Date of Filing:13.07.2009<br /> Date of Order:21.11.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> <br /> Dated: 21ST DAY OF NOVEMBER 2009<br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> <br /> COMPLAINT NO: 1639 OF 2009<br /> <br /> T. Vishwanathan,<br /> “Anugraham”,<br /> 22-Kaveri Street,<br /> Basavanagar,<br /> Bangalore-560 037. Complainant<br /> <br /> V/S<br /> <br /> 1. The Divisional Manager,<br /> M/s United India Insurance Company Ltd., <br /> No. 198, Manjunatha Complex,<br /> II Floor, CMH Road, (Near Double Road)<br /> Indiranagar, Bangalore 560 038,<br /> <br /> 2. Chief Executive Officer,<br /> M/s TTK Healthcare Services Pvt. Ltd.,<br /> (TPA of Ms. United India Insurance Company Ltd)<br /> No. 7, Jeevan Bhima Nagar Main Road,<br /> HAL III Stage,<br /> Bangalore-56-075. Opposite Party<br /> <br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed by the complainant stating that, the complainant has taken treatment with Dr. Salahuddin of Dental Diagnostic Centre, Richmond road, Bangalore to his teeth on the left side of the mouth and submitted the required mediclaim documents including the original x-ray along with the claim request to TTK Health Care Services Pvt. Ltd., as early on 07/03/2009 who is the TPA for United India Insurance Company Limited. Before submitting the claim, he has visited TTK Health Care Services at Jeevan Bima Nagar and consulted with Dr. Nagabhooshan Rao over telephone who in turn informed him that it does not need any hospitalisation. Based on that he has submitted the claim and accordingly the claim department of TTK Health Care Services accepted his claim and also promised him that within 21 working days his claim will be settled. Since he could not get any communication from TTK Health Care Services even after a month, he tried to contact, but he could not get a proper reply. Even after lapse of three months, he could not get a proper reply about his claim. He requested Mr. Somashekar, Development Officer of United India Insurance Company Limited to assist him in getting the claim at the earliest. But to his surprise he has been informed by Mr. Somashekar that his file is rejected wherein no reason has been told and till now he has not received any communication from TTK Health Care Services till date in this regard. The complainant has reported this matter to the Divisional Manager, United Insurance Company Ltd., Indiranagar vide e-mail on 3rd June 2009. But he could not get any reply from this officer. Hence the complainant prayed to direct the opposite parties to settle his claim of Rs. 19,400/-. <br /> 2. Notice was issued to opposite parties through RPAD. Notice was served. The opposite party appeared through Advocate and filed defence version stating that the opposite party had issued an individual health insurance policy bearing No.072500/48/08/97/000000147 for personal health insurance. It is submitted that as per the contract of insurance the coverage is given to the complainant on the policy conditions, in which it is specifically narrated the nature of treatment and place of treatment etc. Admittedly the complainant had taken treatment in a clinic which does not come under the definition of hospital/nursing home as defined hereinabove at 2.1 of the policy conditions. As such the complainant became ineligible for the claim. He has not been treated or admitted in a hospital as per the definition clause 2.1. Therefore, the claim rightly came to be rejected by the opposite party No.2. The rejection of the claim made by the opposite parties itself does not amount to deficiency of service and the complainant cannot claim on that ground, when the same is justified. If at all a claim which is not eligible all futile efforts made by the complainant to make it eligible can not be considered as harassment and deficiency of service. Hence, the allegation made by the complainant is baseless and not sustainable. The averments made in complaint are incorrect and complainant is not entitled for any amount of compensation much less to the tune of Rs.19,400/-. The claim is not maintainable either in law or on facts. Hence, the opposite party prayed to dismiss the complaint. <br /> 3. Affidavit evidence and documents filed. I have gone through the pleadings of parties, documents and affidavit evidence. Complainant has not engaged the Advocate. He personally argued his case and argument of learned Advocate for the opposite party filed. Heard the arguments. <br /> 4. In the light of the arguments advanced before us following points arise for consideration:<br /> 1. Whether the opposite party has committed deficiency in service?<br /> <br /> 2. Whether the repudiation of the claim by the opposite party is justified?