Jharkhand

Bokaro

CC/17/73

Sushil Kumar Yadav - Complainant(s)

Versus

The Branch Manager, Raksha T.P.A. Pvt. Ltd. - Opp.Party(s)

Ajay Kumar

18 Jun 2018

ORDER

Complainant Sushil Kumar Yadav has filed this complaint for a claim of Rs. 1,00056/- with 12% interest and compensation of Rs. 15000/- for mental harassment and litigation cost of Rs. 6000/-.

2          The case of the complainant in short is that complainant is a policy holder including his wife Roma Yadav vide policy No. 52613304 under SAIL Mediclaim scheme 2016-17 for retired SAIL employee and their spouse having MIN No. 4722542  and  4722543 through Raskha TPA along with IFFCO TOKIO G.I. Company Ltd. as insurance. As per the terms and conditions O.P. Insurance Co. is liable for hospitalization benefit reimbursement upto Rs. 2,00,000/- each member.

            In the Month of May 2016 Roma Yadav suffering from advanced renal failure was referred to Sanjay Gandhi Post Graduate institute of Medical Science, Lucknow for better treatment. She admitted on 27.05.2016 and telephonically informed the insurance co. Since O.P. has not provided cashless card hence paid the bill incash. After admission Roma Yadav was treated and she was discharged on 13.06.2016 and ultimately she expired on 23.06.2016. The complainant applied for re-imbursement of the bill to the TPA on 29.06.2016 in prescribed claim form along with all necessary documents. A query was sent by insurance co. for the claim number 106191617164822 and it was replied with supporting documents on 09.09.2016 but the claim has still not settled.

            Complainant then sent a legal notice on 01.04.2017.

Hence this complaint has been filed and O.P. Insurance Co. is liable for deficiency in service.

3          The complainant has filed following Anxs in support of his case:-

Anx-1 and 1/1 Copy of claim form and receipt by TPA.

Anx-2 Copy of the discharge summary (11 sheets).

Anx-3 to 3/40 Copies of discharge bills and admission payment receipts.

Anx-4 Copy of the reply query letter.

Anx-5 Copy of the legal notice.

4          O.P. No.1 and 2 Raksha TPA Pvt. Ltd. in spite of notices, have not appeared and Ex-parte proceeding has been initiated against them.

5          O.P. No.3 IFFCO TOKIO General Insurance Ltd. appeared and filed. W. S. It is submitted that the complaint is not maintainable. However, the policy has been admitted and also admitted that the claim form was submitted by the complainant and a query letter was issued on 10.09.2016 but the complainant has not submitted the documents as the claim is premature. It is denied by the O.P. that the complainant has send the documents as per the query letter and has also denied to have received the legal notice and therefore, the complainant is liable to be dismissed.

            The following Anxs have been filed:-

Anx-A- Copy of the terms and conditions.

Anx-B- Copy of the discharge  summary.

Axn-C Copy of the query letter.

                                                            F I N D I N  G S

6          We perused the record and hold the complainant having paid premium for the Mediclaim policy for himself and his wife therefore both are beneficiary under the SAIL Mediclaim scheme and as such both are consumers. The dispute is also a consumer dispute.

7          On perusal of the complaint petition and W.S., the policy is admitted and submission of the claim form is also admitted. The only objection is that the complainant has not replied the query letter dt. 10.09.2016 issued by TPA.  Anx-4 filed by the complainant shows the query letter was replied and duly received on 09.09.2016 by the TPA O.P. No.1 and 2 who have not appeared in this case. Therefore, the contention of the insurance co. O.P. NO.3 that the claim is premature is not justified and insurance Co. O.P. No.3 is liable for deficiency in service and the complainant is entitled for the claim regarding re-imbursement of the medical bill which is within maximum amount payable of Rs. 2,00,000/- as per the terms and conditions.

8          Accordingly we allow the claim of the complainant and direct to O.P. No.3 IFFCO TOKIO General Insurance Co. Pvt. Ltd. to pay Rs. 1,00,056/- ( Rs. One lac fifty six) only with interest of 6% (six percent) per annum from the date of received of the claim till realization within 60 days.

            O.P. No.3 is further directed to pay Rs. 5,000/- (Rs. Five thousand) only as compensation for mental harassment and litigation cost of Rs. 3,000/- (Rs. Three thousand) only.

            All the payment must be paid within time limit given above failing which the rate of interest on the main claim shall be enhanced to 12% (Twelve percent) per annum till realization.