In  the  Court  of  the

Consumer Disputes Redressal Forum, Unit -I, Kolkata,

8B, Nelie Sengupta Sarani, 4^th Floor, Kolkata-700087.

CDF/Unit-I/Case No.288 / 2012 .  

1)                   Suchitra Mukherjee,    

            33A/1, Sarat Ghosh Gaden Road,

            2^nd Floor, Kolkata-31.                                                                                               ---------- Complainant

---Versus---

1)                   Regional Manager,

            United India Insurance Co. Ltd.  

            Himalaya House (2^nd & 3^rd Floor), 38-B, J.L. Nehru Road,

            Kolkata-71, P.S. Shakespeare Sarani.            

2)         Divisional Manager,

            United India Insurance Co. Ltd.

            VIII, C.I.T. Complex, Dakshinapan,

            2, Gariahat Road (South), Kolkata-68, P.S. Lake.

2)       Chief Administrative Officer,

Heritage Health Services Pvt. Ltd.

Nicco House (5^th Floor), 2, Hare Street,

Kolkata-1,    P.S.  Hare Street.                                                                                 ---------- Opposite Parties

Present :           Sri Sankar Nath Das, President.

                        Dr. Subir Kumar Chaudhuri, Member.

Order No.    9   Dated  25-03-2013.

            The case of the complainant in short is that the complainant is a policy holder and is a consumer who has been insured by o.p. insurance company. Complainant insured herself with United Insurance Co. Ltd. Under The Individual Health Insurance Policy – 2010, Policy no.030800/48/11/97/00005158, period of insurance being from 12.11.11 to 11.11.12. The total sum insured was Rs.1,50,000/- and the complainant regularly paid premium to the tune of Rs.6200/-.

            Complainant was admitted in Desun Hospital on 31.12.11 for (a) Lower Respiratory Infection, (b) Obstructive Airway Disease, (c) Fluid Overload due to Left Ventricular Failure with Underline Dilated Cardio Myopathy. After undergoing treatment she was discharged on 2.1.12. Complainant complied with the requird formalities and submitted all the necessary documents to claim the insured amount which was to the tune of Rs.64,816/-.

            Insurance company through o.p. no.3 TPA paid Rs.14,372/- against the complainant’s claim of Rs.64,816/- deducting considerable amount most arbitrarily and illegally and by a D.D. No.12208346 58 JB 1 R 29 dt.8.2.12 drawn on Bank of America, Rs.14,372/- was paid to the complainant.

            Complainant sent a letter to o.p. no.2 dt.3.5.12 which was duly received, wherein the complainant agitated her grievance and also pointed out that the concerned o.p. had assured her that the balance amount shall be paid to her shortly. Again on 26.5.12 by another letter the complainant placed her claim before o.p.

            By a letter dt.12.6.12, o.p. through their TPA (o.p.3) informed the complainant that as per policy condition no.1.2 D Note No.1, the deductions were justified since charges payable would be limited to charges applicable to the entitled category. However, an amount of Rs.6071/- as discount given by the hospital which was deducted was refunded by o.p.

            It is further submitted that while settling the claim through o.p. no.3 (TPA), the o.p. termed the letter dt. 8.2.12 as full and final settlement. However, from the letter dt.12.6.12, it is clear that errors were there in deductions which was rectified by o.p. to the extent of refunding the discounted amount of Rs.6071/- which shows that the sanction of Rs.14,372/- could not have been full and final settlement. The comlainant’s claim of balance amount of Rs.50,444/- was never paid by o.p. Hence the case was filed by the complainant with the prayer contained in the petition of complaint.

            All the o.ps. had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. Ld. Lawyer of o.ps. in the course of argument submitted that the case has got no merit and the same is liable to be dismissed.