BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Complt.  Case No : 14 of 2010

Date of Institution: 11.01.2009

Date of Decision  : 16.07.2010

Veena Gupta wife of Sh.Arun Gupta, R/o H.No.449, Sector 46-A, Chandigarh.

 ……Complainant

V E R S U S

1]       The New India Assurance Company Limited, through its Divisional Manager, SCONo.347-348, Sector 35-B, Chandigarh.

2]       The Divisional Manager, The New India Assurance company Limited, Divisional Office-III, SCO 37-38, Sector 17-C, Chandigarh.

.…..Opposite Parties

CORAM:          SH.LAKSHMAN SHARMA                         PRESIDENT

                    SH.ASHOK RAJ BHANDARI            MEMBER

                    MRS.MADHU MUTNEJA                        MEMBER

PRESENT:     Sh.Kapil Kumar, Adv. for the complainant.

Sh.Navin Kapur, Adv. for the OPs.

PER MADHU MUTNEJA, MEMBER

                The instant complaint has been filed by Smt.Veena Gupta, complainant under Section 12 & 13 of the Consumer Protection Act, claiming compensation against the OPs for refusing to make payment towards complete medical expenses of the complainant.

1]             The facts of the case are as under;-

                The complainant had obtained an Accidental Policy No.350300/42/07/01/00000174 from OP No.1 from 16.9.2007 to 15.9.2008 for a sum of Rs.3.00 lacs.  A sum of Rs.1335/- was paid as premium.  At the time of issuance of the policy, the complainant was informed by the representative of OP No.1 that in case of accident a sum of Rs.3,000/- per week will be paid to the complainant as compensation along with the amount spent on the purchase of medicine on submission of original medical bills.  A copy of the policy has been attached with the complaint. 

                The complainant met with an accident on 2.9.2008. From 3.9.2008 she was under treatment of Dr.Sandeep Gupta (M.S. Ortho.) as well as a Physiotherapist.  The complainant suffered injuries on her backbone and was advised complete bed rest till the problem was cured.  The OPs were informed about the accident and the original bills of payment made to the hospital, consultant, surgeon, pathological, laboratories, chemist and fitness certificate from treating physician/surgeon were furnished to them.  Also actual bills of medicines, doctor fee and other charges were forwarded to the OPs.  After various correspondence between the parties, copies of which have been put on record, the OPs settled the claim of the complainant for a sum of Rs.97,680/-.  This amount was sent by cheque to the complainant.  However, this amount was accepted by the complainant only under protest on 6.11.2009 while demanding the balance amount, along with the claim of Rs.3000/- per week as agreed by the OPs at the time of issuing the policy.   The complainant is still ailing and on the bed. Her husband has further spent an amount of Rs.30,400/- from 1.9.2009 to 31.12.2009 on her medicines besides other expenses. 

                The complainant states that the OPs have only paid a sum of Rs.97,680/- against the bill amount of Rs.1,29,061/-.  They have also not paid a sum of Rs.1,98,000/- towards the claim of Rs.3000/- per week w.e.f. 3.9.2008 to 31.12.2009. 

                A legal notice to the OPs was sent for payment of balance amount.  Since no action was taken by the OPs to make the payment, the complainant has filed the instant complaint claiming the amount as well as compensation of Rs.2.00 lacs for mental torture and harassment suffered due to the act of the OPs and Rs.25,000/- towards the cost of litigation.

2]             After admission of the complaint, notices were sent to the OPs. 

3]             The OPs in their reply have stated that the complainant has been indemnified to the full extent as per the entitlement under the Insurance Policy and has already been paid Rs.97,680/- for which a complete and valid discharge has already been given by her.  She is now estopped from raising any further demand after executing a valid discharge to the OPs.  The competent authority has after due consideration, taken the decision regarding the amount of compensation to be paid to her and there is no deficiency in service on the part of either of the OPs. 

