West Bengal

Bankura

CC/116/2023

Prasenjit Malakar - Complainant(s)

Versus

The Branch Manager, Star Helth and allied insurance Co.Ltd. - Opp.Party(s)

04 Apr 2024

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION BANKURA

Consumer  Complaint No. 116/2023

Date of filing-12-12-2023

Present

1. Samiran Dutta                                 Ld. President

2. Siddhartha Sankar Bhui                 Ld. Member

 

For the Complainant: Self 

For the O.P: Ld. Advocate-Mahadev Chakraborty

Prasenjit Malakar,S/O-Ranjit Malakar,Age-39,R/O-SN Road,Parthapur,P.O-Natagarh,Kol-700013,Presently residing at Bara Kalitala,P.O+P.S&Dist-Bankura,Pin-722101,Mob-9088386950/9883085781                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Complainant

V e r s u s

1. The Branch Manager,Star Health and allied insurance company limited,2^nd Floor B-9/277/CA Beside Axis Bank,Central Park,Kalyani,P.O-Kalyani,Nadia-741235
2. Star Health and allied insurance company limited,Nigamananda Panthasala,1^st Floor,Patpur,Jail Road,P.O&P.S&Dist-Bankura,Pin-722101,W.B
3.  Star Health and allied insurance company limited,1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai-600034,Tamil Nadu                                                                                                                                                                                

                                                                                                                                                                                 Opposite Party 

 

FINAL ORDER / JUDGEMENT

Order No.06                                                                             

Dt. 04/04/24

Complainant is present in person.

O.P is represented by the Adv.

The case is fixed for argument.

After hearing argument from both sides the commission proceeds to dispose of the case as here under:

The complainant’s case is that he obtained a medical policy Family Health Optima Insurance plan from the O.P for the year 2023-24 vide policy no-11230242628402 on payment of premium regularly from year to year since 2017. While the policy was valid and in force the complainant on 08/10/2023 was suffering with loose motion and vomiting more than 10/15 times and having no other alternative he was admitted on the same day at Savier Maternity and Nursing Home as inpatient as per advice of the consulting doctor.  After treatment he was discharged on 10/10/2023. During the period of hospitalization the complainant has incurred medical expenses of Rs-15530/- with medicine bill of Rs-479/-.

There after the complainant preferred claim application on 17/10/2023 to the O.P for reimbursement of the said amount paid by him. But the O.P repudiated his claim by letter dated 04/11/2023 on the ground that the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted. Hence this case.

O.P contested the case by filing a written version admitting the claim to the tune of Rs-15459/- after deduction of Rs-550/- without reiterating the ground of repudiation as above.

                                                                                   Decision with reasons

Having regard to fact of the case, contention submission and document on both sides the commission finds that the Complainant is entitled to get reimbursement of medical claim for Rs-15459/- which is found admissible as per terms and condition of the mediclaim policy. The O.P has repudiated the claim without any justifiable reason. It is the good gesture of O.P to admit the claim in the W.V and also at the time of hearing.

Accordingly the case succeeds.

Hence it is ordered that the case be and the same is allowed on contest but without cost. O.P/Insurance Company is directed to pay to the Complainant Rs-15459/- towards reimbursement of mediclaim within a fortnight from this date in default the law will take its own course.

Both parities be supplied copy of this order free of cost.

 

               ____________________                                        _________________

              HON’BLE   PRESIDENT                                    HON’BLE MEMBER