West Bengal

Paschim Midnapore

CC/4/2024

Tapan Kumar Bose - Complainant(s)

Versus

Star Health and Allied Insurance Company Lilited - Opp.Party(s)

28 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PASCHIM MEDINIPUR.

Samiran Dutta, Ld. President

-and-

Angshumati Nanda,Ld.Member.

Complaint Case No.C.C/04/2024

Tapan Kumar Bose

S/O- Late Gajendranath Bose

At- Habibpur (BaramThan)

P.O. Midnapore

P.S.- Kotwali

Dist- Paschim Medinipur

PIN-721101

                                                                        ….……Complainant.

 

-Versus-

 

 

Star Health and Allied Insurance Company Limited

Represented by Legal Manager

Globsyn Crystals Building Tower-II, 3rd Floor

Block-EP, Sector V

Saltlake, Kolkata -700091.

            .......................Opposite Party.

Date of filing: -16.01.24                                                                                                    Date of disposal: -28.10.24

Order No.12  

 

Contd……2

-2-

                             C.C. Case No. CC/04/2024

Final Order/Judgment

Samiran Dutta, Ld. President:-

 

Both parties file hazira through Ld Advocate. The case is fixed for hearing argument. After hearing argument/written argument the Commission proceeds to dispose of the case as hereunder.

            The Complt. case is that he has a Group Health Insurance Policy No. being P/191113/01/2023/002183 valid from 04.10.2022 to 03.10.2023 issued by the O.P./Insurance Co. with sum assured Rs.4,00,000/- . While the policy was in force the Complt. on 31.01.2023 attended the chamber of specialist Dr. Santosh Kumar who advised for surgery of left knee replacement and accordingly he underwent surgical operation at Belview Clinic, Kolkata for which he incurred total medical expenses of Rs.2,29,969/- out of which Rs.1,67,701/- has been reimbursed by the O.P./Insurance Co. together with Rs.4,220/- on 05.01.2024 as the full and final settlement of claim. The Complt has approached this Commission for appropriate relief claiming the balance unsettled claim amount and  Rs.30,000/- as the post operative physiotherapy bill.

            O.P./Ins.Co. contested the case by filing W.V. contending inter-alia that the Complt. is not entitled to what he prays for in this case as the entire claim amount is not admissible under the terms and condition of the policy.

Decision with reasons:-

            Having regard to the facts of the case,contention and submissioin and documents of both sides the commission finds that the O.P./Ins.Co. has partly settled  the claim leaving aside Rs.88,050/- as still undisbursed. O.P./Ins.Co. could not cite the ground of deduction from the admissible claim amount. Accordingly the Complt. is entitled to get Rs.88,050/- as the full and final settlement of the claim towards the reimbursement of medical expenses incurred by the Complt.

 

                  Hence it is,

Ordered.

 

that the case is be and same is allowed on contest but without cost. O.P./Ins, Co. is directed to pay to the Complt. Rs.88,050/- with litigation cost of Rs.2,000/- towards the  medi-claim within one month from this date, in default law will take its own course.

 

 

 

(Smt.A.Nanda)                                                                                                    (Samiran Dutta)

 Ld. Member                                                                                                          Ld.President                                                                                                                                                           District Commission

            Paschim Medinipur