Jharkhand

Bokaro

CC/18/72

Buddhi Nath Mishra - Complainant(s)

Versus

Iffco Tokio General Insurance Co. Ltd. - Opp.Party(s)

Ram Lal Gope

07 May 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 72/2018

 Date of Filing-21-06-2018

 Date of Order-07-05-2022

Buddhi Nath Mishra, S/o Late Baidya Nath Mishra,

R/o- Q.No- 709, Sector-3/D, B.S. City Thana, P.O- Sector-II, District- Bokaro Jharkhand.

                                      Vr.

1. M/s Iffco Tokio General Isurance Co. Ltd. Unit Nos. 52-63 Mezzanine floor Ansal Fortune Arcade Sector 18, Noida, Uttar Pradesh

2. Raksha TPA Pvt. Ltd. An ISO 9001:2008 Certified Co. Branch Office ato MF-12, City Centre, Sector- IV, B.S.City, Jharkhand, Pin- 827004

3. Sail/Bokaro Steel Plant Chif Executive Officer Ispat Bhawan Administrative Building, 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. 14,254.55 with interest @ 12% per annum  on account of medical expense  and to pay Rs. 10,000/- & Rs. 5,000/- as compensation and litigation cost respectively to him.
2. Complainant’s case in brief is that he is retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy which was covering the OPD treatment at BGH and indoor patient treatment at different hospitals. During the enforcement of the insurance policy complainant and his wife were treated at BGH as OPD patient and from 03.03.3016 to 15.02.2017 they purchased medicines of Rs. 5325.55/- and 8929/- prescribed by the Doctors. Further case is that policy is covering Rs. 4,00,000/- for treatment and for reimbursement of the amount, 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 appeared on 13.12.2018 but has not filed any W.S. in the case. Inspite of due service of notice O.P. No.2 has not appeared hence case is being proceeded Ex-parte against them.
4.  O.P. No.3 appeared and has filed W.S. admitting the insurance coverage of the complainant and his wife and it is mentioned that in respect to OPD treatment Rs. 4000/- is payable to the Ex-employees and their spouse who are below the age of 70 years and Rs. 8000/- is payable to the employees and their spouse above the age of 70 years on their treatment within all Government/SAIL/SAIL recognized hospital.
5.  Record shows that initially O.P. No.1 has shown interest in settlement of the matter but later on said O.P. left to take any interest in the matter. Hence case has been taken up for decision on merit.
6. As documentary evidence Annexure 1,2 and 3 are the photo copy of acknowledgement slip dt. 07.03.2017, photo copy of claim form of OPD and photo copy of postal receipts. Annexure 4,5 and 6 are the photo copy of acknowledgement slip dt. 07.03.2017, photo copy of claim form of OPD and photo copy of mediclaim scheme and Annexure 7 is the photo copy of legal notice which have been filed by the complainant.
7.   From perusal of Annexure 1 and 4 it appears that claim of the complainant and his wife was received by the Raksha TPA Pvt. Ltd. Bokaro on 07.03.2017 and on same day claim form of OPD was also received which have been acknowledged with due receipts. It also appears from annexure 2 and 5 that through OPD claim form complainant and his wife have submitted all the original receipts/bills regarding purchase of medicines and those receipts have been dully acknowledged by the TPA. In this way it is apparent that the complainant has well proved the fact that through proper receipts he has purchased the medicines on advise of the doctors of BGH as it is apparent from Annexure 2 and 5. Contrary to it there is no pleading or evidence by O.P. No1 & 2 to disprove above facts.
8.  On perusal of para-3 (ii) and para-7 of the W.S. of O.P. No.3  it appears that any retired employee of the SAIL is entitled to get upto  Rs. 4000/- reimbursed in case  he is below the age of 70 years and he will get upto Rs. 8000/- reimbursed in case he is above the age of 70 years.
9.  

 

10   Thus we find and hold that the claim of the complainant is being   

    allowed in the manner indicated here in below:-

O.P. No.1 and 2(Insurance Co. & TPA )are directed to pay Rs. (5326+4000) = 9326/- (Rs nine thousand three hundred twenty six) only to the complainant within 60 days from today otherwise they will pay interest thereon @ 10% per annum from 21.06.2018 (the date of filing of the case). Further they are directed to pay Rs. 1000/- as compensation related to various type of harassment and Rs. 1000/- as litigation cost within 60 days from today.