Jharkhand

Bokaro

CC/16/108

Md. Sulaiman - Complainant(s)

Versus

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

Amardeep Jha and Poonam

30 Mar 2019

ORDER

Complainant Md. Suleman has filed this complaint for claim of Rs. 1,39,995/- with compensation of Rs. 40,000/- and litigation cost of Rs. 20,000/-.

2          The case of the complainant in short is that complainant is an ex- employee of SAIL and paid premium of mediclaim facilities of SAIL and O.P. United India Insurance Co. Ltd. Complainant has MIN No. 4700327. The complainant having problem of right inguinal hernia and he was admitted in Apollo Belinegal hospital at Kolkata on 18-02-2015 and discharge on 24-12-2015 and he has incurred cost of Rs. 1,34,995/- for entire treatment as during hospitalization benefits and post hospitalization benefit.

            Complainant filed a claim. The TPA issued a letter demanded OT Notes with duration of procedure of O.T. satisfied by the trating doctors but the payment was not cleared and a legal notice was sent but there was no positive steps and reply, hence this case has been filed.

3          Complainant has filed following documents in support:-

Anx-1 Copy of discharge slip.

Anx-2 to 2/4 Copies of bills.

Anx-3 Copy of the legal notice.

4          O.P. No.1 and 2 appeared and filed W.S. It is submitted that the complaint is not maintainable and this O.P. has no pecuniary interest in the claim and there are only responsible for settled of the bills on the basis of guideline issued by company. It is submitted that amount of Rs. 36000/- have been deducted of TDS has been paid to the complainant on 12.01.2016 keeping in view of the maximum amount of Rs. 40,000/-capping in case of hernia pas per in terms and conditions and this O.P. is only a agent of insurance co. and therefore, there is no deficiency on the part of this O.P.

5          Anx-A has been filed by O.P. No.1 and 2.   

6          O.P. No.3 United India Insurance Co. Ltd. has also appeared and filed W.S. it is submitted that the complaint is not maintainable as there is no cause of action and further complainant is entitled for imbursement of Rs. 40,000/- as in patient and Rs. 4000/- out patient. It is further submitted that TPA has not provided a break up bill and medicine etc as such the complainant has failed to provide documents which is required by TPA and therefore, the denial reimbursement of claim bill and therefore, the complainant is not entitle for any relief.

F I N D I N G S

7          We perused the record and documents filed by both sides.

            The hospital bill has been denied by the insurance co. O.P. No.3 on technical ground that some of the documents have not been provided but it appears that TPA has demanded those documents which was not provided by hospital to the complainant, therefore, the ground taken by the O.P. No. 1 and 2 suggesting the insurance co. is highly technical. It is fact that complainant is a retired SAIL employee and paid premium for covering the mediclaim insurance of the complainant sustained medically. The complainant had right inguinal hernia for which he was admitted in the hospital at Kolkata which has issued in patient bill along with the receipt Anx-2 and 2/1 to show the genuine claim of the complainant. As such the terms  and conditions of capping only Rs. 4000/- is not acceptable because it has been held by NCDRC in RP No. 3258/13 relied that the condition were not extended at the time of premium submitted to the complainant and further this is against the natural justice. Therefore, the plea of the insurance co. cannot be accepted and therefore, the claim of the complainant is partly allowed related to the ailment as mentioned in the complaint petition regarding hernia and this is deficiency in service on the part of the insurance co. It is clear from Anx-A that Rs. 36,000/- has already been paid in the account of the complainant on 12.01.2016 vide cheque UTR No. 161BH1244/UGX1L12. The complainant is entitled for medicines bill marked two series only 2 to 2/4.

8          Accordingly, the part claim is allowed of the complainant and we direct to O.P. United India Insurance Co. Ltd. to pay Rs. 1,28,496/-  - Rs. 36000/-= 94,941/- (Rs. Ninety four thousand nine hundred forty one) only to the complainant with interest of 6% per annum from date of filing of this case i.e. 24.09.2016 till realization.

            We further direct The O.P. insurance Co. to pay compensation of Rs. 10,000/- (Rs. Ten thousand) only and litigation cost of Rs. 5000/-(Rs. Five thousand) only to the Complainant.

            All the payments must be paid within 60 days of this order, failing which the rate of interest shall be enhanced to the claim amount of Rs. 94,941/- to 12% till realization.