BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.108 of 2016
Date of Instt. 10.03.2016
Date of Decision: 13.02.2018
1. Vishal Chadha son of Sh. Prithvi Raj Chadha.
2. Hema Chadha wife of Sh. Vishal Chadha both residents of House No.8, Sat Nagar, Sodal Road, Jalandhar City.
..........Complainants Versus
1. Star Health and Allied Insurance co. Ltd. Regd and Corporate Office: New Tank Street Valluvar Kottam High Road Nungambakkam Chennai-600034 Through its Managing Director, Manager.
2. Managing Director Manager Star Health and Allied Insurance Co. Ltd. Regd and Corporate Office: New Tank Street Valluvar Kottam High Road Nungambakkam Chennai-600034
3. Office of Insurance Ombudsman, SCO No.101, 102 and 103, Second Floor, Batra Building Sector 17-D, Chandigarh-160017 Through its Manager.
4. The Manager, Office of Insurance Ombudsman, SCO No.101, 102 and 103, Second Floor, Batra Building Sector 17-D, Chandigarh-160017.
5. Star Health and Allied Insurance Co. ltd. EH-198, 2nd Floor, Nirmal Complex, GT Road, Jalandhar.
..….…Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. Rajneesh Khanna, Adv Counsel for the Complainants.
Sh. AK Arora, Adv Counsel for the OP No.1, 2 and 5.
OP No.3 and 4 exparte.
Order
Karnail Singh (President)
1. This complaint filed by the complainants, wherein alleged that the complainant is running the factory under the name and style of Chadha Enterprises, situated at Basti Peer Daad, Jalandhar. The complainant No.1 has opted the insurance policy covering the complainant No.1 as well as the complainant No.2 and the entire family of the complainant No.1 i.e. Vishal Chadha, Hema Chadha, Ashima Chadha daughter of the complainant No.1 and Abishek Chadha son, with the OPs on 30.03.2015 for a period of one year, which will be completed on 29.03.2016, vide insurance policy No.P/161125/01/2015/003176 dated 30.03.2015. The complainant No.1 after opting the said insurance policy with the OPs, the complainant No.1 has paid the annual premium of his said insurance policy of Rs.11,607/-. The complainant No.1 at the time of opting the above said medical policy covering all the medical risks of the complainant No.1 and 2 as well as his family members. That on 12.06.2015, the complainant No.2 i.e. wife of the complainant No.1 after getting half day leave from her school went to Nangal alongwith complainant No.1 to meet her parents. That on 12.06.2015 at about 3.30 PM, when the complainant No.2 was coming from stairs of her parental house, then she suddenly fell down from the stairs and due to that she got a knee pain in her left knee and thereafter, the complainant No.2 was brought to BBMB Hospital, Nangal for her treatment, but after reaching at Hospital, it was known to the complainant that the doctors of the BBMB Hospital are sitting only up to 2 PM and after 2 PM, no concerned doctors are available and then the complainant No.1 decided to take complainant No.2 to Jalandhar for her proper treatment as at that time the complainant No.2 was in a very severe pain and accordingly, complainant No.1 gave vovern SR tablet to complainant No.2 with a believe that the pain in the knee of the complainant No.2 will definitely come less, but the pain of the complainant No.2 did not reduce rather it become intolerable during the entire night of 12/13-06-2015, then on 13.06.2015, the complainant No.1 has decided to take complainant No.2 at Jalandhar for her proper treatment and accordingly, they proceeded at about 2.30 PM on 13.06.2015 from Nangal to Jalandhar and straightway reached at Mangat Hospital, Jalandhar and has got medico legal examination of complainant No.2. The doctor also got conducted an X-Ray over the left knee of the complainant No.2 and doctor suggested the complainant No.2 that there is a problem of soft tissue injury knee and has advised complainant No.2 for complete bed rest for 10 days with medical subscriptions fully mentioned in the medical slip dated 13.06.2015. The complainant No.2 has taken brufen 400 tablet for about 3 days, but found no relief and ultimately, they decided to take complainant No.2 for proper treatment before the specialist of the Knee Injury to Dr. Pushpinder Singh Bajaj, Arthroscopy of New Delhi. The said doctor on 13.06.2015 i.e. Dr. Pushpinder Singh Bajaj Specialist Arthroscopy has advised complainant No.2 for X-Ray and MRI and after seeing the report of X-Ray and MRI, the doctor on 16.06.2015 has suggested complainant No.2 for the operations of her left knee. Before conducting the operation of the left knee of complainant No.2, doctor has asked the complainant No.1 to produce the insurance policy and accordingly, the complainant No.1 produced the insurance policy and then doctor asked the complainant No.1 to get the operation of the complainant after paying the requisite charges and then submitted his entire medical claim over the treatment/operation to the insurance company and after getting operation of the left knee of the complainant No.2, the complainant paid total amount of Rs.1,52,818.90/- for the entire treatment and after coming back Jalandhar, they submitted the medical insurance claim for release of the said medical expenditure with the OP and accordingly, OP No.1 and 2 appointed a Surveyor, who visited the house of the complainant and made an enquiry regarding left knee injury of the complainant No.2 and also asked for some documents, which were duly handed over to the Surveyor, but the medical claim of the complainant No.2 has been repudiated, vide letter dated 19.09.2015 by mentioning that the injury of the complainant No.2 is an old injury and not acute trauma alongwith the other reasons mentioned therein. After declining of the medical claim, the complainant has issued a legal notice to the OP by submitting that there is deficiency in service on the part of the OP and declining of release of medical claim of the complainant is