BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.187 of 2019
Date of Instt. 28.05.2019
Date of Decision: 06.03.2023
1. Sh. J. K. Bhatia age about 63 years R/o 25-A Friends Colony, Opposite DAV College, Jalandhar, Punjab.
2. Mrs. Anju Bhatia aged about 54 years W/o Sh. J. K. Bhatia R/o 25-A Friends Colony, Opposite DAV College, Jalandhar, Punjab.
..........Complainants
Versus
1. United India Insurance Company Limited, 8, Patel Chowk, Above Mehra Transport, Jalandhar 144008.
2. United India Insurance Company Limited, Registered and Head Office No.24, Whites Road, Chennai:600014
3. M/s Raksha TPA (P) Ltd. 1st Floor, Madhya Mar, SEC: 44D, Chandigarh through its Managing Director/General Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Present: Sh. Amit Gauba, Adv. Counsel for the Complainants.
Sh. R. K. Sharma, Adv. Counsel for OPs No.1 & 2.
OP No.3 exparte.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the OP No.1 is the branch office, OP No.2 is the head office and OP No.3 is the TPA of the OPs No.1 and 2. OP No.3 is a Performa party and no Relief is claimed against OP No.3. The complainant no.1 had been taken family medicare policy from OPs No.1 and 2 since 2009 and time to time he had renewed the same and the latest policy which he renewed from OPs No.1 and 2, vide policy bearing no.2013022818P102366894 and paid annual premium of Rs.25,656/- to OPs. The said policy was issued for the period from 20/05/2018 to 19/05/2019. The persons insured under the said policy is complainant no.1 along with his wife namely Mrs. Anju Bhatia i.e. complainant no.2. The policy was duly issued by OPs No.1 and 2 to the complainants. As per the policy, OPs were duty bound to indemnify the health risk of both the above complainants. On 13/06/2018 i.e. within the policy period, complainant no.2 Mrs. Anju Bhatia slipped in bathroom and she got Fracture in upper Jaw and some teeth were broken. She also got minor injuries on her arm and abdomens. She got First Aid at Joshi Superspeciality & Multispeciaity Hospital, Jalandhar. The OPs were appraised about the whole incident of accident and admission of complainant no.2 in Joshi Superspeciality & Multispeciaity Hospital, Jalandhar and complainants applied for Cashless Facility for the treatment of complainant no.2, but OP No. 3 denied for the same vide Letter dated 14/06/2018 and stated nor Dental Treatment neither cashless facility be accorded. Thereafter, Mrs. Anju Bhatia i.e. Complainant no.2 operated in Dewan Dental Centre, Opp. Kamal Hospital, Kishanpura Chowk, Jalandhar by Dr. Sanjeev Dewan and the total expenditure incurred on the medical treatment of Mrs. Anju Bhatia was about Rs.1,24,500/-. Thereafter, complainant no.1 after completing all the formalities as asked by the OPs submitted the required claim form to them along with the supporting documents i.e. Medical Opinion, Treatment Record and Payment Receipts. Thereafter, complainants had approached OPs many a times for getting his claim, but OPs always avoided complainants on one pretext or the other. Moreover, wherever any document in furtherance of the medical claim of complainants, was demanded by the opposite parties, the same was very much provided by complainant. The complainants served a legal notice dated 20.11.2018 to the OPs and in reply to this legal notice, the OPs says that the patient has been given dental treatment which falls outside the scope of the policy. As per terms and conditions of the policy which is duly reflected in the policy covers dental treatment or surgery of any kind necessitated by accident and requiring hospitalization is duly covered under the policy, as per clause 4.8 of the policy cover. There is deficiency in service by the OPs by repudiating the genuine insurance claim of the complainants as such OPs are indulged in unfair trade practices and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay cost of medical treatment of Rs.1,24,500/- further OPs be directed to pay a compensation of Rs.50,000/- for causing mental tension and harassment to the complainant and Rs.20,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, but despite service OP No.3 failed to appear and ultimately, OP No.3 was proceeded against exparte, whereas OPs No.1 & 2 appeared through its counsel and filed joint written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the answering OPs No. 1 & 2, as such the same is liable to be dismissed. It is further averred that as per exclusion clause of the insurance policy Dental Treatment or Surgery of any kind are excluded from the scope of insurance policy unless necessitated by accident and requiring hospitalization.
