Orissa

Cuttak

CC/253/2023

Jayjit Mohanty - Complainant(s)

Versus

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

K Nayak & associates

13 Aug 2024

ORDER

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

C.C.No.253/2023

Jayjit Mohanty,

S/o: Biswajit Mohanty,

116,Madhukunj,Station Square,

Bhubaneswar,

At present At: Old College Lane,

Nimchouri,P.S:Lalbag,Dist:Cuttack.                                 ... Complainant.

 

          Vrs.

 

1.       Managing Director,

Star Health & allied Insurance Co. Ltd.,

Sri Balaji Complex,No.1,New Tank Street,

Valluvar,Kottam High Road,

                     Nungambakkam,Chennai-600034.

 

2.        Branch Manager,

Star Health & allied Insurance Co. Ltd.,

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

Gajanana Complex,(Dolamundai),

                  P.O:Buxibazar,Town/Dist:Cuttack.                                  ...Opp.Parties

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    28.07.2023

Date of Order:  13.08.2024

 

For the complainant:             Mr. K.K.Nayak,Adv. & Associates.

For the O.P                :             Mr. R.C.Sahoo,Adv. & Associates.

 

Sri Debasish Nayak,President

 Case of the complainant as made out from the complaint petition in short is that he had obtained Health Insurance policy from the O.Ps for himself and his family members vide policy no.11230201049501 where the sum assured was of Rs.50,00,000/- and it was effective from 22.10.2022 to 21.10.2023.  As the complainant had wanted to be treated for his Maxillary cyst/tumour for which he had requested the O.Ps for cashless treatment as they were the insurers of his insurance policy but the same was rejected by the O.Ps with an observation that he had undergone dental treatment which is not admissible as per the Exclusion Clause of the insurance policy.  In this context, when the complainant further contacted his treating physician Akash Sachdev who is a Maxillofacial Surgeon, he clarified that the complainant is having a tumour at the right maxillary jaw which has nothing to do with dental procedure and no dental implant is planned. The surgery advised was peripheral osteotomy followed by enucleation and excisional biopsy was advised under GA.  After getting such clarification from the treating physician, the complainant again had contacted the O.Ps but his request was again turned down by the O.Ps.  The complainant thereafter had undergone treatment by spending from his own pocket.  He had deposited a sum of Rs.5,25,000/- at the Max Health Care Superspeciality Hospital,Saket at New Delhi and had also spent about Rs.2,50,000/- for other miscellaneous expenses for his treatment in the said hospital where he was from 9.5.2023 to 12.5.2023.  After being discharged from the hospital, the complainant has come up with his petition before this Commission claiming that he was treated for Maxillary Cyst/tumour which is not a dental issue and thus he has prayed before this Commission through his petition seeking direction to the O.Ps to reimburse Rs.5,25,000/- alongwith another sum of Rs.10,00,000/- for loss of reputation.  He has further prayed for a sum of Rs.5,00,000/- for his mental agony and sufferings and also another sum of Rs.5,00,000/- for his travelling and boarding expenses.

          Together with his complaint petition, the complainant has annexed copies of several documents in order to prove his case.

2.       The O.Ps have contested this case and have filed their joint written version wherein they have stated that they had received pre-authorization request from Max Superspeciality Hospital at New Delhi for cashless treatment of maxillary cyst/tumour  of the complainant through letter dated 8.5.2023.  The O.Ps had requested the Hospital authorities to provide diagnostic/clinical reports of the complainant.  In response to their such letter, the prescriptions dated 2.5.23, 4.5.23 and 6.5.2023 were issued from the said hospital which were scrutinized and it was noticed that the said treatment was excluded under the Exclusion clause-32 of the said policy.  It is for the said reason, on 9.5.23 the request for cashless treatment of the complainant was rejected.  Through the written version, the O.Ps have urged that the complainant had not added the said hospital as a party to this case. According to the O.Ps, the Maxillary Cyst/tumour treatment is a dental problem/dental disease caused due to infection of the maxillary sinuses and is related to problems with drainage and thus the said treatment falls under the Exclusion clause-32 of the Insurance policy as obtained by the complainant of this case.  Accordingly, they have prayed through their written version to dismiss the complaint petition as filed by the complainant.

