DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: WEST TRIPURA : AGARTALA

 

 

CASE   NO:   CC- 59 of  2023

 

 

 

 

 

-VERSUS-

 

 

 

1. The Branch In charge,

Star Health and Allied Insurance Co., Ltd.,

Netaji Chowmuhani, N.S. Road,

2nd Floor, above HDFC Bank,

Agartala, Tripura-799001,

P.S. West PS, P.O.- Head Post Office.

 

2. The Manager,

Bank of Baroda, Agartala Branch,

Kaman Chowmuhani, Agartala-799001,

P.S. East PS, P.O. Head Post office. ....Opposite Parties. 

 

3. The Chief Executive Officer of ILS Hospital,

Agartala, Tripura West,

P.O. New Secreteriat, Pin- 799010,

P.S. New Capital Complex.....Pro-forma Opposite Parties.

 

  

 ________PRESENT__________

 

 

 SRI GOUTAM DEBNATH

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR(SMT) BINDU PAUL

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA. 

 

SRI SAMIR GUPTA

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA. 

 

 

C O U N S E L

 

 

For the O.P. No.1 : Sri Mridul Kanti Arya,

 

For  the  O.P. No.2 : Sri Subhendu Bhowmik,

 

 

 

 

 

 

F I N A L     O R D E R

1. This case is filed by Smt. Jhumur Ghosh of Shibnagar, Agartala here-in-after called the 'Complainant' against (1) The Branch-In-charge, Star Health and Allied Insurance Co. Ltd., Netaji Chowmuhani, Agartala, here-in-after called 'the O.P. No.1' (2) The Manager, Bank of Boroda, Kaman Chowmuhani, Agartala here-in-after called 'the O.P. No.2' and (3) The Chief Executive Officer of ILS Hospital, Agartala Tripura, here-in-after called 'the O.P. No. 3'.

1.1 The fact of the complainant in short is that the  complainant is the policy holder for Medi- claim vide policy no- P/191313/01/2020/000111  for period form 18 June, 2009 to 6th July, 2023 with the opposite party no.1. 

1.2 On 14.04.2023 she was admitted in the ILS Hospital Agartala where in it was detected that she is suffering from hyperglycaemia/ hypertensive Encephalopathy/ hypocalcaemia and under went treatment there  and discharged on 15.04.2023.

1.3 After completion of the treatment the ILS Hospital authority raised bill for an amount of Rs.55,717/- and accordingly the complainant as per insurance policy claimed the said bill amount from the O.P. No.1 but the O.P. No.1 denied any payment.  

1.4 Advocate's Notice was sent on 03.05.2023 and 06.05.2023 respectively through speed post but the O.P. No.1  did not reply nor paid any amount.

1.5 Hence, this complaint claiming Rs.55,717/-, with 12% interest, compensation of Rs. 1,00,000/- and Rs.1,00,000/- for mental agony and Rs. 25,000/- for litigation cost. 

 

2. The O.P. No.3 is strike out as per order dated 25.07.2023 as not a necessary party.

2.1 The O.P. No.1 and 2 appeared and filed written objections denying the allegations of the complainant made in her complaint petition. 

2.2 The O.P. No.1 in written objection stated that the  case is not maintainable and admitted that Sri Samir Ghosh took the policy of Insurance for himself and his wife Jhumur Ghosh covering the period of illness of Jhumur Ghosh. However, on receiving payment request it was found that the complainant suffered from pre- existing disease relating to diabetes arising out of  diabetes and other complications arising out of diabetes. As such, as per the exclusion clause the complainant is not entitled to any compensation.

2.3 The O.P. No.2 also submitted written objection denying any deficiency of service on the part of O.P. No.2 as O.P. No.2 is a corporate agent of O.P. No.1. 

3. The parties submitted evidence on affidavit and documents.

4. During the course of argument Learned Counsel of the complainant submitted that the policy continued from 2019 onward and was renewed time to time and at the time of taking the policy the complainant did not suffer from any pre-existing disease to the knowledge of the complainant.

4.1 On the other hand, Learned Counsel of the O.P. No.1 submitted that the discharge summary of the complainant proves that the complainant was diabetic which is a pre-existing disease.

 

5. The following points are taken for discussion and decision:-

 

6. Both the points are taken up together.

6.1 The discharge summary of the complainant from ILS Hospital dated 05.04.2023 proves that the final diagnosis was “Acute hyperglycemic state; hypertensive encephalopathy; acute gastritis and hypokalemia”.

6.2 To prove suppression of fact it is necessary that the complainant had knowledge of any pre-existing disease and suppressing such pre-exisiting disease obtained the policy of insurance.

6.3 The complainant in the case is an old lady of 61 years old who continued Health Policy from the year, 2019 till the year, 2023 renewing the same time to time. The diagnosis of ILS Hospital as mentioned in the discharge summary does not suggest that the complainant suffered from any pre-existing disease and has anything to do with diabetes. As such, it can not be said that the complainant having knowledge of pre-existing disease obtained policy of health Insurance by suppressing such fact. Hence, the refusal of the O.P. No.1 to pay the bill of the Hospital is deficiency in service on the part of the O.P. No.1. 

7. Both the points are decided accordingly.

 

8. In the result, it is ordered that the O.P. No.1 shall pay the hospital bill i.e., the sum of Rs.55,717/- with interest @ 7.5% P.A. from 10.07.2023 i.e., the date of filing of this case till the date of actual payment. The O.P. No.1 shall also pay a further sum of Rs.25,000/- to the complainant as compensation which is inclusive of litigation cost. 

 

9. The case stands disposed off.

 

10. Supply copy of this Final Order free of cost to the parties.  

 

Announced.

 

 

 

SRI  GOUTAM DEBNATH

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

 

 

DR(SMT) BINDU PAUL

MEMBER,

DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA.

 

 

SRI SAMIR  GUPTA

MEMBER,

DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA.