DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, LUCKNOW
CASE No.164 of 2005
Sri V.K. Gupta,
S/o Late Sri C.L. Gupta,
R/o 55, Gopal Nagar,
Near Krishna Nagar, Lucknow.
……Complainant
Versus
- National Insurance Co. Ltd.,
Divisional Office-IV, 43,
Jeevan Bhawan, Hazratganj,
Lucknow.
- Divisional Manager,
National Insurance Co. Ltd.,
Divisional Office-IV, 43,
Jeevan Bhawan, Hazratganj,
Lucknow.
.......Opp. Parties
Present:-
Sri Vijai Varma, President.
Smt. Anju Awasthy, Member.
Sri Rajarshi Shukla, Member.
JUDGMENT
This complaint is filed by the Complainant against the OPs for payment of insurance claim of Rs.71,924.00, 18% interest of Rs.20,499.00 from 03.06.2002 to 31.01.2005, interest on above amount from 01.02.2005 to the date of actual payment, damage and cost of litigation.
The case in brief of the Complainant is that he had taken house holders insurance policy No.2001/3600960 valid for the period from 22.03.2002 to 21.03.2003 against premium of Rs.1,683.00. The above policy had accidental coverage of Complainant as well as three members his wife and two sons of his family. The policy had risk coverage of the Complainant’s son Mr. Mudit Gupta. On 26.11.2002 at 10.00 am Mr. Mudit Gupta met with very serious accident by a
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scooter and suffered multiple fractures in his right leg while going on the road in his side at Sector 7, Noida. Thereafter the Complainant’s son was admitted in the Kailash Hospital and Research Centre Ltd. for treatment and was discharged from the hospital on 05.12.2002. A sum of Rs.71,924.00 was incurred by the Complainant towards treatment of his son. Thereafter an FIR was lodged by the Complainant in the concerned policy station at Gautam Buddh Nagar, Sector 20, Noida and the copy of the same was forwarded to the OP No.2 with all the bills. A personal accident claim form was also filed by the Complainant, duly completed in all respect and deposited the same before the OP No.2. In spite of completion of all the required formalities, the claim of the Complainant was not settled and is still pending. In this regard, the Complainant made several personal visits to the office of OP No.1 for the settlement of claim but nothing was done and lastly the OPs refused to settle the claim orally. Then the Complainant requested the OPs vide letter dated 02.07.2003 to settle the claim and pay accordingly, otherwise the OPs shall be responsible to pay 18% interest upto the date of settlement of the same but neither the claim was settled nor any reply in this regard was received from the OPs. A legal notice dated 25.01.2005 was served upon the OP No.2 but no reply was received from OP No.2. The above act of the OPs constitutes negligence, unfair trade practice and deficiency in service, hence this complaint.
The OPs have filed the WS wherein it is mainly submitted that the annexure 1 filed with the complaint by the Complainant is a premium receipt but not a policy. From the perusal of the above document it seems that it was issued to some Mr. V.K. Gupta for his house hold insurance by receiving a premium of Rs.1,583.00 only. From the perusal of annexure 3 of the complaint it seems that some Sri V.K. Gupta lodged a report on 02.12.2002 at 11.40 at P.S. Sector-20,
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Noida, District Gautam Budh Nagar which does not connect with the story of the Complainant. There was no information in respect of the accident as alleged by the Complainant in the office of the OPs. The Complainant never met the officials of the answering OPs in respect of the alleged claim and he did not file any documents in this respect. No letter of the Complainant was received in the office of the answering OPs. The Complainant did not file the relevant policy to prove that he was holder of the policy issued by the OPs as alleged in the complaint. The Complainant neither informed about the alleged accident to the answering OPs nor submitted any documents like copy of policy, cover note, copy of endorsement of personal accident, copy of FIR, Medical Report and claim form etc. to the OPs. The OPs are not in a position to deny or accept the insurance as alleged in the complaint at this stage without ascertaining the status of the policy, copy of which was not furnished by the Complainant. If the Complainant furnishes the copy of policy/cover note/endorsement letter to the OPs, the OPs reserve their right to file additional WS or amend the present WS. The complaint is time barred and is not maintainable. There is no deficiency in service on the part of the OPs and as such the complaint is not maintainable, hence the Complainant is not entitled to any relief and his complaint is liable to be dismissed with costs.
The Complainant has filed objection to the WS of OPs.
The Complainant has filed his affidavit with paper No.A-1 to A-1/36 and 5 annexure with the complaint. The Complainant also filed written arguments with 4 papers, supplementary written arguments and 5 documents. The OPs have filed the affidavit of Sri H.S. Singh, Senior Divisional Manager, National Insurance Co. Ltd. The OPs have also filed their written arguments with 7 papers.
Heard Counsel for the parties and perused the entire record.
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In this case, the Complainant had taken a house holder policy from the OPs and according to the Complainant the policy included accidental coverage of the Complainant as well as three members of his family including his son. The Complainant’s son Mr. Mudit Gupta was injured in an accident on 26.11.2002 and had to be hospitalized in Kailash Hospital and Research Centre at Noida where after he got his treatment and was discharged on 05.12.2002. When the Complainant pressed a claim of Rs.71,924.00 the amount spent by him in the treatment of his son, then the same was not settled and hence he had to file this complaint. The OPs on the other hand have taken the stand that the Complainant’s did not file the relevant policy for proving that he was the holder of the policy. Besides the complaint is time barred.
