Punjab

Ludhiana

CC/14/392

Shri Rarjesh - Complainant(s)

Versus

United India Ins.Co.Ltd - Opp.Party(s)

20 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 392 of 21.05.2014

                                                                                                                    Date of Decision: 20.02.2015

                                                                                                                   

Rajesh Singla s/o Sh.Sadhu Ram, Aggarson Fasteners, F-61, Phase-VII, Focal Point, Ludhiana.

……Complainant

Versus 

1. United India Insurance Company limited, Branch Office- Miller Ganj, Ludhiana, through Sh.T.R.Shaad, Sr.Branch Manager.

2. Sh.T.R. Shaad, Sr. Branch Manager, United India Insurance Company Limited, Branch Office-Miller Ganj, Ludhiana.

…..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member

                   Smt.Babita, Member

 

Present:       Sh.C.S.Chopra, Advocate for complainant.

                   Sh.M.R.Saluja, Advocate for OPs.

 

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Rajesh Singla s/o Sh.Sadhu Ram, Aggarson Fasteners, F-61, Phase-VII, Focal Point, Ludhiana (herein-after in short to be referred to as ‘complainant’) against United India Insurance Company limited, Branch Office- Miller Ganj, Ludhiana, through Sh.T.R.Shaad, Sr.Branch Manager and others (herein-after in short to be referred as ‘OPs’)- directing them to reimburse the full compensation for the period 10.6.12 to 14.12.12 besides the medical expenses incurred by the complainant from his own pocket as per the claim form alongwith the documents annexed with this complaint, to pay Rs.1.00 lac as compensation for mental agony, torture and harassment, to pay Rs.30,000/- as cost of litigation to the complainant.

2.                Brief facts of the complaint are that complainant insured himself insured from OP, vide Personal Accident policy no.201401/42/11/01/00000863 for the last many years and total sum insured under the aforesaid policy was Rs.4.00 lacs. During the currency of the aforesaid policy, the complainant met with an accident in the intervening night of 9/10.6.12, when he had got hit against the bed, while going to toilet. In the said accident, the complainant got severe injuries on his knee. Immediately, thereafter, the complainant was moved to Government Multi Specialty Hospital, Sector 16, Chandigarh, wherein initial treatment of the knee injuries started by the doctors in duty. Thereafter the complainant got himself treated from Dr.Santosh.K.Aggarwal, Shivalik Hospital & Trauma Centre, Mohali. Later on the complainant got himself treated from Dr.Praveen Taneja, Ortho Care, # 1203, Sector, 42-B, Chandigarh. The complainant has to remain admitted in the aforesaid hospitals for his knee treatment for different intervals and incurred huge expenses thereof from his own pocket and the complainant had to remain on complete bed rest from 10.6.12 to 14.12.12 (i.e. for more than six months). Even Doctor Praveen Taneja of Ortho Care, aforesaid, had opined/advised that the complainant would only be in a position to attend his portion of normal duties after 14.12.12. Even as of now the complainant is not in a position to attend his normal day to day activities. The complainant had submitted his claim for reimbursement of the amount incurred on the treatment of the complainant for the aforesaid i.e. 10.6.12 to 14.12.12 plus medical expenses. All the relevant documents, including medical records, bed head tickets and the certificate issued by the doctors had also been submitted. However, vide letter bearing reference no.TRS/2012-13/4260 dated 26.3.13, the Ops had only accorded approval for compensation for total bed-rest and medicines as Rs.33,600/-, stating therein that the complainant is only entitled to six weeks’ bed rest compensation and not more, as per the opinion given by the panel doctors of the insurance company. Complainant also got issued legal notice dated 24.6.13 upon the OPs. Thereafter the complainant received a letter dated 20.09.13 from the Ops, wherein they mentioned that the complainant had already been suffering from Chomdromalacia Patella disease and it was which is why Government Multi Specialty Hospital, where the complainant had consulted on 10.6.12 did not specify the complainant’s accident. The said view of the OPs clearly shows that the OPs had no intention to settle the rightful claim of the complainant. While issuing the aforesaid letter, the insurance company has relied upon the opinion of Dr.N.D.Avasthi, Orthopaedic and Dr.Suresh Gupta (who are stated to be a Panel doctors of the Insurance Company). However, it is submitted that the said opinion is materially different from the opinion given by Dr.P.K.Taneja, M.S.Ortho, DA, Consultant Orthopaedic Surgeon, Chandigarh. Claiming the above act as deficiency in service on the part of the OPs, the complainant has filed this complaint.

