DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: WEST TRIPURA : AGARTALA

 

 

CASE   NO:   CC- 41 of  2023

 

Sri Bapi Datta,

S/O- Late Sankar Chandra Datta,

Bardowali, Near Modern Club,

P.O. A.D. Nagar,

P.S. A.D. Nagar,

District- West Tripura,

Pin- 799003. ...........Complainant.

 

 

-VERSUS-

 

 

1. SBI General Insurance Company Ltd.,

Registered Office; 9th floor, 

A & B Wing,

Fulcrum Building, Sahar Road,

Adheri East, Mumbai- 400099.

 

 

2. SBI General Insurance Company Ltd.,

Registered Address: Sriram Plaza, Ground Floor,

Ker Chowmuhani, T.G. Road,

Agartala, P.S. West Agartala, 

District- West Tripura,

Pin- 799002.

(To be represented by its Branch Manager).

 

 

3. Medi Assist Insurance TPA Private Ltd.,

(Formerly known as 

Medi Assist India TPA Private Ltd),

Registered office: 

Cashless Processing Centre, 

No- 252/2, Kodichikkanahalli Main Road,

Opposite Kailash Building,

Bommanahalli, Bangalore- 560 068. .......Opposite Parties.

 

 

 

    __________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 Subhajit Chakraborty,

 

 

 

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 Sri Bapi Datta of Bordowali, Agartala, West Tripura here-in-after called 'the complainant' against the O.Ps namely SBI General Insurance Co. Ltd., Mumbai (2)The Branch Manager, SBI General Insurance Co. Ltd., Ker Chowmuhani, Agartala, Tripura West & (3)Medi Assist Insurance TPA Pvt. Ltd., Bangalore alleging deficiency in service on the part of the O.Ps.

1.1 The case in short is that the complainant subscribed a Health Insurance policy from the O.P. SBI General Insurance Co. Ltd namely “Arogya Plus Policy” on 30.05.2020 vide policy no- 0000000017793236 for a period w.e.f. 30.05.2020 to 29.05.2021. 

1.2 Thereafter renewed the said policy on the next year w.e.f. 30.05.2021 to 29.05.2022 vide policy no- 0000000017793236-01 and again on the next year  vide policy no- 0000000017793236-02 on payment of Rs.10,502/- for the sum assured of Rs.3,00,000/-.w.e.f. 30.05.2022 to 29.05.2023 and the policy is live till date having the benefit of cashless treatment.

1.3 On 27.12.2022 the complainant visited Rabindranath Tagore International Institute of Cardiac Sciences  for this treatment where he was diagnosed  that he was suffering from double Vessel Coronary Artery Disease and good LV Systolic Function there after underwent immediate Coronary Angioplasty and PTCA with stenting to LCx and Lad on 30.12.2022 in the said hospital and discharged on 01.01.,2023. 

1.4 On 01.01.2023 the O.P. by email informed the complainant they rejected the cashless Treatment Claim. Since the O.P. did not settle the insurance claim for cashless treatment amounting Rs.2,82,070/-. Complainant   paid the final bill for Rs.2,65,156/- with an discount of Rs.16,915/-.

1.5 Finally on 27.02.2023 the O.P. No.1 rejected the health insurance reimbursement claim of the complainant on the ground that the complainant was a patient of D.M. (Diabetes Mellitus).   

1.6 Hence, the complainant filed this case before this commission for getting cashless benefit of his Insurance policy, compensation and litigation cost amounting to Rs.4,65,156/-.

2. The O.Ps submitted written objection on the ground that the complainant at the time of taking the Policy of insurance suppressed the material fact that he was patient of D.M. (Diabetes Mellitus). 

3. Both the parties submitted evidence and documents.

4. Hearing argument the following point is taken up for discussion and decision:-

 

DECISION AND REASONS FOR DECISION:-

5. Hearing argument and on perusal  of documents, we find that the O.Ps have not submitted the Proposal Form. As such vide order dated 02.02.2024 the O.P.s were directed to submit the proposal form so that we can ascertain whether the complainant suppressed  such fact of as alleged. 

5.1 Learned Counsel S. Chakraborty appearing for the O.Ps in his usual fairness submits that the proposal form could not be traced out inspite of their best endevour. Therefore, we are not in a position to conclude that the complainant suppressed any material fact at the time taking the policy. The stand of the O.P. has not been proved. 

6. The point is decided accordingly.

7. In the result,  the O.Ps are directed to pay sum of Rs.2,65,156/- i.e., the cost of the treatment to the complainant. This amount has to be paid within 30 days from today, otherwise it shall carry interest @ 7.5 % P.A. till the date of actual payment. 

8. The case stands disposed of.

9. Supply copy of this order free of cost to the parties. 

 

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.