Jharkhand

Bokaro

CC/16/48

Smt. Uma Devi - Complainant(s)

Versus

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

Amardeep Jha and Poonam

15 Dec 2022

ORDER

          District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-17-05-2016

Date of final hearing-15-12-2022

 Date of Order-15-12-2022

Case No. 48/2016

     Smt. Uma Devi W/o Umesh Prasad

     R/o- Q.NO.-2-572, Sector-2/C,

     P.O.- Sector-2, P.S.- B.S.City, District- Bokaro, Jharkhand

Vs.

1. The Branch Manager,  E-Meditek (TPA) Sevices Ltd.

Plot No. HC-07, Ground Floor, City Centre, Sector-IV,

P.O. & P.S.- Sector-IV

     2. The E-Meditek (TPA) Services Ltd.

           Plot No. 577, Udyog Vihar, Phase-V, Gurgaon, Haryana

3.  Branch Manager, United India Insurance Company Ltd.

Bye Pass Road, Chas, P.O. & P.S.- Chas,

P.O. & P.S.-Chas, District- Bokaro Jharkhand

                             Present:-

                             Shri Jai Prakash Narayan Pandey, President

        Shri Bhawani Prasad Lal Das, Member

          

      PER- J.P.N Pandey, President

-Judgment-

1. Complainant is absent, on the other hand O.P. No.3 is present through his Learned Counsel. None turned up on behalf of complainant on repeated call. It reveals from the record that this case is pending at the stage of argument in which complainant is absent since long therefore, heard argument of Ld. Counsel for O.P. No. 3.  In the given facts as per provision of Section 38 (3) (c) Consumer Protection Act. 2019 case has been taken up for decision on merit on the basis of materials available on record.

 

2. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 47057/- on account of medical expense incurred during treatment of complainant  and to pay Rs. 30,000/-  as compensation and Rs. 20,000/- as litigation cost.
3. Complainant’s case in brief is that her husband is retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy for himself and his wife (complainant) and O.Ps. have provided  MIN No. 4739378 for herself which was valid at the relevant time. Further case is that due to illness complainant got herself admitted in Christian Medical College (CMC), Vellore on 04.08.2015 and discharged on 06.08.2015 from the hospital for which Rs. 34616.74/- was paid to the hospital by the complainant. Further case is that there was other expense for pre and post hospitalization period.  Complainant applied for reimbursement of the above amount but inspite of repeated requests no action was taken by the O.Ps.  Thereafter legal notice was served having no impact. Hence this case has been filed with above mentioned prayer.  

 

4.   O.P. No.1 & 2 TPA have appeared and they have filed W.S. mentioning therein that they are not responsible to pay any amount rather they are agent of O.P. No.3 only with view to process the matter.
5. On behalf of O.P. No.3 (United India Insurance Co.) W.S. has been filed in which it is mentioned that as per policy contract claim has  to be ascertained. Further ground is that the claim has been repudiated as there is exclusion in the policy vide condition No. 5.6 that the hospitalization charges in which radiological/laboratory investigations/ other diagnostic studies have been carried out which are not consistent with or incidental to the diagnosis of treatment of positive existence or presence of any ailment, sickness or injury for which confinement at any hospital/nurshing home has taken place, hence the answering O.P. denied the claim on account of the above mentioned terms of the policy.
6.    On the basis of above pleadings we have to see whether complainant is entitled to get relief as claimed or not?
7. On careful perusal of the papers annexed with the complaint petition it appears that complainant claims herself to be treated at CMC, Vellore for the problem related to Seronegative Spondyloarthritis, Osteoporosis. Photo copy of the discharge summary issued by CMC, Vellore is in conformity to the case of the complainant in which it has been mentioned that for above mentioned problem patient was admitted and diagnosed. Patient has also been directed to visit the hospital for follow up in 6 months. In this way it seems that rejection of the claim is not justified by the O.P. Therefore, in light of above discussion we are of the view that complainant is able to prove its case for grant of relief as prayed. Accordingly this point is being decided in favour of the complainant.
8. However, on perusal of photo copy of the claim form (Annexure-B) it appears that claim for Hospitalization benefit is for Rs. 34,460/- only and other claims are related to pre and post hospitalization benefits in respect to Rs. 6130/- and Rs. 6467/- respectively but there is no any chit of paper to show such pre and post hospitalization medical expense. Therefore, we are of the view that only the claim for Rs. 34,460/- is liable to allowed and rest of the claim is not admissible. Since complainant is absent since long hence he is not entitled to get relief related to cost of legal expense.

9. Accordingly prayer of the complainant is being allowed in the following manner:-

 O.P. No.3 United India Insurance Co. Ltd. is directed to pay Rs. 34,460/- to the complainant within 60 days from receipt/production of copy of this Judgment and also to pay Rs. 5000/- as compensation.

 

 

(J.P.N. Pandey)

                                                                                      President

                                                                                     

         

    (B.P.L Das)

   Sr. Member