Jharkhand

Bokaro

CC/18/8

Ramashry Sharma - Complainant(s)

Versus

The Manager, Raksha T.P.A. Pvt Limited - Opp.Party(s)

11 Mar 2019

ORDER

Complainant Rameshwar Sharma filed this case for a claim of Rs. 2100/- with interest and Rs. 5000/- as compensation for mental harassment.

2          The case is that complainant and his wife both having MIN No. 4718960 and 4718961 paid premium for mediclaim. Complainant is a ex-employee of the SAIL.

            Both got treatment at Bokaro General Hospital as OPD (Out door Patient) and purchased medicine for Rs. 1153/- and Rs. 947/- on 08-08-2016. The bills were submitted to T.P.A. O.P. No.1. Complainant also clears the queries of T.P.A. On 05-12-2016 but even after several visits to T.P.A, the bills were not cleared. TPA had given only assurances.

Even after legal notice the claim has not been cleared. Hence the case is filed.

3          Complainant filed the documents in support of the claim:-

            Anx-1- Copy of the renewal of policy for 2016 dt. 31-03-2017.

            Anx-2- Copy of the receipt of claim by T.P.A.

            Anx-3- to 3/2 Copies of the legal notice.

            Anx-4- Copy of term & Condition  

4          O.P. No. 1 & 2 Raksha TPA Pvt. Is not appeared in spite of notice hence ex-parte proceeding initiated against both.

5          O.P No.3 IFFCO TOKIO General Insurance Co. Ltd. appeared and filed W.S. It is submitted that the case is not maintainable as there is no merit. It is admitted that the complainant and his wife availed treatment at Bokaro General Hospital and purchased medicines for himself of Rs. 947/- having claim No. 106191617185422 and his wife for Rs. 1153/- having claim No. 106191617185420 during July and August 2016 and they submitted that claim for re-imbursement. It is submitted that TPA has noticed the Diagnosis of the claimant has not been cleared and sent a query letter  but the claimant has not submitted any document and for that the claim is pre-matured and non payable due to non submission of essential document and therefore, there is no deficiency in service.

5          O.P. No.4 SAIL has also appeared and filed W.S. and it is submitted that there is no cause of action against them because SAIL is not involved in the assessment of the claim. The Insurance Co. is liable for assessment; therefore, there is no deficiency on the part of the SAIL.

                                                           

 

 

F I N D I N G S

6          We perused the record and the documents filed. The complainant as well as his wife both have taken mediclaim policy on payment of premium of the contract between the SAIL and the Insurance Co. They are beneficiary, therefore, they are a consumer and the dispute is a consumer dispute.

7          It is admitted by the O.P. that the complainant for himself and his wife have purchased medicines for Rs. 947/- and Rs. 1153/- in total Rs. 2100/- on the prescription of the doctor of B.G.H. The TPA has not appeared on whose behalf. The Insurance co. has not cleared the claim on the only ground that it appears of diagnosis submitted.

            In the instant case the treatment given to the complainant and his wife free of cost only some of the medicines have been purchased on the prescription of the BGH doctor. Anx-2 is sufficient to show the claim was received by the TPA on behalf of the insurance Company. The ground taken for non process of the claim is based on technical ground which is not acceptable in the light of natural justice and therefore we hold the insurance Company is liable for re-imbursement of the claim and therefore, it is deficiency in service on the part of the insurance co.

8          Accordingly we allow the claim of the complainant and the O.P. IFFCO TOKIO General Insurance Co. Ltd. is hereby directed to pay Rs. 2100/- (Rs. Two thousand one hundred) only with interest of 6% from 08.08.2016 till realization, the date of receipt of the claim.

            O.P. Insurance Co. is further directed to pay compensation of Rs. 2000/- (Rs two thousand) only for mental agony and litigation cost of Rs. 500/-(Rs. Five hundred) only to the complainant.

            All the payment must be paid within 45 days of this order, failing which the rate of interest of the main claim shall be enhanced of 10% P.A. till realization.