Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that Opposite Party No.2 has availed a corporate policy no.40630908 for their employees, which is valid till 31.03.2023. Complainant was working with Opposite Party No.2 as an A.M. Member and ID of the complainant was 0000131417. On 05.12.2022, the complainant met with an accident and she got multiple injuries on face, right eye and upper teeth, the accident was reported in various newspapers of 06.12.2022. Thereafter the complainant was admitted in Divine Care Hospital, Moga Road, Galoti, Tehsil Dharamkot, District Moga on 05.12.2022. The doctor at the above said hospital Diagnosed her for multiple injuries and the doctors after completing treatment referred her to eyes specialist and dental surgeon. Thereafter she approached to Dr.Nitin Gupta, who performed surgery for rooted broken teeth due to trauma and extraction and was discharged on 13.12.2022. The complainant spent Rs.52,906/- on her treatment. After discharge from the hospital, the complainant sent scanned bills and other documents to Opposite Party No.1, through email for reimbursement, but the Opposite Party No.1 repudiated the claim of the complainant by describing it as a claim for fever vide their email dated 06.02.2023 and when they were informed that this is a case of accident and not fever, then vide email dated 24.06.2023, Opposite Party No.1 informed that dental benefits are not covered under the policy. The complainant also issued a notice dated 24.06.2022 to Opposite Party No.1, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.52,906/- as medical expenses and Rs.8000/- as compensation for absent days from duty alongwith upto date interest @ 18% p.a. from the date of claim.
b) To pay Rs.2,00,000/- as compensation and damages.
c) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Party No.1 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable as the complainant has attempted to misguide and mislead this Commission; the present complaint filed by the complainant with mala-fide intention and has not come before this Commission with the clean hand; the claim of the complainant does not fall within the purview of the Insurance as granted by the replying opposite party, hence the complainant is not entitled for any claim under the policy; intricate question of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and the other party should have to cross examine the witnesses and the matter involved in this case cannot be decided in summary manner and the complainant, if so advised, may approach the Civil Court; the complaint is false, frivolous and vexatious in nature; the complainant is estopped from filing the present complaint by his own acts, conduct, omissions and acquiescence; the complainant has tried to challenge the veracity of decision of the opposite party to repudiate the claim. The Company has repudiated the claim under the said policy by a speaking order, which lists out the specific reasons for the decision. By no stretch of imagination the said decision can be brought under the umbrella of 'Deficiency in Services'; the complainant is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified monies from the Opposite Party and hence the complaint deserves to be dismissed in limine; this Commission has no jurisdiction to entertain the present complaint. The complainant has failed to demonstrate any deficiency in service on the part of the Opposite Party. In the present case, the Opposite Party has strictly acted as per the terms and conditions of the policy contract. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. This Forum cannot pass any order in contravention to the terms and conditions of the policy contract; the insurance is a contract of utmost good faith and that the contract of insurance is based on Doctrine of Uberrima Fides and even if any due diligence is done by the insurance company, it does not change the basic element of an insurance contract; the complainant has sought relief on the basis of allegations which are not supported by any documentary evidence to substantiate the same. Therefore, the complaint does not deserve any consideration by this Commission; there is no deficiency in service rendered by the opposite party in the present case, and the opposite party is not a necessary or a proper party to present dispute.
Further averred that the replying opposite party company issued a Group Mediclaim Insurance Policy with plan name of "Group Care 360" bearing Group Policy No. 40630908 covering 34,103 primary members with 99,227 dependents, for the policy period of 01-04-2022 till 31-03-2023 for sum insured of Rs.8,525,774,113. Believing the information and details provided by the Proposer including the medical history to be true and correct in all respect and giving due credence to the under writing norms of replying opposite party Company, a Policy issued. The copy of Schedule bearing relevant details of the Policy along with policy bond having terms and conditions were duly sent and delivered to the Proposer. Further, no assurance was given to the Complainant beyond the terms and conditions of the Policy. Policy kit containing all relevant documents was duly delivered to the Complainant from time to time, thereby giving an opportunity to the Complainant to verify and examine the benefits, terms and conditions of the Policy taken by the Complainant. The Complainant never approached the replying Opposite Party Company stating that any information given in the Policy Schedule was incorrect. The replying opposite party received a Reimbursement Claim for the hospitalization of the complainant at DC Hospital, Kot- Ise- Khan from 03-122022 till 13-12-2022 because of the injuries she suffered in a fatal accident. Upon receipt of the claim, along with the submitted documents, the case was analysed and it was not registered only due to Dental Benefit not covered- Claim does not fall under permanent partial disablement benefit criteria or any other benefit criteria as per policy terms and conditions. Averred that information given by the proposer about the proposed insured in the Proposal Form in case of Insurance forms the foundation of contract of insurance between the Proposer/Insured and the Insurance Company. Averred further that the claims are paid by any Insurance Company out of the common pool of funds belonging to all policyholders of the Company which makes it obligatory upon the Insurance Company to check the genuineness and admissibility of each claim before honoring it in the larger interest of all the policy holders. The Insurance Company cannot do injustice to genuine policyholders by allowing inadmissible claims. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. Upon service of notice, none appeared on behalf of Opposite Party No.2, hence Opposite Party No.2 was proceeded against exparte.
