Jharkhand

Bokaro

CC/21/2022

Shashi Bhusan Singh - Complainant(s)

Versus

The Branch Manager Birla Sun Life Insurance - Opp.Party(s)

Sri Kant Kumar Sharma

13 Sep 2022

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-07-02-2022

Date of final hearing-13-09-2022

 Date of Order-13-09-2022

Case No. 21/2022

    Shashi Bhusan Singh S/o Late S.P. Singh

     R/o Hirak Point Menko More, Hirak Square, Block-B, Dhanbad

Vs.

    1. The Branch Manager Birla Sun Life Insurance Chandra Kala Bhwan M/5, Sector-4, B.S.City 827004

 2. MD India Health Insurance TPA Pvt. Ltd. S.No. 46/1, E-Space 42 Building 3^rd Floor Pune Nagar RD Vadgaonsheri Pune 411014 Mharashtra 

                             Present:-

                             Shri Jai Prakash Narayan Pandey, President

      Shri Bhawani Prasad Lal Das, Member

          Smt. Baby Kumari, Member

     PER- J.P.N Pandey, President

•  

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 85,000/- on account of medical expense incurred during his treatment and to pay Rs. 30,000/-  as compensation and Rs. 7000/- as litigation cost.
2. Complainant’s case in brief is that he purchased insurance policy No. 007156199 from O.P. Birla Sun Life Insurance Co. for 5 years commencing/valid from 30.11.2016 till 30.11.20121 and also paid due premium. Further case is that due to Malaria and Enteric fever complainant was admitted in Kasturba Seva Sadan, Dhanbad on 21.03.2017 and discharged on 01.04.2017 after proper treatment for which he paid Rs. 85000/- to the hospital and thereafter applied for its re-imbursement, which was rejected by the O.P. on account of hospital/hospitalization eligibility. Inspite of issuance of legal notice no action was taken hence this case has been filed with above mentioned prayer.
3. Notice was issued against O.Ps. through registered post and it was received by O.Ps. on 17.02.2022 and 19.02.2022 respectively but inspite of due receipt of the notice O.Ps. have not appeared hence vide order dt. 15.06.2022 case is being proceeded ex-parte against the O.Ps.
4. During evidence complainant has examined himself as C.W.-1 and he has proved his case by his oral evidence and also through documentary evidence annexed with the record which is disclosing that at page 1 & 2 legal notice has been filed, at page 3 to 12 are photo copy of insurance policy paper, at  page 13 to 35 are the photo copy of the papers related to treatment of the complainant, payment receipts, the admission sheet, discharge summary etc. at page 36 & 37 claim rejection statement has been filed.
5. From the papers submitted it is apparent that on 21.03.2017 complainant was admitted in the hospital for treatment of Malaria and Enteric fever who was treated there and discharged on 01.04.2017, during which he paid total Rs. 85000/- to the hospital and medical store etc. As per claim rejection letter claim has been denied on account of Hospital/Hospitalization Eligibility. It appears that there is no specific reason for rejection of the claim nor there is any supportive paper for rejection of the claim. Therefore, on careful perusal of all the papers specially the claim rejection paper we are of the view that the ground for claim rejection is not specific, rather it is vague and misleading. In other words mere on hyper technical approach rejection of the claim has been made. Therefore, we are of the opinion that ground for rejection of the claim is not acceptable, accordingly, claim of the complainant appears to be genuine and liable to be allowed.
6. Accordingly the prayer of the complainant is being allowed in the manner indicated here in below:-

O.P. No. 1 (Birla Sun Life Insurance Co. Ltd.)  is directed to pay Rs. 85,000/- to the complainant within 45 days from receipt/production of this order and also to pay Rs. 7,000/- as compensation and Rs. 5,000/- as litigation cost within 45 days from receipt/ production of this order, failing which this O.P. will pay interest @ 10% P.A. on Rs. 85,000/- from 07-02-2022 ( i.e. the date on which complaint was filed) till the date of  final payment.