                      President

                                                                                     

         

  (Baby Kumari)

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