4. In order to prove his case, the complainant has placed on record Ex.C1 to Ex.C9 and her affidavit Ex.C10 and copy of document Ex.C11.
5. On the other hand, Opposite Party No.1 has placed on record affidavit of Smt.Shruti Saxena, Authorized Signatory of Care Health Insurance Co. Ltd. Ex.OPs1/1 alongwith copies of documents Ex.OPs1/2 to Ex.OPs1/6.
6. We have heard the ld. counsel for both the parties and also gone through the record.
7. It is not disputed that Opposite Party No.2 i.e. Indusind Bank Ltd. availed a Corporate Policy bearing no.40630908 covering their employees and complainant was duly insured under the said policy. It is also evident on record that complainant met with an accident and got multiple injuries and got admitted in D.C. Hospital, Kot-Ise Khan on 05.12.2022 and thereafter was discharged on 13.12.2022. There is no denial of the fact that the claim lodged for the reimbursement of expenses incurred by the complainant on her treatment has been declined and thus, complainant was forced to file the present complaint.
8. Now, the moot question to be decided is that whether the claim of the complainant has genuinely been declined by Opposite Party No.1 or not?
9. Perusal of the record reveals that due to fall in the road side accident, the complainant was got admitted in D.C. Hospital, Kot-Ise Khan on 05.12.2022, where after been treated for her external injuries pertaining to eyebrow and upper & lower lips, she was referred to dental surgeon for further dental treatment. Also it is well evident on record that complainant as per advise of the treating doctor took her treatment from Dr.Nitin’s Dental Clinic & Implant Centre on 14.12.2022. After being treated from the hospital, complainant raised the bills amounting to Rs.52,906/- with Opposite Party No.1, but they failed to pay the claim of the complainant on the ground that ‘Dental benefit is not covered in policy’. In support of their assertions, ld. counsel for the Opposite Party No.1 has referred Permanent Exclusion no. 2(44) of the policy terms and conditions, which is as under:-
Dental, Orthodontics, Periodontics, Endodontics or any preventative dentistry no matter who gives that treatment.
In our concerted opinion the ground as well as the exclusion clause so relied upon by Opposite Party No.1 for declining the claim of the complainant is wrong and unjustified as the same is well covered under the policy terms and conditions no.8 under the heading Optional Benefit 8: Dental Care (on OPD basis) under the heading ‘Accidental Damage to natural teeth following the Accident’, the contents of same are reproduced as under:-
“The Company will indemnify up to the amount specified in the Certificate of Insurance, for the initial treatment required immediately within thirty (30) days following damage to natural teeth caused by an accident and provided the Insured has been covered under the policy since before the accident happened.
10. Perusal of the record reveals that when the alleged accident occurred, the complainant was admitted for treatment at D.C. Hospital on 05.12.2022 (Ex.C6) and under the effect of Local Anaesthesia stitching on her right eyebrow and upper and lower lips (Inside) done. It is further evident that treating doctor at D.C. Hospital further referred the complainant to Dr.Nitin Gupta for further dental treatment and accordingly complainant took her treatment from Dr.Nitin Gupta on 14.12.2022. From the record available, it transpires that complainant availed the medical treatment under medical exigency occurred due to road side fall only and not on account of any treatment taken by choice for any cosmetic purposes. So, from the above, we are of the view that the exclusion/condition so referred above by Opposite Party No.1 is not maintainable and denial of the present claim on that ground is unjustified and not legal. Also the policy terms and conditions in question do cover the case of the complainant as per condition no.8 as referred above.
11. It is also pointed out by ld. counsel for the Opposite Party No.1 that complainant has raised his claim by mentioning the bills pertaining to hospitalization period from 05.12.2022 to 13.12.2022 and has not claimed bill so, issued by Dr. Nitin’s Dental Clinic & Implant Centre. In our considered opinion the contention of Opposite Party No.1 is not effective for the reason that in her claim form Ex.OPs1/4, under the heading ‘Details of the treatment expenses’ claimed it is duly mentioned against the column Hospitalization Expenses Rs.29,406/- and against the Column Post Hospitalization Expenses Rs.23,500/-, the said amount is duly mentioned in the bill dated 05.01.2023 issued by D.C. Hospital, Kot-Ise-Khan as Dentist Bill. Hence, the complainant has rightly claimed the amount of Rs.52,906/-.
12. From the discussion above, we partly allow the present complaint and direct Opposite Party No.1 to pay an amount of Rs.52,906/- (Rupees Fifty Two Thousand Nine Hundred Six only) to the complainant. Opposite Party No.1 is also directed to pay compository costs of Rs.10,000/-(Rupees Ten Thousand only) as compensation to be paid to the complainant for causing mental and physical harassment and for thrusting litigation. Complaint against Opposite Party No.2 stands dismissed. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite Party is further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission