Jharkhand

Bokaro

CC/62/2019

Sri Amar Nath Sah - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

Ajay Kumar Jha

02 Aug 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 62/2019

 Date of Filing-23-03-2022

 Date of Order-02-08-2022

Sri Amar Nath Sah S/o Late Khobhari Sah,

 R/o Sector-2/B, Qr.No. 2-335, Bokaro Steel City.

                                      Vr.

1. M/s Uninted India Insurance co. ltd. 24, Whites Road, Chennai, Tamil Nadu-600014 Having Branch Office Plot No. A/17, 2^nd Floor, City Center, Sector-4, Bokaro Steel City

 2. M/s MD India Health Insruance TPA Pvt. Ltd. S.No. 46/1, E-Space A-2 Wing, 3^rd Floor Pune Nagar Road, Vadgon Shrei Pune -411014 Maharashtra.

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. 23,397/- on account of medical expense incurred during his treatment and to pay Rs. 10,000/-  as compensation and Rs. 5000/- 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. 4739895 for himself and his wife
   valid for relevant period. During the enforcement of the insurance policy the complainant was admitted in Nav Jyoti Eye Clinic, Plot No. 229, Co-operative Colony, B.S. City, District Bokaro on 15-04-2018 for operation of Cataract and discharged on same day after operation and proper care during that very period Rs. 23,397/-  was paid by the complainant to the Hospital. Complainant applied for reimbursement of the said amount but his claim has been denied on the ground that his claim was misrepresented. Thereafter, legal notice was served having no impact. Hence this case has been filed with above mentioned prayer.
3.   Inspite of due service of notice O.P. No. 2 has not appeared and has not filed W.S.
4.  O.P. No.1 (United India  Insurance Company Ltd.) appeared and has filed W.S. mentioning therein that claim of the complainant has been repudiated as there was misrepresentation of facts.  Further reply is that this O.P. has given justified and correct reasons regarding repudiation of the claim.
5. Only point for consideration is that, Whether ground for denial of the claim by O.Ps. is lawful ground based on facts of the case or not? Whether Complainant is entitled to get any relief as prayed?
6. First of all we would like to mention here about the photo copy of repudiation letter in which it has been written that On perusal of the scrutiny of above mentioned claim documents, the date of inception 11 April 2018 patient treated for RIGHT EYE CATARACT on 15 April, 2018. It is evident that the “CLAIM HAS BEEN REPUDIATED AS THERE IS MISREPRESNTATION OF FACTS IN THE CLAIM DOCUMENTS”. Hence the claim is not admissible as per policy clause mentioned.
7. On care full perusal of the repudiation letter it is apparent that only on the ground that there was misrepresentation of facts in the claim paper it has been repudiated. The report of surveyor is on record which shows that he has investigated the matter on 10.09.2018 and reported that at that very time hospital was found closed since August, 2018. It is very much clear from the record and documents that operation was conducted on 15.04.2018 and there is no any evidence on record to show that on 15.04.2018 clinic was not functional. Mere on the basis that in the month of Sept. 2018 clinic was found closed since August 2018 repudiation of the claim appears to be baseless and beyond the true facts. Therefore, we are of the view that repudiation of the claim is not justifiable rather it is based on arbitrary decision which is not acceptable at all. Hence there is deficiency in service and claim is liable to be accepted. 

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

O.P. No. 1 (United India Insurance Co. Ltd.)  is directed to pay Rs. 23,397/- to the complainant within 60 days from receipt/production of this order and also to pay Rs. 2,000/- as compensation and Rs. 1,000/- as litigation cost within 60 days from receipt/ production of this order, failing which this O.P. No.1 will pay interest @ 10% P.A. from 23-03-2019 ( i.e. the date on which complaint was filed) till the date of  final payment.