Jharkhand

Bokaro

CC/17/82

Shambhu Nath Tiwary - Complainant(s)

Versus

The E- Meditek (TPA) Services Ltd. - Opp.Party(s)

Amardeep Jha and Poonam

15 May 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-26-05-2017

Date of final hearing-15-05-2023

 Date of Order-15-05-2023

Case No. 82/2017

Shambhu Nath Tiwary,

R/o Plot No. 89, Lohanchal Colony, P.O. and P.S.- Sector-12

District- Bokaro, Jharkhand

                                      Vrs.

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

     Plot No. 577, Udog Vihar, Phase-5, Gurgaon, Haryana.

 2.  Universal Sompo General Insurance Co. Ltd.

      Expres  I.T. Park, Plot No. EL-94 T.T.C. Industrial Area,

      MIDS, Mahape,  Navi Mumbai, Maharashtra.

 3.  The E-meditek (TPA) Sevices Ltd.

                  Plot No. HD-11, Ground Floor, Sector-4

     District- Bokaro, Jharkhand.

 

Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant has filed this case with prayer to direct the O.Ps. to pay Rs. 62,864/- as medical expense paid to the hospital for his treatment, to pay Rs. 20,000/- as compensation and to pay Rs. 10,000/- as litigation cost.
2. Complainant’s case in short is that he obtained Mediclaim policy of Universal Sompo General Insurance Co. Ltd. vide policy No. 2817/54327082/00/000 valid from 05.11.2015 to 04.11.2016 and during that very period he became ill hence he was admitted in Shivam Hospital, at Plot No. E-2, Laxmi Market, Sector-4, P.O.& P.S.- Sector-4, District- Bokaro, Jharkhand on 24.04.2016 and discharged on 30.04.2016 after treatment. Further case is that for the treatment he paid Rs. 62,864/- to the hospital concerned, thereafter, submitted dully filled up claim form with the O.Ps. along with all relevant papers but claim was not settled inspite of repeated requests. Further case is that complainant served legal notice to the O.Ps. having no impact hence this case has been filed with above mentioned prayer.
3. O.P. No.1 & 3 (TPA) have filed W.S. mentioning therein that they have neither realized the premium nor premium was to be paid to them rather they are having no liability in the case. Further reply is that on observation it was found that claim was not fulfilling the hospitalization criteria hence it has been refused.
4. O.P. No.2 Universal Sompo General Insurance Co. Ltd. has filed W.S. mentioning there in that the statement made in para 2 to 5 of the complaint petition are true which are accepted, rest of the statements are denied. Further reply is that just after 5 months from joining the policy treatment has been done which was found not supported with proper claim documents. Further reply is that inspite of availability of several other hospitals why complainant has chosen the Shivam Hospital it is not being cleared. Further reply is that E-Meditek is solely authorized to settle the claim subject to its maintainability hence E-Meditek has reported that said claim is not claim, hence it is prayed to dismiss the case.
5. Point for consideration is whether complainant is entitled to get relief as prayed or not?
6. On careful perusal of the pleadings of the parties it is very much clear that following points are either admitted or not disputed points :-

1. That complainant is insured person of the O.P. Insurance Co.
2. That complainant has submitted claim form for his treatment in the hospital from 24.04.2016 to 30.04.2016.
3. That at the time of treatment insurance policy of the complainant was effective.
4. That the treatment  of the complainant in the hospital concerned has not been disputed.
5. That the payment made by the complainant to the hospital has also not been disputed.

 

7. To prove its case complainant has produced photo copy of the insurance policy (Annexure‑ A), photo copy of the Medical papers including final bill  showing payment of Rs. 62,864/- to the hospital by the complainant (Annexure‑ B), photo copy of claim form (Annexure‑ C) and photo copy of the Legal Notice (Annexure‑ D). Except above noted papers no any other paper or evidence either oral or documentary has been produced by the complainant.
8. No any evidence either oral or documentary has been produced by the O.Ps. inspite of denial of several facts or raising several other points for which they were liable to prove.
9. On careful perusal of the papers produced by the complainant it appears that for the complain of chest pain, restlessness, weakness, sweating etc. complainant was admitted and treated in the hospital from 22.04.2016 to 30.04.2016 and he paid Rs. 62,864/- to the hospital concerned. It is admitted fact that complainant applied for settlement of claim before the O.Ps. but O.Ps. have not paid the amount on the ground for which they are having no any evidence. O.P. No.2 Insurance Co. says that  he is not liable to pay or decide about the claim rather O.P. No.1 & 3 are liable to decide it who have decided it. O.P. No.1 & 3 have stated that they are not liable for the claim because premium has not been paid to them. O.Ps. are failed to show that how the claim is not payable in the eye of law or as per terms and conditions of the insurance policy.
10. Therefore, we are of the view that there is deficiency in service by the O.Ps. and  complainant is able to prove his case for grant of relief as prayed, accordingly this point is being decided.
11. Accordingly prayer of the complainant is being allowed in the following manner:-

O.P. No.2 Universal Sompo General Insurance Co. Ltd. is directed to pay Rs. 62,864/- to the complainant within 60 days from receipt/production of the copy of this order, failing which complainant will be entitled to get interest @ 10% per annum from 26.05.2017 (the date on which case was filed). Further O.P. No.2 is directed to pay Rs. 7,000/- compensation and Rs. 3000/- as litigation cost to the complainant within above mentioned period.

 

•  

(J.P.N. Pandey)

                                                                                      President

 

The opposite party case has

not been produce for argument before me

          S/d   

                                                                               (Baby Kumari)

                                                                                       Member