Complainant Smt. Bimla Devi filed this case with a claim of Rs. 44,067/- with 12% interest per annum and compensation of Rs. 40,000/- and other reliefs.

2          The case in brief is that husband Lal Bahadur Rai was ex-employee of the SAIL and took Mediclaim policy under SAIL Mediclaim Scheme having policy No. 041100/48/15/41/00000002 and MIN No. 4723649.

            Due to aliment of throat, complainant, firstly admitted at Apollo Gleneagles Hospital at Kolkata under Doctor Archana Ranade and TPA had provided cashless facility for the admission period 13.07.2015 to 17.07.2015.

            On follow up, complainant again met Dr. Ranade who advised to be admitted for further treatment and she was admitted on 18.11.2015 to 21.11.2015. This time TPA did not provide cashless facility and advised to produce bills for re-imbursement.

            On 23.12.2015, complainant filed her claim form and she claimed pre-hospitalization benefit for Rs. 500/- and hospitalization benefit of Rs. 41383.94 and Post hospitalization of Rs. 1683.25 for medicine and consultation fee of Rs. 500/-, in total Rs. 44067/-. But on 10.03.2016 TPA gave letter of repudiation, thus, this is deficiency in service on the part of O.Ps.

3          Complainant has filed the following documents in support :-

Anx-1 to 1/7 Copies of bills and medicine bills.

Anx-2 Copy of Receiving the claim by TPA.

Anx-3 to 3/1 Copies of letter of repudiation and letter to deny cashless facility.

Anx-4 Copy of payment of Rs. 41383.94 by the complainant.

            One witness Lalbahadur Ray husband, examined as C.W. 1 .

4          O.P. No.1 and 2 both TPA E-Meditek do not appeared and ex-parte proceeding is initiated.

5          O.P. No.3 M/s United India Insurance Co. Ltd. appeared and filed its W.S. It is submitted that there is no cause of action and case is not maintainable owing to the ground, there was no active line of treatment. Hence re-imbursement was denied in the light of clause 5.6 of terms and conditions.

                                                             F I N D I N G S

6          We perused the record. Complainant is the beneficiary under mediclaim scheme of the SAIL and paid premium for the policy. Therefore, we hold that she is the consumer and the dispute is a consumer dispute.

7          The main objection of O.P. No.3 the insurance co. is that there was no active line of treatment, therefore, the claim is denied due to clause 5.6, the exclusion clause for investigation and other diagnostic studies.

            We do not agree with contention of O.P. No.3 as because earlier the complainant was under surgery of her throat for cyst and this current hospitalization is in continuation of the earlier treatment and as per advice, she was again admitted in the hospital for continued further treatment. Therefore, the claim should not come under the purview of clause 5.6 of the terms and conditions and this is deficiency in service on the part of the O.P. No.3 for repudiation.

            Therefore, we hold O.P. No.3 liable for payment of the claim.

8          Accordingly, the claim of the complainant is allowed and we direct O.P. No.3 M/s United India Insurance Co. Ltd. to pay Rs. 44,067/-(Rs. forty four thousand sixty seven) only in round of Rs. 44070/- (Rs. Forty four thousand seventy) only with 6% (six percent) interest per annum till realization since the date of filing claim dt. 23.12.2015.

            O.P. No.3 is further directed to pay compensation for mental harassment of Rs. 5000/-(Rs. Five thousand) only with litigation cost of Rs. 3000/- (Rs. Three thousand) only.

            All the payments must be paid within 60 days of this order, failing which the rate of interest on the main claim shall be enhanced to 10% per annum till realization.