                On merits, the OPs have submitted that the complainant and her husband had taken individual personal accident policies and were covered for a sum of Rs.3.00 lacs each.  After the accident, the complainant had taken treatment from various doctors. All treatment papers produced by and on behalf of the complainant were sent for expert opinion to Dr.Gaurav Sawhney, M.S. (Ortho.) D. Ortho.  The doctor opined that such patients would require bed rest for not more than 3 months, and if longer, not more than 6 months.  After detailed discussion with the insured, Sh.Arun Gupta agreed to receive the weekly benefit of Rs.3,000/- per week for a period of twenty five weeks. An amount of Rs.75,000/- has already been paid to the complainant on this account.

                With regard to the medical bills submitted by the husband of the complainant, the OPs submit that all the bills were not duly signed and sanctioned by the doctor/hospital.  Such unsigned/unstamped bills could not be accepted or validated without authentication by the concerned doctor/hospital.  Therefore, out of a sum of Rs.1,29,061/-, a sum of Rs.97,680/- was paid to the complainant as per her entitlement under the policy.  This amount included Rs.75,000/- already mentioned earlier and Rs.22,680/- against validated bills. Photocopies of all medical bills submitted by the complainant along with list of the same have been enclosed as annexures to the reply.

                The OPs also submit that the husband of the complainant offered to submit certain original bills and fitness certificate from the concerned doctors later on, towards completion of claim formalities but actually  never submitted the same to the OPs.  Since all the medical bills were not duly prescribed, signed and sanctioned by the doctor/ hospital, they could not be admitted in toto.  The complainant was reminded vide many letters to complete the claim formalities.  An Investigation report by the Investigator appointed to assess the claim has also been placed on record.  The Investigator in his report has stated that the complainant had fallen in the bathroom and her spine & vertebra was badly damaged.  She was unable to stand.  The doctor advised complete bed-rest for a few weeks.  When the Investigator visited the complainant on 15.10.2009 at her residence, he found that she had improved a lot and she could move around with a help of stick.  She was sitting on a chair in the house.  When the Investigator visited her again on 20.10.2009, he found that the complainant had improved further and could do her household work perfectly.  The complainant also told the Investigator that she was ready to get the claim for 6 months from the date of injury, as advised by her consultant doctor.   The opinion of the Investigator is as under:-

“From my discreet and exhausting inquiries made by me I come to the conclusion that the claim is justified.  The claim is found to be genuine and may be settled subject to the terms and conditions of the policy.  Moreover the desired papers of the claim are attached herewith given by the insured.  The insured agreed with the doctors who attended on the patient during the period that the maximum period for the rest is six month.  The charges for the attendant are not covered under the Policy.  The consent of the insured is attached herewith.  The claim may be settled as per terms and conditions of the Policy.”   

                The OPs state that they are not liable to pay any further amount to the complainant beyond what has already been paid to her for which a complete and valid discharge has already been singed by her.

4]             We have heard the ld.Counsel for the parties and also perused the documents placed by way of evidence on record by both the parties.

5]             The ld.Counsel for the complainant wished to stress upon the fact that the patient was still ailing and needed to be compensated for all medical treatment, medicines, investigations as well as Rs.3000/- per week from the date of accident till date. 

6]             The ld.Counsel for the OP wished to lay reliance on the expert opinion  of Dr. Gaurav Sawhney, M.S. (Ortho.) D.Ortho, who had held that as a result of injuries sustained by the patient, she would need bed rest for a maximum period of 6 months even if it was an exceptional case.  All bills submitted by the complainants put on record show that most of them have not been validated by the concerned doctors. Only the ones which were validated by the doctors could be considered for reimbursement to the complainant.            Taking this fact into consideration, how can we hold the insurance company liable for any other expenses if not validated by the doctors/hospital.

7]             In view of the above discussion and evidence placed on record, we are of the opinion that the payment made by the OP Insurance Company against the bills submitted by the complainant and validated by the doctors/hospital, along with amount @Rs.3000/- for 25 weeks; all totaling to Rs.97,680/- is justified.  The complainant cannot claim entitlement for any further amount from the OPs.

8]             Therefore, this complaint is hereby dismissed.  All parties are left to bear their own costs.

9]             Certified copies of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

16.07.2010                                                                      Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

                                       Sd/-

                                       (ASHOK RAJ BHANDARI)

MEMBER

                                                                                      Sd/-

                                                             (MADHU MUTNEJA)

MEMBER

‘Om’