Jharkhand

Bokaro

cc/15/136

Smt. Purnima Srivastava - Complainant(s)

Versus

The E-Meditek - Opp.Party(s)

Amardeep Jha and Poonam

07 Aug 2018

ORDER

Complainant Smt. Purnima Srivastava has filed this case for a claim of Rs. 77,440/- and compensation of Rs. 10,000/- for harassment with litigation cost of Rs. 10,000/-.

2          The brief fact of the case is that the husband of the complainant was ex-employee of SAIL who with the help of O.P. insurance company made mediclaim coverage of their Ex-employee and spouse on payment of premium. The complainant has MIN No. 4720412.

            Complainant was admitted in Sarvoday Hospital at Bokaro for incisional Hernia on 26.02.2015 and discharged on 02.03.2015 after treatment. She made her claim for re-imbursement of the medical expenses with all relevant documents of treatment. The complainant expended Rs. 1,17,990/- for the treatment but the O.P. has only paid Rs. 40,550/- and refused to pay the balance of Rs. 77,440/- without any reasonable ground.

            O.P. did not give any response to her letter. Then she sent a legal notice on 31.08.2015 but O.P. did not replied. Therefore, the O.P. is deficient in service and liable to pay the entire cost of the treatment. Hence, this case is filed.

3          The following documents have been filed in support by the complainant:-

Anx-1 Copy of payment receipt of Rs. 1,17,260/-.

Anx-2 to 2/4 Copies of payment details of Rs. 400/,Rs.150/-, RS.

                 100/-  (Rs. 650/-)

Anx-3 Copy of hospital certificate.

Anx-4 Copy of Discharge paper.

Anx-5 Copy of prescription.

Anx-6 Copy of TPA, E-Meditek regarding documents and

            certificate.

Anx-7 Copy of Legal Notice dt. 31.08.2015.

Anx-8 Copy of claim settlement of Rs. 40,550/-.

            Complainant has also relied on the law reported in M/s E-Meditek (TPA) services Vrs. Parag Mukherjee & others delivered in Revision Petition before NCDR on 02.02.2017, in R.P. No. 3258 of 2013 between M/s National Insurance Co. Ltd. Vrs. Radhey Shayam Balwada dt. 04.03.2014 and In Appeal 1884/16 of S.C.D.R.C. in M/s United India Insurance Co. Ltd. Vs. S.K.S. Yadav & M.D. India Health Care Services (TPA) Pvt. Ltd.

4          O.P. No.1 &2 M/s E-Meditek (TPA) appeared and filed W.S. in which it has been submitted that TPA has no role to settle the claim dispute and claim dispute is only settled by Insurance Co. So, they are not liable for any deficiency and they act under the guidelines of the insurance co.

5          O.P. No.3 M/s National Insurance Co. ltd. appeared and filed W.S. It is submitted that there is no cause of action and the complainant is not entitled for any claim on the ground of capping mentioned in clause 8.0 (g) in which Rs. 40,000/- is maximum limit for Hernia Repair.

            It is submitted that O.P. has partly approved the claim for Rs. 40,000/- and pre/post expenditure of Rs. 550/- to the complainant. Hence, there is no deficiency in service and case is fit to be dismissed.

            Anx-A Copy of Group Mediclaim Insurance Policy is filed.

F I N D I N G S

6          We perused record and the documents filed by both the sides. We have no hesitation to hold that complainant wife of the ex-employee of SAIL, is a beneficiary and consumer, having paid premium for Mediclaim policy under Group Medical claim scheme of the SAIL and the dispute is a consumer dispute.

7          It is admitted that complainant is covered under the mediclaim policy. It is also admitted by O.P. due to capping clause in the policy mentioned in clause 8.0 (g) only Rs. 40,550/- was cleared out of the total claim of Rs. 1,17,990/-.

            Clause 8.0 (g) only says capping of Rs. 40,000/- on Hernia repair. This clause does not specify the details of capping. Meaning thereby, what is the capping of surgery, medicine necessary test etc. The basket capping of Rs. 40,000/- is not justified in natural justice. It appears that the policy terms filed as Anx-A does not reveal the facts for the year, it is applicable. In the instant case it is not cleared.

            There is no proof to show every employee were explained the capping clause. This must be reasonable. Any Mediclaim policy is meant for benevolent purpose not for income. There is no proof on record to show that complainant filed this claim for benefit. Therefore, by capping a limit in all circumstances is beyond the scope of reasonability and against the principle of natural justice.

            The deduction reason shown in Anx-8 cannot be accepted as reasonable and TPA should have considered for payment. The total of this deduction in Rs. 68,440/- and this amount is liable to be re-imbursed.

8          In the result, we allow the part claim of Rs. 68,440/- in favour of the complainant.

            O.P. M/s National Insurance Co. Ltd. is directed to pay Rs. 68,440/- (Rs. Sixty eight thousand four hundred forty) only to the with compensation of Rs. 5000/- (Rs. Five thousand) only and litigation cost of Rs. 3000/- (Rs. three thousand) only.

            All the payment must be paid within 60 days, failing which O.P. will be liable to pay interest @ 10% till realization on the claim amount since the date of filing of this case i.e. 20.11.2015.