Haryana

Karnal

469/2012

Barahmjeet Alias Paramjeet Singh Alias Bharamjeet - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

J.M. Mehta

15 Feb 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.     

                                                               Complaint No.469 of 2012

                                                               Date of instt.: 25.9.2012

                                                                Date of decision: 15.02.2016

 

Barahmjeet alias Paramjeet Singh alias Bharamjeet @ Birhamjit son of Shri Dhan Singh resident of village Peer Baroli Post office Lallupura tehsil Gharaunda  District Karnal.

.                                                                   ……..Complainant.

                                      Vs.

1.The Divisional Manager, Oriental Insurance company Ltd. Divisional Office No.14, Plot No.80, F.I.E. Patpar Ganj, Industrial Area ,Delhi – 110092 having its Local Office, Opposite Bus stand, Karnal,Haryana.

3. Dr.Balbir Wsingh Virk, Virk Hospital Pvt.Ltd. 363, Randhir Lane, near Dayal Singh College,Karnal.

                                                                           ……… Opposite Parties.

                     Complaint u/s 12  of the Consumer

                     Protection Act.

Before          Sh.K.C.Sharma……….President.             

                   Sh.Anil Sharma…….Member.

Present:       Sh.N.M.Mehta Advocate for the complainant.

                   Sh.A.K.Vohra Advocate for Opposite Party No.1.

                        Sh.G.P.Singh Advocate for the Opposite Party no.2.

 

ORDER

 

                   This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986, on the averments that he got two insurance policies from Opposite Party no.1 i.e. policy No.271700/48/2010/800 for a sum of Rs.3,00,000/- and another policy no.271700/48/2010/801 for a sum of Rs.2,50,000/- vide cover note   dated 24.8.2009  issued by Shri Ram Pal, the  agent of the Opposite Party No.1. The said policies were effective for the period of 24.8.2009 to 23.8.2010.  He met with an accident at Gharaunda on 29.9.2009.  On the same day, he was admitted in Virk Hospital Private Limited, Karnal/Opposite Party no.2 and remained under treatment  of various doctors. He was operated  upon for his right leg four times on different dates by the Opposite Party  No.2 and  has suffered 30% permanent disability as per certificate issued by the Board of Doctors of General Hospital, Karnal. He sent intimation to Opposite Party no.1 on 5.10.2009 and thereafter lodged claim. He furnished the required documents to Opposite Party no.1, but his  claim was repudiated. He spent an amount of more than Rs.3.00 lacs on his treatment, but the doctors of Opposite Party no.2 only issued the bills as mentioned in para no.10(i) of the complaint. He again remained admitted in the hospital  from 22.3.2010 to 23.3.2010 and another operation was performed, but the Opposite Party no.2 did not issue the bill. The acts and conducts of the Opposite Parties amounted to deficiency in service, due to which he suffered mental pain and harassment apart from financial loss.

 

2.                Notice of the complaint was given to the Opposite Parties. Opposite Party No.1  filed written statement controverting the claim of the complainant on various grounds. Objections have been raised that the complaint is not maintainable in the present form; that the complainant has no loucs standi and cause of action to file the complaint; that the  complainant has not approached this Forum with clean hands and that the complaint is false and frivolous and has been filed just to harass the Opposite Party no.1.

 

                   On merits, it has been submitted that there was one day delay in lodging the Daily Diary Report. The Opposite Party no.1 asked the complainant vide letters dated 12.10.2009, 15.11.2009, 18.3.2011  and 30.5.2011 for supplying the  necessary documents for processing the claim, but he never submitted the required documents.  Even the claim form was not submitted by the complainant.  As per the report of the investigator, the medical record produced by the complainant  appeared to be manipulated, therefore, the claim of the complainant was closed as “ No Claim” due to non compliance of the required  claim formalities by him and letter dated 30.5.2011 was sent to him in that regard. It has further been averred that insurance company was not liable to pay any compensation for the  disability suffered by the complainant as the said disability was less than 40%.  Moreover, the liability of the  Opposite Party No.1  was only to the extent of Rs.50,000/- subject to the terms and conditions of the insurance policy as per Section  2 of the policy. The other allegations made in the complaint have been denied.

 

3.                The Opposite Party no.2 filed separate written statement disputing the claim of the complainant. Objections have been raised that the complaint does not disclose any cause of action against the Opposite Party  no.2; that the complainant has not approached this Forum with clean hands; that the complainant is estopped from filing the complaint by his own acts and conduct and that the complainant has no loucs standi to file the present complaint.

 

                   On merits, it has been admitted that the complainant was admitted in the hospital of Opposite Party no.2 on account of injuries sustained by him in a road side accident and  he was operated upon for the same .It has been pleaded that valid receipts were given to the complainant against payments received from him. In fact, a total sum of Rs.40,000/- was received from the complainant. There was no deficiency in services on the part of Opposite Party no.2. The other allegations  have been denied.

 

4.                In evidence of the complainant, his affidavit Ex.C1 and affidavit of Sh.Ram Pal Ex.C41 and documents Ex.C2 to Ex.C40 and Ex.C42 and Ex.C43 have been tendered.

 

5.                On the other hand, in evidence of the Opposite Parties, affidavits of Shri Balbir Singh Virk Ex.O1 and Dr.Vipin Gupta Ex.O2 and documents Ex.O3 to Ex.O6 have been tendered.

