Ex-P A R T E O R D E R
PER SHRI. S. G. CHABUKSWAR – HON’BLE MEMBER
1) This is a complaint for the reliefs against the Opposite Party for Rs.1,21,000/- Hospitalization expenses with interest @ 21% p.a., Rs.2,00,000/- compensation for mental agony and Rs.25,000/- cost of the complaint.
2) The case of the Complainant in short is as under –
The Complainant had taken Mediclaim Policy from the Opposite Party. The husband of the Complainant had paid the policy premium Rs.7,317/-. The said policy is bearing No.260300/48/09/8500001366 for the period from 30/07/2009 to 29/07/2010 and amount is Rs.1,00,000/- excluding bonus. The bonus amount is Rs.21,000/- for the period 30/07/2009 to 29/07/2010.
3) According to the Complainant, She was hospitalized on 07/03/2010 for treatment of Kidney Transplant and the treatment was completed on 15/03/2010. The Complainant had informed the Opposite Party about the hospitalization for the kidney transplant in advance. The Complainant had submitted the claim form for Rs.1,77,292.55 to TPA of the Opposite Party. The Complainant had submitted the claim form alongwith all documents of hospital, bills to TPA on 10/05/2010. After expiry of one month from the date of submitting the claim the Complainant made enquiry with the TPA but the TPA made false promise stating that claim is under process and it will take time. Thereafter she issued notice to the Opposite Party for the claim amount but the Opposite Party neither replied the notice nor paid the amount. Lastly on 04/11/2011 the Complainant through her advocate issued notice to the Opposite Party and demanded the claim amount. The Opposite Party served with the notice but Opposite Party did not make payment. Hence, this complaint for the reliefs as mentioned in above para no.1
4) The Opposite Party did not appear in spite of service of notice hence, complaint proceeded ex-parte against the Opposite Party.
5) The Complainant has filed documents alongwith the complaint. The Complainant has submitted her affidavit of evidence on 31/05/2012. She has submitted written argument on 22/08/2012. We heard Shri. Rajesh Dedhia, Ld.Advocate for the Complainant.
6) The copy of insurance policy filed at Exh.A-9 shows that the Complainant has obtained from the Opposite Party Mediclaim Policy baring No.260300/48/09/8500001366 for the period 30/07/2009 to 29/07/2010 of Rs.1,00,000/-, bonus Rs.21,000/- and its premium was Rs.7,317/-. The copy of admission history and physical assessment form issued by Jupiter Hospital, Thane (W) shows that Complainant was admitted in the said hospital for transplant (Ponon) Nephrectomy on 07/03/2010. The medical bill shows that Complainant was discharged from the said hospital on 15/03/2010. The Complainant has produced the bills issued by the Jupiter Hospital, Thane (W), dtd.15/03/2010. As per the said bills the Complainant has paid bed charges Rs.23,000/-, Doctor visit charges Rs.2,000/-, X-ray charges Rs.1,650/-, Service charges Rs.6,435/-, Blood charges Rs.900/-, etc. total Rs.1,51,595/-. The affidavit of evidence, pleading and documents produced by the Complainant remained unchallenged. The Opposite Party has not appeared and denied the pleading and documents of the Complainant. There is nothing on record to disbelieve the above said evidence and document of the Complainant. The evidence clearly goes to show that the Complainant has obtained mediclaim policy from the Opposite Party of Rs.1,00,000/- and bonus Rs.21,000/-. The Complainant was admitted in the Jupiter Hospital, Thane (W), for Kidney Transplant (Ponon) (L) Nephrectomy on 07/03/2010. She was discharged on 15/03/2010. The Complainant made expenditure on medical treatment Rs.1,51,595/-. The Complainant had submitted claim form for Rs.1,77,295.55 with the TPA of Opposite Party on 10/05/2010. The Complainant had sent notices and letters through her advocate and demanded the claim amount. The Complainant had made demand of claim amount but Opposite Party failed to pay it to the Complainant. The mediclaim policy of the Complainant is of Rs.1,00,000/- and bonus Rs.21,000/-. The Complainant has claimed said amount Rs.1,21,000/-. In view of this we hold that Complainant is entitled to Rs.1,21,000/- towards the medical expenses with interest @ 6% p.a. from the date of demand of claim i.e. 10/05/2010, Rs.3,000/- as compensation for mental agony and Rs.2,500/- cost of the complaint.
7) In the result complaint deserves to be allowed with cost hence, we proceeds to pass following order –
O R D E R
i. Complaint No.325/2011 is partly allowed with cost against Opposite Party.
ii. Opposite Party is directed to pay to the Complainant Rs.1,21,000/- (Rs.One Lakh Twenty One Thousand Only) towards
medical expenses with interest @ 6% p.a. from 10/05/2010 till the realization of said amount.
iii. Opposite Party is directed to pay to the Complainant Rs.3,000/-(Rs.Three Thousand Only) towards compensation for
mental agony.
iv. Opposite Party is directed to pay to the Complainant Rs.2,500/- (Rs.Two Thousand Five Hundred Only) towards the cost
of complaint.
v. Opposite Party is directed to pay amount mentioned in above para Nos. ii, iii & iv to the Complainant within 45 days
from the date of service of this order.
vi. Certified copies of this order be furnished to the parties.
