Punjab

Ludhiana

CC/21/201

Harinder Singh - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

complaint in person

03 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 201 dated 09.04.2021.                                                        Date of decision: 03.07.2024. 

 

Harinder Singh Dhall aged 75 years son of S. Mohinder Singh, Resident of 304-C, Model Town Extension, Ludhiana. 94631-63830.

                                                                                      ..…Complainant

                                                Versus

M/s. United India Insurance Company Limited, Registered & Head Office: 24, Whites Road, Chennai-600014, through its Managing Director/Director/Authorized Signatory/Chairman.                                                                                                                                   …..Opposite party 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. M.S. Sethi, Advocate.

For OP                           :         Sh. R.K. Chand, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant being a retiree of State Bank of India was covered under Corporate Insurance Policy of OP vide policy No.1202002818P114211757  valid up to  15.01.2020 for Rs.3,00,000/-, the premium of which was auto debited from his savings account No.10883294411 with State Bank of India, Civil Lines, Ludhiana. The complainant lodged a claim of Rs.1,26,680/- with the OP vide claim No.54551920474606, which the complainant denied on flimsy grounds without making any enquiry. The complainant stated that he fell from stairs of his house situated at Jalandhar and got hairline fracture on his lower jaw  causing loss of dental bridge, duly mentioned in the history report dated 18.12.2019 of Harpreet Eye and Dental Care Centre, Jalandhar. The complainant undergone Rehab Full Lower Arch with Bicortical Implants surgery of lower jaw for the recovery. The complainant remained admitted in the hospital from 18.09.2019 to 20.09.2020 for treatment upon which he spent Rs.1,26,680/-. On 27.09.2019, the complainant submitted all the bills and medical reports with the OP for reimbursement of his claim. However, the OP denied the claim by stating that the case of the complainant is not an accidental case nor the condition of 5 rooms is applicable in the case of dental and lower jaw treatment. The complainant further stated that he filed a complaint before Insurance Ombudsman but his claim was not accepted. The complainant made several requests to the OP to settle his claim but to no effect. The complainant claimed to have suffered mental tension and agony due to deficiency in service on the part of the OP for which he is entitled to compensation. In the end, the complainant has prayed for issuance of direction to the OP to pay Rs.1,26,680/- along with compensation of Rs.50,000/- and litigation expenses of Rs.10,000/-.

2.                Upon notice, the OP appeared and filed written statement and assailed the complaint by taking preliminary objections on the ground of maintainability; lack of jurisdiction; suppression of material facts etc. The OP stated that on receipt of the claim, it was entertained, registered and referred to M/s. Raksha Health TPA Pvt. Ltd. and the complainant was requested to submit the documents in support of his claim. M/s. Raksha Health TPA Pvt. Ltd. Processed the claim and found that the claim of the complainant is not payable and returned the file to the OP with his observation and opinion in his report. On receipt of report, the officials of the OP scrutinized the file of the complainant and found that the claim is not payable and repudiated the same vide repudiation letter dated 18.10.2021 in terms of exclusion clause 4.8 of the policy. According to the OP, the claim of the complainant was rightly repudiated.

                   On merits, the OP reiterated the crux of averments made in the preliminary objections. The OP has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy ID Card issued by the OP, Ex. C2 is the copy of claim Form dated 23.09.2019, Ex. C3 is the copy of Email, Ex. C4 is the copy of clinical notes of Harpreet Eye and Dental Care Centre, Ex. C5 is the copy of discharge summary, Ex. C6 is the copy of receipt of Rs.600/- dated 18.09.2019 of Jalandhar OPG Centre and copy of X-ray report, Ex. C7 is the copy of bill of Rs.480/- dated 18.09.2019, Ex. C8 is the copy of receipt of Rs.600/- dated 21.09.2019 of Jalandhar OPG Centre and X-ray report, Ex. C9 is the copy of receipt of Rs.200/- dated 18.09.2019, Ex. C10 is the copy of receipt dated 18.09.2019 and closed the evidence.

