Jharkhand

Bokaro

CC/16/114

Alakh Raj Singh - Complainant(s)

Versus

The E- Meditek - Opp.Party(s)

Annu Kumari

23 Dec 2021

ORDER

          Complainant has filed this case with prayer for direction to O.Ps. to pay insurance claim of Rs. 22,000/- and for payment of Rs. 20,000/- and Rs. 10,000/- as compensation and litigation cost respectively.

2       In short case of the complainant is that he obtained Health Insurance Policy No. 548914864 from O.Ps. and thereafter, due to fever and other ailments like vomiting , pain abdomen etc he was admitted in the Shivam Hospital, Laxmi Market, Sector-4 , B.S.City, Bokaro, where treatment was done. Further case is that he was admitted in the hospital on 22.02.2016 and discharged on 04.03.2016, thereafter, he submitted claim before the O.Ps. for re-imbursement of Rs. 33000/-  incurred on treatment but only Rs. 10,000/- was paid and rest of the claim was refused, hence Legal Notice was served having no response thereafter, this case has been filed.

3       O.P. No.2 has filed W.S. mentioning therein that as per Third Party Administrator claim for 5 days @ Rs. 2000/- per day was admissible hence, Rs. 10,000/- has been paid and partial claim has been disallowed on the ground that “TPA Authorized Medical Examiner feels the number of days of hospitalization is extended for the purpose of claim and hence reduced to the genuine number of the days in tune with the nature of treatment”. It is further case of the O.P. No.2 that as per terms and conditions of the policy only Rs. 2000/- per day was to be paid to the complainant and there was  no condition to re-imburse the entre treatment cost.

4       O.P. No.2 has also filed W.S. mentioning therein that this O.P. having no pecuniary or financial interest in the matter in the claim hence having no liability, however, as Third Party Administrator he has discharged his legal liability.

5         In support of claim complainant has filed photo copy of hospital treatment form, admission record, discharge slip, pathological reports, description of bills and copy of legal notice.

6       O.P. No.2 has filed copy of letter dt. 20.05.2016 written by TPA and copy of letter dt. 23.05.2016 written by this O.P. to the claimant. On behalf of O.P. TPA copy of terms condition of the Policy, copy of receipt and copy of Proposal Form For Health Insurance Policy have been filed.

7       On careful perusal of the pleadings of the parties and scrutiny of the papers filed by both the parties it is apparent that facts related to existence of the policy on the relevant date as well as partial acceptance of the claim are admitted facts.

8       Only point for consideration is whether complainant is entitled to get Health Benefit under the policy concerned for the entire period of hospitalization or not ?

9       On perusal of the copy of the Proposal Form it is apparent that policy was obtained for daily cash benefit of Rs. 2000/- in case of hospitalization of insured persons.  There is no terms and conditions in the proposal form that in case of claim TPA will decide it. The treatment papers show that the insured was suffering with Enteric Fever and UTI. Pathological Reports are confirming it. There is no any evidence on record to show that decision of the TPA will be final and claim should be examined by the panel of the doctors of TPA. Hence the fact related to right of the O.Ps. in respect to acceptance of partial claim has not been substantiated by any evidence. It was the sole discretion of the treating doctor to decide the days of hospitalization according to condition of the patient to save his life. The treating doctor has issued all relevant papers in support of the claim. Therefore, we are of the opinion that complainant is entitled to get amount @ Rs. 2000/- per day for the entire hospitalization period i.e. from 22.02.2016 at 04.:45 P.M. to 04.03.2016 at 06:30 P.M. which comes to the tune of 11 days only because in the year 2016 February was of 29 days and the first day of admission was made in the evening at 04:45 P.M. and on the last day at 06:30 P.M. patient was discharged.

10     Therefore, in our opinion there is deficiency in service by the O.P. No.2 by rejection of partial claim.  Hence, again rest of the partial claim of the complainant is being allowed. Accordingly, it is ordered that :-

                   O.P. No.2 is directed to pay total claim for 11 days only  hospitalization  benefit @ Rs. 2000/- per day after deduction of the amount already  paid. In other words O.P. No.2 shall pay Rs. 22000/- (total admissible amount ) minus Rs. 10,000/- (already paid) = Rs. 12,000/- as hospitalization benefit to the complainant within 60 days from today and also to pay Rs. 5000/- compensation and Rs. 5000/- litigation cost respectively.  In case, total amount Rs. 22,000/- is not paid within 60 days then O.P. No.2 shall pay interest on it @ 9% per annum from 28.09.2016.