Complainant Sri Ram Ashray Choudhary has filed this complaint for a claim of Rs.53,991/- with 18% interest from the date of the claim submitted to O.P., and Rs. 55,000/- Compensation for mental harassment and litigation cost of Rs. 10,000/- .

2          The case of the complainant in short is that complainant took group insurance mediclaim scheme under SAIL in the year 2011 and MIN No. has been allotted to him as well as to his spouse Sheo Kalo Devi. The Policy has been renewed from time to time since 2011 to 2014 and extended up to 31-03-2015. During the coverage period of the policy his wife Smt Sheokalo Devi having Min No. 4713115, suffered from kidney problem and she was admitted in Bokaro General Hospital (B.G.H) on 18-12-2014 at 3:40 PM and discharged on 21-01-2015 from B.G.H. and the complainant paid a sum of Rs. 53,991/- and for the reimbursement of the same was filed with claim on 30-01-2015 to T.P.A., E-Meditek but the payment is held up till date. Late Sheokalo Devi expired in B.G.H. on 11-02-2015. The complainant approached the O.P. several times and lastly on 04-02-2016 but the amount has not been paid which is deficiency in service on the part of the O.P.

            A legal notice was sent on 06-02-2016

3          Complainant has filed the following documents.

            Anx-1&1/1 Copies of payment and renewal of Mediclaim Poilcy.

            Anx-2- Copy of the Medical book of Sheokalo Devi.

            Anx-3 &3/3 Copies of the Prescriptions and Admission forms, Medical Book

            Anx-4 to  4/7 Copies of Medical bills.

            Anx-5 Copies of Discharge Ticket.

            Anx-6- Death Certificate of B.G.  H.

            Anx-7- Receiving of the T.P.A. for the claim

            Anx-8- Copy of the legal Notice.

4          O.P. No. 1& 3 E-Medictek appeared and filed W.S. It is submitted that an amount of Rs. 36,000/- has been paid to the complainant on 11-01-2016 for the maximum payable in the case of Hernia of Rs40,000/-.

5          O.P. No. 2 National Insurance Co. ltd. has appeared and filed W.S. along with  Anx-A, Anx-B.

            It is submitted the complaint is not maitainable and the complaint is filed on baseless statements since the complainant has not submitted IPD papers with daily nursing prognosis chart with medicines administered for justification of higher antibiotics . therefore the TPA has not clear the claim mentioning “No active line of treatment” and therefore the claim was denied and therefore the claim of the complainant is not genuine and valid and it is liable to be dismissed.

            Anx-A is the copy of the No claim letter and Anx-B is the copy of the terms and conditions.

FINDINGS

6          We perused the record, since complainant has paid premium for the Mediclaim scheme of the SAIL therefore the complainant and his wife are beneficiaries under the scheme. Thus we hold the complainant is a consumer in this case and the dispute is a consumer dispute.

7          The O.P. National Insurance co. has not denied the policy and beneficiaries status of wife of the complainant late Sheo Kalo Devi. The only objection for not clearing the claim is that the complainant has not filed attested copy of IPD papers of the B.G.H. for treatment of his wife who later expired in B.G.H.

            The objection of the O.P. is highly technical which is against the principle of natural justice and therefore we hold the O.P. National Insurance Co. is liable for the deficiency in service.

            The complainant has filed Anx-4 series for the expenses on purchasing medicine as per the advice of doctors in B.G.H. which amounts to Rs. 49,887.85(Forty Nine Thousand Eight Hundred Eighty Seven and Eighty Five Paisa Only) in rounded figure 49,880/-(Forty Nine Thousand Eight Hundred Eighty Only) for which the complainant is entitled against the claim of Rs. 53,991/- and the O.P. insurance company is liable to reimburse the claim upto Rs.49,880/- (Forty Nine Thousand Eight Hundred Eighty Only).

8          Thus we allow the part claim of the complainant and O.P. National Insurance co. is directed to pay Rs. 49,880/- with interest of 8% (Eight Percent)P.A. since 30-01-2015, the date when the claim was received by TPA appointed by the Insurance Co.

            O.P. Insurance Co. is further directed to pay compensation of Rs. 5000/- (Five Thousand only) and litigation cost of Rs.2000/-(Two Thousand) to the complainant

            All the payment must be paid within 60 days of passing of this order felling which rate of interest on the allowed claim amount shell be enhanced to 12% P.A.(Twelve Percent) till realization.