Jharkhand

Bokaro

CC/18/149

Chhotelal 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. 149/2018

     Chhotelal Singh

     R/o Qr.No. 2-524, Sector-2/C, Boakro,

      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. 37,200/- 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. 4709394 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 05.01.2018 and discharged on 11.01.2018 from the hospital for which Rs. 37,200/- 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 having no impact. 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 in which it is mentioned that as per policy contract claim has  to be ascertained and original discharge summary, bifurcated and consolidated bill, investigation report with detailed information of hospital and doctor on it, of the complainant as hospitalization proof is not provided by the complainant for verification. Further ground is that the claim has been repudiated as there is manipulation in claim documents. Further reply is that during investigation/enquiry it was found that ‘ there is no existence of any hospital namely Bokaro Health Care Hospital. The hospital is permanently closed for last five-six months’. Further reply is that chemist shop Multi Medicle Hall from which medicines were purchased is located 15 K.M. away from the hospital which is clear that something is fishy. Further reply is that the Laboratory Health Care Diagnostics from which the investigations are claimed to be done does not have any records. There was no computer, no register in the lab so computerized lab reports are not possible. There is no admission note or prescription of doctor showing the patient needed to be admitted and further needed oxygen for saving life. Further reply is that on scrutiny of documents it was also found that treating doctors name was not mentioned that means that there was no doctor for treatment. In this way under collusion with the complainant it is attempt to grab the mediclaim amount. Further reply is that as per clause 5.8 of the Group Mediclaim Policy “the company shall not be liable to make payment under this policy in respect of any claim if such claim be in any manner fraudulent or supposed by any fraudulent means or device whether by the insured person or by any other person acting on his behalf”. Further reply is that as per IRDA norms concerned hospital is not fulfilling the criteria of hospital hence claim has been rightly repudiated and case is liable to be dismissed.
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 that during investigation it was found 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. The owner of the hospital has verbally confirmed that said hospital has been permanently closed. Photo copy of discharge ticket shows that no any detail has been mentioned in it and description of the doctor has also not been mentioned in it. 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. There is no evidence on record to show that there was need of admission of the complainant in the hospital.
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 rather photo copy of investigation report along with photo copy of some photographs are justifying the reply given by the O.P. insurance co. 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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