Jharkhand

Bokaro

CC/16/147

Lakshman Mishara - Complainant(s)

Versus

Sr. Divisional Manager, United India Inurance Co. - Opp.Party(s)

30 Aug 2018

ORDER

Complainant Lakshman Mishra has filed this case for a claim of Rs. 1,29,984/- with interest @ 10% per annum and compensation of Rs. 50,000/- and other relief for his wife Smt. Amira Mishra suffering from cancer.

2          The case of the complainant is that he is retired SAIL employee and took heath care scheme of the SAIL and the insurance company for year 2015-16 on payment of premium for both his and his spouse Smt. Amira Mishra having MIN No. 4733077.

            Smt. Amira Mishra was diagnosed a case of cancer stage-4 during treatment of abdominal pain at CMC, Vellore. She was admitted in the hospital on 10.07.2015 for further treatment. On the basis of her examination, cancer was confirmed and she was given chemotherapy and discharged on 16.07.2015. The charge for first chemo was directly paid to hospital but medicine expenses during hospitalization is unpaid of Rs. 28,626/- under claim No. 10071506657.

            Five chemo was further given in the interval of 21 days. Out of six chemotherapy, thee chemo injection were given by hospital free of charge under Hospital Assistance Program but hospital charged for medicine and for pathological test during hospitalization.

            The cost of 3^rd chemo was paid by TPA but cost of Rs. 35,786/- for 2^nd chemo was not paid which was claimed having claim No. 100081507128.

            Complainant claimed extra medicine charge of Rs. 2750/- under claim No. 100091507273 which  is still pending.

            This first chemo costs Rs. 36,453/- vide claim No. 10011605309 given on 11.01.2016 in still not paid by O.P.

            An amount of Rs. 14,507/- which includes MRI charges of Rs. 7260/- and Rs. 7247/- for OPD treatment, claimed vide claim No. 100091500401. The opposite party paid Rs. 3893/- (max. 4000/-) of OPD charge but MRI charge is not paid and still pending which is being incurred during hospitalization.

            Complainant claimed Rs. 19,215/- for day care treatment vide claim No. 100081511821 but only Rs. 107/- was paid by TPA and rest of Rs. 19,108/- remains pending.

            In total Rs. 2,59,030/- was incurred expenses out of which Rs. 64,719/- has been only paid and rest of Rs. 1,29,983/- is due to be paid through all the claim and this is deficiency in service of O.P.

3          The following documents are filed for support of the claim:-

Anx-1 Copy of the Discharge Certificate of CMC, Vellore.

Anx-2 to 2/3 Copies of claim forms.

Anx-3 Copy of MIN Number of SAIL.

            Apart from these, several letters of correspondence are filed.

            Complainant Lakshman Mishra has himself examined on affidavit.

4          O.P. No.1 and 2 M/s United India insurance Co. Ltd. appeared and filed W.S.

            It is submitted that the case is not maintainable is absence of cause of action. The Insurance is admitted that cost of first chemo was paid directly to CMC, Vellore but other medicine charge was not paid as documents were not given. It is admitted Rs. 36,084/- was paid but not said about Rs. 35,786/- of 2^nd chemo (Claim No. 1000815507128).

            As regards claim of Rs. 2750/- for 4^th chemo is concerned, it is submitted that no documents was given on query. Therefore, the claim was denied. As regards, Rs. 36,453/- is concerned, it is submitted the injection “RITUXIMAB” is on the day care basis which is not included in day care list and it was denied.

            As regards, claim of Rs. 19,108/- is concerned. The annual re-imbursement as per the terms and conditions of Rs. 4,000/- has already been exceeded after payment of claim of Rs. 3,893/- for OPD treatment under the claim No. 100091500401 and therefore, only Rs. 107/- was paid.

            Therefore, there is no deficiency on the part of the O.P. for the claim of the complainant.

4          O.P. No.3 E-Meditek has also appeared and filed W.S. and supported the W.S. of the O.P. No.1 and 2.

                                                            F I N D I N G S

5          We perused the record and documents filed by the complainant. Complainant along with his wife Smt. Amira Mishra are beneficiaries under the SAIL Mediclaim scheme on payment of premium. Therefore, they are consumer and the dispute is a consumer dispute.

6          On perusal of the Anx-2 series, it appears that the complainant is entitled for relief only for the claims of Rs. 28,626/- under claim No. 10071506657, for Rs. 35,786/- under the claim No. 100081507128, Rs. 2,750/- under the claim No. 100091507273, for Rs. 36453/- under the claim No. 10011605309 for which the defense of the O.P. No.1 and 2 and O.P. No.3 cannot be accepted on the basis of natural justice because the claims are genuine during the hospitalization  of Smt. Amira Mishra for her treatment for cancer. The argument advanced by the O.Ps. are technical in nature and cannot be accepted against the principle of natural justice.

7          Thus, we allow the part claim of the complainant for Rs. 1,03,615/- (Rs. One lac three thousand six hundred fifteen) only with interest of 6% per annum from the date of submission of claim.

            We direct the O.P. M/s United India Insurance Co. Ltd. to pay Rs. 1,03,615/- (Rs. One lac three thousand six hundred fifteen) only with interest of 6% (six percent) per annum from the date of submission of claim within 60 days of this order till realization.

            We further direct the Insurance co. to pay Rs. 10,000/- (Rs. Ten thousand) only for mental agony and harassment and litigation cost of Rs. 5000/- (Rs. Five thousand) only.

            All the payments must be paid within 60 (sixty) days from passing of this order, failing which the rate of interest on the part payment allowed shall be enhanced to 10% per annum till realization.