West Bengal

Bankura

CC/21/2020

Sri Pradip Kumar Laha - Complainant(s)

Versus

Oriental Insurance Company Limited, Burdwan Branch - Opp.Party(s)

Jayanta Kumar Mukhopadhyay

02 Jan 2024

ORDER

   IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA

  Consumer Complaint No. 21/2020

                                                         Date of Filing:   15/10/2020                                              

Before:                                        

1. Samiran Dutta                            Ld. President.      

2. Siddhartha Sankar Bhui            Ld. Member. 

 

For the Complainant:  Ld. Advocate Jayanta Kr. Mukhopadhyay

For the O.P.:  Ld. Advocate Chandi Charan Adhvaryyu

 

Complainant  

Sri Pradip Kumar Laha, Vill. & P.O. – Gangajal Ghati, P.S. – Gangajal Ghati, District Bankura, Pin – 722133

Opposite Party

1. Oriental Insurance Company Limited, Burdwan Branch, Represented by its Branch Manager, Vidya Bhavan, 2^nd Floor, Machantala, Bankura, P.O., P.S. & District Bankura, Pin – 722101.

2. Heritage Health Insurance, TPA Insurance Pvt. Ltd., Nicco House, 2^nd Floor, 7, Hare Street, W.B. City Kolkata – 700 001..

 

FINAL ORDER / JUDGEMENT

 

Order No.31

Dated:02-01-2024

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 he has a Health Insurance Policy with O.P./Insurance Co., Policy No. being 313106/48/2020/356, valid from 06/10/2019 to 05/10/2019 with Sum Assured enhanced from Rs.1 Lakh to Rs.2 Lakh. All on a sudden the Complainant got her  spouse Rina Laha admitted at the Mission Hospital on 04/04/2020 and remained hospitalized for necessary treatment and management of meningitis till her discharge on 20/04/2020 and the Complainant has thereby incurred medical expenses of Rs.4,58,439/- out of which he has received only Rs.90,000/- from the O.P. as part of the settled claim. The Complainant has therefore approached this Commission for appropriate relief.

O.P./Insurance Co. contested the case by filing a written version contending inter alia that the Complainant is not entitled to get the relief as prayed for as per terms and condition of the Policy due to exclusion clause for pre-existing disease.

                                                                                                                                                                                    Contd……p/2

 

                                                                        Page: 2                                                                                                                                          

                                                                                                -: Decision with reasons: -

Having regard to the facts of the case, submission, contention and documents from both sides the Commission finds that there is no pre-existing disease mentioned in the column of the Policy itself and as such no question of pre-existing disease arises in this case. The O.P./Insurance Co. is bound to pay to the Complainant maximum to the extent of enhanced Sum Assured value of Rs. 2 Lakh subject to deduction as per rule. Accordingly the Complainant is to get further Rs.90,000/- as the reimbursement for medical expenses in addition to Rs.90,000/- already received by him. By withholding legitimate claim the O.P./Insurance Co. has compelled the Complainant to file the instant case and so the O.P./Insurance Co. is to bear the Litigation cost of Rs.10,000/- for the same.                                                                                                                                                            

Hence it is ordered……..

That the case be and the same is allowed on contest but without cost. The O.P./Insurance Co. is directed to pay to the Complainant Rs.90,000/- as reimbursement of mediclaim together with Litigation cost of Rs.10,000/- within one month from this date in default law will take its own course.

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

 

 ____________________                _________________         

HON’BLE   PRESIDENT          HON’BLE MEMBER