DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC No. 281 of 26.09.2007<br /> Decided on : 31-01-2008 <br /> <br /> Parveen Garg, Development Officer, Life Insurance Corporation of India, Bathinda, R/o 10 Bharat Nagar, Bathinda. ... Complainant<br /> Versus<br /> <br /> 1.The New India Assurance Company Limited, Regional Office : Fourth Floor, Surya Tower, 108, The Mall, Ludhiana. 141 001, through its Regional Manager.<br /> 2.The New India Assurance Company Limited, Registered & Head Office: New India Assurance Building, 87, Mahatma Gandhi Road, Fort, Mumbai: through its Managing Director. ...Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM :<br /> Sh. Lakhbir Singh, President<br /> Sh. Hira Lal Kumar, Member<br /> Dr. Phulinder Preet, Member<br /> <br /> For the Complainant : Sh. S.K. Goyal, Advocate.<br /> For the Opposite parties : Sh. Vinod Garg, Advocate.<br /> <br /> O R D E R<br /> <br /> LAKHBIR SINGH, PRESIDENT<br /> 1. Complainant is serving as Development Officer in Life Insurance Corporation of India (Here-in-after referred to as 'LIC') for the last 16 years. Presently he is posted at Bathinda. He was covered under Group Medi Claim Policy of the opposite parties during the year 2005-2006. Monthly premium of Rs. 76.46 is being deducted from his salary at source. Copies of the terms and conditions were not provided to him. No policy has been issued. His signatures were not obtained on any policy papers. In the year 2005-2006, he had to undergo Dental Flap Surgery due to disease chronic Periodontitis which is dangerous disease. He was advised to undergo surgery from Orthodontist. Accordingly he has undergone treatment/surgery from Dental Clinic Orthodontic and Pderiodontic Centre, 1332, Sector 33-C, Chandigarh. Surgery was performed by Dr. Prerna and Dr. Sohinder J Singh of this Clinic. Treatment continued from 27.11.05 to 13.1.06 in six sittings of four hours each i.e. on 27.11.05, 1.12.05, 12.12.05, 20.12.05, 29.12.05 and 13.1.06. At every sitting same type of surgery/treatment was given to the different parts in his mouth. If surgery is done in one go, patient cannot be able to take food or liquid for some days. He had to incur expenditure of Rs. 30,000/- including expenses on medicines. After undergoing surgery, medi-claim was submitted by him to opposite party No. 1 through its Divisional Office. On 6.2.06, letter was received by Mr. Kehar Singh, Manager, O.S. LIC, Divisional Branch, Ludhiana from Administrative Officer of the opposite parties whereby receipt of the documents sent by him was acknowledged and some clarifications were sought, which are as under : <br /> (a) Original Discharge Card with details of procedure of operation<br /> (b) X-ray film before the treatment and all other x-rays<br /> On 14.2.06 Branch Manager, LIC, Bathinda had received letter from his Divisional Office, Ludhiana intimating that some clarifications were required for early settlement of the claim. Accordingly original discharge card, details, procedure of operation and one CD of digital X-rays were sent by him to Manager (O.S.)LIC, Divisional Office, Ludhiana for onwards submission to the opposite parties. On 10.3.06, Branch Manager, LIC Bathinda had received letter from his Divisional Office vide which he was informed that medi-claim of the complainant is not payable as per letter of the opposite parties dated 8.3.06 as group medi-claim insurance policy of LIC of India covers as per policy condition No. 1.0(A) Hospitalisation expenses for medical/surgical treatment at any hospital in India. The said employee was not hospitalised and his treatment also falls under exclusion clause No. 4.7 of the policy which reads as “Dental treatment or surgery which is corrective, cosmetic or aesthetic procedure including wear or tear of tooth extraction unless arising from disease or injury/accident and which requires hospitalisation for treatment.<br /> Thereafter complainant requested the Manager (O.S.) Divisional Office, Ludhiana to look into the matter for early settlement of the claim. Complaint was also submitted by him regarding rejection of his claim by the opposite parties to Core Centre, Consumer On line Resource & Empowerment Centre (supported by Ministry of Consumer Affairs, Govt. of India, Managed by Consumer Co-ordination Council (CCC). He had also sent letters to the General Manager of opposite party No. 2 on 5.8.06, 31.8.06 and 13.10.06 but no reply was received. Thereafter complaint was filed by him before Consumer Fora. Complainant alleges that rejection of the medi-claim is illegal, arbitrary and without any legal basis as he has undergone surgical operation from Specialist doctor. He had to remain hospitalised for four hours on each sitting. As per General medi-claim policy condition, Surgery read “Dental Surgery is covered”. According to Dr. Prerna, Periodontist and Dr. Shoinder J. Singh, Orthodontist Periodontitis is a disease and for its cure Dental Flap surgery is required and it is not a corrective cosmetic or aesthetic measure . Thus there is no need of hospitalisation. He alleges that due to adamant attitude of the officials of the opposite parties he has undergone mental and physical tension. In these circumstances, this complaint under Section 12 of the Consumer Protection Act, 1986 (Here-in-after referred to as 'Act') has been preferred by him seeking direction from this Forum to the opposite parties to release him the insurance medi-claim amount; pay Rs. 50,000/- as compensation for physical and mental harassment and Rs. 10,000/- as litigation expenses.<br /> 2. Opposite parties filed reply of the complaint taking legal objections that complaint has been filed merely to injure their goodwill; complaint is not maintainable; complainant has got no locus standi and cause of action to file it; complainant is not consumer; complicated questions of law and facts are involved which require voluminous evidence and documents for determination and such evidence cannot be taken by this Forum in summary procedure and as such, complaint should be decided by civil court; complaint is false and frivolous and complainant has concealed the material facts. Complaint No. GIC/135/NIA/11/07 was filed by the complainant on 1.8.06 on the same cause of action. It was dismissed by the Insurance Ombudsman vide order dated 14.9.06. On this score as well, complaint is liable to be dismissed. They do not deny the fact that complainant was covered under Group Medi-claim Policy for the year 2005-2006 of New India Assurance Company Limited. Premium of Rs. 76.46 was being deducted from his monthly salary at source. They do not admit in clear words that complainant had to undergo Dental Flap Surgery in 2005-2006 due to disease chronic Periodontitis which is a dangerous disease and that he was advised by Orthodontist to undergo it. According to them, Dental Clinic Orthodontic and Periodontic Centre, 1332 Sector 33-C, Chandigarh, does not fall within the definition of Hospital/Nursing Home as per the provisions of Medi-claim Insurance Policy. Complainant was not hospitalised. Treatment was not covered by the terms and conditions of the Policy. They deny that a sum of Rs. 30,000/- was spent on medicines. Similarly they deny that treatment of the complainant was continued from 27.11.05 to 13.1.06. They do not admit that complainant had six different sittings of 4 hours each for his treatment on 27.11.05, 1.12.05, 12.12.05, 20.12.05, 29.12.05 and 13.1.06. There is no specific denial regarding filing of the claim by the complainant before opposite party No. 1 through his Divisional Office. Similarly there is no clear cut denial regarding the receipt of the letter dated 6.2.06 by Sh. Kehar Singh, Manager (O.S.). L.I.C. Divisional Branch, Ludhiana from their Administrative Officer whereby receipt of the documents of claim of the complainant was acknowledged and clarification was sought as under : <br /> (a) Original Discharge Card with details of procedure of operation<br /> (b) X-ray film before the treatment and all other x-rays<br /> Similarly the receipt of the letter dated 14.6.06 by the Branch Manager of LIC ,Bathinda from Divisional Office, Ludhiana through which some clarifications were sought by the opposite parties for settlement of the claim of the complainant has not been specifically denied. They admit that claim of the complainant was repudiated vide letter dated 8.3.06 as claim was not payable as per terms and conditions of the policy. Treatment was not taken in any Hospital/Nursing Home as defined under the terms and conditions of the policy. Complainant was not hospitalised for the alleged treatment. Further more dental treatment or surgery which is corrective, cosmetic or aesthetic procedure including wear or tear of tooth extraction is not covered unless arising from disease or injury/accident which requires hospitalisation for treatment. Alleged treatment of the complainant falls within the exclusion clause. Hence, complaint is not maintainable. They deny that repudiation of the claim is illegal, arbitrary and without legal basis.<br /> 3. In support of his averments contained in the complaint, complainant has produced in evidence his affidavit (Ex. C-1), photocopy of Medi-claim Insurance Policy of New India Assurance Co. (Ex. C-2), photocopy of Medi-claim Insurance Policy of United India Insurance Co. (Ex. C-3), photocopies of treatment record (Ex. C-4 & Ex. C-5), photocopies of receipts (Ex. C-6 to Ex. C-10), photocopies of Treatment Procedure (Ex. C-11 to Ex. C-12), photocopies of letters dated 6.2.06, 14.2.06, 6.3.06, 10.3.06 ,7.4.06 and 10.4.06 (Ex. C-13 to Ex. C-18 respectively), photocopies of some more letters (Ex. C-19 to Ex. C-26), photocopy of another letter (Ex. C-27), photocopy of pay summary (Ex. C-28), Certificate (Ex. C-29) and photocopy of Classification of diseases of the Periodontium (Ex. C-30).