Rajasthan

StateCommission

A/1116/2014

United India Ins. Co. Ltd. Through Manager - Complainant(s)

Versus

Suresh Chand Kala S/o Late Sh. Gaindi Lal Kala - Opp.Party(s)

Shubham Arora

06 Oct 2015

ORDER

BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION,RAJASTHAN,JAIPUR BENCH NO.1

 

FIRST APPEAL NO: 1116 /2014

 

United India Insurance Company Ltd. Through Manager 140301-UII, B.O.I Jaipur Jangid Bhawan, M.I.Road, Jaipur.

 

Vs.

 

Suresh Chand Kala s/o Late Gaindilal Kala r/o House No.458, Kala Bhawan, Nataniyon ka Rasta, Chaura Rasta, Jaipur & ors.

 

Date of Order 6.10.2015

 

Before:

 

Hon'ble Mr.Vinay Kumar Chawla-Presiding Member

Mr.Liyakat Ali- Member

 

Mr. Sanjeev Arora counsel for the appellant

Mr. Mohit Gupta counsel for the respondent no.1

None on behalf of respondent no.2

 

2

 

BY THE STATE COMMISSION

 

This appeal has been filed against the judgment of learned DCF Jaipur First dated 10.10.2014 by which the complaint was allowed.

 

Brief facts giving rise to this appeal are that the complainant had taken a medical policy covering medical expenses of self, his wife and his daughter which was effective from 20.1.2011 to 19.1.2012. His wife had undergone treatment on 22.11.2011 to 27.11.2011 in Gautam Hospital and Research Centre and then from 27.11.2011 to 7.1.2012 in Bhagwan Mahaveer Psychiatric & De-addiction Centre, Jaipur. He had spent Rs. 9688/- and Rs. 37,983/- respectively on her treatment which he claimed under the policy. The TPA vide his letter dated 20.4.2012 informed the complainant that as per policy terms expenses related to all phychiatric and psychosomatic disorders are not payable. Hence this claim is not admissible. He was further advised to confirm the same from clause 4.6 of the medi claim policy. The complainant filed a consumer complaint and the opposite party no.1 defended the complaint on the ground that the complainant had not taken any treatment in the above hospitals. However, on the basis of evidence

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produced by the complainant the learned DCF came to the conclusion that claim was payable under the terms of the policy.

 

The learned counsel for the appellant has argued before us that the claim was not payable under clause 2.2 of the policy. The TPA had wrongly mentioned clause 4.6 in the rejection letter. The learned counsel for the complainant has argued that clause 4.6 relates to cost of spectacles and contact lenses, hearing aids which is not applicable here. Similarly he has also drawn out attention to another clause 4.6 which deals with expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician. He has further argued that clause 2.2 which the learned counsel for the company has referred relates to the Domiciliary hospitalisation. The learned counsel for the complainant further argues that the complainant's wife remained admitted first to the Gautam Hospital and Research Centre and then she was admitted to Bhagwan Mahaveer Psychiatric & De-addiction Centre, Jaipur. The complainant has produced discharge tickets of both the hospitals and the clause 2.2 is not applicable here.

 

We have heard both the learned counsels. On perusal of

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the record, we find that clause 4.6 on which the TPA has rejected the claim has no relevance in the present case. There are three policy covers available on record, in one policy cover clause 4.6 relates to cost of spectacles and contact lenses, hearing aids, in another relates to expenses on vitamins and tonics and in third cover clause 4.6 relates to convalescence, general debility or run-down condition etc. In none of the policy covers clause 4.6 mentions exclusion regarding the treatment of Schizophrenia. Similarly the clause 2.2 relates to Domiciliary hospitalisation which is not relevant here. In this case there is sufficient evidence to hold that complainant's wife remained admitted in the hospital and relevant documents were produced before the learned DCF.

 

Hence, we find no force in this appeal. The TPA has rejected the claim without any basis. The appeal is dismissed with cost of Rs.11,000/-. The order of the learned DCF may be complied with within one month from the date of this order.

 

(Liyakat Ali) (Vinay Kumar Chawla)

Member Presiding Member

 

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