Punjab

StateCommission

FA/12/1180

Ranjit Singh - Complainant(s)

Versus

Apollo Munich Health Insurance Company Ltd. - Opp.Party(s)

Sandeep Chopra

19 Nov 2015

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,  PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

                                     

                   First Appeal No.1180 of 2012

 

                                                Date of Institution: 06.09.2012

                                                Date of Decision:  19.11.2015

 

Ranjit Singh S/o Dalip Singh, R/o 2334/1, Street No.6, Janta Nagar, Gill Road, Ludhiana.

 

 

                                                                                                                        …Appellant/Complainant           

            Versus

 

1.      Apollo Munich Health Insurance Company Limited, 10th Floor, Building No.10, DLF Cyber City, Phase II, Gurgaon, Haryana                 122022, through its Authorized Signatory/Manager.

 

2.      Branch Office, Apollo Munich Health Insurance Company Ltd., Branch Office, Feroze Gandhi Market, Bhai Wala Chowk,                        Ludhiana its Authorized Signatory/Manager.

 

                                                                                                                         ..Respondents/Opposite parties

                                                           

 

First Appeal against order dated 25.07.2012 passed by the District Consumer Disputes Redressal Forum, Ludhiana

Quorum:-

 

          Shri J. S. Klar, Presiding Judicial Member.

             Shri. H.S. Guram, Member

 

 

Present:-

 

          For the appellant                  : Sh. Sandeep Chopra, Advocate

          For the respondent                : None

         

          . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

          The appellant of this appeal (the complainant in the complaint) has directed this appeal against the respondents of this appeal (the opposite parties in the complaint), challenging order dated 25.07.2012 of District Consumer Disputes Redressal Forum Ludhiana, dismissing the complaint of the complainant. The instant appeal has been preferred against the same by the complainant now appellant.

2.      The complainant Ranjit Singh has filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments that he took individual personal accident premium policy no.110600/21002/2000041909 for the period 21.10.2010 to 20.10.2011 from OPs. The complainant unfortunately met with an accident on 06.05.2011 by falling from Activa (scooter) bearing no.PB10 8776, while driving it. The complainant was taken to DMC where he was given treatment and his Activa was handed over to mechanic for repair. The complainant did not recover from the treatment at DMC and thereafter was admitted at Hunjan Bone & Joint Hospital Ludhiana on 13.05.2011 and was discharged therefrom by advising the bed rest till 12.07.2011. The complainant informed the office of OPs with regard to his cashless treatment but the OPs denied above cashless facility and rather asked the complainant to get the treatment first of all and then to submit the bills for reimbursement. The complainant paid the bills from his own pocket and OPs had not paid the 1% of sum assured/week (i.e. Rs.5,000/- per weeks) while the patient was on rest, as per advice of the doctor and the complainant thereafter submitted all the original papers of the claim to the office of OPs at Ludhiana and it was admitted, vide claim no. ID C/11002/00006379. The OPs started harassing the complainant by asking for one document or the other instead of giving him the insurance claim for his treatment. The OPs finally repudiated arbitrarily the lawful claim of the complainant on 15.12.2011 through email. The complainant has, thus, filed the present complaint directing the OPs to pay Rs.61491/- as expenses incurred by him during the hospitalization, Rs.45,000/- as 1% of sum assured/week (i.e. Rs.5000/- per week), while patient was advised rest by the doctor. The complainant thereby claimed Rs.1,06,491/-,  Rs. 1 lac as compensation for mental harassment, Rs.10,000/- as costs of litigation, besides Rs.25,000/- as miscellaneous expenses.  The complainant claimed total amount of Rs.2,23,991/- along with 24% interest per month from the date of submission of claim to TPA.

3.      Upon notice, OPs appeared and filed written reply and contested the claim of the complainant vehemently, by raising   preliminary objections that the Consumer Forum has no territorial jurisdiction to try the complaint. The complaint is alleged to be not maintainable because complex questions of facts and law are involved in it, requiring elaborate evidence for settlement. The complainant is alleged to be estopped by his own act and conduct from filing the complaint. Any deficiency in service on the part of OPs was strongly denied. The OPs further pleaded that, vide letter dated 29.11.2011, OPs asked the complainant to submit the below noted documents :-

* Details of accident including the date, place and nature of injury.

