Jharkhand

Bokaro

CC/17/38

Ram Lakhan Choudhary - Complainant(s)

Versus

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

M.D. Ravi Ahmed

25 Jan 2019

ORDER

The complainant Ram Lakhan Choudhary has filed this case for claim of Rs. 25,798/- along with compensation of Rs. 50,000/- for mental harassment and litigation cost of Rs. 20,000/- and travelling cost of Rs. 1800/-.

2          The case of the complainant is that the complainant is an ex-employee of the SAIL, having MIN No. 4741193 under the mediclaim scheme of the SAIL.

            Complainant was suffering from fever and pain and admitted at Bokaro General Hospital, Bokaro on 02.04.2016. During hospitalization on doctor prescription some medicines and injection was purchased from the market by the family members, as the same were not available at B.G.H. Other treatment cost was free of cost. The complainant was discharged on 12.04.2016 from the hospital and filed th claim of the medicines purchased from out side of the B.G.H. to TPA with all relevant documents but the O.P. has not paid the amount till date and this is deficiency in service on the part of the O.P.

3          The complainant has filed the following documents in

           support:-

Anx-1- Photo copy of claim submitted before TPA on10.05.16

Anx-2 to 2/1 Photo copies of Medical Card.

Anx-3 to 3/1 Photo copies of prescriptions.

Anx-4 Photo copy of discharge ticket.

Anx-5 to 5/1 Photo copies of cash memo of medical shop.

Anx-6 Photo copy of  legal notice.

4          O.P. No.1 Raksha TPA Pvt. Ltd. Has not appeared and ex-parte proceeding initiated.

O.P. No.2 IFFCO TOKIO General Insurance Co. Ltd. has appeared and filed W.S. It is submitted that the case is not maintainable as the complainant has suppressed the material fact, however, the mediclaim scheme has been admitted by the O.P. of the complainant for the period 01.04.2015 to 31.03.2016. It is also admitted that the complainant has submitted the claim along with documents before the TPA and the amount of the claim of Rs. 25,798/- cleared and the said claim was fully paid through NEFT on 10.02.2017 in the account of SAIL, Bokaro hence this is not deficiency in service and this case is liable to be dismissed.

5          This O.P. has also filed Anx-A Copy of terms and conditions and Anx-B Copy of details of payment.

                                                            F I N D I N G S

6          We perused the record and documents available on the record, being the beneficiary under the medical scheme of the SAIL between the insurance co. IFFCO TOKIO General Insurance Co. Ltd. For the period admittedly as 01.04.2016 to 31.03.2017, therefore, the complaint is maintainable and the dispute is a consumer dispute filed within limitation.

7          Admittedly, the O.P. as such the claim amount was cleared by TPA and the claim was cleared and the payment has been deposited in the account of SAIL through NEFT and for which O.P. has filed the Anx-3 in support of payment. It appears that it is also admitted in the W.S. Complainant has made claim before TPA and, the amount of the claim which has been cleared by the insurance co. the same amount  should have been paid in the account of the complainant which is reasonable but in this case the O.P. has paid the amount in the account of SAIL which is beyond imagination.

8          In the above fact and circumstances, mistake on the part of the O.P. IFFCO TOKIO General Insurance Co. Ltd. should have been paid the amount in the account of the complainant and this is deficiency in service.

9          Thus, we allow the claim of the complainant and the O.P. insurance co. is directed to pay the claim amount of Rs. 25,798/-(Rs. Twenty five thousand seven hundred ninety eight) only directly in the account of complainant Ram Lakhan Choudhary with interest of 6% P.A. from 03.02.2017 the date of NEFT payment along with compensation of Rs. 3000/- (Rs. Three thousand) only for mental harassment and litigation cost of Rs. 1500/- Rs. One thousand five hundred) only .

            All the payments must be paid to the complainant within 45 days of this order, failing which the rate of interest shall be enhanced 12% till realization.

10        Insurance Co. shall be entitled to recover the amount from the SAIL which has been paid by the insurance co. of the claim of the complainant.