F.A.No.131  OF 2012 AGAINST C.C.NO.98 OF 2010 DISTRICT FORUM-II VIJAYAWADA AT KRISHNA DISTRICT 

Between:

                                                                                                                                                                                                                                           Appellant/complainant

The Branch Manager,

The New India Assurance Co., Ltd.

B.O.620702, RR

Vijayawada, Krishna District                                                                                                                                  Respondent/opposite party

Counsel for the Appellant              M/ 

Counsel for the Respondent           M/s                                                          

QUORUM:   SRI R.LAKSHMINARASIMHA RAO, HON’BLE MEMBER

                                        &

                        SRI THOTA ASHOK KUMAR, HON’BLE MEMBER

 MONDAY THE TWENTY   DAY OF MARCH

                                   TWO THOUSAND THIRTEEN

Oral Order (As per Sri

                                        ***

1.             The complainant has filed appeal contending that the District Forum has granted partial amount for reimbursement of clam and the respondent-insurance company admitted his employment, the occurrence of accident and treatment administered to him by several doctors.

2.             The appellant is working as an electrical engineer with M/s Surya   `3,000/- @ `500/- week.

3.             The appellant intimated the respondent-insurance company about his meeting with accident and on 19.12.2006 requested the respondent-insurance company to issue claim form which the respondent-insurance company issued on 17.04.2007.The appellant said to have been medically treated by

4.             The respondent-insurance company resisted the claim on the premise that the appellant violated the terms of the insurance policy by not intimating the respondent-insurance company of the accident immediately and there was delay of 30 days in reporting the accident. The appellant submitted claim form 17 months after the accident occurred and along with  claim form he  submitted on 22.0.2008 the  copy of MRI report and copy of insurance policy . The appellant failed to submit original X-ray and MRI scan As the appellant failed to submit medical record, his claim form could not be settled. The investigator had not found the name of the appellant in the OP list of the Global Hospital. On 14.12.2006

5.             The respondent, in support of his claim, filed his affidavit and the documents, ExA1 to A31. On behalf of respondent-insurance company, its Administrative  filed his affidavit and the investigation report,ExB1.

6.             The District Forum allowed the complaint on the premise that the appellant met with accident and undergone treatment by various doctors which did not yield any positive result. The District Forum opined that the appellant was fed up with his condition as no relief could be felt with the treatment he had undergone at various hospitals.

7.             The point for consideration is whether the order of the District Forum suffers from misappreciation of facts or law?

8.             The appellant through letter dated 19.12.2006 intimated the respondent-insurance company that he is an employee of M/s Surya

9.             The employer of the appellant, M/s Surya  M/s Surya

10.            The appellant submitted claim form belatedly and along with the claim form, he submitted the documents such as medical bills along with prescriptions, original MRI Scan Report, Doctor and employer certificate.    The terms of the insurance policy prescribe for intimation immediately after the accident and lodging of  claim  within reasonable time. The appellant intimated the respondent 30 days after the occurrence of accident and he submitted claim after a period of 17 months which certainly is violation of the terms of the insurance policy. The respondent acquiesced with the delay caused in intimation and submission of claim.  The objection for non-settlement of the claim is non-submission of medical record such as MRI and X-ray films by the appellant.

11.            The respondent contends that the appellant’s claim can be settled on his submitting his medical record which would be sent to its panel doctor for his opinion and based on his opinion the claim would be settled. Admittedly, the appellant had not  submitted , for the reasons to known to him, the original  film of X-ray and MRI Scan and he claims for settlement of his claim basing on the documents, medical bills associated with prescription and MRI scan report and the medical certificate issued by the panel doctor of the respondent-insurance company.

12.            The learned counsel for the appellant has submitted that the District Forum has made the appellant’s consulting several doctors and his not following the treatment of single doctor, the basis to disallow the part of the amount claimed. The learned counsel for the respondent-insurance company has contended that the physical disability suffered by the appellant is 1% and he is not entitled to any amount unless he submits the original MRI Scan and X-ray films.  The District Forum awarded a sum of Rs.10

13.            The appellant filed 5 cash bills and copy of X-ray report and MRI report. The reasoning of the District Forum that the appellant had not stuck to the treatment of single doctor and his consulting several doctors would entitle him to a part of his claim not the entire claim does not meet the requirement of reasonableness. The investigator observed in his report that the appellant was not attending to his duty since the date of accident, i.e., 10.02.2006 and doctor He refers to the two aspects as follows;

“Further, I have visited the place M/s Surya st floor, Besant Road, Vijayawada-2 and there I could meet the proprietor and during discussions, he stated that   He has drawn salary @ Rs.15  I have asked him to show me the attendance register and wage register.  But, they could not show me and told they are not having any records and that tot his is a two year old case.

Further, I have visited the place M/s global Medical Centre, Vijayawada and there I have enquired in the OP Department and not found the name of the complainant (  Then I got doubted and show them the MRI Report dated 14.12.2006 and they raised another doubt that the Bill No. is not mentioned in the report and hence they could not locate the claimant.

Further, I could meet   Since then, he has not seen the patient and he   I have shown him the prescriptions and certificate issued by him.  He told that he has not given any prescriptions to  request of the patient “

14.            The respondent had not sought for opinion of its panel doctor basing on the documents already submitted by the appellant. At the same time, we cannot lose sight of the appellant’s failure to submit the original films of X-ray and MRI Scan. A balance has to be struck between the respondent’s negligence in settlement of claim and the appellant’s failure to produce the X-ray film and MRI Scan film. Taking into consideration of the circumstances, we are inclined to enhance the compensation awarded by the District Forum from `10,000/- to `17,000/-.

15.            In the result, the appeal is allowed enhancing compensation awarded by the District Forum from `10,000/- to `17,000 The costs of the proceedings quantified at `3,000/-.

                                                                        MEMBER

                                                                        MEMBER

                                                                    Dt.25.03.2013

కెఎంకె*