State Consumer Disputes Redressal Commission
Parveen Garg vs Niac on 9 November, 2012
PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 228 of 2008
Date of institution: 14.03.2008
Date of decision : 09.11.2012
Parveen Garg, Development Officer, Life Insurance Corporation of India,
Bathinda resident of 10, Bharat Nagar, Bathinda.
.....Appellants
Versus
1. The New India Assurance Company Limited, Regional Office, 4th
Floor, Surya Tower, 108, The Mall, Ludhiana - 141 001 through its
Regional Manager.
2. The New India Insurance Company Limited (Regd.) and Head Office
: New India Insurance, Assurance Building, 87, Mahatama Gandhi
Road, Mumbai through its Managing Director.
.....Respondent
First Appeal against the order dated 31.01.2008
passed by the District Consumer Disputes
Redressal Forum, Bathinda.
Before:-
Sardar Jagroop Singh Mahal,
Presiding Judicial Member
Shri Vinod Kumar Gupta, Member Argued by:-
For the appellant : Sh.Manish Bansal, Advocate For the respondent : Sh.R.K.Bhatti, Advocate for Sh.Puneet Sharma, Advocate JAGROOP SINGH MAHAL, PRESIDING JUDICIAL MEMBER This is complainant's appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 31.1.2008 passed by the learned District Consumer Disputes Redressal Forum, Bathinda (in short the District Forum) vide which the complaint was dismissed.
2. The case of the complainant is that he is covered under the group mediclaim policy of the OPs for the year 2005-06 and the First Appeal No.228 of 2008 2 amount of premium is being deducted from his salary every month. He had to undergo Dental Flap Surgery due to chronic periodontitis which according to him is a dangerous disease. The treatment was taken by him from Dental Clinic Orthodontic and Periodontic Centre, 1332, Sector 33-C, Chandigarh which continued for the period from 27.11.2005 to 13.1.2006 in six different sittings on which he spent a sum of Rs.30,000/-. The complainant applied to the OPs for payment of the compensation and submitted all the relevant documents but his claim was repudiated. The complainant, therefore, filed the present complaint for issuing directions to the OPs to reimburse the amount of Rs.30,000/- spent by him on his treatment and to pay him Rs.50,000/- as compensation for mental tension and physical harassment and Rs.10,000/- as litigation expenses.
3. The claim was opposed by the OPs alleging that as per the terms and conditions of the policy, the claim submitted by the complainant is not covered. It was alleged that voluminous evidence and the documents are required for determination of the case which is not possible in these summary proceedings. According to them, the dental clinic from which the treatment is alleged to have been obtained by the complainant does not fall under the definition of a hospital nor the complainant was ever hospitalised to become entitled to the payment of Rs.30,000/-. It was maintained that since the treatment was not taken in any hospital/nursing home as defined under the terms and conditions of the policy, the OPs were not liable to make the payment. Their contention is that they have rightly repudiated the claim and, therefore, the complainant is not entitled to any compensation. First Appeal No.228 of 2008 3
4. Both the parties were granted opportunity to adduce necessary evidence in the case in support of their contentions.
5. After hearing arguments of the learned counsel for the parties and perusing the record, the learned District Forum vide impugned order dated 31.1.2008 dismissed the complaint. The complainant has challenged the same through the present appeal.
6. We have heard arguments of the learned counsel for the parties and have perused the record.
7. Ex.C3 is the mediclaim insurance policy, on the basis of which, the complainant claims compensation. Clause 2.3 of the policy provides as follows : -
"2.3 Expenses requiring Hospitalisation for minimum period of 24 hours are admissible. However, this time limit will not apply to specific treatments, i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotrips (Kidney stone removal), Tonsillectomy, D & C taken in the Hospitalisation/Nursing Home, Anti Rabies Vaccine (Rabies) and the insured is discharged on the same day the treatment will be considered to be taken under hospitalisation Benefit."
8. In order to succeed in this complaint, it is necessary for the complainant to prove that he has taken treatment form a hospital/Nursing home and secondly that he remained admitted for a minimum period of 24 hours. There is an exception under Clause
(b) when due to technological advances hospitalisation is required for less than 24 hours only.
9. Clause 2.1 of Ex.C3 describes the hospital/nursing home meaning an institution established for indoor care and First Appeal No.228 of 2008 4 treatment of sickness and injuries. It should be registered as a hospital or nursing home with the local authorities and is under the supervision of registered and qualified Medical Practitioner. If it is not so, then it should comply with the minimum criteria that it should have atleast 15 in-patient beds, fully equipped operation theatre of its own and fully qualified nursing staff under its employment round the clock. The complainant has not produced any evidence to prove that the Dental Clinical satisfies any of these conditions. Admittedly, it is not an Institution for indoor care and treatment of the patients. No certificate has been produced to suggest if it has been registered as a hospital or nursing home with the local authorities. There is no evidence to suggest if the Dental Clinic has atleast 15 in-patient beds and has fully equipped operation theatre of its own. We are, therefore, of the opinion that the Dental Clinical does not satisfy the definition of hospital/nursing home.
10. As per Clause 2.3, the next requirement is the hospitalisation for minimum period of 24 hours. Admittedly, the complainant was not hospitalised for a period of 24 hours as indoor patient in the clinic. This condition could be waived under Sub Clause (b) where the treatment is such that the hospitalisation requires specialised infrastructure facilities or due to technological advances, hospitalisation is required for less than 24 hours only. In the present case, the complainant was not, at all, admitted as indoor patient and there was, therefore, no hospitalisation even for a period of less than 24 hours.
11. Viewed from any angle, we are of the opinion that the treatment taken by the complainant is not covered under the First Appeal No.228 of 2008 5 Group Mediclaim Policy obtained by him. The learned District Forum examined various provisions of the Policy vis-à-vis the facts of the case and rightly came to the conclusion that the complainant is not entitled to the compensation prayed for. We are, therefore, of the opinion that the complaint filed by the complainant was rightly dismissed. There is no merit in this appeal and the same is, accordingly, dismissed. Parties are left to bear their own costs.
Copies of the orders be supplied to the parties free of costs.
(JAGROOP SINGH MAHAL) PRESIDING JUDICIAL MEMBER (VINOD KUMAR GUPTA) MEMBER November 09, 2012.
Paritosh