3.                 On notice of the complaint, OPs appeared through their counsel and filed written statement taking preliminary objections that there is no deficiency in service on the part of the OPs and the claim was settled for Rs.33,600/-, but the complainant did not come forwarded to receive it; the complainant; the complainant got hit against the bed during the night 9/10.6.12 and he received injury on his right knee, while the prescription slip dated 10.6.12 of Government Multi Specialty Hospital, Chandigarh shows it to be a case of pain in knee; MRI and X-ray report and treatment chart shows that the complainant was received minor tissue injury and mild knee joint effusion; on the basis of the opinion of Dr.Suresh Gupta and Dr.N.D.Avasthi, the complainant was advised bed rest for 6 weeks and on the basis of said opinion, the claim was allowed to Rs.33,600/-, which includes Rs.24,000/- for 6 weeks @ Rs.4000/- per week and also awarded Rs.9600/- as medical expenses and the same was offered to the complainant, but complainant did not turn up to receive the same. The injury of the knee had been recovered maximum when the complainant took treatment from Dr.Taneja as per X-ray report dated 12.7.12. Further the recommendation of Bed rest for more than 6 months is required only where the patient is totally bed rideen. Moreover, the doctor of Government Multi Specialty Hospital did not mention about the accident which shows that complainant already suffering from Chondro Malacia Patela Disease because Chondra Malacia is choronic pathology which taken years together in some cases to give signs and symptoms. Therefore, the complainant was having pre-existing disease and the treatment expenses of the same is not payable under term no.4.1 of the policy. Further from the X-rays report, it is clear that there is no major injury and Patela Femoral joint is normal. On merits, admitting the contents of some of the para and further denying the contents of other remaining paras, Ops prayed for the dismissal of the complaint.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Rajesh Singla Ex.CW1/A, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C11. On the other hand, Ld. counsel for OPs has adduced the evidence by way of duly sworn affidavit of Sh.Jagtar Singh, Senior Divisional Manager, United India Insurance Co. Ltd. Divisional Office no.6, Focal Point, Ludhiana Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 to Ex.R11.

5.                Case was fixed for arguments. Ld. counsel for both the parties filed their written arguments. Ld. counsel for complainant filed written arguments averring that on the intervening night of 9/10.6.12 complainant got his against the bed and he got severe injuries on his knee. Complainant was moved to Government Multi Specialty Hospital, Sector 16, Chandigarh. The complainant did not get relief from the treatment at the aforesaid hospital and got himself treated from Dr.Santosh.K.Aggarwal, Shivalik Hosptial and Trauma Centre, Mohali. The complainant  was unable to bear the pain and thereafter complainant got himself treated from Dr.Parveen Taneja, Ortho Care, # 1203, Sector 42-B, Chandigarh and complainant was advised bed rest from 10.6.12 to 14.12.12. Ld. counsel for complainant further submitted that as per Ex.C6 of Dr.Parveen Teneja patient was asked to restrain physical activity. In nutshell doctor advised him bed rest upto 14.12.12, while the OP’s company has allowed the claim for 6 weeks only and so they are found to be deficient in service. Moreover, the OP’s company has relied on the opinion of their own panel of doctors Dr.Suresh Gupta and Dr.N.D.Avasthi.

6.                Refuting the allegations leveled by the complainant, Ld. counsel for OPs filed written arguments averring that Ops have genuinely settled the claim of Rs.33,600/- including compensation @ Rs.4000/- per week for the bed rest of 6 weeks, Rs.9600/- as medicines expenses, which is on the basis of Dr.Suresh Gupta and Dr.N.D.Avasthi, M.B.B.S, M.S. Ortho Surgeon. The complainant himself stated that he got hit against the bed and received minor injury and after that he first went to Government Multi Specialty Hospital, whereby the prescription shows that patient complained pain in his right knee and doctor advised him pain killer and on the next day he changed his doctor and went to shivalak Hospital and prescription Ex.C3 shows that the complainant had swelling and pain in his right knee and asked him to get MRI and X-ray scanned. Doctor advised 10 days bed rest. MRI report shows that ‘Mild Knee Joint effusion. Accordingly to the opinion of panel of doctors of the OPs complainant received minor injury and required bed rest for maximum 6 weeks. So, the claim Rs,33,600/- is rightly settled. Further submitted that the complainant went on changing the doctors, so he may get suitable doctor who could issue false certificate in order to get inflated claim. Complainant has not produced doctor fee and receipts either. MRI report and X-ray report Ex.C3 to Ex.C5 shows that there is everything normal in the knee of the complainant. Moreover, as per Ex.R4 and Ex.R5 “Patella shows subchondral lucency suggestive of Chondromalacia, which does not develop within days or month, but it takes years to develop. Moreover if the complainant has a disease of Osteoarthrities, which must have been pre-existing because it takes years to develop. Opinion of Dr.Suresh Gupta and Dr.N.D.Avasthi had not been falsified by the complainant in any manner.

