BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.
Complaint No: 190 of 19.03.2015.
Date of Decision: 13.01.2016.
- Smt. Raj Rani w/o. Sh. Parshotam Dass Goyal,
- Parshotam Dass Goyal, husband of Raj Rani Goyal, both residents of 4-A, Madhuban Enclave, Barewal Road, Ludhiana.
..… Complainants
Versus
United India Insurance Co. Ltd. through its Senior Branch Manager, 818, Industrial Area-B, above Allahabad Bank, Partap Chowk, Ludhiana.
…..Opposite parties
Complaint under the Provisions of Consumer Protection Act, 1986
QUORUM:
SH. G.K. DHIR, PRESIDENT
SH. S.P. GARG, MEMBER
COUNSEL FOR THE PARTIES:
For complainants : Sh. S.S. Sekhon, Advocate
For OP : Sh. D.R. Rampal, Advocate
ORDER
PER G.K. Dhir, PRESIDENT
1. Complainants filed complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) by claiming that complainant No.2 purchased personal accident policy bearing no.201003/42/13/01/00000185 from OP valid from 24.11.2013 to 23.11.2014 on payment of premium. Policy purchased by the complainants includes the medical treatment expenses and bed rest compensation. Complainant No.1 met with an accident on 04.06.2014 at Ludhiana, due to which she was treated by Dr. Vishal Garg of Garg Hospital, Punjab Mata Nagar, Ludhiana. Doctor advised two weeks bed rest and thereafter he again advised bed rest for two more weeks. On 19.07.2014, doctor advised complainant for physiotherapy for recovery of injury suffered by complainant No.1 in accident. Complainant No.1 lodged complaint on 23.07.2014 for getting claim of Rs.21,996/-. Intimation regarding accident was also given by complainant to OP, but OP without applying their mind paid an amount of Rs.3000/- for one week bed rest plus Rs.750/- as medical expenses being 25% of the bed rest claim. It is claimed that complainant is eligible for 50% of the medical expenses for bed rest, but OP has paid Rs.3750/- only by transferring the said amount in the bank account of complainant through ESC. OP has not paid the bed rest expenses treatment for period from 04.06.2014 to 06.07.2014 despite sending registered notice dated 09.02.2015. The claim has neither been settled and nor rejected and that is why the claim petition for getting medi-claim amount of Rs.18,246/- + Rs.31,754/- as damages along with litigation expenses of Rs.20,000/-.
2. In written statement by OP, it is pleaded interalia, as if the complaint in present form is not maintainable; complaint being false and frivolous merits dismissal; complaint is bad due to non joinder and misjoinder of necessary parties because registered head office and divisional office has not been impleaded as party. Besides it is claimed that complainant has not approached this Forum with clean hands. Claim of complainant was minutely scrutinized by competent doctor namely Dr. B.C. Singla and he worked out the amount regarding treatment of complainant No.1 by assessing the same as Rs.3750/- and same was paid through ECS by OP. It is claimed that there is no deficiency in services on the part of OP and complainants are estopped by their act and conduct from demanding further amount. As complicated question of law and facts are involved and as such civil court is competent to decide the present complaint. Admittedly, policy was valid from 24.11.2013 to 23.11.2014 and complainant No.1 sustained injuries on 04.06.2014. It is claimed that treatment as alleged to be required in fact was not required and that is why complainant No.1 was not in need of bed rest for long period of six weeks. Due payable amount has already been paid and as such, by denying each and other averment of the complaint, prayer made for dismissal of complaint.
3. Complainants to prove their case tendered affidavit Ex. CA of Smt. Raj Rani along with documents Ex. C1 to Ex. C13 and thereafter, counsel for complainant closed evidence.
4. On the other hand, counsel for opposite party tendered affidavits Ex. RA of Sh. Satnam Singh Basra and Ex. RB of Dr. B.C. Singla along with documents Ex. R1 to Ex. R14 and then closed evidence.
5. Written arguments not submitted by any of the parties, but only oral arguments have been addressed and those were heard. Record carefully gone through.
