Complainant Pardeep Sehgal vide the present complaint filed U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the titled opposite party to make payment of remaining claim amount of Rs.64,000/- with interest @ 12%per annum. Opposite party be further directed to pay Rs.10,000/- for deficiency in services, Rs.10,000/- for mental harassment and Rs.5,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that he obtained a policy from the opposite party bearing no.36160042100100200126 after making the payment of premium. On 1.9.2011 he met with an accident and suffered injuries in an accident at Jassur (Himachal Pradesh). He was admitted to Kalyani Hospital, Pathankot from 1.9.2011 to 17.9.2011. Afterwards he was taken to specialized treatment to Amandeep Hospital, Amritsar, where he remained admitted twice i.e. firstly from 12.12.2011 to 22.12.2011 and then from 21.7.2013 to 24.8.2013. The doctors advised during the whole period for complete bed rest without break from 1.9.11 till 19.3.2013. He further pleaded that as the policy has been duly issued by the opposite party and as per terms and conditions of the policy he is entitled for the clam. The terms and conditions of the policy clearly provides that admissible claim is 1% of the sum assured per week towards bed rest plus 40% of the admissible claim as medical expenses. The sum insured is Rs.1,00,000/-. As per the certificates of the hospital, he remained on complete bed rest for 81 weeks, meaning thereby the bed rest amount as per policy comes to Rs.81,000/- plus medical expenses 40% of Rs.81,000/-, which comes to Rs.32,400/-. Hence his total admissible claim comes to be Rs.1,13,400/-. As the amount exceeds the sum insured, as such he is entitled for the amount of Rs.1,00,000/- i.e. sum insured. The claim has been filed and all the formalities have been duly completed. The claim form was duly signed and stamped by the Amandeep Hospital, also provided to the Insurance Company, but the insurance company made false excuses on one pretext or another. The insurance company again demanded fresh claim form from him on 18.05.2015 on their request again new claim form duly signed by the Hospital authorities given by him and received by the office of the opposite party. Opposite party has directly credited the amount of Rs.36,000/- in his account through NEFT without his consent. He approached the opposite party to get the remaining amount but they started making false excuses. He has next pleaded that he sent legal notice through his counsel Sh.Surjit Singh Rana, Advocate to get the remaining claim and in reply to the notice, the insurance company sent reply dated 10.9.2015 through Sh.Raman Puri, Advocate and refused to give his remaining claim. The insurance company is alleging that they gave claim on the basis of one report, they have taken from Dr.Jatinder Salhotra. The said report, if any is forged and manipulated one and  he failed to understand how the Doctor Jatinder Salhotra issued such report without examining him. The medical record of Amandeep Hospital, Amritsar is very much clear and is true one. There is deficiency in service on the part of the opposite party who failed to make the payment of remaining amount of Rs.64,000/-. Hence this complaint.

3.       Upon notice, the opposite party insurer appeared through its counsel and filed its written version taking the preliminary objections that the present complaint is not maintainable against opposite party because the claim as per terms and conditions of the policy of insurance based on the expert opinion of panel doctor has been paid to the complainant as per his entitlement. On merits, it was submitted that opposite party does not have any personal knowledge about the injuries allegedly received by the complainant or his period of treatment, hence it is not accepted that the complainant has suffered the disablement or is unable to work from 1.9.2011 to 19.3.2013. The complainant is not entitled to Rs.1,00,000/- compensation as alleged. As per expert opinion given by Doctor Jatinder Salhotra, MS (Ortho), bed rest of 81 weeks for type of ailment suffered by the complainant is not given. As per opinion of Dr.Salhotra, for such type of ailment/disablement bed rest is for three to six months and the complainant has been paid for 26 week, which was Rs.26,000/- plus Rs.10,000/- towards medicinal expenses. The payment has been made as per terms and conditions of the policy of insurance. It was further submitted that the certificate issued by Amandeep Hospital and other hospital was incomplete. The complainant was asked to provide duly completed certificate, for which he took lot of time. The claim of Rs.36,000/- has been paid to the complainant as per terms and conditions of the policy and as per his entitlement. The report of Dr.Salhotra is correct. He is a qualified and experienced doctor; his opinion is very relevant in this case. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 along with the other documents exhibited as Ex.C2 to Ex.C98 and closed the evidence.

5.        On the other hand, Sh.Natha Ram, Admn Officer of the opposite party tendered into evidence his own affidavit Ex.OP1, alongwith the other documents Ex.OP2 to Ex.OP6 and closed the evidence.

6.      We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants in the wake up of the arguments as duly put forth by the respective learned counsels of the present contestants. We find that the present dispute has arisen on account of the OP insurers’ unilateral settlement at the ‘partial’ amount of Rs 36,000/- against the complainant’s medical claim (Ex.C5) for the ‘full’ insured amount of Rs.1,00,000/- in terms of the applicable Health Insurance Policy. The impugned ‘claim’ comprised of applicable ‘expenses’ @ Rs.1,000/- per week for ‘81’ weeks of ‘total’ disablement bed-rest ‘actually’ suffered through by the patient complainant (in road-accident multi-fracture injuries) w e f 01.09.2011 to 19.03.2013. The disablement ‘forced’ bed-rest (as having actually suffered) by the complainant has been duly ‘certified’ by the ‘2’ treating Hospitals (Ex.C3 & Ex.C4) as also having been duly accepted by the OP insurer’s designated investigator in his claim-report (Ex.C2) of 27.04.2015.

7.       However, it is not understood as to why the OP insurers still requisitioned ‘expert’ opinion (Ex.OP2) of its empanelled orthopedic-surgeon Dr Jatinder Salhotra who could simply ‘opine’ that such type of ‘multi- fractures’ cause ‘total-disablement’ that can ‘extend’ from minimum ‘3’ to ‘6’ months; and further the OP insurers (on the strength of this expert opinion) allowed applicable expenses for ‘26’ weeks i.e., 26,000/- + 40% (10,000/-) and paid Rs.36,000/- in the complainant’s Bank A/c. We find the OP ‘interpretation’ of expert-opinion Ex.OP2 as totally ‘ill-founded’ and ‘arbitrary’. Dr Jatinder Salhotra has expressed his opinion that ‘disablement’ can be caused for ‘minimum’ period of 3-6 months and that certainly goes to say that the ‘disablement’ can be for more than 3-6 months as in the present case it had been from 01.09.2011 to 19.03.2013. Somehow, we are of the considered opinion that such an ‘erroneous’ (framed) misinterpretation (at the best) be termed as ‘unfair trade practice’ coupled with ‘deficiency in service’  and that lines up the OP insurers for an adverse statutory award under the Consumer Protection Act’ 1986. 

8.       In the light of the all above, we partly allow the present complaint and thus ORDER the OP insurers to settle and pay the impugned claim in full to the complainant on the basis of his having suffered ‘total-disablement’ resulting into bed-rest with effect from 01.09.2011 to 19.03.2013 (as per the certification by treating Hospitals Ex.C3 & Ex.C4) strictly in terms of the related health policy in accordance with the IRDA guidelines on ‘settlement of claims’ besides to pay him Rs.5,000/- as cost and compensation within 30 days of receipt of the copy of these orders otherwise the aggregate awarded amount shall carry interest @ 9% PA from the date of the orders till actual payment. 

9.       Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

          (Naveen Puri)

                                                                      President   

Announced:                                              (Jagdeep Kaur)

June 01, 2016                                                    Member

*MK*