Haryana

Ambala

CC/71/2012

SANCHIT VASHISHT - Complainant(s)

Versus

M/S NATIONAL INSURANCE CO,LTD. - Opp.Party(s)

R.K SINGH

28 Feb 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 71 of 2012

                                                          Date of Institution         : 29.02.2012

                                                          Date of decision   : 01.03.2017

 

          Sanchit Vashisht age 20 years S/o Sh. Sandeep Kumar Vashisht R/o House      No. 2528, Bangali Mohalla, Ambala Cantt.    

                ……. Complainant.

 

1. M/s National Insurance Company Limited Divisional Office, 106, Railway road, Ambala Cantt through its Divisional Manager.
2. M/s Medsave Healthcare (TPA) ltd, SCO 121-122-123, Second floor, Sector-34A, Chandigarh, 160034.

 

                  ….…. Respondents.

 

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER                             

 

Present:       Sh. R.K. Singh, counsel for complainant.

                   Ms. S. Rashmi Sharma, counsel for OP.  

 

ORDER:

 

                   In nutshell, brief facts of the present complaint are that the complainant took insurance policy from OP No. 1 at Ambala Cantt under their medi-claim Insurance Scheme vide policy No. 420400/48/11/8500000035 and paid premium was paid to OP No. 1. The complainant took this policy for the year 26.04.2011 to 25.04.2012. further submitted that the complainant met with an accident 27.08.2011 near King Fisher Tourist Complex, Ambala, Chandigarh highway Indica Car hit the complainant from the back side and the complainant got face injuries, then the complainant was shifted to Civil Hospital, Ambala Cantt, then after first aid, the complainant was shifted to the hospital of Nagpal Dental Clinic, Ambala Cantt for dental treatment, when the complainant remained hospitalized from 27.08.2011 to 19.09.2011 and paid Rs. 10,500/- to Dr. Nagpal. Further submitted that the complainant submitted all the relevant paper to OP No. 1 but OP No. 2 repudiated the claim of the complainant by referring clause No. 4.7 of the policy. It is pertinent to mention here that at the time of taking of the policy the OP No. 1 never disclosed any terms and condition to the complainant, nor the copy of the terms and condition was supplied to the complainant, even otherwise the OP illegally repudiated the claim of the complainant. Hence, the present complaint.

2.                Upon notice, OP appeared and filed written statement submitting that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of clause 4.7, dental treatment or surgery of any kind unless requiring hospitalization. FIR is produced, even a letter dated 27.09.2011 sent to Sandeep Kumar Vashisht father of Sanchit Vashisht who was the policy holder to provide the details of accident, MLC, FIR Specify the associated injuries and treatment provides infrastructure of hospital provide bill, breakup under Rs. 10,500/- but no reply or document was ever submitted. The claim of the complainant is repudiated by referring clause no. 4.7 of the policy condition in which it specifically mentioned that “all dental treatment unless requiring hospitalization are excluded vide exclusion clause No. 4.7 of the policy”

3                 To prove his version complainant tendered his affidavit as Annexure C-X along with documents as annexure C-1 to C-7 and close his evidence. On the other hand, counsel for the Ops has also tendered affidavit as Annexure RW1-A alongwith documents as Annexure R-1 to R-3 and close his evidence.

4.                We have heard counsel for the parties and carefully gone through case file. It is admitted by the OP that the complainant has obtained the medi-claim insurance policy for the period of 26.04.2011 to 25.04.2012 from them. The case of the complainant is that  he met with an accident on 27.08.2011 got injuries including fractures in the front teeth.  To prove his case, complainant has placed on record OPD Slip dated 27.08.2011 of General Hospital, Ambala Cantt as Annexure C-2,  statement of father of complainant Sh. Sandeep Vashistha ( Annexure C-3) whereby he has stated that His son  was hit by an Indica Car from back side and fell down in which he had faced injuries  and he was taken to civil hospital from where he was relieved after an hour treatment. After recovery of stitches now he had dental treatment because in accident  three front teeth were damaged. He has also placed on record document Annexure C-4 and C-5 which are bill of Rs.10,500/- for root canal treatment and summary of diagnose/treatment at  Nagpal Dental Clinic, Ambala Cantt  whereby it is revealed that  the complainant has been treated as on OPD basis. Whereas on the other hand, the case of the OP company is that patient admitted with the case of fracture front teeth. Dental Treatment not covered.  Hence, repudiation of the claim of complainant was made under clause 4.7 (Root Canal Treatment). Counsel for OP has drawn our attention towards  policy document Annexure R-1 EXCLUSION CLAUSE: The company shall not be liable to make any payment under  this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of: ‘Dental treatment of surgery of any kind unless requiring hospitalization.’

                   After hearing learned counsel for the parties and going through the record placed on file, we are of the view that complainant has never remained admitted in the Nagpal Dental Clinic for treatment and thus the complainant has miserably failed to prove his case qua hospitalization. Accordingly, we find that the OP has rightly repudiated the claim of complainant and thus the complaint being devoid of  merits stands dismissed with no order as to costs. Copy of the order be sent to the parties concerned, as per rules. File after due compliance be consigned to record room.

Announced on: 01.03.2017                                  (D.N. ARORA)

                                                                                       President

 

    

     (PUSHPENDER KUMAR)

                                                                                       Member