STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

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