DATE OF FILING                    :     03.04.2014.

DATE OF S/R                            :      14.05.2014.

DATE OF FINAL ORDER      :     30.12.2014.

Sankar Prasad Bhattacharya,

89/3, Shib Narayan Road, P.O. Uttarpara, District Hooghly,

PIN  712258.………………………………………………………… COMPLAINANT.

• Versus -

   

  Star Health & Allied Insurance Co. Ltd.,

  ( New ) Parmer House ( 3^rd floor ),

  P4, Dobson Lane, New Howrah Bridge Approach Road,

  P.S. Golabari,

  Howrah 711101…… …………………………………………………OPPOSITE PARTY.

   

                                                  P    R    E     S    E    N     T

   

  President     :     Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.

  Member      :      Shri P.K. Chatterjee.

  Member       :     Smt. Jhumki Saha.

                           

                                                   F  I   N   A    L       O   R   D    E     R

   

   

• 1. The instant case was filed by complainant U/S 12 of the C.P. Act, 1986 wherein the complainant has prayed for direction upon the o.p. Star Health & Allied Insurance Co. Ltd., for disbursing the medi claim amount to the tune of Rs. 42,000/- as in spite of proper receipts and documents issued by the hospital authority, o.p. repudiated the claim.
  2. The o.p. in their written version contended interalia that the medi claim could not be reimbursed as the complainant was suffering from preexisting disease.

3.        Upon pleadings of both parties two points arose for determination :

i)          Is there any deficiency in service on the part of the O.P.  ?

2. Whether the complainants areentitled to get any relief as prayed for ?

DECISION  WITH   REASONS      :

4. Both the points are taken up together for consideration. Admittedly the policy was incepted on 20.8.2013 and the complainant was admitted at the nursing home on 14.11.2013 i.e., within three months from the date of inception. The main contention of the o.p. is that since 24 months did not expire since inception of the policy, no question of imbursement does arise ; that the complainant suppressed his preexisting disease of Trachea infection.

5. Be that as it may, there is no material to show that the complainant had any symptoms like chest pain or LRTI or LVF. Nor the complainant was medically checked up by the insurance company. In fact we trace no fraudulent means to suppress his disease. It cannot be expected that each and every person should do medical studies before taking any mediclaim policy.The policy at hand was a one-time mediclaim policy for the senior citizens. It is in fact very natural that aged persons may be succplible to sudden ailment. The o.p. did not act properly in repudiating the claim when the complainantgenuinely paid the policy charge. It is immaterial if the bout of attack dawned within one week or three months like the case at hand. We are therefore, of the view that this is a fit case where the prayer of the complainant shall be allowed. Both the points are accordingly disposed of.

      Hence,                             

O     R     D      E      R      E        D

      That the C. C. Case No. 180  of 2014 ( HDF 180  of 2014 )  be and the same is allowed on contest with costs as   against  the O.P. 

      The O.P. be directed to reimburse the mediclaim amount of Rs. 42,000/- to the complainant within  30 days from the date of this order together with interest at the rate of of 9 per cent per annum since 24.12.2013 till full satisfaction. 

      The o.p. be further directed to pay Rs. 5,000/- to the complainant  (  Rupees five thousand ) towards litigation costs.

      No order as to compensation.

      The complainant is at liberty to put the decree into execution after expiry of the appeal period.

      Supply the copies of the order to the parties, as per rule.

DICTATED  &    CORRECTED

BY   ME.  

  (    T.K. Bhattacharya  )                                              

  President,  C.D.R.F., Howrah.