DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

  C.C. NO. 221/2023

Date of Institution: 15.05.2023

Judgment Reserved on: 22.12.2023

Judgment Passed on: 05.01.2024

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

Judgment By: Sh. S.S. Malhotra (President)

JUDGMENT

1. By this Judgment the Commission shall dispose off the complaint of the complainant alleging deficiency in service by OP in not reimbursing the medical bill with respect to his overseas dental treatment.
2. Brief facts stated by the complainant in the complaint are that the complainant through internet portal had a travel insurance policy on 16.06.2022 from OP and had paid Rs.28630/- vide receipt number RA070941372 for travel to UK and Canada for the period from 20.06.2022 to 26.09.2022 and the validity of this policy was further extended w.e.f. 13.07.2022 to 19.10.2022 by paying additional premium of Rs.9296/-. However on 04.10.2022 when the complainant was in Canada, he had an acute pain in his Jaw (Jabda) and was not able to eat, chew or drink and accordingly was rushed in emergency to the nearest dentist, where, the dentist after carrying out radiography of region, suggested  that future course of action is to be carried out in India as the treatment was not possible to be completed within his short stay period in Canada but immediate treatment was given for temporary relief and he paid 119.85 Canadian Dollars to the Doctor concerned and after coming back to India the complainant submitted his claim for Rs.7318.17 which is equivalent to 119.85 Canadian Dollars, but despite having received this claim, the OP denied the claim on the ground that treatment has been done by removal of crown of all decay and assess restorability of the decayed tooth. It is stated by the complainant that no treatment was provided by the Doctor at Canada for treatment of decay tooth by removal of crown as alleged but he only provided the emergency dental treatment which is well covered within the insurance policy i.e. “dental emergency treatment”. It is further stated that there was no issue with respect to the dental health when the complainant left India on 20.06.2022 nor he had any knowledge about the condition of his teeth at that time nor he had any problem in his teeth and therefore the ground taken by the OP is without any merit and is against the written documents given by the doctor concerned. The complainant even approached the office of Ombudsmen but the insurance company offered only 50% of the claim amount, which was not acceptable to the complainant and therefore after the dismissal of the matter before Insurance Ombudsmen, he filed the present case inter-alia praying that he be given Rs.7309.18 towards treatment, with interest @9% which comes to Rs.332/- and compensation of Rs.50000/- and OP also be directed to refund the policy amount of Rs.37926/- which was spent by the complainant for taking the policy.
3. The OP was served on 14.06.2023 but filed the written statement on 08.08.2023 i.e. beyond the statutory period and therefore it was ordered that the same would not be read for the purpose of defense of the OP and as such the Commission is of the opinion that there is no necessity to incorporate the facts of the WS herein.
4. The complainant has filed his own evidence alongwith written arguments. The Commission has heard the arguments and perused the record.
5. The admitted facts are that the complainant had the policy which covered dental emergency treatment and when he was in Canada he suffered acute pain in his Jaw (Jabda), he visited the doctor who conducted certain radiograph of region and Canadian Dollar of 119.85 which is equivalent to Rs.7309.18 were paid by the complainant which the OP did not reimburse, rather repudiated the claim. It is also quite surprising that complainant had paid an amount of Rs.37926/- towards premium and his claim was just of Rs.7300/- approximately which has been repudiated by the OP despite there being a valid policy of the OP.
6. The contention of OP, in the repudiation letter is that as per medical report provided, the diagnosis is for recurrent decay under, near the crown and the treatment has been done for tooth which has been decayed and since the treatment was with respect to decayed tooth, such condition starts prior to the policy start date, it means it was a pre-existing ailment. Apart from this simple repudiation letter the OP has not been able to put forward either its defense or writing any letter to the  complainant  seeking any clarification which may show as to  on  what  basis  the  OP  has  arrived  to  this  conclusion that  the  complainant had a pre-existing  disease.  Even  the  base  of  such  presumption  is   not   on  record  and therefore the opinion of the OP, which is merely based on the presumption cannot be accepted.  The law with respect to pre-existing disease contains two factors:
   1. That there should be such disease and that disease has been concealed intentionally by the complainant i.e. despite having knowledge of that disease, it was not disclosed.
   2. The OP was required to prove on record that complainant had a problem of tooth decay prior to taking of the policy and not only this, OP had also to prove that complainant was well within knowledge with respect to ailment and had concealed that ailment intentionally.
7. There is no such record filed by the OP in this regard and its opinion is in complete disregard to the settled principle of law.
8. Therefore the commission of the opinion that the complainant has been able to prove the deficiency on the part of OP and OP has not been able to prove that the complaint was suffering from pre-existing disease of dental decay. Accordingly, the complaint of the complainant is allowed thereby directing the OP to pay Rs.7309/- with interest @9 per annum alongwith compensation or Rs.15000/- from the date of filing the complaint till the realization.
9. The relief with respect to payment/return of the insurance amount however, is not allowed as once the premium has been paid and claim has been raised, the policy has now been utilized for the purpose for which it was taken and no benefit would ensue. Accordingly, this part of prayer is rejected.
10. This whole amount is payable by OP within 30 days from the date of receipt of the copy of the order, failing which this amount would carry the interest @ 18% per annum on whole amount of Rs.22309/- (including compensation amount) from the date of filing of complaint till it is actually paid.   
11. Copy of the Judgment be supplied/sent to all the parties free of cost as per rules.
12. Announced on 05.01.2024.
13. File be consigned to Record Room.