DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: WEST TRIPURA : AGARTALA

 

CASE   NO:   CC- 55 of  2023

 

Smt. Subidita Das,

W/O- Sri Sadhan Chandra Das,

14 Krishnanagar, Colonel Chowmuhani,

P.O. Agartala, P.S. West Agartala,

District- West Tripura. ...........Complainant.

 

 

-VERSUS-

 

 

1. The Senior Divisional Manager,

 

2. The Senior Divisional Manager,

 

3. The Managing Director,

 

4. The Divisional Manager,

 

5. CITI Bank, 2nd Floor,

 

 

    __________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.Ps : Sri Gitangshu Sekhar Das,

 

 

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 Smt. Subidita Das of Krishnanagar, Agartala, West Tripura(here-in-after called “the Complainant”) against (1)The Senior Divisional Manager, New India Assurance Company Ltd., Mumbai (here-in-after called the “O.P. No.1”), (2)The Senior Divisional Manager, New India Assurance Company Ltd., Tamil Nadu(here-in-after called “the O.P. No.2”), (3)The Managing Director, Indian Health Care Private Service Ltd., Chennai(here-in-after called the “O.P. No.3”), (4)The Divisional Manager, New India Assurance Company Ltd., Agartala, West Tripura(here-in-after called the “O.P. No.4”), (5)CITI Bank, Chennai, Tamil Nadu(here-in-after called the “O.P. No.5”) alleging deficiency in service on the part of the O.Ps.

1.1 The case of the complainant in short is that the complainant purchased a Medi Claim Insurance Policy covering period from 01.05.2022 to 30.04.2023 vide certificate No. 712500/GH/MAY2022/25190 issued by the O.P. No. 1 & 2  for a sum of Rs.10,00,000/-. 

1.2 On 27.02.2023 the complainant was admitted at Dr. Mohan's Diabetics Specialities Centre at Chennai, Tamil Nadu State for her treatment from 27.02.2023 to 01.03.2023. As per advise of the doctors various clinical laboratory tests were done there and incurred medical expenditure of Rs.51,780.20/-. 

1.3 Complainant placed claim before the O.Ps for reimbursement of her medical expenditure but the O.Ps did not pay the said amount on the ground that the admission is only for investigation purpose and does not followed the active line of treatment and also that as per claim documents the patient does not support the need of hospitalization. 

1.4 Complainant served Legal Notice upon the O.Ps  on 24.03.2023 but the O.Ps neither replied to the said notice nor did they pay the cost of medical expenditure. 

1.5 Hence, this complaint.

2. The case has been proceeded exparte against the O.P. No. 3 & 5 vide order dated 11.10.2023.

2.1 O.P. No.1, 2 & 4 in their joint written objection stated that the policy was obtained from Chennai and the complainant was admitted in Chennai Hospital and all the correspondence also took place in Chennai and hence this Commission has no jurisdiction to entertain this petition. The complainant did not mention for which disease the treatment was done. 

2.2 As per clause 4.4 of the policy condition the complainant is not entitled to get any claim for medical tests and evaluation.

3. Both the parties submitted evidence on affidavit along with documents. 

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

  (ii) Whether the complainant is entitled to get the Medical reimbursement under the policy?

DECISION  AND  REASONS:-

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

5.1 During the course of argument Learned Counsel of the complainant has submitted some more documents and submitted that the total amount now has increased to Rs.96,000/-. 

5.2 Per contra Learned Counsel Mr. G.S. Das appearing for the Insurance Company argued that the complainant was admitted in the hospital not for any treatment but for investigation, as such not entitled to any reimbursement as per exclusion clause of the policy of insurance.

5.3 The exclusion clause of policy of Insurance ie.., clause No. 4.4 and 4.4.1 read as follows:-

  Investigation and evaluation(code- Excl 04)

  a. Expenses related to any admission primarily for diagnostic and evaluation purposes. 

  b. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment. However, treatment for any symptoms illness, complications arising due to physiological condition for which aetiology is known is not excluded. It is covered with a sub limit of up to 10 % of sum insured per policy period.” 

5.4 The complainant has not submitted any prescription or discharge summary to show that any medical treatment was given to the complainant except good number of investigation and the hospital raised bill for investigation and doctors fees including bed charges etc. Thus, in view of the above exclusion clause we are constrained to conclude that the alleged treatment of the complainant and claim is barred by the exclusion clause of the policy of insurance as quoted above.  

6. Hence, the complainant is not entitled to any reimbursement from the O.Ps. 

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.