Erakala Malsoor,S/o Ramalaxmaiah,Occ:Coolie R/o.Muthalgudem(V),Kusumanchi(M),Khammam District - Complainant(s)
Versus
The Oriental Insurance Co.Ltd.,Rep by its Branch Manager ,H.No.11-3-100/1,Wyra Road ,Khammam - Opp.Party(s)
23 Nov 2010
ORDER
BEFORE THE DISTRICT CONSUMER FORUM AT KHAMMAM Varadaiah Nagar, Opp CSI Church consumer case(CC) No. CC/09/114
Erakala Malsoor,S/o Ramalaxmaiah,Occ:Coolie R/o.Muthalgudem(V),Kusumanchi(M),Khammam District
...........Appellant(s)
Vs.
The Oriental Insurance Co.Ltd.,Rep by its Branch Manager ,H.No.11-3-100/1,Wyra Road ,Khammam
...........Respondent(s)
BEFORE:
Complainant(s)/Appellant(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
ORDER
BEFORE THE DISTRICT CONSUMERS FORUM AT KHAMMAM Dated this, the 23rd day of November, 2010 CORAM: 1. Sri.Vijay Kumar, B.Com.L.L.B., President, 2. Smt.V.Vijaya Rekha, B.Sc. B.L., Member 3. Sri.R.Kiran Kumar, B.Sc., B.L., Member C.C. No.114/2009 Between: Erakala Malsoor, S/o Ramalaxmaiah, Age:45yers, Occu:Coolie, R/o Muthalgudem (V), Kusumanchi (M), Khammam District. Complainant And The Oriental Insurance Co. Ltd., rep. by its Branch Manager, H.No.11-3-100/1, Wyra Road, Khammam. Opposite parties. This C.C. came before us for hearing in the presence of Sri K.Rama Chandra Murthy, Advocate for complainant and of Smt.P.Sandhya Rani, Advocate for opposite party; upon perusing the material papers on record; upon hearing arguments, and having stood over for consideration, this Forum passed the following:- ORDER (Per Smt.V.Vijaya Rekha, Member) This complaint is filed under section 12(1) of the Consumer Protection Act, 1986. The brief facts of the complaint are that the complainant is working as a Coolie and taken Personal Accident Policy from the opposite party vide policy bearing No.431401/48/2008/1109, for an amount of Rs.1,00,000/-. The policy is in force from 07-11-2007 to 06-11-2008, which covered the medical expenses for normal risk also. On 10-11-2007, while the complainant came on the Bullock Cart with a load of cotton bags, it was turned turtle and the complainant fell down and sustained injuries over the stomach, immediately he was shifted to RMP doctor, Mutyalagudem. After taking first aid, the complainant was shifted to the Mamata General Hospital, Khammam for better treatment and joined as inpatient vide IP No.11/381, after conducting required examinations, the doctors found that the complainant sustained blunt injury over the abdomen to the gallbladder and conducted explorative laparotomy Cholecystectomy and discharged on 30-11-2007 with an advise to take fallow-up treatment and complete bed rest. Therefore, the complainant had taken treatment for more than one year and incurred an amount of Rs.50,000/- towards medical and other expenses. After discharging from the hospital, submitted claim form with required documents. Instead of settling the claim, the opposite party appointed an investigator after lapse of long time and rejected the claim by mentioning that the accident occurred prior to commencement of the policy and the cause of injury was due to fall from the toddy tree. The complainant further submitted that as per the medical record, he sustained injury over the stomach due to fall from the bullock cart and the policy was in force as on the date of accident i.e. on 10-11-2007 and as such the opposite party is liable to pay the expenses, incurred by him according to the conditions of the policy. However, the opposite party rejected the claim, which amounts to deficiency of service and due to which, the complainant suffered a lot and incurred more than Rs.50,000/- towards medical and other expenses and prayed to direct the opposite party to pay Rs.50,000/- towards medical expenses together with 12% interest p.a. from the date of accident and Rs.45,000/- towards damages and Rs.5000/- towards costs. 2. Along with the complaint, the complainant filed his affidavit and also filed the following documents, which were marked as exhibits. Ex.A1:- Photo copy of the medical report of the claimant and claim form. Ex.A2:- Policy copy. Ex.A3:- Premium payment receipt. Ex.A4:- Letter dated 03-12-2008 addressed by the B.M. of opposite party. Ex.A5:- Letter dated 23-06-2009 addressed by the B.M. of opposite party. Ex.A6:- Letter dated 26-08-2009 addressed by the B.M. of opposite party. Ex.A7:- Medical Certificate issued by the Mamata General Hosptial, Khammam, in the name of the complainant. Ex.A8:- Discharge Summary Card & Discharge Summary Ex.A9:- Prescriptions, prescribed on inpatient tickets numbering in 27. Ex.A10:- Medical Bills, numbering in 28. Ex.A11:- Patient ID Card, dated 04-03-2008. Ex.A12:- Photograph of the complainant. 3. On being noticed, the opposite party appeared through its counsel and filed counter by denying the averments, mentioned in the complaint and submitted that after receiving the letter, dt.11-12-2007 regarding the injuries, the opposite party sent claim form to the complainant. The complainant submitted the same without required documents, as required and as such the opposite party requested to furnish medical record regarding the treatment. But the complainant failed to furnish any documents and addressed a letter, dt.16-12-2008 by stating that the documents were misplaced. Therefore, the opposite party appointed an investigator for investigating the facts and for collecting the medical record. As per the investigation report, the opposite party came to know that the complainant sustained abdominal injury prior to taking of policy and he had taken treatment with the R.M.P. doctor at his village. The opposite party also contended that the complainant never taken treatment at Mamatha General Hospital, Khammam and the alleged injury took place prior to the existence of policy, which was due to fall from the toddy tree and as such they repudiated the claim on 23-06-2009. The opposite party further submitted that the sum assured under the policy for death is Rs.1,00,000/- and as per the terms and conditions of the policy, where loading for medical extension cover is 25%, the policy is extended to include payment of medical expenses due to accident up to 25% of capital sum or 50% of the admissible PA claims amount or actual medical expenses incurred, which ever shall be less and also averred that the documents/medical record, furnished by the insured are not genuine and created for the purpose of filing the present case, therefore they repudiated the claim and as such there is no deficiency on the part of them and prayed to dismiss the complaint with exemplary costs. 