Punjab

Ludhiana

CC/14/593

Kuldeep Singh - Complainant(s)

Versus

National Ins.Co.Ltd - Opp.Party(s)

Bhag Singh

27 Mar 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 593 of 28.08.2014

                                                                                                                    Date of Decision: 27.03.2015

                                                                                                                   

1. Kuldeep Singh s/o Shamsher Singh,

2. Geeta Rani w/o Sh.Kuldeep Singh,

Both residents of House no.9860, Joshi Nagar, Haibowal Kalan, Ludhiana.

……Complainants

Versus 

National Insurance Company, Branch office at SCO-38, 2^nd Floor, Feroze Gandhi Market, Ludhiana.

 

…..Opposite party 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                     Sh.Sat Paul Garg, Member

                     Smt.Babita, Member

 

Present:       Sh.M.S.Sethi, Advocate for complainant.

                   Sh.D.R.Rampal, Advocate for OP.

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Kuldeep Singh s/o Shamsher Singh and Smt.Geeta Rani w/o Sh.Kuldeep Singh, residents of House no.9860, Joshi Nagar, Haibowal Kalan, Ludhiana (herein-after in short to be referred as ‘complainants’) against National Insurance Company, Branch office at SCO-38, 2^nd Floor, Feroze Gandhi Market, Ludhiana (herein-after in short to be referred as ‘OP’)- directing them to pay the claim amount to the complainant and to pay the amount of Rs.4,25,000/- plus CB Rs.91250/- alongwith litigation expenses to the complainant.

2.                Brief facts of the complaint are that complainant had purchased one Family Medical policy, vide policy no.404502/48/13/8500000783 dated 12.11.13 valid upto 11.11.14 and paid Rs.18,818/- as premium, in his name for Rs.4,25,000/- and in the name of complainant no.2 for Rs.4,25,000/- and their son namely Navdeep Singh and daughter namely Navjot Kaur for Rs.2,50,000/- each. The complainant no.2 was suffering from Cough and Cold Diseases and she used to take Cough Syrup of Different Companies since long for her treatment. She used to keep empty cough syrup bottles in her house as she is in need of the same for purchasing the another cough syrup of same company. The complainant no.2 also put some Toilet Cleaner in the empty bottle of Cough Syrup from some Large Bottle. Unfortunately complainant no.2 by mistake kept the said Toilet Cleaner in Refrigerator, thereafter when she suffered from Cough Attack and suddenly she picked up the Toilet Cleaner from the Refrigerator in lieu of Cough Syrup and after consuming the same, she started feeling uneasiness and then the complainant no.1 took the complainant no.2 to the DMC and Hospital on 7.12.13 and got admitted in Emergency, then she was shifted to ICU and started vomiting and after 4 days, vide DDR no.27 dated 11.12.13 her statement were recorded, vide which, complainant no.2 recorded that there is no fault on the part of her family member and it is only mistake of complainant no.2 to consumer the toilet cleaner in place of Cough Syrup. Thereafter on 17.2.14, the complainant no.2 was shifted to Apollo Hospital for Food Pipe and Abdomen Operation and an amount of Rs.9,37,127/- had been spent on the treatment of the complainant no.2. The observation made by the doctors in medical documents that it may happen by mistake and only insurance company by making their own thought without going through DDR lodged by the police and also medical treatment by the doctor shows no fault of the complainant no.2. But the OP failed to claim of the complainant was not paid and OP also issued ‘No claim letter’ dated 23.7.14. Claiming the above act as deficiency in service on the part of the OP, complainant has filed this complaint.

