The brief facts of the present case are that the complainant had health care policy vide master MAHAME0001,certificate No.MIB1466121000100 after paying premium from the respondents and same is valid from 17-09-2019 to 16-08-2020. The limit of the coverage of policy was Rs.1,00,000/-. On 31.12.2019, the complainant suffered from high grade fever shivering. Due to this critical condition, he got admitted in Raj hospital, Madlauda, Assandh Road, Panipat and remained there as indoor patient from 31.12.2019 to 06.01.2020. The doctor conducted various tests and X- ray etc. of the complainant. The complainant was given conservative treatment in conjunction with lab results, clinical history and other diagnostics evidence by competent as well as experience and qualified doctor. The complainant has spent Rs.98,760/- on his treatment. The complainant immediately informed the respondents about this fact through telephonically and as per direction of the respondents, the complainant also supplied original documents such as discharge summery, original bills and complete indoor papers of Raj hospital, Panipat to the concerned official/agent. It is pertinent to mention here that the concerned official /agent of the respondents also obtained signature of the complainant on few blank/ unfilled papers. The respondents assured the complainant his medical bills will be reimbursed within few days. After that the complainant contacted the respondents through telephonically with the request to reimburse his medical bills but previously respondents started to prolong the matter under one pretext or other. Thereafter on 21.07.2020. respondents repudiated the claim of the complainant without any sufficient cause or reason.  Due to this, the complainant has come to this Commission with the prayer to direct the respondents to reimburse the payment of medical bills i.e. amount of Rs.98,760/- alongwith interest @ 18% P.A. and compensation of Rs.50,000/- on account of mental pain and agony alongwith Rs.15,000/- as litigation expenses.

2.                Upon notice, respondents appeared and filed written statement taking preliminary objections regarding maintainability, jurisdiction, estoppal, locus standi, cause of action and suppression of true and material facts. It is submitted that the patient was diagnosed with enteric fever, UTI and Vomiting and diarrhea, got the treatment as allopathic conservative treatment from BAMS doctor which does not meet the criteria of insurance policy. The complainant has lodged the claim vide claim No.HRA0338794 with the office of the respondent insurance company and the said claim was dealt by J.D. Health Care Services, Kharar, District Mohali, Punjab for verification of the facts. The said care services has submitted the report and doctors Satinder Khatri of Raj Hospital Madlauda is a very non-cooperatives and he provided a improper statement. The said doctor is MD in Ayurvedic medicines. The said hospital has indoor lab facility and run by doctor and no pathologist available in the hospital. The said services submitted the observations as mentioned below:-

• No proper ICP were maintained in the Hospital, only four pages.
• Previously several cases have been investigated from this Hospital. In previous cases, format of all patients' bill is almost same, in all bills, parameter and usable utensils has been mentioned.
• Whole Vitals are written in a single stretch.
• No IPD and Lab Register, Tarrif List and Medicine purchasing invoice provided by the Hospital.
• Doctor is very non cooperative and he provides a improper Statement, As per Doctor Statement, patient admitted in the Raj Hospital, Panipat on dated 31.12.2019 and discharge on dated 06.01.2020.
• As per Doctor Statement, Qualification of Doctor is MD in Ayurvedic medicine.
• No pathologist available in the Hospital, Lab runs under supervision of treating doctor himself.

                   After receiving the report and documents by the competent authority has observed the report and documents and according to the terms and conditions of the policy, the treatment was given by BAMS doctor and the competent authority recommended that the claim of the claimant has declared repudiated as allopathic treatment was given to the complainant, which does not meet the criteria of condition of the policy of insurance. The said repudiation intimation was given to the complainant. So, the said claim was not payable under the terms and conditions of the policy and this fact is/was very much in the knowledge of the complainant. Hence, the answering respondents are not liable to pay any claim amount and prayed for dismissal of the present complaint.

3.                In order to prove the allegations of the complaint, the complainant has filed his sworn affidavit Ex.CW1/A and closed the evidence after tendering the following documents;

4.                On the other side, the respondents filed sworn affidavit Ex.RW1/A of Dr. Gurpreet Singh, Authorized Signatory of J.D. Health Care Services and affidavit Ex.RW2/A of Kathiravan. N. Senior Legal Executive of the Insurance Company and  closed the evidence after tendering the  document i.e. Reimbursement insurance claim verification report as Ex.R1.

