Chandigarh

StateCommission

A/156/2023

NATIONAL INSURANCE CO. - Complainant(s)

Versus

P. S. BEDI & OTHERS - Opp.Party(s)

R.C GUPTA

22 Aug 2023

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	156 of 2023
Date of Institution	:	05.07.2023
Date of Decision	:	22.08.2023

 

 

 

 

 

 

National Insurance Company through its authorized officer, Mumbai Corporate Regional Office, 2^nd Floor, 14 Jamshedji Tata Road, Churchgate, Mumbai – 400020 now through its authorized signatory of Chandigarh Regional Office, SCO No.332-334, Sector 34-A, Chandigarh.

….Appellant/Opposite Party No.1.

Versus

1]      Sh. P. S. Bedi s/o Sh. N. S. Bedi, Aged 71 years resident of House No.1154, Sector 8-C, Chandigarh.

...Respondent/Complainant.

2]      The Heritage Health Insurance TPA 506, 5^th Floor, Tower Near Radisson Blue Hotel, TonkDurgapnee Jaipur – 302018

          2^nd Address: 5^th Floor, Nicco House, 2 Hare Street Bagh, Kolkatta – 700001. (Given up vide order dated 18.10.2022).

3]      The Authorized Officer, IRDA Nanakramguda, Gachilbowli, Hyderabad – 500032.

4]      Indian Bank Association through its authorized officer, 6^th Floor, Centre 1, Building World Trade Centre 1 Cuff Parade, Mumbai.

          ...Respondents/Opposite Parties No.2 to 4.

 

BEFORE:           MR. RAJESH K. ARYA, PRESIDING MEMBER

                        MR. PREETINDER SINGH, MEMBER

 

ARGUED BY :-  

Sh. R. C. Gupta, Advocate for the appellant.

Sh. P. S. Bedi, respondent No.1 in person.

Respondent No.2 already given up vide order dated 18.10.2022 before District Commission-II, U.T., Chandigarh.

Service of respondents No.3 & 4 dispensed with vide order dated 11.07.2023.

PER  RAJESH  K. ARYA, MEMBER

                   This appeal has been filed by opposite party No.1 - National Insurance Company (appellant herein) against order dated 17.05.2023 passed by District Consumer Disputes Redressal Commission-II, U.T., Chandigarh (in short ‘District Commission), vide which, consumer complaint No.672 of 2021 filed by the complainant – P. S. Bedi (respondent No.1 herein) has been allowed against the appellant by directing it to reimburse an amount of Rs.64,525/- to respondent No.1 with 9% interest from the date of repudiation i.e. 23.04.2021 till realization besides awarding Rs.15,000/- as compensation and Rs.10,000/- as costs of litigation. The order has been directed to be complied with within a period of 45 days from the date of receipt of its certified copy, failing which, the appellant has been directed to pay additional cost of Rs.10,000/-. However, the complaint was dismissed against opposite parties No.3 & 4.

2]                Briefly stated the facts as culled from the impugned order are that respondent No.1 took Group Insurance Policy being retired employee of Punjab National Bank through IBA from National Insurance Company and accordingly, respondent No.2/opposite party No.2 - The Heritage Health Insurance TPA issued Health Cards, to respondent No.1 and his wife, bearing No.HHS100700310313 and 314. They got dental treatment from Clove Dental and incurred expense to the tune of Rs.64,525/-.  When respondent No.1 lodged the claim with the appellant, the same was rejected by the appellant. Hence, consumer complaint was filed before the District Commission.

3]                On the other hand, the appellant/Opposite Party No.1 – National Insurance Company Ltd. pleaded that the insurance company vide letter dated 23.4.2021 repudiated the claim under Clause 4.16 of the policy  on the ground that any expenses whatsoever incurred by the insured person in connection with or in respect of dental treatment or surgery of any kind which are done in dental clinic and those that are cosmetic in nature are not payable under the insurance policy. It was further pleaded that respondent No.1 had not taken the dental treatment on account of injury, therefore, the same was not covered under the definition of ‘emergency dental treatment” and the insurance policy.

4]                Record of District Commission transpires that opposite party No.2 (respondent No.2 herein) was given-up by respondent No.1/complainant in the consumer complaint vide order dated 18.10.2022.

5]                However, respondent No.3/opposite party No.3 - IRDA pleaded that the whole claim made by respondent No.1 wasagainst the Insurance Company and no relief had been sought against it.

6]                Nobody turned up despite service of notice on behalf of respondent No.4/opposite party No.4 - Indian Bank, before the District Commission, therefore, it was proceeded exparte vide order dated 18.10.2022 by the District Commission.