 

6.                We have appraised the evidence on record,  the material circumstances of the case and the arguments advanced by the learned Counsel for the parties.

 

 

7.                There is no dispute between the parties regarding the fact that the complainant had obtained two insurance policies, one for Rs. three lac and another for Rs.2,50,000/- from Opposite Party no.1, which were valid for the period of 24.8.2009 to 23.8.2009. As per the case of the complainant, he met with an accident on 29.9.2009. This fact has also not been disputed by the Opposite Parties specifically in their written statements. Evidence of the complainant by way of his affidavit Ex.C1 regarding factum of accident and suffering of injuries by him in the said accident has gone unrebutted and unchallenged, therefore, there is no reason to disbelieve the same. Thus, it stands established that the complainant had met with an accident on 29.9.2009 and suffered injuries in the said accident.  The complainant further submitted that he remained admitted in Virk Hospital, Karnal from 29.9.2010 to 3.10.2010 and again  from 22.3.2010 to 23.3.2010. The certificates issued by  Dr.Balbir Singh Virk of Virk, Hospital, Karnal Ex.C12 and Ex.C14 are also to the same effect. In these certificates, it was specifically mentioned that an amount of Rs.25000/- approximately was charged from the complainant for his treatment, during the period of 29.9.2010 to 3.10.2010. The complainant has also produced the record of the treatment, the bills regarding payments made to Opposite Party no.2 and the bills regarding the purchase of medicines. The total amount of these bills comes to Rs.84486/-.

 

8.                The claim of the complainant was made as “No Claim” by the Opposite Party no.1, vide letter dated 30.8.2012, the copy of which is Ex.O3, according to which he had not complied with the required claim formalities as mentioned in the letter dated 30.5.2011, the copy of which is Ex.O4.  A perusal of Ex.O4 reveals that Opposite Party no.1 required from the complainant the  exact  time of accident, the details of treatment taken  prior to admission in Virk Hospital, pre-operative x-ray films and details of the bill of Virk Hospital for Rs.14,500/-. The informations sought were not material for processing the claim and it appears that Opposite Party no.1 sought such informations just to prolong the matter or make out a ground to make the claim of the complainant as “No Claim”. The factum of accident and injuries suffered by the complainant in that accident were not disputed, therefore, there was no necessity to  seek information regarding exact time of accident, because that would not have served any purpose. When the complainant had produced the treatment record, the question of seeking the pre-operative x-ray films  from him,  which would have been in the record of the hospital could not arise.  For details of bill of Rs.14, 500/-  record of the hospital could  be checked by the investigator. The fact remains that the complainant had paid Rs.14,500/- to the Opposite Party no.1 vide receipt Ex.C25, wherein it was mentioned that  the amount was charged for hospitalization and operation.  Asking the complainant to furnish such informations and produce x-ray films was not justified, therefore, making the claim of the complainant as “ No Claim”  on such ground amounted to deficiency in  services on the part of Opposite Party no.1.

 

9.                Faced with such situation, the learned counsel for the Opposite Party no.1 contended that as per Section  2 of the Insurance policy,  the liability of the Opposite Party no.1 was only to the extent of Rs.50,000/- subject to the terms and conditions of the policy.

 

10.               The complainant has produced copies of the certificates of insurance in respect of both the policies as Ex.C20 and Ex.C21.  A perusal of these certificates show that Ex.C20 was a GPA  policy and the  sum insured was Rs.3.00 lac, whereas Ex.C21 was in respect of  Nagric Suraksha policy of Rs.2.50 lac  and under the same  the  personal accident coverage was upto Rs.2.00 lac and hospitalization coverage was  of Rs.50,000/-. Copy of the letter of the complainant dated 27.8.2010 is on the file, but neither of the parties has produced the same in evidence. This Forum is to follow summary procedure, therefore, such document, which is lying on the file can also be taken into consideration. According to the said letter, the complainant claimed compensation under the  Nagric Suraksha policy. Even otherwise, the hospitalization charges could be given under the Nagric Suraksha Policy and there was no mention of hospitalization charges in GPA policy. Under such circumstances, the complainant is held entitled to compensation of Rs.50000/- only under the Nagric Suraksha Policy from the Opposite Party no.1.

 

11.                         As a sequel to the foregoing discussion, we accept the present complaint and direct the Opposite Party no.1 to make the payment of Rs.50000/- to the complainant alongwith interest @ Rs.9% per annum from the date of filing of the present complaint i.e. 25.09.2012 till its actual realization.  The complainant shall also be entitled for a sum of Rs.11000/- for the mental agony and harassment caused to him and for the litigation expenses. The Opposite Party no.1 shall make the compliance of this order within a period of thirty days from the date of receipt of the copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

 

Announced
dated: 15.02.2016

                                                                    (K.C.Sharma)

                                                                   President,

                                                         District Consumer Disputes

                                                          Redressal Forum, Karnal.

            (Anil Sharma ) 

               Member.

 

 

 

 

Present:       Sh.N.M.Mehta Advocate for the complainant.

                   Sh.A.K.Vohra Advocate for Opposite Party No.1.

                        Sh.G.P.Singh Advocate for the Opposite Party no.2.

 

                   Arguments heard. Vide our separate order of the even date, the present complaint has been accepted. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

 

Announced
dated: 15.02.2016

                                                                    (K.C.Sharma)

                                                                   President,

                                                         District Consumer Disputes

                                                          Redressal Forum, Karnal.

            (Anil Sharma ) 

               Member.