Date of Filing: 13.10.2008<br /> Date of Order: 15.07.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 15TH DAY OF JULY 2009<br /> <br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> <br /> COMPLAINT NO: 2213 OF 2008<br /> <br /> Devaraj G.<br /> S/o. N. Gopala Mudalai<br /> M/s. Kotak Urja Private Ltd.<br /> No. 378, 10th Cross, 4th Phase<br /> Peenya Industrial Area<br /> Bangalore 560 058 Complainant<br /> <br /> V/S<br /> <br /> 1. M/s. Swastik General &<br /> Health Care Services (P) Ltd.<br /> Kamadhenu Corner, No. 399, II Floor<br /> 1st Main, 1st Stage, 3rd Phase<br /> Manjunatha Nagar, WOC Main Road<br /> Bangalore 560 010<br /> <br /> 2. M/s. United India Insurance Co. Ltd.<br /> D.O. 3 No. 24, Classic Building<br /> 1st Floor, Richmond Road<br /> Bangalore 560 025 Opposite Party<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed under section 12 of the Consumer Protection Act, 1986.<br /> The facts of the case are that complainant had taken Swasthic Accident Care Policy from the 1st opposite party. The said policy is valid from 02.06.2007 to 01.06.2008. The first opposite party has got tie up with the second opposite party and accordingly the policy has been issued to the complainant. The complainant is a construction worker. During the construction work at M/s. Kotak Urja Pvt. Ltd. he fell down in the work spot on 23.03.2008 resulting in an injury to his left hand shoulder joint. He was admitted to hospital on 27.03.2008 and surgery was conducted on 01.04.2008 and discharged on 10.042008. After discharge the complainant visited the hospital several times for further follow up treatment. For the treatment he has spent Rs. 1,18,852/-. On 12.06.2008 complainant submitted his claim. Opposite party No. 1 sent a letter to the complainant stating that his claim had been rejected by the opposite party No. 2 insurance company. Complainant sent demand notice. In spite of that opposite parties have not settled the claim. Hence, the complaint seeking direction to the opposite party to settle the claim and to pay damages. <br /> 2. Notice was issued to opposite parties. Opposite parties have put in appearance through respective advocates. Defence version filed. Opposite party No. 1 submitted that claim lies against opposite party No. 2. There is no cause of action against opposite party No. 1. Opposite party No. 2 rejected the claim under the policy terms and conditions. <br /> 3. Opposite party No. 2 in its defence version submitted that it is true that complainant had insured through opposite party No. 1 for hospitalisation benefit. Policy period was from 02.06.2007 to 01.06.2008. Policy was issued subject to various terms and conditions. Investigator was appointed to investigate the matter and report and he submitted the report that claim is not genuine. From discharge summary it discloses that patient is 62 years old and suffering from Arthritis and diabetic. Since hospitalisation for ailment of arthritis is not covered under the policy the claim was repudiated. There was no deficiency of service on the part of opposite party No. 2. Therefore, opposite party No. 2 requested to dismiss the complaint.<br /> 4. The respective parties have filed affidavit evidences.<br /> 5. Arguments are heard.<br /> 6. The points for consideration are:<br /> 1. Whether the repudiation of the claim by opposite party No. 2 is justified in this case?<br /> 2. Whether the complainant is entitled for claim amount from the opposite party No. 2?<br /> 7. I have gone through the complaint, defence version, affidavit evidences and documents.<br /> 8. The Swastik Accident Care Certificate has been produced. The period of insurance was from 02.06.2007 to 01.06.2008. M/s. United India Insurance Co. Ltd. is the insurer. Hospitalisation benefit due to any accident is Rs. 1,00,000/-. Death benefit due to any accident is Rs. 1,00,000/-. It is the case of the complainant that he is a construction worker. During the construction work at M/s. Kotak Urja Pvt. Ltd. he fell down in the work spot on 23.03.2008 resulting injury to his left shoulder joint. Immediately, he was shifted to Amrutha Clinic and their Dr. Nityanand treated him. In spite of 4 days treatment no improvement was found in his health condition and therefore, he was shifted to Pristine Hospital, Bangalore for further treatment. He was admitted as inpatient on 27.03.2008 and surgery was conducted on 01.04.2008 and he was discharged from hospital on 