State Consumer Disputes Redressal Commission
Branch Manager, United India Insurance ... vs Gian Singh, on 4 August, 2020
STATECONSUMER DISPUTES REDRESSALCOMMISSION,ODISHA,CUTTACK
C.D. APPEAL NO.91 OF 2002
(From an order dated 28.12.2001 passed by the District Forum,
Sundargarh - II, Rourkela in C.D.Case No. 904 of 2000)
Branch Manager,
United India Insurance Company Ltd.,
Branch Office No. II, 2nd Floor,
R.K.Clinic Building,
Udit Nagar, Rourkela, Now Represented
through the Asst. Manager R.O. Cell,
United India Insurance Co.Ltd., Bhubaneswar
... Appellant
Vrs.
1. Gian Singh,
Qr No. E - 89, Koel Nagar,
Po - Saktinagar, Sundargarh
2. Sr. Manager (Personnel - PL Wel & ES),
Personnel Department, SAIL,
Rourkela Steel Plant, Rourkela
... Respondents
____________
For the appellant : M/s S.Roy & Associates
For respondent No.1: M/s S.Misra & Associates
For respondent No.2: None
_____________
P R E S E N T:
THE HON'BLE DR. JUSTICE D.P.CHOUDHURY,PRESIDENT
AND
DR. S.MOHANTY,MEMBER
2
DATED THE 04th AUGUST,2020
ORDER
DR. D.P. CHOUDHURY,J., PRESIDENT This appeal is directed u/s 15 of the Consumer Protection Act, 1986 (hereinafter called the "Act") against the order dated 28.12.2001 passed by the learned District Forum, Sundargarh - II, Rourkela in C.D.Case No. 904 of 2000 wherein the District Forum has directed the appellant to pay Rs.26,099.75 to respondent No.1 besides Rs.3,000/- towards compensation and Rs.300/- towards litigation cost. It is further directed that if the amount would not be paid within 30 days from the date of receipt of the order, appellant would pay interest at the rate of 14% per annum from the date of default till actual payment.
2. Appellant was OP No. 1 whereas respondent No.1 was the complainant and respondent No. 2 was OP No. 2 before the learned District Forum. Hereinafter the parties to this appeal shall be referred to with reference to their respective status before the District Forum.
3
3. Learned counsel for the appellant submitted that complainant was an ex employee of Rourkela Steel Plant and as per the procedure, he and his family Members including spouse are of beneficiary of Group Medi-claim Scheme for retired employees and their spouse of Steel Authority of India floated by OP No.1. As such they have purchased Medi-claim policy bearing Nos. (MIN) 03603735 for self and 03603736 for his spouse namely, Prakash Kaur. According to him, the complainant was checking health of his wife regularly in the Hospital of Rourkela Steel Plant (in short RSP) and his wife was referred to B.M.Birla Heart Research Centre, Calcutta for Coronary Angiography Test and as such she was allegedly became hospitalised from 9.11.1999 to 12.11.1999 during which angiography test was performed.
4. Learned counsel for the appellant further submitted that after being discharged from the Hospital the complainant claimed the treatment expenses for Rs.24,445/- as indoor 4 patient and Rs.1,654.75 as OPD treatment cost at such hospital at Kolkata from O.P.No.1.
5. Learned counsel for the appellant next contended that after investigating the claim of the complainant, it was found that Prakash Kaur, the spouse of the complainant was already suffering from heart disease prior to 1.4.1999 date of commencement of his policy. According to him, since the complainant has not disclosed about pre-existing disease, he is not entitled to reimburse the said cost. But the learned District Forum committed error in law by not understanding the real facts and circumstances of the case and passed order directing the appellant to pay such amount and also to pay Rs.3,000/- towards compensation besides cost of litigation as Rs.300/-. Hence, it is submitted to set aside the impugned order of the learned District Forum by allowing the appeal.
