Complainant Krishna Devi W/o Sri Lalit Prasad filed this complaint with a claim of Rs. 78,844/- with 12 % interest from 28.11.2014 and compensation of Rs. 30,000/- with litigation cost of Rs. 20,000/-.
2 The case of the complainant is that Lalit Prasad husband of the complainant is a retired SAIL employee and has taken a group Mediclaim insurance policy of the SAIL vide policy No. 351200/46/13/8500000174 valid from 25.01.2014 to 24.01.2015. The insurance covered Rs. 2,00,000/- each per head pertaining to cashless treatment.
As the complainant was suffering from lower back ache, radiating along with left leg and left shoulder for the last 7 months which was increasing day by day, she was admitted in BGH and thereafter on advice of treating doctor she went CMC Vellore for proper treatment. After investigation doctor admitted her in hospital for care and proper treatment in routine manner on 24.05.2014 and discharged on 31.05.2014. The treatment was going on with consent of E-Meditek TPA O.P. No.3 on telephonic conversation. The hospital charged Rs. 78844/- and the O.P. No.3 did not provide cashless facility against terms of contract but the O.P. National Insurance Co. repudiated the claim vide its letter dated 28.11.2014 on the advice of O.P. No.3 that no active line of treatment during the hospitalization given to the patient which is violation of terms and conditions and hence this case is filed on the ground of deficiency in service.
3 Complainant filed the following documents:-
Anx-1 Copy of the discharge summary.
Anx-2 Copy of the discharge bill.
Anx-3 Copy of claim form.
Anx-4 Copy of letter of demanding documents by O.P. No.3.
Anx-5 Copy of the repudiation letter.
Anx-6, 6/1 & 6/2 Copies of investigation reports.
Anx-7 Copy of payment of premium.
Anx-8 Copy of request for cashless payment.
4 O.P. No.1 and 2 the National Insurance Co. Ltd. appeared and filed W.S. It is submitted that this complaint is not maintainable due to violation of terms and conditions and there is no cause of action. The Policy is admitted for the period 25.01.2014 to 24.01.2015 and the O.P. No.3 has given justified and correct reason for repudiation of the claim. Therefore, the complaint is liable to be dismissed.
5 No document has been filed by O.P. No.1 and 2.
O.P. No.3 has not appeared and Ex-parte proceeding is initiated.
F I N D I N G S
6 We perused the record that the complainant is a consumer being beneficiary of the group Mediclaim scheme of the SAIL and the dispute is a consumer dispute.
7 The ground taken by the O.P. cannot be accepted that no active line of treatment was given to the complainant. The complainant was admitted in CMC Vellore, a reputed medical institution, and she was treated there with the advice of the doctor and after investigation and admission in the hospital. Therefore, the bill raised by the CMC Vellore cannot be disbelieved and the complainant has paid the amount of Rs. 78,844/- from his own pocket and the O.P. No.3 did not provide cashless facility which is against the natural justice and against the terms and conditions of the policy and therefore, the repudiation of the claim cannot be sustained on the basis of natural justice and therefore this can be termed as deficiency in service by the insurance co. who is liable to pay the amount paid by the complainant in her treatment.
8 Accordingly we allow the claim of the complainant and the O.P. M/s National Insurance Co. Ltd. is directed to pay Rs. 78,844/- (Rs. Seventy eight thousand eight hundred forty four) only to the complainant with interest of 8% (Eight percent) per annum since 31.05.2014 the date of discharge from the hospital.
The O.P. National Insurance Co. Ltd. is further directed to pay compensation of Rs. 10,000/- (Rs. Ten thousand) only for mental harassment and litigation cost of Rs. 2000/- (Rs. Two thousand) only.
All payments must be paid within 60 days of passing of this order, failing which the rate of interest on the claim amount shall be enhanced to @ 12% (Twelve percent) per annum till realization.
