Jharkhand

Bokaro

CC/18/144

Baleshwar Singh - Complainant(s)

Versus

MD India Health Care Service (TPA) Pvt. Ltd. - Opp.Party(s)

Amardeep Jhaa and Poonam

13 Feb 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-22-11-2018

Date of final hearing-13-02-2023

 Date of Order-13-02-2023

Case No. 144/2018

     Baleshwar Singh

      R/o Qr.No. 397, Sector-3/A, P.O. + PS- B.S.City,

      District Bokaro, Jharkahnd

Vs.

    1. MD India Health Care Service (TPA) Pvt. Ltd.

        S.No. 46/1 E-space A-  2 building, 3^rd floor, pune, Nagar Road,

        Vadgaon, Sheri, Pune (Maharashtra), Pin 411014

    2. Divisional Manager, United India Insurance Co. Ltd.

        At Plot No. A/17, Second Floor, Sector-4, City Centre,

        Sector-4, Bokaro Steel City

     3. D.G.M. Personal SAIL Corporate Office,

         SAIL Ispat Bhawan, Lodhi Road, New Delhi                        

 

Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

 

PER- J.P.N Pandey, President

-Judgment-

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 32,173/- on account of medical expense incurred during treatment of complainant  and to pay Rs. 20,000/-  as compensation and Rs. 10,000/- as litigation cost.
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 for himself and his wife and O.Ps. have provided  him MIN No. 4745537 which was valid at the relevant time. Further case is that due to illness complainant got himself admitted in Bokaro Health Care Hospital at Plot No. 109, Co-operative colony, Bokaro Steel City, District Bokaro (Jharkhand)  on 27.01.2018 and discharged on 02.02.2018 from the hospital for which Rs. 32,173/- was paid to the hospital by the complainant. Complainant applied for reimbursement of the above amount but inspite of repeated requests no action was taken by the O.Ps.  Thereafter legal notice was served which has been replied negatively. Hence this case has been filed with above mentioned prayer.  

 

3.   O.P. No.1 & 3 TPA and SAIL/ BSL Bokaro respectively have not appeared inspite of due service of notice.
4. On behalf of O.P. No.2 (United India Insurance Co.) W.S. has been filed mentioning therein that case is time barred and claim has been repudiated as there is manipulation in the claim documents hence claim is not maintainable as per policy clause mentioned. As per clause 5.8 of the policy, company shall not be liable to make payment under this policy in respect of any claim of such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the insured person or by any other person acting on his behalf, hence the claim does not fall within the purujed of the policy terms and conditions hence it is prayed to dismiss the case.
5. On the basis of above pleadings we have to see whether complainant is entitled to get relief as claimed or not?
6. On careful perusal of the papers annexed with the complaint petition it appears that complainant claims himself  to be treated at Bokaro Health Care Hospital about which it is said vide reply dt. 31.07.2018 (Annexure-C) by the O.P. on  legal notice of the complainant (Annexure-C) that during investigation it was found that said hospital was closed from last five to six months. About that very hospital it is said that it is not fulfilling criteria of a hospital as per IRDA norms. To meet that very objection there is no any evidence by the complainant to contradict the reply given by the O.P.  As per photo copy of reply to legal notice of the complainant it is clear that during investigation by O.P. it is found that concerned laboratory was having no computer and there was no any record maintained but the papers submitted are computer print out of that very laboratory. On this aspect also there is no evidence of the complainant.
7.  Therefore, in light of above discussion we are of the view that complainant is not able to prove its case for grant of relief as prayed. Accordingly this point is being decided against the complainant.

9 Accordingly prayer of the complainant is being dismissed. In the facts of the case parties shall bear their own costs.

 

(J.P.N. Pandey)

                                                                                      President

                                                         

         

                                                                               (Baby Kumari)

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