BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no.104 of 2014
Date of Institution : 4.8.2014
Date of Decision : 15.4.2015
Subhash Jain, aged about 58 years son of Sh.Siri Ram Jain, r/o Gali Dr.Mathura Dass Wali, Rori Bazar, Sirsa.
……Complainant.
Versus.
1. Senior Branch Manager, Life Insurance Corporation of India, near Sangwan Chowk, Sirsa.
2. Senior Divisional Manager, Life Insurance Corporation of India,
Divisional Office, Rohtak, S.C.O.-1,2,3, Sector-1, Rohtak-124001.
3. Manager TPA Services, SCO-56, First Floor, Entry from Front side, Sector-30-C, Chandigarh-160030.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI VINOD JAIN…………………PRESIDENT
SMT.GURPREET KAUR GILL……MEMBER.
Present: Sh.K.L.Tantia, Advocate for the complainant.
Sh.K.K.Relan, Advocate for the opposite parties no.1&2.
Opposite party no.3 already exparte vide order dated 30.9.2014.
ORDER
Undisputedly, complainant Subhash Jain has Jiwan Arogya comprehensive health plan insurance policy from Life Insurance Corporation of India i.e. from the opposite parties. Number of the insurance policy is 178982375. It was taken on 22.9.2011. During the period of its subsistence, on 8.4.2014, the complainant, met with an accident when he was travelling in a lift. All of a sudden, the lift stopped and fell down, as a result of which, the complainant, received multiple fracture injuries on his person i.e. in both his toes/ankle joint bones, in backbone spine/L-3 he was medically treated, initially in ‘Holy Nursing Home’, Sirsa and then in ‘Chawla Nursing Home’, Hisar. On 10.4.2014, he was operated upon for his fracture injuries by Dr.Parveen Chawla M.S. (Ortho) of ‘Chawla Nursing Home’, Hisar. It was for replacement of both the toe bones. The complainant was discharged from that hospital on 23.4.2014, with further follow up medical treatment. The complainant duly lodged his medi-claim of Rs.2,95,400/-, with the opposite parties, i.e. Rs.1,84,000/- for major surgical operation, Rs.69000/- for ICU charges; Rs.41,400/- for day care surgical benefit and Rs.1000/- ambulance charges. But, the complainant was paid only Rs.83,600/- i.e. for day care surgical benefits and ambulance charges. He was not paid for major surgical charges of Rs.1,84,000/- (being 40% of policy amount of Rs.4,60,000/-, on the plea that he did not undergo for major surgery. The complainant wrote many letters to the opposite parties, for his said claim, but it was repudiated, vide final letter of the opposite parties dated 10.7.2014 (Ex.C19 or Ex.R3); hence this complaint, filed on 1.8.2014, for a direction to the opposite parties for payment of said sum of Rs.1,84,000/-, with up to date interest, besides for damages for his harassment, mental agony etc. and litigation expenses.
2. Simple case of the opposite parties, in their joint reply, is that the complainant has not undergone for any major surgery, under category no.1 or II of the insurance policy in question, so he is not entitled for this claimed amount. The opposite parties have, however, given the details of hospital cash benefit and other surgical benefits of total sum of Rs. 83,600/-, given to the complainant, which are not disputed.
3. The opposite parties have also taken various preliminary objections in their reply i.e. against the maintainability of the complaint in the present form; want of cause of action of the complainant to file the complaint; suppression of true and material facts; that there is no ‘consumer’dispute between the parties and that the complainant should have availed departmental remedy available, before its Zonal Officer.
4. In order to make out his case, the complainant has placed on record Ex.C1-his own supporting affidavit; Ex.C2-supporting affidavit of Sh.Hazur Singh; Ex.C3-copy of his city scan report of CMC hospital, Hisar dated 19..4.2014, showing that the complainant was having comminuted fracture of bilateral calcaneum; Ex.C4-copy of its payment receipt of Rs.5000/- dated 19..4.2014; Ex.C5-forwarding letter of the complainant dated 28.4.2014, for submitting his claim (Ex.C6), for total sum of Rs.2,95,400/-; Ex.C7-copy of medical certificate given by the concerned treating doctor on prescribed proforma, regarding performing said major surgery on the person of the complainant; Ex.C8-copy of letter of the complainant, written to the Branch Manager of the opposite parties dated 17..4.2014, for early payment of his claim; Ex.C9-copy of claim intimation form of the complainant; Ex.C10-insurance policy; Ex.C11-copy of premium paid receipt; Ex.C12-copy of letter of the opposite parties, written to the complainant, demanding some documents; Ex.C13-copy of its compliance letter of the complainant dated 22.5.2014; Ex.C14-copy of medical certificate that the complainant was not under the influence of alcohol at the time of accident; Ex.C15-copy of forwarding letter of the complainant dated 5.6.2014, for sending required medical certificate Ex,C16 to the opposite parties that he had undergone major surgery for his both the toes; Ex.C18- copies of letters of the complainant dated 20.6.2014 and 7.7.2014 respectively, for early settlement of his claim; Ex.C19-copy of impugned repudiation letter of the opposite parties dated 10.7.2014; Ex.C20-copy of booklet of the insurance policy and Ex.C21-postal receipt.
