State Consumer Disputes Redressal Commission
United India Insurance Company, vs Dr.Indra Rupchand Ostwal, on 4 July, 2011
1 F.A.No. :06/2011
Date of filing:24.12.2010
Date of order:04.07.2011
MAHARASHTRA STATE CONSUMER DISPUTES REDRESSAL
COMMISSION, MUMBAI, CIRCUIT BENCH AT AURANGABAD.
F.A. NO.:06 OF 2011
IN COMPLAINT CASE NO. :169 OF 2010
DISTRICT FORUM : PARBHANI.
United India Insurance Company,
Through its Division office
Aurangabad Division Aurangabad,
Through Divisional Manager. ...APPELLANT
(Org.Opp.No.2)
VERSUS
1. Dr.Indra Rupchand Ostwal,
R/o Ostwal Hospital Indraprast
Doctor Colony, Near Bus stand,
Parbhani.
2. Managing Director,
India Health Care Service(TPA) Ltd,
S.No.46/1 E Space, A-2 Building,
Third Floor, Pune-Nagar Wadgaonshevri,
Pune. ...RESPONDENTS
(No.1-Org.Complainant,
No.2-Org.Opp.No.1)
Coram : Mrs.Uma S.Bora, Hon`ble Presiding Member.
Shri.K.B.Gawali, Hon`ble Member.
Present : Adv.Shri.S.V.Kulkarni for appellant, Adv.Smt.Asha Rakh for respondent.
O R A L O R D E R Per Mrs.Uma S.Bora., Hon`ble Presiding Member.
1. United India Insurance Company, Aurangabad challenges in this appeal the judgment and order passed by Dist.Forum, Parbhani on 15.11.2010 while deciding complaint case No.169/2010.
2 F.A.No. :06/20112. The facts giving rise to this appeal are as under.
Complainant Dr.Indra Rupchand Ostawal is doctor by profession and resident of Parbhani. Since 2006 he used obtained mediclaim policy for Rs.1,25,000/-. For the period 14.8.2008 to 13.08.2009 he obtained policy No.230601/48/08/97/000650. On 20.7.2009 there was trouble in his teeth. Therefore he approached dentist Dr.Chandak at Parbhani. After primary investigation complainant was advised to go to Aurangabad for further treatment. Accordingly, on 21.7.2009 complainant approached Dr.Deokar in 'Saket Multi Specialty Dental Clinic', Aurangabad. After taking x-ray it was found that in some teeth there is infection. It was advised by said doctor that root canal treatment with ceramic bridge is to be conducted. Accordingly said treatment was taken by complainant. For the said treatment complainant required to spend Rs.25,606.85/- as expenses. As complainant is mediclaim policy holder he filed his claim for said expenses. On 22.8.2009 his claim repudiated on the ground that as per Exclusion Clause No.4.7 his claim is not permissible. Therefore he approached Dist.Forum by demanding compensation.
3. Appellant Insurance Company appeared before the Forum and resisted the claim. It is submitted by Insurance Company that his claim was investigated by the mediclaim expert team and it was found that complainant did not took the treatment as per policy condition. As per policy condition Clause No.4.7 " Dental treatment or surgery of any kind unless requiring hospitalization". As per contention of Insurance Company complainant is not entitled to mediclaim as he was not admitted in any hospital for minimum 24 hours.
4. After hearing both the parties Dist.Forum allowed the complaint and directed appellant to pay Rs.25,606.85/- with interest @ 9% from 3 F.A.No. :06/2011 2.8.2009. Forum also directed appellant to pay Rs.3000/- towards mental agony and Rs.1000/- towards cost.
5. Dissatisfied with the said judgment and order, United India Insurance Company came in appeal.
6. Adv.Shri.S.V.Kulkarni appeared for appellant, Adv.Smt.Rakh appeared for respondent No.1. It is submitted by counsel for appellant that treatment taken by complainant is not come under purview of policy condition. As per policy condition complainant is to be admitted in the hospital for minimum 24 hours. As in the present case complainant only took the treatment without admitting in the hospital he is not entitled to any mediclaim amount.
7. Adv.Smt.Asha Rakh for respondent No.1 submitted that complainant is medical practitioner and he continuously used to obtain mediclaim policy. Policy document which was produced by Insurance Company on record does not contain the Sub-clause No.2.3 of the definition clause. Policy document which was supplied to the complainant is included Clause No.2.3 of definition and as per said definition for the dental surgery there is no need of admission in the hospital for minimum 24 hours. Sub-clause 2.3 of Definition clause of policy reads as under.
"Expenses on Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy(Kidney Stone Removal), D & C, Tonsillectomy taken in the hospital /Nursing home and insured is 4 F.A.No. :06/2011 discharged on the same day, the treatment will be considered to be taken under hospitalization benefit".
It is submitted by Adv.Smt.Rakh that Dist.Forum rightly allowed the complaint.
8. We heard both the counsels and perused the record. As per Clause No.4.7 'Dental treatment or surgery of any kind unless requiring hospitalization' is excluded from mediclaim. But Sub-clause No.2.3 of definition clause is clearly explained that for dental surgery hospitalization of minimum 24 hours is not necessary. It is also reveal from the record that policy document which was produced by Insurance Company on record did not contain the clause of definition but policy document supplied to complainant with said clause. In these circumstances we are of the view that Dist.Forum rightly appreciated the facts and record. We do not want to interfere the judgment and order passed by Dist.Forum. We pass the following order.
O R D E R
1. Appeal is dismissed.
2. Appellant to pay Rs.2000/- as cost to the respondent No.1 in appeal.
3. Respondent No.1/org.complainant is entitled to withdraw Rs.25,000/- which were deposited by the appellant in this Commission at the time of filing appeal.
4. No order as to cost.
5. Pronounced and dictated in the open court.
6. Copies of the order be sent to both the parties.
5 F.A.No. :06/2011K.B.Gawali, Mrs.Uma S.Bora Member Presiding Member Mane