For the Complainant                      -  Mr. Ashok Kumar Roy, Advocate

For the OPs                                       -  Mr. A.K. Bandopadhyay, Advocate

FINAL ORDER/JUDGEMENT

SHRI SWAPAN KUMAR MAHANTY, PRESIDENT

Brief facts of consumer complaint:-

Complainant filed the instant consumer complaint U/s 12 of the Consumer Protection Act, 1986 pleaded therein that he himself and his son Rick Dasgupta obtained Floter Mediclaim Insurance Policy being No. 0304002817P119323198 from OPs 1 & 2 for a sum of Rs. 2,50,000/- each for the period 01.03.2018 to 28.02.2019. It is also pleaded that on  08.08.2018 Rick Dasgupta was admitted to VIP  Apex Medical Centre Pvt. Ltd. with Cerebral Pulsy and Hyponatremia and after improving his condition patient was referred to Dental surgeon for opinion. Dental surgeon advised for dental treatment of Rick Dasgupta under general anesthesia. It is further pleaded that Rick Dasgupta accidently falls on the floor for which his face and teeth damaged. OPs denied to reimburse the medical expenses incurred by the complainant quoting Clause No. 4.3 of the Policy condition though there is no condition that “Bruxism” will not cover under the policy. The OPs committed deficiency in service. Hence, the prayer for acceptance of consumer complaint sought.

Per-contra, OP-1 United India Insurance Company Ltd. filled WV pleaded therein that the son of the complainant Rick Dasgupta was admitted to VIP Apex Medical Centre Pvt. Ltd. Baguiati on 08.08.2018 with complaint of no sleep for 60 hours and discharged on 22.08.2018. It is also pleaded that during hospitalization patient’s vital parameters were under control in order to perform multiple tooth extraction under General Anesthesia and the treating doctor never mentioned the cause of hospitalization with relate to patient’s history of Cerebral Palsy.  It is further pleaded that patient is a known case of Cerebral Palsy and he was admitted to hospital for pleural effusion on earlier occasion from 04.07.2018 to 19.07.2018 for which an amount of Rs. 1,30,927/- was paid to the complainant under the same policy period. Sum insured of Rick Dasgupta under the policy is Rs. 2,50,000/- and at present balance sum insured under the policy is Rs. 1,19,073/- Dental Treatment or surgery of any kind unless necessitated by accident and requiring hospitalization is excluded from the scope of policy as  per clause No.  4.8. Thus, the insurance company is not under legal obligation to pay insurance claim. Prayer for dismissal of consumer complaint sought.

Despite service of notices OPs 2 & 3 did not turn up to contest the consumer case. As such, the consumer case has proceeded ex-parte against OPs 2 & 3.

Decision With Reasons

Complainant filled affidavit in evidence. There is recital in affidavit that contents of complaint are true and correct and nothing has been concealed therein. OP-1 did not file any affidavit in evidence in spite of given opportunities. Both parties have also filed their BNAs.

Short question for adjudication in this complaint is whether the claim of the complainant in the facts and circumstances of the case is payable. This leads to another question whether the claim is covered within the parameters of the policy or there exists any encumbrances. We have perused the record of the case and given a thoughtful consideration to the subject matter.

The facts not in dispute are that the complainant is an employee of the Bank Employees’ Co-operative Bank Ltd. and a policy holder of a tailor-made Group Mediclaim Policy for Bank Employees’ Co-operative  Bank being No.  0304002817P1193-23198 for the period 01.03.2018 to  28.02.2019. Complainant was the primary insured member and his son Rick Dasgupta as the dependant member with total sum insured of Rs.  2,50,000/- on floater basis. It is admitted by both sides that Rick Dasgupta was admitted in VIP Apex Medical Centre Private Limited, Baguiati on  08.08.2018 with complaint of “no sleep for 60 hours” and discharged on 22.08.2018. We may note here that during hospitalization patient’s vital parameters were brought under control in order to perform multiple tooth extraction under General Anesthesia as it appears from Discharge Summary. Needless to add that the treating doctor vide certificate dated 21.11.2018 did state that the etiology of ailment is dental caries and need for hospitalization due to severe local pain in tooth and inability to take food orally. Therefore, it is crystal clear that the treating doctor never mentioned the cause of hospitalization as related to patient’s history of Cerebral Palsy. Patient information dated 08.08.2018 goes to show that Rick Dasgupta has a past history of Cerebral Palsy.

Clause 4.8 of the Insurance Policy goes to show that “Dental treatment or surgery of any kind unless necessitated by accident and requiring hospital”. Thus, the OP-1/ Insurer repudiated the claim of the complainant vide letter dated 06.12.2018. The complainant never objected to the terms and conditions of the policy and, therefore, now cannot raise any objection with respect to the clauses.

It is averred from Para-14 of the consumer complaint that “patient was disable, he off and on fall on the floor of the room and that causes  accident and damage the face and tooth of the patient, therefore, no one can say that the patient, therefore, no one can say that the dental caries has no cropped up due to accident of sudden fall on the floor of the house.” The plea taken by the complainant is not believable as the patient information dated 08.08.2018 do not support the claim of accident and damage of face  and tooth due to fall down on the floor of the room. Neither the complainant nor the patient made any complaint to the doctor of VIP Apex Medical Centre Private Limited to this aspect during admission.

The terms & conditions of the policy must be given paramount importance and it is not open for any court to add, delete or substitute any words therein. It is also well settled that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss-suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed to determine the extent of liability of the insurer. Thus, we have no scope to bypass the policy condition under any circumstances. As such, rejection of claim of the complainant is justified. In our opinion, there is no deficiency in services for rejecting the claim of the complainant on the part of the OP-1. Thus, the complainant is not entitled to get any relief as prayed for. Hence, we answer only point accordingly.

In view of the foregoing discussion, the OP-1 cannot be fastened for deficiency in service in terms of law or policy terms & conditions. Thus, the consumer complaint is dismissed on contest against the OP-1 and also dismissed ex-parte against the rest OPs.  However,  no order as to costs.

A copy of this order as per statutory requirements be sent to the parties free of charge.