State Consumer Disputes Redressal Commission
Shahjha W/O Shahid Shekh vs Star Health & Allied Insurance Company ... on 9 May, 2024
Reportable jkT; miHkksDrk fookn izfrrks"k vk;ksx] lfdZV cSap] dksVk le{k%& ekuuh; Jh ,l-ds-tSu] ihBklhu lnL; ¼U;kf;d½ ekuuh; Jh jkeQwy xqtZj] lnL;
ifjokn la[;k 03@2019 'kkgtgka csok 'kkfgn 'ks[k] tkfr& eqlyeku] fuoklh&edku uEcj&141] vkn'kZ uxj] catkjk dksyksuh] HkS:th ds eafnj ds ikl] cYyHk uxj] xqekuiqjk] dksVk] jktLFkkuA ifjokfn;k cuke 1- LVkj gsYFk ,.M bykbZM bU';ksjsal dEiuh fyfeVsM] irk&fxzohusUl fMikVZesaV uEcj&1] U;w Vsd a LVªhV] oYywoj dksV~Ve gkbZjksM] uuxenDde pSUubZA 2- LVkj gsYFk ,.M ,ykbZM bU';ksjsl a dEiuh fyfeVsM] ,sfj;k vkWfQl] vkWfQl vkWQ n bU';ksjsal vksecqnleu] thou fuf/k] AA fcfYMax] xzkm.M ¶yksj] Hkokuh flag ekxZ] t;iqj] jktLFkkuA 3- czkap vkWfQl LVkj gsYFk ,.M ,ykbZM bU';ksjsal dEiuh fyfeVsM] eYVhijit Ldwy ds Bhd lkeus] iq:'kokuh] cl okyksa ds edku ds ihNs] xqekuiqjk ]dksVk] jktLFkkuA foi{khx.k mifLFkr%& 1- ifjoknh dh vksj ls Jh psru dqekj ikjk'kj] vf/koDrk 2- foi{khx.k dh vksj ls Jh v'kksd dV~Vk] vf/koDrk cgl lquus dh fnukad %& 02-05-2024 fu.kZ; lqukus dhfnukad %& 09-05-2024 2 jkT; miHkksDrk vk;ksx lfdZV cSap] dksVk ifjokn la[;k 03@2019 'kkgtgka cuke LVkj gsYFk ,.M ,ykbZM bU';ksjlsa dEiuh fyfeVsM ,oa vU;
fu.kZ;
jkT; miHkksDrk vk;ksx] lfdZV cSap] dksVk [}kjk Jh ,l-ds-tSu] ihBklhu lnL; ¼U;kf;d½] ifjokfn;k 'kkgtgka us foi{khx.k ds fo:) mHkksDrk laj{k.k vf/kfu;e] 1986 ds rgr jktLFkku jkT; miHkksDrk vk;ksx] lfdZV cSap] dksVk esa ,d ifjokni= bu vfHkopuksa ds lkFk izLrqr fd;k gS fd mlds ifr dk vkdfLed fu/ku fnukad 01-09-2017 dks jkorHkkVk fLFkr 'kVy Mse] ØksØksMkbZy fidfud ikWbZaV ij ikuh esa iSj fQly tkus ls gks x;k gSA ifjokfn;k ds e`rd ifr 'kkfgn 'ks[k us vius thou dh lqj{kk gsrq foi{kh chek dEiuh ls fnukad 28-12-2016 dks 25]00]000@&:i;s chek/ku ds fy, chek ikWfylh yh FkhA ifjokfn;k us chek nkok izLrqr fd;k rc foi{khx.k us 'kjkc ihus ds dkj.k e`R;q gksuk crkrs gq, chek nkok vLohdkj dj fn;k] tcfd mldk ifr 'kjkc ugha ihrk FkkA bl izdkj ifjokfn;k us 25]00]000@&:i;s chek/ku jkf'k fnyk;s tkus dk vuqrks"k pkgk gSA 02- foi{khx.k us tokc ifjokni= izLrqr dj ;g fy[kk fd ;g izdj.k flfoy U;k;ky; ds }kjk fopkj.kh; gS D;ksfa d foLr`r lk{; dh vko';drk gSA tokc ifjokni= esa chek ikWfylh gksuk Lohdkj djrs gq, ;g fy[kk x;k fd ,Q-,l-,y- tkap fjiksVZ ds vuqlkj ifjokfn;k ds ifr us ?kVuk okys fnu 'kjkc ih j[kh Fkh D;ksfa d iksLVekVZe ds le; fy;s x;s foljk esa ,Ydksgy dh ek=k ik;h xbZ gSA bl izdkj mUgksua s chek ikWfylh dh 'krZ dk mYya?ku gksus ls chek nkok vLohdkj fd;k tkuk crk;k rFkk ifjokni= [kkfjt fd;s tkus dk fuosnu fd;k gSA 03- mHk;i{k dh vksj ls 'kiFk&i= ,oa fofHkUu nLrkostkr izLrqr fd;s x;s gSa] ftudk vko';drk vuqlkj foospu fd;k tkosxkA 04- mHk;i{k ds fo}ku vf/koDrkx.k dh cgl lquh xbZ ,oa i=koyh dk voyksdu fd;k x;kA 3 jkT; miHkksDrk vk;ksx lfdZV cSap] dksVk ifjokn la[;k 03@2019 'kkgtgka cuke LVkj gsYFk ,.M ,ykbZM bU';ksjlsa dEiuh fyfeVsM ,oa vU;
05- gLrxr izdj.k esa fufoZokfnr :i ls ifjokfn;k ds ifr us foi{khx.k ls vius thou dh lqj{kk ds fy, chek ikWfylh yh Fkh] blfy, mHk;i{k ds e/; ifjokfn;k ,oa lsokiznkrk ds laca/k ekStwn gSA 06- bl chek ikWfylh dh Terms and Conditions ds vuqlkj General Exclusions la[;k 4 fuEuizdkj gS%& Any claim for Death or Disablement of the Insured Person from
(a) intentional self-injury/suicide or attempted suicide or (b) whilst under the influence of intoxicating liquor or drugs or (c) self-endangerment unless in self-defense or to save life.
mijksDr General Exclusions ds vuqlkj fo}ku vf/koDrk foi{khx.k dk ;g rdZ gS fd ,Q-,l-,y fjiksVZ ds vuqlkj e`rd ds foljk esa ,Ydksgy dh ek=k ik;h x;h gS] ftldk ;gh vFkZ fudyrk gS fd e`rd us ?kVuk okys fnu 'kjkc ih j[kh Fkh] blfy, chek nkok ns; ugha gSA 07- i=koyh esa iqfyl tkap ls lacfa /kr nLrkostkr lyaXu gS] ftuds voyksdu ls ;g ik;k tkrk gS fd fnukad 01-09-2017 dks Jh jktsUnz pkS/kjh ouj{kd dh M~;wVh 'kVy Mse] jkorHkkVk ij Fkh rc e`rd ,oa mldk lkFkh jkekorkj oS".ko mDr ouj{kd ds ikl vk;s] ouj{kd us 100@&:i;s dh jlhn dkVdj mu nksuksa dks 'kVy Mse ij Hkze.k djus dh vuqefr ns nh rc nks ?kaVs i'pkr jkekorkj us Jh jktsUnz pkS/kjh ouj{kd dks vkdj crk;k fd mldk lkFkh ØksØksMk;y fidfuad ikWbaV ij ikuh esa Mwc x;kA Jh jktsUnz pkS/kjh }kjk iqfyl esa lwpuk nh xbZA iqfyl }kjk e`rd 'kkfgn dh yk'k ekspZjh vkj-,-ih-ih- gkWfLiVy jkorHkkVk esa lqjf{kr j[kok;h x;hA exZ la[;k 17@2017 /kkjk 174 n.M izfØ;k lfgark esa ntZ dj tkap 'kq: dh xbZA e`rd ds iksLVekVZe ds le; foljk fy;k x;k] jlk;fud tkap ds i'pkr mDr foljk esa ,Ydksgy dh ek=k ik;h x;h gS fdUrq bl ,Ydksgy dh ek=k ds vk/kkj ij ;g fu"d"kZ ugha fudkyk tk ldrk fd e`rd ds }kjk 'kjkc dk lsou fd;s tkus ds ifj.kkeLo:i gh 'kjkc ds u'ks esa jgrs gq, u'ks ds dkj.k og ikuh esa Mwck gks D;ksafd i=koyh ij ,slh dksbZ lk{; ugha gSA ifjoknh i{k ds vuqlkj iSj fQlyus ls e`rd ikuh esa Mwck gS rFkk mldh e`R;q gqbZ gSA foi{khx.k dh vksj ls dksbZ vUos"k.k ugha djk;k x;k gS 4 jkT; miHkksDrk vk;ksx lfdZV cSap] dksVk ifjokn la[;k 03@2019 'kkgtgka cuke LVkj gsYFk ,.M ,ykbZM bU';ksjlsa dEiuh fyfeVsM ,oa vU;
rFkk iqfyl us Hkh ,Q-,l-,y- fjiksVZ ds vk/kkj ij e`rd dks 'kjkc ih;s gksuk ekuk gSA iqfyl us Hkh ,slk fu"d"kZ ugha fn;k gS fd 'kjkc ihus ds dkj.k e`rd ikuh esa Mwck gks vFkkZr~ ,slk lkfcr ugha gS fd e`rd 'kjkc ds u'ks esa engks'k gksdj ikuh esa Mwc x;k gksA ,slh fLFkfr esa General Exclusions la[;k 4 ds rgr ;g ekeyk doj ugha gksrk gSA rdZ ds rkSj ij bl ekeys esa ,DlDywtu DykWt la[;k 4 ds rgr doj gksuk Hkh ekuk tkos rc Hkh foi{khx.k dh vksj ls ;g lkfcr ugha fd;k x;k gS fd chek ikWfylh ds lkFk mDr ,DlDywtUl chek/kkjd dks ns fn;s x;s gksA 08-¼i½ foi{khx.k dh vksj ls ekuuh; loksZPp U;k;ky; dk U;kf;d n`"Vkar Civil Appeal no. 1375/2003 M/s Suraj mal Ram Niwas Oil mills Pvt. Ltd. Vs United India Insurance Co. Ltd. & Anr. izLrqr fd;k x;k gS fdUrq bl ekeys esa ,DlDywtu DykWt dk ekeyk ugha Fkk cfYd ;g ekuk x;k Fkk fd izR;sd dalkbuesaV dks Hkstus ls igys chek dEiuh dks Li"V :i ls lwfpr fd;k tkuk pkfg,A ¼ii½ foi{khx.k dh vksj ls ekuuh; loksZPp U;k;ky; dk U;kf;d n`"Vkar 1966 AIR (SC) 1644 General Assurance Society ltd. Vs chandumull Jain & Anr. fu.kZ; fnukad 07-02-1966 izLrqr fd;k x;k gSA bl ekeys esa chek ikWfylh fujLr djus lacaf/kr fookn FkkA vr% ;g U;kf;d n`"Vkar Hkh gLrxr izdj.k ij ykxw ugha gksrk gSA ¼iii½ foi{khx.k dh vksj ls ekuuh; loksZPp U;k;ky; dk U;kf;d n`"Vkar Civil Appeal no. 5103/2002 AIR 2009 (SC) 2026 Deokar Exports Pvt. Ltd. Vs New India Assurance Company Ltd. fu.kZ; fnukad 23-09-2008 izLrqr fd;k x;k gS fdUrq bl U;kf;d n`"Vkar okys ekeys esa chek/kkjd }kjk izLrko fn;k] ftls dqN eksfMfQds'ku ds lkFk Lohdkj fd;k x;k] ftls dkm.Vj iziksty dgk tkosxkA vc chek /kkjd bl dkm.Vj iziksty dks Lohdkj dj ldrk Fkk] euk dj ldrk Fkk vFkok ml dkm.Vj iziksty dk Hkh dkm.Vj iziksty ns ldrk FkkA izLrkod us ,slk dqN ugha fd;k] chek lafo/kk gksuk ugha ekuk x;kA ;g U;kf;d n`"Vkar fdlh Hkh n`f"V ls gLrxr izdj.k ls lacfa /kr ugha gSA 5 jkT; miHkksDrk vk;ksx lfdZV cSap] dksVk ifjokn la[;k 03@2019 'kkgtgka cuke LVkj gsYFk ,.M ,ykbZM bU';ksjlsa dEiuh fyfeVsM ,oa vU;
09- gLrxr izdj.k esa ;g fu"d"kZ fudyrk gS fd foi{khx.k us ,DlDywtu DykWt la[;k 4 ds vk/kkj ij tks chek nkok vLohdkj fd;k gS] og mfpr ugha gS rFkk lsoknks"k dh Js.kh esa vkrk gSA ifjokfn;k leLr chek/ku jkf'k 25]00]000@&:i;s izkIr djus dh vf/kdkfj.kh gS rFkk bl jkf'k ij ifjokni= izLrqr djus dh fnukad ls 09 izfr'kr okf"kZd nj ls C;kt Hkh izkIr dh vf/kdkfj.kh gSA ifjokfn;k dks cSad C;kt nj ls vf/kd C;kt nj fnyk;k x;k gS] blfy, ifjokfn;k ekufld larki isVs dksbZ jkf'k izkIr djus dh vf/kdkfj.kh ugha gS fdUrq ifjokn O;; isVs 50]000@&:i;s dh jkf'k izkIr djus dh vf/kdkfj.kh gSA ifjokfn;k dk ifjokni= foi{khx.k ds fo:) blh izdkj Lohdkj fd;s tkus ;ksX; gSA vkns'k ifjokfn;k dk ifjokni= foi{kh la[;k 1 yxk;r 3 ds fo:) la;qDr% ,oa i`Fkdr% Lohdkj fd;k tkdj ;g vkns'k fn;k tkrk gS fd foi{khx.k vkt ls nks ekg ds vanj ifjokfn;k dks leLr chek/ku jkf'k 25]00]000@&:i;s ¼v{kjs :i;s iPphl yk[k ek=½ vnk djsxsa rFkk ifjokni= izLrqr djus dh fnukad 19-03-2019 ls rk&vnk;xh bl jkf'k ij 09 izfr'kr okf"kZd nj ls C;kt Hkh vnk djsxsAa 2- foi{khx.k vkt ls nks ekg ds vanj ifjokfn;k dks ifjokn O;; ds :i esa 50]000@&:i;s ¼v{kjs :i;s ipkl gtkj ek=½ vnk djsxsa rFkk bl vof/k esa mDr jkf'k vnk ugha djus ij fu.kZ; dh fnukad ls rk&vnk;xh 50]000@&:i;s ¼v{kjs :i;s ipkl gtkj ek=½ ij Hkh 09 izfr'kr okf"kZd nj ls C;kt vnk djsxsaA ¼jkeQwy xqtZj½ ¼,l-ds-tSu½ lnL; ihBklhu lnL; ¼U;kf;d½ ljkst@&