* First consultation paper after injury took place.

* FIR

* Circumstances of injury in detail.

* Last 3 months salary slips indicating the base salary with other components.

* Copy of driving license.

* X-ray film, MRI Film along with the report supporting the diagnosis.

The complainant had failed to comply with the demanded requirement, despite issuance of letter dated 12.08.2001 to him for submitting the above-mentioned documents. Another letter dated 20.09.2011 was also sent to complainant for claiming x-ray reports supporting the diagnosis. OPD card dated 7.5.2011 and doctor's consultation report dated 09.5.2011, wherein there was no mention of any fall or accident. Even OPs obtained medical advice from Dr. Sunil Kumar, Dr. Aman Sarin, the doctors of Dr. B.L Kapur Memorial Hospital, New Delhi and they recommended for repudiating the claim because no radiological evidence of PIVD has been recorded. MRI should have been done at the time of injury. PIVD is generally degenerative disc not caused by the road accident. It was further pleaded that PIVD not result of any accident dated 06.5.2011 by the complainant. The complaint is alleged to be false and frivolous. Even the factum of accident was also disputed by the OPs, as pleaded by the complainant and OPs, thus, prayed for the dismissal of the complaint.

4.      The complainant tendered in evidence, his affidavit Ex.CW-1/A  along with copies of documents Ex.C-1 to Ex.C-7.  As against it; OPs  tendered in evidence affidavit of Sameer Bhatnagar Vice President-Legal & Compliance of Apollo Munich Health Insurance Company Ltd Ex.RW-1 along with copies of document Ex.R-1 to Ex.R-8. On conclusion of evidence and arguments, the District Forum Ludhiana, dismissed  the complaint of the complainant by virtue of order dated 25.07.2012 under challenge in this case. Dissatisfied with the order of the District Forum, Ludhiana, the instant appeal has been preferred against the same by the complainant now appellant.

5.      We have heard learned counsel for the appellant as none has appeared on behalf of respondents and we have also gone through the record of the case.

6.      Two fold points are involved in this case for determination before us in this case. The first point is whether any such accident really took place, as pleaded by complainant or not? The plea of OPs now respondents in the appeal is that no such accident took place on 06.05.2011, as pleaded by the complainant. The complainant has specifically pleaded the date of accident in the complaint, as 06.05.2011. There is also affidavit Ex.CW-1/A of complainant on the record. He stated in his affidavit that his accident took place on 06.05.2011. Ex.C-1 is "individual personal accident premium". Ex.C-2 is discharge card of Hunjan Bone & Joint Hospital Ludhiana of complainant proving that he was admitted thereon 13.05.2011 and was discharged on 02.06.2011 for PIVD and requisite treatment was provided to him. Ex.C-2 is certificate issued by Dr. Balwant Singh of Hunjan Bone & Joint Hospital to the effect that complainant suffered from PIVD. Ex.C-2 is prescription slip of DMC regarding treatment of the complainant. Ex.C-3 is letter sent from OP to complainant regarding submission of documents. Ex.C-3 is OPD Card issued by DMC College & Hospital Ludhiana. Similarly, another document Ex.C-3 is daily attendance register. Ex.C-3 is driving license of the complainant.

