Complainant Sachindra Prasad Pandey filed this complaint with a claim of Rs. 4,08,362/- with interest 18% since 26.08.2016 and compensation of Rs. 2,00,000/- for harassment.

2          The case of the complainant is that the complainant is a retired SAIL employee and covered under the Mediclaim scheme of the SAIL. On 22.06.2016 the complainant met with an accident and sustained injury leading to multiple fractures and permanent loss of vision in right eye. He was admitted in RB memorial Hospital on 22.06.2016 at Darbhanga from where he was referred to higher centre for further treatment on 23.06.2016 and he was admitted in Rajeshwar Hospital, Patna from 23.06.2016 to 08.07.2016. Thereafter, he submitted medical bills for reimbursement of Rs. 4,08,362/-  and submitted the claim to the Raksha TPA on 26.08.2016 but TPA did not clear the bills and assured to clear within 15 days and also asked in the first week of January, 2017 and asking some verbal enquiry which was submitted on 10.01.2017 and dully received by the TPA. Again the TPA submitted a printed query letter dt. 18.03.2017 but since the papers already were submitted in the office of TPA, they have asked for this query. However, he again submitted reply on 31.03.2017.

            The TPA even after 8 months had not cleared the bills and taken time unnecessarily which is deficiency in service. He also submitted the scheme is for Rs. 2,00,000/- for each member (wife and husband) and in case, the amount can be clubbed in the year. Thereafter, legal notice was sent but there is no reply and hence this case.

3          The following Anxs have been in support of the claim:-

Anx-1 &1/1 Copies of Discharge Certificate.

Anx-2 to 2/30 Copies of medical bills.

Anx-3 Copy of Money Receipts.

Anx-4 , 4/1 and 4/2 Copies of Receipt of the claim by TPA.

Anx-5 & 5/1 Copies of query dt. 23.03.2017 and 30.03.2017.

Anx-6 Copy of legal notice.

4          O.P. No.1 and 2 IFFCO TOKIO General Insurance Co. Ltd. appeared and filed joint W.S.  It is submitted that the complaint is not maintainable, however, the policy is admitted for the period of 01.04.2016 to 31.03.17 for Rs. 2,00,000/- -per member with clubbing (Floater) facilities under hospitalization as per the terms and conditions. It is submitted that the complainant was discharged on 08.07.2016 but had not given any information which is violation of terms and conditions of 7.1. It is submitted that the claim is still pending due to non submission of documents which was asked by letter dt. 18.03.2017 and the claim of the complaint is wrong and false that he was being harassed and liable to be dismissed.

The O.P. has also filed the documents which have already been filed by the complainant. Therefore, there is no need to repeat the Anxs by the O.P.

5          O.P. No.3 Raksha TPA has not appeared in spite of notice served upon him and Ex-Parte proceeding is initiated.

                                                F I N D I N G S

6          We perused the record and find, the complainant is consumer being beneficiary under the Mediclaim scheme between SAIL and IFFCO TOKIO General Insurance Co. Ltd. and since the premium has been received by the O.P. therefore, the complainant is a consumer and the dispute is a consumer dispute.

7          On perusal of the documents filed by the complainant as well as the O.P. it is admitted position that the complainant is beneficiary under the Mediclaim scheme in between the SAIL and Insurance Co. It is also admitted regarding clubbing of claim of Rs. 2,00,000/- for each member. The only objection by the insurance co. is that during the admission in the hospital, no information was given within 48 hours which is violation of the terms and conditions. The objection raised by the O.P. is highly technical in nature and for this reason the claim of the complainant cannot be denied for the natural justice. Therefore, the objection raised by the O.P. cannot be accepted and this is deficiency in service on the part of the insurance co.

            TPA employed by the insurance co. has not denied the genuineness of the claim of the complainant. Therefore, as per the terms and conditions of the Mediclaim policy by clubbing (Floater) the claim of the complainant, Rs. 2,00,000/- each for the members (Wife and husband), the complainant is entitle for reimbursement of Rs. 4,00,000/-. The insurance Co. is liable for the payment.

8          Accordingly we allow the claim of the complainant upto Rs. 4,00,000/- after clubbing the insurance cover of both the spouse. Thus we direct the O.P. IFFCO TOKIO General Insurance Co. Ltd. to pay Rs. 4,00,000/- (Rs. Four lac) only with interest of 8% per annum from the date of submission of claim on 26.08.2016 till realization.

            The O.P. Insurance co. is further directed to pay compensation of Rs. 3,000/- (Rs. Three thousand) only for mental harassment and Rs. 1,000/- (Rs. One thousand) only as litigation cost.

            All the payments must be paid within 60 days of this order, failing which the rate of interest on the main claim shall be enhanced to 12% per annum till realization to the complainant.