Jharkhand

Bokaro

CC/65/2022

Sanjay Ojha - Complainant(s)

Versus

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

Amardeep Jha and Poonam

01 Apr 2023

ORDER

Ld. Counsel for both the parties are present. Heard both the parties and perused the case record.

                                      Complainant‘s case in brief is that he has obtained Mediclaim policy of the O.P. vide customer ID No. 15151557-1 valid during relevant period. Further case is that due to some illness complainant was admitted in Shivam Hospital, plot No. E-2, Laxmi Market, Sector-4, P.O.&P.S.- Sector-4, District Bokaro Jharkhand on 18.01.2022 and discharged on 21.01.2022 for which he paid Rs. 64,830/- to the hospital which was not paid by the O.Ps. inspite of fulfillment of all norms, hence this case has been filed with prayer to direct the O.Ps. to pay Rs. 64,830/- as medical expense, Rs. 50,000/- as compensation and Rs. 20,000/- legal cost.

                                       O.P. has filed W.S. admitting the fact regarding opening of the policy and its validity period as well as its norms. At para ‘l’ & ‘n’ of the W.S. it has been admitted that inspite of repudiation of the claim it was once again considered and it has been noted that an amount of Rs. 61,451/- can be settled to the insured and amount Rs. 1660/- paid for investigation and diagnosis, Rs. 1219/- related to medicines within hospital easy fix, high flow mask, nebulizer mask and registration fee of Rs. 500/- are not payable as per terms of the policy. Hence it is submitted that Rs. 61,451/- may be paid to the complainant.

                                       Rejoinder on that very W.S. has also been filed and it has been mentioned that on the basis of admissions made in W.S. case can be disposed off with prayer related to compensation and litigation cost.

                                       On careful perusal of the W.S. filed by the O.P. it is very much clear that the amount related to Rs. 1219/- in respect to payment towards HI FLOW MASK, NEBUILIZER MASK are not payable because it is related to non medical items but registration fee and investigation charges cannot be disallowed. There is no justification for deduction of Rs. 1660/- + Rs. 500/- total Rs. 2160/-. Therefore, in view of admissions we are of the view that complainant is entitled to get Rs. 61,451/- + Rs. 2160/- Total Rs. 63,611/- as medical expense incurred during his treatment as per terms and conditions of the policy under consideration.

                                       In the result, prayer of the complainant is being allowed in the following manner:-

                                       O.Ps. Star Health and Allied Insurance Co. Ltd. are directed to pay Rs. 63,611/- to the complainant within 60 days from receipt/production of copy of this order and in case of failure in payment of above amount within above mentioned period, O.P. shall pay interest @ 10% per annum from 02.05.2022 (i.e. the date on which case was filed). In the facts and circumstance of the case parties shall bear their own costs.