Punjab

Ludhiana

CC/15/554

Surinder Singh - Complainant(s)

Versus

Religare health Ins.Co.Ltd - Opp.Party(s)

S.S.Rajput Adv.

30 Jan 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No.554 of 17.09.2015

Date of Decision          :   30.01.2017

 

Surinder Singh aged 46 years son of Shri S.Gurdev Singh, resident of Quarter No.29-B, II Floor, P.S.Sadar, Civil Lines, Opp.Sehkari Co-Operative Bank. Ludhiana.

….. Complainant

Versus 

 

1.Religare Health Insurance Company Limited, GYS Global, Plot No.A3, A4, A5, Sector 125, Noida, U.P.201301, through its Director/MD.

2.Bajaj Capital Insurance Broker, Feroze Gandhi Market, Backsdie Hotel A, Ludhiana, through its Officer Incharge.

3.Gaurav Sharma son of Shri Ved Parkash Sharma, Employee/Commission Agent, Religare Health Insurance Company Limited, c/o Golden Plaza, First Floor, The Mall Road, Ludhiana.

 

..…Opposite parties

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

For Complainant              :         In person with Sh.Satwinder Singh, Advocate      

For OP1                           :         Sh.G.S.Kalyan, Advocate

For OP2                           :         Sh.S.S.Rai, Advocate

For OP3                           :         Ex-parte

 

PER G.K DHIR, PRESIDENT

 

1.                           Shorn of unnecessary details, the case of the complainant is that he availed medical insurance policy No.10175008 form Ops with validity for the period from 9.12.2014 to midnight of 8.12.2015  by paying the premium of Rs.18,937/-. As per that family floater policy, complainant was insured for a sum of Rs.5 lac. This policy was availed through OP3, the agent of OP1. OP2 is the broker of OP1. Complainant is working in Punjab Police. During continuation of the policy, complainant went to Parliament House, New Delhi on Session Duty from Punjab Police Department and he joined there on 20.2.2015. While on duty, the complainant slipped from stairs and met with an accident resulting in fall on 20.3.2015 during morning hours. After this accident, complainant approached Dr. Lovenesh G.Krishana, Professor Orthopedic Medical Center/Dispensary, Parliament, House-1, New Delhi and he gave medicines to the complainant for one week. Complainant felt numbness in his right thigh and pain in whole leg. After completing the duties in Parliament Session, the complainant returned back to Ludhiana on 20.3.2015 at night. Even after return to Ludhiana, complainant still felt pain in his right thigh and whole leg, due to which, he consulted Dr Harmandeep Singh, M.S.Ortho, Apollo Hospital, Ludhiana on 30.3.2015. The said doctor advised the complainant to undergo   MRI  L Spine and even gave medicine for one week. Complainant got the MRI conducted from Arora Neuro Centre, Mall Road, Ludhiana. Thereafter,          Dr. Harmandeep Singh again was approached by the complainant and he advised for surgery. Complainant even consulted Dr.T.N.Shandgi on 1.4.2015, who too advised the complainant to undergo surgery. Complainant was referred to DMC & Hospital, Ludhiana and accordingly, he got himself admitted there on 6.4.2015. Complainant remained under supervision of Dr.R.K.Kaushal during this treatment. Complainant was discharged from the DMC & Hospital, Ludhiana on 13.4.2015. During this period of admission, complainant underwent major surgery operation on 8.4.2015. Sum of Rs.1,35,060/- approximately were spent on treatment. DMC & Hospital, Ludhiana referred the case of the complainant to Ops for cashless policy benefits, but the claim of the complainant was not registered by Ops in a wrong and illegal manner. That is alleged to be an act of gravest deficiency in service and adoption of unfair trade practice on the part of Ops. Legal notice dated 7.8.2015 was got served by the complainant through counsel for calling upon Ops to pay the claim amount, but to no effect. This complaint filed for seeking directions to Ops to make payment of the claim amount and even pay compensation for mental harassment and agony of Rs50,000/-. Litigation expenses of Rs. 10.000/- more claimed.

