District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-31-01-2019

Date of final hearing-20-04-2023

 Date of Order-20-04-2023

Case No. 29/2019

 Nirpati Nayak S/o Late Narayan Nayak,

 R/o Sector-2/C, Qr.No. 1-345, Bokaro Steel City

Vs.

1. M.D. India Health Care Service (T.P.A) Pvt. Ltd.

S.NO. 46/1, E-Space-A-2 Building, 3^rd Floor

Pune Nagar Road, Vadgaon, sheri,

Pune (Maharastra) Pin 411014

2. The Divisional Manager, United India Insurance Co. Ltd.

Plot No. A/17, Second Floor, Sector-4, City Center,

P.O. and P.S. – Sector-4, B.S.City, District-Bokaro

3. D.G.M Personnel SAIL Corporaton Office SAIL,

Ispat Bhawan, Lodhi Road, New Delhi Pin 110003

 Present:-

                             Shri Jai Prakash Narayan Pandey, President

Shri Bhawani Prasad Lal Das, Sr.Member

                  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. 2,22,783/- as medical expense and to pay Rs. 2,50,000/-  as compensation for various type of harassment and also to pay Rs. 20,000/- as litigation cost.
2. Complainant’s case in brief is that he being ex-employee of the SAIL/BSL opted for Mediclaim policy for hiself. He was provided MIN No. 4746208 which was valid from 11.04.2018 to 10.04.2019. Further case is that he became ill for which he was treated at B.M. Birla Heart Research Centmre, Kolkata and Angiography was done for which he paid Rs. 19,500/- later on doctors decided to do open heart surgery for which he was admitted in the hospital and operated  on 03.05.2018 for which he paid Rs. 2,14,000/- to the Hospital. Further case is that in respect of both bills O.Ps. approved Rs. 16,000/- and Rs. 1,84,000/- respectively but inspite of repeated requests dt. 05.05.2018 and 10.05.2018  of the hospital there was no response by the O.Ps. to the hospital hence complainant was compelled to pay all amount directly to the hospital. Further case is that complainant submitted his claim before the O.Ps. along with all relevant documents but his claim was not settled thereafter, legal notice was served having no positive response, hence this case has been filed.

3.   O.P. No.1 & 2 have not filed W.S. inspite of due service of notice and appearance hence vide order dt. 29.11.2021 they have been debarred from filing W.S. however they have filed written notes of argument later on. Non  appeared on behalf of O.P. No.3.

4. Point for consideration is whether complainant is entitled to get relief as prayed ?

5. On perusal of the papers annexed  with the complaint  petition as well as with the written notes of argument filed by the O.P. it appears that complainant has filed photo copy of Legal notice (Annexure-1), photo copy of Postal receipts (Annexure-2), photo copy of Acknowledgment slip regarding filing of claim for Rs. 2,22,783/- before O.Ps.  (Annexure-3), photo copy of first page of Medical book of the complainant   (Annexure-4), photo copy of first page of Bank pass book of the complainant  (Annexure-5), photo copy of paper of the hospital concerned related to estimated cost of CAG (Annexure-6), photo copy of Certificate issued by the hospital concerned regarding estimated cost of CABG (Annexure-7), photo copy of authorization letter No. 1 of O.Ps. regarding pre authorization of Rs. 16,000/- (Annexure-8), photo copy of authorization letter No. 2 of O.Ps. regarding pre authorization of Rs. 2,00,000/- (Annexure-9), photo copy of  receipts of the hospital concerned (Annexure-10), photo copy of discharge slip (Annexure-11), photo copy of final invoice  (Annexure-12), photo copy of final invoices  (Annexure-13 to 18) and photo copy of paper showing deposit of renewal amount of the insurance policy (Annexure-19).
6. It reveals from the written notes of argument of the O.Ps. 1 & 2 that earlier claim of the complainant for Rs. 29,600/- was repudiated on the ground of fraud hence present claim has also been repudiated. Further it is admitted that complainant has renewed his policy from 11.04.2018 to 10.04.2019 and when he was admitted for treatment at B.M. Birla Hospital, Kolkata and Mediclaim office has given approval/pre-authorization for Rs. 2,00,000/- only but in the mean time the earlier claim of the complainant was found fraudulent hence this claim has also been repudiated and pre- authorization has been canceled.
7. In this way it is very much apparent that the claim of the complainant was earlier approved by the O.P. and accordingly pre- approval for Rs. 16,000/- (Annexure-8) and Rs. 1,84,000/- (Annexure-9) was given to the hospital which was valid for the period between 30.04.2018 to 07.05.2018 and 30.05.2018 to 06.06.2018 respectively but later on it has been withdrawn. O.P. has not shown any provision to convince the Commission that if any claim will be found fraudulent then all other subsequent claims shall also be treated as repudiated. There is no any denial about right of the complainant regarding his right related to re-imbursement of the treatment cost from O.Ps. On careful perusal of annexure-3,6,7,8,9, 10, 11, 12, 13, 14, 15, 16, 17, 18 it is apparent that claim of the complainant for Rs. 2,22,783/- is being established for its re-imbursement. We are of the view that there is no any legal and valid ground for O.Ps. to deny the claim of the complainant.

8. In light of above discussion we are of the view that complainant has proved his case for grant of relief as prayed, accordingly this point is being decided in favour of the complainant.

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

         O.P. No. 2 United India Insurance  Co. Ltd. is directed to pay Rs. 2,22,783/- to the complainant within 60 days from receipt/production of the copy of this order, failing which this O.P. will pay interest @ 10% per annum  on that very amount from 31.01.2019  (i.e. the date on which case was filed). Further O.P. No.2 is directed to pay compensation of Rs. 20,000/- for various types of harassment caused to the complainant for his genuine claim and to pay Rs. 7000/- as litigation cost within above mentioned period.

(J.P.N. Pandey)

                                                                                      President

(B.P.L Das)

   Sr. Member

                                                                               (Baby Kumari)

                                                                                       Member