West Bengal

Bankura

CC/23/2023

Sri Hiren Kumar Nandi - Complainant(s)

Versus

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

Sandip Chakrabarty

21 Jul 2023

ORDER

                        IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION,  BANKURA

  Consumer Complaint No. 23/2023

Date of Filing: 27.02.2023

Before:                                        

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.

For the Complainant:  Ld. Advocate Sandip Chakraborti

For the O.P. : Ld. Advocate Mahadev Chakraborti

 

Complainant

Sri Hiren Kumar Nandi, S/O Sri Sankar Prasad Nandi, Vill.- Rakhabani, Nohari, P.O. + P.S.- Garbetta, Dist.- Paschim Midnapur, Present Residence- C/O- Dr. Shanti Rakshit, Near Smashan Kali Mandir, Nutanchati, P.O., P.S. & Dist.- Bankura. Pin- 722101

 Opposite Party

1.Branch Manager, Star Health and Allied Insurance Company Limited,Nigamananda Panthasala, 1^st  Floor, Patpur, Jail Road,   P.O., P.S. & Dist.- Bankura. Pin- 722101, West Bengal.

2. Star Health and Allied Insurance Company Limited, 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai- 600034. Tamil Nadu.

3.Sri Dayamoy Bangal (Agent), S/O- Late Bholanath Bangal, Vill.- Kulmura, P.O.- Keshiakole, P.S. & Dist.- Bankura. Pin-722155 (Expunged)

 FINAL ORDER / JUDGEMENT            

                                                                                                                                               

Order No.06

Dated:21-07-2023

Both parties file hazira through advocate.

Joint W.V. is filed by the O.P.1 & 2 and copy served.

O.P. No.3 who is the agent of O.P.1 & 2 is not a necessary party in this case and so his name be expunged from this case.

Ld. Advocate for the complainant has insisted for early disposal of the case preferably today without fixing the case for argument.

Ld. Advocate for the O.P. is also agreed to the same as there is no point of dispute to be decided in this case.

Hence the case is taken up for disposal.

The Complainant’s case is that he has a Family Health Optima Insurance Plan from O.P. No.2 commencing from 28-08-2019 and renewed from year to year. The wife of the Complainant Smt Sharmistha Nandi fell ill due to fever and on 14-10-2022 she visited Dr. M.M. Chinya for medical treatment and took medicines as per prescription but she could not recover from the fever and her physical condition deteriorated with high grade fever.

                                                                                                                                                                                        Contd……p/2

Page: 2

Accordingly she was admitted at Jeevan Suraksha Hospital, Katjuridanga, Bankura on 18-10-2022  under Dr. Subrata Bhattacharya, M.D., Medicines and remained admitted in the said Hospital till 21-10-2022 and was discharged on the same day with stable condition. During her admission she had undergone severe clinical tests and examinations. The Complainant had to pay Rs.43,000/- as Hospital charges for the treatment of his wife to the said Hospital. Thereafter the Complainant submitted Medical Reimbursement bill of Rs.43,000/- to the O.P. No.1 along with all medical papers but the same was refused by O.P. No.1 authority citing the exclusion Clause as hospitalization for treatment of fever is outside the purview of such Mediclaim Policy. The Complainant has therefore approached this Commission for appropriate relief.

The O.P. No.1 & 2 contested the case by filing a joint written version stating clearly therein that initially they decided to settle the claim at Rs.40,549/- which was intimated to the Complainant via email dated: 02-03-2023 but the Complainant did not respond to the same. The O.P. No.1 & 2 have reiterated their stand in the written version also stating that final admissible amount after permissible deduction is Rs.40,549/- and this is the maximum quantum of liability as per terms of the Policy and IRDAI guidelines. With the submission of this written version the O.P.s have prayed for proper order in the matter.

-: Decision with reasons: -

The Commission has gone through entire materials on record including the Reimbursement Medical Bill of Rs.43,000/- with break up obtained from Jeevan Suraksha Hospital Pvt. Ltd. Without disputing the Reimbursement Bill the O.P.1 & 2 have however settled the claim at Rs.40,549/- after permissible deduction of Rs.3,180/-. The Commission has examined the terms and conditions of the Policy and IRDAI guidelines and found the settled amount to be justified and proper.

In the result the case succeeds. However the Complainant is entitled to a Litigation cost of Rs.2,000/-  as the O.P. 1 & 2 have delayed the settlement the settlement of claim compelling the Complainant to file this case to this Commission for seeking appropriate relief.

Hence it is ordered……..

That the case be and the same is allowed on contest against O.P. No.1 & O.P. No.2 but without cost.

O.P. No.1 & 2 are directed to pay to the complainant Rs.40,549/- together with Litigation cost of Rs.2,000/- within  a month from this date in default the law will take its own course.

Both parties be supplied copy of this order free of cost.

 

 ____________________                _________________          _________________

HON’BLE   PRESIDENT          HON’BLE MEMBER         HON’BLE MEMBER