Jharkhand

Bokaro

CC/141/2019

Ram Deo Roy - Complainant(s)

Versus

MD India Health Care Service TPA Ltd. - Opp.Party(s)

Dadan Singh

04 Mar 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-08-08-2019

Date of final hearing-04-03-2023

 Date of Order-04-03-2023

Case No. 141/2019

  Ram Deo Roy S/o Late Mana Roy,

  Sector-8/A, Qr.No. 2211, B-Road, Bokaro Steel City, Bokaro

Vs.

1. MD. India Health Care Service (TPA) Pvt. Ltd.

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

Nagar, Vadagaon, Sheri, Pune Maharashtra, Pin 411014

2. Divisional Manager, Untied India Insurance Co. Ltd.

Plot no. A/17, Second Floor, Sector-4, City Centre,

Sector-4, Bokaro

3. Chief General Manager, Personal Departement

A.D.M. Building Sail, Bokaro Steel Plant,

B.S.City, 827001, 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 for direction to O.Ps. to pay him Rs. 26,398/- on account of medical expense incurred during his treatment and compensation of Rs. 10,000/- and legal expense Rs. 5000/-.
2. Complainant’s case in brief is that he is a retired SAIL, BSL employee and as per policy of the company he opted for Mediclaim policy for himself and his wife. He was provided MIN No. 04716280  which was valid at the relevant time. Further case is that due to eye trouble  of the complainant he was admitted in Muskan Hospital and Research Centre, Chas  on 17.07.2018 and discharged on same day after eye operation and hospitalization charge Rs. 26,000/- was paid by the complainant who also purchased medicine for Rs. 398/-.  Later on complainant claimed said amount from the O.Ps. who kept it pending inspite of repeated requests. Hence this case has been filed with above mentioned prayer. 

 

4.   O.P. No. 1  (TPA) has not appeared nor filed W.S. inspite of due service of notice.
5. O.P. No.3 & 4 appeared and have filed W.S. admitting the facts of the case but they have submitted that they are not liable to pay the amount related to medical expense.
6. On behalf of O.P. No.2 (United India Insurance Co. Ltd.) no W.S. was filed rather written notes of argument has been filed by this O.P. admitting the cost of the lense, medicines, implementation total Rs. 19,648/- in lieu of Rs. 26,398/-.
7.  It is very much apparent that O.P. Insurance Co. is admitting the claim for Rs. 19,648/- only in which the fee of the doctor and hospital charges have been excluded without assigning any reason. Ld. Counsel for the O.P. No.2 has not shown any terms and conditions of the policy which is permitting the insurance co. to deduct the operation charge and charge of the hospital. Genuineness  of the claim is not in dispute, submission of the claim form has also not been disputed. Therefore, we are of the view that genuine claim of the complainant related to Rs. 26,398/- has not been settled by the O.Ps. for a long period which shows deficiency on the part of O.P. No. 1 & 2. Therefore, complainant is entitled to get relief as indicated below:-
8.   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. 26,398/- 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 08.08.2019 (i.e. the date on which case was filed). Further O.P. No.2 is directed to pay compensation of Rs. 2,000/- for various types of harassment caused to the complainant for his genuine claim and also to pay Rs. 1000/- as litigation cost within above mentioned period.

 

(J.P.N. Pandey)

                                                                                      President

 

                                                                  

                  

                                                                               (Baby Kumari)

                                                                                       Member