West Bengal

Bankura

CC/78/2017

Sri Pradip Kumar Patra - Complainant(s)

Versus

The Branch Manager United India Insurance Co. Ltd. - Opp.Party(s)

Jayanta Kumar Kukhopadhyay

12 Oct 2023

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION BANKURA

Consumer  Complaint No. 78/2017

Date of filing-23-11-2017

Present

1. Samiran Dutta                                                                                             Ld. President

2. Siddhartha Sankar Bhui                                                                             Ld. Member

For the Complainant: Ld. Advocate Jayanta Kumar Mukhapadhyay  

For the O.P: Ld. Advocate-Shib Sankar Ghosh

Pradip kumar Patra,S/O-Late Bimala Pada Patra,R/O-256/5,Pratap Bagan,Bankura,P.O,P.S&Dist-Bankura,Pin-722101

                                                                                                                                                                                                                                                                                                                                                    Complainant

V e r s u s

1. The Branch Manager,United India Insurance Co.Ltd,P.O,P.S&dist-Bankura,Pin-722101
2. Heritage Health TPA Insurance Pvt.Ltd.NiccoHouse,5^th Floor,2,Hare Street ,Kol-700001

                                                                                                                                                                            

                                                                                                                                                                                 Opposite Party 

FINAL ORDER / JUDGEMENT

Order No.48                                                                             

Dt. 12/10/23

Both parties filed hazira through Advocate.

Today 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 has a health insurance policy with OP No-1. Policy no being 03150828 valid from 29-09-2016 to 28-09-2017. On 10-04-2017 the complainant underwent Left eye cataract operation at Calcutta Eye Research Foundation under the care and supervision of Doctor Amitabha Biswas and incurred medical expenses of Rs-23011/=. The Complainant duly submitted claim application for Rs-23011/= with O.P-2/TPA out of which only 5406/= has been paid by settlement repudiating claim of balance Rs-17605/=.

Hence this case.

O.P-2/TPA contested the case by filing a self contained note stating that the complainant is not entitled to get more than Rs-5406/= as the balance claimed amount is not admissible as per terms and condition of the policy.

O.P-1/Insurance Company also filed W.V to that effect.

                                                                                          Decision with reason

Having regard to the facts of case, submission, contention and documents on both sides the Commission finds that the complainant has incurred Rs-6011/= for medical test and medicine as per medical expenditure bill submitted by the complainant. It is the normal rule of terms and conditions of mediclaim Policy that the policy holder must be reimbursed the charges for medical test and medicine if he undergoes operation. O.P-2 cannot deny the claim of Rs-6011/= apart from payment of Rs-5406/=towards settlement of the claim.

The complainant is therefore entitled to further claim of Rs-6011/=from O.P-2.

Hence, it is ordered.

 That the case is allowed on contest in part but without cost.

The O.P-2/TPA is directed to pay Rs-6011/= to the complainant within one month from this date in default law with take its own course.

      Both parities be supplied copy  free of cost.

 

               ____________________                                           _________________

              HON’BLE   PRESIDENT                                      HON’BLE MEMBER