Now, it is to be seen that whether this complaint is time barred or not and whether the OPs have not committed any deficiency in service in not entertaining the claim as the policy was not furnished by the Complainant and its consequences.
Now, we first take up the point that this complaint is time barred or not? The OPs have taken the stand that this complaint is time barred but nowhere it has been spelt out as to how this complaint is time barred. Besides it is clear from the complaint that the Complainant had pressed the claim with the OPs and that OPs had not settled the claim. In fact it is admitted by the OPs that they were not supplied with the status of the policy and other documents. From the aforesaid, it is clear that the OPs had not settled the claim till the filing of the case, therefore the cause of action did subsists and it cannot be said that this complaint is time barred and it is accordingly decided.
According to the Complainant he had taken a house holder policy for the period 22.03.2002 to 21.03.2003 against a premium of Rs.1,683.00 the policy No. being 2001/3600960. He has filed copy of the policy which is
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annexure 1 which shows that the house holder insurance policy was taken by the Complainant by paying a premium of Rs.1,583.00. According to the Complainant this policy included accidental coverage of the Complainant and three members of his family including Complainant’s son Mudit Gupta but this fact that the policy contained accidental coverage of the Complainant and members of the family is not clear from the copy of the policy document filed by the Complainant. The OPs admit in their WS that annexure 1 filed by the Complainant is a premium receipt but not a policy and according to them the Complainant failed to produce the copy of the policy and hence it cannot be said that the policy included accidental coverage of the Complainant and his family members. Now, here a question arises as to where the original policy is which must have been issued by the OPs in consequence of the premium receipt taken by them the copy of which has been filed by the Complainant as annexure 1. It is argued by the learned Counsel for the Complainant that the original policy was never provided to the Complainant but the fact is that the Complainant had taken this house holder policy which included the accidental coverage and the OPs have filed photocopies of his insurance policies of the year 1998-99, 1999-00, 2000-01 wherein the accidental coverage of the family members is mentioned and on the basis of these documents it is vehemently argued by the learned Counsel for the Complainant that all these policies show that the personal accidental coverage was given in the house holder policy and the same was the case in the house holder policy taken by him for the year 2002-03 but as the policy documents were not provided to the Complainant that is why this fact that the policy contained accidental coverage cannot be shown. Now, here it is incumbent upon the OPs to file the copy of the policy which is always kept with the OPs while issuing the policy documents to the Complainant, to show that no such personal
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accident as was claimed by the Complainant was given to the Complainant while issuing him the house holder policy the premium of which was taken as is evident from annexure 1 but as discussed above the OPs have miserably failed in producing the relevant documents to prove that the policy in question did not contain accidental coverage of the Complainant and his family members. Therefore, on the basis of the documents produced by the Complainant and on the basis of the statements made by him on oath in his affidavit it is concluded that the Complainant had taken a house holder policy the premium of which is filed as annexure 1 which contained the accidental coverage of the Complainant and his family members including Mudit Gupta.
Now, we have to examine the claim of the Complainant regarding the expenditure incurred by the Complainant on the treatment of his son Mudit Gupta when he met with an accident in Noida on 26.11.2002. In this regard, the Complainant has filed a photocopy of the FIR as annexure 3 wherein it is clearly mentioned that the Complainant’s son Mudit Gupta met with an accident by a scooter and the scooterist had left the scooter on the spot. The Complainant has filed the accidental claim form and has also filed photocopies of the receipts of the amount etc. spent by him in Kailash Hospital in the treatment of his son Mudit Gupta. The OPs have admitted in their WS that Sri V.K. Gupta R/o Noida lodged a report on 02.12.2002 but they deny that the contents of FIR connected with the story of the Complainant. However, there does not appear to be any reasoning for such denial whereas there is mentioning of accident whereby the Complainant’s son Mudit Gupta was injured. The Complainant has filed the copies of the treatment his son got in the Kailash Hospital and the OPs have not challenged that the documents were false or that they were not genuine. In fact there is no justification to disbelive the documents medical
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papers, receipts regarding the amount spent by the Complainant in the treatment of his son Mudit Gupta. As the Complainant’s son Mudit Gupta was covered under the house holder policy taken by the Complainant, therefore the OPs were duty bound to settle his medical claim but as the OPs did not do so, therefore they have committed deficiency in service, therefore the Complainant is entitled to get the amount spent by him in the treatment of his son with interest from the OPs. From the receipts filed by the Complainant, it is clear that the Complainant had spent Rs.71,924.00 in the treatment of his son, hence the Complainant is entitled this amount from the OPs with interest. The Complainant appears to have been harassed in this regard, hence he is also entitled to get compensation as well as cost of the litigation.
ORDER
The complaint is partly allowed. The OPs are jointly and severally directed to pay the amount of expenses incurred in the treatment of Rs.71,924.00 (Rupees Seventy One Thousand Nine Hundred Twenty Four Only) with 9% interest from the date of filing of the case till the final payment is made to the Complainant.
The OPs are also directed to pay Rs.5,000.00 (Rupees Five Thousand Only) as compensation and Rs.3,000.00 (Rupees Three Thousand Only) as cost of the litigation to the Complainant.
The compliance of the order is to be made within a month.
(Rajarshi Shukla) (Anju Awasthy) (Vijai Varma)
Member Member President
Dated: 20 November, 2015