2.                 In written statement filed by OP1, it is claimed that the complaint filed without disclosing any cause of action; complainant has not approached this Forum with clean hands and that there is no deficiency in service on the part of OP1. Complainant approached OP1 for health insurance and terms of the same were explained to the complainant while issuing cover note along with terms and conditions of the policy. Complainant filled the proposal form dated 8.12.2014 after fully understanding the terms and conditions of the policy. A complete booklet along with policy was issued to the complainant. During the policy period, OP received a cashless request for hospitalization dated 6.4.2015 for treatment of Disc Extrusion and Prolapse of the complainant from DMC & Hospital, Ludhiana. After receipt of pre-authorization (cashless) request, officials of OP company applied their mind for ascertaining the merits of the claim. After scrutinizing, officials of OP came to know that ailment of the complainant was as a result of degenerative changes in the spine. This was suggested by MRI report called MRI Scan of Lumbrosacral Spine dated 30.3.2015. In that report, it was mentioned that impression gathered from all the tests is Lumbar Spondylosis. OPs further consulted Dr.C.H.Asrani for getting his expert opinion. As per observations made by the said doctor:-

“Spondylosis refers to degenerative changes in the spine such as bone spurs and degenerating intervertebral discs

Degenerative Disc Disease: Degeneration of the discs particularly in the moving sections of the spine (cervical and lumbar levels) is a natural process of aging…. In a certain number of patients, the disc degeneration leads to spinal “instability”, the condition in which the spine is unable to bear the patient’s weight or perform its normal functions without disabling pain.

In the light of all the above observations the expert opinion has concluded that the present complaint of the complainant is a degenerative disc disease (disc dissication) and not caused due to a trauma and hence is covered only after two years of continuous coverage of the policy. Since the policy period start date is December 9, 2014, hence the claim is not payable.”

3.                 Further, it is claimed that in view of this expert opinion, cashless request was denied vide letter dated 6.4.2015 in view of clause 4.1(B)(1)(1) of the terms and conditions of the policy. As per clause 4.1(B)(1)(i) of the policy, any claim for or arising out of illnesses and Arthritis (if non-infective), Osteoarthritis and Osteoporosis, Gout, Rheumatism and Spinal Disorders, joint replacement surgery, shall not be admissible during the first 24 consecutive months of coverage of the insured person by the insurance company. Admittedly, the complainant sent legal notice dated 7.8.2015 after the denial of cashless treatment request, but the same   was duly replied vide letter dated 28.8.2015. Ops have not acted arbitrarily, but the claim repudiated after due consideration of merit of the claim and as such, prayer made for dismissal of the complaint with special costs.

4.                 In separate written statement submitted by OP2, it is claimed that relief claimed is not claimable against OP2 because OP2 being a broker has separate legal entity. Contract of insurance was arrived at by the complainant and OP1. Besides, the purpose of making investment in the insurance policy was specified by the complainant himself in the proposal form. Complainant has not deposited any sum/fees/charges in favour of OP2. Entire responsibility of clearing the insurance claim is of OP1 and not of OP2. OP2 as broker just coordinated with            insurance company in releasing the claim amount to the complainant. Complainant since inception of the policy was aware about all the facts and even qua limited role and responsibility of OP2. Complaint alleged to be filed falsely against OP2 by concealing the material facts. Complainant himself visited Ludhiana branch office for availing the insurance policy. The policy was purchased by the complainant after reading and understanding the terms and conditions of the policy and by submitting duly signed proposal/application form to OP2, who as a prudent organization duly informed the complainant by taking follow up action with OP1 and OP3 by writing email. Complainant thereafter never contacted/approached OP2. As per clause 1 of acknowledgment receipt, OP2 received the premium for onwards transmission to the concerned insurer. In clause 4, it is specifically mentioned that responsibility of Broker after contract of insurance is not there because the insurer is to act at its own after receipt of proposal and premium. Liability of OP2 was confined to forward the proposal and premium only. The receipt issued by OP2 is neither a cover note and nor any acknowledgement of commencement of insurance. No inducement or incentive whatsoever was offered by OP2 to the complainant. Each and every other averment of the complaint denied virtually.

5.                 OP3 is ex-parte in this case.

6.                 Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C32 and thereafter, he along with his counsel closed the evidence.

7.                 On the other hand, counsel for OP1 tendered in evidence affidavit Ex.RA1 of Sh.Ramnique Sachar, Manager(Legal) along with documents Ex.R1 to Ex.R6 and then closed the evidence.

8.                 Counsel for OP2 tendered in evidence affidavit Ex.RA2 of Sh.Vishwas Sethi, authorized representative along with documents Ex.R2/2 to Ex.R2/11 and thereafter, closed the evidence.