3.                On notice of the complaint, OP appeared through his counsel and filed written statement taking preliminary objections that the complaint is not maintainable in the present form; the complaint is false and frivolous one; complaint is bad for non joinder and misjoinder of necessary parties; the complainants have not come to this Forum with clean hands and have suppressed the material facts. The complainants have violated the terms and conditions of the insurance policy and competent authority of OP minutely scrutinized the claim of complainant no.2 Geeta Rani and found that complainant no.2 has intentionally self  inflicted injuries by use of intoxicating substance and claim of the complainant no.2 falls under exclusion clause 4.8 (4.10 in the revised mediclaim policy) and was treated as no claim and claim/repudiation letter dated 23.7.14 was duly posted to the complainants as there is violation of policy conditions; intricate question of law and facts are involved in this case and this case cannot be summarily decided by this Forum and only civil court is competent to decide the present case. On merits, denying the contents of all other paras submitted that complainants gave an intimation dated 10.12.13 to OP with regard to hospitalization complainant no.1 Geeta Rani in DMC Hospital on 7.12.13 and Doctor B.C.Singla was deputed for investigation and verification of the record of the treatment of the complainant. The said doctor personally inspected the record from DMC Hospital and prepared the note from the record of DMC Hospital and gave his medical opinion dated 27.1.14 and observed that complainant no.2 had Alleged Corrosive Ingestion with Esophageal & Gastric Injury with and Esophageal Perforation injuries. The doctor observed that complainant no.2 was managed conservatively. After that she had blood vomiting, oral cavity, Tongue was blackish, charred. Throat was blackish, erythromatus at platelet with mucosal ulcer. The patient had burning epigastric pain due to corrosive Acid Poisoning present on 7.12.13, She was operated on 13.12.13 under GA and Exploratory laprotomy with jejunostomy were done and said doctor opined that case of complainant no.2 falls under exclusion clause 4.8 of insurance policy. Intentional self injury use of intoxicating substances. On receipt of said medical opinion the OP issued one letter dated 4.6.14 to the complainant stating that claim is not maintainable and 10 days time was again given to the complainant to reply the said letter. The complainants gave vague reply dated 17.6.14. The OP also sought medical opinion from Dr.Tarsem Lal Gupta and said doctor minutely studied the documents of the file and found that complainant no.2 was diagnosed of Alleged Corrosive Ingestion with Esophageal & Gastric Injury with and Esophageal Perforation injuries and gave medical opinion dated 11.7.14 recomending the case of complainant no.2 be treated as per exclusion clause 4.8 (4.10 in New Medi-claim policy) and treatment of intentional self inflicted injury is excluded of the preview of the policy. On receipt of aforesaid medical opinion of Dr.B.C.Singla and Dr.Tarsem Lal Gupta, the competent authority of OP minutely scrutinized the claim of the complainant no.2 and found that complainants have violated the terms and conditions of the insurance policy. The complainant no.2 has intentionally self inflected injuries by use of intoxicating substance and claim of the complainant no.2 falls under exclusion clause 4.8 (4.10 in the revised mediclaim policy) and was treated as no claim and no claim/repudiation letter dated 23.7.14 was duly posted to the complainant as there is violation of policy conditions on the part of complainants. The complainants are not entitled to any compensation. At the end, Ld. counsel for OP prayed for the dismissal of the complaint.

4.                In order to prove his case, Ld. counsel for complainants has placed on record affidavit of complainant no.1 Sh.Kuldeep Singh Ex.CA1 and affidavit of complainant no.2 Smt.Geeta Rani, Ex.CA2, wherein, the same facts have been reiterated as narrated in the complaint and placed on record affidavit of Sh.Navjot Kamal d/o Kuldeep Singh and Geeta Rani, Ex.CA3, affidavit of Sh.Navdeep Singh s/o Kuldeep Singh and Geeta Rani Ex.CA4, Sh.Ranjit Singh s/o Shamsher Singh r/o 9860, Joshi Nagar, Haibowal Kalan, Ludhiana Ex.CA5, affidavit of Sonia w/o Ranjit Singh s/o Shamsher Singh r/o 9860, Joshi Nagar, Haibowal Kalan, Ludhiana Ex.CA6, affidavit of Sh.Ashok Kumar s/o Manohar Lal r/o 34, Guru Teg Bahadur Nagar, St. No.3, Chandigarh Road, Ludhiana Ex.CA7 and also placed on record documents Ex.C1 to Ex.C84. On the other hand, Ld. counsel for OP has placed on record affidavit of Sh.Kamaljit Singh, Deputy Manager, National Insurance Co. Ltd. DO IV, Kesar Ganj Chowk, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement, affidavit of Dr.B.C.Singla, Singla Clinic and Clinical Lab, 392 Baba Balak Nath Mandir Road, Ghumar Mandi, Ludhiana Ex.RB and affidavit of Dr.Tarsem Lal Gupta, Gupta Clinic, Ghumar Mandi Chowk, Civil Lines, Ludhiana Ex.RC and also placed on record documents Ex.R1 to Ex.R12.

