FINAL ORDER/JUDGEMENT

SMT. SAHANA AHMED BASU, MEMBER.   

            The complaint case in brief is that the complainant is a Group Policy Holder of Retd. Employee of Bank of India with United India Insurance Co , Mumbai .  The complainant submitted a claim Of Rs.22,452/- on 05.03.2019 along with claim of Rs.8443/- for eye surgery of his wife. Pre hospital expenditure was reimbursed with deduction of an amount of  Rs.8891/-  by the OP , but Post hospital bill yet not sanctioned . As per Rule 7 of the OP both bills are payable by the OP within 60 days of post operation period .Therefore , the complainant has to approached before this commission for getting reliefs .

O.P. contested the case by filing written version assailing the maintainability of the case. Denying all the allegations against them OP states that they are a licensed TPA and entrusted with the responsibility by the insurance companies to process mediclaim(s)  on behalf of the Insurance Companies  in accordance with the terms and conditions of the insurance Policy and thus the complaint is bad in law for non-joinder of party as the policy was issued by United India Insurance  Co. Ltd which has not been made a necessary party in the present complaint. Hence the complaint is liable to be dismiss on this ground .

We have travelled over the complaint petition as well as the documents filed by the complainant in support of his contention together with the written version  submitted by the O.P. in their support.

The admitted fact is that the complainant is a group policy holder of Retd. Employee of Bank of India with United India Insurance Co. Fact also remains that wife of the complainant was admitted on 22.02.2019 for Senile Cataract operation on right eye at Second Sight South End Eye Centre Pvt. Ltd. and discharged on same day  for which the complainant preferred a cashless claim of an amount of Rs.22,452/- and Rs.8443/- as pre and post hospitalization expenditure . In clause 7 of said Mediclaim policy it is clearly mentioned :that

“The Medi claim policy allows reimbursement of relevant medical expenses incurred towards the ailment / disease for which hospitalization was necessitated 30 (thirty) days prior to hospitalisation and up to 60 (sixty) days after discharge . This is subject to the limits prescribed in the policy .”

The complainant submitted that the pre hospitalization bill has been  reimbursed with a deduction of Rs.8891/-, but supplemental bill of Rs.8843/- yet not sanctioned.

Op submitted that a cashless claim being claim No. 1902590 for Rs.36600/- was claimed for treatment of Mrs. Ratna Bose i.e. complainant’s wife which was approved & settled for Rs.30,000/- and paid to Second Sight South end Eye Centre Pvt.ltd  on 18.03.2019 vide NEFT-UTR no. 19940528790 . A sum of Rs.6000/- was deducted towards Non-Medical Expenses .It is also submitted by the OP that the Beneficiary applied for a post hospitalization claim  being Claim No . 19318682 for a sum of Rs.22,453/- which was approved & settled for Rs.13539/- vide NEFT on 10.05.2019 , UTR No. 19970513868. The reason for deduction are given in Settlement letter dated 11.05.2019 and claim No. 19393610 for Rs.8443/- is pre-post claim of main claim No. 19025940and since cataract limit has already been exhausted the claim No. 19393610 is rejected as per Clause 2.44 of the policy terms and conditions . But Op did not  file any single document in respect of their submission . Moreover , daily order of this Commission goes to show that the complainant filed reply to the questionnaire of the OP on 17.03.2021 and on 02.11.2021 the OP was directed to file E/chief on 09.12.2021 and on 09.12.2021 neither OP nor their Ld. Advocate was present on repeated call . There was also no prayer on the part of the OP for extension of time to file E/chief . As such, on 18.01.2022 the case was fixed for final hearing. Due to pandemic situation the Op got enough time, but miserably failed to follow the further procedures.  This gesture of the O.P. is not good enough before us.  Such act of OP clearly proves that OP was negligent and deficient in providing their service to the complainant.

In view of the above discussion we are of the opinion that the OP was deficient in service and the complainant is entitled to get relief as prayed for .

As such , the complaint case succeeds .

Hence

ORDERED

That the complaint case is allowed on contest against OP with cost of Rs. 5000/- within 30days from the date of this order to the complainant .

OP is further directed to pay Rs.8443/- as reimbursement of supplemental bill within stipulated period .

The complainant is given the liberty to put the case in execution if the arder is not complied .

Liberty be given to the complainant to put the order in execution, if the OP transgress to comply the order.