Jharkhand

Bokaro

CC/18/59

Sonapati Devi - Complainant(s)

Versus

The Branch Manager, E- Meditek - Opp.Party(s)

Amardeep Jha and Poonam

21 Jun 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 59/2018

  Date of Filing-07-05-2018

 Date of Order-21-06-2022

Sonapati Devi W/o Ram Nath Singh,

R/o Sector-9, St-4, Q.No- 1113

P.O.- Sector-9, P.S.- Harla

Bokaro Steel City District- Bokaro.

                                      Vr.

1. The Branch Manager, E-Meditek (TPA) Service Ltd. Plot No. HC-07, Ground Floor, City Centre Sector-4, District-Bokaro.
2.  The E-Meditek (TPA) Services Ltd.

Plot No. 577, Udyog Vihar, Phase-V, Gurgaon, Haryana

3. The Divisional Manager, United India Insurance Co. Ltd.

Plot No. A/17, City Centre, Sector-4, P.O. and P.S- Sector-4, District- Bokaro Jharkhand

Present:-

          Shri Jai Prakash Narayan Pandey, President

           Smt. Baby Kumari, Member

                                                -Order-

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 84,588/- on account of medical expense incurred during treatment of complainant  and to pay Rs. 10,000/-  as compensation and Rs. 5000/- as litigation cost.
2. Complainant’s case in brief is that her husband is retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy vide MIN No. 04723318 for himself and for the complainant which was valid at the relevant time. During the enforcement of the insurance policy the complainant became ill and she was admitted in Rabindranath Tagore, International School of Cardiac Sciences at Kolkata on 06.01.2016 and discharged on 12.01.2016 after treatment, during that very period Rs. 84,588/- was paid to the Hospital. Complainant applied for reimbursement of the said amount but inspite of repeated requests no action was taken by the O.Ps.  Thereafter legal notice was served having no impact. Hence this case has been filed with above mentioned prayer.
3.   Inspite of due service of notice non of the O.Ps. have filed W.S. inspite of appearance made by O.P. No.3 by filing Vakalatnama.
4. During argument Learned Counsel for the O.P. No.3 Insurance Co. has submitted written notes of argument and he argued mainly on the point regarding delay in intimation to the insurance co. in respect to alleged claim. Except above ground no other material ground has been raised by the O.P.

5. Now, we have to see whether complainant has prima facie established her case against the O.Ps. or not ?

6.   On perusal of the photo copy of papers submitted by the complainant it appears that Annexure-6 is the photo copy of medical card issued by the O.Ps. which is valid from 01.04.2015 and it is bearing MIN No. 4723318. In this way said mediclaim policy was valid from 01.04.2015 to 31^st March 2016. Annexure-5 is the photo copy of the receipt issued by O.P. No.1 through which all the papers including the claim form for re-imbursement of Rs. 86,538/- was received in the office  of O.P. No.1 on 25.01.2016 in respect to the cost of the treatment of complainant who was discharged from the hospital on 12.01.2016. Annexure- 3 series are the photo copies of the medical examination reports of the complainant which show that for the ailment of the complainant she was subjected to different types of medical examinations.  Annexure-2 is the photo copy of the final bill  in three sheets and according to it total Rs. 84,588/- was paid by the complainant towards her treatment cost. Annexure-1 is the photo copy of discharge summary of the complainant. All the papers are in consonance with the claim of the complainant.

8   On careful perusal and scrutiny of above mentioned documents it is apparent that there was intimation to the O.Ps. regarding treatment of the complainant who has submitted claim form on 25.01.2016. Therefore, mare on the basis that there was few days delay in intimation, claim cannot be kept pending for indefinite period. Hence the argument submitted by the Ld. Counsel for the O.P. Insurance Co. is not acceptable. Therefore, we are of the view that complainant has prima facie established her case and she is entitled to get relief.

9   Accordingly the case of the complainant is being disposed off in  the manner indicated here in below:-

O.P. No. 3 ( the United India Insurance Co. Ltd.) is directed to pay Rs. 84,588/- to the complainant within 60 days from today otherwise this O.P. will pay interest @ 10% per annum from 07.05.2018 (the date on which complaint was filed). Further this O.P. is directed to pay Rs. 5000/- as compensation for various type of harassment and also to pay Rs. 2000/- as litigation cost within 60 days from today