DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
SOUTH 24 – PARGANAS
AMANTRAN BAZAR, BARUIPUR, KOLKATA-700 144
C.C. CASE NO. 150 OF 2019
DATE OF FILING DATE OF ADMISSIO DATE OF FINAL ORDER
30.08.2019 13.09.20 16.03.2020
Present : President : Asish Kumar Senapati
Member : Jhunu Prasad
COMPLAINANT : Rathindra Nath Mitra of 2/3, Madhu Pati Block Mohan Garden, P.O. - Narendrapur, Dist. – South 24 Parganas, Pin – 700103, W.B. Phone No. – 9330036142.
O.P. No.1 : Sunil Kumar Saha, Agent Code No. BA0000014462, Ph. No. – 033-24254021 / 9831032767 of Star Health and Allied Insurance Co., Branch Office – Garia, F1-04A, 3rd Floor, 116, Briji Road, LP – 149/3, Garia, P.S. – Narendrapur, Kolkata – 700 084.
O.P. No. 2 : M/S Star Health and Allied Insurance Co., Branch Office – Garia, F1-04A, 3rd Floor, 116, Briji Road, LP – 149/3, Garia, P.S. – Narendrapur, Kolkata – 700 084.
For the Complainant : Ananda Banerjee, Advocate.
For the O.P. No.1 : None.
For the O.P. No.2 : Niraj Kumar Singh, Advocate.
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JUDGMENT
Sri Asish Kumar Senapati, President.
One Rathindra Nath Mitra (hearin-after referred to as the complainant) has filed the case against one Sunil Saha and M/S. Star Health and Allied Insurance Company Ltd. (hearin after referred to as the O.Ps.) praying for compensation alleging deficiency in service.
The sum and substance of the complaint may be stated as follows:
The complainant had an insurance policy under the O.P. No. 2 vide policy no. P/191125/01/2019/001241 for medical treatment and he paid total premium of Rs. 5,252/- vide receipt no. 1350001280 on 09.06.2018. The complainant admitted at Smile and Profile Dental Care Clinic, Mohamayatala, Garia, Hindustan More for his dental surgery and spent more than Rs. 1,00,000/- and was an indoor patient for more than one month. The complainant claimed Rs. 78,910/- from the O.P. No. 2 but unfortunately the O.P. No. 2 ignored the claim of the complainant in spite of the fact that the complainant paid insurance premium. It is also the case of the complainant that he purchased the medical Insurance policy through the O.P. No. 1 who is an agent of O.P. No. 2. The O.P. No. 2 assured the complainant that he would get expenses of dental surgery, medicines and also treatment carried out for any dental including examination, filling ,crowns, extraction of truth, excluding any form of cosmetic surgery and also assured that dental treatment unless necessitated due to accidental injuries and requiring hospitalization any form of cosmetic surgery. The complainant sent several letters to the O.P. No. 1 but no result. Hence, the complaint has been filed praying for compensation of Rs. 1,50,000/- against the O.Ps.
The case was admitted on 13.09.2019 and one Keya Mali, Ld. Advocate filed a petition dated 17.10.2019 praying for allowing her time for filing Vakalatnama and written version on behalf of O.P. No. 1 but ultimately no W.V. had been filed by O.P. No. 1. On 10.12.2019 Star Health and Allied Insurance Company Ltd. had been added as O.P. No. 2 and filed written version denying material allegations made out in the complainant contending that the O.P. No. 2 issued the insurance policy covering the complainant for a sum insured Rs. 1,00,000/- and the complainant claimed Rs. 78,910/- for reimbursement and medical expenses for dental treatment vide claim no. CAI/2019/191125/0157615 and it is the specific case of the O.P. No. 2 that the claim of the complainant has been repudiated in terms of exclusion clause No. 5 of the policy which runs thus “Dental treatment unless necessitated due to accidental injuries and requiring hospitalization any form of cosmetic surgery and / or implants” and repudiation letter was sent to the complainant on 01.09.2018. Therefore, the O.P. No. 2 has no deficiency in service. The O.P. No. 2 has prayed for dismissal of the complaint.
On the basis of the written version and the written complaint the following points are framed for proper adjudication of the case:
- Is the complainant a consumer?
- Has this forum jurisdiction to entertain the complaint?
- Have the O.Ps. any deficiency in service, as alleged by the complainant?
- Is the complainant entitled to get any relief, as prayed for?
Decisions with reasons
Point nos. 1 and 2:
The Ld. Advocate for the complainant submits that the complainant is a consumer as he hired service of the for consideration. It is urged that the complainant purchased medical insurance policy and his dental treatment was within the period of the policy.
In reply, the Ld. Advocate for the O.P. No. 2 has not submitted anything.
