State Consumer Disputes Redressal Commission
United India Insurance Co. Ltd. vs Sonia Mittal on 25 October, 2017
Daily Order 2Nd ADDITIONAL BENCH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH. First Appeal No.538 of 2017 Date of Institution: 17.07.2017 Order Reserved on : 10.10.2017 Date of Decision: 25.10.2017 United India Insurance Company Limited, Divisional Office, Railway Road, Sangrur through Sh. Parveen Gupta, Deputy Manager, United India Insurance Company Limited, Regional Office, SCO 123-124, Sector 17-B, Chandigarh. Appellant/Opposite party Versus Smt. Sonia Mittal w/o Sh. Abhishek Mittal, c/o Jagan Nath Amar Nath, Shop No.112, Old Grain Market, Sunam Distt. Sangrur. respondent/complainant First Appeal against order dated 16.05.2017 passed by the District Consumer Disputes Redressal Forum, Sangrur. Quorum:- Shri Gurcharan Singh Saran, Presiding Judicial Member. Shri Rajinder Kumar Goyal, Member Present:- For the appellant : Sh. D.P. Gupta, Advocate For the respondent : Sh. B.B. Bagga, Advocate RAJINDER KUMAR GOYAL MEMBER :- ORDER
The appellant/opposite party (hereinreferred to as OP) has filed the present appeal against the order dated 16.05.2017 passed in Consumer Complaint No.34 by District Consumer Disputes Redressal Forum, Sangrur (herein after referred as District Forum) vide which the complaint filed by the complainant was allowed and directed 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 realization. It was further directed to pay to the complainant an amount of Rs.5000/- as compensation and Rs.5000/- on account of litigation expenses.
2. Complaint was filed by the respondent/complainant (hereinafter referred as complainant) under Consumer Protection Act, 1986 (in short, "the Act") against the OP on the averments that the complainant got a family medicare insurance policy bearing number 1117022814P108532793 for the period from 16.1.2015 to 15.1.2016 from Op. 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. It was 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, & 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 prayed that the OPs be directed to pay Rs.56,080/- along with interest @ 18% per annum from the date of treatment till realization and further be directed to pay Rs.50,000/- on account of mental torture, agony, inconvenience and Rs.22,000/- as litigation expenses.
3. Upon notice , OP contested the complaint and filed their written reply taking preliminary objections 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 was admitted that the complainant obtained the policy in question from the OP for the period from 16.1.2015 to 15.1.2016. It was 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 cannot be covered as hospitalization required to get the claim. It was denied that there is any deficiency in service on the part of OP. Complaint is without merit and it be dismissed with special costs.
4. Before the District Forum the parties led their respective evidence.
5. In support of the allegations the complainant had tendered in evidence the affidavit as Ex.C-1, Ex.C-2 to Ex.C-16 copies of documents and closed evidence. On the other hand, the learned counsel for the OP had tendered in evidence the affidavit as Ex.OP-1, Ex.OP-2 copy of insurance policy, Ex.OP-3 copy of letter dated 6.3.2017 and closed the evidence.
6. After going through the allegations as alleged in the complaint, written version filed by OP evidence and documents brought on record, the complaint filed by the complainant was allowed as referred above.
7. Aggrieved with the order passed by the District Forum, the appellant/opposite party has filed the present appeal.
8. We have heard the learned counsel for the appellant/opposite party and respondent/complainant and had perused the record carefully.
9. Counsel for the appellant/opposite party argued that the claim has been repudiated as per policy terms and conditions wherein treatment taken on OPD basis is not covered. It was further stated that exclusion Clause 4.8 provides that dental treatment or surgery should have been necessitated by the accident and in addition it will also require hospitalization. In the present case, there was accident but there was no hospitalization. He further argued that District Consumer Forum has awarded Rs.56,080/- by mis-calculations as receipt is only of Rs.48,500/- on account of dental treatment by Dr. Siddharth Dental Practice,Sunam and the other bills if pertaining to the complainant are not for dental treatment.
