West Bengal

Bankura

CC/81/2016

Sri Ardhendu Sakhar Gupta - Complainant(s)

Versus

Branch Manager, Eastern Finance Insurance Pvt. Ltd. - Opp.Party(s)

Tapan Dey

04 Oct 2023

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA

  Consumer Complaint No. 81/2016

           Date of Filing: 03/11/2016

Before:                                        

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.            

For the Complainant:  Ld. Advocate Tapan De

For the O.P. : Ld. Advocate Ardhendku Sekhar Ghosh

Complainant  

Sri Ardhendu Sekhar Gupta, S/o Late Krishna Gobinda Gupta, Vill + P.O.Sendra, Bankura

Opposite Party                                                                                                                                                

1.Branch Manager, Eastern Finance Insurance/Broking Pvt. Ltd., College Road (Ground Floor of Bangiya Gramin Bikash Bank), Bankura

2.Star Health & Allied Insurance Co. Ltd., SM-10 Ambedkar Sarani, City Centre, Durgapur-713 216, District-Burdwan

3. Star Health & Allied Insurance Co. Ltd., KRM Centre, 6^th Floor, No.2 Harrington Road, Chetpet, Chennai-600 031

4.Sri Tapan Kumar De (Agent), S/o Late Gobardhan De, Village & P.O.Sendra, Bankura

 FINAL ORDER / JUDGEMENT        

                                                                                                                                                   

Order No.27

Dated:04-10-2023

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 had one Family Health Optima Insurance Plan issued by O.P. No.3/Insurance Co. Policy No. being P/191114/01/2016/004163 valid from 12/09/2015 to 11/09/2016. On 01/06/2016 the Complainant’s minor son Sri Suman kalyan Gupta experienced some breathing problem and on the very day he was admitted at Bankura Seva Niketan Hospital and discharged on 04/06/2016 with the diagnosis of mild allergic asthema and thereafter he was again admitted on 13/06/2016 at the same Hospital and discharged on 17/06/2016. During his hospitalization twice in the said Hospital the Complainant has incurred medical expense of Rs.42,000/-. Thereafter the Complainant’s son visited Appolo Hospital, Chennai for proper and better treatment and now he is quite okay and there the Complainant incurred Rs.8,000/- as the medical expenses. On 25/06/2016 the Complainant

                                                                                                                                                                                        Contd……p/2

                                                                                                          Page: 2

preferred mediclaim with the O.P./Insurance Co. but the same was repudiated in spite of furnishing requisite documents. The Complainant has therefore approached this Commission for mediclaim of Rs.50,000/- with compensation.

O.P./Insurance Co. contested the case by filing a written version contending inter alia that the Complainant is not entitled to get the mediclaim as he did not furnish the requisite documents as asked for and in absence of requisite documents claim could not be settled. O.P. No.1/Insurance Broker and O.P. No.4 Insurance Agent also filed written version separately.

-: Decision with reasons: -

Having regard to the facts of the case, contention, submission and documents on both sides the Commission finds that the Complainant’s son did not in fact undergo any medical treatment or surgery for his breathing problem but he was rendered Conservative treatment as is evident  from the Discharge Certificate (Annexure- B & C) issued by Bankura Seva Niketan Hospital for his two phased hospitalistion but all the medical bills submitted by the Complainant relate to the charges for medical test and investigation. It is a common principle of any mediclaim policy  that the insured is not entitled to get the medical claim for hospitalization charges for undergoing tests and diagnostic investigation unless medical treatment / surgery is done.

As stated above Conservative treatment will not come within the purview of the terms and condition of the mediclaim policy for reimbursement of medical expenses as prayed for by the Complainant.

Hence it is ordered……..

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

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

 

 ____________________                _________________           _________________

HON’BLE   PRESIDENT          HON’BLE MEMBER        HON’BLE MEMBER