West Bengal

South 24 Parganas

CC/518/2014

Subrata Das . - Complainant(s)

Versus

1. Branch Manager, Star Health and Allied Insurance Company Ltd. - Opp.Party(s)

20 Nov 2015

ORDER

DISTRICT CONSUMER DISPLUTES REDRESSAL FORUM

SOUTH 24 – PARGANAS , AMANTRAN BAZAR , BARUIPUR , KOLKATA-700 144.

 

C.C. CASE NO. ___518  OF ___2014____

 

DATE OF FILING : 21.10.2014     DATE OF PASSING JUDGEMENT:_13.10 .2015__

 

Present                        :   President       :   Sri Udayan Mukhopadhyay

 

                                        Member(s)    :  Smt.  Sharmi Basu  & Sri Jinjir Bhattacharya                                      

 

COMPLAINANT                  :  Subrata Das, B/26/1, Bapuji Nagar, P.O Regent Estate, P.S. Regent Park, Kolkata – 92.

 

-VERSUS  -

 

O.P/O.Ps                                :       1. Branch Manager, Star Health and Allied Insurance Company Ltd.

Branch Office-Behala, 2^nd Floor, 738/2, Diamond Harbour Road, P.S. Behala, Kolkata – 700 008.

2.    Branch Manager, Star Health and Allied Insurance Company Ltd. New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600 034, P.S Nungambakkam.

3.   Institutre of Neuroscience, Kolkata, 185/1, A.J.C Bose Road, Kolkata -17. P.S. Beniapukur.

 

________________________________________________________________________

 

                                                            J  U  D  G  E  M  E  N  T

 

            Smt. Sharmi Basu, Member

            The petition of complaint made under section 12 of the C.P Act ,1986 has been filed by Subrata Das against the O.Ps on the ground of part repudiation of medical claim by the O.P nos. 1 and 2 .

            Facts of the case arising out of the petition of complaint are that complainant took a mediclaim insurance policy and has renewed the same for the period from 25.11.2013 to 24.11.2014 . Complainant’s mother Gita Rani Das became seek on 1.1.2014 and she was taken to Sri aurobindo Seva Kendra for her treatment and she was shifted to Institute of Neuroscience , Kolkata, O.P-3 . The complainant informed the incident of his mother’s hospitalization to the Insurance company, O.P nos. 1 and 2 and requested them for cashless treatment facility. But Insurance Company only paid Rs.10,000/- for that purpose. The total bill amount raised by the hospital authority was Rs.1,47,877/- . The O.P Insurance Company paid only Rs.42,000/- ,though the sum assured is Rs.1,00,000/-. Several requests followed by  letter dated 14.5.2014 yielded no result. Hence, this case, praying for payment of Rs.58,000/- , cost and compensation.

            O.P nos. 1 and 2 contested the case by filing written statement denying all the material  allegations leveled against them, contending inter alia that on scrutiny claim records the claim was settled and paid Rs.42000/- under 50% co-pay. The positive case of the O.Ps is that admission of the mother of the complainant was due to complication of the pre-existing disease i.e hypertension. Hence, as per terms and conditions of the policy, the O.Ps applied the 50% co pay, as per exclusion clause 5 and the O.Ps had partly repudiated the claim due to non-disclosure of pre-existing disease at the time of inception of the policy. There is no deficiency in service on their part and the O.Ps pray for dismissal of the case with cost.

            O.P-3 also contested the case by filing written version and denied all the material allegations leveled against them. It has been admitted by the O.p-3 that complainant’s mother got admitted there on 1.1.2014 and she was diagnosed with left side ICH (Cerebellar) and treated with Conservative Medical Management in the hospital of O.P-3 and she was discharged on 20.1.2014. A bill of Rs.1,47,877/- was raised which included bed  charges, pathological investigation chares, doctor’s professional charges, hospital consumption charges, cost of medicine etc.  The O.P-3 also admitted that Rs.42000/- was paid by the Insurance Company and the rest amount was paid by the complainant himself. The positive case of the O.p-3 is that no relief has been sought for against it and it has prayed for dismissal of the case.

 After scrutinizing four corners of the case following points are in limelight :

1. Whether there is any deficiency in service on the part of the O.Ps under the purview of the C.P Act.
2. Whether the complainant is entitled to get relief as prayed for partly or fully.

                                                            Decision with reasons

 

Let a plain copy of judgement be supplied to the parties free of cost as per rule.

 

 

Member                                   Member                                                           President

 

 

Dictated and corrected by me

 

 

 

                        Member

 

 

 

 

 

 

 

 

 

The judgement in separate sheet is ready and is delivered in open Forum. As it is ,