7]                After hearing the contesting parties and going through the material available on record, the District Commission allowed the complaint against the appellant whereas it was dismissed against opposite parties No.3 & 4, as stated above.

8]                The order of the District Commission has been assailed on the ground that the District Commission has failed to take notice of the fact that the treatment taken by respondent No.1 and his wife was neither because of accidental injuries nor any illness but the same was caused on account of normal wear and tear of the denture and further implant placed. It has further been stated that the District Commission in an incorrect and arbitrary manner relied upon Clause 2.12 i.e. definition of dental treatment and Clause 2.15 with respect to emergency dental treatment and on endorsement on the treatment card that this procedure was emergency and for functional rehabilitation. It has further been stated that the District Commission also ignored the operative clause and the coverage under Clause 1.2 of the Policy and the exclusion clause 4.16, which says that dental treatment or surgery of any kind whichare done in a dental clinic and those are cosmetic in nature are excluded. It has further been stated that even expert opinion sought by respondent No.1 says that the tooth implant is a surgical procedure and as per terms and conditions of the contract of insurance, the same is excluded from the coverage as per policy condition 4.16.

9]                On the other hand, respondent No.1 appeared in person and argued that the policy is being taken since 2015 and dental problems are covered under policy clause 2.12 and thus, the District Commission rightly passed the award. He further argued that it was a Group Insurance Policy and there is no age limit for the same. He further argued that Clause 1.2 clearly mentions that if insured person suffers any illness or diseases or sustains bodily injury due to an accident, it is covered. It has further been argued that the exclusion clause 4.16 is only for cosmetic treatment, which was not there in his case and Dental Council of India has clarified in its executive committee meeting held on 22.01.2021 that tooth implant is a surgical procedure. Lastly, respondent No.1 prayed for dismissal of the appeal with costs.

10]              After hearing the Counsel for the appellant and respondent No.1 in person and going through the documentary evidence/material available on record, we are of the considered view that the appeal is liable to be dismissed for the reasons to be recorded hereinafter. The sole basis of repudiation of claim of respondent No.1 is Clause 4.16 of the Policy, which reads thus:-

                             "4.16 Dental treatment or surgery of any kind which                                      are done in a dental clinic and those that are cosmetic                                   in nature."

11]              From bare reading of this clause 4.16, it is clear that the purpose of this very clause is to exclude any kind of dental treatment or surgery of any kind, which are done in a dental clinic including those, which are cosmetic in nature, out of the purview of the coverage under the Policy. However, in the instant case, the documentary evidence available on record of the District Commission makes it abundantly clear that the treating doctor specifically opined that the case of respondent No.1 was taken up as an emergency procedure as he was having severe pain and swelling was increasing. The said doctor further mentioned that procedure done was neither the cosmetic procedure nor elective and rather was purely emergency with functional rehabilitation. The doctor further opined that if the same was not done, it could lead to life threatening complications. Further, as per the Dental Council of India, the tooth implant is a surgical procedure and in our opinion, such surgical procedure could either be undertaken in a clinic or a hospital. It may also be stated here that it is very common that for any kind of treatment, whether it is dental or else, one has to go to the hospital or a clinic. It is also very common that health issues/problems of various kinds including dental problems do occur to a person of an age of a Senior Citizen like respondent No.1 is and when we specifically talk of dental issues, it can occur in any age. Therefore, this Commission feels that the Insurance Companies should come forward and consider the claims of the consumers in such like situations and curtail the practice of repudiating the genuine claims under the Policy. In our opinion, incorporating such exclusions in the policy ousting the dental treatment or surgery of any kind done in a dental clinic goes against the interest of the consumer and is totallyunconscionable. It was not on account of any wear and tear of denture as neither respondent No.1 nor his wife ever got the denture. Thus, the procedure done by the treating doctor being surgical one under emergent conditions and not cosmetic, therefore, it was very much covered under Clause 1.2 operative Clause of the Policy. Therefore, in our concerted view, the District Commission rightly held that such hyper technical ground to deny the claim of respondent No.1 was unjustified and amounted to unfair trade practice. We are further of the considered view that the District Commission rightly vide the impugned order directed the appellant to reimburse the claim alongwith interest besides awarding compensation and litigation costs. Therefore, the order of the District Commission, being just and legal, is liable to be upheld and the appeal deserves dismissal.

12]              For the reasons recorded above, the appeal being devoid of any merit is dismissed with no orders as to costs.

13]              Certified copy of this order be sent to the parties free of charge.

Pronounced.

22.08.2023.

(RAJESH K. ARYA)

PRESIDING MEMBER

 

 

 

 

(PREETINDER SINGH)

MEMBER

 

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