4.                On the other hand, the counsel for the OP tendered affidavit Ex. RW1/A of Ms. Nirmala Joshi, A.M. of the OP as well as affidavit Ex. RW1/B of Dr. Amandeep Singh, Regional Manager of M/s. Raksha Health Insurance TPA Private Limited, Ludhiana along with documents Ex. R1 is the copy of report of TPA dated 19.10.2019, Ex. R2 is the copy of Claim Form dated 23.09.2019, Ex. R3 is the copy of discharge summary, Ex. R4 is the copy of ID Card of the OP, Ex. R5 is the copy of Aadhar Card of the complainant, Ex. C6 and Ex. C7 are the copies of receipts dated 18.09.2019 and 19.09.2019, Ex. R8 is the copy of receipt dated 21.09.2019, Ex. R9 is the copy of receipt of Rs.600/- dated 18.09.2019 of Jalandhar OPG Centre, Ex. R10 is the copy of X-ray report, Ex. R11 is the copy of receipt of Rs.600/- dated 21.09.2019 of Jalandhar OPG Centre, Ex. R12 is the copy of X-ray report, Ex. R13 is the copy of prescription slip dated 18.09.2019, Ex. R14 is the copy of clinical notes of Harpreet Eye and Dental Care centre, Ex. R15 is the copy of receipt of Rs.480/- dated 18.09.2019 of Dr. Harpreet Eye & Dental Care Centre, Ex. R16 is the copy of receipt of Rs.200/- dated 18.09.2019, Ex. R17 is the copy of repudiation letter dated 18.10.2021, Ex. R18 is the copy of insurance policy and closed the evidence. 

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement along with affidavits and documents produced on record by both the parties.

6.                The complainant, a senior citizen of more than 75 years of age, being a retiree of State Bank of India availed insurance policy namely Group Health Policy (Tailor Made) Ex.R18 from the OP. The complainant got himself admitted in Harpreet Eye and Dental Care Centre at Jalandhar on 18.09.2019 with the complaint of difficulty in chewing of teeth in lower Arch. According to the complainant, he sustained hairline fracture on his lower jaw due to fall from stairs of the house situated at Jalandhar. Further according to the complainant, he remained hospitalized from 18.09.2019 to 20.09.2019 for the treatment and discharge summary is Ex. C5. He spent an amount of Rs.1,26,680/- upon his treatment for which he preferred a claim with the OP vide claim form Ex. C2 = Ex. R2. The claim was investigated by Dr. Vaibhav, MBBS of M/s. Raksha Health Insurance TPA Pvt. Ltd. And he recommended the repudiation of claim vide report Ex. R1. The operative part of Ex. R1 regarding observation and opinion as per submitted documents is reproduced as under:-

                   “Observation and Opinion (as per submitted documents)

C/o hair line fracture due to fall from stair lower jaw leading to loss of teeth (rehab bicortical implants lower arch). As per available records the prescription dated 18/09/2019, Patient is having complaint of difficulty in chewing for which full lower arch with bio cortical implant were implants were advised. There is no history of any injury mentioned in this prescription. Dental implantation done on 18/09/2019 and 21/09/2019 on OPD basis. There is no hospitalization as the hospital has only clinical set up. The treatment is also OPD based treatment and do not require hospitalization. There is no other injury in the patient which happens due to fall from stairs in a 73 years hypertensive patient. Dental treatment falls under permanent exclusion of policy. Hence claim non payable as per clause 4.8. Hence, claim is recommended for repudiation & claim file is being sent to you for required action.”

7.                The reports and documents submitted by the complainant were scrutinized by the officials of the OP and found that the claim is not payable vide repudiation letter dated 18.10.2021 Ex. R17 for the following reasons:-

“We refer to your claim submitted for reimbursement of Hospitalization expenses. On going through the claim papers, we observe that the claim is not payable on account of the following:

• The Patient Harinder Singh was admitted in Harpreet Eye And Dental Care Centre (Jalandhar) with the case of hair line fracture due to fall from stair lower jaw leading to loss of teeth, rehab bicortical implants lower arch.
• The said case is of dental treatment in which treatment taken by insured in form of dental implant.
• As per available records the prescription dated 18/09/2019, Patient is having complaint of difficulty in chewing for which full lower arch with bio cortical implant were implants were advised.
• There is no history of any injury mentioned in this prescription. Dental implantation done on 18/09/2019 and 21/09/2019 on OPD basis.
• There is no hospitalization as the hospital has only clinical set up. The treatment is also OPD based treatment and do not require hospitalization.
• There is no other injury in the patient which happens due to fall from stairs in a 73 years hypertensive patient.
• Thus we are unable to make pay-abilitty of the claim. Hence the claim is being repudiated as per policy clause 4.8”

The denial clause/s with description is/are reproduced below for your ready reference:

As per Clause 4.8: Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization.