We have gone through the written version and written complaint, evidence of both parties and documents filed by both sides. On a careful consideration we find that the complainant had an insurance policy under the O.P. during the period of his dental treatment and the complainant paid premium for the said policy. Therefore, we have no hesitation to hold that the complainant is a consumer. We also find that the cause of action arose within the territorial jurisdiction of this forum and the claim amount is also within pecuniary limit of this forum. Hence, both the points are disposed of in favour of the complainant.
Point nos. 3 and 4:
Both the points are taken up to whether for the sake of brevity and convenience.
The Ld. Advocate for the complainant submits that the complainant spent more than Rs. 1,00,000/- for his dental treatment and he submitted the claim with the O.P. No. 2 vide claim no. CLI/2019/191125/0157615 on 22.08.2018. It is argued that the complainant claimed only Rs. 78,910/- by furnishing relevant medical papers and documents. He submits that the O.P. No. 2 repudiated the claim vide letter dated 04.09.2018 illegally and without any basis. It is contended that the complainant was treated by doctors of Smile and Profile Dental Care Clinic and his treatment was covered under the medical insurance policy. He submits that the O.Ps. may be directed to pay the claimed amount and compensation to the complainant.
In reply the Ld. Advocate for the O.P. No. 2 submits that the complainant was a policy holder of Senior Citizens Red Carpet Health Insurance Policy under Star Health and Allied Insurance Company Ltd. but his dental treatment was not covered under the policy. It is urged that the O.P. No. 2 has slightly repudiated the claim of the complainant vide letter dated 04.09.2018 as the treatment of the complainant is not covered under the policy vide exclusion clause no. 5 of the said policy and the company is not liable to make any payment in respect of any expense for dental treatment or surgery of any kind unless necessitated due to accidental injuries and requiring hospitalization. It is submitted that the dental treatment of the complainant was for multiple decayed teeth on both jaws as per prescription issued by Dr. Sougata Chowdhury of Smile and Profile Dental Care Clinic dated 18.04.2018. He contends that there was no accidental injury requiring hospitalization of the complainant for his dental treatment. He draws our attention to a decision reported in 2010 (10) SCC 567 wherein it has been held that “In a contract of Insurance, the rights and obligations are governed by the terms of the contract which have to be strictly construed, no exception can be made on the ground of equity (Para – 22)…………………………Words in an insurance contract, held, must be given paramount importance and interpreted as expressed without any addition, deletion or substitution”. He also draws our attention to another decision reported in 1999 (6) SCC 451, wherein it has been held that “The Insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the Insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the Insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein.”
We have gone through written complaint, written version, evidence of both sides and documents submitted by the both sides. We have gone through the decisions referred by the Ld. Advocate for the O.P. No. 2. Admittedly the complainant was a policy holder of Senior Citizens Red Carpet Health Insurance Policy under the Star Health and Allied Insurance Company Ltd. and he claimed a sum of Rs. 78,910/- from the O.P. No. 2 for medical reimbursement for treatment of his teeth. Admittedly the O.P. No. 2 received the claim and repudiated claim vide letter dated 09.04.2018. It is the case of the complainant that any kind of dental treatment is covered under the policy but it is the specific case of the O.P. No. 2 that the treatment received by the complainant was not covered under the policy as per exclusion clause no. 5 of the terms and conditions of the policy. We have gone through exclusion clause no. 5 of the policy wherein it is found that the dental treatment unless necessitated due to accidental injuries and requiring hospitalization, any form of cosmetic surgery and / or implants. Therefore, on a plaint reading of exclusion clause no. 5 of the policy it is clear that treatment for the decayed teeth and extraction of teeth is not covered under the policy. With due regard to the decision as referred by the Ld. Advocate for the O.P. no. 2 we have no hesitation to say that any contract of insurance rights and obligations are covered by the terms and contract which has been strictly construed, no explanation cannot be made on the ground of equity and insured cannot claim anything more than what is covered by the insurance policy. Therefore, we find that the O.P. no. 2 has rightly repudiated the claim of the complainant as dental treatment of the complainant was not covered under the terms and conditions of the policy. Therefore, we find that the complainant has failed to establish any deficiency in service on the part of the O.P.s and the complainant is not entitled to get any relief in this case.
In the result, the case fails.
Hence,
It is ordered,
That the complaint case be and the same is hereby dismissed exparte against the O.P. No. 1 without cost and dismissed on contest against the O.P. No. 2 without cost.
Let Copy of Final order be supplied to both parties/ their Agents/ Ld. Advocates free of cost as per rules.
The Final order also be made available in: www.confonet.nic.in.
Directed and corrected by me,
President
Member President
Today is fixed for delivery of final order.
Final order containing 6 pages is ready. It is sealed, signed and delivered in open forum.
It is ordered that,
That the complaint case be and the same is hereby dismissed exparte against the O.P. No. 1 without cost and dismissed on contest against the O.P. No. 2 without cost.
Let Copy of Final order be supplied to both parties/ their Agents/ Ld. Advocates free of cost as per rules.
The Final order also be made available in: www.confonet.nic.in.
