Jharkhand

Bokaro

cc/15/95

Smt. Karmi Devi - Complainant(s)

Versus

The E- Meditek - Opp.Party(s)

Amardeep Jha and Poonam

06 Jul 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 95/2015

  Date of Filing-28-08-2015

 Date of Order-06-07-2022

Smt. Karmi Devi W/o Suraj Deo Mahto

R/o- Bhojpur Colony, Chas, P.O. and P.S.- Chas,

District- Bokaro, Jharkhand

                                      Vr.

1. The E- Meditek (T.P.A) Services Ltd.

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

P.O. and P.S.- Sector-4, District- Bokaro, Jharkhnd.

2.  

Plot No. 577, Udyog Vihar, Phase-V, Gurgaon, Haryana

3. The Branch Manager, National Insurance Co. Ltd.

Bye Pass Raod, Chas, P.O. and P.S.- chas, District- Bokaro, Jharkhand

Present:-

          Shri Jai Prakash Narayan Pandey, President

          Smt. Baby Kumari, Member

                                                -Order-

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 70,348/- on account of medical expense incurred during her treatment and to pay Rs. 20,000/-  as compensation and to pay Rs. 5000/- as litigation cost.
2. Complainant’s case in brief is that her husband is retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy vide Policy No. 351200/46/14/8500000260, Reference No. 100021503840 for himself and his wife
   (Complainant) valid for relevant period. During the enforcement of the insurance policy the complainant became ill and she was admitted in Fortis Hospital Ltd. at Anandpur, E.M.Bye-Pass Road, Kolkata for treatment where she was admitted on 07-02-2015 and discharged on 10-02-2015 during that very period Rs. 70,348/- was paid by her to the Hospital. Complainant applied for reimbursement of the said amount but her claim has been denied on the ground that she was admitted in hospital only for diagnostic purpose. Thereafter legal notice was served having no impact. Hence this case has been filed with above mentioned prayer.
3.   Inspite of due service of notice O.P. No.1 & 2 have not appeared and have not filed W.S.
4.  O.P. No.3 (National Insurance Company Ltd.) appeared and has filed W.S. mentioning therein that the complainant has not provided all relevant documents nor she has filed details of insurance policy. Further reply is that main liability is against O.P. No.1 and O.P. No.2. Further reply is that this O.P. has given justified and correct reasons regarding repudiation of the claim. Further reply is that claim is totally false and highly inflated.
5. Only point for consideration is that, Whether ground for denial of the claim by O.Ps. is lawful ground based on facts of the case or not? Whether Complainant is entitled to get any relief as prayed?
6. First of all we would like to mention here about the photo copy of repudiation letter (Only Page 1&3 have been filed) in which it has been written that “ We are in receipt of the claim form & associated documents of SMT KARMI DEVI. On scrutiny of the same, we observe that he/she was admitted in Fortis Hospitals Limited, patient admitted with c/o LOW BACK PAIN RADIATING TO RIGHT THIGH, SOB since 1 years as per documents available, patient admitted for evaluation and diagnostic purpose which can be done on OPD basis.

In this regard, we wish to inform you that the Claim is not payable as Per-

.) Exclusion- Patient admitted only for diagnostic purpose (Not fulfilling the basic need of hospitalization refer 3.0 (b) and 6.0 (V) & (VI)

In view of the above, we regret to inform you that, as per the instructions of National Insurance Co. Ltd. the claim is being denied on account of the above mentioned terms of the policy. For any further clarifications, you may directly contact the insurer.”

7. On care full perusal of the repudiation letter it is apparent that only on the ground that patient was admitted only for diagnostic purpose claim has been denied. No where it has been mentioned in the repudiation letter that claim is being denied because of non submission of the papers by the complainant or Complainant is not insured person. Therefore the reply of the O.P. insurance company in respect to non submission of original papers, non discloser of MIN No. etc is not acceptable.
8. Photo copy of discharge summery of the patient is on record accordingly “Patient was having low back pain radiating to right thigh for last one year and recently pain has increased. Further she is having complaints of pain in bilateral knee joint, shortness of breath on exertion. Bilateral pedal edema for last one year.” About the treatment given to the patient in the hospital it has been mentioned that “The patient was evaluated and treated conservatively with oral Steroids, DMARD’s and other supportive medications. She has been suggested for Rest for two weeks ”
9. On perusal of the repudiation letter as well as the discharge summery of the complainant we are of the opinion that the complainant was admitted in the hospital for her treatment and after examination and evaluation treatment has been provided to her by the concerned hospital and contrary to it there is no evidence by the O.P. Insurance company to prove that the discharge summery and other treatment papers are only confined to the diagnostic of the complainant. Therefore we are of the opinion that there is deficiency in service by the O.P. Insurance company and claim has been denied on baseless ground. Accordingly both points are being decided in favour of the Complainant and against the O.Ps..

5   Accordingly the prayer  of the complainant is being allowed in the manner indicated here in below:-

O.P. No. 3  (National Insurance Co. Ltd.)  is directed to pay Rs. 70,348/-  to the complainant within 60 days from today and also to pay Rs. 5,000/- as compensation and Rs. 2,000/- as litigation cost within 60 days from today,  failing which this O.P. No.3 will pay interest @ 10% P.A. from 28-08-2015 ( i.e. the date on which complaint was filed) till the date of  final payment.