Jharkhand

Bokaro

CC/17/14

Ram Deo Sharma - Complainant(s)

Versus

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

M.P. Vishwakarma

30 Apr 2019

ORDER

Complainant Ram Deo Sharma has filed this case with prayer for direction to the O.P. to pay Rs. 62000/- against claim for treatment of his wife namely Pano Devi and litigation cost and harassment of Rs. 30,000/-.

2          The case of the complainant is that he took mediclaim policy vide policy No. 041100/48/15/41/00000002 and claim No. 100121514158 under the SAIL with his wife Smt. Pano Devi, who had fallen ill and had been treated in CMC Vellore. It is further the case of the complainant that he demanded Rs. 62000/- against the said treatment in CMC Vellore.  He has further stated that he has submitted all documents to the O.P. including letter date 22.11.2016 but O.Ps. did not pay the claim amount. Thereafter, this complainant has been filed on 17.01.2017.

3          Following documents have been filed in support:-

            Anx-1and 1 /2 - Photo copies of premium receipt.

            Anx-2 and 2/1- Photo copy of notice dated 12-11-2016

            Anx-3- Photo copy of reminder notice to O.P.

            Anx-4- Photo copy of letter of E- Meditek dated 23-02-2016

            Anx-5- Photo copy of biopsy report of Panu devi

            Anx-6- Photo copy of document received by E- Meditek

Dated 21-04-2015

4          O.P. appeared and filed W.S. in which O.P. has admitted that complainant is insured in insurance policy which is valid from 01.04.2015 to 31.03.2016. It is further stated that the terms and conditions of the insurance policy has not been fulfilled by the complainant.  The complainant has not given any document regarding the treatment. It is also denied that any letter was given on 22.11.2016. As such the entire case is false.

F I N D I N G S

5          Heard the parties and perused the record.  We find and hold that complainant being beneficiary has covered under insurance policy as such the complainant is a consumer and the dispute is a consumer dispute. The case is well within limitation.

6          From the perusal of the documents, it is transpired that Pano Devi was admitted in CMC Vellore, her Hospital No. 3362908 and bill No. E014021 and bill amount is Rs. 17,705/- during the her treatment from 24.10.2015 to 27.10.2015, as an inpatient for which inpatient Discharge bill shows Rs. 17,705/- and other bills are of OPD, as  such maximum amount as per terms of policy may be given Rs. 4000/- only.

7          We hold that O.Ps. have not paid the amount to the complainant, it is deficiency on the part of the O.P.

8          We direct the O.P. to pay Rs. 17,705/-+ Rs. 4000/-= Rs. 21,705/- (Rs. Eleven thousand three hundred ninety five) only to the complainant within 60 day from the date of this order, with interest @ 10% per annum till realization.

            We further direct to the O.P. to pay Rs. 3000/- (Rs. Three thousand) as compensation and Rs. 500/-(Rs. Five Hundred) as litigation cost.