Jharkhand

Bokaro

CC/17/85

Rupa Devi - Complainant(s)

Versus

Universal Sompo General Insurance Co. Ltd. - Opp.Party(s)

Amardeep Jhaa and Poonam

15 May 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-26-05-2017

Date of final hearing-15-05-2023

 Date of Order-15-05-2023

Case No. 85/2017

Rupa Devi

R/o Qr. NO. 487, Sector-3/A, P.O- Sector-3,

P.S.- B.S.City , District- Bokaro, Jharkhand

                                      Vrs.

1. Universal Sompo General Insurance Co. Ltd.

    Express I.T. Park, Plot No. EL-94 T.T.C. Industrail Area,

     MIDC, Mahape, Navi Mumbai, Maharashra

2. The Branch Manager,  Allahabad Bank,

    D.P.S. School Branch,  Sector-04, B.S. City, Bokaro, Jharkhand.

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 to direct the O.Ps. to pay Rs. 1,65,702/- as medical expense paid to the hospital for her treatment, to pay Rs. 50,000/- as compensation and to pay Rs. 20,000/- as litigation cost. 
2. It is important to mention here that O.P. No.2 has been added vide order dt. 17.08.2017 but said O.P. has not preferred to appear before the Forum inspite of due service of notice hence vide order dt. 21.06.2018 case is being proceeded ex-parte against O.P. No.2.
3. Complainant’s case in short is that she obtained Mediclaim policy of Universal Sompo General Insurance Co. Ltd. vide policy No. 2827/55749543/00/000 valid from 07.01.2016 to 06.01.2017 and during that very period she became ill hence she was admitted in Shivam Hospital, at Plot No. E-2, Laxmi Market, Sector-4, P.O. & P.S.- Sector-4, District- Bokaro, Jharkhand (here in after referred as hospital) on 14.04.2016 and discharged on 23.04.2016 after treatment. Further case is that for the treatment she paid Rs. 95,000/- to the hospital concerned. Thereafter, submitted dully filled up claim form with the O.P. No.1 along with all papers but claim was not settled inspite of repeated requests. Further case is that again she became ill and was admitted in that very hospital on 30.07.2016 and discharged on 06.08.2016 after treatment for which she paid Rs. 70,702/- to the hospital and submitted claim form before the O.Ps. which was not settled. Further case is that complainant served legal notice to the O.Ps. having no impact hence this case has been filed with above mentioned prayer.
4. O.P. No.1 Universal Sompo General Insurance Co. Ltd. has filed W.S. and apart from other ornamental plea it has been mentioned there in the W.S. that the statement made in para 1 to 3 of the complaint petition are matter of record. Further reply is that the statement under para 4 to 10 of the complaint petition are denied. Further reply is that just after joining the policy complainant was admitted in the hospital. Further reply is that inspite of availability of several other hospitals why complainant has chosen the Shivam Hospital it is not being cleared. Further reply is that the present complaint is frivolous and vexatious which is liable to be dismissed. Further reply is that complainant is under connivance with the hospital and has filed this case. Further reply is that the first claim of the complainant has been denied on the ground that there was major discrepancies and misrepresentation because without ultra sound there was diagnosis of septicemia etc. and laboratory  reports  have not been supervised and verified by pathologist, blood culture has not been carried out etc.  Further reply is that second claim has been closed for the reason of non submission of required documents with claim. Hence it is prayed to dismiss the case.
5. Point for consideration is whether complainant is entitled to get relief as prayed or not?
6. On careful perusal of the pleadings of the parties it is very much clear that following points are either admitted or not disputed by the parties :-

1. That complainant is insured person of the O.P. Insurance Co.
2. That complainant has submitted claim form for her treatment in the hospital from 14.04.2016 to 23.04.2016.
3. That at the time of treatment insurance policy of the complainant was effective.
4. That again complainant was admitted in the said hospital for her treatment from 30.07.2016 to 06.08.2016  for which she has submitted claim form with the O.P. No.1.

 

5. That the treatment of the complainant in the hospital concerned has not been disputed.
6. That the payment made by the complainant to the hospital has also not been disputed.

 

7. To prove its case complainant has produced photo copy of the insurance policy effective at the time of treatment (Annexure‑ A), photo copy of the Medical papers showing her admission in the hospital from 14.04.2016 to 23.04.2016  including final bill  showing payment of Rs. 95,000/- to the hospital by the complainant (Annexure‑ B), photo copy of submission of first claim form before O.P. No.1 for Rs. 95,262/- (Annexure‑ C), photo copy of the Medical papers showing her treatment in the hospital from 30.07.2016 to 06.08.2016  including final bill showing payment of Rs. 70,702/- to the hospital by the complainant (Annexure‑ D), photo copy of submission of second claim form before O.P. No.1 for Rs. 70,702/- (Annexure‑ E) and photo copy of the Legal Notice (Annexure‑ F). Except above noted papers no any other paper or evidence either oral or documentary has been produced by the complainant.
8. No any evidence either oral or documentary has been produced by the O.Ps. inspite of denial of several facts or raising several other points for which they were liable to prove. In this way there is nil evidence from the side of O.P. in support of contents of the W.S.
9. On careful perusal of the papers produced by the complainant it appears that for treatment of the disease as mentioned in the medical papers for the first time complainant was admitted and treated in the hospital from 14.04.2016 to 23.04.2016 and she paid Rs. 95,000/- to the hospital concerned for which she has submitted claim form before the O.P. No.1 with all supportive papers.  Further it appears that for the second time complainant was again admitted in said hospital on 30.07.2016 and discharged on 06.08.2016 after treatment of the ailment as mentioned in the medical papers and she paid Rs. 70,702/- to the hospital for her treatment. It is admitted fact that complainant applied for settlement of claim before the O.P. but O.P. has not paid the amount on the ground for which they are having no any evidence. O.P. is failed to show that how the claims are not payable in the eye of law or as per terms and conditions of the insurance policy.
10. Therefore, we are of the view that there is deficiency in service by the O.P. No.1 and complainant is able to prove her case for grant of relief as prayed, accordingly this point is being decided.
11. Accordingly prayer of the complainant is being allowed in the following manner:-

O.P. No.1 Universal Sompo General Insurance Co. Ltd. is directed to pay Rs. 1,65,702/- (Rs. 95,000/- + Rs. 70,702/-) to the complainant within 60 days from receipt/production of the copy of this order, failing which complainant will be entitled to get interest @ 10% per annum from 26.05.2017 (the date on which case was filed). Further O.P. No.1 is directed to pay Rs. 10,000/- compensation and Rs. 5000/- as litigation cost to the complainant within above mentioned period.

•  

(J.P.N. Pandey)

                                                                                      President

 

The opposite party case has

not been produce for argument before me

          S/d   

                                                                               (Baby Kumari)

                                                                                       Member