BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.
Complaint Case No.202 of 2019.
Date of institution: 12.07.2019.
Date of decision:22.02.2022.
Sukhbir age about 35 years S/o Prem Singh R/o near Bus Stand Village Dhand, District Kaithal, Tehsil and District Kaithal.
…Complainant.
Versus
- Star Health and Allied Insurance Company Ltd., SCO 94, First Floor Sector-17, Back Side of Silver Sand Kurukshetra-136118.
- Star Health and Allied Insurance Company Ltd., SCO No.101, 102, 103, Second Floor, Batra Building, Sector 17-D, Chandigarh-160017.
- Amit Chaudhary Baba Ji Enterior and Decorater near Asha Ram Bapu Ashram R.K.Puram Colony Gaushala Road, Kaithal, Mob.No.9017554000, 7876534184 Email-Mituchaudhary89@gmail.com.
….Respondents.
Complaint under Section 12 of the Consumer Protection Act
CORAM: DR. NEELIMA SHANGLA, PRESIDENT.
SMT. SUMAN RANA, MEMBER.
SH. RAJBIR SINGH, MEMBER.
Present: Sh. Vikram Singh Nain, Advocate, for the complainant.
Sh. P.P.Kaushik, Advocate for the respondents.No.1 & 2.
Respondent No.3 exparte.
ORDER
DR. NEELIMA SHANGLA, PRESIDENT
Sukhbir-Complainant has filed this complaint under Section 12 of Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the respondents.
In nutshell, the facts of present case are that the complainant has taken a family health optima insurance plan from the respondents vide policy No.P/211123/01/2019/003204 dt. 20.12.2018 till 19.12.2019 of limit covering 5 lakhs and recharge benefit of Rs.1.5 lakhs through Op No.3. This family health insurance plan covers complainant, his wife Sonia Rani and his sons namely Dig Vijay and Vishavveer. The case of complainant is that on 03.03.2019 the son of complainant namely Vishavveer was admitted in Sunder Hospital Kurukshetra with Dr. Anil Walia, MBBS with the diagnosis ACUTE BRONCHITES. Complainant has submitted all the receipts and bills etc. regarding this treatment but the respondents have rejected the claim of complainant stating that the treatment of the insured was done by BAMS Doctor. The bills/receipts clearly show that the treatment record was duly signed by Dr. Anil Walia, MBBS. So, it is a clear cut case of deficiency in service on the part of respondents and prayed for acceptance of complaint.
2. Upon notice, the respondents No.1 & 2 appeared before this Commission, whereas respondent No.3 did not appear and was proceeded against exparte vide order dt. 17.01.2020 of this commission. Respondents No.1 & 2 contested the complaint by filing their written version raising preliminary objections with regard to locus-standi; maintainability; cause of action; that the complainant has concealed the true and material facts from this commission. The true facts are that Sukhbir after completely understanding the terms and conditions of their product FAMILY OPTIMA INSURANCE PLAN covering Sukhbir-self, Sonia Rani-Spouse, Digvijay & Vishaveer, dependant children had submitted the duly signed proposal form and offered to pay Rs.15,287/- yearly towards the initial premium against the sum insured of Rs.5,00,000/- and upon receiving the proposal form, the policy in question was issued. The answering respondents received the claim intimation dt. 20.03.2019 and after scrutiny of the claim records towards reimbursement of medical expenses of Rs.9665/-, it was observed that the claim of complainant falls in the first policy year and treatment record/investigation report are signed by Dr. Satinder Singh Saini, BAMS practitioner, who prescribe allopathic medicines. All the medical treatment record provided by complainant bears seal and signatures of Dr. Satinder Singh Saini BAMS which clearly confirms that insured patient was treated under Allopathic medicine for which a BAMS Doctor is not authorized and qualified. Hence, the claim of complainant was rightly repudiated by competent authority as per terms and conditions of policy and the same was communicated to the complainant vide letter dt. 31.03.2019. There is no deficiency in service on the part of respondents. On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.
3. To prove his case, learned counsel for the complainant tendered into evidence affidavit Ex.C1 alongwith documents Anneuxre-C2 to Annexure-C14 and thereafter, closed the evidence on behalf of complainant.
4. On the other hand, learned counsel for the respondents No.1 & 2 tendered into evidence affidavit Ex.RW1/A alongwith documents Annexure-R1 to Annexure-R11 and thereafter, closed the evidence on behalf of respondent No.1 & 2.
5. We have heard the learned Counsel for both the parties and perused the record carefully.
6. It is argued by Sh. Vikram Singh Nain, Adv. for the complainant that the complainant had taken a family health optima insurance plan from the respondents vide policy No.P/211123/01/2019/003204 dt. 20.12.2018 till 19.12.2019 of limit covering 5 lakhs and recharge benefit of Rs.1.5 lakhs through Op No.3 and complainant duly paid Rs.15,287/- to the respondents. It has been further argued that this family health insurance plan covers complainant, his wife Sonia Rani and his sons namely Dig Vijay and Vishavveer. It has been further argued that on 03.03.2019 the son of complainant namely Vishavveer was admitted in Sunder Hospital Kurukshetra with Dr. Anil Walia, MBBS with the diagnosis ACUTE BRONCHITES. Complainant has submitted all the receipts and bills etc. regarding this treatment but the respondents have rejected the claim of complainant stating that the treatment of the insured was done by BAMS Doctor.
Sh. P.P.Kaushik, Adv. for the respondents No.1 & 2 stated that the objection was taken by the company that Dr. Anil Walia and Dr. Satinder Singh Saini are practicing jointly in the hospital while Dr. Anil Walia is M.B.B.S. and Dr. Satinder Saini is B.A.M.S.
7. Dr. Anil Walia is the signatory of discharge report vide Annexure-R5. Dr. Anil Walia, M.B.B.S. is competent to allopathic give treatment to the patient Vishavveer as claim is filed through his father Sukhbir. Annexure-R11 is the details of the bill assessment sheet to the tune of Rs.9665/-, while Annexure-R5 is the discharge summary which is signed by Dr. Anil Walia, M.B.B.S. and Dr. Satinder Singh Saini, B.A.M.S.
8. Thus, as a sequel of above discussion, the respondents No.1 & 2 are directed to pay Rs.9665/- to the complainant Sukhbir alongwith interest @ 6% p.a. w.e.f. due date till its actual realization within two months. In default, this amount shall carry a penal interest of 9% p.a. Hence, this complaint is accepted accordingly. A copy of said order be sent to the parties free of cost. File be consigned to record-room after due compliance.
Announced in open court:
Dt.:22.02.2022.
(Dr. Neelima Shangla)
President.
(Rajbir Singh), (Suman Rana),
Member. Member.
Typed by: Sanjay Kumar, S.G.
