Jharkhand

Bokaro

CC/20/2022

Shashi Bhusan Singh - Complainant(s)

Versus

The Manager, Star Health Insurance - Opp.Party(s)

Shri Kant Kumar Sharma

16 Jun 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-07-02-2022

Date of final hearing-16-06-2023

 Date of Order-16-06-2023

Case No. 20/2022

1. Shashi Bhusan Singh S/o Late S.P. Singh

2. Manorama singh W/o Shashi Bhushan Singh

     Both R/o Hirak Point Menko More, Hirak Square,

     Block-B, Dhanbad

Vs.

1. The Manager Star Health Insurance

Plot No. 146, Sandhya Niwas

Manohar Co Operative Road, B.S.City- 827012

2. Star Helth Insurnace

349, Business point unit no. 204/205,

2.  

Andheri East Mumbai 400069

 

 Present:-

                             Shri Jai Prakash Narayan Pandey, President

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-Order-

1. Complainant’s case in brief is that he has obtained Star Health Insurance Policy for his spouse Manorama Singh which was effective from 29.03.2017. Further case is that insured Manorama Singh was admitted in Khushi Nursing Home who was discharged on 17.01.2018 and complainant paid Rs. 67,500/-  to the hospital, accordingly claim form was submitted before the O.P. but it was rejected on the ground that there is no positive proof for supporting the diagnosis though the report clearly shows that insured was suffering from acute pancreatitis for which she was treated.  Later on legal notice was send having no impact. Hence this case has been filed with prayer to direct the O.P. to pay Rs. 67,500/- as medical expense, Rs. 25,000/- as compensation and Rs. 5000/- as litigation cost.
2. As per W.S. of the O.P. Insurance policy, insurance coverage of the insured are admitted facts. According to W.S. the claim has been rejected on the ground that on scrutiny of the claim it was observed that the submitted investigation report and USG report reveals pancreas are normal, Serum amylase and lipase are normal hence there is no positive proof for supporting the diagnosis. Other please are formal in nature. Hence it is prayed to dismiss the case.
3. Now point for adjudication is that whether complainant is entitled to get relief as prayed or not?
4. In support of the case complainant has produced medical papers and on careful perusal of those papers it appears that as per blood report dt. 04.01.2018 and 10.01.2018 serum amylase and serum lipase are almost normal. As per ultrasography report pancreas is normal in size and echotexture showing smooth and regular outline. Pancreatic duct is not dilated. No pancreatic calcification is noted. Perpancreatic areas appear normal. Therefore, on careful perusal of investigation report of the patient concerned it appears that there is no supportive papers to show acute pancreatitis. In this way it is apparent that repudiation of claim by the O.P. is based on the documentary evidence  related to investigation reports.
5. Another important aspect of the case is that main aggrieved person is the Manorama Singh who is insured person about whom it is said that she was admitted and treated in the hospital but neither she filed this case nor she has deposed before this Commission to prove her grievance. In this way it appears that on this ground also case is liable to be dismissed.
6. In light of above discussion we are of the opinion that complainant has not proved his case for grant of relief as prayed and there is no deficiency of service by the O.P. Accordingly this case is dismissed on contest. In the facts of this case parties shall bear their own costs.

 

                                                                            S/d

(J.P.N. Pandey)

                                                                                      President

                                                                  

         

S/d   

(Baby Kumari)

                                                                                                    Member