5.                We have heard the arguments advanced by learned counsel for the parties and gone through the material on record thoroughly and carefully.

6.                The claim case of the complainant was got investigated by the insurance company from J.D. Health Care Services vide report Ex.R1 dated 25.02.2020. On perusal of this report, recommendation was made that claim may be repudiated as allopathic treatment given by BAMS Doctor which does not meet the criteria of insurance company. Only on the basis of this recommendation, the claim of the complainant was repudiated. No doubt, it is established from this report Ex.R1 that patient was remained admitted in Raj Hospital, Panipat from 31.12.2019 to 06.01.2020. Doctor made statement that his qualification was M.D. in Ayurvedic Medicine and hospital having indoor lab facility run by lab technician, doctor was very non-cooperative. As per treatment record Ex.C2 to Ex.C9 and Ex.C11 to Ex.C12, the insured patient was diagnosed with enteric fever, UTI and vomiting as well as diarrhea and insured patient was managed conservatively. As per discharge summary Ex.C4, the insured patient was admitted in hospital on 31.12.2019 and discharged on 06.01.2020. After treatment the hospital gave treatment bill Ex.C10 for Rs.98,760/- which was paid by the insured complainant. The treating hospital was duly registered with the authority of Haryana Government as per certificate Ex.C1. The complainant has filed his sworn affidavit Ex.CW1/A wherein he has reiterated all the assertions as made in the complaint.

7.                After discharge from the hospital, the insured complainant submitted his claim for reimbursement of Rs.98,760/- to the respondents. As already discussed vide reimbursement insurance claim verification report Ex.R1, the claim was repudiated as it was recommended that allopathic treatment given by BAMS doctor does not meet the criteria of the company. Keeping in view the nature of treatment and disease, even BAMS doctor was not barred to treat these diseases. Even BAMS doctor can conduct minor surgery and he can use allopathic medicine under his supervision and therefore the rejection of the claim of the complainant merely on the ground that doctor was not co-operative and he was having degree of M.D. Ayurvedic or BAMS doctor is not justified. Therefore, the repudiation of the claim of the complainant has not been justified by the respondents by evidence on record. Even Dr. Gurpreet Singh, Authorized Signatory of J.D. Health Care Services who investigated the matter has submitted his report Ex.R1 and in sworn affidavit Ex.RW1/A, he deposed that he was appointed by Royal Sundaram General Insurance Co. Ltd. with the direction to insurance claim verification pertaining to claim No.HRA0338794 of patient Virender Singh admitted on 31.12.2019 and discharged on 06.01.2020 with regard to verify the treatment record of Raj Hospital, Panipat which is run by Dr. Satinder Khatri. He submitted his report with the opinion on 25.04.2020 and suggested that claim may be repudiated as Allopathic treatment given by BAMS doctor which does not meet criteria of insurance company. The insurance company without applying its mind and on the basis of report of Dr. Gurpreet Singh, has repudiated the claim of the insured complainant. The respondents have produced affidavit of Kathiravan. N, Senior Legal Executive as Ex.RW2/A  who has deposed the facts as stated in the written statement. He also deposed that the report submitted by J.D. Health Care services that Dr. Satinder Khatri of Raj Hospital was very non-cooperative and he provided improper statement and said doctor was in M.D. Ayurvedic having indoor lab facility run by the doctor and no pathologist was available in the hospital. Hence, the statement of senior legal executive of the insurance company is also based on report Ex.R1. Therefore, the repudiation of the claim of the complainant by the respondents is totally unjustified and present complaint is liable to be accepted.  

8.                For the reasons recorded above, we allow the present complaint against the opposite parties/respondents and direct them as under;

1. To reimburse Rs.98,760/-(Rupees Ninety Eight Thousand Seven Hundred Sixty only) to the complainant as treatment expenses  alongwith interest @ 9% per annum from the institution of this complaint till realization.
2. To pay Rs.10,000/- (Rupees Ten Thousand Only) as compensation to the complainant for causing physical harassment and mental agony besides Rs.5,500/- (Rupees Five thousand five hundred only)  as litigation expenses.

9.                The compliance of order shall be made by the opposite parties/respondents within 45 days from the date of receipt of the copy of this order.

10.              Miscellaneous application(s), if pending, stands disposed off in terms of this order.

11.              This order be communicated to the parties free of costs and file be consigned to the record-room.