West Bengal

Bankura

CC/43/2024

Smt. Sujata Goswami - Complainant(s)

Versus

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

Sandip Chakraborty

22 Aug 2024

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA

  Consumer Complaint No.43/2024

       Date of Filing: 17/05/2024

Before:                                        

1. Samiran Dutta                                     Ld. President      

2. Siddhartha Sankar Bhui                    Ld. Member

For the Complainant:Ld. Advocate Sandip Chakrabarti

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

Complainant:

Smt. Sujata Goswami, W/O.- Sir Partha Sarathi Goswami, R/O.- Baruipara, Teleberia, P.O.- Teleberia, P.S.- Onda, Dist.- Bankura,PIN- 722144, Contact No.- 9064970739.   

Opposite Party:

1. Branch Manager, Star Health and Allied Insurance Company Limited, Branch Office – Durgapur, SM – 10, Ambedkar sarani, City Centre, Durgapur, Paschim Bardhaman – 713216, West Bengal, Phone No.- 18004252255.
2. Star Health and Allied Insurance Company Limited, No.- 15, Sri Balaji Complex, 1^st Floor, Whites Lane, Whites Road, Roy Apettah, Chennai – 600014. Contact No.- 0442888649.
3. The Appropriate Authority, M/S. EF Insurance Broking Pvt. Ltd. College Road, P.S. and District – Bankura. PIN – 722101. Contact No.- 9836930444.

FINAL ORDER / JUDGEMENT     

                                                                                                                                                      

Order No.05

Dated:22-08-2024

Both parties file hazira through Advocate.

The case is fixed for argument.

After hearing argument from both sides the Commission proceeds to dispose of the case as hereunder: -

The Complainant’s case is that she has a Cashless Family Health Optima Insurance Policy for self/spouse and minor son commencing from 04/08/2020 and renewed from year to year till 04/08/2024 with sum assured Rs.3 Lakh with Recharge benefit of Rs.75,000/-. While the policy was in force the Complainant’s husband Partha Sarathi Goswami suddenly got a critical vision problem for which he visited Disha Eye Hospital, Durgapur on 19/06/2023 and thereafter Vivekananda Hospital Pvt. Ltd., Durgapur on 24/07/2023 and finally went to Christian Medical College, Vellore where he was admitted on 03/08/2023 and after operation of Brain Tumor attributable to the  vision problem and he was discharged on 15/08/2023 and during this period he incurred medical expenses of Rs.3,99,977/- from his own pocket though the scheme of the policy was Cashless and the claim application was accordingly preferred but it was settled in part at Rs.1,80,316/-. Being dissatisfied with part settlement of mediclaim the Complainant has approached this Commission for appropriate relief.

                                                                                                                                                                                   Contd…..p/2

Page: 2

O.P./Insurance Co. contested the case by filing a written  version admitting therein the insurance claim to the effect that the total bill amount is Rs.3,99,977/- and after statutory deduction of Rs.51,917/- it comes to Rs.3,48,060/- out of which Rs.1,80,316/- has already been disbursed to the Complainant and so the balance admissible amount is Rs.1,67,744/- which the Complainant is entitled to get as full and final insurance claim.

-: Decision with reasons:-

Having regard to the facts of the case, contention, submission, and documents on both sides the Commission finds that O.P./Insurance Co. has admitted the mediclaim of Rs.1,67,744/- towards reimbursement of medical expenses of the Complainant’s husband but the Policy Holder could not avail of the Cashless benefit of the Policy and it is a discredit on the part of the O.P./Insurance Co. to deprive cashless benefit of the Policy. In this case the Policy Holder has been mentally harassed as they were compelled to collect liquid cash to pay the medical bill specially of Christian Medical College, Vellore. No explanation is forthcoming from the side of O.P./Insurance Co. as to why and under what circumstances cashless benefit of the policy could not be provided to the Policy Holder.

Apart from payment of mediclaim as above the Commission directs the O.P./Insurance Co. to pay compensation of Rs.35,000/-for denial of cashless benefit.

Hence it is ordered…….

That the case be and the same is allowed on contest but without cost.

O.P./Insurance Co. is directed to pay to the Complainant Rs.1,67,744/- as the mediclaim together with compensation of Rs.35,000/- within a month from this date in default law will take its own course.

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

 

 __________________                                       ________________         

 HON’BLE   PRESIDENT                           HON’BLE    MEMBER