9.                 Written arguments submitted by Op1 as well as OP2 separately each, but not by the complainant. Oral arguments of counsel for parties heard. Records gone through minutely. 

10.               Copy of proposal form Ex.R2/2 along with cheque of premium of Rs.18,937/- Ex.R2/3 are produced on record to show that the complainant submitted proposal form and even paid the premium for purchase of the policy in question through OP2. Acknowledgement receipt Ex.R2/11 is produced on record by OP2. Perusal of clause 1 printed on this acknowledgement receipt Ex.R2/11 reveals that proposal form and premium received by OP1 only for the purpose of onwards transmission to the concerned insurer. Further, as per clause 4 endorsed on Ex.R2/11 itself, OP2 not to bear the responsibility for the acts of the insurer in connection   with submitted proposal, once the proposal stand forwarded to the insurer. As per clause 5 endorsed on Ex.R2/11, responsibility of OP2 strictly confined and limited to the forwarding of proposal and premium. In view of these clauses endorsed on Ex.R2/11 itself, it is obvious that OP2 as broker helped complainant in submitting the proposal form and forwarding the premium amount. But this complaint filed for getting claim amount in respect of the treatment got by the complainant in DMC & Hospital, Ludhiana during period from 6.4.2015 to 13.4.2015 and as such, virtually the claim stacked on the basis of contract of insurance arrived at between the complainant and OP1. Role of agent came to an end after submission of proposal form and forwarding the premium to insurance company is the proposition of law laid down in case of Director General of Police, Chandigarh and another vs. Jeevan Lata-II(2006)CPJ-119(N.C.). Even as per law laid down in case Golden Trust Financial Services and another vs. Malwa Devi-I(2009)CPJ-264(Jharkhand State Consumer Disputes Redressal Commission, Ranchi), in case, accidental insurance claim under the insurance policy not settled by the insured after submission of the proposal form and forwarding the premium amount by the agent G.T.F.S., then certainly liability remains of the insurance company and not of the agent/broker like GTFS. Same is the proposition of law laid down in cases P.M.Systems and Financial Services (P) Ltd vs. Narayan Ch.Mitra and others-IV(2007) CPJ-407(West Bengal State Consumer Disputes Redressal Commission, Kolkata) and Golden Trust Financial Services vs. Madhuri Singh-III(2006)CPJ-409(Bihar State Consumer Disputes Redressal Commission, Patna). Ratio of both these cases is fully applicable to the facts of the present case, particularly in view of the endorsements on receipt Ex.R2/11 as referred above. Op2 just acknowledged the liability of forwarding the proposal form and premium amount to the insurer. There is no allegation against OP2 that after receipt of the proposal form and premium amount, the same has not been forwarded by OP2 to the insurer i.e. Op1. As OP2 provided due services of forwarding the premium and proposal form received from the complainant, to OP1 and as such, there is no deficiency in service on the part of OP2, the agent-cum-broker at all. So, certainly submission advanced by counsel for OP2 has force that complaint against OP2 is not maintainable and as such, same merits dismissal. OP3 is just an employee or agent of OP1 and as such, liability of paying the claimed insurance amount for treatment in question is not that of OP3. Being so, complaint against OP2 and OP3  not  maintainable and merits dismissal and is hereby dismissed.

11.               Certainly, submissions advanced by Sh.G.S.Kalyan, Advocate representing OP1 has force that in contract of insurance, rights and obligations are strictly governed by the policy of insurance and no exception or relaxation thereto on the ground of equity is permissible. These submissions are based on ratio of case titled as Deokar Exports Pvt. Ltd. vs. New India Assurance Company Limited-2009(2)CLT-15(S.C.). So, certainly rights and obligations in this case to be governed by the terms and conditions of the contract of insurance. Ex.C1 is the notice sent by the complainant to Ops after repudiation of claim through counsel and this notice was sent through postal receipts Ex.C2 to Ex.C4 and there is no denial qua these facts. So, certainly complaint has been filed after serving legal notice and finding  that action has not been taken. Ex.C5 is the medical record of complainant obtained from the Police Hospital, Ludhiana. Mentioning of diseases in question not made anywhere in Ex.C5. Ex.C6 is copy of driving license of complainant, whereas, Ex.C7 is the health insurance card issued under the policy in question by  Op1 to the complainant. Complainant along with Paramjot Singh(son) and Kamaljeet Kaur(wife) were insured for sum of Rs.5 lac during period from 9.12.2014 to midnight of 8.12.2015 under Floater Insurance Policy Scheme is a fact borne from the contents of Ex.C8. OP2 is just           shown as broking agent in Ex.C8. There was no pre-existing disease suffered by the complainant or his wife or his son as per disclosure made in Ex.C8.

