Jharkhand

Bokaro

cc/15/122

Bhuwaneswar Pathak - Complainant(s)

Versus

Managing Director - Opp.Party(s)

Rajesh Pradeep Singh

09 Jan 2019

ORDER

This case has been filed by the complainant Bhuwaneshwar Pathak for a claim of Rs. 29,000/- as hospitalization charge with 18% interest along with compensation of Rs. 10,000/- and litigation cost Rs. 5000 with other reliefs.

2          Complainant Bhuwaneshwar Pathak is an ex-employee of Bokaro Steel Plant and he retired on 31.07.2007. After retirement complainant took Mediclaim Policy covered himself and his wife (Manorama Devi) under the Mediclaim scheme. Their policy had been renewed for the period 01.04/2015 to 31.03.2016 by paying the adequate renewal fees/charges.

                        The present claim of the complainant of Rs. 29,000/- for medicine and hospitalization between the period 22/04/2015 and 24/-4/2015 at Bokaro General Hospital for the treatment of Ca Prostate has been repudiated just to harass the complainant.

            It is further stated by the complainant that opposite parties have arbitrary and malafide repudiated the claim of Rs. 29,000/- of the complainant without any valid justification just to harass the complainant who is an old aged retired person which amount to deficiency in service as well as unfair trade practice by the E-Meditek (TPA) Services Ltd. as well as by the United India Insurance Ltd. for which both of them are equally liable.

3          Anx-1- Photo copy of order of rejection of claim.

Anx-1/1- Photo copy of reply of legal notice to petitioner.

Anx-2 to 2/1- Photo copies of Legal  Notice.

Anx-3 to 3/1 Photo copy of claim receiving slip and claim form.

Anx-4 to 4/2 Photo Copies of Discharge  Ticket.

Anx-5 to 5/2 Photo Copies of Retail Invoice.

 

4          After issuance of notices, opposite parties appeared but O.P. No. 1 & 2 has not filed W.S. after getting several adjournments.

            O.P. No.3 United India Insurance Co. Ltd. has filed W.S.

            It is stated that complainant has no cause of action against this O.P. and there is no deficiency in service on the part of the O.P. It is further stated that as per policy important exclusions and term and conditions the above claim of the applicant is not payable under SAIL Mediclaim Scheme and this insurance company shall not be liable to made any payment in respect of any expenses whatsoever insured by the insured by insured hospitalization on charged in which radiological/laboratory investigation/ other diagnostic studies have been carried out which are not consistent with or incidental to the diagnosis of treatment of positive existence or presence of any ailment sickness or injury for which confinement at any hospital/Nursing Home has taken place. It is further stated that complainant was admitted on 20.04.2015 was treated with injection Luprid and was discharged on 22.04.2015. The admission in this regard for the same, the above claim is not payable as per above exclusion clause No. 5.6 under SAIL Mediclaim scheme, the insurance company is not liable to make any payment in respect of any expenses whatsoever incurred by the insured person and the above facts and circumstances of the case, the claim against this O.P. is not legally maintainable and liable to be dismissed with cost.  

5          Following documents have been filed by the opposite party in support his case:-

Anx-A Photo copy of Medical Policy.

                                                           

F I N D I N G S

6          We perused the record and the documents filed by both the sides.

            We hold, at first that complainant, being beneficiary under the SAIL Mediclaim Scheme, is a consumer and the dispute is a consumer dispute.

7          The main claim of the complainant of Rs. 29,000/- was repudiated by the TPA and the Insurance company only on the ground of exclusion clause NO. 5.6 of the terms and the conditions.

            The exclusion clause is seemed to be arbitrary and against the natural justice. A consumer has to abide by the advice of doctor for the treatment and necessary diagnostic test. There is no proof provided by the O.P. insurance company that the complainant got himself admitted in the hospital without any need for treatment. The complainant being beneficiary has nothing to do with the terms and condition which is against the natural principal of justice. Therefore, the ground of repudiation is not accepted and we hold the O.P. M/s United India Insurance Co. Ltd. is liable for deficiency in service.

8          In the result, the main claim of the Rs. 29,000/- as per bills receipts is allowed with interest 6% P.A. from the date of the claim i.e. 18.05.2015.

            The O.P. M/s United India Insurance Co. Ltd. is hereby directed to pay Rs. 29,000/- (Rs. Twenty nine thousand) only with interest of 6% P.A. since 18.05.2015 till realization. O.P. is further directed to pay compensation of Rs. 2000/- (Rs. Three thousand) only and litigation cost of Rs. 1500/-(Rs. One thousand five hundred) only.

            All the payments must be paid to the complainant within 60 days of this order, failing which rate of interest shall be enhanced to 10% p.a. till realization.