Jharkhand

Bokaro

CC/17/2021

Rajniti Sharma - Complainant(s)

Versus

The Divisional Manager, Untied India Insurance Co. Ltd. - Opp.Party(s)

Ranjeet Kumar

04 Aug 2023

ORDER

                District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-20-04-2021

Date of final hearing-04-08-2023

 Date of Order-04-08-2023

Case No. 17/2021

Rajniti Sharma, S/o Late Ram Singh,

R/o Flat No. 4W2, Lav Apartment, Road No.-5,

Phase-II, Vastu Vihar, Chira Chas, P.S. Chas, District- Bokaro

                                      Vrs.

1. The Divisional Manager,

          United India Insurance Company Limited,

          Divisional Office, Plot No. A-17, City Centre,

          Sector-4, Bokaro Steel City, 827004

2. The Authorised Signatory,

MD India Health Insurance TPA Pvt. Ltd.

Quality Circle, Sector-1, Near B.S.City,

P.S.- Bokaro Steel City, Bokaro 827001

Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant’s case in brief is that he being retired SAIL/BSL employee is a member of Group Medical Scheme for the year 2018-19 having MIN No. 04747139 which was effective during relevant period. Further case is that on 10.07.2018 complainant was admitted in All India Institute of Medical Science, New Delhi  (in short AIIMS) for treatment of Right  Parietal Convexity Meningioma and discharged on 25.07.2018 about which intimation to O.P. was given and after discharge complainant submitted claim form on 14.08.2018 for Rs. 1,31,694/-. Further case is that O.P. No.2 again asked and demanded some papers as well as some details which were fulfilled but no payment has been made. Further case is that later on it was found that actual claim was for Rs. 1,05,194/- which was not paid, rather O.Ps. have repudiated the bonafide claim on flimsy and baseless ground, thereafter, legal notice dt. 22.07.2020 was served on the O.Ps. having no impact. Hence this case has been filed with prayer to direct the O.Ps. to make payment of Rs. 1,05,194/- with interest @ 18% per annum, to make payment of Rs. 25,000/- as compensation and to make payment of Rs. 10,000/- as legal expense.
2. As per O.P. No.1 & 2 complainant failed to provide papers in respect to claim amount of Rs. 1,31,694/- or Rs. 1,05,194/- for reimbursement of hospitalization charge hence claim has been repudiated. Further reply is that final bill of treatment for Rs. 20,000/- has been filed instead of above mentioned amount hence treating the case as suspicious claim has been closed, hence it is prayed to dismiss the case with cost.
3. Point for determination is whether complainant is able to prove his case for grant of relief as prayed?
4. On perusal of the papers submitted by the complainant it appears that he has submitted claim form before the O.Ps. for payment of Rs. 1,31,694/- but as per O.Ps. he failed to submit the papers such as receipt etc. regarding payment made to the hospital.
5.  Entitlement of the complainant regarding reimbursement of the claim is not in dispute. It is also not in dispute that complainant was treated at AIIMS, New Delhi on the alleged dates.
6. On perusal of payment receipt dt. 25.07.2018 it shows that total service amount is Rs. 46,670/- to which complainant has paid to the hospital concerned on 25.07.2018  or prior to it, receipt dt. 25.07.2018 shows that till 25.07.2018 total service amount is Rs. 46,670/- and till that very date advance was already paid Rs. 40,220/- and only due amount was Rs. 6450/- which was paid successfully through debit card. Except this receipt there is no any other paper to prove that complainant has paid more amount than the amount mentioned in receipt dt. 25.07.2018. Complainant has not produced discharge summary of the hospital before this Commission. What to talk about production of documents before the O.Ps. to justify the claim of Rs. 1,05,194/- complainant failed to produce copy of those documents before this Commission also except the receipt dt. 15.07.2018 for payment of Rs. 46,670/- only.
7. In light of above discussion we are of the view that complainant is entitled to get reimbursement of Rs. 46,670/- only to which he has proved vide payment receipt and to that very extent there is deficiency in service by the O.Ps.
8. Hence prayer of the complainant is being partly allowed in the following manner:-
9.  

 

(J.P.N. Pandey)

                                                                                      President

 

 

                  

                                                                               (Baby Kumari)

                                                                                       Member