Jharkhand

Bokaro

CC/9/2022

Chandrakant Jha - Complainant(s)

Versus

The Branch Manager MD India Health Insurance TPA Pvt. Ltd. - Opp.Party(s)

Gopal Prasad Singh

03 Mar 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-25-06-201

Date of final hearing-03-03-2023

 Date of Order-03-03-2023

Case No. 09/2022

Chandrakant Jha S/o Jagdish Jha

 R/o Qr.No. 2-123, Sector-2/B, P.O. and P.S.- B.S.City, Bokaro

Vs.

 1. The Branch Manager MD India Health Insurance TPA Pvt. Ltd.

        S.No. 46/1, E space, A-2 Wing, 3^rd Floor, Nagar Road,

        Vadgaon, Sheri, Pune Maharashtra Pin 411014

2. Divisional Manager, New India Insurance/ Assurance Co. Ltd.

     Plot No. C/27, Cit Centre, Sector-4, P.O. and P.S.- Sector-4,

      B.S.City, District- Bokaro, Jharkhand 827004

3. E.D. (P&A) SAIL/Bokaro Steel Plant, Administration Building

      Bokaro Steel City District- Bokaro Jharkhand 827001

 4. C.G.M. Personnel SAIL/Bokaro Steel Plant Administration

     Building Bokaro Steel City, District- Bokaro Jharkhand 827001

 Present:-

                             Shri Jai Prakash Narayan Pandey, President

Shri Bhawani Prasad Lal Das, Member

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-Order-

1. Complainant has filed this case with prayer for direction to O.Ps. to pay him Rs. 63,795/- on account of medical expense incurred during his treatment and compensation of Rs. 50,000/- and legal expense Rs. 3000/-.
2. Complainant’s case in brief is that he is a retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy for himself and his wife. He was provided MIN No. 4730414  which was valid at the relevant time. Further case is that due to illness of the complainant he was admitted in Institute of Neurosciences, Kolkata, W.B.  on 10.03.2021 and discharged on 13.03.2021 and hospitalization charge Rs. 63,795/- was paid by the complainant inspite of approval of cashless treatment for Rs. 45,750/-.   Later on complainant claimed said amount from the O.Ps. who denied it on the ground that the treatment given to the patient does not support the need for hospitalization. Thereafter legal notice was issued but claim was not settled.  Hence this case has been filed with above mentioned prayer. 

 

4.   O.P. No. 1  has not appeared nor filed W.S. inspite of due service of notice.
5. On behalf of O.P. No.2 (New India Insurance/Assurance  Co. Ltd.) W.S. has been filed in which it is mentioned that there is no proper line of treatment to the claimant and it has been observed that the treatment given to the patient does not support the need for hospitalization, rather it would have been avoided. Further reply is that hospitalization is not justified hence as per clause No. 10.06 of the policy  claim has been repudiated.
6. O.P. No. 3 & 4 have filed W.S. by admitting the fact that complainant was their employee and he is covering with the insurance policy but these O.Ps. are not liable for reimbursement of the claim.  
7. On the basis of above pleadings we have to see whether complainant is entitled to get relief as claimed or not?
8. On careful perusal of the reply of the O.P. Insurance co. it is very much clear that there is no dispute regarding capacity of the complainant in filing of the case or in filing the claim papers. W.S. shows that the line of treatment given to the patient shows that hospitalization is not justified rather said treatment was to be availed on OPD basis. Further its shows that only for observation patient was admitted and there was no active line of treatment hence it does not support the need for hospitalization.
9. On this aspect we would like to mention here that photo copy of the Discharge Certificate dt. 13.03.2021 related to Institute of  Neurosciences, Kolkata  shows that the specialist doctor has admitted the patient in the hospital on 10.03.2021 who was discharged on 13.03.2021 and patient was diagnosed for Essential Tremor, Hypertension, Non valuable Atrial Fibrillation for which he was examined, investigated and treated with the medicines which were required for the purpose of treatment as it is apparent from photo copy of the discharge summary issued by that very hospital. Photo copy of the bills of that very Hospital is supportive to the claim of the complainant. Similarly there is no denial regarding expenses incurred during treatment of the patient at Kolkata. The complainant has produced photo copy of legal notice dt. 16.12.2021, photo copy of postal receipt with track report, photo copy of denial of the request by the O.P., photo copy of discharge certificate, photo copy of bill dt. 13.03.2021 and photo copy of payment receipts as well as photo copy of claim form submitted before the O.Ps., photo copy of medical card and medical book.   These papers are supportive to the case of the complainant and proving the fact that as per advice of the specialist doctor patient was admitted and treated in the hospital because it was essential at that very time.
10. A certificate dt. 24.03.2021 issued by the treating doctor has also been filed by the complainant in which doctor has certified that “the complainant was admitted in the hospital for acute exacerbation of Tremor of both hand, which was hampering his daily activity of living, making him dependant for eating on family member. Injection Botox was given for clinical purpose not for cosmetic purpose”.
11.  Complainant has filed print out of SMS received on his cell phone registered with the hospital which shows that earlier O.P. has approved the cashless treatment of the complainant for Rs. 45,750/- but inspite of approval of cashless treatment of the complainant later on the expense of the hospital has not been reimbursed rather claim has been repudiated. On perusal of the entire record it appears that there is no denial of the O.P. regarding the facts mentioned in the complaint petition in respect to approval of cashless facility and there is no any evidence by the O.P. to contradict the opinion expressed by the specialist doctor regarding suggestion to admit the patient in the hospital. It appears that without any specialist’s opinion O.P. Insurance co.  has repudiated the claim which is not justified. Therefore, it is very much clear that genuine claim of the complainant related to Rs. 63,795/- has not been settled by the O.Ps. which shows deficiency on the part of O.P. No.1 & 2.   Therefore, complainant is entitled to get relief as indicated below:-
12.   Accordingly prayer of the complainant is being allowed in the following manner:-

    O.P. No. 2  New India Insurance/Assurance  Co. Ltd. is directed to pay Rs. 63,795/- to the complainant within 60 days from receipt/production of the copy of this order, failing which this O.P. will pay interest @ 10% per annum  on that very amount from 12.01.2022 (i.e. the date on which case was filed). Further O.P. No.2 is directed to pay compensation of Rs. 7,000/- for various types of harassment caused to the complainant for his genuine claim and also to pay Rs. 3000/- as litigation cost within above mentioned period.

 

(J.P.N. Pandey)

                                                                                      President

                                                                                       (B.P.L Das)

   Sr. Member

                                                                            

                  

                                                                               (Baby Kumari)

                                                                                                    Member