West Bengal

Bankura

CC/77/2017

Sri Avik Kumar Sinha - Complainant(s)

Versus

Heritage health TPA Pvt. Ltd. - Opp.Party(s)

13 Apr 2023

ORDER

    IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION BANKURA

  Consumer Complaint No. 77/2017

Date of Filing: 21.11.2017

Before:                                        

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.

For the Complainant:  Ld Advocate Banamali Chowdhury

For the O.P.Ld. Advocate Bamashis Banerjee

Complainant  

Sri Avik Kumar Sinha, S/o –Asoke Kumar Sinha, Subhankar Pally, P.O.& P.S & Dist- Bankura

Opposite Party          

1. Heritage Health TPA Pvt. Ltd.,2-Hare Street, Kolkata-700001.
2. Manager, united India Insurance company Limited,240A/natunchati, Bankura-722101.
3. The Divisional Manager,United India Insurance company Limited, Cirty Centre, Durgapur, Burdwan,PIN-713216.

 

FINAL ORDER / JUDGEMENT                 

                                                                                                                                       

Order No.32

Dated:13-04-2023

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 has a Family Health Insurance Policy under O.P. vide Policy No.0315082816P107677580 valid from 12-09-2016 to 11-09-2017 at Yearly Premium of Rs.3,267/-.  On 29-03-2017 the wife of the complainant Arpita Sinha suffered severe pain in her abdomen and she was taken to Bankura Seva Niketan Hospital where she  was advised admission. The attending RMO diagnosed acute chole cystitis and advised medicines and accordingly USG of abdomen of her wife was done on 31-03-2019 and she was taken to the Lifeline Nursing Home where after perusing the report of USG  Dr. Biswanath Mukherjee sought for Second opinion for urgent Lap Chole cystitis.

                                                                                                                                                                                       Contd……p/2

Page: 2

On 19-04-2017 she was taken to the chamber of Dr. Ramesh Pandey, Laparoscopic Surgeon at Raniganj Burdwan who advised some medicines, Laboratory Tests and on 26-04-2017 after examination of the patient and perusal of reports she was admitted on 03-05-2017 at Anandalok Hospital at Raniganj and Dr. Ramesh Pandey undertook the laparoscopic operation of the Gall Bladder of the complainant’s wife and she was discharged on 05-05-2017 and on 10-05-2017 Dr. Ramesh Pandey examined her and removed stitches and advised medicines.

Thereafter on 22-05-2017 the complainant submitted stipulated claim form duly filled in with requisite documents before the O.P. No.2 calculating the total expenses of Rs.37,850/- incurred for his wife’s  treatment but the O.P. authority  in denial of the said claim has sent a letter dated: 18-12-2017 to the complainant with admissible claim amount of Rs.10,435/- after deduction as per terms and condition of the Policy.

Complainant has therefore approached this Commission claiming the full amount of Rs.37,850/- as the medical expenditure incurred by the complainant for treatment of his wife.

The O.P. No.2 & 3 jointly filed a written version contending inter alia that out of the claim amount of Rs.37,850/- the complainant is entitled to get only Rs.10,435/- after deduction of Rs.27,415/- which is admissible as per terms and conditions of the Insurance policy.      

  -:Decision with Reasons:-

Having regard to the facts of the case, materials on record and the submission and contention on both sides the Commission finds that the policy contract entered into by and between the parties (vide Annexure-1) contains deduction Clause-1.2 on the basis of which inadmissible amount has been deducted from the claim of the complainant giving him an offer of Rs.10,435/- as the admissible amount towards the claim of the complainant. Such Insurance policy is based on contract by and between the parties and none of the parties can go beyond the Policy contract.

                                                                                                                                                                                            Contd…..p/3

Page: 3

Considering the Sum Assured value of Rs.50,000/- and proportionate deduction of the medical expenses in terms of the Policy contract the Commission finds that the settlement of claim amount of the complainant at Rs.10,435/- is quite justified in conformity with the terms and conditions of the Policy but the Commission finds from the record that the O.P./Insurance authority took about seven months to settle the claim of the complainant and such delay for disposal of the claim case is not desirable and the complainant is entitled to get compensation on that score.

The case therefore succeeds in part.               

                                                                                        Hence it is ordered……..

That the case be and the same is allowed in part against the O.P.

The O.P.s are directed to pay to the complainant Rs.10,435/- together with Rs.5,000/- as compensation within one month from this date in default the decretal amount will be realized in due process of law.

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

 

   _________________                     ________________              _________________

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