illegal, null and void and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the said medical claim, to the tune of Rs.1,52,818.90/- alongwith interest @ 18% per annum from the due date till its realization and further OPs be directed to pay a sum of Rs.10,00,000/- on account of the deficiency in service and Rs.6,00,000/- on account of harassment and humiliation and Rs.50,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, but despite service OP No.3 and 4 failed to appear and ultimately, OP No.3 and 4 were proceeded against exparte, whereas OP No.1, 2 and 5 appeared through their counsel and filed their joint written reply and contested the complaint by taking preliminary objections that the complainant has concealed the material facts in his application that he does not have any medical history and accordingly, the complainant was insured with the answering OP and further submitted that the policy clearly states the proposal, declaration and other documents if any given by the proposal form the basis of the policy of insurance, subject to terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the company undertakes if the insured person shall contact any disease or suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require the insured person, upon the advice of the duly qualified physician/medical specialist or duly qualified surgeon to incur hospitalization expenses for medical/surgical treatment at any Nursing Home, Hospital in India as herein defined as an inpatient the company will pay to the insured person the amount of such expenses as are reasonable and necessarily incurred in respect by or on behalf of the insured person up to the limits indicated. It is further alleged that there is no deficiency in service on the part of the OP and even no cause of action accrued to the complainant to file the present complaint and further alleged that the complainant has concealed the material facts from the Forum, therefore the complainant is not entitled for the relief. On merits, the factum in regard to purchase of insurance policy by the complainant and submission of medical claim is not denied, but the other allegations as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merits and the same may be dismissed.
3. In order to prove the case, one of the complainant himself tendered into evidence affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-89 and closed the evidence.
4. Similarly, counsel for the OP No.1, 2 and 5 tendered into evidence affidavits Ex.OP1/A and Ex.OP1/B alongwith some documents Ex.OP-1 to Ex.OP-5 and further tendered into evidence two another affidavits Ex.OP-1/C and Ex.OP-1/D alongwith document Ex.OP-6 and in additional evidence also tendered repudiation letter Ex.OP-7 and then closed the evidence.
5. We bestowed our thoughtful consideration to the submissions made by learned counsel for the parties and also gone through the case file very minutely.
6. The case of the complainants in regard to getting an insurance policy by OP No.1 for himself as well as for his wife i.e. OP No.2 and dependent children, is not denied by the contesting OP No.1, 2 and 5 and further, it is also admitted that the complainant No.2 Hema Chadha filed an insurance claim in regard to injury caused on her right Knee and the same was admittedly repudiated by the contesting OP, vide repudiation letter dated 19.09.2015 Ex.OP-7 and the said repudiation letter is challenged by the complainant on the ground that the same is illegal, null and void and wrongly repudiated the insurance claim of the complainant.
7. The plea taken by the OP in the repudiation letter is that after receiving an insurance claim of the complainant, Investigation Officer was entrusted, who enquired the matter and submitted his report Ex.OP-3 and even the matter is also got probed from A. K. Sharma, Regional Vigilance Officer, who placed on the file his affidavit Ex.OP1/B, wherein stated that he investigated the claim of the insurance company in regard to injury caused to Hema Chadha and also recorded her statement and accordingly, he submitted his report. Similarly, the matter has been also probed by an other Vigilance Officer of Insurance Company i.e. Ramesh Chand Panwar, whose affidavit is available on the file Ex.OP1/C, who inquired the matter from the hospital, where from allegedly got treatment by the complainant i.e. from doctor Pushpinder Singh Bajaj, Holy Angels Hospital, Delhi and further, OP also examined Dr. B. Pasupathy, whose affidavit is available on the file Ex.OP1/D, who doubt a suspicion on the knee injury of the complainant on the basis of medical reports and categorically stated that the injuries are old one and on the basis of these evidence, the claim of the complainant was repudiated by the OP by taking a plea that the Investigator has visited the school, where insured patient works and verified the attendance register and observed that the insured was at her school at Jalandhar on 12.06.2015, till afternoon and took leave for half day, whereas as per the declaration submitted by her, she had fallen from stairs at 03:00 pm at Nangal in Himachal Pardesh, which is far away from Jalandhar and further, plea taken by the OP for repudiation of the claim is that the insured patient was non-cooperative and was shouting during the visit for claim verification and even the insured patient and her husband told at the investigation that they had gone to Nangal in Himachal Pradesh and there on 12.06.2015, she fell down from stairs, whereas in Dr. P.S. Bajaj's report it is written that she fell down at her home and further submitted that the doctor has thoroughly examined the case and gave the medical opinion that the complex tear and chondral damage on the MRI indicate that this is an old injury and not acute trauma and on the basis of these evidence, the claim of the complainant is rightly repudiated.