Since the claim does not fall within the purview of the Policy terms conditions, we regret our inability to admit the claim. If you have any other information or documents to substantiate admissibility the claim, please provide the same within 15 days of receipt of this letter.

We also reserve the right to repudiate the claims on the grounds available to us subsequently.”

 

8.                Now the point of determination arises whether the OP was justified in repudiating the claim?

9.                Ex. R18 is the Tailor Made Group Health Policy meant for retirees of State Bank of India. Before adverting the case on merits, the relevant clauses of the policy terms and conditions required to be reproduced as under:-

                   “2.1 Accident:

An accident is a sudden, unforeseen and involuntary event caused by external, visible and violent means.

2.14 Hospitalization:

Hospitalization means admission in a Hospital/Nursing Home for a minimum period of 24 consecutive hours of inpatient care except for specified procedure/treatments, where such admission could be for a period of less than 24 consecutive hours.

4.7. Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization.”

 

10.              At the time of admission, a prescription slip was generated by Dr. Nancy Dhiman and its two version have been brought on record, one is Ex. C4, the other is Ex. R14. Both are discrepant with regard to the age of the patient and history of incident. In Ex. C4, the age has been mentioned as 74 years and under the heading of complaint and it is recorded therein that the patient gave history of fall from stair case, whereas in Ex. R14 since the age is recorded as 73 years and no history of fall has been mentioned. According to the counsel for the OP, Ex. R14 was submitted by the complainant at the time of submitting the claim. So the contradictions with regard to age and history remained un-reconciled and thus causing a serious doubt with regard to version of the complainant. The complainant is permanent resident of Ludhiana and it has not brought on record how he travelled to Jalandhar. The house in which he was staying whether that was owned by him or he was staying as a guest in the house of some relative. Further no date, time and place of alleged fall has been pleaded or proved by the complainant.

11.              The prescription and the bill of Harpreet Eye and Dental Care Centre, Jalandhar does not reflect that it is a super specialist dental hospital equipped with in door facilities. The medical record produced of said dental care centre do not reflect that at the time of admission, the concerned doctor ever advised the admission to the hospital. No IPD record or treatment chart has been brought on record by the complainant to substantiate his claim that he actually remained admitted in the hospital. Further there is no corresponding injury on the face, lips or any other part of the body of the complainant to corroborate the fact of fall by the complainant. So in these circumstances, even if assuming that the complainant had taken the treatment from the said Harpreet Eye & Dental Care Centre, Jalandhar but the complainant could not establish that the said injury was due to fall or he was hospitalized for three days for the purpose of dental treatment. The clinic set up of the said hospital is not equipped to cater dental services for indoor patients. Even the dental OPG X-ray was conducted from another centre known as Jalandhar OPG Centre. Meaning thereby the primary X-ray facility was also not present in Harpreet Eye & Dental Care Centre. So the OP has rightly invoked clause 4.7 of the policy although same has been inadvertently mentioned as 4.8 in the repudiation letter Ex. R17.  So the complainant has failed to discharge initial onus to prove the deficiency in service on the part of the OP by any cogent and convincing evidence.  The Hon’ble Supreme Court of India in its judgment in SGS India Ltd. Vs Dolphin International Ltd. in Civil Appeal No.5759 of 2009 decided on 06.10.2021 (LL 2021 SC 544) by the Hon’ble Supreme Court of India while relying upon on its own judgment reported as Ravneet Singh Bagga v. KLM Royal Dutch Airlines & Anr. As well as Indigo Airlines v. Kalpana Rani Debbarma & Ors. (LL 2021 SC 544), has held as under:-

“19.  The onus of proof of deficiency in service is on the complainant in the complaints under the Consumer Protection Act, 1986. It is the complainant who had approached the Commission, therefore, without any proof of deficiency, the opposite party cannot be held responsible for deficiency in service.”

12.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.  

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:03.07.2024.

Gobind Ram.