Exclusion Clause 4.8 of the insurance policy reads as under:-
4 Exclusions:
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:
4.8 Dental Treatment or Surgery of any kind unless necessitated by accident and requiring hospitalization
It is ample clear from the wording of above exclusion clause that Dental Treatment or Surgery of any kind is excluded from the coverage of policy unless necessitated by accident and requiring hospitalization. There is no evidence of any accident in the present case. Otherwise also the treatment necessitated by any accident is payable only in case the insured had been hospitalization. In present case there is no Hospitalization, as such the claim of the complainants has been rightly repudiated as Exclusion Clause No.4.8 after due application of mind vide letter dated 14-03-2019 and the complainant was informed accordingly. Moreover, the expenses claimed are pertaining to fixing of Dental Implants which are not covered under the policy and fall under cosmetic and aesthetic treatment. It is further averred that there is neither any negligence nor any deficiency in service nor unfair trade practice on the part of the OPs No. 1 & 2. Repudiating the claim which is not payable as per terms and conditions of the insurance policy does not amount to any deficiency in service or unfair trade practice. The claim of the complainant stands repudiated vide letter dated 14-03-2019 as per terms and conditions of the insurance policy after due application of mind and the complainant was informed accordingly. On merits, it is admitted that the complainant had taken family medicare policy from OPs No.1 and 2 for the period 20.05.2018 to 19.05.2019 and it is also admitted that the complainant applied for cashless facility, but the same is repudiated by the OPs, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It is admitted that the complainant had taken the Family Medicare Policy from OPs No.1 & 2 bearing no.2013022818P102366894 for the period 20.05.2018 to 19.05.2018. The same has been proved as Ex.C-1/O-1. It is admitted that the complainant applied for cashless facility. It is alleged by the OPs that the complainant No.2 requested for cashless treatment for dental treatment, which is not covered under the conditions of the insurance policy, as such, the payment for dental treatment was not payable. The complainant has proved the letter Ex.C-2 of OPs No.1 & 2 dated 14.06.2018 vide which the cashless facility was denied as the treatment was not payable under the insurance policy. It is denied that the complainant No.2 slipped in the bathroom and got fractured in upper jaw. It has been alleged by the OPs that the complainant submitted only two bills for Rs.7500/- and Rs.27,000/- i.e. dated 18.06.2018 and 07.09.2018. The complainant has proved on record the medical opinion, treatment record and payment receipts Ex.C-3 to Ex.C-11, but the same have been denied by the OP except submission of two bills has been admitted. Legal notice has been proved as Ex.C-12. The repudiation letter Ex.C-16 has been proved.
7. Perusal of Ex.C-16 shows that the claim of the complainant was repudiated on the ground that ‘dental treatment fall outside the scope of the policy, hence the same is not admissible as per clause 4.8 of the policy’. As per 4.8 of the insurance policy, ‘dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization’. The OPs have relied upon the condition No.4.8 in Ex.C-1/O-1.
8. The Ld. Counsel for the OPs has relied upon the law laid down by the Hon'ble National Commission, in a case titled as ‘R.W.Z. Ghyaz Ahmed Vs. New India Assurance Co. Ltd. & Ors’, wherein his Lordship held as under:-
‘Insurance Mediclaim - Insurance was hospitalized for viral fever, dental injury - Claim for reimbursement of expenditure repudiated by insurer - Deficiency in service of insurer - Expenses related to treatment taken as an outdoor patient, for dental problems, was outside the scope of insurance policy, falling under the exclusion Clause-Claim was rightly repudiated’.
