DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  34

                                                Instituted on:    23.01.2017

                                                Decided on:       16.05.2017

Sonia Mittal wife of Abhishek Mittal C/o Jagan Nath Amar Nath, Shop NO.112, Old Grain Market, Sunam, Distt. Sangrur.

                                                        …Complainant

                                Versus

United India Insurance Company Ltd. Divisional Office, Railway Road, Sangrur through its Divisional Manager.

                                                        ..Opposite party.

For the complainant  :       Shri S.S.Ratol, Adv.

For Opp.party          :       Shri Satpal Sharma, Adv.

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

Order by : Sukhpal Singh Gill, President.

1.             Smt. Sonia Mittal, complainant (referred to as complainant in short) has preferred the present complaint against the opposite party (referred to as OP in short) on the ground that the complainant got a family medicare insurance policy bearing number 1117022814P108532793 for the period from 16.1.2015 to 15.1.2016.  The case of the complainant is that during the subsistence of the insurance policy, the family of the complainant met with an accident on 19.11.2015 while returning from Chandigarh and as such were admitted to Civil Hospital Rajpura and thereafter they were shifted to Khanna for further treatment after reaching their family members.  It is further averred that in the accident, the teeth of the complainant were fractured and she got  treatment from Dr. Sidharath Phull at Kashmiri Hospital, Naya Bazar, Sunam, where she spent an amount of Rs.56,080/- on her treatment.  The complainant immediately intimated the OP regarding her accidental treatment and the Op deputed its investigator and verified the bills of medicines from the concerned hospital.  Thereafter the complainant completed all the formalities, but the OP repudiated the claim of the complainant on the ground that the treatment was taken on OPD basis only, which is totally wrong and illegal as the complainant took treatment of fracture in the teeth, as no admission in the hospital was required for the treatment of teeth.  Thus, alleging deficiency in service on the part of the OP, the complainant has prayed that the OP be directed to pay to the complainant the insurance claim of Rs.56,080/-  along with interest @ 18% per annum from the date of treatment till realisation and further claimed compensation and litigation expenses.

2.             In reply of the complaint, preliminary objections have been taken up on the grounds that the present complaint is baseless and flagrant abuse of process of law and that the complainant has no locus standi to file the present complaint. On merits, it is admitted that the complainant obtained the policy in question from the OP for the period from 16.1.2015 to 15.1.2016. It is further admitted that the complainant submitted her claim form and intimated the OP on 19.11.2015 that her family met with an accident, when they were coming from Chandigarh and that the complainant intimated the OP that in this accident the teeth of the complainant were fractured and she got treatment from Dr. Sidharath Phull at Kashmiri Hospital, Sunam, where she spent an amount of Rs.56080/-, but the claim of the complainant was repudiated as the claim was not covered under the terms and conditions of the policy as OPD was not covered  as the hospitalisation was required to get the claim.   Lastly, the OP has prayed that the complaint be dismissed with special costs. The other allegations levelled in the complaint have been denied in toto.

3.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-16 copies of documents and closed evidence. On the other hand, the learned counsel for the OP has produced Ex.OP-1 affidavit, Ex.OP-2 copy of insurance policy, Ex.OP-3 copy of letter dated 6.3.2017 and closed evidence.

4.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits  acceptance, for these reasons.

5.             It is an admitted fact between the parties that the complainant got family medicare insurance policy for the period from 16.1.2015 to 15.1.2016 from the OP for Rs.2,00,000/- on floater basis, as is evident from the copy of insurance policy Ex.OP-2 on record. It is also not in dispute that the complainant met with an accident on 19.11.2015 when she was returning from Chandigarh along with his family members and as such the complainant, her husband and her child were admitted in Civil Hospital Rajpura and from where they were shifted to Khanna for better treatment.  It is also an admitted fact that in the accident the teeth of the complainant were fractured for which she took treatment from Dr. Sidharath Phull of Sunam.  It is also not in dispute that the complainant submitted the documents to the OP for settlement of the claim.  But, the OP repudiated the claim of the complainant on the ground that treatment was taken on OPD basis only, whereas the admission was required in the hospital to get the claim.  Now, the question, which arises for determination before us is that whether the OP has rightly repudiated the claim or not.

6.             It is an admitted fact between the parties that the complainant suffered teeth in the fracture in an accident while she was coming from Chandigarh along with her family members on 19.11.2015.  Ex.C-6 is the identity card issued by the OP to show that the complainant is a member and covered under medicare policy.  Ex.C-7 is the copy of prescription slip dated 19.11.2015 issued by Ivy Hospital, Khanna, wherein it has been shown that the complainant, her husband Shri Abhishek Mittal and her son Himanksh Mittal were admitted in the hospital and took treatment and Ex.C-10 to Ex.C-12 are the copies of medical bills issued  by Ambica Medicos, Khanna for Rs.5580, Rs.236/- and Rs.2245/- and Ex.C-15 is the bill issued by Dr. Siddharth Phull of Sunam for Rs.48,500/-. Since it is an admitted fact on record that the complainant suffered teeth fracture only in the accident and in this case, we feel that there is no requirement of regular admission in the hospital, as obviously teeth treatment is given on various visits and the same can be taken without getting any admission in the hospital.  Further it is a matter of common knowledge that in the teeth treatment there is no requirement to remain admitted in the hospital.  Since it is an admitted case of the parties that the complainant suffered only teeth treatment, as such, we feel that the repudiation of the claim under exclusion clause 4.7 is not proper and in the teeth treatment there is no requirement of hospitalisation, more so when, it is proved on record that the complainant suffered fracture of teeth in the accident only on 19.11.2015 near Rajpura.  Further it is worth mentioning here that it is not the case of the OP that the complainant did not suffer any accident on 19.11.2015 and has filed a false claim to get undue benefit.  In the circumstances of the case, we feel that the OP has wrongly repudiated the claim of the complainant. As such, we feel that the ends of justice would be met if the OP is directed to pay to the complainant the claim amount of Rs.56,080/-.

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

8.             Accordingly, in view of our above discussion, we allow the complaint and direct the OP to pay to the complainant an amount of Rs.56,080/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 23.01.2017 till realisation.  We further order the OP to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and further an amount of Rs.5000/- on account of  litigation expenses.

9.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 16, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

                                                                (Sarita Garg)

                                                                    Member

                                                        (Vinod Kumar Gulati)

                                                                    Member