DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 87   of   2021

 

 

Sri Joydeep Roy Barman,

S/O- Sri Samir Ranjan Barman,

38, Akhaura Road, Old RMS Chowmuhani,

P.O. Agartala, P.S. West Agartala,

District- West Tripura- 799001. .............Complainant.

 

 

-VERSUS-

 

 

1. Star Health and Allied Insurance Company Ltd.,

Having its registered and corporate office:-

at 1, New Tank Street,

Valluvur Kottam High Road, 

Nungambakkam, 

Chennai- 600034.

 

2. Star Health and Allied Insurance Company Ltd.,

Having its Branch Office at Netaji Chowmuhani,

N.S. Road, above HDFC Bank, Agartala, 

Tripura-799001.

 

3. Mr. Amitava Chowdhury,

Branch Manager, 

Star Health and Allied Insurance Company Ltd.

Having office at Netaji Chowmuhani, N.S Road,

Above HDFC Bank, Agartala, Tripura- 799001.

 

4. Mr. Debrata Chakraborty,

Agent having Intermediary Code No. BA0000323632

Of Star Health and Allied Insurance Company Ltd.,

Having Branch Office at Netaji Chowmuhani,

N.S. Road, Above HDFC Bank, Agartala,

Tripura-799001. ..................Opposite Parties.

 

 

 

 

   

__________PRESENT__________

 

 SRI GOUTAM DEBNATH

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA, AGARTALA.

 

 

C O U N S E L

 

For the Complainant : Sri Bhabani Rn. Bhattacharjee,   Learned Advocate. 

 

 

For the O.Ps : Sri Mridul Kanti Arya,

  Sri Pritam Deb,

  Sri Santunu Chakraborty,

  Learned Advocates.

 

 

ORDER  DELIVERED  ON:   10.04.2023.

 

F I N A L    O R D E R

1. This case is filed U/S 35 of Consumer Protection Act, 2019 by the complainant, Sri Joydeep Roy Barman of 38, Akhaura Road, Agartala, West Tripura(in short 'Complainant') against the Opposite Parties namely (1) Star Health and Allied Insurance Company Ltd., New Tank Street, Chennai( in short 'O.P. No.1'), (2) Star Health and Allied Insurance Company Ltd., Netaji Chowmuhani, Agartala, West Tripura(in short 'O.P. No.2'), (3) Mr. Amitava Chowdhury, Branch Manager, Star Health and Allied Insurance Company Ltd., Netaji Chowmuhani, Agartala, West Tripura(in short 'O.P. No.3'), (4) Mr. Debabrata Chakraborty, Agent having Intermediary Code No. BA00003236323 of Star Health and Allied Insurance Company Ltd., Netaji Chowmuhani, Agartala, West Tripura alleging deficiency of service on the part of the O.Ps. 

1.2 The fact of the case in short is that on 23.03.2018 the complainant purchased a Health Insurance Policy namely Family Health Optima Insurance Plan with the O.P. i.e., Star Health and Allied Insurance Company Ltd. for himself and his wife and daughter(having Family Size of 2A+ 1C) vide Policy No.P/191313/01/2018/000131 on payment of premium of Rs.22,875/- against sum insured of Rs.10 lakhs. 

1.3 The premium was renewed on 25.03.2019 on payment of premium of Rs.28,019/- vide Policy No. P/191313/2019/000393. Again renewed on 2020 the same was renewed on payment of an amount of Rs.28,019/- covering a period from 27.04.2020 to midnight of 26.04.2021. On the 3rd year limit of coverage stood at Rs.13,50,000/-. 

On 6th January, 2021 the wife of the complainant  gave birth to a caesarean baby at Agartala Government Medical College, Agartala. Soon after the birth of the second baby girl, the complainant informed the agent of Star Health and Allied Insurance Company, Mr. Debabrata Chakraborty for inclusion of name of the baby girl under the Policy which was due to expire on 26.04.2021. He was informed that Midterm inclusion facility was available.

1.5 Accordingly, after some days the agent supplied a form and took birth certificate and informed that no additional premium was required to be paid for inclusion of the new born baby girl in the plan and she would be entitled to 10% of the Sum Insured. 

