West Bengal

Bankura

CC/7/2024

Swarna Kanta Mandal - Complainant(s)

Versus

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

Jayanta Kumar Mukherjee

25 Sep 2024

ORDER

  IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA

  Consumer Complaint No.07/2024

       Date of Filing:  09/01/2024

Before:                                        

1. Samiran Dutta                                     Ld. President      

2. Siddhartha Sankar Bhui                    Ld. Member

 

For the Complainant:Ld. Advocate Jayanta Kumar Mukherjee

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

 

Complainant:

Swarna Kanta Mandal,S/O-Bholanath Mandal,R/O-Kenduadihi,B.B.D Nagar,P.S&Dist-Bankura,P.O-Bankura,Pin-722102,Mob-9434481015

 

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,SN-10,Ambedkar Sarani,City Centre,Durgapur,Pin-713216

 

FINAL ORDER / JUDGEMENT  

Order No.11

Dated:25-09-2024

Both parties file hazira through Advocate.

The case is fixed for argument.

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

The Complainant’s case is that he took Family Health Optima Insurance Plan Policy for self, spouse and minor daughter from O.P./Insurance Co., Policy No. being 11230223072102 renewed for the period from 24/12/2022 to 23/12/2023 with Sum Assured Rs.5 Lakh. While the Policy was in force the Complainant having some problem of left ankle got admitted at MIOT International, Chennai on 06/04/2023 and was discharged on 10/04/2023 after surgical treatment and during hospitalization he incurred medical expenses of Rs.1,91,437/- which he paid from his own pocket despite having Cashless facility of the Policy. Mediclaim was duly forwarded to the O.P./Insurance Co. for reimbursement of the said amount supported by requisite documents but the same was repudiated by Letter dated: 16/06/2023 for non-production of requisite documents. The Complainant has therefore approached this Commission for  appropriate relief.

                                                                                                                                                                                       Contd…..p/2

Page: 2

O.P./Insurance Co. contested the case by filing a written version contending inter alia that the Complainant has pre-existing disease of the same nature prior to the commencement of the Policy and as such the Complainant is not entitled to get the reimbursement of mediclaim for suppression of material fact.

-: Decision with reasons:-

Having regard to the facts of the case, contention, submission, and documents on both sides  the Commission finds that  the Complainant was admitted at MIOT International, Chennai on 06/04/2023 and before admission he was examined by Dr. Ashok Selvaraj of the said Hospital on 05/04/2023 where it was mentioned in the prescription as the past history of the patient to the effect that the patient came with complaints of pain and swelling in left ankle on and off since February and swelling was sudden in onset, gradually progressive in nature and since February pain and swelling has increased. But when he was discharged on 10/04/2023 the Discharge Summary given by the same Doctor has mentioned the same patient history save and except that he came with complaints of pain and swelling in left ankle since two years.

Now the question which one of the patient history recorded by the treating Doctor is to be accepted so as to come to the decision as to whether the patient had pre-existing disease since two years prior to the commencement of the policy or since February, 2023 i.e. after commencement of the Policy.

Ld. Advocate for the O.P./Insurance Co. could not give any explanation for such different recording of the patient history with regard to the duration of the disease.

Ld. Advocate for the Complainant has submitted before the Commission that the patient history recorded before the admission of the patient should be accepted for fair disposal of the case.

There is however no material on record produced on behalf of the O.P./Insurance Co. to establish hospitalization or surgical treatment for similar nature of ailment of the Complainant prior to the commencement of the Policy. 

                                                                                                                                                                                          Contd…..p/3 

Page: 3

In view of the conflict of recording of patient’s history as to the fact of pre-existing ailment the Commission  should take pro-consumer view overruling the fact of pre-existing disease of the Complainant. Repudiation of mediclaim in the given facts and circumstances of the case is not at all justified. The Complainant is therefore entitled to get the relief as prayed for.

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.1,91,437/- as the full and final settlement of mediclaim 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