Jharkhand

Bokaro

CC/17/159

Ram Swarup Prasad - Complainant(s)

Versus

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

08 Mar 2019

ORDER

This complaint is filed by the husband Ram Swaroop Prasad, duly permitted by the forum to represent the consumer Munki Devi for a claim of Rs. 58687 and compensation of Rs.15000/- and  litigation cost of Rs. 5000/-

2          The case in short is that Ram Swaroop Prasad is an ex-employee of the SAIL having MIN No. 4711654 and her wife Munki Devi has MIN No. 4711655.

            Munki Devi was treated through operation of her fractured Right Femur bone in Bokaro General Hospital (B.G.H.) on 31-03-2017. Being SAIL employee treatment was given free but medicine was purchased outside on the prescription of the doctor. She put her claim through proper channel to the Insurance Company through T.P.A. appointed for the year 2016-17. But her claim has not been paid till filing of the complaint. Hence this complaint is filed.

3          The following documents are filed in support of the claim:-

            Anx-1- Copy of renewal of mediclaim for the year 2016 period till   31-03-2017.

            Anx-2- Copy of Query letter dt. 01-05-2017

            Anx-3- Copy of letter to CEO- TPA for claim

            Anx-4&4/1- Copy of Admission record of B.G.H.

            Anx-5 to 5/2- Copies of Treatment chart of B.G.H.

            Anx-6 to 6/5- Copies of medicine bills purchased outside.

4          O.P. No.1 IFFCO TOKIO General Insurance Co. ltd. appeared and filed W.S. It is submitted that the complaint is frivolous, vexatious and not maintainable. It is admitted that wife of the Ram Swaroop Prasad was admitted in B.G.H. for operation on 16-03-2017 and after operation on 31-03-2017 she was discharged on 14-04-2017 and claim was submitted before TPA. It is submitted that due to non submission of some of the documents, the claim could not be processed as pre- mature.

            The policy is admitted for the period 01-04-2016 to 31-03-2017 there is no deficiency in service and this O.P. is not liable.

5          O.P. No.2 T.R.A. has not appeared after notice hence, ex- parte proceeding has been started.

6          O.P. No.3 SAIL Bokaro appeared and filed written statement. It is submitted that this O.P. is only concerned to inform claim to TPA on request of the member of the mediclaim. Therefore, there is no deficiency of his part.

            O.P. No.1 has filed copy of the policy Anx-A and Anx-B, term and condition, Anx-C list of the hospitals.

FINDINGS

7          We perused the record and found that Munki Devi wife of Ex- SAIL employee is a beneficiary of the mediclaim policy between SAIL and the insurance company on payment of premium. Hence we hold that she is a Consumer and the dispute is consumer dispute.

8          The contention of O.P. Insurance Co. that necessary documents for process were not submitted and claim could not be processed. But by the documents submitted by the Complainant which was not controverted by the O.P. No.3 SAIL in its W.S., is sufficient to show that plea of the Insurance Company is highly technical and cannot be accepted. The copies of the prescription and medicine bills submitted are sufficient to support the claim. On such a flimsy ground the claim of the Complainant cannot be kept in abeyance of the process. Therefore, we found there is a deficiency on the part of the O.P. Insurance Company who is liable to pay the claim.

9          Accordingly, we allow the claim of the complainant. We direct O.P. IFFCO TOKIO General Insurance Co. Ltd. to pay Rs. 58687/- to the complaint with interest @ 6% till realisation.

            We further direct to pay compensation of Rs. 5000/- and litigation cost of Rs. 2000/- to the complainant.

            All the payment must be paid within 60 days of this order failing which the rate of interest on main claim shall be enhanced to 10 % p.a. till realisation.