DISTRICT CONSUMER DISPUTES REDRESSALCOMMISSION: WEST TRIPURA : AGARTALA

 

CASE   NO:   CC- 04 of  2023

 

Sri Dhiraj Dhar,

S/O- Lt. Sudhangshu Dhar,

North Joynagar, Agartala, 

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

District- West Tripura, Pin- 799001. ...........Complainant.

 

-VERSUS-

 

1. Branch Manager,

 

2. The Medi Assist Insurance TPA Private Limited, 

 

3. Medicare TPA Services (I) Pvt. Ltd., 

 

    __________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 Prabal  Kumar Ghosh,

 

 

 

 

F I N A L    O R D E R

1. Dhiraj Dhar herein after called the complainant has filed this petition alleging inter alia that he obtained Health Insurance i.e., Arogya Plus Policy on 04.02.2022 from the O.P. No.1 and the policy paper was issued on 04.02.2022 for the period 04.02.2022 to 19.02.2025. As per requirement all medical tests were undergone before taking the policy as directed by the O.P. No.1. 

1.1 The complainant fell ill and took medical assistance from Fortis Hospital, Kolkata for the period 12.08.2022 to 18.08.2022 but the complainant had to pay Rs.64,611/- to the Hospital as O.P. failed to reimburse the amount.

1.2 As per advise of the doctor the complainant was admitted in Fortis Hospital, Kolkata an surgical operation was conducted on the abdomen of the complainant on 09.09.2022. This time the complainant was admitted for the period 09.09.2022 to 12.09.2022 and had to spent Rs.1,43,638/-. Thus, in total the complainant had to spent Rs.2,08,249/-. The complainant contacted the O.P. and claimed the amount but to no good. Hence, the complainant served Legal Notice on 28.11.2022. After that the O.P. No.2 asked for medical documents from the complainant which were submitted but to no good. 

1.3 Hence, this case.

2. Summon was served upon the O.Ps but the O.Ps failed to contest the case as such vide order dated 15.03.2023 exparte order was passed against the O.Ps. Thereafter, at the argument stage learned Counsel of the O.Ps appeared. Hence, the O.P. was given a chance to argue the case in absence of written objection. 

On 16.01.2023 Learned Counsel of the O.P. asked for another set of Medical documents from the complainant to consider the case of the complainant but to no good.

 

4. Learned counsel of the O.P. has prayed for adjournment today which is rejected. 

5. Hearing argument of the Learned Counsel of the complainant the following points are taken up for discussion and decision:-

DECISION AND REASONS:-

6. Perused the Policy document which was issued on 20.02.2022. In fact it is not denied by the O.Ps also.  

6.1 The complainant has submitted medical documents of the Fortis Hospital showing that she was admitted on 12.08.2022 and was discharged on 18.08.2022. A sum of Rs.64,611/- was charged by the Hospital. Again the complainant was admitted in the same Hospital on 9th September, 2022 and was discharged on 12th September, 2022. This time the complainant had to pay Rs.1,43,638/- as we find from the discharge summary. As such in total, Rs.2,08,249/- which the complainant is entitled to be reimbursed by the O.P. No.1. 

7. Both the points are accordingly decided in favour of the complainant.

ORDER:-

8. In the result, it is ordered that the O.P. No.1 shall pay Rs.2,08,249/-to the complainant with interest @ 7.5% P.A. from the date of filing of this case i.e., 19.01.2023 till the date of actual payment.

9. The case stands disposed off. 

10. Supply copy of this order to both 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.