DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: WEST TRIPURA : AGARTALA

 

CASE   NO:   CC- 58 of  2023

 

Sri Shubhrangshu Sengupta,

S/O- Lt. Rajani Kanta Sengupta,

Jogendranagr, Sen Bari,

Kataseola, Dukli, West Tripura,

P.S. East Agartala, Tripura- 799004.

P.O. Agartala College. ...........Complainant.

 

-VERSUS-

 

1. The Health Claims Hub,

 

2. Manager Axis Bank,

 

    __________PRESENT__________

 SRI GOUTAM DEBNATH

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR (SMT) BINDU PAL

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 Prabal Kr. Ghosh,

 

For the O.P. No.2 : Smt. Pushpita Chakraborty,

 

 

 

F I N A L    O R D E R

 

1. This case is filed U/S 35 of the Consumer Protection Act, 2019 by Sri Shubhrangshu Sengupta of Dukli , Agartala, West Tripura against the O.P. namely (1)The Health Claims Hub, Tata AIG General Insurance Co. Ltd., Hyderabad, Telengana and (2) Manager Axis Bank, A.D. Nagar, West Tripura alleging deficiency in service on the part of the O.Ps.

1.1 The case in short is that the complainant purchased a Mediclaim policy from the O.P. NO.1 vide No. 0238821942 w.e.f. 14.02.2022  and paid premium to the O.P. No.1. As per advise of the O.P. No.1 the complainant was admitted at AVN Arogta Ayurveda Hospital on 30.03.2022 at Madurai, Tamil Nadu and discharged on 18.04.2022. 

1.2 The hospital authority raised bill for Rs.1,48,460/- against the claim no. 2022051900068. The complainant as per terms and condition approached to the O.P. No.1 for paying the bill to the hospital but the O.P. No.1 did not pay any bill to the Hospital.

1.3 Complainant issued Lawyer's Notice on 29.10.2022 to the O.P. No.1 but the O.P. did not respond to the said notice of the complainant. Again on 28.04.2023 complainant sent reminder through speed post but the O.P. remained silent. Ultimately the complainant had to pay the said medical bill of the Hospital. Complainant suffered to a great extent due to the health problem and huge loss of his business.

1.4 It is also stated by the complainant that the O.Ps are deficient in service and thus liable to pay medical treatment bill of Rs.1,48,460/- as per terms and condition of the policy of insurance, compensation of Rs.3,00,000/-, Rs.2,00,000/- for mental agony and tension etc. also Rs.25000/- towards litigation cost.   

2. The O.P. No.1 contested the case by filing written statement denying the allegations made by the complainant in his complaint petition. It is stated by the O.P. No.1 that  it is clear from the treatment record that the patient is K/C/O hypertensive nephropathy, H/O Chorodial disease since 1 and half year hence, claim falls under pre-existing disease.   

2.1 The complainant was denied cashless facility as the need of hospitalization is not justifiable in this case for admission and the claim is repudiated as per Section 5 Clause5(i) of the policy which is as follows:-

2.2 O.P. No.2, Axis Bank also contested the case by filing their written statement denying the allegations of the complainant and stated that as the O.P. No.2 is the facilitator so there is no deficiency in service on their part. Also stated that there is no specific cause of action against the O.P. No.2 to file the complaint petition and unnecessarily they have been made party to this case and the O.P. No.2 in no way is liable to settle the claim as alleged by the complainant. There is no deficiency in service on their part and prayed for dismissal of the complaint petition.

3. Complainant submitted evidence on affidavit along with documents.

3.1 The O.P. No.1 also submitted evidence on affidavit.

 

4. Hearing argument followings points are taken up for discussion and decision:-

 

  Decision and Reasons for Decision:-

5. Both the points are taken up together for discussion and decision.

5.1 It was the diagnosis of the doctor concerned that the patient suffered from K/C I.O. Avascular Necrosis since 6 months. This term means lack of blood circulation. We are impressed by the argument of the Learned Counsel of the complainant that this policy continue from the year, 2014 and at the time of renewal there is no scope for submitting proposal from again so as to conclude that the complainant suppressed any pre-existing disease, that may be the reason that the O.P. Insurance company has not been submitting the proposal form of the complainant so as to evaluate whether the complainant suppressed any pre-existing disease which he was aware at the time of taking the policy and in absence of the proposal form we may not  come to any conclusion  that the complainant is guilty of suppressing material information of pre-existing disease. As such, the O.P. Insurance company i.e., the O.P. No.1 is guilty of deficiency in service. The O.P. No.2 being corporate agent of O.P. No.1 is absolved from any responsibility as the O.P. No.2 has not indicated any deficiency in service on the part of O.P. No.2 at the time of taking the policy for and on behalf of the O.P. No.1. So, the O.P. No.1 is directed to pay the actual medical bill incurred by the complainant to the tune of Rs.1,48,460/- with interest @ 7.5% P.A. from the date of his preferring claim to the O.P. No.1 i.e., 29.10.2022 when Demand Notice was served upon the O.P. No.1. The O.P. No.1 shall pay a further sum of Rs.25,000/- as compensation which is inclusive of litigation cost. 

6. The points are decided accordingly.

7. The case stands disposed off.

 

 

8. Supply copy of this order to the parties free of cost.   

Announced.

 

 

SRI  GOUTAM DEBNATH

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA,AGARTALA

 

 

 

SRI SAMIR  GUPTA

MEMBER,

 DISTRICT CONSUMER DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,AGARTALA.