8. We have considered the over all circumstances as discussed above and find that the version of the OP is solely dependent upon surmises and conjectures because there is no solid and effective evidence brought on the file by the OP in regard to prove the allegations for declining the claim of complainant. First of all as per the Investigator, who alleged that the complainant was present at Jalandhar on 12.06.2015 till afternoon and then how she fell down from the stairs at 03:00 PM at Nangal, which is in Himachal Pradesh and the same is far away from Jalandhar. As per the version of the complainant as alleged in her affidavit as well as in the complaint, she alleged that she got half day leave at 11:30 AM and proceed to Nangal with her husband and we find that the conclusion of the Investigator is not proved in regard to the Sub Division Nangal falls in Himachal Pradesh, whereas Nangal is apparently falls in Punjab and it is just near to Dasuya, which is not far away from the Jalandhar rather the said distance can be covered by its own vehicle near one and half hour, if so then, the complainant can reach at Nangal at least 02:00 PM or 02:30 PM and accordingly, the conclusion taken by the OP for rejection the claim is not appropriate. So, for the concern of non-cooperation of the insured patient, is not acceptable because the insured patient herself gave a writing in regard to incident, which is hand written of the complainant Hema Chadha and copy of the same Ex.OP-5 is produced on the file by the OP itself. So, this version of the OP is also not tenable. Further, plea taken by the OP that the husband of the complainant told to the Investigator that they had gone to Nangal and there she fell down from stairs, whereas as per Dr. P.S. Bajaj treatment papers, wherein it is written that she fell down at her home. We find that it is not necessary to mention by the doctor whether the house, where she fell down from the stairs is her parental house or in-laws house, house means house of either side. So, this fact also does not create any doubt in regard to incident happened with the insured patient Hema Chadha and further, the OP made a reliance upon the investigation of Dr. B. Pashupati, whose affidavit is Ex.OP1/D and report Ex.OP-6, but the said doctor never examined the insured patient rather he examined only medical papers and there from he observed that the injury is old one, but this opinion of the doctor cannot be considered as final because the same is not relied upon any definite substances rather it relied upon the medical documents i.e. documents, which are issued by the doctor from whom the complainant has got treatment, if there is any old injury on the knee of the complainant, then it is the duty of the OP to bring on the record of the doctor, where from the insured patient was taking treatment, but no doctor has been examined by the OP to prove these factors in regard to pre-existing disease of the insured patient. So, with these observations, we find that the points taken by the OP for rejecting of the insurance claim are not based on any solid and probable evidence, on the other hand, the complainant placed on the file his affidavit Ex.CA and also brought on the file medicine bills, Slip of the Mangat Hospital Ex.C-1 and report of the Delhi Hospital Ex.C-5 and Discharge Summary of the Delhi Hospital Ex.C-6 and Admission Record of the Delhi Hospital Ex.C-13 and further, Bills of Medicines Ex.C-27 and Report Ex.C-29 of the Doctor, who conducted the operation of the complainant and wherein categorically mentioned that the said injury is four days back. So, when the doctor conducting the operation, categorically stated that the injury is four days back, then how we can accept the version of the other Dr. B Pasupathi, who made reliance on the basis of documents not examined the patient in person and further, complainant brought on the file copy of the insurance policy Ex.C-50 and report of the Mangat Hospital Ex.C-58 showing the treatment taken by the complainant from that hospital. So, it is clearly established that the insured patient Hema Chadha got a treatment from Dr. Pushpinder Singh Bajaj, who conducted the operation of the complainant in Holy Angles Hospital, Delhi and where she remained admitted from 18.06.2015 to 19.06.2015, despite the genuine claim of the complainant, the same is not paid by the contesting OP rather the illegally, arbitrarily and wrongly declined the same for which the complainant is entitled.
9. In the light of above detailed discussion, we reach to conclusion that the complainant is able to prove the allegations and accordingly, the complaint of the complainant is partly accepted and OP No.1, 2 and 5 are directed to pay the medical claim to the tune of Rs.1,52,818.19/- alongwith interest thereon @ 9 % per annum from the date of repudiation of claim i.e. 19.09.2015, till realization and further OP No.1, 2 and 5 are directed to pay compensation to the complainant for humiliation and harassment, to the tune of Rs.25,000/- and also directed to pay litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Harvimal Dogra Karnail Singh
13.02.2018 Member President