7.      The OPs relied upon the affidavit of Sameer Bhatnagar Vice President Legal & Compliance of Apollo Munich Health Insurance Company       Ltd Ex.RW-1 and Ex.R-1 to Ex.R-4 are letters sent to the complainant for submitting the FIR. Ex.R-5 is the photocopy of certificate issued by Dr. B.L Kapur of Memorial Hospital that PIVD is generally a degeneration of disc not usually caused by road accident. Similarly, Ex.R-6 is the certificate issued by DMC Ludhiana to the effect that complainant suffered from the road accident. It is recorded in it that he suffered from the road accident on 09.05.2011. This is the main document relied upon by OPs to the effect that the complainant has given a wrong date of accident. We find that Ex.R-6 is the only photocopy of certificate issued by DMC Ludhiana, which has not been proved on record by any person. On what basis this document has been prepared, is also not established before us. Consequently, we do not attach much significance to Ex.R-6, which is sheet anchor of the case of OPs. Mere non-registration of FIR would not be fatal to the case of the complainant. Undoubtedly, the complainant suffered injury and received treatment therefor, as proved above. A person does not happily go to the hospital without any injury received by him in the road accident. The affidavit of complainant remained un-rebutted on the record by the OPs that accident took place on 06.05.2011. The District Forum has not appreciated the controversy in proper angle. Consequently, we are of this view that affidavit of the complainant remained irrefutable evidence on the record and it is sufficient to hold that accident actually took place on 06.05.2011 only. We, thus, record this finding on the basis of the above referred evidence on the record.

8.      Now, we come to grips with the second point of the controversy, as to whether complainant had suffered from PIVD disease already, which was degenerative in nature or it was the cause of the accident. On this point, the complainant has specifically pleaded in the complaint that he suffered injury in roadside accident on 06.05.2011 whereby this disease resulted from. The complainant is 36 years of age and it is not possible that he would have developed this disease at such a young age. This fact is proved on record by Ex.C-2 the discharge card issued by Hunjan Bone & Joint Hospital. The OPs mainly pressed into service the opinion collected by them of Dr. Suneel Kumar Ex.R-5 and of Dr.Pankaj Mahindra Ex.R-6. The photocopy of opinion Ex.R-6 does not touch the point of PIVD at all. Dr. Suneel Kumar in the photocopy of his opinion Ex.R-5 stating that MRI should have been done at the time of injury. PIVD is generally a degeneration of disc not usually caused by road accident. Neither there is affidavit of Dr. Suneel Kumar on the record to prove Ex.R-5 nor original or primary evidence of it has been tendered before us. Even in summary proceedings, there should be ex-facie evidence on the record to reach the conclusion. The complainant tendered in evidence Ex.C-3 the photocopy of literature with regard to Prolapsed Inter-Vertebral Disc (Slip Disc) in the causes of PIVD. It is recorded in it that this problems relates to spine and are due to life style or postural problems. It is further recorded in it that more sitting, driving, bending, more table working, standing, travelling in excess and sometimes due to sudden falling, pushing, pulling or jerk or some cases in accident also and rather they are the major causes of PIVD. The literature on this point is contained in Ex.C-3 and it does not rule out the possibility that PIVD cannot be caused by sudden falling, pushing, pulling or jerk or some cases in accident and these are the major causes of PIVD. On the basis of this literature contained in Ex.C-3, we find no substance in the submission of OPs that PIVD is not directly caused by falling down in some accident. No contrary medical literature has been cited by OPs before us.

9.      The factum of taking the policy by the complainant is not disputed one. We conclude that claim of the complainant has been rejected by the District Forum erroneously resulting into dismissal of his complaint. The order of the District Forum under challenge in this case is not legally sustainable and is ordered to be reversed herein.

10.    As a result of our above discussion, we accept the appeal of the appellant and by setting aside the order of the District Forum Ludhiana dated 25.07.2012, we allow the complaint and direct the OPs now respondents to settle the claim of the complainant in accordance with the terms and conditions of the "Personal Accidental Insurance Policy" within  a period of 30 days from the date of receipt of copy of the order. The OPs are further directed to provide interest to complainant @ 9% p.a from the date of submission of his claim till its actual payment on the settled amount, besides Rs.20,000/- as costs of litigation.

11        Arguments in this appeal were heard on 17.11.2015 and the order was reserved. Copies of the order be communicated to the parties as per rules.

12.    The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                          (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

                       

                                                         

                                                                           (H.S.GURAM)

                                                                              MEMBER

 

November 19,  2015                                                           

(ravi)