5. In reply thereto, the opposite parties have simply placed on record Ex.R1-supporting affidavit of Sh.R.C.Mathur, its Divisional Manager; Ex.R2-copy of terms and conditions of the insurance policy and Ex.R3-copy of impugned repudiation letter dated10.7.2014 i.e. duplicate of Ex.C19.
6. We have gone through the record of the case carefully and have heard Shri K.L.Tantia, learned counsel for the complainant and Shri K.K.Relan, learned counsel for opposite parties no.1&2. We are of the considered opinion that there is every merit in this case of the complainant and so, it deserves acceptance.
7. Various preliminary objections taken by the opposite parties, in their reply, are not pressed before us during arguments. We also do not find any merit in any preliminary objection. There is no defect in the form of the complaint, nor any defect is pointed out. Since the complainant was insured under the insurance policy and he received multiple injuries, in the accident and insurance claim of the complainant, was repudiated , so, he has cause of action, as well as, locus standi to file this complaint. There is nothing to show as to which true or material fact has been concealed by him. The complainant is the ‘consumer’ being insured with the opposite parties, for valuable consideration. Therefore, all the preliminary objections, are hereby decided against the opposite parties, but in favour of the complainant.
8. Simple question before this Forum is, as to whether or not the complainant underwent for any major surgery?. If he had undergone for major surgery, then certainly and undisputedly, he is entitled for claimed amount of Rs.1,84,000/-, otherwise not. In this regard, undisputedly, the opposite parties had demanded medical certificate from the complainant, and the complainant had duly sent required medical certificate of the operating surgeon i.e. of Dr.Parveen Chawla, MS (Ortho) of ‘Chawla Nursing Home’, Hisar. Ex.C16 is the copy of that medical certificate. Original was sent by the complainant to the opposite parties, vide his forwarding letter Ex.C15. Therein, the doctor, not only certified that the complainant had undergone for major surgery, but he has also given the details thereof. Therefore, it is proved that the complainant had undergone for major surgery and so, was entitled for the claimed amount.
9. Not only this, as per entry at serial no.95 in Ex.R2, “Interposition reconstruction of joint” is major surgery. Here, in the case in hand, the complainant had undergone major operation for reconstruction of both of his toe joint bones. It is so certified by the doctor. It is also not disputed. Therefore, on this ground as well, it was a case of major surgery.
10. Not only this, undisputedly, the complainant was also having fracture in his spine/L-3 backbone, for which he was also medically treated there in said hospital. As per entry at serial no.101 of major surgery in Ex.R2 “Fixation of fracture of spine”, is also a major surgery. Therefore, on this ground as well, it is a case of major surgery. Concerned Orthopedic treating doctor, had not only given his own certificate Ex.C7, mentioning the details of said surgery, but had also subsequently given his certificate Ex.C16 in this regard, on prescribed proforma, which was sent by the complainant to the opposite parties. There is nothing against this medical entry. Therefore, the complainant was entitled for major surgery claim i.e. for Rs. 1,84,000/-, which was not given to him. It is not only gross deficiency of service on the part of the opposite parties, but is also totally unfair trade practice.
11. Resultantly, this complaint is hereby allowed, with a direction to the opposite parties, to pay Rs.1,84,000/- (Rupees One Lakh Eighty Four thousand) to the complainant, with interest @ 10% per annum, from the date of filing of this complaint i.e. 1.8.2014, till payment. The complainant is also hereby awarded compensation of Rs.10,000/- (Rupees Ten Thousands), for his harassment, mental agony etc. and litigation expenses of Rs.5500/- against the opposite parties.
Announced in open Forum. President,
Dated:15.4.2015. Member. District Consumer Disputes
Redressal Forum, Sirsa.
Subhash Jain Vs LIC
Present: Sh.K.L.Tantia, Advocate for the complainant.
Sh.K.K.Relan, Advocate for the opposite parties no.1&2.
Opposite party no.3 already exparte vide order dated 30.9.2014.
Learned counsel for opposite parties no.1&2 closed the evidence, after tendering documents Ex.R1 to Ex.R3 in evidence. Arguments heard. For orders to come up on 15.4.2015
Dated:13.4.2015. Member. President,
DCDRF,Sirsa.
Present: Sh.K.L.Tantia, Advocate for the complainant.
Sh.K.K.Relan, Advocate for the opposite parties no.1&2.
Opposite party no.3 already exparte vide order dated 30.9.2014.
Order announced. Vide separate order of even date, complaint has been allowed with costs. File be consigned to record room after due compliance.
Announced in open Forum. President,
Dated:15.4.2015. District Consumer Disputes
Redressal Forum, Sirsa.
Member.
