West Bengal

Bankura

CC/78/2023

Smt. Kalpana Dey - Complainant(s)

Versus

The Manager, Star Health and Allied Insurance Co.Ltd - Opp.Party(s)

Jayanta Kumar Mukhopadhyay

03 Apr 2024

ORDER

   IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA 

  Consumer Complaint No. 78/2023

                                                      Date of Filing: 28/08/2023                                             

Before:                                        

1. Samiran Dutta                            Ld. President.      

2. Siddhartha Sankar Bhui            Ld. Member. 

                                                         

For the Complainant:  Ld. Advocate Jayanta kr. Mukherjee

For the O.P.:  Ld. Advocate Mahadev Chakrabarty

 

Complainant  

Smt. Kalpana Dey,W/O-Bankachand Dey,R/O-Gopinathpur Mahalla,P.S&Dist-Bankura,P.O-Bankura,Pin-722101,Mob-9474142212

Opposite Party                                       

1.The Manager, Star Health and Allied Insurance Co.Ltd,Registered office: No-1,New Tank Street,Valluvarkottam High Road,Nungambakkam,Chennai-600034

2.Branch manager,Star Health and Allied Insurance Co.Ltd.,1^st Floor Patpur,JailRoad,P.O&P.S-Bankura,Pin-722101,W.B.                                                                                   …………………… Principal O.P

3.Chief Manager, Punjab National Bank Bankura Rabindra Sarani Branch,P.O&P.S-Bankura,Pin-722101,W.B.                                                                                                                                      …………Proforma O.P       

                                                                  

                                                                            FINAL ORDER / JUDGEMENT

Order No.08

Dated: 03-04-2024

Both parties file hazira through Advocate.

The case is fixed for argument.

Prayer for adjournment on behalf of the O.P. is considered but rejected.

After hearing argument from both sides the Commission proceeds to dispose of the case as hereunder: -

The Complainant’s case is that she and her spouse as Bank Customer with O.P. No.3/Bank purchased a Policy namely Star Group Health Insurance Policy-Gold issued by O.P. / Insurance Co., Policy No. being P/191136/01/2022/006480 valid from 05/03/2022 to 04/03/2023 covering the Sum Assured at Rs.5 Lakh. On 17/10/2022 the Complainant had an accidental fall in her residence at about 11.30 a.m. and she was badly injured with Femur fracture and was admitted at Hardik Medical Diagnostic Centre, Bankura on 18/10/2022 and was discharged on 07/11/2022. During the period of hospitalization the Complainant underwent surgery and incurred medical expenses totaling Rs.2,51,253/-. The Complainant duly submitted claim application for reimbursement of above medical expenses but it was repudiated by letter dated:24/01/2023 on the ground that as per condition No.13 of the Policy the Insured could not submit all the requisite documents as asked for. The Complainant has therefore approached this Commission for appropriate relief.

                                                                                                                                                                                         Contd……p/2

Page: 2

O.P./Insurance Co. contested the case by filing written version raising the same ground of repudiation of mediclaim of the Complainant including the ground of pre-existing disease.

-: Decision with reasons: -

Having regard to the facts of the case, submission, contention and the documents on both sides the Commission finds that admittedly the Complainant suffered accidental injury in her residence which was diagnosed as femur fracture and underwent  treatment and surgery at Hardik Medical Diagnostic Centre, Bankura from 18/10/2022 to 07/11/2022 for which she incurred medical expenses of Rs.2,51,253/- as is evident from the medical bills on record.

Ld. Advocate for the O.P./Insurance Co. has contended before the Commission that the Complainant is not entitled to get any relief in this case as she has a history of pre-existing disease of diabetes mellitus, anxiety neurosis as mentioned in the repudiation letter dated: 24/01/2023. But all the above mentioned diseases have no proximate nexus with Femur fracture and as such Femur Fracture cannot be said to be a pre-existing disease of the Complainant and no medical papers and documents relating to the above mentioned diseases i.e. diabetes mellitus, anxiety neurosis are required to be submitted before the O.P./Insurance Co. for settlement of reimbursement of mediclaim for treatment and surgery for Femur Fracture. The Commission thinks that O.P./Insurance Co. has unjustifiably repudiated reimbursement of mediclaim for Rs.2,51,253/-. The Complainant is therefore entitled to get the relief as prayed for in this case with reasonable compensation.                                                                                                                                         

Hence it is ordered……

That the case be and the same is allowed on contest but without cost.

O.P./Insurance Co. is directed to pay to the Complainant Rs.2,51,253/- towards reimbursement of mediclaim with compensation of Rs.10,000/- for repudiation of the same on flimsy ground within one month from this date in default law will take its own course.

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

 

____________________                 _________________         

HON’BLE   PRESIDENT           HON’BLE MEMBER