<br /> 4. In rebuttal, on behalf of the opposite parties affidavit of Sh. P K Jain, Senior Divisional Manager (Ex. R-1), photocopy of Claim Form (Ex. R-2), photocopies of letters dated 31.1.06, 8.3.06 and 1.8.06 (Ex. R-3 to Ex. R-5 respectively), photocopy of order dated 14.9.06 (Ex. R-6) and photocopies of Insurance Policies (Ex. R-7 to Ex. R-8) have been tendered in evidence.<br /> 5. We have heard learned counsel for the parties. Besides this, we have gone through the record and written brief of arguments submitted on behalf of the opposite parties.<br /> 6. Complainant had preferred complaint, copy of which is Ex. R-5 to Ombudsman against the opposite parties for non-settlement of the medi-claim. Ombudsman vide his order dated 14.9.06, copy of which is Ex. R-6 has held the repudiation of the claim to be in order. Contention of the learned counsel for the opposite parties is that since the complaint has been dismissed by the Ombudsman this complaint is not maintainable, is not tenable in view of the observations of the Hon'ble National Commission in the case of Kamleshwari Prasad Singh Vs. National Insurance Company Limited 2005 (CTJ) 747 (CP)(NCDRC) in which it has been held that Ombudsman does not discharge any judicial or quasi judicial functions and complainant may not accept his decision. He can take the rejection of his claim by the Insurer before the Consumer Fora if he so likes.<br /> 7. Complainant has reiterated his version in his affidavit Ex. C-1. Ex. C-4 to Ex. C-12 are the copies of the treatment record and the receipts regarding the payment of the amount for treatment. A perusal of this record reveals that he has spent a sum of Rs. 24,600/- for his treatment.<br /> 8. Complainant had submitted his claim under Group Medi-claim policy through his Divisional Office. Claim has been repudiated vide letter dated 8.3.06 of the opposite Insurance Company on the grounds that Group medi-claim insurance policy covers hospitalisation expenses for medical/surgical treatment at any hospital in India, complainant was not hospitalised and thirdly his treatment falls under the Exclusion Clause No. 4.7 of the policy. <br /> 9. Arguments pressed into service by Mr. Goyal, learned counsel for the complainant are that rejection of the medi-claim of the complainant by the opposite parties is illegal, arbitrary and without any legal basis as complainant has undergone surgical operation from a specialist doctor. He has to remain hospitalised for four hours on each sitting for undergoing surgical procedure/treatment which is clear from the relevant record of the Orthodontist. As per general mediclaim policy condition, “Dental Surgery is covered”. It is clearly envisaged in clause 2.3 of the prospectus of Medi-claim Insurance Policy of the opposite parties that expenses on Hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments i.e. Dialysis, Chemotherapy, Radio-therapy, Eye Surgery, Dental Surgery, Lithotrips (Kidney stone removal) Tonsillectomy, D&C taken in the hospitalisation/Nursing Home and the insured is discharged on the same day the treatment will be considered to be taken under hospitalization benefit. Exclusion 4.7 applies to any dental treatment or surgery which is a corrective, costmetic or aesthetic procedure, including wear and tear unless arising from disease or injury and which requires hospitalisation for treatment. He further argued that according to Dr. Prerna, Periodontist and Dr. Sohinder J. Singh, Orthodontist Periodontitis is a disease and for its cure Dental Flap surgery is required and it is not a corrective, cosmetic or aesthetic measure and there is no need of hospitalisation. He further argued that there is clear cut deficiency in service on the part of the opposite parties in repudiation of the claim.<br /> 10. Mr. Garg, learned counsel for the opposite parties argued that complainant did not get medical treatment from the prescribed hospital. He did not remain hospitalised for a minimum period period of 24 hours for which expenses for treatment are admissible. Moreover Exclusion Clause 4.7 is also applicable. For this, he drew our attention to the affidavit Ex. R-1 of Sh. P K Jain, Senior Divisional Manager of the opposite Insurance Company.<br /> 11. We have considered the respective arguments.