In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, 4th Floor, Kolkata-700087.
CDF/Unit-I/Case No.10/2012
1) Biplab Ray,
100A, Karaya Road, Ballygunge,
P.S. Karaya, Kolkata-19. ---------- Complainant
---Versus---
1) Star Health and Allied Insurance Co. Ltd.
Branch Office - South Kolkata
200/2C, Rash Behari Avenue, 3rd Floor,
P.S. Gariahat, Kolkata-29. ---------- Opposite Party
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member.
Smt. Sharmi Basu, Member
Order No. 13 Dated 18-03-2013.
The case of the complainant in short is that complainant took the advantage of the aforesaid insurer’s new scheme of health and hospitalization benefit insurance viz Star Senior Citizens’ Red Carpet Insurance Schedule introduced a few years back and insured himself first in the year of 2008 for an assured sum of Rs.2 lakhs per year paying an all-inclusive annual premium of Rs.9500/- vide policy certificate no.P/191112/01/2009/000405. The complainant continues to renew the insurance every year paying annual premium for the assured sum of Rs.2 lakhs and the last renewal was effected on 27.10.011 for a period of one year valid till 26.10.12 paying annual premium of Rs.9326/- for the sum assured of Rs.2 lakhs.
During the time of first coverage and collecting the premium the insurer did not disclose that there were certain exceptions and limitations for settlement of insurance clams for the senior citizens for a new categories of illness but subsequently incorporated the restricted clauses in t he insurance policy certificate along with the rider clauses.
The insurer does not have the approval of the Insurance Regulatory Development Authority (IRDA) fo implementing such limitations or exceptions on the senior citizens in settling health insurance claims and without having such sanction from IRDA the insurer company is carrying on wrongful business practice depriving their esteemed customers like senior citizens.
Complainant was admitted at one of the insurers’ nominated hospitals, viz. Dr. Nihar Munsi Eye Foundation on 10.8.11 for treatment and removal of cataract on right eye under Phacoemulsification procedure with IOL at the advice of the attending eye surgeon on a package deal of Rs.22,500/- being the total cost of the operation under the policy no.P/191112/01/2011/001701 valid from 27.10.10 to 26.10.11.
Complainant prior to the operation was told by the hospital that the insurer company h ad sanctioned a part of the operation cost upto Rs.15,000/- out of total package cost of Rs.22,500/-, eventually, the complainant had to pay the balance amount of Rs.7500/- before release from the hospital.
Later the complainant lodged a claim with the insurer company for reimbursement of Rs.7500/- but the insurer declined to entertain the claim. Complainant then lodged a complaint with the IRDA filling up the prescribed format through e-mail and the IRDA in turn referred the complaint to the insurer asking the company to take necessary action.
Complainant again underwent similar surgical operation to remove the cataract on left eye admitting at the same nominated hospital on 23.11.11 under the current policy period vide policy no.P/191112/01/2012/002780 on a package deal of Rs.18,500/- for which insurer company sanctioned only 70% cost to the tune of Rs.12,950/- and the complainant was made to pay the balance amount of Rs.5550/-. Hence the case was filed by the complainant with the prayer contained in the petition of complaint.
O.p. 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.p. in the course of argument submitted that the case has got no merit and the same is liable to be dismissed.
Decision with reasons:
