| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL) ISBT KASHMERE GATE DELHI CC/224/2015 Sh. Brij Mohan Bhatia S/o Sh. Tirath Ram Bhatia R/o C-119, 2nd Floor, Moti Nagar, New Delhi-110015. …..COMPLAINANT VERSUS United India Insurance Company Ltd. (Service effected through its Chairman/Principal Officer/Managing Director/Manager 216, 3rd Floor, Hardhian Singh Road, New Delhi-110005. Vipul Medcorp TPA Private Limited 515, Udyog Vihar, Phase 5, Gurgaon, Haryana. …..OPPOSITE PARTIES Quorum: Ms. Rekha Rani, President Ms. Manju Bala Sharma, Member Dr. R.C. Meena, Member ORDER Ms. Rekha Rani, President - Instant complaint was filed by Sh. Brij Mohan Bhatia (in short the complainant) under Section 12 of the Consumer Protection Act 1986 as amended up to date inter-alia pleading therein that he was having family medicare policy of United India Insurance Company Ltd. (in short OP1) since 2009. His son Karun Bhatia (in short the deceased) was also insured under the said policy bearing number 042500/48/12/06/00001141 valid from August 2012 to August 2013. On 26.07.2012 at about 10:00 P.M. deceased along with his friends went to attend a party in vehicle no. DL 1CM 1197 Make Honda City which was driven by Prabhjot Singh. While returning the driver was driving the vehicle rashly and negligently. He was overtaking other vehicles from both sides. While overtaking the other vehicles, the driver lost control over the vehicle and hit the same against the divider due to which the rear left door of the car opened and the deceased fell on the road sustaining fatal injuries. An FIR No. 268/2013 was registered on 27.07.2013 under Section 279/304 A IPC at P.S. Moti Nagar, New Delhi. Deceased was admitted in Kalra Hospital where the complainant incurred the medical expenses of Rs. 1,00,839/-. After seeing critical condition of the deceased, complainant shifted him to BL Kapur Hospital where the deceased was admitted from 27.07.2013 to 21.08.2013 and then he expired. Complainant paid a sum of Rs. 17,16,564/- as medical expenses at BL Kapur Hospital.
OP repudiated the claim observing that the deceased had taken alcohol. Complainant tried to persuade OP1 to understand that deceased was not driving the vehicle but was sitting at the rear seat but OP1 did not do anything. Hence, instant complaint was filed seeking direction to OP to pay to the complainant Rs. 4,00,000/- as medical Reimbursement, Rs. 3,00,000/-towards compensation for causing mental agony along with interest @ 36% per annum from 05.08.2013 till its realization and cost of litigation. - On receipt of notice, OP appeared and contested the claim vide its written statement. It is pleaded that the complaint is not maintainable as the Detailed Accident Report has already been filed and is pending in the court of Ms. Santosh Snehi Mann, Presiding Officer, MACT, Delhi. It is stated that complainant has filed the instant complaint only to satisfy his “lust for money”. It is further stated that he is not a consumer. It is also stated that the deceased was found intoxicated due to which cashless facility was rejected. It is denied that there was any deficiency in service on part of OP1. It is denied that the claim is payable.
- Both sides adduced evidence by way of affidavits. We have heard Sh. Vaibhav Sinha, counsel for complainant.
- It is not in dispute as is evident from the written statement of OP that complainant took medicare policy for himself and his family members with an insurable interest to the extent of Rs. 2,00,000/-. It is also submitted in the written statement of OP that due to non-submission of requisite documents claim was not investigated. Order dated 03.11.2015 of our predecessor bench shows that complainant was directed to prefer his claim with the OP and OP was directed to process the same within 30 days of receipt of the claim.
- Cashless facility for the treatment of the deceased was rejected by OP vide its letter dated 29/07/2013stating that “CASE IS NOT PAYABLE AS PER CLAUSE4.8 (USE OF INTOXICATION DRUGS/ALCOHOL)”.
- Complainant has placed on record a letter of OP dated 21/12/2015 which indicated that complainant submitted the claim papers to TPA for payment of the claim amount. The claim was rejected by OP observing that “as per the indoor treatment record of Kalra Hospital, patient was smelling of alcohol as accident happened while driving vehicle under the influence of Alcohol which is not payable as per terms and condition of policy’s clause no. 4.8”.
- It is vehemently contended on behalf of OP that claim is not maintainable as the deceased was diving being intoxicated having taken alcohol thereby violating terms and conditions of the policy.
- Report under Section 173 Code of Criminal Procedure was filed in the court of Sh. Rajender Kumar, Ld. MM, Tis Hazari Courts, Delhi based on the accident in question. It reads that a notice under Section 133, Motor Vehicles Act was served on Mrs. Jaswinder Kaur, w/o Late Sh. Manmohan Singh, r/o C-9, Upper Ground Enclave, Street No. 6, Himgiri Enclave, Chander Vihar-110041, the owner of the car which was involved in the accident in question. In reply to the notice, she submitted that she is the registered owner of the vehicle number DL 1CM 1197. She further stated that on 27.07.2013 her son Prabhjot Singh was driving the vehicle and hit the same against pillar number 333 outside Kalra Hospital. She also stated that the vehicle was not insured.
- Complainant has clearly pleaded in Paras 3 and 4 of the complaint that his son was sitting in the rear left seat of the vehicle and Prabhjot Singh was driving the vehicle. OP has not disputed the same specifically in corresponding Paras 3 and 4 of its written statement that Prabhjot Singh was driving the vehicle.
- In view of the above report of the police where reply of the registered owner of the vehicle is reproduced to the effect that her son Prabhjot Singh was driving the vehicle, plea of the complainant is substantiated that deceased was not driving the vehicle but was simply an occupant in the car at the time of the accident. Even if the deceased had consumed alcohol and was intoxicated, it has nothing to do with the accident. Accident happened because Prabhjot Singh was driving the vehicle rashly and negligently. As such repudiation of the claim is not justified.
- Complaint is allowed. OP1 is directed to pay the insured amount of Rs.2,00,000/- to the complainant. OP is further directed to pay a sum of Rs.1,00,000/- as compensation for causing mental agony to the complainant. Further OP1 is directed to pay litigation expenses of Rs. 25,000/- to the complainant. The above said amount shall be paid within 30 days from today failing which 9% interest per annum shall be payable from the date of order till the date of payment. Copy of this order be sent to the parties as statutorily required. File be consigned to record room.
Announced on Day of 2019. | |
