DIST.CONSUMER DISPUTES REDRESSAL COMMISSION, KHURDA, BHUBANESWAR:

                                                -ooOoo-

C.C.CASE NO. 238/ 2019

Aditya Prasad Bhatta,  aged about 48years,

S/o- Prahalald Bhatta, Plot No.1625/ 2948, Firhsery Lane,

PO- Chintamaniswar, PS- Laxmisagar, Bhubaneswar,

Dist – Khurda, Pin – 751006

….     Complainant             

-Vrs.-

1. THE STAR HEALTH &  ALLIED INSURANCE

COMPANY LIMITED, 24, 1^st Floor,  SCR,  Bapuji Nagar, Bhubaneswar – 751009,

Dist : Khurda, Through the Branch Manager.

2. THE STAR HEALTH & ALLIED INSURANCE

          COMPANY LIMITED, Sri Balaji Complex, Whites Road,

Chennai – 600014, through the Managing Director.

3. The Sunshine Hospital, Laxmisagar Square, Cuttack-Puri Road,

Bhubaneswar, Pin -751006,

….     Opp. Parties 

For the complainant      :         Sri Brajaraj Sai (Adv.)

For the O.Ps 1 & 2        :         Sri D.P.Tripathy & Associates  (Adv.)

For the O.P.3                 :         Exparte

DATE OF FILING         :         19/08/2017

DATE OF ORDER        :         20/03/2023

ORDER

K.C.RATH, PRESIDENT

1.       This is an application U/s 12 of the C.P.Act, 1986.

2.       The complainant’s case in brief is that, the complainant had procured a medi-claim policy from the OPs bearing No. p/191211/01/2019/002523 and the said policy was valid from 12/06/2018 to 11/06/2019. Arpita  Bhatta, who is the daughter of the complainant was also a beneficiary under the policy. It so happened, during the policy period, i.e. on 26/04/2019, Arpita Bhatta became senseless and was admitted in Sunshine hospital. She was treated there for five days and discharged on 30/04/2019. The doctor who discharged her  diagnosed the disease as “Seizure  Disorder Dyselectrolytemia”. The complainant spent Rs.54,295/- for the purpose of  such treatment. He lodged claim before the OPs. But the OPs rejected the claim on the ground that it was an act of intentional self injury / self intentional injury.   Hence this complaint.

3.       On the other hand,  the OP.3  is  set exparte and the OPs 1 & 2  filed written version contending therein that,  the complainant has not approached this Commission in clean hand and suppressed the material facts to mis-guide the learned Commission. It is further contended by the OPs that,  although it is submitted by the complainant that Arpita Bhatta  was under treatment for “Seizure Disorder Dyselectrolytemia”.  But actually, she was treated for Para- suicidal behavior.  She was playing Blue whale game for which she sustained cut injury and was treated for that. The Insurance company shall not be liable to make any payment under the policy in respect of any claim, which is fraudulent in nature. In brief, it is contended by the OPs that as the complaint bears no merit, it is

liable to be dismissed with cost.   

4        Perused the materials on record. The discharge summary (Annexure-2)  clearly indicates that,  Arpita Bhatta  was treated for “Seizure Disorder Dyselectrolytemia”. The plea of the OPs that there is suspected hospitalization of medication intake,   due to which she got injury in her body, is not sustainable in the eye of discharge summary. Further, the plea that Arpita Bhatta was being treated for Para- suicidal behavior, is also not supported by any medical document. Since the complainant had procured medi-claim policy in which Arpita Bhatta was a  beneficiary, she was certainly entitled for medical expenses incurred for the treatment of her disease  called “Seizure Disorder Dyselectrolytemia”. Therefore, the complaint bears merit.  Hence it is ordered.

ORDER

The complaint is  dismissed exparte against the OP.3 and allowed on contest against the OPs 1 & 2.  The OPs 1 & 2 are    jointly & severally liable to pay the claim amount and as such, both the OPs 1 & 2 are directed to pay a sum of Rs.54,295/- (Rupees fifty-four thousand two hundred ninety-five) only  to the complainant.  Besides, the OPs 1 & 2 are directed to pay  compensation of Rs.10,000/-   (Rupees ten thousand) only  towards mental agony suffered by the complainant and a further sum of Rs.2000/-  (Rupees two thousand) only towards litigation expenses.  The order be complied with by the OP Nos. 1 & 2    within a period of  thirty days from the date of communication of this order,   failing which the complainant will be  at liberty to execute the order  against the OPs 1 & 2   in accordance with law.

The order is pronounced on this day the  20^th  March,  2023  under the seal & signature of the President and Member (W) of the Commission.

                                                                                      (K.C.RATH)    

                                                                                       PRESIDENT

 Dictated & corrected by me

          President                                                                                    

I agree                                                                            

(S.Tripathy)                                                                           

Member (W)                                                                                                                                                 

Transcribed by Smt. M.Kanungo, Sr.Steno