12.               Perusal of Ex.C9 reveals that the complainant got treatment on   20.3.2015 under Central Government Health Scheme in OPD of Rajya Sabha Dispensary. Only a tablet for one week was prescribed there and as such, this slip Ex.C9 corroborates the claim of the complainant that he got treatment from the dispensary of Parliament House at New Delhi on 20.3.2015. Type of disease not mentioned in Ex.C9 and nor the course of treatment mentioned in Ex.C9 and as such, this document Ex.C9 does not lead us to the conclusion that treatment by the complainant for degenerative changes was got in Rajya Sabha dispensary on 20.3.2015. Ex.C10 is the bill showing the purchase of 10 tablets by the complainant from Krishna Chemists, New Delhi.

13.               Contents of MRI Scan of Lumbosacral Spine Ex.C11 show that on 30.3.2015,  Arora  Neuro  Centre  Pvt.  Ltd., Ludhiana found that L4-5 & L5  -S1 discs of the complainant were desiccated. Further, this report Ex.C11 shows that L4-5 disc did show annular tear in left posterolateral and left foraminal location. As per this report Ex.C11, the disc shows asymmetric diffuse bulge causing mild compression of left traversing nerve root. Further, as per this report Ex.C11, L5-S1 disc shows right posterolateral extrusion with superior and inferior migration causing compression of right traversing S1 nerve root and thecal sac. This report Ex.C11 in fact has been taken into consideration by OP1 for repudiating the claim. Fees of Rs.2500/- were charged by the Arora Neuro Centre Pvt. Ltd, Ludhiana from the complainant through receipt Ex.R12 for doing MRI L/S Spine on 30.3.2015. It was after this report of MRI that the complainant contacted Dr.Chhaya Shadangi at Ludhiana on 1.4.2015, who prepared slip Ex.C13. In Ex.C13 itself, it is mentioned that complainant fell down from stairs on 20.3.2015, due to which, he felt pain and numbness in his right side and right side leg/foot. Complainant was advised excision of exuded disc L5-S1 treatment. Complete bed rest for 7 days was advised to the complainant through Ex.C13 itself. It was thereafter that the complainant got treatment from DMC & Hospital, Ludhiana as revealed by contents of Ex.C14 to Ex.C16 and even he purchased medicines through bills Ex.C17 to Ex.C23. Bill Progress Chart of the complainant during his admission in DMC & Hospital, Ludhiana from 6.4.2015 to 13.4.2015 produced as Ex.C24 for showing as if amount of Rs.1,26,579/- was spent on this treatment. Complainant remained under treatment of Dr.R.K.Kaushal during this treatment. Micro Lumbar Dissectomy was done on 8.4.2015 by Neuro Surgery Team and thereafter, complainant was discharged in stable condition is a fact borne from the contents of hospital course record of DMC & Hospital, Ludhiana Ex.C24. Ex.C25 is the detail bill along with other relevant records Ex.C26 has also been produced. Ex.C27 is the discharge summary showing as if really the complainant admitted for treatment in DMC & Hospital, Ludhiana for period from 6.4.2015 to 13.4.2015. Repudiation of claim for this treatment was done through Ex.C29 to Ex.C31=Ex.R4 on the ground that MRI is suggestive of chronic changes and ailment was due to degenerative spinal disorder causing disc bulge and nerve compression. This repudiation done in view of clause 4.1(b)(1)(1) of policy because treatment of spinal disorders covered after two years of continuous policy coverage. However, this treatment was got by the complainant in the first year of the policy and as such, it is vehemently contended by Sh.G.S.Kalyan, Advocate for OP1 that repudiation of claim is justified. Cashless treatment request even was repudiated is a fact borne from the contents of Ex.C31.

14.               Policy certificate along with other documents were sent to the complainant by OP1 through letter Ex.R1. Proposal form annexed with this Ex.R1 shows that the complainant was not suffering from any disease earlier. Certainly, after going through clause 4.1(b) of the terms and conditions of the policy, it is made out that any claim for or arising out of Arthritis(if non-infective), Osteoarthritis and Osteoporosis, Gout, Rheumatism and Spinal Disorders, joint replacement surgery to remain in admissible during the first 24 consecutive months of coverage of the insured person. As the surgical treatment got by the complainant and as such, it is vehemently contended by Sh.G.S.Kalyan, Advocate for OP1 that exclusionary clause 4.1(b) is applicable. These submissions of counsel for OP1 vehemently opposed by counsel for the complainant by contending that in fact this treatment got on account of injury sustained in fall by the complainant during duty in Parliament Session at New Delhi.