5.                Case was fixed for arguments. Ld. counsel for complainant filed written arguments, wherein, it is averred that the terms and conditions regarding exclusion clause 4.8 and 4.10 in the revised mediclaim policy were never explained/disclosed to the complainant. No such evidence has been adduced by the Ops that said terms and conditions were ever provided to him relying upon the judgements. Further submitted submitted that Dr.B.C.Singla has not examined the bottle as consumed by the complainant no.2 nor it was sent to laboratory test. Further his report cannot be relied upon because it was not based on medical science/literature. He has relied upon hospital treatment, but no statement of treating doctor was taken and no statement of family members including patient as well as treating doctor nowhere given the report that patient consumed intentionally rather as per affidavit (Ex.R6) of Dr.B.C.Singla, it is only his opinion without any conclusive proof to the effect that patient consumes toilet cleaner intentionally so recommending case by said dr.B.C. Singla that case fall under the exclusion clause 4.8 is not genuine, justified and proper. Further dr.Tersam Lal Gupta has nowhere disclosed his competency and qualification in his affidavit. Further he has given his opinion only based on the file without physically inspection/visit to the patient and hospital as well as no statement of treating doctor was taken and no statement of family members including patient consumed intentionally rather as per his report R9, it is only his opinion without any conclusive proof to the effect that patient consumer toilet cleaner intentionally so recommending case by said Tarsemt Lal Gupta that case fall under the exclusion clause 4.8 is not genuine, justified and proper. Ld. counsel for complainant also relied upon the judgements passed in cases titled as The Oriental Insurance Co. Ltd. Vs Rattan Singh passed by Hon’ble Sate Commission, Punjab, Chandigarh in First Appeal no.869 of 2011, United India Insurance Company Limited Vs Santosh Rani passed by Hon’ble State Commission, Punjab, Chandigarh in First Appeal no.1150 of 2012.

6.                Ld. counsel for OP argued that policy is admitted. The complainant was admitted in DMC and Hospital on 7.12.13 and DD was registered after 4 days. Ld. counsel for OP also relied upon Ex.R6, wherein it is deposed that Patient alleged to take corrosive ingestion (toilet cleaner) on 7.12.13 night and had 4-5 vomiting Containing Gastric contents. First which had no blood but after that patient had Haematomiss. In the last para of the said document, it is opined by said doctor that case falls under the exclusion clause 4.8. Intentional self injury use of intoxicating substances. So case should be settle as terms and conditions of policy. In the light of the claim of the complainant is not valid. As such, claim was repudiated.

7.                We have gone through the pleadings of the complainant as well as defence taken by OPs and have gone through the written arguments submitted on behalf of complainant and have also perused the entire record placed on file.

8.                It is evident that complainant no.2 consumed toilet cleaner, which she alleges that she had kept in the freeze, it is only by mistake, she consumed the same considering it to be a cough syrup and DDR was registered after four days. As per Ex.R6 opinion of Dr.B.C.Singla of Singla’s Clinic, it is very much clear that it was the case of Intentional self injury. So, it is not understood that toilet cleaner was kept in the freeze and how it was consumed. The averments made by the complainant are not tenable.

9.                In view of the above discussion, the present complaint is hereby dismissed with no order as to cost. Copy of the order be supplied to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:27.03.2015 

Hardeep Singh