Orissa

Cuttak

CC/96/2022

Dr Asit Kumar Sethi - Complainant(s)

Versus

Managing Director,Star Health Allied Insurance Co Ltd - Opp.Party(s)

S Satapathy & associates

27 Mar 2024

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C.No.96/2022

 

Dr. Asit Kumar Sethi,

S/o: Late Arjun Sethi,Plot No.936,

Mahanadivihar,Cuttack-753004,

Odisha.                                                                                      ... Complainant.

 

          Vrs.

 

1.     The Managing Director,

Star Health and Allied Insurance Company Ltd.,

Regd. and Corporate Office:1,New Tank Street,

Valluvar Kottam High Road,Nungambakkam,

                Chennai-600034

 

2.     The Zonal Manager,                                 

    Star Health and Allied Insurance Company Ltd.,

Plot No.23 E,Ashok Nagar,Janpath,Bhubaneswar-751009.

 

3.     The Branch Manager,

Star Health and Allied Insurance Company Ltd.,

Plot No.1677(P)/1678(P), Holding No.608,2^nd Foor,

Gajanan Complex(Dolamundai),

                 P.O:Buxibazar,Cuttack-753001.                                                    ...Opp.Parties

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    19.05.2022

Date of Order:  27.03.2024

 

For the complainant:         Mr. Srinibash Satpathy,Adv.  & Associates.

For the O.Ps              :         Mr. R.C.Sahoo,Advocate.

 

Sri Debasish Nayak,President.                                          

Case of the complainant bereft unnecessary details as made out from the complaint petition in short is that the complainant had availed a Family Health Optima Insurance Policy from the O.P company on 7.3.2015 vide policy No.P/191211/01/2022/015761.  He had paid the premium alongwith GST to a total of Rs.24,149/-. Being renewed from time to time it was effective from 9.3.2022 to 8.3.2023 which covered the complainant, his wife and his minor son with an assured amount of Rs.5,00,000/- right from the date of obtaining the policy uninterruptedly.  The son of the complainant having high fever was admitted to Shanti Memorial Hospital at Cuttack on 13.4.2021 and was treated there as an indoor patient till he was discharged.  A bill amount of Rs.1,10,000/- was raised there towards the treatment and medicine including investigation reports, bed-charges etc.  But inspite of the health insurance policy coverage, the O.Ps had not paid the said amount for which the complainant was compelled to pay the same from his pocket on 20.4.2021.

          That apart, Dr. Sudha Sethi, the wife of the complainant having tested Covid-19 positive was also admitted to the said Shanti Memorial Hospital at Cuttack on 13.4.2021 and had undergone treatment there as an indoor patient till she was discharged on 20.4.2021.  The treatment expenses of Dr. Sudha Sethi, the wife of the complainant was of Rs.1,22,000/- and the said bill amount was paid by the complainant when the O.Ps had not paid the same inspite of the insurance policy coverage for her also.  Thus, the complainant after failing to get the cashless insurance coverage towards the medical treatment of his wife and son has come up with his case before this Commission after issuing legal notice to the O.Ps on 9.4.2022.  The complainant through his complaint petition has claimed from the O.Ps the total hospitalisation expenses as incurred and paid by him to the tune of Rs.2,32,000/- alongwith a sum of Rs.50,000/- towards his mental agony and further a sum of Rs.20,000/- towards his litigation expenses.  He has also prayed for any other order as deemed fit and proper.

2.       The O.Ps have conjointly filed their written version here in this case wherein they have stated that the case of the complainant is not maintainable which is liable to be dismissed.  According to them, both the patients who are son and wife of the complainant, have undergone medical treatment at Shanti Memorial Hospital of Cuttack but against the Clinical Guidelines of the Management of Covid-19 and the said hospital authorities should have been made a party in this case.   As such, according to the O.Ps, the complaint petition is hit by the principles of non-joinder of necessary parties.  According to the O.Ps, both the son and wife of the complainant should have managed to remain under home isolation and care particularly when the complainant and his wife both are doctors by profession.  Due to the health policy, the complainant had got both  his wife and son admitted at a private hospital to set the liability on the O.Ps and had managed to procure inflated bills in order to derive insurance benefits.  The O.Ps had repudiated the health insurance claim of the complainant since because as per the guidelines of the Ministry of Health & Family Welfare, Govt. of India and AIIMS,New Delhi.  The patients with mild symptoms need not to admitted to hospital rather, should be on self-isolation at home.  Contrary to such guidelines, the complainant had admitted his wife and son in a private hospital for which the claim when made was repudiated by the O.Ps.  The O.Ps ofcourse have admitted about the insurance policy of the complainant covering his wife and son but the contention of the O.Ps is that the complainant has admitted his wife and son at a private hospital contravening the guidelines issued for Covid-19 by the Govt of India and AIIMS as well.   It is for the said reason they have prayed for dismissing the complaint petition as filed.

