State Consumer Disputes Redressal Commission
United India Insu.Co.Ltd. vs Omprakash Gupta on 4 September, 2024
M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PLOT NO.76, ARERA HILLS, BHOPAL
FIRST APPEAL NO.393 OF 2020
(Arising out of order dated 12.12.2019 passed in Case.No.425/2018 by
District Commission, Jabalpur No.2.)
UNITED INDIA INSURANCE COMPANY LIMITED,
1415, RAJKIRAN BHAWAN, INFRONT OF HOTEL
SATYA ASHOKA, WRIGHT TOWN,
JABALPUR 482002 ... APPELLANT.
Versus
1. OM PRAKASH GUPTA,
R/O 506, DUTT RESIDENCY,
INFRONT OF RAILWAY STATION,
JABALPUR 482001.
2. PARAMOUNT HEALTH SERVICES & INSURANCE
T.P.A PRIVATE LIMITED,
PLOT NO.A 442 ROAD NO.28,
VAGLEY INDUSTRIAL ESTATE
THANE (WEST) 400604 .... RESPONDENTS.
BEFORE :
HON'BLE SHRI A.K.TIWARI, ACTING PRESIDENT
HON'BLE DR. (MRS.) MONIKA MALIK, MEMBER
COUNSEL FOR PARTIES :
Shri Ajay Kumar Pandey, learned counsel for the appellant.
None present for respondents.
-2-
ORDER
(Passed on .09.2024) The following order of the Bench was delivered by Dr.(Mrs) Monika Malik, Member :
This is an appeal by the opposite party no.1 / appellant - United India Insurance Company Limited (hereinafter referred to as 'Insurance Company') against the order dated 12.12.2019 passed by the District Consumer Disputes Redressal Commission, Jabalpur no.2 (for short 'District Commission') in complaint case no425/2018, whereby the District Commission has partly allowed the complaint filed by the complainant / respondent no.1.
2. Facts of the case in brief are that the complainant / respondent no.1 had obtained a medi-claim policy of Rs.3 lakhs from the Insurance Company. The complainant / respondent no.1 approached Sanjeevani Heart Hospital, Satana, District Nashik regarding his heart ailment for which he was admitted in the said hospital. Rs.1,41,500/- were spent as his treatment expenses and when he approached the Insurance Company regarding the payment of claim amount, the same was denied on the ground that the claim with regard to treatment under EECP-CAD treatment is not payable. He therefore, alleged deficiency in service against the Insurance Company.
3. The Insurance Company resisted the complaint and stated that the hospital in which the complainant / respondent no.1 had received treatment is not a registered hospital and -3- the complainant / respondent no.1 was treated by a homeopathic doctor who is not authorized to carry out the procedures for which the complainant / respondent no.1 was admitted. Quoting clause No.5.8 and 2.13 of the policy conditions, the Insurance Company denied payment of claim amount to the insured.
4. The District Commission partly allowed the compliant and directed payment of claim amount i.e. Rs.1,41,500/- alongwith compensation of Rs.10,000/- and Rs.5,000/- as costs within a period of two months. Hence, this appeal.
5. Heard.
6. Learned counsel for the Insurance Company argued that the District Commission has ignored the important aspect of the case that the Sanjeevani Hearts hospital Satana, where the complainant / respondent no.1 was treated is not a registered hospital. Also, he received the treatment from a homeopathic doctor who is not authorized to provide treatment regarding ACT and EECP-CAD. Despite that the District Commission has allowed the complaint and the impugned order therefore, deserves to be set aside.
7. We find that the District Commission vide impugned order after relying on the submissions of the complainant / respondent no.1 has observed that the claim regarding homeopathic treatment is covered under the insurance policy. However, the issue involved in the case was whether the ACT and EECP treatment regarding which claim was made could be given by the treating doctor in the matter or not. It was to be seen by the District Commission that whether the treating doctor was -4- authorized to carry out the above mentioned treatment and procedures considering his qualifications.
8. The District Commission has missed out to make an observation in aforesaid regard. The District Commission has thus not decided the matter in its correct perspective.
9. In view of the aforesaid, we deem it appropriate that the case be remanded back to the District Commission for decision afresh.
10. Parties are directed to appear before the District Commission on 07.10.2024
11. Record of the case be sent at the earliest.
12. The District Commission is expected to pass reasoned order on the point that whether the treating doctor was authorized to provide the treatment which was given to the complainant / respondent no.1 in his hospital.
13. The District Commission is directed to proceed further in the matter in accordance with law and decide the case as expeditiously as possible, but not later than six months from the appearance of the parties before it.
14. With the aforesaid observations and directions the appeal stands disposed of, with no order as to costs.
(A.K.Tiwari) [Dr.(Mrs)Monika Malik]
Acting President Member