7.                We have gone through the pleadings of the complainant as well as defence taken by the OPs and gone through the written arguments submitted on behalf of both the parties and also perused the entire record placed on file.

8.                It has been observed that the complainant underwent treatment from Government Multi Specialty Hospital, Chandigarh and thereafter went to Shivalak Hospital and Trauma Centre, Mohali and MRI of the right knee was also carried out and according to which diagnosis was as follows:-

                   Stain of medical and lateral collateral ligaments.

                        Grade II teat in anterior and posterior horns of lateral meniscus.

                        Mild tricompartmental osteoarthritis of knee joint.

                        Grade III chondromalacia patellae.

                        Mild knee joint effusion is seen.

 

                   Further Ex.C4 comprises of many prescriptions of Dr.ParveenTaneja, wherein the doctor has further advised him to take bed rest and the said doctor also advised him to restrain physical activities and to avoid movement, but it is not proved on record that the said disease of the complainant was a result of hitting the bed side, rather as per Ex.R4 dated 12.7.12 and Ex.R5 dated 25.7.12 complainant was suffering from osteoarthritis and as per X-ray reports complainant was having Osteoporosis with subchondral erosion and this symptoms do not appear to be the result of hitting against bed, but is appear to be a pre-existing disease because it takes years to be develop. According to Ex.R8 Chondromalacia Patellae, is a condition, which has been thought to be analogous to primary osteoarthritis, affects the patellofemoral joint of young adults (especially women). In certain cases the particular cartilage covering the patella and subsequently that covering the patellar articular surface of the femur, becomes softened, fibrillated and finally ulcerated. Although this sequence of events is identical with that seen elsewhere in primary osteoarthritis, in this joint it occurs in early life as a normal event so that its pathological significance is hard to ascertain and these pathological changes are by no means always present. The more general term anterior knee pain more accurately described this condition and indicates that other pathological processes may be at work to produce the symptoms. The condition has been treated by various surgical procedures aimed directly at the cartilage (drilling and shaving). It is doubtful if these procedures are beneficial, although regeneration of fibrocartilage following drilling of the patella in advanced osteoarthritis of the knee has been described. There is a view that the condition is associated with an increase in the contact pressure between the patella and the lateral femoral condyle caused by a tendency for the patella to be drawn laterally in involved knees. Treatment based on this view taken the form of division of the lateral patellar retinaculum and occasionally or transposition of the tibial tubercle. Useful pain relief has been reported after these operations. As a last resort the patella is sometimes excised, but this leads to considerable weakness of the knee and may not always relieve pain.

9.                Further Ex.R6 clearly gives the details of the required treatment, which the complainant was required to undergo and according to Dr.N.D.Avasthi Orthopedic Surgeon there was no major injury to the knee and as such the patient may be confined to complete bed rest maximum of six weeks only. But notwithstanding with above observations about the opinion of this doctor it is further clearly observed that the OPs are not been able to make rebuttal regarding the prescriptions Ex.C4 alongwith other prescriptions of Ortho Care The Bone and Joint Centre Max Super Specialty Hospital dated 4.7.12, 12.7.12, 25.7.12, 8.8.12, 28.8.12 and 15.11.12, where the patient periodically has been advised rest for 20 days; 15 days; 3 weeks; 3 weeks, one month, one moth and one month respectively.

10.              In view of the above discussion, the present complaint is partly allowed and Ops are directed to re-consider the claim of the complainant as per the advise of the above noted prescriptions of Max Super Specialty Hospital and the claim already allowed to the extent of Rs.33,600/- by the OPs may be revised further if found admissible as per terms and conditions and in the light of the above prescriptions with no order as to cost. Copy of the order be supplied to the parties, free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.