STATE CONSUMER DISPUTES REDRESSAL COMMISSION MADHYA PRADESH FIRST APPEAL NO. SC/23/A/19/1313 VIKAS SACHDEV PRESENT ADDRESS - MADHAV NAGAR, KATNI, DIST. KATNI,MADHYA PRADESH.

.......Appellant(s)

Versus STAR HEALTH & ALLIED INSU. LTD.

PRESENT ADDRESS - NR. MAA DURGA HOSPITAL, WONDER PLAY SCHOOL GALI, ADARSH COLONY, KATNI. 483501,MADHYA PRADESH.

STAR HEALTH & ALLIED INSU. LTD.

PRESENT ADDRESS - 1 NEW TECH STREET, VALLUWAR KOTTAM, HIGH ROAD, LUNGAMBACKAM, CHENNAI 600034,MADHYA PRADESH.

.......Respondent(s)

BEFORE:

HON'BLE MRS. JUSTICE SUNITA YADAV , PRESIDENT HON'BLE MRS. DR. MONIKA MALIK , MEMBER FOR THE APPELLANT:

VIKAS SACHDEV FOR THE RESPONDENT:

STAR HEALTH & ALLIED INSU. LTD.

DATED: 05/01/2026

ORDER

M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO. 1313 OF 2019

(Arising out of order dated 18.06.2019 passed in C.C.No.22/2017 by District Commission Katni)

VIKAS SACHDEVA,

S/O SHRI NARAYANDAS SACHDEVA,

R/O MADHAV NAGAR, KATNI (M.P.) … APPELLANT.

Versus

1. STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED THROUGH OFFICER-IN-CHARGE, NEAR MAAN DURGA HOSPITAL, WONDER PLAY SCHOOL GALI, ADARSH COLONY, KATNI (M.P.)

2. STAR HEALTH & ALLIED INSURANCE CO.LTD.

THROUGH OFFICER-IN-CHARGE, 1, NEW TAKE STREET, VALLUVAR KOTAM, HI ROAD, LUNGAMBAKAM, CHENNAI-600 034 …. RESPONDENTS.

BEFORE :

HON’BLE JUSTICE SUNITA YADAV : PRESIDENT HON’BLE DR. MONIKA MALIK : MEMBER COUNSEL FOR PARTIES :

Shri Mohan Chouksey, learned counsel for the appellant.

None for the respondent no.1 None for the respondent no.2.

O R D E R

(Passed On 05.01.2026)

Per Say Justice Sunita Yadav, President:

The appellant/complainant has filed this appeal against the order dated

18.06.2019 passed by the District Consumer Disputes Redressal Commission, Katni (for short ‘District Commission’) in C.C.No.22/2017 whereby complaint filed by him has been dismissed.

2. In short, the facts of the case are that the complainant/appellant had obtained Family Health Optima Insurance -2-

Policy for himself and his family for coverage of Rs.4,50,000/-. On 30.05.2016 during medical check-up it was found that the complainant's wife was suffering from Breast Abscess and on 11.07.2016 admitted in Breach Candy Hospital, Mumbai for treatment. Despite request, the opposite party-insurance company did not provide cashless facility for treatment to the complainant. The complainant incurred Rs.2,90,815/- in treatment of his wife and on claim being made, the opposite party- insurance company paid only Rs.1,00,000/- to the complainant. It is submitted that against the claim of Rs.12,775/- only Rs.511/- were paid. Again on 17.10.2016 his wife was admitted in hospital situated at Mumbai in which he incurred Rs.97,384/- out of which Rs.82,300/- were paid. The complainant therefore alleging deficiency in service on part of the opposite party-insurance company filed a complaint before the District Commission seeking relief of Rs.2,18,163/- incurred as treatment expenses along with compensation and costs of Rs.65,000/-.

3. The opposite parties-insurance company in their reply before the District Commission admitted that the complainant and his family got insured under the Family Health Optima Insurance Policy with them and denied the allegations made in the complaint. It is submitted that the complainant's wife was suffering from breast abcess and this fact was suppressed by her and the complainant at the time of taking insurance policy. The insurance company paid a sum of Rs.1,00,000/- to the complainant and rest amount was not paid as the complainant had obtained the policy by suppressing the pre-existing disease of his wife. Since the complainant has filed the present complaint for enhancement of amount and therefore the complaint is not maintainable before the District Commission.

4. The District Commission dismissed the complaint holding that the present dispute is with regard to quantum dispute and such disputes are not maintainable before the District Commission.

5. Learned counsel for the comp