6. It is vehemently contended by Sh. Sukhjinder Singh Sekhon, Advocate representing complainant that reasons for delay in sending intimation has been duly explained in para No.1 of Ex. R4 and as such, the delay cannot be taken into consideration for repudiating major part of claim qua accidental injuries in question. In para No.1 of Ex. R4, it is specifically mentioned that though accidental injuries occurred on 04.06.2014, but doctor advised complete bed rest for four weeks because of the serious nature of the injuries and that is why delay in sending intimation took place. This letter Ex. R4 was written by complainant to OP in response to its letter dated 08.09.2014 placed on record as Ex. R3. Intimation qua accidental injuries was submitted by complainant to OP through email dated 15.06.2014 is a fact borne from contents of Ex. R3 and same fact borne from email Ex. R2. If email qua accident in question dated 04.06.2014 could have been sent on 15.06.2014, then why the same was not sent immediately after 04.06.2014, Qua that no due explanation coming forth on record and as such, virtually the submitted explanation through para no.1 of Ex. R4 is unreasonable and unbelievable, particularly when different ages of complainant No.1 mentioned in Ex. R4, Ex. R3 and insurance policy Ex. C1. In Ex. C1 issued on 24.11.2013 age of complainant No.1 given as 74 years, but in Ex. R3, it is mentioned as if in records of hospital same shown as 76 years, but in the claim form same mentioned as 79 years. On account of that, proof of correct age of complainant No.1 demanded through Ex. R3 and that is why date of birth of complainant mentioned as 25.10.1936 in Ex. R4. Technical error must not come in the way of granting due relief to a consumer and as such, if different ages with range of 72 to 79 years mentioned, then on account of that, due relief to complainant (if required) cannot be denied.
7. As per case of OP, after receipt of intimation, Dr. B.C. Singla was appointed by the insurance company and he found that entitlement of complainant No.1 for bed rest amount was for one week only. In support of that, affidavit Ex. RB has been tendered in evidence and as such, claim of complainant for one week bed rest amount has been approved on the recommendations of Dr. B.C. Singla. In this affidavit Ex. RB itself, it has been mentioned that complainant No.1 sustained only soft tissue injury on right shoulder and no bone injury was seen after doing X-ray. For soft tissue injury, the reasonable requirement for bed rest as has been found to be one week by Dr. B.C. Singla and as such, case of OP is believable in this respect, particularly when the same fact being mentioned in letter Ex. R1 sent by Dr. B.C. Singla to senior branch manager of OP. It is on account of this, that the amount of Rs.3000/- has been allowed for bed rest of one week, but Rs.750/- on account of medical expenses. Undisputedly amount of Rs.3750/- has been disbursed to complainant through ECS transaction. However, complainant claims that Rs.21,996/- including medical expenses of Rs.3996/- is payable and that is why letter Ex. R5 has been written.
8. In Ex. R7 personal accident insurance claim form, it is mentioned that complainant No.1 unable to attend his normal duties from period 04.06.2014 to 19.06.2014, but at the same time in column No.5, it is mentioned as if complainant partially able to attend his normal duties from 04.06.2014 to 19.06.2014. There is contradiction in the assertions contained in para no.5 of Ex. R7 itself and as such, contents of this claim form cannot be accepted as correct that actually two weeks rest was required.
9. Complainant claims to have got treatment from Dr. Vishal Garg, but as per advice of that doctor six weeks rest was required as disclosed by contents of Ex. R8. No affidavit of Dr. Vishal Garg has been tendered in evidence and nor certificate of that doctor has been produced. So reliance on Ex. R8 alone can not be placed for finding that actually six weeks rest was required, particularly when in sub column No. c of column 7 of Ex. R8, it is mentioned that complainant is able to attend to any portion of his normal duties w.e.f. 18.07.2014, but at the same time it is also mentioned that resumption of normal duty fully is permissible w.e.f. 01.08.2014 and tearing of cuff is described as nature of injury in column no.2 of Ex. R8 itself. In the absence of certificate or affidavit of Dr. Vishal Garg, certainly complainant unable to prove that she actually required bed rest for six weeks, particularly when contradiction exists in Ex. R7 and Ex. R8 as to whether bed rest required for two weeks or six weeks actually.
10. After going through clause 14 of Ex. R12/R13, it is made out that medical expenses means those expenses that an injured person has necessarily and actually incurred for medical treatment on account of illness or accident on advice of medical practitioner. Said treatment must be a necessary requirement of treatment as per prescription of medical practitioner. That prescription of Dr. Vishal Garg not proved by way of production of his certificate or affidavit as discussed above. So allowed claim of Rs.3750/- cannot be treated as illegal and unjustified. Being so, there is no deficiency of service on the part of OP.
11. As a sequel of above discussion, the complaint stands dismissed without any order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.
(Sat Paul Garg) (G.K. Dhir)
Member President
Announced in Open Forum.
Dated:13.01.2016.
Gobind Ram.
