Jharkhand

Bokaro

CC/86/2022

Ram Pravesh Choudhary - Complainant(s)

Versus

The Chairman Steel Auhtority of India Limited - Opp.Party(s)

Mukesh Kumar choudhary

14 Sep 2023

ORDER

                District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-27-05-2022

Date of final hearing-14-09-2023

 Date of Order-14-09-2023

Case No. 86/2022

Ram Pravesh Choudhary, S/o Late Chathi Choudhary,

R/o Qr.No. 1075, Street-26, Sector-9/C, P.O.- Sector-9,

P.S.- Harla, District- Bokaro Jharkhand

                                      Vrs.

1.Director In -Charge, SAIL, Bokaro Steel Plant, Steel Authority of India Ltd. A.D.M. Building, Bokaro, Jharkhand 827001

2. The Manager, United India Insurance Company Branch Office- At-A/17, Floor No.2, City Centre, Sector-4, B.S.City, District- Bokaro 827004

3. Md. India Health Insruance TPA Pvt. Ltd.

Branch Office at Near Railway Ticket Counter/ B.S.City Thana, Sector-1, P.O.- Sector-1, B.S.City, District- Bokaro Jharkhand 827001

Present:-

                             Shri Jai Prakash Narayan Pandey, President

Shri Bhawani Prasad Lal Das, Sr.Member

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant’s case in brief is that he is retired SAIL/BSL employee and as per scheme of the SAIL he has been provided Health Insurance Mediclaim Policy of United India Insurance Co. Ltd.  for himself and his spouse. As per norms of the insurance policy insurance company has to provide cashless treatment facility to the employees and said policy was valid at the time of relevant period. Further case is that complainant was provided MIN No. 4728694 and during that very period health benefit up to Rs. 4,00,000/- was to be covered by that very policy. Further case is that due to chronic Kidney Disease complainant was admitted in CMC, Vellore hospital on 22.04.2019 and after treatment discharged on 17.05.2019 and inspite of request cashless facility was denied, hence complainant paid Rs. 4,13,305.45 as treatment cost to the hospital for which he made claim before the O.Ps. for its reimbursement, which was refused and till date it has not been paid. Further case is that complainant sent legal notice dt. 26.03.2022 to the O.Ps. which was replied by O.P. No.2 but payment has not been made. Hence this case has been filed with prayer to direct the O.Ps. to make payment of Rs. 4,13,305.43 with interest @ 12% from 22.04.2019 till its realization and to make payment of Rs. 1,00,000/- as compensation for various type of harassment and to pay Rs. 50,000/- as litigation cost.
2. O.P. No.2 Insurance Co. appeared and has filed W.S. mentioning therein that suit attracts the doctrine of res-judicata as the claim amount is settled and paid earlier. Further reply is that the relief as prayed by the complainant totally false and highly inflated and no amount payable is made out on the part of the O.P. and claim of the complainant is wrong. Further reply is that the O.P. has demanded original authentic (pre printed, with sl. No., date, stamp and seal) paid receipt of Rs. 2,12,507/- only which the complainant had still not submitted about which he alleged to deposit at the time of discharge from the hospital. Further reply is that the payable amount may be approx Rs. 3,50,000/- after deduction of nonpayable items which is subject to submission of the original authentic receipt of Rs. 2,12,507/-. Hence it is prayed to dismiss the case.
3. Point for determination is whether complainant is entitled to get relief as prayed ?
4. On careful perusal of the pleadings of the parties it is very much clear that the fact related to liability of reimbursement of medical cost by O.P. No. 2 & 3 is admitted fact and it is not in dispute. Further the fact regarding treatment of the complainant on relevant dates at CMC, Vellore is also not in dispute and further  the fact that complainant has incurred the cost of the treatment is also not in dispute.
5. On careful perusal of para 21,22&23 of the W.S. of O.P. No.2 it is very much apparent that the liability of making the payment towards reimbursement of the treatment cost has been impliedly admitted by the insurance company. Only dispute is that complainant has not provided payment receipt of Rs. 2,12,507/- to the O.P. as per his choice hence payment has not been made. On query Ld. Counsel for the O.P. has not satisfied the Commission that on which basis said figure of Rs. 2,12,507/- has been written in the W.S. On perusal of para 6 of the W.S. it appears that O.P. has mentioned that the claim amount is settled and paid earlier but it appears that there is no iota of truth in this statement in light of other facts mentioned in the W.S. It is very much clear from the annexures from Page 1 to page 128 of the complaint petition that complainant has proved all the relevant facts for grant of relief. On perusal of page 12, 13, 14& 15 of the Annexures (Evidence) it is apparent that complainant has made payment of Rs. 1,99,000/- on 18.05.2019 and on same date he has also made payment of Rs. 14,305/- about which he has filed cash receipt, discharge bill summary, deposit in slip as well as slip of ICICI Bank. Discharge summary bill shows that total bill of Rs. 4,13,305.43 was to be paid to the hospital to which complainant has paid with due cash receipt of the CMC, Vellore which is at page 12 of the Annexure. To made it more clear today complainant has filed his bank account statements which are in consonance with the fact related to making payment by the complainant to the hospital.
6. In light of above discussion, we are of the view that mere on hyper  technical approach the genuine claim of the complainant is not being paid to him who is very old person unable to stand without help of others. Hence in  light of above discussion we are of the opinion that complainant is entitled to get reimbursement of medical expense to the extend of the coverage of the policy. As per para 7 of the complaint petition the insurance policy is covering only the medical cost up to Rs. 4,00,000/-. Therefore, we are of the view that there is deficiency in service on the part of O.P. No.2 & 3 and they are liable to make payment of the medical cost up to Rs. 4,00,000/- only.
7. Hence prayer of the complainant is being allowed in the following manner:-

O.P. No.2 is directed to make payment of Rs. 4,00,000/- to the complainant within 60 days from receipt/production of the copy of this order failing which this O.P. will pay interest @ 12% per annum on above mentioned amount from 27.05.2022 i.e. the date on which case was filed. Further O.P. No.2 is directed to make payment of Rs. 25,000/- as compensation and Rs. 10,000/- as litigation cost within above mentioned period.

 

 

Sd/-

(J.P.N. Pandey)

                                                                                      President

 

 

Sd/-

(B.P.L Das)

   Sr. Member

                                                                            

                  

                                                    Sd/-                           

  (Baby Kumari)

                                                                                       Member