<br /> 12. Ex. C-30 is the photocopies of pages 58 to 59 of Medical Book Clinic Periodontology, 8th Edition – A Prism Indian Edition. A perusal of it reveals that Periodontitis is the most common type of periodontal disease and results from extension of the inflammatory process initiated in the gingiva to the supporting periodontal tissues. Hence it is a disease. Exclusion Clause 4.7 of Group Medi-claim policy, copy of which is Ex. R-7 is not applicable. Exclusion Clause 4.7 pertains to the dental treatment or surgery which is a corrective, costmetic or aesthetic procedure, including wear and tear, unless arising from disease or injury and which requires hospitalisation for treatment. In other words opposite parties cannot apply this exclusion clause. Complainant is relying upon the copies of the terms and conditions of the Medi-claim Insurance Policy of the opposite Insurance Company, copy of which is Ex. C-2. Reliance is also placed by him on the copy Ex. C-3 of Medi-claim Insurance Policy of United India Insurance Company Limited. They are not applicable to the case in hand. Relevant period of Group Medi-claim Insurance Policy is from 1.4.0-5 to 31.3.06. Copy of the relevant Group Medi-claim Insurance Policy of the opposite Insurance Company is Ex. R-7. It was purchased by L.I.C. for its employees including the complainant. Complainant received treatment/surgery from Dental Clinic Orthodontic and Periodontic Centre, 1332, Sector 33-C, Chandigarh. Question is as to whether this Dental Clinic was hospital ? Complainant was required to get treatment from the hospital as defined in the policy itself, copy of which is Ex. R-7. Insured is entitled to Hospitalisation expenses for medical/surgical treatment at any Nursing Home/Hospital in India as defined in the Policy. Hospital/Nursing Home is defined in Clause 2.1 in Ex. R-7. Learned counsel for the complainant failed to show that clinic from where complainant received treatment and got done surgery is covered by the definition of Hospital;/Nursing Home as defined in Clause 2.1 of Ex. R-7. In other words, Clinic does not fulfill the criteria of hospital as defined in the Policy. Complainant has himself pleaded in para No. 4 of the complaint that treatment was continued from 27.11.05 to 13.1.06 in six different sittings of four each on 27.11.05, 1.12.05, 12.12.05, 20.12.05, 29.12.05 and 13.1.06. As per terms and conditions of the policy, copy of which is Ex. R-7 expenses for medical treatment can be claimed when there is hospitalisation of the assured for a minimum period of 24 hours. Clause 2.3 of the policy is reproduced as under :-<br /> “2.3 Expenses requiring Hospitalisation for minimum period of 24 hours are admissible. However, this time limit will not apply to specific treatments i,.e, Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy ( Kidney stone removal), Tonsillectomy, D&C taken in the Hospital;/Nursing Home, Anti Rabies Vaccine (Rabies) and the insured is discharged on the same day, the treatment will be considered to be taken under Hospitalisation Benefit.<br /> However, any treatment other than as mentioned above which requires hospitalisation for period of less than 24 hours are covered provided :<br /> a) The treatment should be such that it necessitates hospitalization and the procedure involved required specialized infrastructural facilities in hospitals<br /> b) Due to technological advances hospitalization required is less than 24 hours.”<br /> Contention of the learned counsel for the complainant that in case of dental surgery hospitalisation for minimum period of 24 hours is not applicable, is not acceptable in view of Clause 2.3 reproduced above. As per stance of the complainant each sitting of his treatment was of four hours. It means that he was taking the treatment and was coming back after four hours. There is no evidence that he was admitted and remained hospitalised for a minimum period of 24 hours. He was taking treatment as outdoor patient and was coming back after getting the treatment. Dental surgery is not excluded from the purview of Clause 2.3 of the Policy.<br /> 13. As a result of what has been discussed above, conclusion is that medi-claim submitted by the complainant to the opposite parties has been rightly repudiated as he did not get treatment from the Hospital/Nursing Home as defined in Clause 2.1 of the policy nor did he remain hospitalised for a minimum period of 24 hours in such hospital. When it is so, there is no deficiency in service on the part of the opposite parties in repudiation of his claim.<br /> 14. In view of our foregoing discussion, complaint being devoid of merits. Accordingly, it is dismissed leaving the parties to bear their own costs.<br /> Copy of this order be sent to the parties concerned free of cost and file be consigned. <br /> Pronounced :<br /> 31-01-2008 (Lakhbir Singh )<br /> President<br /> <br /> <br /> (Hira Lal Kumar)<br /> Member<br /> <br /> <br /> (Dr. Phulinder Preet)<br /> Member <br />