Complainant Dinesh Chandra Rai filed this complainant for a mediclaim of Rs. 1,00,977/- with 18% interest since 25-04-2015 and compensation of Rs. 40,000/- and litigation cost of Rs. 30,000/-

2          The Case of the complaint is that he is a retired SAIL employee and taken mediclaim policy of the SAIL Scheme on payment of premium, valid from 01-04-2015 to 31-03-2015 form O.P. United India Insurance Co. Ltd.

            Complainant fell ill on 25-04-2015 and treated at Max Specialty Hospital at New Delhi. Complainant filed claim form for reimbursement of the claim but inspite of submission of original document O.Ps did not pay the claim.

            Then complainant sent a legal notice but there was no reply. Hence this case is filed.

3          Complainant has filed the following documents is support:-

            Anx-1, 1/1,1/2,1/3- Copies of MIN numbers, renewal of policy etc.

            Anx-2- Copy of legal notice dt. 02-12-2015.

            Anx-3- Copy of discharge summary.

            Anx-4- to 4/1- Copies of medical prescription

            Anx-5-to 5/5- Copies of Inpatient bill and detail bills

4          O.P. No.-1 M/s United India Insurance co. ltd appeared and filed W.S. It is submitted that the case is not maintainable as there is no cause of action. It is submitted that several letters issued to supply the documents but it was not given and at last on 18-02-2016 letter was issued to give bank details with cancelled cheque but the same was not supplied and the claim was under consideration. Hence there is no deficiency in service and the compliant is liable to be dismissed.

            No document is filed by O.P. No.1

5          O.P. No.2 E-Meditek (TPA) has not appeared and ex-parte proceeding is initiated.

6          O.P. No.3 SAIL appeared and filed W.S. it is submitted that this O.P. only received premium and transferred to Insurance Co. and has no role in process of the claim, therefore the O.P. is not liable for any deficiency in service.

F I N D I N G S

7          Perused the record, we hold that complainant is a beneficiary under SAIL mediclaim policy with insurance policy and complainant paid premium for the policy so he is a consumer and the dispute is a consumer dispute.

8          As regard re imbursement claim is concerned, O.P. Insurance Company has not denied the policy for the period of claim, meaning thereby it is admitted.

            Now the only objection that documents were not sent, by O.P. Insurance Company the complainant has filed the Anx 5 series and Anx4 series to justify the claim. No letter dt. 18-02-2016 is filed by O.P. to show the fact that O.Ps. was considering the claim therefore we hold that complainant has proved his claim and entitled for the claim and O.P. Insurance Co. is liable for deficiency in service.

9          Therefore, we allow the claim of the complainant and O.P. M/s United India Insurance Co. Ltd. is hereby, directed to pay Rs 1,00,977/- round off Rs. 1,00,980/-  (One lac nine hundred eighty) only with 6% (six percent) interest P.A. since 25-04-2015 till realization.

            Insurance co. is further directed to pay Rs. 5000/- (Rs. Five thousand) only as compensation for mental harassment and litigation cost of Rs. 3000/- (Rs. Three thousand) only to the complainant.

            All the payment must be paid within 60 days failing which the rate of interest on main claim shall be enhanced to 12% (twelve percent) p.a. till realization.