Jharkhand

Bokaro

CC/18/82

Chandreshwar Sah - Complainant(s)

Versus

M/s Raksha TPA Pvt. Ltd. - Opp.Party(s)

29 Mar 2022

ORDER

1. Complainant has filed this case with prayer for direction to O.Ps. to pay the amount (Rs. 800/ + 5810) = Rs. 6610/- on account of the medical expense of the complainant with 18% interest and for payment of Rs.3,000/- and Rs. 5,000/-  as compensation and litigation cost respectively to the complainant.
2. Complainant’s case in brief is that the complainant obtained Mediclaim policy of O.P. IFFCO TOKIO through Raksha TPA Pvt. Ltd. for the year 2016-17. Further case is that complainant was treated at BGH Bokaro and Fortis Hospital, Delhi who paid Rs. 800/- and Rs. 5810/- respectively for which he submitted claim with the O.Ps. on 15July 2016 and later on some queries were raised which were replied on 29.11.2016 and 03.03.2017 inspite of it payment was not made, hence after service of legal notice case has been filed with above mentioned prayer.
3.  O.P. No.3 IFFCO TOKIO General Insurance Co. Ltd. appeared and has filed W.S. mentioning therein that case is not maintainable and complainant has not approached this Commission with clean hand. Further reply is that during process of the claim some queries were raised to which complainant has not replied. Contents of para No.2 to 5 of the complaint petition have been denied. Further reply is that since required queries have not been satisfied hence both the claims are prematured in nature due to non submission of the documents hence case is liable to be dismissed.
4.  In reply to the W.S. further reply has been submitted by the complainant that required queries have already been answered with submission of the required documents in the office of M/s Raksha TPA with due receipt dt. 03.03.2017. Hence reply is not maintainable. In support of reply photo copy of the receipt dt. 03.03.2017 issued by Raksha TPA Pvt. Ltd. Bokaro has also been submitted.
5.  On careful perusal of the pleadings of the parties it is apparent that following facts are not under dispute:-

1. That on the relevant date when complainant got treated himself at BGH and Fortis Hospital, Delhi there was insurance policy enforced in his favour.
2.  That complainant has submitted the total bill for Rs. 6610/- before the O.Ps.
3.  That claim of the complainant has not been paid.

6. In light of above admitted facts and on the basis of the pleadings of the parties only question for consideration is that whether complainant is entitled to get the amount as claimed in his favour ?
7.  It is very much clear from the pleadings of the parties that claim for the treatment and purchase of the medicines at B G H Bokaro and Fortis Hospital Delhi was received in time in the office of O.Ps. but O.P. made queries vide later dt. 20.1.2016 and 14.08.2016 respectively to provide treating doctor certificate mentioning the ailment for which treatment taken for prescription dt. 02.06.2016 and 09.07.2016 respectively.  The paper produced by the complainant shows that he has replied about the queries and submitted documents before the O.Ps. on 03.03.2017. Therefore, we are of the opinion that compliance of the query has already been made by the complainant and nonpayment on this basis is not justified. Therefore, there is deficiency in service by the O.Ps. Further we are of the opinion that mere on the basis of absence of some medical terminology in the prescription of the doctor claim of the complainant cannot be withheld because complainant cannot dictate the doctor. Therefore, we are of the opinion that prayer of the complainant is liable to be accepted.
8.    Accordingly, the prayer made by the complainant is being allowed in the following manner:-

O.P. No.1 and 2 are directed to pay Rs. 6610/-(Rs. Six thousand six hundred and ten) to the complainant as claim amount within 60 days from today, failing which they shall pay interest thereon @ 10% per annum from 18.07.2018 till the realization of the money. Further O.P. No.1 &2 are directed to pay compensation of Rs. 2000/- and litigation cost of Rs. 1000/- within 60 days from today.