Complainant Bindeshwar Roy filed this compliant for a claim of Rs. 2,02,881.08 with 18% interest from the date of claim submitted and compensation of Rs 50,000/- for mental torture and litigation cost of Rs. 20,000/-

2          The Case of the complainant is that being a retired SAIL employee complainant took Mediclaim policy of SAIL Scheme by paying premium for him and his wife. The policy renewed for the year 2016-17 the hospitalization benefit reimbursements is upto 2 lacs per member ( with clubbing facility between employees and spouse) as per terms and condition and after hospitalization for medical expenses upto 60days shall be considered in the claim.

            During period of policy from 01.04.2016 to 31.03.2017, the complainant suffered chromic SD+1 problem and in doctor’s advice admitted in HMRI Hospital at Patna for better treatment. He was admitted on 03.05.2016 for Neuron surgery and discharged on 08-05-2016. Since the complainant has no cashless card, he incurred hospital charges and medicines on cash payment. The complainant incurred Rs. 1,99,113.08 of Paras HMRI hospital against pathological tests, surgery chargers, medicines, etc and also incurred Rs. 3,768/- for post hospitalization checkup and medicines with 60days of prescribed limit. In this way he incurred Rs. 2,02,881.08 (1,99,113.08 +3,768) for treatment.

            Complainant filed a claim on 23-05-2016 before TPA RAKHSA TPA PVT. LTD.  at Bokaro who acknowledged the receipts. A query letter of TPA was fully complied on 01-07-2016 but his claim has not been cleared. Even there is no reply of e-mail.

            Then legal notice was served on 10-11-2016   but no reply was received Hence, the case is filed.

3          Complainant relied on following documents:-

            Anx-1 and 1/1 Copy of renewal of Mediclaim policy and payment.

            Anx-2-  and 2/1 copies of receipt of two claims form by TPA

            Anx-3-  Copy of query letter dated 13-06-2016 of TPA

            Anx-4-  Copy of Discharge Summary

            Anx5-  and 5/4 Copies of Medical bills

            Anx-6- Copy of OPD Card

            Anx-7- Copy of e-mails to TPA dt. 03-11-16

            Anx-8- Copies of Speed post receipts.

            Anx-9- Copy of legal notice and track reports.

4          O.P. No.1 did not appear and ex parte proceeding initiated.

5          O.P. No.2 IFFCO TOKIO General INSURANCE CO. LTD. appeared and filed a petition instead of filing written statement, that the claim of the complainant is settled and paid Rs. 1,87,498/- into the account of the complaint on 09-01-2017 and information is also given to the complainant and as such the complaint is not maintainable and liable to be dismissed O.P. filed copy of payment details. Anx-A

F I N D I N G S

6          We perused the complaint and the documents, we hold that complainant is a beneficiary under Mediclaim scheme of the SAIL by paying premium amount, therefore he is a consumer and O.P. is service provider. The dispute is also a consumer dispute.

7          The O.P. No.2, the IFFCO TOKIO GENEARL INSURANCE CO. LTD. has not filed written statement, this means this O.P. has nothing to say about the facts stated in the complaint. Instead of filing W.S, O.P. No.2 has filed information to this effect that payment of Rs. 1,87,498/- has been settled towards the claim of the complainant and remittance of the amount in the account of the complainant.

            The O.P. No.2 has not clarified the details of the lesser amount of the settlement against the claim amount of Rs.1,99,113/- + Rs 3,768/- = 2,02,881/-. Hence without any clarification, settlement for lesser amount than the claim amount is certainly not acceptable and it is deemed to be deficiency in service.

            Therefore, O.P. No.2 is liable to pay claim amount Rs. 2,02,881/- rounded off to Rs. 2,02,880/- with interest.

8          Thus we allow the claim of the complainant and direct O.P. IFFCO TOKIO General INSURANCE CO. LTD.  to pay Rs. 2,02,880/-(Two Lac Two Thousand Eight Hundred Eighty only ) less Rs. 1,87,498/-(One Lac Eighty Seven Thousand Four Hundred Ninety Eight Only) = 15,382/-(Fifteen Thousand Three Hundred Eighty Two Only) with interest of 10% form 23-05-2016 till 06-01-2017.

            We further direct to O.P. Insurance Company to pay compensation of Rs. 5000/- (Five Thousand Only) and litigation cost of Rs. 2000/-(Two Thousand Only)

            All the payment must be paid within 60days form passing of this order failing which the rate of inertest will be enhanced to 15% on the claim amount till realization.