District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-13-07-2022

Date of final hearing-21-06-2023

 Date of Order-21-06-2023

Case No. 124/2022

Ramyash Ojha S/o Late B. Ojha

R/o Qr.No. 2088, Sector-12/C, P.O. and P.S.- Sector-12,

District- Bokaro, Jharkhand

Vs.

1. The Branch Manager Indian Bank,

Gurudwara Road, Chas, P.O. and P.S.- Chas,

District- Bokaro, Jharkhand

2. Heritage Health Insurance TPA Private Ltd.

Nice House, 5^th Floor, No.2, Hari Street Kolkata 700001 West Bengal

 Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant’s case in brief is that he is retired employee of Allahabad Bank to whom Mediclaim policy No. 251100502010000336 of Heritage Health Insurance, valid from 01.11.2020 to 31.01.2021 has been provided through the Bank. Further case is that during that very period complainant was admitted in Muskan Hospital and Research Centre on 12.08.2021 and he was operated for cataract for which he paid Rs. 42,586/- to the hospital and purchased medicines of Rs. 1011/- accordingly he submitted claim form before the O.P. but only Rs. 21000/- was paid and rest of the amount Rs. 1011/- and Rs. 21,586/- has not been paid till date. Therefore, this case has been filed with prayer to direct the O.Ps. to pay Rs. 1011/-, Rs. 21,586/- as medical expense, to pay Rs. 30,000/- as compensation and Rs. 10,000/- as litigation cost to the complainant.
2. O.P. No.1 appeared and has filed W.S. mentioning therein that this O.P. is having no concern with payment of medical expense of the complainant rather he has simply provided the Mediclaim  policy through the O.P. which was valid as alleged hence case is liable to be dismissed against this O.P.
3. Inspite of due service of notice O.P. No.2 has not filed W.S. rather he has filed simply copy of letter dt. 25.10.2022 without any forwarding letter or W.S. hence vide order dt. 18.03.2023 case is being proceeded Ex-parte against him.
4. Point for determination is that whether complainant is entitled to get relief as claimed ?
5. It is admitted fact that on submission of claim of Rs. 42,586/- O.P. TPA processed it and made payment of Rs. 21,000/- only. In this way genuineness and admissibility of the claim of Rs. 42,586/- is not in dispute. Only dispute is whether complainant is entitled to get reimbursement of entire expense or less. So far, the evidence is concerned it is apparent from Annexure-B that hospital concerned has made treatment by operation of cataract surgery and used IOL to which hospital is purchasing in bulk. From perusal of final bill at page 7 of annexure it shows that total Rs. 42,586/- has been paid by the complainant to the hospital for which he has submitted claim before the O.P. vide claim form at page 12 & 13 of the annexure. On perusal of letter dt 26.10.2022 of the O.P. it appears that only Rs. 21,000/- has been paid by the O.P. and Rs. 21,586/- has not been paid on reasonable and customary clause. No any paper or rule etc. has been filed by the O.P. to show that under which provision such type of deduction has been made. In this way it appears that on this score there is deficiency in service by the O.P. No.2.
6. So far, the claim of Rs. 1011/- is concerned it is being disclosed by letter dt. 26.10.2022 of O.P. Insurance co. that amongst it Rs. 611/- has already been paid to the complainant on 01.02.2022 and rest of Rs. 400/- has not been paid for want of supporting papers. In this way it is apparent that in respect to this claim payment has already been made and complainant is not able to show that how said payment of Rs. 611/- is not in accordance with actual facts. However inspite of receipt of said payment complainant has not disclosed this fact before this Commission. In this way on this aspect there is no deficiency by the O.P.
7. Therefore, in light of above discussion we are of the view that the claim of the complainant for payment of Rs. 1011/- has not been substantiated by supportive papers rather part payment of Rs. 611/- has already been made about which complainant has not taken any step to rectify the complaint petition. Accordingly prayer for payment of Rs. 1011/- is not acceptable. So far, claim of Rs. 21,586/- is concerned it is very much clear that there is no justification by the O.P. No.2 regarding deduction of said amount hence the prayer in this regard is liable to be accepted.
8. Accordingly prayer of the complainant is being partly allowed in the following manner:-

O.P. No.2 is directed to make payment of Rs. 21,586/- to the complainant within 60 days from receipt/production of copy of this order, failing which he shall pay interest on said amount @ 10% per annum from 13.07.2022 (i.e. the date on which case was filed). Further O.P. No.2 is directed to pay compensation of Rs. 3000/- and litigation cost of Rs. 2000/- to the complainant within above mentioned period.

J.P.N. Pandey)

                                                                                      President

                                                                                                                     S/d             (Baby Kumari)

                                                                                       Member