Chandigarh

DF-II

CC/672/2021

P.S.BEDI S/O N.S.BEDI - Complainant(s)

Versus

The Natinal Insurance Company. - Opp.Party(s)

In Person.

17 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	672 OF 2021
Date  of  Institution	:	08.10.2021
Date   of   Decision	:	17.05.2023

 

 

 

 

P.S.Bedi s/o Sh.N.S.Bedi, aged 71 years, resident of House No.1154, Sector 8-C, Chandigarh.

            …..Complainant

 

Versus

1]  The National Insurance Company through its uthorised officer, Mumbai Corporate Regional Office, 2^nd Floor, 14 Jamshedji Tata Road, Churchgate, Mumbai 400020

2]  The Heritage Health Insurance TPA 506, 5^th Floor, Tower near Radisson Blue Hotel, Tonk Durgapnee Jaipur 302018 {Given-up vide order dated 18.10.2022}

2^nd Address: 5^th Floor, Nicco House 2 Hare Street Bagh, Kolkatta 700001

3]  The Authorised Officer, IRDA Nanakramguda, Gachilbowli, Hyderabad 500032

4]  Indian Bank Association through its authorized officer, 6^th Floor, Centre 1 Building World Trade Centre 1 Cuff Parade Mumbai.

    ….. Opposite Parties

 

BEFORE: MR.AMRINDER SINGH SIDHU,    PRESIDENT

              MRS.SURJEET KAUR,           MEMBER

                                               

Argued by :- Complainant in person.

Sh.Nitin Gupta, Counsel of OP No.1

OP No.2 given up

None for OP No.3

OP No.4 exparte.

 

PER SURJEET KAUR, MEMBER

 

        The case of the complainant is that he took Group Insurance Policy being retired employee of Punjab National bank through IBA from National Insurance Company (Ann.-1) and accordingly TPA issued Health Cards to complainant and his wife bearing No.HHS100700310313 and 314 (Ann.-2).  It is pleaded that the complainant and his wife got dental treatment from Clove Dental and incurred expense to the tune of Rs.64,525/- (Ann.-3).  The complainant lodged claim with OP Insurance Company for reimbursement of said amount, but the OP Insurance Company neither paid the amount nor rejected the claim. Therefore, the present complaint has been filed alleging deficiency in service on the part of OPs.

 

2]      The Opposite Party No.1 – National Insurance Company Ltd. has filed written statement and while admitting the factual matrix of the case, stated that the insurance company vide letter dated 23.4.2021 (Ann.OP-1/B) repudiated the claim of the complainant under Clause 4.16 of the policy  on the ground that any expenses whatsoever incurred by the insured person in connection with or in respect of dental treatment or surgery of any kind which are done in dental clinic and those that are cosmetic in nature is not payable under the insurance policy. It is stated that the complainant had not taken the dental treatment on account of injury, therefore, the dental treatment of the complainant is not covered under the definition of ‘emergency dental treatment”. It is stated that the claim of the complainant is not covered under the insurance policy and therefore, the insurance company righty repudiated the claim.  Other allegations have been denied with prayer to dismiss the complaint.

3]      The OP No.2 was given-up by the complainant as is clear from order dated 18.10.2022.

4]      The OP No.3-IRDAI also filed written statement stating the whole claim made by the complainant is against the OP Insurance Company and no relief has been sought against OP No.3-IRDAI. It is stated that the complaint is basically between the complainant and OPs No.1 & 2 only and it has nothing to do in the matter. Denying other allegation, OP NO.3 prayed for dismissal of complaint qua it.

 

5]      OP No.4 did not turn up despite service of notice, hence OP NO.4 was proceeded exparte vide order dated 18.10.2022.

 

6]      Replication has also been filed by the complainant thereby controverting the assertions of OP No.1 made in its reply.

 

7]      Parties led evidence in support of their contentions.

 

8]      We have heard the complainant in person, ld.Counsel of OP No.1 and also gone through entire documents on record including written arguments.  

9]      As per the case of the complainant, he and his wife insured with OP Insurance Company, get dental treatment and incurred expenses of Rs.64,525/-. The sole grouse of the complainant is that their reimbursement claim was rejected by the OP Insurance Company illegally on the ground that the same was taken in Dental Clinic under Clause No.4.16 of Policy (Ann.OP-1/B).

10]     After going through the documents on record, it is evident from Page No.41 of the Paper-book which is the copy of detailed treatment by treating doctor, who specifically has given his opinion, after treating the patient/consumer to the effect that “xxxxx PROCEDURES IS NOT A CONSMETIC PROCEDURE & NEITHER ELLECTIVE. THE PROCEDURE IS PURELY EMERGENCY WITH FUNCTIONAL REHABILITATION.  IF NOT DONE CAN LEAD TO LIFE THREATENING COMPLICATIONS.”

   

11]     Also at Page No.52 of the Paper-book(Ann.-4), Deputy Secretary of Dental Council of India has opined that tooth implant is a surgical procedure.  More so, we feel dental treatment if has to be taken, the patient/consumer has to visit Dental Clinic and nowhere else. 

 

12]     In the light of the above discussion, we are of the considered opinion that the OP Insurance Company took a hyper technical objection of Dental Clinic to deny the genuine claim of the complainant, which is duly covered under Clause 2.12 of the Policy, which is reproduced as under:-

2.12 DENTAL TREATMENT means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.

 

        Such hyper technical ground to deny the claim to the complainant is unjustified and amounts to unfair trade practice.

 

13]     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OP No.1 is directed as under:-

1. to reimburse an amount of Rs.64,525/- to the complainant  with interest @9% P.A. from the date of repudiation i.e. 23.4.2021 till its realization
2. to pay 15,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

        This order be complied with by the OP No.1 within 45 days from the date of receipt of its certified copy, failing which, it shall be liable to pay additional cost of Rs.10,000/- apart from above relief.

 

14]     The Complaint against OPs No.3 & 4 stands dismissed.     

        Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced                                                     

17^TH May, 2023                        

                                                                        Sd/-

(AMRINDER SINGH SIDHU

PRESIDENT

 

 

Sd/-

(SURJEET KAUR)

MEMBER