10.04.2008. After discharge also he visited the hospital several times for follow-up treatment. During the course of treatment it is the case of the complainant that he has spent Rs. 1,18,852/-. He had put up claim with the opposite parties but the opposite party No. 2 unfortunately repudiated the claim vide letter dated 28.07.2008. The only contention taken up by the opposite party No. 2 for rejecting claim is the complainant was suffering from arthritis and diabetes. Therefore, the claim is not admissible as per terms and conditions of the policy. The complainant has produced discharge summary of the hospital. As per the discharge summary he was admitted as inpatient to hospital on 27.03.2008 and he under went surgery on 01.04.2008 and he was discharged on 10.04.2008. In the history column the doctors have opined C/o sudden onset of pain at left shoulder joint and fever since 2 days following a fall in the factory. Patient had pain – post oil massage done for left shoulder. Numbness of left lower limb. Known Diabetic, on treatment. Pain in lower mandibular teeth and cheek since 1 month. The complainant has produced affidavit evidence of Dr. Hemanth Kumar an Orthopaedic Surgeon working at Pristine Hospital, Bangalore. The Doctor in his affidavit has clearly stated that the patient presented before him on 27.03.2008 with a history of sudden onset of pain at left shoulder following a fall in the factory. Doctor has stated in the affidavit that he was given treatment for septic arthritis left shoulder, which was acute onset, secondary to post oil massage done for pain in left shoulder, which was following a fall in a factory. The surgery is conducted for the Septic Arthritis left shoulder which was not pre-existing. Therefore, it is clear from the summary report of hospital and also by the affidavit evidence of Dr. Hemanth Kumar that the complainant sustained injury in the accident due to fall and for that he had taken treatment. As per the condition of mediclaim insurance policy the company has under taken to pay the claim if insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident and such injury require hospitalisation by the advice of duly qualified surgeon / physician. In this case the complainant admittedly had been admitted as inpatient in the hospital on advise of qualified doctor and surgery was done on him on 01.04.2008 and he was discharged from hospital on 10.04.2008. Therefore, the opposite party No. 2 is bound to pay the hospitalisation expenses for medical / surgical treatment. The repudiation of claim by the opposite party No. 2 is wholly unjustified. There are no just, fair and reasonable grounds to reject the claim. The complainant has put up claim for Rs. 1,18,852/-, the amount spent by him towards hospitalisation treatment. But as per the policy the insurance company is liable to pay hospitalisation benefit due to any accident to the extent of Rs. 1,00,000/-. Therefore, the maximum amount that could be paid to the complainant is Rs. 1,00,000/- as per the policy. Therefore, it is just, fair and proper to direct the opposite party No. 2 insurance company to pay Rs. 1,00,000/- to the complainant. Consumer Protection Act is a social and benevolent legislation intended to protect better interests of the consumers. The protection of the consumers is the need of the society. The insurance company cannot take a very technical view so as to deny the benefit of policy. Consumer forums have got duty to do justice on the basis of equity and good conscience. The judgements should be dehors technicalities of law. Therefore, this is a fit case to allow the claim. In the result I proceed to pass the following:<br /> ORDER<br /> 9. The Complaint is allowed. The opposite parties No. 1 and 2 are jointly and severally directed to pay Rs. 1,00,000/- (hospitalization benefit) to the complainant within 30 days from the date of this order. In the event of non-compliance of the order within the above period the said amount carries interest at 10% p.a. from the date of this order till payment / realisation.<br /> 10. Complainant is also entitled for Rs. 1,000/- towards costs of the present proceedings from the opposite parties.<br /> 11. Send the copy of this Order to both the parties free of costs immediately. <br /> 12. Pronounced in the Open Forum on this 15TH DAY OF JULY 2009. <br /> Order accordingly,<br /> <br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> <br /> MEMBER MEMBER<br /> <br />