Haryana

StateCommission

A/440/2016

RAMESH KUMAR GUPTA - Complainant(s)

Versus

NATIONAL INSURANCE CO. - Opp.Party(s)

SUKHDEEP PARMAR

16 Dec 2016

ORDER

 

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

HARYANA PANCHKULA

                  

                                                First appeal No.440 of 2016

Date of the Institution: 18.05.2016

Date of Decision: 16.12.2016

 

Ramesh Kumar Gupta S/o Shri Maman Chand R/o H.No.1142 Sector-55, Faridabad.

                                                                             .….Appellant

 

Versus

 

1.      National Insurance Company Ltd. 5-C/1-2. B.P. Railway road, NIT Faridabad through its Manager.

2.      M/s Park Mediclaim TPA Pvt. Ltd, 702, Vasant Tower, Rajendera Place, New Delhi-110008 through its Director/Proprietor.

                                                                             .….Respondent

CORAM:    Mr.R.K.Bishnoi, Judicial Member

                    Mrs. Urvashi Agnihotri, Member

 

Present:-    Mr.R.K.Chaudhary proxy counsel for Mr.Sukhdeep Parmar , Advocate for the appellants.

                   Mr.J.P.Nahar, Advocate for the respondents.

 

O R D E R

R.K.Bishnoi, JUDICIAL MEMBER:

 

     It is alleged by complainant that he obtained medi-claim insurance policy from the opposite parties (O.Ps.) including his wife for the period 03.03.2011 to 02.03.2012. The said policy was further renewed for the period 03.03.2013 to 02.03.2013 and total insurance value was Rs.Two lakhs i.e. Rs. One lac for each. He further got this insurance policy renewed for the period 14.03.2014 to 13.03.2015.  On 15.12.2012 his wife slipped and got injured her right knee. Initially Ayurvedic treatment was obtained at the house, but, when there was no improvement he went to Dr. K.C.Gupta Orthopedic specialist on 23.02.2013 when there was no relief from his treatment she received treatment from Nikhil Gupta from 08.03.2013 to 20.04.2013. However there was no recovery and replacement of knee was advised.  He also took his wife to Veero Devi Memorial Orthopedic & Trauma Centre, Faridabad on 26.02.2013 and thereafter Metro Heart Institute, Faridabad on  03.06.2013 from where she was discharged on 06.06.2013. He spent Rs.1,95,000/- on her treatment as mentioned in the bill. He submitted claim with the O.P. and supplied all the documents, but, his request was not accepted.  Registered notice was also issued, but, to no use. Resultantly he was forced to file complaint.

2. O.P. filed reply controverting his averments and alleged that his claim was repudiated on 31.12.2013 as ‘no claim’ and intimation to this effect was also sent to him.  A letter was written to complainant to supply X-ray, MRI and other documents, but, he did not give any document.  He put forward different stories at different times about the injuries, as mentioned in preliminary objection No.3. He did not get policy renewed from 03.03.2012 to 02.03.2013 during which period the incident took place. His pleadings about cost of treatment were also varying from time to time. At one place it was alleged that he spent Rs.2,50,000/- and at other place he alleged expenditure of Rs.One lac, so his request was rightly declined.

3.  After hearing both the parties, the District Consumer Disputes Redressal Forum, Faridabad (In short “District Forum”)  dismissed the complaint vide order dated 21.04.2016.

4. Feeling Aggrieved, therefrom, complainant-appellant has preferred this appeal  on the ground that the learned District Forum should have decided his claim on merits, which was well within time.

5.  Arguments heard.  File perused.

6.  Learned counsel for the O.Ps. vehemently argued that   there is variance in the version of the complainant about the incident of receiving injury.  It is alleged in complaint that she slipped due to mud on 15.12.2013, but, told to Dr.Nikhal Arora that she was having pain since six months as mentioned in certificate dated 08.03.2013.  In this way she did not receive injury as alleged by him and he is not entitled for any compensation.

7.  This argument is devoid of any force. If it is mentioned in Annexure 5 dated 08.03.2013 that she fell six months ago it does not mean that his version is altogether false.  She might have fallen previously also and again in the month of December 2012.  It has no- where come in evidence that she did not receive injury in the month of December.  Initially an injury can be minor but repeated fall can aggravate the problem and one can be forced to go to the doctor, so her version cannot be doubted.  Learned District Forum did not dismiss his complaint on this ground, rather it was dismissed on the ground that he was not having insurance cover on the date of incident.  Appellant-complainant has produced insurance policy for the period 03.03.2012 to 02.03.2013. It shows that complainant was having insurance policy at that time  which could not be produced  before District forum due to inadvertence.  So, it is clear that complainant was having insurance policy on the date of incident and his wife received injuries as alleged by him.  As per Ex.10 it is clear that she was operated upon and he has spent Rs.1,95,000/- on her treatment.  Minor variations are no ground to disbelieve version of any party. So these arguments are of no avail. Hence complainant is awarded compensation to the tune of Rs.One lac as prayed by him alongwith interest @ 9% per annum from the date of filing of complaint till realization. He is also awarded compensation of Rs.11000/- for mental agony and harassment and Rs.5500/- as litigation expenses.  The /opposite parties-respondents shall pay the amount within 30 days from the date of receipt of this order.

 

December 16th, 2016

Mrs.Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench

S.K.