Jharkhand

Bokaro

CC/17/148

Sachidanand Upadhyay - Complainant(s)

Versus

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

18 Feb 2019

ORDER

The complainant Sachidanand Upadhyay has filed this case for claim of Rs. 3,40,020/- along with compensation of Rs. 50,000/- for mental harassment and litigation cost of Rs. 10,000/- .

2          The Case of the complainant in short is that complainant is a retired employee of Bokaro Steel Plant and he covered under group mediclaim claim scheme with his spouse.

            He has been receiving his policy every year since retirement and paid Rs. 5,008/- as premium cost. The Complainant and his wife are entitled for reimbursement of Rs. 2,00,000/- each in year. The amount can be clubbed Rs. 4,00,000/- for either the complainant and his wife on 27/01/2017 complainant was admitted in Manipal Hospital, Bengaluru, Karnataka for developed severe pain and discharged on 02/02/2017 Complainant had informed the O.P. about the treatment vide e-mail dt 28-01-2017

            Complainant had not taken the benefit of cashless facility and he had paid the bill amount of Rs. 3,40,020/- to the hospital directly through bank credit of Rs. 3,20,000/- and Rs. 20,020/- in cash.

            He submitted all documents original bill in the office of O.P. No.2 on 23/02/2017along with cancelled cheque and claim form.

            Complainant was assured several times that the bill amount would be reimbursed “soon” but the complainant has not received any payment till date. From the facts narrated above, O.Ps are negligent and difficult in providing services to the complainant.

3          Following documents have been submitted by the complainant:-

            Anx-1- Copy of Medical card of Sachidanand Upadhyay.

            Anx-2- Copy of Renewal premium for the year 2016.

            Anx-3- & 3/1 Copies of claim form and acknowledgment.

            Anx-4- 4/1- Copies prescriptions

            Anx-5- Copy of inpatient bills and receipts.

            Anx-6- Copy of discharge summary.

4          After issuance of notice O.P. No.1 is present and filed W.S.

            It is submitted that the complainant has filed this complaint under reply as being absolutely false, baseless, incorrect, illegal, frivolous, misconceived.

            It is further submitted that the Contention of Para 1 to 7 about admitting in Hospital Manipal, Bengaluru and spent Rs. 3,40,020/-.

            It is further alleged that after several reminder letter, complainant did not submit the required claim document i.e. original installation reports the RADIOLONY FLIMS and details brade up of various amounts ans mentioned in patient filed Bill cam Receipt.

            O.P. has filed a Ruling of Honable Supreme Court “Ravneet Sing Vers Royal Dutch Airlines.

            Another  Rulling of Honble Supreme Court is United India Insurance Co. Ltd. Vr. Harchandai Chandenlal 2004 & SCC 644 and General Insurance Society Ltd. Vrs. Chandmall Jail 1966 3SC R500 etc.

            It is further submitted that this complaint is not at all maintainable since there is no cause of action and there is no  deficiency in service and the part of O.P. Insurance Co. Hence this Complainant is liable to be dismissed.

5          Following documents have been filed by the O.P. No.1 in support of their case:-

            Anx- A:- Photo Copy of welcome letter and its terms and condition.

            Anx-B:- Photo Copy of query letter as claim.

6          O.P. No.3 is present and filed W.S. It is admitted that Complainant and his spouse cover under Mediclaim Scheme This O.P. is no relationship of Customer and Service Provider between SAIL, BSL and this O.P. has been made unnecessary party in this Complainant petition.

FINDINGS

7          We perused the record. Having paid premium for the mediclaim Complainant is a Consumer and dispute.

8          The objection O.P. Insurance Co. Is highly technical and cannot be accepted. Complainant has submitted all the documents received from the hospital along with in patient bills and receipts are sufficient to pro bonafide payments and is entitled for reimbursement of the claim amount. This is clear deficiency in service on the part of the Insurance company.

9          Therefore, We allow the claim of the Complainant and we direct O.P. IFFCO Tokio General Insurance Co. Ltd. To pay Rs. 3,40,020/- with interest @ 8% p.a. Since the date of claim form submitted to TPA i.e. 23-02-2017.

            We further directed the O.P. Insurance Company to pay Rs. 5000/- as compensation for mental harassment and litigation cost of Rs. 2000/-.

            All the payment must be paid with 60 days affecting which the rate of intrest on main claim shall be enhanced to 12% p.a. till realisation.