BEFORE THE SOUTH MUMBAI  DISTRICT  CONSUMER DISPUTES REDRESSAL FORUM,

                                                           O.No.

Complaint No.SMF/MUM/CC/2014/175

   Date of filing : 11/07/2014                                                                                                     

                                                                           Date of Order:  25/09/2017

Leela Jose,

101, Rajmata CHS Ltd.,

Plot No. 31, Near RTO,

Andheri (West),

Mumbai.                                                             ….. Complainant.    

  V/s.

1.MDINDIA HEALTHCARE
   SERVICES (TPA) Pvt.Ltd.,

   Kimatrai Bldg, 77-79, Third Floor,

   Maharshi Karve Marg,

   Marine Lines, Mumbai – 400 002.

2. UNITED INDIA INSURANCE CO.LTD.,

    DO-XI, E-85, Himalaya House,

   8^th Floor, K.G. Marg,

   New Delhi – 11 0001.                             ….. Opposite Party/ies

                    Coram:

Shri. G.K. Rathod                :   Hon’ble President

Shri. S.R. Sanap                   :   Hon’ble Member

Appearance:  Complainant             –        Shri. C .A. Jose (On Authority)

(Husband of the Complainant)  

                       For Opponent No. 1           -        Ex-parte

                       For Opponent No. 2 -        Adv. Smt. Krishna D. Sharma       

// J U D G M E N T //

PER SHRI. G.K. RATHOD – HON’BLE  PRESIDENT

              The Complainant has filed this complaint against the Opponents as she is consumer within the meaning of the Consumer Protection Act, 1986. The First Opposite Party is engaged in the business of Third Party Administrator Healthcare Services and the settlement of the claims under Group Mediclaim Scheme for Retired Employees of Steel Authority of India Ltd. and their spouses and they are carrying on their business at the aforesaid address.  The Opposite Party No. 2 is the Insurance Company appointed by Steel Authority of India Limited to provide healthcare insurance services to the retired employees of Steel Authority of India Ltd. and their spouses.  The Complainant was a member of Group Mediclaim Scheme 2012 for retired employees of Steel Authority Of India Limited and continued to be so also with MIN No. 8303989 and under the Scheme, she is entitled to receive maximum amount of Rs. 2,00,000/- per annum from the TPA / Insurance Company towards hospitalized treatment on presenting the claim for reimbursement alongwith supporting documents. 

(2)              The Complainant was admitted to Vaidyaratnam Nursing Home, Thrissur, Kerala 680306 on 20/09/2012 and discharged on 09/10/2012 for the treatment of  SANDHIGATAVATHAM (severe pain on knees and ankles). Claim intimation in the prescribed form alongwith attending Doctor’s certificate was sent to the Opposite Party and she was allotted Authorization No. CCN MDI 1411230 by the Opposite Party No.1. The claim was submitted with the Opponent for the claim amount of Rs. 37,766.31paise. The said claim was repudiated by the Opponent on 19/12/2012 quoting some clause which does not appear anywhere in the Booklet titled “Group Mediclaim Scheme 2012 for retired employees of Steel Authority of India Limited.  It is further submitted that the Opponent repudiated her claim in contravention of Clause No. 6 of the said Booklet, which entitled the member to get admitted to any hospital or Registered Nursing Home in India.   Her spouse  C.A. Jose had been writing letters and sending emails to the Opponent for  speedy settlement of her claim but no use.  As there is a deficiency in service on the part of the Opponent Nos. 1 and 2 and has caused immense mental agony and distressed to her and his spouse by repudiated her claim.  Therefore, this complaint is filed for the repayment of Rs. 37,766.31 paise alongwith an interest @ 18% from 01/12/2012 till the reimbursement of the claim amount, as also claimed Rs.30,000/- towards the cost of the compensation and expenses incurred throughout the proceedings, Rs. 50,000/- towards the cost of immense mental agony and distress caused to the Complainant. 

(3)               To support her contention, the Complainant has filed affidavit, written arguments alongwith the documents has also orally argued.

(4)               The matter proceeded exparte as against Opposite Party No.1.

(5)               The Opponent No. 2 has filed their written statement alongwith documents.  The Opponent N0. 2 has denied the contentions of the complaint in toto.  It is submitted that the Complainant has taken the treatment in Nursing Home, which is not in the list of approved hospitals of the Opponent No. 2  and she has also taken OPD treatment and therefore, it is crystal clear that the Complainant’s claim is rightly repudiated. There is no deficiency in service and unfair trade practice on the part of the Opponent No.1.

To support their contentions, the Opponent No. 2 has filed affidavit, written arguments,  has also orally argued.

(6)              From the above facts and circumstances, the following points arouse for our consideration.

Reasoning :-

(7)                        After perusal of all the documents produced on the record, it is mentioned on Annexure - I on sub clause (b) that :

“b)Hospitalization :

1)Hospitalization facility can be availed from  any Hospital or Registered Nursing Home in India.  However, the Mediclaim member can avail Cashless Facility under Hospitalization only in hospitals in empanelled by the Insurance Company for this purpose(List at Page 39) ”.

It has also filed List of Empanelled Hospitals for  Cashless  Under TPA.  From the record, it appears that the Complainant has taken Group Mediclaim Scheme 2012 for Retired Employees Of Steel Authority Of India Ltd..  As per the Hospital report, the Complainant was hospitalized on 20/9/2012 and discharged on 9/10/2012 for severe pains in knee and ankle.  But after going through the policy, the Insurance Company found that the claim does not fall in the ambit of terms and conditions and hence the Complainant’s claim was repudiated on 19/12/2012.  The  List of Sail Approved Hospitals & Nursing Homes For OPD Treatment under Sail Mediclaim Scheme of all over India on page Nos. 23 to 32 for the treatment under the scheme.  But nowhere is mentioned the Hospital’s name in which the Complainant has taken the treatment and therefore, the claim was rightly repudiated.  We found substance from the facts and documents filed by the Opponent No. 2 and hence we have answered point Nos. 1 and 2 in the negative and the claim of the Complainant deserved to be dismissed.  

(8)              Hence the following order :-

//O R D E R//

1. The complaint stands dismissed.

    

2. Parties to bear their own costs.

    

3. Certified copy of this order be supplied to both the parties free of costs.

    

        

      sd/-xxx                                                   sd/-xxx

 (Shri. S.R. Sanap)                                       (Shri.G.K. Rathod)

  Hon’ble  Member                                       Hon’ble President

Note:-  As the pleadings, affidavits, documents, written arguments of the parties are in English, the order in the proceeding is passed for the better knowledge of the parties in English.

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