15.               Repudiation of claim in fact has been done by the Ops after obtaining report Ex.R6 of Dr.CH Asrani, who is an MBBS doctor practicing as Consultant Family Physician and Insurance Claims Consultant. After going through page no.2 of this report Ex.R6, it is made out that in the opinion of this doctor, Spondylosis refers to degenerative changes in the spine such as bone spurs and degenerating intervertebral discs.

16.               However, as per search on ‘Google Internet’, Spondylosis is more of a descriptive term than it is clinical diagnosis. Literally it can be translated to mean that one has both pain and spine degeneration, regardless of what is causing the pain or where the degeneration is occurring. So, by the alleged treatment of Spondylosis  alone it cannot be inferred as to what clinical diagnosis provided by terming a spinal problem as Spondylosis. Complete description of Spondylosis as such ignored in report Ex.R6 by the Dr.C.H.Asrani. Though, disc desiccation is an extremely common degenerative change of intervertebral discs, but degenerative change with advancing age may be one of the causes of Spondylosis. Degeneration is a natural process of aging is rightly held in report Ex.R6, but reference to the certificate dated 7.4.2015 of treating doctor of DMC & Hospital, Ludhiana is not at all made in Ex.R6. Photostat copy of said certificate produced by the Ops themselves. Perusal of the same reveals that Surinder Singh patient was not operated for chronic changes. Rather, surgery was planned for Disc Extrusion and Prolapse due to Trauma on 20.3.2015. That Trauma as per discharge summary Ex.C27 virtually was on account of alleged fall from stairs on 20.3.2015, for which, the complainant got treatment from the dispensary in Rajya Sabha initially. Question arises as to what is Disc Extrusion and what are causes of Disc Extrusion. As per search on ‘Google Internet’, Disc Extrusion Causes:- The body’s natural aging process is the primary cause behind disc extrusion. However, there are many additional factors that can spur extrusion or speed its onset, including:-

*Sudden injuries, traumas or accidents, such as those that may occur during a fall, high impact or car crash

*The repetition of strenuous movements, including jobs that involve a significant amount of manual labour and sports that demand the use of the lower back

*Improperly lifting heavy objects

*Malnutrition

*Excess weight or obesity

*Lack of exercise

*Genetic predisposition or congenital complication

*A blow to the back

*Sudden twisting

*Rapidly sitting or standing, especially in elderly adults.

17.               So from this, it is obvious that sudden injuries due to fall even may cause disc extrusion. In such circumstances, doctor who submitted report Ex.R6 was required to ascertain as to whether really the Disc Extrusion surgery was planned in DMC & Hospital, Ludhiana on account of traumatic sudden fall of complainant on 20.3.2015 or not? That aspect has not been discussed in Ex.R6. Rather, the conclusion regarding degenerative disc disease (disc dessication) given on general basis by keeping in view the general notion of Spondylosis. That approach of Dr.C.H.Asrani, who submitted report Ex.R6 is not correct. So, reliance on report Ex.R6 could not have been placed for repudiating the claim. Even reference of this treatment of Disc Extrusion and Prolapse made in para no.3 of affidavit Ex.RA of Sh.Ramnique Sachar, Manager(Legal) of OP1. Complainant throughout had been claiming as if he suffered the problem in question after fall and representations in this respect repeatedly made by him before the doctors concerned as disclosed by OPD Slip Ex.C13 of Dr.Chhaya Shadangi and also to doctor of DMC & Hospital, Ludhiana as disclosed by discharge summary Ex.C27. In such circumstances, it was obligatory on part of Dr.C.H.Asrani to find that treatment in question got by the complainant for disease that occurred due to degenerative change exclusively and not due to Trauma on account   of sudden fall. That possibility is not excluded through report Ex.R6, despite the fact that MRI Scan report Ex.C11 shows as if L4-5 disc was having annual tear in left posterolateral. Annual tear is often caused by two things i.e. 1) Degeneration of the spine and (2) injury. Further, as per search on ‘Google Internet’, it has been       found that while the natural aging process of the spine is most often the cause of an annual tear, but  sometimes a sudden injury can cause the outer layer of the disc to tear and cause pain. Further, as per this internet search on ‘Google Internet’, the causes include aging and traumatic injury. This internet search reads as under:-

Aging:- Due to the continued stress and pressure placed on discs in the spine, they break down over time. By age 30, a person’s discs have begun to weaken and dry out, making the discs susceptible to an annual tear. Additionally, years of weight gain can add unnecessary pressure to the discs and cause the elasticity in the outer layer of the discs to eventuality stretch and tear.