6. In spite of notice, respondent No.1 did not appear and service of notice is made sufficient.
5
7. Learned District Forum after hearing both parties has passed the impugned order by allowing the complaint.
8. Considered the submission of the learned counsel for the appellant, perused the DFR including the impugned order and the documents annexed to it.
9. The only issue is to be settled here whether the complainant has proved the deficiency of service on the part of OP No.1 for repudiating the claim.
10. It is admitted fact that the complainant has purchased the policy under Group Medi-claim Scheme for the year 1999 for retired employees of RSP for himself and for his wife. It is not in dispute that his wife was referred to B.M.Birla Heart Research Centre, Calcutta for angiography test and there she was hospitalised for the purpose from 9.11.1999 to 12.11.1999.
11. Both parties relied upon the Medical Treatment Book of Prakash Kaur wife of the complainant vide Medical Book No. 3589-A. The book shows that she is under treatment since 1985. 6 The Book also shows that she usually take treatments as outdoor patient in the Hospital of RSP and get entries in the book. The contention of OP No.1 is that she was taking medicine Serbitrate for chest pain on 1.3.1999 but no serious treatment was found to have been rendered except the fact that on 1.10.1999, she was referred for Coronary angiography at B.M.Birla Heart Research Centre, Calcutta as there became a case of unstable IHD. The documents of B.M. Birla Heart Research Centre, Calcutta made details study but gave final opinion that minimal coronary artery disease with good LV function are there. Thus found no significant disease and all other organs of heart have normal function.
12. Aforesaid treatment reports and the final report do not prove that the spouse of the complainant was having IHD before 31.3.1999. Any person claiming chest pain having taken Serbitrate cannot be taken as patient of IHD unless it is confirmed. But the report of Dr.M.R.Das produced by OP No.1 7 shows that since there was complaint of chest pain and she was using anti - anginal drugs, she was suffering from IHD and as such presumed that she was suffering from Coronary Heart Disease from 1.3.1999 till investigation at B.M.Birla Heart Research Centre, Calcutta. This view is based on the records produced before Dr.Das but he has not clinically examined Prakash Kaur. So the opinion is not acceptable for reversing the case of the complainant. OP No.1 has not produced any other medical opinion to confirm such opinion of Dr.Das. Apart from this when the diagnosis at B.M.Birla Heart Research Centre, Calcutta gives clean cheat, the contention of OP No.1 that she was having IHD before the policy purchased is indefensible and untenable.
13. The next submission of OP No.1 is that there is an exclusion clause which forbede the expenses incurred for diagnosis and such clause 7(6) is as follows:-
"xxx xxx xxx
7. Important Exclusions:8
xxx xxx xxx (6) Any expenses incurred for diagnosis etc. not consistent with treatment for injury/illness/disease."
14. On thorough examination of aforesaid clause, it is clearly found that the expenses incurred for diagnosis etc. not consistent with treatment for injury/illness/disease is excluded. Now the diagnosis for IHD cannot be said outside the treatment of Prakash Kaur as it is evident from Medical Book that when she got unstable chest pain, she was referred to B.M.Birla Heart Research Centre for confirming IHD. records to the Hospital concerned for examination. On the other hand, the diagnosis was made consistent with disease for which she was receiving treatment just before the reference made. So the case of spouse of complainant is not coming under the exclusion clause.
15. In view of the above, we are of the view that OP No.1 has committed error by repudiating the claim of the complainant and the argument of learned counsel for the appellant is not tenable one. Thus, we agree with the finding of the learned District Forum. The complainant has proved deficiency of 9 service on the part of OP No.1 by repudiating the claim illegally. We dispose of the appeal by modifying the order by substituting the rate of interest as 12% instead of 14% per annum but rest part of .the order of the learned District Forum are affirmed.
16. The appeal is disposed of accordingly. No cost.
Supply free copy of this order to the respective parties.
..............................
(Dr.D.P.Choudhury,J President I agree.
.....................
(Dr.S.Mohanty) Member Cuttack Dated 04th August, 2020