West Bengal

Bankura

CC/47/2022

Tanmoy Banerjee - Complainant(s)

Versus

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

Jayanta Kumar Mukhopadhyay

03 Oct 2023

ORDER

  IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA

  Consumer Complaint No.47/2022

          Date of Filing:  28/12/2022

 

Before:                                        

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.

 

For the Complainant:Ld. Advocate Jayanta Kumar Mukhopadhyay

For the O.P: Ld. Advocate Mahadev Chakraborty

Complainant:

Tanmoy Banerjee, S/O Hiranmoy Banerjee, at Kenduadihi, District- Bankura, PIN-722 102    

                                                                                                                                    

Opposite Party:                                                                  

1.Star Health and Allied Insurance Co Ltd, Shri Balaji Complex No.15, White Lane, Whites Road, Royapettah, Chennai-600014

Registered Office No.1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai-600034

2. Branch Office: Star Health and Allied Insurance Co Ltd, 1^st Floor Patpur, Jail Road, Bankura, PIN-722 101                                                                                                                                   

3.SBI, Bankura Branch, represented by Branch Manager, Town Branch, Bankura- 722 101

4.BSMCH, Medical School, Kenduadihi, Bankura- 722 102

5. Christian Medical College Vellore, Private, Christian Community-run Medical School, Hospital and Research Institute, CMC, IDA Scudder Rd., Vellore, Tamil Nadu- 632 004                                                                                                               

 

 JUDGEMENT  

Dated:03-10-2023

The case is fixed for delivery of judgement.

                                                                                                                                                                                        Contd……p/2

Page: 2

The Complainant’s case is that he has a comprehensive mediclaim Insurance Policy with O.P. Insurance Company Policy No. being P/191136/01/2022/002781 valid from 15/09/2020 to 14/09/2021. The Complainant was admitted for treatment of Haemoptysis with other allied diseases at Christian Medical College, Vellore from 19/04/22 to 29/04/22 having incurred Rs.2,51,501/- as the medical expenses for the same. Accordingly the Complainant submitted the claim with the O.P. for reimbursement of the said amount along with all requisite medical papers and documents. But the claim was settled at Rs.1,53,229/- after deduction of Rs.98,272/-, out of which 99,629/- has already been paid to the Complainant keeping a balance amount of Rs.53,610/-. The Complainant has therefore approached this Commission for appropriate relief for recovery of entire claim amount.

O.P. contested the case by filing a written version contending inter alia that deduction has been made as per terms and condition of the Policy and for non availability of the supporting documents and as such the Complainant is entitled at best to Rs.53,610/-which is admissible in his case.

-: 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 under treatment and hospitalized at Christian Medical College, Vellore from 19/04/2022 to 29/04/2022 for his lung disease known as Haemoptysis and the deducted amount of Rs.98, 272/- all relate to investigation and diagnosis purpose. According to the terms and condition of the Policy investigation charges should also be included with medical expenses in case of treatment of the disease. The O.P. cannot deny the investigation charges as the Complainant has undergone medical treatment at the said Hospital.

However, in this case some of the tests and investigations do not relate directly to the medical treatment of the Complainant and so the Complainant is not entitled to get reimbursement of the entire deducted amount of Rs.98,272/- but on consideration of the related investigations and diagnosis charges the Complainant is entitled to get Rs.50,000/- out of total deduction of Rs.98,272/-. Thus the Complainant is entitled to get reimbursement of balance amount of Rs.53,610/- plus Rs.50,000/- as discussed above.

                                                                                                                                                                                        Contd……p/3

Page: 3

Ld. Advocate appearing for the O.P. has however made objection to the same but the Commission overrules the objection for the reasons as stated above.

The case therefore succeeds in part.

Hence it is ordered…….

That the case be and the same is allowed in part on contest but without cost.

O.P. Insurance Company is directed to pay to the Complainant Rs. (53,610/- + 50,000/-) totalling Rs.1,03,610/- within a 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       HON’BLE MEMBER