District Consumer Disputes Redressal Commission, Bokaro
Date of Filing-25-06-2021
Date of final hearing-07-02-2023
Date of Order-07-02-2023
Case No. 23/2021
Ravish Kumar S/o Late Brijnandan Singh,
R/o Qr.No. 307, Sector-3/E, Bokaro Steel City
Vs.
1. The Branch Manager, The New India Insurance Co. Ltd.
City Centre, Sector-4, Bokaro Steel City, Pin 827004
2. The Branch Manager
Md. India Health Insurance TPA Pvt. Ltd.
Pune Nagar Road, Budgamsheri,
Pune Maharashtra Pin 411014
3. The Exective Chief/ Director
Md. India Health Insurance TPA Pvt. Ltd.
Registered Head Office at- S.No. 46/1, E-Space, A-2 Wing,
3rd Floor, Pune Nagar Road, Vaduon Sheri, Pune-411014
4. The Br. Manager/ Chief Branch Manager
Md. India Health Insurance TPA Pvt. Ltd.
Sector-1, Near-B.S. City Thana, Quality Circle,
Bokaro Steel City, Jharkhand 827001
Present:-
Shri Jai Prakash Narayan Pandey, President
Smt. Baby Kumari, Member
PER- J.P.N Pandey, President
-Judgment-
- Complainant has filed this case with prayer for direction to O.Ps. to pay him Rs. 1,31,018/- on account of medical expense incurred during treatment of his father and compensation of Rs. 1,00,000/- and legal expense Rs. 10,000/-.
- Complainant’s case in brief is that he is son of a retired SAIL, BSL employee namely late Brij Nandan Singh and as per policy of the company his father opted for Mediclaim policy for himself and his wife. His father was provided MIN No. 04706407 which was valid at the relevant time. Further case is that due to illness father of the complainant was admitted in BGH on 14.10.2019 but treating doctor referred him to Apollo Hospital in Kolkata where he was admitted on 25.10.2019 and discharged on 30.10.2019 and hospitalization charge Rs. 77,865/- was not paid by the O.Ps. rather it was paid by the complainant. Later on again his father was admitted in Ranchi Urology Centre on 08.11.2019 and discharged on 11.11.2019 for which complainant paid Rs. 53,153/-. Lastly father of the complainant died on 10.09.2020. Inspite of repeated requests O.Ps. have not paid claim. Thereafter legal notice was issued but claim was not settled. Hence this case has been filed with above mentioned prayer.
- O.P. No. 2, 3 & 4 have not filed W.S. inspite of due service of notice. Hence they have been debarred from filing W.S. vide order dt. 11.07.2022.
- On behalf of O.P. No.1 (New India Insurance 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 claim has been repudiated.
- On the basis of above pleadings we have to see whether complainant is entitled to get relief as claimed or not?
- 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 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.
- On this aspect we would like to mention here that photo copy of the discharge ticket dt. 22.10.2019 related to Bokaro General Hospital shows that the specialist doctor has admitted the patient in BGH on 14.10.2019 who was discharged on 22.10.2019 and patient has been referred to higher centre for better management. As per advise of the treating doctor at BGH patient was admitted in Apollo Hospital, Kolkata on 25.10.2019 and he was discharged on 30.10.2019 as it is apparent from photo copy of the discharge summary issued by that very hospital. Photo copy of the bill of the Apollo Hospital is supportive to the claim of the complainant. The photo copy of the discharge summary of Ranchi Urology Centre is showing that same patient was admitted in that very hospital on 08.11.2019 and discharged on 11.11.2019 who was suffering with prostate cancer and he was properly treated as indoor patient. Similarly there is no denial regarding expenses incurred during treatment of the patient at Kolkata and Ranchi. The complainant has furnished photo copy of the claim details related to second claim of Rs. 53,153/- which shows that still claim has not been rejected. These papers are supportive to the case of the complainant and proving the fact that as per advise of the specialist doctor patient was admitted and treated in the hospital because it was essential at that very time. On perusal of the entire record it appears that there is no any evidence by the O.P. to contradict the opinion expressed by the specialist doctors regarding suggestion to admit the patient in the hospital. It appears that without any specialist’s opinion O.P. Insurance co. has either repudiated the claim or it has been kept pending which is not justified. Therefore, it is very much clear that genuine claim of the complainant related to Rs. 77,865/- and Rs. 53,153/- total Rs. 1,31,018/- has not been settled by the O.Ps. which shows deficiency on the part of O.P. No.1. Therefore, complainant is entitled to get relief as indicated below:-
- Accordingly prayer of the complainant is being allowed in the following manner:-
O.P. No. 1 New India Insurance Co. Ltd. is directed to pay Rs. 1,31,018/- to the complainant within 60 days from receipt/production of the copy of this Judgment, failing which this O.P. will pay interest @ 10% per annum on that very amount from 25.06.2021 (i.e. the date on which case was filed). Further O.P. No.1 is directed to pay compensation of Rs. 10,000/- for various types of harassment caused to the complainant for his genuine claim and also to pay Rs. 5000/- as litigation cost within above mentioned period.
(J.P.N. Pandey)
President
(Baby Kumari)
Member
