Jharkhand

Bokaro

CC/18/95

Krishana Devi - Complainant(s)

Versus

The General Manager, Raksha TPA Pvt. Ltd. - Opp.Party(s)

Mahesh Lal Vishwakarma

14 Jul 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 95/2018

  Date of Filing-03-08-2018

 Date of Order-14-07-2022

Krishna Devi W/o Late Chandra bhushan Pandey

R/o- Qr.NO-310, Sector-1/C, P.O.& P.S. B.S. City,

District- Bokaro Jharkhand.

                                      Vr.

1. The General Manager Raksha TPA Pvt. Ltd. Head Office C/o- Escorts Corporate Centre 15/5 Mathura Road, Faridabad Hariyana-121003

2. The General Manager IFCO TOKIO General Insaurance Co. Ltd. IFCO TOKIO Tower-II, Plot No.-3, Sector-29, Gurgaon-122001 (Hariyana)

3. The CEO SAIL Bokaro Steel Plant ADM. Building, B.S. City, Bokaro

 

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. 51,150/- with 12% per annum interest on account of medical expense incurred during treatment of complainant  and to pay Rs. 25,000/-  as compensation and Rs. 15,000/- as litigation cost.
2. Complainant’s case in brief is that he is retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy vide MIN No. 04722125 for himself and his wife which was valid at the relevant time. During the enforcement of the insurance policy the complainant got operated for Gall Bladder stone for which he was admitted in the Survoday Hospital, Sector-4, City Centre, Bokaro (In short hospital)  and was admitted on 01.06.2016 and discharged on 04.06.2016 for which Rs. 51,150/- was paid to the hospital by the complainant. Complainant applied for reimbursement of the above amount but inspite of repeated requests no action was taken by the O.Ps.  Thereafter legal notice was served having no impact. Hence this case has been filed with above mentioned prayer.  

 

3.   O.P. No.3 SAIL/ BSL Bokaro appeared and has filed W.S. in which there is no comment on the claim of the complainant and it has been admitted that complainant has obtained mediclaim policy valid relevant period.

 

4. On behalf of O.P. No.2 (Insurance Co.) W.S. has been filed in which there is no specific denial in respect to facts mentioned in paras 1 to 11 of the complaint petition. However, it is mentioned at para 5 of the W.S.  that complainant was to provide some papers related to treatment but it has not been provided hence claim has been closed due to non submission of documents. It has also been mentioned that during relevant period complainant was entitled for the re-imbursement or cashless treatment upto Rs. 2,00,000/- for one person.
5.  On the basis of above pleadings we have to see whether complainant is entitled to get relief as claimed or not?

 

6. It is admitted fact that complainant was fully covered with the insurance policy and for the operation of the Gall Bladder stone  he was entitled to have facility by the Insurance Co. Another admitted fact is that only on the basis of the fact that demanded documents were not submitted to the TPA hence claim has been closed. It is not the case that claim has been repudiated.

 

7. Since genuineness of the documents is not in dispute hence it is not being discussed in detail. Only there is dispute that complainant has not provided demanded documents hence on this aspects discussion is being made. On perusal of the photo copy of the documents produced by the complainant it appears that complainant has submitted claim form for re-imbursement of Rs. 51,150.77 along with all other relevant papers to the O.P. No.1 with due receipt dt. 04.06.2016 and thereafter he has submitted other demanded papers on 11.09.2016, therefore, it cannot be said that demanded papers have not been submitted by the complainant. Hence we are of the opinion that there is deficiency in service by the O.P. No.1 & 2 hence claim of the complainant is liable to be accepted. Accordingly this point is being decided in favour of the complainant.

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

O.P. No. 2   (IFCO TOKIO General   Insurance Co. Ltd.) is directed to pay Rs. 51,150/- to the complainant within 60 days from today otherwise this O.P. shall pay interest @ 10% per annum from 03.08.2018 (the date on which complaint was filed) on that very amount. Further this O.P. is directed to pay Rs. 3000/- as compensation for various type of harassment and also to pay Rs. 2000/- as litigation cost within 60 days from today.