4. In support of his averments, the complainant filed his chief examination affidavit and Dr.Vanama Shankar Rao, R.M.P., filed chief examination affidavit. The complainant also filed a memo by submitting to treat the contents of chief affidavit as written arguments on his behalf. 5. In view of the above submissions, now the point that arose for consideration is, whether the complainant is entitled to the relief as prayed for? It is an admitted fact that the opposite party had issued Personal Accident Individual Policy to the complainant by collecting the premium and also admitted that the policy was in force from 07-11-2007 to 06-11-2008. It is the case of the complainant, on 10-11-2007 he sustained abdominal injury due to fall from the bullock cart while carrying cotton load and taken treatment in Mamata General Hospital, Khammam for 20 days as inpatient and undergone Cholecystectomy and incurred Rs.50,000/- towards medical and other ancillary expenses. On the other hand, the opposite party denied the averments with regard to the date of accident and cause of injury by submitting that the injury was taken place prior to the date of policy, which was caused due to fall from the toddy tree and also taken a plea that the insured has not taken treatment at Mamata General Hospital, Khammam, and repudiated the claim as the documents furnished by the insured were not genuine. After having perused Exs.A7 to A11, we have observed that as per Ex.A2, the policy is in force from 07-11-2007 for a period of one year and as per Exs.A7 & A8, the insured/complainant joined as an inpatient in Mamata General Hospital, Khamamm on 10-11-2007 for abdominal injury, which was caused due to fall from the Bullock Cart and taken treatment for a period of 20 days i.e. from 10-11-2007 to 30-11-2007 as in patient and undergone Cholecystectomy and as per Ex.A10, he incurred an amount of Rs.3,562.38/-towards medical expenses during the course of treatment as in patient and also spent an amount of Rs.100/- towards medical certificate. Ex.A8 is the discharge summary, wherein clearly prescribed to take complete rest for another one month and continuous medication and as such, the plea taken by the opposite party in this regard is not acceptable and with regard to the entitlement is concerned, as per the conditions of the policy where loading for medical extension cover is 25%, the policy is extended to include payment of medical expenses due to accident up to 25% of capital sum or 50% of the admissible PA claims amount or actual medical expenses incurred, which ever shall be less and as such in view of the above condition and the entire medical bills filed by the complainant, the entitlement is limited to the medical expenses actually incurred which is the less amount and as per the said bills, the complainant had incurred Rs.3,562.38ps/- towards medical expenses at the time of taking treatment as inpatient and with regard to the follow-up treatment, he failed to file any proof except ID card, which is marked as Ex.A11, which speaks that the complainant went to Mamatha General Hospital, Khammam for follow up treatment on 04-03-2008 i.e. after 3 months from the date of discharge and as such it is deemed that the complainant had taken continuous treatment for months together and also incurred some amounts towards medical expenses for that period. In view of the aforesaid discussion and conditions of the policy, the opposite party cannot escape from its liability to bear medical expenses, actually incurred by the complainant at the time of treatment as in patient and out patient. Therefore the point is answered accordingly in favour of the complainant by holding that the opposite party is liable to pay the total medical expenses incurred by the complainant during the course of entire treatment. In the result, the complaint is allowed in part, directing the opposite party to pay an amount of Rs.3,562.38/-towards medical expenses incurred, during the course of treatment as inpatient and Rs.3000/- towards medical expenses for follow-up treatment and on these amounts, the complainant entitled to the interest @9% p.a. from the date of repudiation i.e. from 23-06-2009. Further directed to pay Rs.2000/- towards cost of the litigation. Typed to my dictation, corrected by me and pronounced by us, in this Forum on this 23rd day of November, 2010. President Member Member District Consumers Forum, Khammam Appendix of evidence Witnesses examined for complainant and opposite parties: -None- Exhibits marked for complainant:- Ex.A1:- Photo copy of the medical report of the claimant and claim form. Ex.A2:- Policy copy. Ex.A3:- Premium payment receipt. Ex.A4:- Letter dated 03-12-2008 addressed by the B.M. of opposite party. Ex.A5:- Letter dated 23-06-2009 addressed by the B.M. of opposite party. Ex.A6:- Letter dated 26-08-2009 addressed by the B.M. of opposite party. Ex.A7:- Medical Certificate issued by the Mamata General Hosptial, Khammam, in the name of the complainant. Ex.A8:- Discharge Summary Card & Discharge Summary Ex.A9:- Prescriptions, prescribed on inpatient tickets numbering in 27. Ex.A10:-Medical Bills, numbering in 28. Ex.A11:-Inpatient Card, dated 04-03-2008. Ex.A12:-Photograph of the complainant Exhibits marked for opposite parties:- -Nil- President Member Member District Consumers Forum, Khammam
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