Traumatic Injury:- Injuries to neck and back discs can be sustained while participating in high-impact sports (hockey, gymnastics, football etc.). Automobile accidents can also cause a traumatic injury that leads to an annual tear, excessive force, no matter the cause, can lead to injury of the tough outer layer of the disc.

18.               Excessive Force even can lead to the injury of the tough outer layer of the disc and this excessive force can be applied on account of sudden fall and as such, it was obligatory for the doctor submitting report Ex.R6 to ascertain as to whether the excessive force was the cause of annual tear or not? As per report Ex.C11 of MRI Scan of Lumbosacral Spine of Arora Neuro Centre Pvt. Ltd., L5-S1 disc did show right posterolateral extrusion and that extrusion may be caused due to fall even as per Google internet search referred above and as such, theory of fall even must have been considered while submitting report Ex.R6. Details for excluding the symptoms emerging in question, having not occurred due to fall, not taken note of while submitting report Ex.R6 and as such, virtually report Ex.R6 submitted by jumping to the conclusion of suggestive chronic changes. Being so, reliance on the report Ex.R6 is not placed for holding that repudiation of claim is justified. As report Ex.R6 of Dr.C.H.Asrani is held improper and as such, repudiation of claim is unjustified and the order passed by Op1 in this respect liable to be set aside. Rather, for doing due justice, it is required that a Board of Doctors consisting of three specialists should be formed by OP1 within 20 days from the date of receipt of copy of this order. Opinion of the majority of the doctors of the constituted board should prevail for finding as to whether the claim of the complainant is sustainable or not? That opinion must be obtained by OP1 within 30 days from the date of constitution of Board of doctors. After obtaining that opinion, OP1 will pass the fresh orders in respect of allowing or disallowing the claim within 15 days from the date of receipt of opinion from Board of Doctors. If the opinion is vague and two interpretations are possible, then one favouring the policy holder to be followed is the proposition of law laid down in case National Insurance Company Limited vs. Nachhatar Singh-II(2006)CPJ-120(N.C.). Likewise, the Hon’ble Supreme Court of India in case United India Insurance Company Limited vs. M/s Pushpalaya Printers-2004(1)CPC-470,    has  held that where two interpretations are possible, one in favour of the insured should be accepted by authorities. Keeping in view these propositions of law in mind and the fact that opinion Ex.R6 is not appropriate, it is held that the complainant entitled for compensation for mental harassment and litigation expenses also.  

19.               Therefore, as a sequel of the above discussion, complaint disposed of in terms that OP1 will constitute board of doctors consisting of specialists in the field for ascertaining as to whether treatment got by complainant in question from DMC actually was on account of degenerative changes occurring with age or the said treatment was on account of injury sustained by complainant due to fall. Opinion Ex. R6 of Dr. C.H. Asrani being improper cannot be formed basis for repudiation of the claim and as such, order of repudiation of the claim set aside. Board of doctor consisting of three specialists will be formed by OP1 within 20 days from date of receipt of copy of this order. Opinion of the majority of doctors of the constituted Board will prevail. That opinion be obtained by OP1 within 30 days from the date of constitution of board of doctors. After obtaining that opinion, OP1 will pass fresh orders in respect of allowing or disallowing the claim within 15 days from the date of receipt of opinion from board of doctors. Compensation for mental harassment of Rs.5,000/- (Rupees Five Thousand only) and litigation expenses of Rs.5,000/- (Rupees Five Thousand only) more allowed in favour of complainant and against OP1 only. Complaint against OP2 and OP3 is dismissed. Copies of order be supplied to parties free of costs as per rules.

20.               File be indexed and consigned to record room.

 

                       (Param Jit Singh Bewli)                          (G.K.Dhir)

                                  Member                                          President

Announced in Open Forum

Dated:30.01.2017

Gurpreet Sharma.