Jharkhand

Bokaro

CC/16/26

Smt. Kiran Devi - Complainant(s)

Versus

The E- Meditek - Opp.Party(s)

Amardeep Jha and Poonam

03 Sep 2022

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-18-03-2016

                                                                                                                       Date of final hearing-03-09-2022

 Date of Order-03-09-2022

 

Case No. 26/2016

 

Smt. Kiran Devi W/o Sri Parshuram Pandit

R/o- Flat No.-SE-01, Janki Apartment, Vastu Vihar, Project-II,

Chira Chas, P.O. & P.S.- Chas, District- Bokaro, Jharkhand

Vs.

1. E-Meditek (TPA) Service Ltd.

    Plot No. HD 11, Ground Floor, Sector 4,P.O&P.S- sector- 4,

     District- Bokaro, Jharkhand, Bokaro Steel City 

2. The E-Meditek (TPA) Service Ltd.

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

3. Branch Manager, United India Insurance Co. Ltd.

At Bye Pass Road, Chas, P.O. & P.S.- Chas,

District- Bokaro, Jharkhand

                             Present:-

                             Shri Jai Prakash Narayan Pandey, President

                            Smt. Baby Kumari, Member

 

PER- J.P.N Pandey, President

-Judgement-

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 83,949/- on account of medical expense incurred during her treatment and to pay Rs. 30,000/-  as compensation and Rs. 10,000/- 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 for himself and for the complainant . The MIN No. 473339 has been allotted in the name of the complainant
   valid for relevant period. During the enforcement of the insurance policy the complainant was admitted in BGH for 11 days but her ailment was not cured rather she was referred to A.M.R.I. HOSPITAL LTD. at Dhakuria, Kolkata, where she was admitted on 06.10.2015 and discharged on 12-10-2015 for treatment during that very period Rs. 80,002/-  was paid by the complainant to the Hospital and she purchased medicines of Rs. 3947/- for which also she is entitled for re-imbursement. Complainant applied for reimbursement of the said amount but her claim has been denied on the ground that hospitalization was not essential rather she could have been treated as OPD patient. 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. hence case is proceeding ex-parte against them vide order dt. 01.11.2017.
4.  O.P. No.3 (United India  Insurance Company Ltd.) appeared and has filed W.S. mentioning therein that no any proper line of treatment has been done to the claimant and there was no active treatment in the hospital hence hospitalization is not justified. Further reply is that the hospitalization charges in which radiological/laboratory investigations/other diagnostic studies have been carried out which are not consistent with or incidental to the diagnosis of treatment of positive existence or presence of any ailment, sickness or injury for which confinement at any hospital/nursing house has taken place. Further reply is that this O.P. has given justified and correct reasons regarding repudiation of the claim.
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. On careful perusal of the pleadings of the parties it appears that following facts are either admitted or not disputed facts:-

1. That complainant is the wife of ex-SAIL/BSL employee.
2. That the husband of the complainant was retired from the service of SAIL/BSL.
3. That as per norms/policy of the SAIL/BSL there is provision for medical insurance of ex-SAIL/BSL employees and their spouse.
4. That during the relevant period complainant was being covered with the mediclaim policy issued by the O.P. No.3.
5. That for the mediclaim policy due premium was paid.
6. That complainant was admitted at BGH on 23.09.2015 and discharged from BGH on 03.10.2015 with referral to AMRI, Hospital, Kolkata.
7. That complainant was admitted in AMRI, Hospital, Kolkata on 06.10.2015 and discharged on 12.10.2015.
8. That complainant has submitted claim form before the O.Ps. for reimbursement of the medical expense.

7. First of all in view of above admitted or not disputed facts we would like to mention here about the photo copy of repudiation letter dt. 29.07.2015 in which  on the basis of clause No. 5.6 of the policy it has been mentioned that “the above clause clearly states that radiological/laboratory investigations/other diagnostic studies must be  consistent with or incidental to the diagnosis of treatment of positive existence or presence of any ailment, sickness or injury. Hence we concur with the TPA’s decision accordingly claim has been repudiated”.
8. On careful perusal of the repudiation letter it is apparent that only on the ground that there was no need of hospitalization of the complainant rather her treatment was for diagnostic purpose only her claim has been rejected.
9.  On perusal of annexure-A photo copy of the medical book of the complainant it shows that on 23.09.2015 complainant was admitted in BGH, Bokaro and she was discharged on 03.10.2019 with referral note that “ A case of type -2 diabetic, hypertension with B/L, OA of knee joint with PUO, referred to AMRI, Hospital, Kolkata for treatment, investigation and management”. In this way annexure- A is showing the fact that for 11 days complainant was admitted at BGH, Bokaro for her treatment related to knee joint pain, Diabetic, hypertension etc. This Annexure-A is sufficient to contradict the contents of W.S. of the O.P.
10.  Annexure-B is photo copy of discharge summary of AMRI, Hospital, Kolkata accordingly at the time of admission in the hospital on 06.10.2015 patient was having low grade fever since one and half months, there was loss of appetite and she was having pain in both knee joints. For that very ailment she was admitted in the hospital and several investigations were done to diagnose the real cause of the disease and after treatment she was discharged on 12.10.2015 with direction to take medicines and come for follow up after 4 weeks or SOS. This discharge summary is also corroborative to the annexure-A (the opinion of the doctors at BGH) and contradictory to the statement made in W.S. In this way annexure- A & B are sufficient to prove the claim of the complainant and disprove the ground for repudiation of the claim by the O.Ps.
11.  Annexure-B is accompanied with Inpatient Bill Cum Receipt of the hospital concerned accordingly complainant has paid total Rs. 80002/- only against total bill of Rs. 83497/- after discount of Rs. 3495/-. Therefore, actual payment has been made Rs. 80002/- by the complainant to the hospital concerned which is apparent from photo copy of the papers annexed with the complaint petition and it is being corroborated with photo copy of the claim form submitted by the complainant.
12.  In light of above discussion, after perusal of photo copy of all the papers submitted by the complainant we are of the view that repudiation of the claim of the complainant by the O.Ps. is not justifiable rather complainant is entitled to get reimbursement of the amount Rs. 80002/- from O.P. No.3 which has been paid by her to the hospital concerned during her treatment as indoor patient. Accordingly above points are being decided in favour of the complainant.
5.  

O.P. No. 3 (United India Insurance Co. Ltd.)  is directed to pay Rs. 80,002/- to the complainant within 60 days from receipt/production of this order and also to pay Rs. 7,000/- as compensation and Rs. 5,000/- as litigation cost within 60 days from receipt/ production of this order, failing which this O.P. No.3 will pay interest @ 10% P.A. on Rs. 80,002/- from 18-09-2016 ( i.e. the date on which complaint was filed) till the date of  final payment.