PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

CONSUMER COMPLAINT NO.- 07/2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

Smt. Afrin Parween,

W/O-Mohammed Azhar,

R/O-Kumbharpada near Ghosh Colony, Po-Head Post Sambalpur

PS-Dhanupali,

Dist-Sambalpur-768001                                                .……….......Complainant.

Vrs.

The Branch Manager,

Star Health and Allied Insurance Company Ltd.

2^nd floor, Quality Mansion Nayapada,

Sambalpur-768001.                                               ....……….Opp. Party

Counsels:-

1. For the Complainant         :-       Sri. Mohammed Azhar, representative of Complt.
2. For the O.P.s                       :-       Exparte

Date of Filing:17.01.2023,     Date of Hearing :11.04.2023,     Date of Judgement : 15.05.2023

Presented by Sri Sadananda Tripathy, Member.

1. The Brief fact of the Complainant is that the Complainant opted a health insurance policy with the OP covering the risk of herself and her family members under Young Star Insurance plan with effect from dtd. 29.12.2021 under 2A+1C scheme with a limit of coverage of Rs. 5,00,000/-. The Complainant has paid a sum of Rs. 11,323/- to the OP as premium. The OP has insured the health risk of the policy holder and her family members for a sum of Rs. 5,00,000/- in case of any health related problems. On date 3^rd Oct 2022 the Complainant was suffering with fever and weakness. When she went to Dr. Alekha Prasad Mahapatra Regd No. 9507 for general checkup the Doctor advised her for some blood and urine test. After the test report came and Doctor prescribed her some medicine and said her to take rest. After 2 days on dt. 05.10.2022 the Complainant felt no good so she and her husband decided to check up with another Doctor. She went to Sanjeevani a family Hospital for check up and she was checked up by Dr. Kabir Das Purohit. After a general check up the doctor was consulting to admit her immediately. After the admission of patient the Complainant informed the O.P. regarding her health problem and treatment undergone and requested for cashless treatment prior to her treatment, but the OP rejected her cashless treatment on dtd. 06.10.2022 saying that the patient could have been managed as outpatient and she did not need for hospitalization. However the O.P. requested the Complainant to submit all documents for reimbursement of the expense incurred relating to the treatment of the Complainant. The hospital authority charged a sum of Rs. 13,926/- and as per policy conditions the Complainant is entitled to have cashless treatment but unfortunately the Op did not take any steps to clear the bills of the hospital as a result of which the Complainant was forced to pay the bills to the hospital, on the date 08.10.2022 of her discharge. The total amount of expenses is Rs. 16,679.29/-. When the Complainant met the Star Health Insurance Sambalpur’s Branch Manager for re-consideration of claim, the manager said to meet the doctor and mention the whole matter in his letter head, the patient had a requirement for hospitalization at that moment. The doctor gave the whole matter on his letter head and the Complainant also written application to branch manager for re-consideration of her claim on dtd. 26.11.2022 and she submitted the doctor’s letter and application to the branch. But the claim of the Complainant was not settled.
2. The OP is set ex-parte.
103606587.  

1. Is the Complainant a Consumer of the O.P?
2. Is there any deficiency of service/unfair Trade practice on the part of O.Ps?
3. Whether the Complainant is entitled for getting any relief from the OP?

Issue No. 1 Is the Complainant a consumer of the O.P?

The Complainant had a health insurance policy with the OP covering the risk of herself and her family members under Young Star Insurance plan with effect from dtd. 29.12.2021 under 2A+1C scheme with a limit of coverage of Rs. 5, 00,000/-. The Complainant has paid a sum of Rs. 11,323/- to the OP as premium amount. So the Complainant is the consumer of the OP.

Issue No. 2 Is there any deficiency in service/ unfair Trade practice on the part of O.P?

The Complainant had a valid health Insurance Policy of the OP at the time of treatment and she was admitted in the hospital. Although intimated the OP in time, the OP did not take any step when there is a valid cashless policy/health card. So deficiency in service/ unfair Trade practice on the part of O.P is found.

Issue No. 3 Whether the Complainant is entitled for getting any relief from the OP?

From all the facts of the parties, the Complainant is entitled for getting reliefs what he claims in his complaint petition from the O.P.

                             ORDER

The O.P is directed to pay Rs. 16,679.29/- towards cost of the medical expenses, Rs. 30,000/- towards mental agony and harassment as compensation and Rs. 10,000/- towards cost of the petition to the Complainant within 30 days from the date of order, failing which all the amount will further carry with 9% interest per annum till realization to the complainant.

Order pronounced in the open Court today on 15^th day of May, 2023.

Free copies of this order to the parties are supplied.