Jharkhand

Bokaro

CC/16/102

Bijay Kumar Gupta - Complainant(s)

Versus

The Manager E- Meditek - Opp.Party(s)

Sri Sanjay Kapoor

27 May 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 102/2016

  Date of Filing-09-09-2016

 Date of Order-27-05-2022

Bijay  Kumar Gupta

R/o- Sector-III/A, Qr.No. 670, Bokaro Steel City, Bokaro

                                      Vr.

1. Manager, E- Meditek, Corporate Office Plot No- 577,

Udyog Vihar, Phase V, Gurugram Haryana-122016

2. Branch Manager, National Insurance Co. Ltd.

C-27, City Centre, Sector-4, B.S.City

3. Branch Manager, United India Insurance Co.

A-17, City Centre, Sector-4, B.S.City

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. 1,17,367/- with interest @ 9% per annum  on account of medical expense incurred during treatment of his wife  and to pay Rs. 20,000/- & Rs. 10,000/- as compensation and litigation cost respectively to him.
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. 4721893 for his wife Smt.

Indramani Devi. During the enforcement of the insurance policy the wife of the complainant became ill and she was admitted in the CMC Vellore on 28.10.2015 and discharged on 10.11.2015 and again approached the hospital on 16.12.2015 for removal of catheter during which Rs. 1,17,367/- was paid to the Hospital. Complainant applied for reimbursement of the said 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.1 appeared and has filed W.S. mentioning therein that this O.P. is only processing the claim on behalf of insurance co. as per their guidelines and claim is being reimbursed by the insurance co. hence this O.P. is having no financial liability in the case.
4.  O.P. No.2 (National Insurance Co. Ltd.)  appeared and has filed W.S. mentioning therein that the complainant was not insured by this O.P. at the time of alleged date of treatment hence he is not liable to pay any amount.
5. O.P. No.3 United India Insurance Co. Ltd. has filed W.S. admitting the insurance coverage of the wife of the complainant but it is further mentioned that the claim of the applicant has not been repudiated by this O.P. in absence of necessary documents, despite sending reminders the complainant has not submitted the final bill. Further reply is that the complainant has not submitted the final bill of the treatment hence there is no claim therefore, case is liable to be dismissed.
6.  As documentary evidence the photo copy of discharge summary of the patient Indramani Devi issued from CMC Vellore, photo copy of medical report, photo copy of claim form with acknowledgement dt. 02.12.2015, photo copy of letter dt. 15.01.2016 written by O.P. No.1 demanding documents from sl. No. 1 to 5 including the final bill, photo copy of letter dt. 18.02.2016 demanding detailed final bill written by O.P. No.1 to the complainant and photo copy of legal notice have been filed by the complainant.
7.  On the other hand photo copy of insurance contact of National Insurance co. to show that on the relevant period said insurance co. was not entrusted for medical insurance work during the relevant period has been filed. No any document has been filed by O.P. No.1 and 3.
8.  Point for consideration is whether complainant is entitled to get relief as claimed ?
9.   Following facts are admitted facts in this case:-

i). That Indramani Devi was wife of the complainant.

ii) That  complainant is Ex-employee of the SAIL, Bokaro.

iii) That being Ex-employee of the SAIL, Bokaro complainant is entitled to opt mediclaim policy for his treatment and treatment of his wife on payment of premium.

iv) That complainant obtained mediclaim policy from O.P. vide MIN No. 4721893 for the treatment of his wife.

v) That at the time of treatment i.e. from 28.10.2015 to 10.11.2015 O.P. No.3 United India Insurance Co. was liable to pay the medical expense of the Ex-employees of the SAIL, Bokaro.

Vi)That complainant has submitted claim form to the O.P. No.1 on 02.12.2015 and later on certain documents were demanded by O.P. No.1 vide letter dt. 15.01.2016.

vii) That vide letter dt. 18.02.2016 O.P. No.1 has demanded detailed final bill with cancelled cheque and other bank details of the complainant for payment of the amount through electronic mode.

10.  On perusal of photo copy of the claim form it appears that    complainant has  made claim for reimbursement of Rs. 1,17,367/- as it was paid to the Hospital for treatment of his wife and said claim form was received by O.P. No.1 on 02.12.2015 along with all relevant documents. Letter dt. 15.01.2016 issued by O.P. No.1 discloses that five documents such as 1) discharge summary of the hospitalization, 2) final bill, 3) all investigation reports 4) justification for delayed intimation of the claim and 5) paid receipts against final bill have been demanded from the complainant. Letter dt. 18.02.2016 written by O.P. No.1 shows that through that very letter detailed final bill has been demanded by O.P. No.1 from the complainant. This letter dt. 18.02.2016  is sufficient to show that all the original papers as demanded by letter dt. 15.01.2016 have already been submitted by the complainant and in addition to it vide letter dt. 18.02.2016 detailed final bill was being demanded for making payment. In this way till 18.02.2016 except detailed final bill all other formalities would have been completed by the complainant by deposit of all original papers as per demand of O.P. No.1. It is also noted to be here that all original papers have already been submitted by the complainant to the O.P. No.1 who is E-Meditek (TPA). It was the duty of the TPA to settle the claim with the concerned insurance co. i.e. O.P.No.3 but E-Meditek has failed to do it. Therefore, we are of the opinion that there is deficiency in service by the O.P. No.1 and 3 with the complainant. We are further of the opinion that complainant is entitled to get relief as claimed in following manner.

9   Thus we find and hold that the claim of the complainant is being allowed in the manner indicated here in below:-

O.P. No. 3(United India Insurance Co.)is directed to pay Rs. 1,17,367/- (Rs one lac seventeen thousand three hundred sixty seven) only to the complainant within 60 days from today otherwise he will pay interest thereon @ 9% per annum from 09.09.2016 (the date of filing of the case). Further O.P. No.3 is directed to pay Rs. 10,000/- as compensation related to various type of harassment and Rs. 5000/- as litigation cost within 60 days from today.