Jharkhand

Bokaro

CC/17/80

Mrs Shanti Roy - Complainant(s)

Versus

The Manager, IFFCo Tokio General Insurance Co. Ltd. - Opp.Party(s)

Basant Kumar Aggarwal

21 Feb 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-18-05-2017

Date of final hearing-21-02-2023

 Date of Order-21-02-2023

Case No. 80/2017

Mrs Shanti Roy, W/o Rabindra Nath

R/o Qr.No. 1094, Sector-5/C, P.O. & P.S.- Sector-5,

Bokaro Steel City.

Vs.

1. The Manager, IFFCO-TOKIO GENERAL INSURANCE CO. LTD

IFFCO TOWER 3^RD FLOOR, PLOT NO.3, SECTOR-29

GURGAON-122001 (HARYANA)

2. THE MANAGER, RAKSHA TPA PVT LTD

C/O ESCORTS CORPORATE CENTRE, 15/5 MATHURA ROAD

FARIDABAD, HARYANA 121003

 Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 2,29,579/- with interest at @ 12% per annum on account of medical expense incurred during her treatment and for grant of compensation of Rs. 60,000/- and for Rs. 20,000/- as legal expense.

2.    Complainant’s case in brief is that she is holder of Mediclaim policy No. 52613304 which was renewed time to time and valid from 01.04.2016 to 31.03.2017 during which she was admitted in Apollo Gleneagles Hospital, Kolkata on 22.01.2017 and discharged on 10.02.2017 after treatment related to Hernia and prior to it also she was operated earlier. It is further case that complainant submitted claim for Rs. 2,69,579/- before the O.P. but only Rs. 40,000/- was passed and paid and rest of the claim was refused on the ground of capping/limit for certain procedure. Further case is that earlier also O.P. has paid more than that very amount for same treatment but at this time it is being refused hence this case has been filed with above mentioned prayer.

3. O.P. has filed W.S. admitting the contents related to Mediclaim policy its validity period etc. Submission of claim form for reimbursement of Rs. 2,69,579/- has also been admitted, only on the ground that due to limit/capping and terms and conditions of the policy rest of the amount has not been paid, rather only Rs. 40,000/- was paid. Further reply is that there is no deficiency on the part of the insurance Co. hence case is liable to be dismissed.

4. Point for consideration is whether refusal to pay  rest of Rs. 2,29,579/- is justifiable or not ? And whether there is deficiency in service by the O.P. or not?

5. Since part of the claim related to Rs. 40,000/- has already been paid by the O.P. in respect to same treatment hence most of the facts related to treatment, existence and validity of the policy as well as admissibility of the claim are not in dispute. Only dispute is whether complainant will get reimbursement of entire treatment cost or she will get only Rs. 40,000/- as per capping clause of the insurance policy.

6.   On this aspects we would like to mention here that as per  Mediclaim scheme 2016-17 for retired SAIL Employees there is provision related to capping on procedure related to hernia repair, which is Rs. 40,000/- only, however, there is provision that “the capping/ceilings are applicable on ‘per hospitalization’ basis and only for cases where there are no complications/ multiple diseases”. It is very much clear from perusal of the discharge summary of the complainant that she was having complain and diagnosed  as a patient of “follow up case of obstructed recurrent incision hernia, hypothyroid”. Discharge summary further shows that during treatment in the hospital there was “repair of obstructed ventral hernia + abdominoplasty done under general anesthesia on 15.01.2017. It was found that there was multi loculated ventral hernia, multiple sites of chronic small bowel obstruction due to adhesions. Fibrosis adhesions to previously used mesh”. Photo copy of the discharge summary is on record.

7.   On careful perusal of above noted facts related to discharge summary and the terms and conditions of the insurance policy it is very much clear that apart from hernia patient was treated in the hospital for other ailments also, therefore, refusal to pay rest of the amount by the O.P. is not justified rather there is deficiency in service by the O.P. and complainant has proved its case for grant of relief as prayed in the following manner:-

Accordingly prayer of the complainant is being allowed in the following manner:-

         O.P. No. 1 IFFCO-TOKIO General Insurance  Co. Ltd. is directed to pay rest of Rs. 2,29,579/- to the complainant within 60 days from receipt/production of the copy of this Judgment, failing which he will pay interest @ 10% per annum  on that very amount from 18.05.2017 (i.e. the date on which case was filed). Further O.P. No.1 is directed to pay compensation of Rs. 10,000/- for various types of harassment caused to the complainant for his genuine claim and also to pay Rs. 5000/- as litigation cost within above mentioned period.

 

(J.P.N. Pandey)

                                                                                      President

 

                                                                            

                  

                                                                               (Baby Kumari)

                                                                                       Member