State Consumer Disputes Redressal Commission
Shri Ramesh Inderchand Kothari vs The New India Insurance Co. Ltd on 6 February, 2010
CONSUMER DISPUTES REDRESSAL COMMISSION CONSUMER DISPUTES REDRESSAL COMMISSION MAHARASHTRA STATE, MUMBAI First Appeal no. 1320/2009 Date of Filing: 30/10/2009 Consumer Complaint No.242/2008 District Consumer Forum: Nashik Date of Order: 06/02/2010 1. Shri Ramesh Inderchand Kothari, Appellants 2. Sau Sangeeta Ramesh Kothari, (Org.Complainant) both R/at- Swagat Medicals, Raviwar Karanaja, Nashik-1 V/S Branch Manager, Respondents The New India Insurance Co. Ltd. (Org.Opp.Party) First Floor, Kapadia Commercial Complex, Old Agra Road, Nashik-1 Quorum : Justice Mr.S.B.Mhase, Hon'ble President Mr.S.R.Khanzode,Honble Judicial Member.
Mr.D.Khamatkar, Honble Member.
Present:
Adv.Mr.S.M.Jain for appellant.
Adv.Mr.S.Shenoy for respondent.
:- ORAL ORDER :-
Per Shri S.B.Mhase, Honble President :
This appeal can be disposed of finally at the stage of admission itself.
Complaint no.242/2008 was filed by the appellant before District Forum, Nashik making mediclaim against respondent company for Rs.45,524/-. The said claim has been rejected by the insurance company relying upon the exclusion clause 4.7 namely, any dental treatment or surgery which is a corrective, cosmetic or aesthetic procedure including wear and tear, unless arising from disease or injury and which requires hospitalisation for the treatment.
Admitted facts are that in respect of complainant root canal treatment was carried out by Dr.Kankaria and for the said purpose Dr.Kankaria has charged an amount of Rs.42,800/-. In respect of this amount the claim has been made. Form the receipt which is produced on record, it appears that charges were taken viz for consultation Rs.200/-, X-rays Rs.600/- and for root canal treatment (11,12,21,22) Rs.8,000/- and Crowns/bridge (Procera Crowns in 11, 12, 21,22) Rs.28,000/- and surgical treatment (Re-implementation of 21 and splinting of teeth) Rs.6,000/- and thus, total amount of Rs. 42,800/- has been claimed. It further appears from the said receipt that the dental treatment was given to the appellant/complainant for the oral and maxillofacial injuries due to the accident) form the duration of 24/07/2007 to 28/07/2007. Admittedly, in this period the appellant was not admitted in the hospital run by Dr.Kankaria and or the Dahale hospital, which has referred the patient to Dr.Kankaria. Therefore, all the treatment which the complainant/ appellant has received and has taken, he has admittedly is a outdoor patient and under these circumstances, the insurance company has relied upon the above referred clause.
Ld.Counsel Mr.Jain submitted before us inviting our attention to Definitions clause and prospectus of the mediclaim insurance company (revised) i.e. 2.0. He has vehemently relied upon definition of 2.3 which is as follows:
Expenses of Hospitalization for minimum 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), Tonsillectomy, DNC taken in the Hospital/Nursing Hone and the insured is discharged on the same day; treatment will considered under the hospitalisation Benefit.
Mr.Jain also relied upon the part of 4.7 upon which the insurance company also relies. We have noted the said clause above. From the said clause Mr.Jain relies upon the following portion:
unless arising from disease or injury or which requires hospitalisation for the treatment.
Then his submission is that whenever there is dental surgery wherein the patient was not admitted and after the treatment the patient was allowed to go home, such patients are covered under the clause no.2.3 and later part of 4.7 which is reproduced above and therefore, the repudiation of the claim on the part of insurance company is improper and the District Forum has committed error in accepting the contention of the insurance company and rejecting the complaint.
Ld.Counsel, who appeared for the insurance company submitted that 2.3 as interpreted by Adv.Jain is not correct. According to insurance company, initially to get the hospitalisation charges, the patient shall be admitted at least for 24 hours. However, he further submitted that in respect of the disease and treatment, which are shown in the subsequent part, the hospitalisation may not be necessary, if the insured is discharged on the same day and then the said treatment will be considered to be the treatment under the hospitalisation benefit. He also submitted that clause 4.7 will have to be read in full and it can not be segregated in two parts as is done by Adv.Jain. Any dental treatment or surgery which is a corrective, cosmetic or aesthetic treatment, procedure for the said treatment, the mediclaim cannot be made. He further submitted that even though such corrective, cosmetic or aesthetic treatment required to be carried out in case of accident, there should be hospitalisation for the same for minimum period of 24 hrs. and then only mediclaim can be made.
We have gone through both the clauses. What we have noted that clause no.2.3 is a clause arising in the definition clause and therefore, while interpreting whether there is hospitalisation or not hospitalisation, the said clause no.2.3 will have to be taken into consideration. The word dental surgery is not appearing in clause no.2.3. Therefore, whenever dental surgery has been carried out in a day without admitting the patient, the benefit of the hospital can be extended. However, in order to exclude from this clause, certain procedure have been mentioned. In that it is stated that any dental surgery or cosmetic or aesthetic procedure cannot be claimed to be the subject matter of the mediclaim. Only exception is whether corrective or cosmetic surgery is necessary as a result of disease or injury and which requires hospitalisation for the treatment. In short, after going through this claim, what we find that whenever dental surgery is required because of disease or injury as explained with a hospitalisation, then case can be considered for the medicalim, otherwise it cannot be considered. No doubt from the bills of Dr.Kankaria, it appears that the said procedure was carried out for the oral and maxillofacial injuries due to accident that means there was injury and for correction of the injury treatment of root canal was carried out. Prmia-facie, it may appear that the case is covered. However, the other part of the clause no. 4.7, stipulates requisite period/duration of hospitalisation for the treatment. In the present matter hospitalisation was not required. On the contrary the patient was discharged immediately and therefore, even though the case of the complainant may be of surgery due to accidental injury has a hospitalisation was not necessary and for the said purpose the claim has been rightly rejected. While reading the said clause we cannot ignore the conjunction and appearing in the said clause. Therefore, both the conditions namely, surgery and hospitalisation, both must accompany each other and then only mediclaim would lie. In the present matter, admittedly, there was no hospitalisation for the correction of the injuries and therefore, repudiation of the claim under clause no. 4.7 is justified. We find there is no substance in the appeal. Hence, we pass the following order:-
:-ORDER-:
1. Appeal stands dismissed.
2. Parties shall bear their own costs.
3. Dictated in open court.
4. Copies of the order herein be furnished to the parties.
(D.Khamatkar) (S.R.Khanzode) (S.B.Mhase) Member Judicial Member President Nbh