          Together with their written version, the O.Ps have annexed copies of several documents in order to prove their stand.

          The complainant has filed his evidence affidavit and the same when perused, it appears to be a reiteration of the contents of the complaint petition.

          Similarly, O.P no.1 has filed evidence affidavit through Purnendu Kumar Rath,Zonal Manager on behalf of all the O.Ps here in this case but the contents of the evidence affidavit of the said Purnendu Kumar Rath appears to be a reiteration of the written version of the O.Ps and nothing else.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.Ps?

iii.        Whether the complainant is entitled to the reliefs as claimed by him?

Issue no.II.

Out of the three issues, issue no. ii being the pertinent issue is taken up first for consideration here in this case.

After perusing the complaint petition, the written version, written notes of submission from both sides, evidence affidavit as filed from both sides as well as the copies of documents available in the case record, it is noticed that admittedly the complainant Dr. Asit Kumar Sethi, his wife Dr. Sudha Sethi and minor son Adweja Raj who were covered under the health insurance policy as obtained by the complainant from the O.Ps and the same was in force.  Both the wife and son of the complainant fell ill and were admitted to Shanti Memorial Hospital at Cuttack on 13.4.2021 where they were treated as indoor patients and were discharged on 20.4.2021.  It is also not in dispute that a bill amounting to Rs.1,10,000/- was raised towards the hospitalisation charges and medical expenses of the minor son of the complainant whereas an amount of Rs.1,22,000/- was raised towards the hospitalisation charges and medical expenses of Dr. Sudha Sethi, the wife of the complainant.  The claims of the complainant were repudiated by the O.Ps alleging that both the hospitalisations were against the guidelines of the Govt. of India as well as the AIIMS.  To substantiate such repudiation as made, the O.Ps have filed copy of such guidelines as issued by the Ministry of Health & Family Welfare,Govt. of India dated 17.5.2021 vide Annexure-C.  According to such guidelines, a Covid-19 patient suffering from mild disease was to be treated as home isolation and care where as the Covid-19 patient of moderate disease was to be admitted in the ward and in case of severe disease of Covid-19, the patient is to be admitted in the Intensive Care Unit(ICU).  Here in the present case, as it is noticed that the O.Ps have not filed any scrap of document so as to apprise this Commission that infact Adweja Raj, the son of the complainant and Dr. Sudha Sethi the wife of the complainant were having mild Covid-19 for which they should have been kept under home isolation instead of preferring to be admitted in the hospital.  As it appears and admitted by both the parties of this case that both Adweja Raj &  Dr. Sudha Sethi were admitted to Shanti Memorial Hospital at Cuttack  as indoor patients with effect from  13.4.2021 where they have remained till 20.4.2021 as indoor patients.  But the Govt of India guidelines was issued on 17.5.2021 and nowhere it is reflected therein that the same guideline is to be having any retrospective effect.  That apart, when there is no document on record  being filed by the O.Ps to show that if both Adweja Raj &  Dr. Sudha Sethi were having mild covid-19 and they should have been kept under home isolation,  the allegation as brought by the O.Ps do not hold good and rather the allegations made that being doctors, the complainant had managed to hospitalise his doctor wife and son in a private hospital and had procured inflated medical bills  in order to gain from the Insurance Policy, appears to be ridiculous and against the ethics.  Thus, this important issue goes in favour of the complainant.

Issues no.i & iii.

Having no other way out, when the legitimate claim of the complainant was repudiated whimsically, arbitrarily and unilaterally, the complainant has approached this Commission and as such the case of the complainant is definitely maintainable and he is entitled to the reliefs as claimed by him from the O.P here in this case.  Hence it is so ordered;

ORDER

The case is decreed on contest against the O.Ps who are found to be jointly and severally liable here in this case. The O.Ps are thus directed to pay the complainant the hospitalisation charges to the tune of Rs.2,32,000/- alongwith interest thereon @ 12% per annum from the date claim i.e. 20.4.2021 till the final payment is made. The O.Ps are also directed to pay a sum of Rs.50,000/- to the complainant towards compensation for his mental agony and harassment as caused to him as well as to pay a sum of Rs.20,000/- towards cost of his litigation.  This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on this the 27^th day of March,2024 under the seal and signature of this Commission.         

                                                                                      

                                                                                      Sri Debasish Nayak

                                                                                              President

 

 

                                                                                          Sri Sibananda Mohanty

                                                                                                      Member