To-day is fixed for admission hearing.
Ld. Advocate for the complainant files hazira.
Heard the Ld lawyer. Perused the complaint and the documents thereto.
The case of the complainant, in brief, is that they took family medicare policy 2014 valid for 05.05.2015 to 04.05.2016. Complainant No. 2 had undergone an operation on 11.03.2016 in Sir Gangaram Hospital, Delhi, after consulting with Dr. Dewan and Dr. Jain both of whom found 03rd & 08th tooth impacted. Nowhere in the discharge certificate is there the word which spells “TOOTH”.
Her wisdom tooth was invisible and it may be one of causes of cyst in gum. There may be other reasons for cyst than the tooth as well. ON the belief that it is not tooth problem itself, the complainant applied for insurance claim of Rs. 1,36,670/-. But the OP No. 3 repudiated the claim on the basis of clause 4.8 of the policy on 30.03.2017 commenting that dental treatment not due to accident is excluded from the scope of the policy. The complainant submitted a petition on 29.05.2017 to review the claim to OP No.1 but no reply so far.
On the ground that gum is not tooth and invisible inner tooth, below the gum was removed as a safety measure during operation of cyst, the complainant lodged a grievance petition to the Insurance Ombudsman on 25.07.2017 but the Ombudsman rejected the petition by his order dtd 21.06.2019 which the complainant received on 15.07.2019. Hence the case.
P.T.O
Consumer Case No. 44/S/2019.
A perusal of the case reveals the following:-
- The discharge certificate issued by Sir Gangaram Hospital, Delhi does not mention any word which spells “TOOTH” but it speaks of “molar” which means grinding tooth and “canine” which means incising tooth or incisor.
- Gum is not tooth but is the firm flesh at the bases of the teeth physiologically. The complaint of the patient and diagnosis of the doctor is different from each other. The complainant felt pain in gum/jaw but operation was for cyst enucleation with extraction of canine (incising tooth) and third molar (grinding tooth).
- Clause 4.8 does not speak of patient’s complaint, rather, dental treatment or surgery (to be done by doctor). Clause 1.2.1 provides for hospitalization less than 24 hrs. as admissible, whereas, the complainant No.2 had to remain in hospital for more than 24 hrs.
From the perusal above, this Forum find no merit in the application and hence is not admitted.
The case filed by the complainant is not against the e-mail order dtd. 21.06.2019 of the Ombudsman and the Ombudsman has not also been a party to the case. The interest has been claimed from the date (12.03.2016) following the day of operation (11.03.2016). So it is a fresh case and complainant’s asking for repudiation letter or filing review petition is not the cause of action. However, the complainants have enclosed another petition with the main application asserting that there has been no delay in filing the instant complainant but contradictorily prayed to the Forum to condone the delay if the Forum think so. Sec. 24A(2) of the C.P. Act transpires that it is the complainant who has to satisfy the Forum that he had sufficient cause for not filing the complainant within the limitation period. Moreover the basis of condonation is not the thinking of the Forum.
Further, the proviso to sec. 24A(2) categorically provides that no condonation prayer shall be entertained unless the Forum
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Consumer Case No. 44/S/2019.
record its reason for condoning such delay. In such circumstances the Forum has to record the assertion of the complainant in Para- 13 of the main application as quoted, i.e., no reason of condonation.
Hence this petition also is rejected.
