| Complaint Case No. CC/17/161 | | ( Date of Filing : 04 Dec 2017 ) |
| | | | 1. Prakash Chandra Tiwari | | Plot No.-114, K.K. Singh Colony, Chira Chas | | Bokaro | | Jharkhand |
| ...........Complainant(s) | |
| Versus | | 1. Raksha TPA PVT. Ltd. | | C/o- Escorts Corporate Centre, 15/5 Mathura Road, Faridabad | | 2. IFFCo Tokio General Insurance Co. Ltd. | | SCO-10 First Floor Sector-14, Gurgaon, Hariyana | | Bokaro | | Jharkhand | | 3. Steel Authority of India Ltd. | | Adm Building, Bokaro | | Bokaro | | Jharkhand |
| ............Opp.Party(s) |
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| Final Order / Judgement | - Complainant has filed this case with prayer for direction to O.Ps. to pay insurance claim related to re-imbursement of Out Door Patient (in short OPD) expense Rs. 3192/-, Rs. 70,000/- and Rs. 20,000/- as compensation and litigation cost respectively to the complainant with 18% interest.
- Complainant’s case in brief is that he obtained SAIL Group Mediclaim Insurance Policy from O.P. No.1 for sum insured Rs. 2,00,000/- valid from 01.04.2014 to 31.03.2017 vide policy No. 5707026 covering the complainant and his wife. Further case is that due to knee joint pain, lever & eye problem he got himself treated at Krishna Institute of Medical Science, Hydrabad on 03.08.2016,13.02.2017 and 24.02.2017 and incurred total expense of Rs. 3192/- for which he made repeated requests on several dates as mentioned in the complaint petition with Third Party Administrator (in short TPA) and Insurance Co. having no response hence, Legal Notice was served, in spite of it no payment was made, hence case has been filed.
- On notice, O.P. Insurance Co. appeared and filed W.S. mainly mentioning therein that case is not maintainable because the essential documents like dully filled claim form, indoor case paper, original medical bill, discharge summary, copy of insurance policy and other documents have not been provided to the TPA for scrutinisation of the claim by the complainant hence it is prayed to dismiss the case.
- In spite of service of notice no W.S. has been filed on behalf of other O.Ps.
- On perusal of the pleadings of the parties it apparent that except the fact that complainant has not filed documents before TPA for settlement of the claim there is no other challenge regarding the claim related to re-imbursement of OPD cost. In other words all other facts will be treated as admitted facts.
- Now, only point for consideration is whether complainant has submitted all papers before TPA for settlement of the claim or not ?
- To prove its case complainant has filed photo copy of the claim form submitted before the O.Ps., photo copy medical treatment papers, photo copy of payment receipts, photo copy of conceal cheque, photo copy of paper showing receipt of the papers by RAKSHA TPA Pvt. Ltd. Bokaro in respect to the clam as alleged, photo copy of E-mail of , photo copy letter written to TPA, photo copy of Legal Notice and photo copy of terms and conditions of mediclaim policy.
- On perusal of terms and conditions of the mediclaim policy at point no. 6 it appears that OPD expenses for Rs. 4000/- to Rs. 8000/- as per age criteria are admissible for payment to the policy holder. The photo copy of the receipt shows that on 09.03.2017 all receipts with cancelled cheque have been handed over to the RAKSHA TPA Pvt. Ltd. Bokaro with due receipt. In this way the reply of the O.P. insurance co. is not based on record. The reply of insurance co. has not being substantiated by any paper or evidence. Hence, we are of the view that O.Ps. are liable for deficiency in service in settlement of the claim. Hence, prayer of the complainant is liable to be accepted.
- Accordingly, prayer of the complainant is being allowed in the manner that O.P. No.2 shall be Reimbersed Rs. 3192/- as OPD charge to the complainant within 45 days and to pay Rs. 10,000/- as compensation and Rs. 5000/- as legal cost within 45 days from today failing which said O.P. No. 2 will pay interest @ 10% per annum on Total Rs.18,192/- from 04.12.2017.
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