Jharkhand

Bokaro

CC/17/141

Pushpalata Devi - Complainant(s)

Versus

M/s Iffco Tokio General Insrance Co. Ltd. - Opp.Party(s)

Ananand Vardhan

25 Nov 2022

ORDER

          District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-16-10-2017

Date of final hearing-25-11-2022

 Date of Order-25-11-2022

Case No. 141/2017

Pushpalata Devi W/o- Sri Sudhir Kumar Singh

R/o-Qr.No- 3-316, Sector-2/D, Bokaro Steel City District- Bokaro

Vs.

1. M/s Iffco Tokio General Isurance Co. Ltd. Unit Nos. 52-63 Mezzanine floor Ansal Fortune Arcade Sector 18, Noida, Uttar Pradesh and SCO-10, First Floor Sector-14, Gurgaon, Haryana

2. M/s Raksha TPA Pvt. Ltd. Represented Through its Chief Executive Officer C/o Escort Corporate Centre 15/5 Mathura Road, Faridabad Haryana

3. Sail/Bokaro Steel Plant Chief Executive Officer Administrative Building, Bokaro Steel City, District- Bokaro 

 

                             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. 1,26,278/- with interest @ 18% on account of medical expense incurred during her treatment and to pay Rs. 1,00,000/-  as compensation and Rs. 10,000/- as litigation cost.
2. Complainant’s case in brief is that she is wife of retired SAIL, BSL employee and as per policy of the company her husband opted for Mediclaim policy for himself and complainant
   valid for relevant period. The MIN No. allotted to the complainant is 4735887. During the enforcement of the insurance policy the complainant was admitted in Apollo Gleneagles Hospital, Kolkata on 24-02-2017 and discharged on   01.03.2017 for treatment of chronic liver disease with diabetes mellitus, for which intimation to O.P. No.1 was given to grant cashless facility but it was not provided. Further case is that complainant paid Rs. 1,26,278/- to the hospital for which she applied before the O.Ps. for its reimbursement but it has not been provided. Thereafter, legal notice was served having no impact. Hence this case has been filed with above mentioned prayer.
3. O.P. No.3 (BSL, SAIL) has filed W.S. admitting the fact related to insurance policy, entitlement of the complainant for her treatment etc.
4. O.P. No.1 Insurance co. has filed W.S. mentioning therein that case is prematured because vide letter dt. 19.04.2017 complainant was directed to provide “Treating doctor certificate mentioning probable etiology of the present ailment in this case. Kindly provide copy of complete set of Indoor case papers and vital charting”. Further reply is that compliance of that very direction has not been done hence case is pre-matured. In respect to contents of para 1,2,3,5 of the complaint petition there is no denial of the facts. It has also been mentioned that the cashless claim of the complainant was processed as per the terms and conditions of the policy and same was denied as patient was already discharged prior to cashless approval.  
5. Point for consideration  is that whether complainant is entitled to get relief as claimed or not?
6. Following facts are admitted facts of this case:-

1. That the husband of the complainant was earlier employee of SAIL, BSL, Bokaro and he retired from the service of SAIL, BSL, Bokaro.
2. That as per policy of the SAIL, BSL, Bokaro all retired employees of the SAIL,BSL, Bokaro with their spouse are entitled for medical insurance coverage to the some extent on contributing premium  towards it.
3. That as per norms of the SAIL, BSL, Bokaro complainant has deposited the required premium and was being covered by the mediclaim policy of the O.P.
4. That said mediclaim policy of the complainant was effective for the period for which claim has been made.
5. That complainant was allotted MIN number by the insurance co. as mentioned in the complaint petition.
6. That the complainant suffered with illness as mentioned in the complaint petition and she was admitted in Hospital for the period as mentioned in the complaint petition.
7. That the complainant has made payment of the amount to the Hospital as mentioned in the complaint petition on account of medical expense incurred on her treatment.
8. That the claim of the complainant has not been allowed by the O.Ps. till filing of the case.
9. That cashless facility of the complainant was denied by the Insurance Co. because patient was already discharged prior to the cashless approval.

7.      On careful perusal of the record it appears that Apollo Gleneagles Hospital, Kolkata is the listed hospital of the Insurance Co. where cashless treatment facility by the O.P. was being provided. At para 7 of the W.S. of O.P. No.1 it is mentioned that the cashless claim of the complainant was processed as per the terms and conditions of the policy and same was denied as patient was already discharged prior to cashless approval. This fact shows that if cashless process was completed earlier then complainant would have availed the cashless facility and O.P. No.1 would have pay the all the bills to the hospital directly.  At para 4 of the W.S. of O.P. No.1 it is mentioned that vide letter dt. 19.04.2017 complainant was directed to make available following documents 1- Treating doctors certificate mentioning probable etiology of the present ailment in this case. 2- Kindly provide copy of complete set of Indoor case papers and vital charting”. It is also mentioned that those papers have not been provided by the complainant hence claim has not been settled.

8. On bare perusal of the W.S. of O.P. No.1 it appears that there is no objection of this O.P. in acceptance of the claim, only on the basis of lack of above mentioned papers claim has not been processed. We are of the view that the papers which have been demanded by the O.P. No.1 are not possible to be provided by any patient. Hence it appears that mere on hyper technical basis claim has been withheld by the O.P. No.1, hence there is deficiency on behalf of O.P. No.1 and complainant is entitled to get relief as claimed. The final bill submitted by the complainant shows that only Rs. 1,24,717 has been paid by the complainant to the hospital. Accordingly this point is being decided in favour of the complainant.

9. In light of above discussion prayer of the complainant is being allowed in the following manner:-

  O.P. No.1 M/s IFFCO TOKIO General Insurance Co. Ltd. is directed to pay Rs. 1,24,717/- to the complainant within 60 days from receipt/production of this order, failing which complainant will be entitled to get interest @ 10% on that very amount from 16.10.2017 (the date on which complaint was filed). Further O.P. No. 1 is directed to pay Rs. 15,000/- compensation and Rs. 7,000/- litigation cost to the complainant within 60 days from receipt/production of this order.  

 

(J.P.N. Pandey)

                                                                                      President

 

                                                                                               

 

                                                                              (Baby Kumari)

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