<br /> <br /> 3. Whether the complainant is entitled for Rs.19,400/-?<br /> <br /> REASONS<br /> 5. It is an admitted case of the parties that the complainant has taken individual insurance policy from the opposite party. The policy period was from 25/05/2008 to 24/05/2009. Policy has been produced. The sum assured is for Rs.1,25,000/-. The complainant has paid premium amount of Rs. 5,377/-. It is the case of the complainant that, it is a renewed policy. The complainant has stated in his complainant and affidavit that on 16/02/2009 while he was entering the bathroom in the early morning stepped on a piece of soap and slipped in the bathroom and fallen and got damaged to his teeth on the left side of mouth. He had taken treatment from Dr. Salahuddin of Dental Diagnostic Center, Richmond Road, Bangalore. He had submitted claim with opposite party and unfortunately claim has been rejected. The opposite party has taken defence that claim is not admissible on the ground that he was not admitted and treated in the hospital as per the clause 2.1 of policy conditions and terms. As per the policy terms and conditions Rule 1.1 during the continuance of the policy, any insured person sustains any injury through accident the company has undertaken to pay the amount of the expenses incurred in respect of such injury. The conditions of policy that hospitalisation for minimum period of 24 hours is not applicable to this case. Because this time limit is not applicable to dental surgery, eye surgery, radiotherapy, kidney stone removal etc., under Rule 2.3. Therefore, the opposite party company cannot take defence that there was no hospitalisation of the complainant for a minimum period of 24 hours, because dental surgery is excluded from that rule. Under Rule 3.1 relevant medical expenses incurred during the period up to 30 days prior to hospitalization of disease/illness/injury sustained will be considered as part of claim. In this case, the complainant has stated in the affidavit that he had fallen in the bathroom due to slip and sustained injuries to his teeth and taken treatment at Dental Diagnostic Center, Richmond road, Bangalore. The Doctor has given letter stating that patient name Mr. Vishwanathan, aged 58 years, had came to his clinic on 16/02/2009, and taken following treatment. <br /> 1. Root Canal treatment <br /> 2. Extraction and <br /> 3. FPD in relation to left posterior teeth. <br /> <br /> The patient was billed for Rs. 19,400/-. The certificate of Dr. Salahuddin, Orthodontist, supports the case of complainant because, the complainant also stated in his affidavit and in his pleading that he fell on the bathroom due to slip and sustained injuries to his left side teeth and taken treatment in Dental Diagnostic Centre. The Doctor has also given certificate that the complainant has taken treatment in relation to left posterior teeth and also extraction of teeth. The Certificate confirms the case of the complainant. Therefore, when the complainant has sustained injuries in the unfortunate accident and that led him to take treatment and Doctor has billed for Rs. 19,400/. The opposite party is bound to pay the claim amount. Taking into consideration of all the facts and circumstances of the case, the repudiation of the claim on the part of opposite party is not justified. Consumer Protection Act is a social and benevolent legislation intended to protect better interest of the consumers. In a given case if two interpretations are possible, it is well settled principle of law that an interpretation which is favourable to the consumer shall be given effect. The complainant being a consumer under the C.P Act, his interest deserves to be protected by ordering the opposite party to pay the claim amount. The repudiation of the claim in this case amounts to deficiency in service on the part of the opposite party. Therefore, the points taken for consideration are answered in favour of the complainant. In the result, I proceed to pass the following: <br /> ORDER<br /> 6. The complaint is allowed. The opposite party is directed to pay Rs.19,400/-, the claim amount to the complainant within 30 days from the date of this order. In the event of non compliance of the order within 30 days the above amount carries interest at 9% p.a. from the date of this order till payment/realisation.<br /> <br /> 7. The opposite party is directed to send the amount to the complainant directly by way of D.D or Cheque with intimation to this forum. <br /> <br /> 8. Send the copy of this Order to both the parties free of costs as statutory requirements. <br /> <br /> 9. Pronounced in the Open Forum on this 21ST DAY OF NOVEMBER 2009. <br /> Order accordingly,<br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> MEMBER MEMBER<br /> rhr.,<br /> <br />