Jharkhand

Bokaro

CC/16/127

Anil Kumar Singh - Complainant(s)

Versus

Managing Director, Raksha TPA Pvt. Ltd. - Opp.Party(s)

Rajesh Pratap singh

14 Mar 2019

ORDER

Complainant Anil Kumar Singh has filed this case for claim of Rs. 4,00,000/- with 18% interest per annum and compensation of Rs 10,000/- for mental harassment and litigation cost of Rs. 10,000/-.

2          The case in short is that Anil Kumar Singh after retirement insured as beneficiary under mediclaim scheme of the retired employee of the SAIL, and his spouse. They have MIN No. 4736881 and his wife Lilawati Singh MIN 4736882 respectively and paid premium accordingly.

            On 26.04.2016 during treatment at Apollo Gleneagles Hospital, Kolkata . She was admitted on 21.03.2016 in the hospital. His wife has been covered under the mediclaim insurance for the period 01.04.2016 to 31.03.2017. The total cost incurred of Rs. 14,82,278/- from 21.03.2016 to 26.04.2016. It is alleged RS. 4,00,000/- was paid by insurance till 31.03.2016 (for the period of 01.04.2015 to 31.03.2016). directly to the hospital at Kolkata.

            It is further alleged that the claim application was filed before present TPA for Rs. 10,25,839/- after adjustment of Rs. 4,00,000/- paid to the hospital. It is alleged that even after sending legal notice, the O.P. has not replied the notice or rejected the claim, hence this complaint petition has been filed for deficiency in service.

3          Following documents have been filed by the complainant:-

Anx-1 Photo copy of renewal of mediclaim policy for the of 01.04.2016 to

           31.03.2017.

Axn-2 Photo copy of acknowledgment slip claim by TPA.

Anx-3 Photo copy of legal notice.

Anx-4 Photo copy of final interim bill of hospital.

4          O.P. No.1 and 2 appeared but has not filed W.S. as such they debarred from filing W.S.

5          O.P. IFFCO TOKIO General Insurance Co. Ltd. appeared and filed W.S. It is submitted that the complaint is frivolous and devoid of merits. The Policy is admitted for the period 01.04.2016 to 31.03.2017 and it is submitted that complainant has already got his claim settled as per terms and conditions of his previous policy which was in existence at the time of admission of his wife in the hospital. It is submitted that since the admission of his wife of the complainant was prior to the commencement to the instant policy, the claim lodged by the complainant is not payable which was reported to the complainant and therefore, there is no cause of action arose by the O.P.  to settle the claim.

6          No document has been filed by the O.P. No.3.

 

F I N D I N G S

7          We perused the record and hold the complainant is a consumer as a beneficiary along with his wife under the mediclaim scheme between SAIL and the Insurance co.

            It is admitted that the wife of the complainant was admitted on 31.03.2016 in the hospital and it is also admitted that the earlier TPA E-Meditek has paid Rs. 4,00,000/- directly to the hospital for the insurance period of 01.04.2015 to 31.03.2016.

            Now, the present Raksha TPA Pvt. Ltd. has not appeared and the claim has been filed, vide Anx-2, for the period 01.04.2016 to 31.03.2017. Therefore, the contention of the O.P. No.3 IFFCO TOKIO General Insurance Co. Ltd. that the claim has been settled, is erroneous and cannot be acceptable and therefore, we hold the insurance co. is liable for deficiency in service.

8          Accordingly we allow the claim of the complainant and direct the O.P. IFFCO TOKIO General Insurance Co. Ltd. to pay Rs. 4,00,000/- (Rs. Four lac) only with 10% interest per annum from the date of receipt of the claim i.e. 12.05.2016.

            Insurance Co. is further directed to pay compensation of Rs. 5,000/- (Rs. Five thousand) only for mental harassment and litigation cost of Rs. 2000/- (Rs. Two thousand) only.

            All the payment must be paid within 60 days of this order, failing which the rate of interest shall be enhanced to 18% per annum till realization on the main claim amount.

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