Pay Outstanding Insurance Claim For Dental Treatment: Chandigarh District Commission Holds Religare Health Insurance Liable For Deficiency In Service

The Commission held the Insurance Company liable for deficiency in service by observing that unilateral policy terms should not be imposed on gullible trusting consumers who pay substantial premiums but at the time of compensation, the Insurance Company evades responsibility by using such one-sided clauses.

Brief Facts:

The Complainant got a Health Insurance Policy from the Insurance Company for a one-year term in December 2016, which was subsequently renewed over time. The policy covered the Complainant and her daughter until January 2021. Unfortunately, in December 2019, the Complainant was involved in an accident that required her to be hospitalized. A report (DDR) was filed at the Mauli Jagran Police Station in Chandigarh.

Following various medical tests, it was determined that the Complainant had suffered fractures to both nasal bones and the alveolar process of the maxilla involving damage to the alveolar socket of the left upper incisor, with the left upper median incisor not being visible. The doctor recommended dental correlation and subsequent dental implantation after the Complainant had sufficiently recovered from her internal injuries.

She informed the Insurance Company about the incident and sought approval for cashless medical reimbursement. The Insurance Company granted approval for a cashless medical reimbursement amounting to Rs. 44,897. However, the doctor's advice was to undergo dental implantation after the Complainant's recovery from the internal injuries. Accordingly, the Complainant submitted all the necessary documents, including a duly filled form and supporting materials, to the Insurance Company to claim reimbursement for the dental treatment. The bills from the Hospital and chemists for an amount of Rs. 1,23,793 were also provided.

Despite submitting all the required documents, the Complainant only received Rs. 8,000, leaving a substantial remaining amount unpaid. Despite multiple requests for the reimbursement of the outstanding amount and even sending a legal notice, the Insurance Company did not fulfill the request. The Complainant filed a complaint citing deficiency in the service and unfair trade practice by the Insurance Company.

Contentions of the Opposite Parties:

The Insurance Company contended that the Complainant had initiated a cashless request through the Hospital. During the hospitalization, she was diagnosed with multiple lacerations on the left side, accompanied by ear discharge. Both pre-hospitalization and post-hospitalization claims were approved and directly disbursed to the hospital due to its cashless nature.

Following this, she also filed a post-hospitalization claim for an amount of Rs. 1,18,500. However, only Rs. 8,000 was approved, which pertained to charges associated with root canal therapy. The Insurance Company stated that the dental charges related to the implant were excluded based on the terms and conditions of the policy. The Insurance Company referred to Clause 1.23 in the policy terms and conditions which specifically excluded coverage for implants and cosmetic surgery. The Insurance Company maintained that there was no deficiency of service and denied the allegations stating that the policy's terms and conditions excluded coverage for dental implants.

The Hospital argued that the complaint was not maintainable against them as no relief had been sought against them and requested for dismissal of the complaint.

Observations of the Commission:

The Chandigarh District Commission allowed the complaint against the Insurance Company while dismissing the complaint against the Hospital. It observed that Clause 1.23 of the Policy is not applicable since the dental implantation undergone by the Complainant was a result of injuries sustained in the accident, which cannot be categorized as cosmetic surgery.

The Commission further held that unilateral policy terms should not be imposed on gullible trusting consumers who pay substantial premiums but at the time of compensation, the Insurance Company evades responsibility by using such one-sided clauses.

In conclusion, the Commission directed the Insurance Company to pay the outstanding claim amount of Rs. 1,15,793 to the Complainant, along with an interest rate of 9% per annum calculated from the date of filing the complaint, pay Rs. 10,000 as compensation for causing mental distress and pay Rs. 5,000 as litigation costs.

Case Title: Divya Bhola vs. Religare Health Insurance Company Limited. & Anr.

Counsel for Complainant: Harsh Manocha, Advocate

Counsel for Insurance Company: Ramdeep Partap Singh Advocate

Counsel for Hospital: T.S. Khaira, Advocate

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