District Consumer Commission, Bokaro.
Case No. 22/2019
Date of Filing-19-01-2019
Date of Order-21-07-2022
Before:-
Shri Jai Prakash Narayan Pandey, President
Shri Bhawani Prasad Lal Das, Member
Smt. Baby Kumari, Member
Bhim Singh S/o- Late Parash Nath Singh
R/o- Qr.No. 1-171, Sector-2/A,
P.O. & P.S.- Bokaro Steel City, District- Bokaro, Jharkhand, 827002
Vs.
1. MD India Health Insurance TPA Private Limited
Branch Office at Plot No. C-19A, City Centre, Sector-4, P.O. & P.S.- Sector-4, Bokaro Steel City, District- Bokaro, Jharkhand, Pin 827004
2. Samuhik Durghatna Bima Samiti Sail, Bokaro Steel Plant, Bokaro Steel City
3. United India Insurance Co. Ltd.
H.O. GO XI G85 Himalaya House-8th Floor, Ag Marg
New Delhi-110001
Branch Office- Plot No. A-17, City Centre, Sector-4, P.O. & P.S- Sector-4, Bokaro Steel City, Bokaro
-Order-
Per- J.P.N Pandey, President
- Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 61,215/- with 18% per annum interest on account of medical expense incurred during treatment of complainant and to pay Rs. 25,000/- as compensation and Rs. 10,000/- as litigation cost.
- 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 vide MIN No. 742581 for himself and his wife which was valid from 01.04.2018 to 31.03.2019. During the enforcement of the insurance policy the complainant became ill and was firstly treated at BGH Bokaro , thereafter referred for treatment at Christian Medical College, Vellore, (In short CMC, Vellore) who intimated it to O.P. No.1 on 04.11.2018 thereafter, he was admitted on 04.11.2018 and discharged on 08.11.2018 from CMC, Vellore for which Rs. 61,215/- 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.
- O.P. No.2 SAIL/ BSL Bokaro appeared and has filed W.S. in which there is no comment on the claim of the complainant and it has been admitted that complainant has obtained mediclaim policy valid for relevant period.
- On behalf of O.P. No.1 & 3 (TPA & Insurance Co.) W.S. has been filed in which there is no specific denial in respect to facts mentioned in para 1 to 11 of the complaint petition. However, it is mentioned at para 4 & 6 of the W.S. that complainant was to provide some papers related to treatment but it has not been provided inspite of issuance of letters dt. 06.12.2018 and 16.12.2018 hence claim has been closed due to non submission of documents. It has also been mentioned that intimation to these O.Ps. was not given within 24 hours after admission in Hospital.
- On the basis of above pleadings I have to see whether complainant is entitled to get relief as claimed or not?
- It is admitted fact that complainant was fully covered with the insurance policy and for the alleged treatment he was entitled to have facility by the Insurance Co. Another admitted fact is that only on the basis of the fact that demanded documents were not submitted to the TPA and intimation was not given within 24 hours after admission in Hospital, claim has been closed. It is not the case that claim has been repudiated.
- Since genuineness of the documents is not in dispute hence it is not being discussed in detail. Only there is dispute that complainant has not provided demanded documents and has not given intimation to O.Ps. within 24 hours after admission, hence on this aspect discussion is being made. On perusal of the photo copy of the documents produced by the complainant it appears that complainant has submitted claim form for re-imbursement of Rs. 61,215/- along with all other relevant papers to the O.P. No.1 with due receipt dt. 15.11.2018 as it is apparent from photo copy of the letter dt. 14.11.2018 written by the complainant to the O.P. No.1. Further it is apparent from photo copy of letter dt. 04.11.2018 of the complainant that he has given intimation to the O.P. No.1 regarding admission on 04.11.2018 because on both the papers staff of the O.P. No.1 has made endorsement related to receipt with its date and it has not been challenged by the O.Ps.
- From perusal of repudiation letter dt. 20.02.2019 it is apparent that after filing of this case on 19.01.2019 the O.Ps. have closed the claim on the ground that inspite of repeated requests vide letter dt. 06.12.2018 and 16.12.2018 and also on the ground that intimation was not given within 24 hours after admission in the hospital claim has been closed. On perusal of said letter it appears that attested photo copy of Indoor case paper, patient’s health history/ personal information/pre-operative Anesthesia information, day to day treatment chart of the hospital with daily doctors visit notes have been demanded by the O.Ps. In my opinion the demanded papers are such papers which are usually not being provided by the hospital to the patients. Therefore, I am of the opinion that mere on hyper technical grounds claim has been closed by the O.P. No.1 & 3 inspite of submission of all relevant papers in time and intimation on same day. I would like to mention here that subsequently demanded documents are usually not being provided by the Hospitals to the patients. Hence I am of the opinion that there is deficiency in service by the O.P. No.1 & 3 hence claim of the complainant is liable to be accepted. Accordingly this point is being decided in favour of the complainant.
8 Accordingly prayer of the complainant is being allowed in the manner indicated here in below:-
O.P. No. 3 (United India Insurance Co. Ltd.) is directed to pay Rs. 61,215/- to the complainant within 60 days on receipt/production of this order otherwise this O.P. shall pay interest @ 10% per annum from 19.01.2019 (the date on which complaint was filed) on that very amount. Further this O.P. is directed to pay Rs. 3000/- as compensation for various type of harassment and also to pay Rs. 2000/- as litigation cost within 60 days from today.
