West Bengal

Bankura

CC/2/2019

Amalesh Maity - Complainant(s)

Versus

Branch Manager, United India Insurance Co. Ltd. - Opp.Party(s)

Jayanta Kumar Mukharjee

07 Aug 2023

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA

  Consumer Complaint No. 02/2019

Date of Filing: 11.01.2019

Before:                                        

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.

For the Complainant:  Ld. Advocate Jayanta Kr. Mukhopadhyay

For the O.P. : Ld. Advocate Ashim Kr. Mandal

Complainant  

Amalesh Maity, S/o Ranesh Maity at Abakash Goli, 1^st Feeder Road, Bankura

Opposite Party  

1.Branch Manager, United India Insurance Co. Ltd., Nutan Chati, Bankura

2.Heritage Health Insurance TPA Pvt. Ltd., NICCO House, Hare St., Kolkata-1

 

 FINAL ORDER / JUDGEMENT  

Order No.33

Dated:07-08-2023

Complainant files hazira through Advocate.

The O.P. also files hazira through Advocate with written argument.

The case is fixed for argument. After hearing arguments and perusing written argument the Commission proceeds to dispose of the case as hereunder: -

The Complainant’s case is that he had a Medi-claim Policy being No. 030315082817P103442450 valid from 04/06/2017 to 03/06/2018 issued by the O.P./Insurance Co. While the Policy was in force the Complainant underwent treatment as inpatient at Monipal Hospital, Monipal incurring medical expenses of Rs.93,011/- during the period of hospitalization from 15/02/2018 to 21/02/2018. The Complainant duly submitted claim form to the O.P. Authority along with original documents on 21/05/2018 for reimbursement of the said medical expenditure but the claim was repudiated vide letter dated: 20/06/2018 citing vague and flimsy reasons. The Complainant further made correspondence with the O.P. for reconsideration of his claim but it was finally repudiated vide letter dated: 22/11/2018. The Complainant has therefore approached this Commission praying for appropriate relief with compensation.

                                                                                                                                                                                        Contd…….p/2  

Page: 2

O.P. / Insurance Co. contested the case by filing a written version contending inter alia that the Complainant is not entitled to get any relief in this case as he was an outdoor patient in Monipal Hospital having incurred medical expenses for check up and investigation only without undergoing any medical treatment or surgery. Their further defence is that the Complainant  in the Year-2010 before commencement of the initial Medi-claim Policy – 2012 had the complaint of the same disease as detected in the present case and as such it is a case of suppression of material fact in violation of the terms and conditions of the Policy.

-: Decision with reasons: -

The Commission has gone through the Policy document minutely and carefully and all the medical documents on record including the medical expenditure bill as claimed by the Complainant. After consideration of all the materials on record and the submission and contention on both sides the Commission finds that the Complainant was a patient in Monipal Hospital during the period from 15/02/2018 to 21/02/2018 for the purpose of undergoing Extra Hepatic Portal Venus Obstruction (EHPVO) which is an investigation part of medical treatment and the medical bill as claimed for Rs.93,011/-also relates to all the expenses for the same.

Admittedly the Complainant could not show any proof of medical treatment and surgery for the said disease in Monipal Hospital and according to the terms and conditions of the policy  Hospital expenses for medical / surgery treatment is only covered under the said Policy but in this case the Complainant has not undergone any medical treatment and surgery but he was hospitalized for undergoing medical check-up and investigation and the medical expenses as claimed by the Complainant under those Heads does not come within the purview of the Policy in question.

In fact expenses incurred in Hospital/Nursing Home primarily for evaluation/diagnostic purpose which is not followed by active treatment for the ailment during the hospitalization period is excluded for the purpose of reimbursement.

The contention of Ld. Advocate for the Complainant that no ailment/disease which are pre-existing (treated/retreated/declared/not declared) in the Proposal Form since the inception of the Policy up to fourth year of the Policy is only excluded but beyond that period reimbursement is admissible is not applicable to this case as it relates to the treatment of the disease. In this case though the Policy continued since 2012 to 2018 but the Complainant is not entitled to get benefit thereof simply because the medical expenses relate to the diagnostic part but not to the treatment / surgery.

The O.P. has rightly repudiated the Medi-claim of the Complainant and he is not entitled to get any relief in this case. The case therefore fails.

Hence it is ordered……..

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

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

 

   ____________________                                   _________________                                       _________________

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