          Together with their written version, the O.Ps have also annexed copies of several documents including copy of the said insurance policy.

          The O.Ps have also filed evidence affidavit through one Purnendu Kumar Rath working as Regional head in the O.P Company and when the contents of the evidence affidavit of the said Purnendu Kumar Rath is perused, it is noticed to be a reiteration of the contents 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.P, 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 is 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.

On perusal of the complaint petition, written version, written notes of submission as filed from both the sides, evidence affidavit filed from the side of O.Ps  as well as the copies of documents available in the case record, it is noticed that infact the complainant had obtained a Health Insurance policy from the O.Ps which covered himself and also his family members.  The sum assured therein was of Rs.50,00,000/-.  It is not in dispute that the said policy was inforce when the complainant had undergone treatment for his Maxillary Cyst/tumour at Max Health Care Superspeciality Hospital of Saket at New Delhi where he was treated from 9.5.2023 to 12.5.2023.  It is the contention of the O.Ps that the treatment of Maxillary Cyst/tumour is a dental disease for which the insurance claim regarding cashless treatment when made on behalf of the complainant, it was rejected by them.  In this contention, the O.Ps have urged that as per the Exclusion clause-32, the treatment of Maxillary Cyst/tumour is a dental problem which do not cover as per the terms and conditions of the insurance policy taken by the complainant.  Per contra, while scrutinizing the copies of documents as filed on behalf of the complainant in this case, it is noticed that Annexure-6 is a copy of the mail sent by Dr. Akash Sachdev, Maxillofacial Surgeon having registered no.A-2043.  In the said mail, the said Dr. Akash Sachdev had categorically mentioned that “we would like to bring it to your kind notice that the pathology in the right maxilla which could be a cyst or tumour and has nothing to do with dental procedure & no dental implant is planned.”  It is not in dispute that Dr. Akash Sachdev, the Maxillofacial Surgeon was the treating physician of the complainant at Max Health Care Superspeciality Hospital of Saket at New Delhi.  Moreso, the O.Ps have not challenged about the contents of Annexure-6 as filed by the complainant nor had they made any endeavour to cross examine the said Dr. Akash Sachdev, the Maxillofacial Surgeon who had treated the complainant of this case.  Admittedly, the O.Ps being insurers are not technically expert persons to opine and hold regarding which ailments will fall into which category, rather, it is the doctor who is an expertised person qualified in that score to opine about the same.  Thus, the contention of the O.Ps that treatment of Maxillary Cyst/tumour is a dental problem which falls under the exclusion clause-32 of the insurance policy does not hold good here.  Such arbitrary act of the O.Ps clearly signifies their sinical attitude with  defiant motives to repudiate the bonafide claim of the complainant in this way or the other and nothing else.  It is for this, considering the facts and circumstances of this case in mind and taking into consideration all the copies of documents available in this case, this Commission arrives at an irresistible conclusion that the repudiation of the genuine insurance claim of the complainant as made by the O.P here in this case appears to be an arbitrary and unilateral action and is sheer non-application of proper mind which also signifies deficiency of service on the part of the O.Ps and  also indicates that they had practised unfair trade.  Accordingly, this issue goes in favour of the complainant.

Issues no.i & iii.

From the discussions as made above, the case of the complainant is definitely maintainable and he is thus 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 a sum of Rs.5,25,000/- to the complainant towards his hospital charges with immediate effect.  The O.Ps are also directed to pay the complainant an amount of Rs.2,00,000/- as compensation for his mental agony and harassment including his litigation expenses.  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 13^th day of August,2024 under the seal and signature of this Commission.         

                                                                                      

                                                                                      Sri Debasish Nayak

                                                                                              President

 

 

                                                                                          Sri Sibananda Mohanty

                                                                                                      Member