DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA.<br /> <br /> CC.No.260 of 24.09.2009<br /> Decided on 17.03.2010<br /> Komal aged about 14 minor D/o Inderjeet S/o Sant Ram, resident of 122/3, MES Colony, near Bibi Wala Chowk, Bathinda, through natural guardian (father).<br /> .........Complainant.<br /> Versus<br /> 1. Bajaj Allianz Life Insurance Company Limited Macmet House 5th floor 10B, O.C Ganguly Sarani, Kolkata 700020, through its Managing Director/GM/President.<br /> 2. Branch Manager Bajaj Allianz Life Insurance Company Limited, Bathinda.<br /> 3. Medicare T.P.A. Services (I) Pvt. Ltd., 6 Bishop Lefroy Road, Paul Mansion, Kolkata, through its M.D./GM/Chairman.<br /> ........Opposite parties.<br /> <br /> Complaint under Section 12 of the Consumer Protection Act, 1986.<br /> <br /> QUORUM<br /> <br /> Smt. Vikramjit Kaur Soni, President.<br /> Dr. Phulinder Preet, Member<br /> Sh. Amarjeet Paul, Member.<br /> <br /> Present:-<br /> For the Complainant : Sh.Ashok Gupta, counsel for the complainant.<br /> For Opposite parties : Sh.M.L.Bansal, counsel for opposite parties No.1&2.<br /> Opposite party No.3 already exparte.<br /> ORDER<br /> <br /> VIKRAMJIT KAUR SONI, PRESIDENT:-<br /> 1. In brief, the facts of the complaint are that father of the complainant purchased a mediclaim insurance policy No.0120184653 for his daughter, wife and himself for Rs.1,00,000/- each for family health care valid from 12.02.2009 to 11.02.2010. The opposite parties did not issue any original policy to the complainant, only cards were issued to them. The opposite parties also did not issue any guidelines/details or conditions about policy. Unfortunately, the complainant while playing fell down on ground and suffered grievous injuries in her mouth and she was taken to doctor on 03.04.2009 and after checkup, the doctor told parents of the complainant that upper denture has been fractured and 5-6 teeth on the lower jaw are also in a critical condition. It would take atleast one month time to set right the fractured denture and teeth. Thereafter, the parents of the complainant met the opposite party No.2 who assured the father of the complainant about passing the claim immediately after submission of the bills. The complainant took the treatment and paid Rs.28,300/- for her treatment and got the bills and certificate from the doctor and those sent to the opposite party No.2 for the payment of her claim but the opposite party No.2 did not release her claim rather a letter dated 14.07.2009 was received from opposite party No.3 in which it was mentioned that claim has been repudiated as entire treatment had been done on OPD basis and patient had not been admitted as per policy norms. Therefore, this case would stand repudiated. There is deficiency in service on the part of opposite parties and therefore, the complainant has pleaded that the opposite parties be directed to pay Rs.28,300/- as cost of treatment with interest @ 18% P.A. alongwith compensation to the tune of Rs.60,000/- on account of mental harassment suffered by the complainant and her parents.<br /> 2. The opposite parties No.1&2 filed joint reply and pleaded that after investigation and as per claim submitted by the complainant, entire treatment has been done on an OPD basis and the patient has not been admitted in the hospital as per terms and conditions of the policy, the claim is not payable, only those claims are payable where 24 hours continuous hospitalization is necessary. So, there is no deficiency in service on the part of opposite parties and the complaint is liable to be dismissed.<br /> 3. In order to prove his allegations complainant filed his own affidavits dated 17.11.2009 & 24.09.2009 Ex.C-1 & Ex.C-22 and also brought on record photocopy of claim repudiation letter dated 14.07.2009 Ex.C-2, photocopy of letter dated 28.07.2009 Ex.C-3, photocopies of identity card of Bajaj Allianz Insurance Co. Ex.C-4 to Ex.C-6, photocopies of certificate dated 28.07.2009 & 03.04.2009 Ex.C-7 & Ex.C-9, photocopy of claim form Ex.C-8, photocopies of payment receipt Ex.C-10 & Ex.C-16 to Ex.C-21 and photocopies of prescriptions Ex.C-11 to Ex.C15.<br /> 4. To controvert the evidence of the complainant, opposite parties filed affidavit of Sh.Shailesh Singh Addl.D.M. dated 26.10.2009 Ex.R-1 and also brought on record photocopy of Register letter control Ex.R-2, photocopy of terms and conditions of policy Ex.R-3 and photocopy of Insurance Policy Ex.R-4.<br /> 5. Arguments heard. The complainant has purchased mediclaim policy vide Ex.R-4 in which his wife, daughter and he himself were insured for the benefits of Rs.1,00,000/- in case of illness/disease or injury sustained. The said policy was purchased by the complainant on 17.12.2009. Daughter of the complainant got injured while she was playing, on 03.04.2009. After examining her the doctor informed the complainant that upper denture has been fractured and 5-6 teeth on the lower jaw are also in a critical condition and it would take one month time to set right the fractured denture and teeth of the girl. The complainant took the treatment and paid Rs.28,300/- to the doctor vide Ex.C-16 to Ex.C-21receipts of the payment made to the doctor. After getting the treatment, she has submitted all the documents for reimbursement of the claim to the opposite party Nos.1&2, but the opposite parties did not make any payment and repudiate the claim as per clause 1(i) of Bajaj Allianz Family Care First. It is reproduced as under:- “If Hospitalization is due to one of the following illnesses/procedures/group of illnesses for more than 24 continuous hours, then the Company shall reimburse 95% of the Medical Expenses incurred towards those illnesses/procedures/group of illnesses, subject to a maximum reimbursement limit per Member in a Policy Year.” Whereas in the instant care clause 1(iii) is applicable to the complainant which is reproduced below:- “The Hospitalization requirement for more than 24 hours continuous hours shall not apply if the Hospitalization has taken place due to following 125 day care procedures as mentioned below and in such case, the Company shall reimburse the expenses in the same manner.” At serial No.122 i.e. “Dental surgery due to Accident” does not require hospitalization in addition to it, even in Exclusions clause i.e.clause 6 (f) is reproduced below:-<br /> “Any dental care or surgery of cosmetic nature, extraction of impacted tooth/teeth, orthodontics or orthognathic surgery, or Temporomandibular joint disorder except as necessitated by an Accidental injury.” It is specifically mentioned that dental care as necessitated by an accidental injury is not excluded. <br /> 6. In view of the above terms and conditions of the policy, the decision of opposite parties for repudiating the claim of the complainant is not lawful. Hence, there is deficiency in service on the part of opposite parties. Thus, the complainant is entitled to the payment of the expenditure incurred by complainant's father for her treatment. Therefore, this complaint is accepted with Rs.3,000/- as cost and Rs.10,000/- for mental harassment and Rs.28,300/- as actual expenditure incurred by her father on her treatment. The opposite parties are directed to comply with this order jointly and severally within 30 days from the date of receipt of copy of this order.<br /> 7. The copy of this order be sent to the parties concerned free of cost and file be consigned for record.<br /> <br /> <br /> Pronounced (VIKRAMJIT KAUR SONI)<br /> 17.03.2010 PRESIDENT<br /> <br /> <br /> (DR. PHULINDER PREET)<br /> MEMBER<br /> <br /> <br /> ` (AMARJEET PAUL)<br /> MEMBER <br /> <br /> <br />