Delhi

StateCommission

A/07/1012

NATIONAL INSURANCE COMPANY LIMITED - Complainant(s)

Versus

WHIRLPOOL OF INDIA - Opp.Party(s)

24 Mar 2015

ORDER

IN THE STATE COMMISSION : DELHI

(Constituted under Section 9 of the Consumer Protection Act, 1986)

Date of Decision :  24.03.2015

First Appeal No.1012/2007

(Arising out of the order dated 24.08.2007 in Complaint Case No. 219/2006 passed by District Consumer Disputes Redressal Forum (Central), Kashmere Gate, Delhi)

       

NATIONAL INSURANCE CO. LTD.

Regional Office No.1

Jeevan Bharti

124, Connaught Circus

New Delhi                                                    ……Appellant

                                                      

VERSUS

M/s WHIRLPOOL OF INDIA

Through                     

Mr. Kailash Aggarwal

Senior Manager Legal

Registered Office at 7^th Floor,

Atma Ram House

1, Tolstoy Marg, New Delhi-110001                    …..Respondent

 

CORAM

N P Kaushik, Member (Judicial)

S C Jain, Member

1.     Whether reporters of local newspaper be allowed to see the judgment?

2.      To be referred to the reporter or not?

N P Kaushik, Member (Judicial)

Judgment

1.         The appellant National Insurance Company Ltd. has impugned the orders passed by the Ld. District Forum (Central) Kashmere Gate, Delhi. Vide impugned orders the appellant/OP was directed to pay to the claimants the claim amount as shown in annexure C-X. Besides this compensation to the tune of Rs. 3,000/- to each employee was also awarded.
2.         Facts in brief as disclosed in the complaint are that the complainant M/s Whirlpool of India obtained a mediclaim policy for its employees for the period from 31.10.1998 to 30.10.1999. The complainant paid an amount of Rs. 4,44,564/- to the OP as premium of the policy. OP repudiated the claim in respect of fifty seven employees for an amount of Rs. 8,19,386/-. Details of these claims are contained in the chart at annexure-C. In nutshell, the OP repudiated the claim of these employees on the basis of the grounds given in the letter written by Dr. A.K.Batra, a mediclaim panel Doctor of the OP. The said grounds are reproduced below:-

1. Most of the case sheets did not bear the history of the patient, the past history, examination findings, the reports of investigations, the day to day complaints of the patients and notes of attendance by the RMOs, the operation notes, the dates of surgery, the name of the surgeon, the anesthesia records and the advice on discharge.
2. All the case sheets are in one or two handwritings only and have been written with 3 or 4 pens.
3. The change in treatment on day to day basis, the treatment charts and the TPR charts are all written by one person only and the change in handwriting/pen by the different doctors/nurses with the change in duty is conspicuously not there.
4. In most of the cases the duration of symptoms remains the same e.g. Fever for 5-6 days, vomiting, ghabrahat and giddiness for 1-2 days and general weakness for 7-10 days.
5. In some of the cases, Dr. Upendra has made changes in the reports of the Ultrasonologists for apparent reasons.
6. Pain abdomen/acute abdomen has been mentioned in addition to the primary condition in most of the cases.
7. Several of the cases are for management of Enteric Fever. In all these cases, the duration of fever is of less than one week. The diagnosis of Enteric Fever can be made in Ist week by doing Blood Culture-sensitivity but in none of the cases, this test has been done. Widal test is done usually in II^nd week and is repeated at weekly intervals to monitor the rising/falling titters but in all theses cases the widal test was reported positive in Ist week and the repeat test was not done.

Chloramphanicol, an obsolete drug, was advised to the patients for 10 days in 500-mg BD doses. This dose is subclinical. Administration of Chloramphanicol warrants Blood counts have not been done even once after the initial tests.

8. In cases of Hepatitis-Jaundice, the liver function tests have not been repeated after the initial tests and the period of hospitalisation is generally exaggerated.
9. In case of Acute Pain in left side of chest, the ECG and other cardiological investigations have not been done even in a single case.
10. In several cases the symptoms have been mentioned as Diagnosis and the actual/final diagnosis has not been mentioned.
11. The period of hospitalization in accidental cases appears to be too long when compared with the nature of injuries.
12. The period of hospitalization in the patients undergoing Laproscopic surgeries is usually long. Generally such patients require hospitalisation for 2 days but in most of the cases under view, the period of hospitalization has been 7-8 days i.e. is exaggerated.
13. The details of treatment taken in pre and post-hospitalization periods have not been submitted even in a single case.

 

Dr. A.K.Batra on whose recommendation the OP repudiated the claim was present in the Ld. District Forum when the matter was finally heard. On a query by the Ld. District Forum, Dr. Batra failed to demonstrate as to how the cases in which the claims were allowed were different from the claims in question.

3.             Perusal of the abovesaid grounds shows that the same are general in nature and not specific to each claimants/patient. Ground twelve as has been reproduced above, shows that the patient of ceroscopy surgery remained admitted in hospital for 7-8 days whereas the patient required hospitalisation only for two days. It is not the case of the appellant/OP that the patient did not undergo hospitalisation. No material in support of any grounds of repudiation has been placed on record. Broadly, the OP was swayed by the reputation of Dr. Rupendre who appears to have been charge sheeted in some kidney racket. Mere bad reputation of the doctor cannot be a ground for repudiation of the claims, recommended by him. Ld. Counsel for the Appellant Sh. Pradeep Gour has taken me through the record relied upon by the OP. Not even a single claimant’s claim has been rejected by the OP on merits.
4.             In view of the discussion above, we do not find any illegality or infirmity in the orders passed by the Ld. District Forum. Appeal is thus dismissed being devoid of merits. The same is, therefore, dismissed.
5.             FDR if any deposited by the appellant be released as per rules.
6.             Copy of the orders be made available to the parties free of costs as per rules and thereafter the file be consigned to Records.

 

(N P KAUSHIK)

MEMBER (JUDICIAL)

 

 

(S C JAIN)

144616126.  

 

 

 

 

 

 

 

 

 

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