He has also relied upon the law laid down by the Hon’ble Maharashtra State Commission, in FA No.1320 of 2009, decided on 06.02.2010, titled as ‘Ramesh Inderchand Kothari & Anr. Vs. New India Assurance Company Ltd.’, wherein his Lordship held as under:-
‘Whenever dental surgery is required because of disease or injury as explained with a hospitalization, then case can be considered for medicalim, otherwise it cannot be considered Conditions namely, surgery and hospitalization, both must accompany each other and then only mediclaim would lie In present matter, admittedly, there was no hospitalization for correction of injuries and therefore, repudiation of claim under is justified - No deficiency in service is established - Order of District Forum is upheld
As per the law referred by the Ld. Counsel for the OPs, the insurance mediclaim is payable if it is within the scope of insurance policy. It has been held by the Hon'ble National Commission that expenses related to treatment taken as an outdoor patient, for dental problems, was outside the scope of insurance policy, falling under the exclusion clause and the claim was rightly held to be repudiated. Similarly, it has been held by the Hon’ble Maharashtra State Commission that whenever dental surgery is required because of disease or injury as explained with a hospitalization, then case can be considered for medicalim, otherwise it cannot be considered Conditions namely, surgery and hospitalization, both must accompany each other and then only mediclaim would lie In present matter, admittedly, there was no hospitalisation for correction of injuries and therefore, repudiation of claim under is justified.
9. Now the point is as to whether these citations are applicable to the facts of the present case or not? The complainant has produced on record the prescription of the doctor from whom the complainant No.2 took initial treatment on 14.06.2018. Ex.C-3 shows that there was a history of fall two days ago and she was diagnosed as Dentoalveolar Fracture and Zirconia Crown. She was advised surgery. She suffered injury on face and having swelling and severe pain, then she took the treatment from Dewan Dental Centre on 18.06.2018 and kept on following the treatment till 07.09.2018 as per Ex.C4 to Ex.C11. It is alleged by the OPs that as per terms and conditions and exclusion clause of the insurance policy, the reimbursement and the bills for treatment are not payable since there is no hospitalization in surgery. No doubt in clause 4.8, it has been mentioned that dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization is not payable, meaning thereby that it is excluded if it is not necessitated by accident. Clause 1.2 (i) of this policy Ex.C-1/O-1 says that expenses on hospitalization for minimum period of 24 hours are admissible, however, this time limit is not applied to specific treatments such as dental surgery as mentioned in Sr. No.7 of this condition. It is proved from the prescriptions of the doctors that the complainant suffered injuries and was advised surgery due to fall. The word ‘fall’ is very much covered in the term accident. The literal meaning of accident is ‘physical examples of accidents include unintended motor vehicle collisions, falls, being injured by touching something sharp or hot, or bumping into something while walking. A slip and fall injury is any injury that one sustains after slipping, tripping or stumbling and falling’. Thus, in the present case also, the complainant No.2 suffered injuries on her jaw and face due to fall. As per the prescription and diagnose of the doctor of Joshi Super Speciality Hospital and the treatment plan of the doctor of Dewan Dental Centre Ex.C-17, she had first aid during night when she suffered injuries, but next day she went to take treatment from Joshi Hospital. Thus, the fall is very much covered under the term accident. The law referred by the ld. Counsel for the OP No.1 titled as titled as ‘R.W.Z. Ghyaz Ahmed Vs. New India Assurance Co. Ltd. & Ors’ and ‘Ramesh Inderchand Kothari & Anr. Vs. New India Assurance Company Ltd.’ are not applicable to the facts of the present case, as it is covered under condition No.1.2 (i) of Ex.C-1. As per the condition No.1.2 (i) of the policy, dental surgery is very much covered under the policy. So, the repudiation letter is wrong, illegal and against the conditions of Ex.C-1. The exclusion clause thus is not applicable. Hence, the repudiation letter Ex.C-16 is set-aside.
10. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to pay the amount of two bills i.e. Rs.7500/- and Rs.27,000/-, in total Rs.34,500/-, which were allegedly submitted to the OPs. The complainant has not proved the claim form to show that all the bills, receipts produced in Court, was submitted to the OPs. For the remaining payment, the complainant is directed to submit the bills and receipts and other documents, if any to the OPs within 15 days from the date of receipt of the copy of order and then the OPs will decide the claim of the complainant within 15 days from the date of receipt of the bills and documents from the complainant. The OPs are further directed to pay a compensation to the complainant, to the tune of Rs.10,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The compliance (compensation and litigation) be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Dr. Harveen Bhardwaj
06.03.2023 Member President