10. Counsel for the respondent argued that as per Clause 1.2i of the policy document, in case of dental surgery a period of minimum 24 hours hospitalization is not applicable. Further argued that for the treatment of fracture in the teeth no admission in the Hospital is required. As such the claim is justified. No merit in the appeal. It be dismissed.
11. We are of the opinion that the dental treatment got done by the complainant from Dr. Siddharth Denal Practice, Sunam was necessitated due to accident occurred on 19.11.2015. Counsel for the appellant has contended that the claim of the complainant is not covered under the policy terms and conditions. Therefore, we are to check the relevant terms and conditions of the policy to verify whether the claim of the complainant is covered under the policy terms and conditions. Under Clause-4, Exclusions have been defined and Clause 4.8 reads as under:-
"Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization."
According, to this clause the treatment of complainant should be related to accident and also required hospitalization. In this case, there is no dispute that the injuries were received by the complainant in the accident necessitated her dental treatment. With regard to hospitalization counsel for the OP has referred to Clause 3.14 which reads as under:-
HOSPITALIZATION "Means admission in a Hospital/Nursing Home for a minimum period of 24 In-patient care consecutive hours except for specified procedures/treatments, which such admission could be for a period of less than 24 consecutive hours".
According to which 24 hours admission in the hospital is necessary. However, counsel for the complainant has referred to Clause 1.2i which reads as under:-
"Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, such as, 1 Adenoidectomy 13 Radiotherapy 25 Parenteral chemotherapy 2 Appendectomy 14 Lithortripsy 26 Polypectomy 3 Ascitic/Pleural Tapping 15 Incision and Drainage of abcess 27 Septoplasty 4 Auroplasty 16 Varicocelectomy 28 Piles/Fistula 5 Coronary angiography 17 wound suturing 29 Prostate 6 Coronary angioplasty 18 FESS 30 Sinusitis 7 Dental Surgery 19 Haemo Dialysis 31 Tonsillectomy 8 Dilatation & Curettage 20 Fissurectomy/Fistulectomy 32 Liver aspiration 9 Endoscopies 21 Mastoidectomy 33 Scerotherapy 10 Excision of Cyst/Granuloma/Lump 22 Hydrocele 34 Varicose Vein ligation 11 Eye Surgery 23 Hysteretomy
12 Fracture/Dislocation excluding hairline fracture 24 Inguinal/ventral/Umbilical/femoral hernia This condition will also not apply in case of stay in hospital is less than 24 hours. Therefore, under this Clause, 24 hours admission in case of dental surgery is not required. Therefore, the Clause 3.14 as referred by the counsel for the OP will not apply in this case. We are of the opinion that according to Clause 1.2I the claim of the complainant is covered according to the terms and conditions of the policy.
12. It was next argued by the counsel for the Op that the claim of Rs.56080/- is not admissible to the complainant. Accordingly to the plea prepared by the Doctor who treated the complainant is of Rs.48,500/- (Ex.C-5). He further contended that perhaps the District Forum while allowing the amount added the bills Ex.C-10 and Ex.C-8, these bills related to OPD treatment and not relevant to the dental surgery & in case of other treatments 24 hours admission in the hospital is necessary which is not in this case. Therefore, the complainant will be entitled only the claim for dental surgery which comes to Rs.48,500/-
13. No other point was argued.
14. Sequel to the above, we partly accept the appeal instead of Rs.56,080/- the complainant will be entitled to Rs.48,500/- other directions given by the District Forum will remain the same.
15. The appellant had deposited an amount of Rs.25000/- with this Commission at the time of filing the appeal and another amount of Rs.25,000/-in compliance with the order dated 20.07.2017. These amounts along with interest accrued thereon, if any, be remitted by the registry to the concerned District Forum, after the expiry of 90 days, from the dispatch of the certified copy of the order to the parties; subject to stay, if any, by the higher Fora/Court for release of the above amount and the District Forum may pass the appropriate order in this regard.
16. The appeal could not be decided within the statutory period due to heavy pendency of the Court cases.
17. Copy of the order be communicated to the parties as per rules.
(Gurcharan Singh Saran) Presiding Judicial Member October 25, 2017 (Rajinder Kumar Goyal) PK/- Member