Chandigarh

DF-I

CC/575/2023

P.S. BEDI - Complainant(s)

Versus

UNITED INDIA INSURANCE CO LTD - Opp.Party(s)

01 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/575/2023
Date of Institution	:	14.12.2023
Date of Decision	:	01/08/2024

 

P.S.BEDI SON OF N.S. BEDI RESIDENT OF 1154 SECTOR 8-C CHANDIGARH.

Complainant.

Versus

 

UNITED INDIA INSURANCE CO LTD, CORPORATE CELLGROUND FLOOR VULCAN INSUARANCE BLD 77 VEER NARIMAN ROAD MUMBAI 400020 THROUGH ITS EXECUTIVE MANAGER.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Complainant in person.
	:	Sh. Neeraj Raizada, Advocate for OP.

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties  (hereinafter referred to as the OP). The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that  the complainant is a retired government employee of Punjab National Bank and is a member of group insurance policy No.5001002819PU2263498 (hereinafter referred to be as subject policy) having obtained from OP in the month of November 2019. The complainant had taken dental treatment  from Clove Dental Clinic who charged an amount  of Rs.20735/- from the complainant. Thereafter the complainant had lodged claim Annexure C-1  with the OP but the OP had neither settled the claim nor rejected the same. Thereafter the complainant lodged complaint with insurance OMBUDSMAN. Later on the OP had rejected the claim of the complainant as per clause 4.4 on the ground that  the cosmetic treatment is not covered under the subject policy. However,  the treating hospital has not done cosmetic surgery and the OP had wrongly repudiated the claim of the complainant. In fact the treatment was emergency  surgical treatment regarding which the treating doctor had also issued certificate . The Insurance OMBUDSMAN dismissed the complaint of the complainant vide order Annexure C-3 .  As per circular  issued by Dental Council of India,  it is clarified that the implant is not cosmetic surgery. In this manner as the OP has wrongly repudiated the claim of complainant, the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OP. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of facts and jurisdiction. It is alleged that  the claim of the complainant was repudiated by OP on 18.12.2020 and thereafter the complainant approached  this Commission in 2023 after three years and as such the complaint is barred by limitation. It is further alleged that in fact the claim  lodged by the complainant  being excluded under clause 4.4   of the terms and conditions of the subject policy was rightly repudiated by the answering OP  especially when the same was lodged by the complainant for cosmetic surgery. Moreover, clause 2.15 relates to  emergency dental treatment  and under clause 2.16 the emergency medical treatment has been described the treatment (sudden and unexpected).  However in the instant case as the complainant has not obtained any emergency medical treatment and the claim of the complainant is excluded under exclusion clause and thus the claim of the complainant was rightly repudiated. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their respective claims the parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the complainant in person and learned counsel for the OP and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that  the complainant was covered under the subject policy as is also evident from Annexure R-1  and he had taken Dental Treatment from the treating hospital in the month of November 2019 whereby he spent an amount of Rs.20,735/- and thereafter lodged claim with OP but the same was repudiated by the OP on the ground that the same is excluded under clause 4.4. of the terms and conditions of the subject policy and was not a emergency or unexpected surgery, the case is reduced to a narrow compass as it is to be determined if the  OP is unjustified in repudiating the claim of the complainant and the complainant is entitled for the relief as prayed for  as is the case of the complainant or if the OP has rightly repudiated the claim of the complainant and the complaint being not maintainable is liable to be dismissed as is the defence of the OPs. 
   2. In the back drop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around  the subject policy Annexure R-1  and the relevant clauses of the same are required to be scanned carefully in the light of the repudiation letter Annexure R-2.
   3. Annexure R-2 repudiation letter indicates that the claim of the complainant has been denied by the OP being not covered as per exclusion clause 4.4 of the subject policy. The relevant portion of the same is reproduced as under:-

“On detailed scrutiny of the documents submitted, we observed that:

Patient has undergone Dental treatment which is not covered as per policy terms and conditions. Hence, claim is recommended for repudiation under clause:- 4.4.”

4. As per defence of OP the claim of the complainant was repudiated as per exclusion clause 4.4  of the subject policy being not covered under clause 2.12 and 2.15 of the subject policy. The relevant  portion of the aforesaid clauses are 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.”

 

“2.15 EMERGENCY DENTAL TREATMENT means the services or supplies provided by a Licensed dentist, Hospital or other provider that are medically and immediately necessary to treat dental problems resulting from injury. However, this definition shall not include any treatment taken for a pre-existing condition.”

 

5. Perusal of clause 4.4 clearly indicates that  the dental treatment or surgery  of any kind  which are done in a dental clinic and  those are cosmetic in nature, the same are excluded. However, perusal of certificate issued by the treating hospital available at page 14 of the paper book of complaint clearly indicates that the complainant was treated in emergency condition. The relevant portion of the certificate is reproduced as under:-

“This is to certify that Mr.P.S.BEDI is undergoing dental treatment at clove dental Sector 7 Chandigarh.He reported on 10.11.19 with severe pain and swelling in the left lower back region of mouth. On examination and consulting X ray findings it was revealed that acute infection with pus discharges spreading till bone was evident with 36 tooth. The case was taken up as an emergency and extraction with debridement of pus and infected bone was removed. The condition was very acute and severe and necessary emergency treatment of surgical removal and reimplantation of tooth was done immediately without delay further delay would have caused further infection of tooth leading to space infection which is life threatening complication.”

6.   Thus the certificate issued by the treating hospital itself makes it clear that  the complainant was examined in emergency condition  and was treated by the treating hospital without any delay on finding that delay in treatment could have caused severe infection which could have life threatening. Moreover,  as per  complainant   he was not treated with cosmetic surgery especially when as per the clarification of Dental Council of India in Annexure C-2 that tooth implantation is a surgical procedure making further clear  that the same is not a cosmetic treatment.
7. It is the admitted case of the parties that the complainant has undergone surgery for removal of crown and re-implantation and the same does not fall under the category of cosmetic surgery under exclusion clause 4.4 of the subject policy as is the defence of the OP.
8. So far as the objection of OP with regard to limitation is concerned, we do not find any merit in the same as  the Hon’ble Apex Court vide order dated 10.1.2022 excluded  the period from 15.3.2020 till 28.2.2022  for the purpose of limitation. Evidently the claim of the complainant was repudiated on 18.12.2020 vide Annexure R-2 i.e. the period which  was excluded for the purpose of limitation.  Hence, the limitation period shall start running after  28.2.2022 and as the instant complaint  has been filed on 23.12.2023. hence, the same  is within limitation.    
9. In view of the above, the OP is unjustified in repudiating the claim of the complainant  and the said act of OP amounts to deficiency in service and indulgence in unfair trade practice and the complainant is entitled for the claimed amount.   

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-

 

1. to pay ₹20,735/- to the complainant alongwith interest @ 9% per annum (simple) from the date repudiation of claim i.e. 18.12.2020 till onwards.
2. to pay lump-sum amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment and towards cost of litigation.

 

5. This order be complied with by the OP within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realization.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/08/2024			Sd/- [Pawanjit Singh] President
mp
			Sd/-
			[Surjeet Kaur] Member
			Sd/-
			[Suresh Kumar Sardana] Member