1.6 In the first week of February, 2021 the agent collected the form along with documents.

1.7 On 17th March, 2021 the baby developed fever and was hospitalized in ILS Hospital and being referred went to Apollo Gleneagles Hospital, Kolkata for treatment. Further shifted to NNICU and was discharged on 24.03.2019. Total sum of Rs.1,06,541/- was incurred for the treatment of the baby girl. 

1.8 On 27th March, 2021 the complainant requested the agent to raise claim but to be informed that the documents for inclusion of the baby girl in the current policy are still awaiting for approval. Later on it was informed that the documents submitted in the office were misplaced and Insurance Company could not include the details of the baby girl  in the current policy and thus there cannot be any issue of raising the claim with the Insurance Company.  

1.9 It is stated by the complainant that for the act of the O.P. Insurance Company he had to suffer financial loss. Demand notice was also issued on 12.07.2021 to the O.P. Insurance Company.

1.10 Hence, he filed this case before this Commission claiming compensation of Rs.3,56,541/- along with 10% interest P.A. 

2. O.Ps contested the case by filing written version denying the allegations made by the complainant in his complaint petition. 

2.1 It is stated by the O.Ps that no such intimation for inclusion was received by the insurer and only after admission in hospital on 14th March, 2021 to 26th March, 2021 the complainant contacted the company for claim benefit of inclusion. 

2.2 It is also stated that as the insured failed to intimate the insurer about the birth of New Born and further failed to submit proper proposal from intimating the birth of new born prior to the hospitalization the liability of the insurer do not commence and hence, they are not liable to cover the new born under the policy. Thus, prayed for dismissal of the complaint as there is no deficiency of service on the part of the O.Ps.

3. Complainant filed evidence on affidavit. O.Ps  also filed their evidence on affidavit.

4. On the basis of pleadings, documents, evidence filed by the parties following point is taken up for   discussion and decision:-

(i) Whether the claim of the complainant is justified? 

(ii) Whether there is any deficiency of service on the part of the O.Ps and the complainant is entitled to get compensation and relief as sought for?

5. Heard arguments advanced by the complainant as well as the O.Ps at length. 

DECISION AND REASONS FOR DECISION:-

6. All the points are taken up together for convenience.

6.1 It is the submission of the complainant that he submitted the duly filled up form for inclusion of the new born baby girl in the existing policy. On the contrary the O.Ps stated that they did not receive such intimation from the complainant as such can not raise claim for benefit of coverage of new born baby under the existing policy. 

6.2 As per policy clause the coverage for new born baby starts from the 16th day of its birth till the expiry date of the policy subject to a limit of 10% of the sum insured or Rs.50,000/-, whichever is less, subject to the availability of the sum insured, provided the mother is insured under the policy at least  for 1 year. 

6.3 It is also condition of the policy that the child birth intimation is to be given along with endorsement required. Hence, the last condition of child birth intimation is only directory to facilitate the company to formally include the newly born child in the policy. There is nothing that for non-intimation claim can be rejected. More so, in this case intimation was given to the agent with duly filled up form along with all required documents. Hence, the claim of the complainant is justified and he is entitled to get the benefit of the coverage of new born baby under the existing policy.

6.4 As per policy sum assured was Rs.13,50,000/- and the benefit of the coverage is 10% of the sum insured i.e., Rs.1,35,000/- or Rs.50,000/- whichever is less. Though the complainant incurred Rs.86,541/- towards the treatment of the baby but as per policy he is entitled to the lesser amount i.e., Rs.50,000/-.  

6.5 Accordingly, all the points are decided.

7. In the result, it is ordered that the O.P. No.3, The Branch Manager, Insurance Company shall pay Rs.50,000/-(Rupees Fifty Thousand) to the complainant towards the cost of the treatment of the baby  along with interest @ 7.5% P.A. from today till the date of actual payment, if not paid within 30(thirty) days from today. Further the O.Ps shall pay Rs.10,000/-(Rupees Ten Thousand) as compensation including litigation cost for their deficiency in service. 

The case stands disposed off. Supply a copy of this Final Order free of cost to the complainant and the Opposite parties.

 

 Announced.

 

 

 

SRI  GOUTAM DEBNATH
PRESIDENT,
DISTRICT CONSUMER  DISPUTES 
REDRESSAL COMMISSION,
WEST TRIPURA, AGARTALA

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA,AGARTALA