State Consumer Disputes Redressal Commission
Uiic Ltd. vs Balbir Kaur on 8 May, 2015
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 3 of 2013
Date of institution: 1.1.2013
Date of Decision: 8.5.2015
United India Insurance Company Ltd., having its Regional Office 136,
Feroze Gandhi Market, Ludhiana through its Duly Constituted Attorney Dr.
S.K. Takyar, Manager.
Appellant/OP
Versus
Balbir Kaur wife of Surinder Singh, Resident of C-1, Merado Colony, Gill
Road, Ludhiana.
Respondent/Complainant
First Appeal Under Section 27-A against the
order dated 18.8.2011 passed by the District
Consumer Disputes Redressal Forum,
Ludhiana.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Jasbir Singh Gill, Member
Mrs. Surinder Pal Kaur, Member
Present:-
For the appellant : Sh. Parminder Singh, Advocate
For the respondent : Sh. Vaibhav Sehgal, Advocate
2
FIRST APPEAL NO. 3 OF 2013
Gurcharan Singh Saran, Presiding Judicial Member
ORDER
The appellant/opposite party (hereinafter referred as "the OP") has filed the present appeal under Section 27A of the Act against the order dated 5.12.2012 passed in execution application under Section 27 of the CP Act vide which the Op was directed to pay a sum of Rs. 84,094/- alongwith interest @ 9% p.a. from the date of filing the claim till realization.
2. Consumer complaint No.59 dated 31.1.2011 was filed by Balbir Kaur w/o Surinder Singh against the OP, which was decided by the District Forum, Ludhiana vide order dated 18.8.2011 directing the OP to settle the claim of the complainant and to pay the balance amount after deducting Rs. 25,000/-, which was already paid to the complainant as per terms and conditions of the policy purchased by the complainant. Compliance be made within a period of 45 days, failing which OP shall be liable to pay interest @ 9% p.a. from the date of lodging the claim. The OP was further directed to pay Rs. 3,000/- as compensation and Rs. 2,000/- as litigation expenses.
3. On the basis of that order, the complainant filed an application and it was submitted that despite the order passed by the District Forum, the Ops have not settled the claim of the complainant according to the terms and conditions of the policy as per the order passed by the learned District Forum and accordingly, the request was made to direct the Ops to settle the claim of the complainant as per the order passed by the District Forum.
3FIRST APPEAL NO. 3 OF 2013
4. Whereas the Ops filed reply that on the basis of order passed by the District Forum and considering the terms and conditions of the insurance policy, it was found that 25% of the sum insured is payable to the complainant as she had taken the treatment of hysterectomy and she is further entitled to pre and post hospitalization expenses as 10% of the sum insured, which comes to Rs. 31,650/- and the balance amount was only Rs. 6650/- and pre and post hospitalization comes to Rs. 4256/- and after adding the compensation and litigation expenses, it comes to Rs. 15,906/-, which was paid vide cheque dated 7.10.2011 as a full and final settlement of the claim, therefore, the application is not maintainable and the same be dismissed.
5. After hearing the counsel for the parties and have gone through the order passed by the District Forum and the pleadings in this application, the application was allowed as referred above.
6. Aggrieved with the order passed by the learned District Forum, the appellant/opposite party has filed the present appeal.
7. In the appeal, it has been contended by the counsel for the appellant that the District Forum cannot be go beyond the order passed by the District Forum in complaint No. 59 dated 31.1.2011 and according to that order, the claim of the complainant was to be settled as per the terms and conditions of the policy purchased, after deducting a sum of Rs. 25,000/- already paid. The medical record/discharge summary of the complainant shows the 'operation/produce done' in the hospital as under:- 4
FIRST APPEAL NO. 3 OF 2013 "Patient Mrs. Balbir Kaur was admitted as a case of fibroid uterus. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (High risk) by Dr. Poonam Rastogi and Total abdominoplasty with Redurs placation with Liposuction by Dr. Ajay Abrol on 1.7.2010. Post procedure she was managed with antibiotics, analgesics and antacids. She is being discharged in satisfactory condition."
8. Then he has referred to Clause 1.2 of the terms and conditions of the policy under which explanation in respect of following specified illness will be restricted as detailed below:-
"1.2 In the event of any claim(s) becoming admissible under this scheme, the company will pay through TPA to the Hospital/ Nursing Home or the insured person the amount of such expenses falling under different heads mentioned below, as are reasonably and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto:
A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses. B. ICU expenses not exceeding 2% of the sum insured per day or actual amount whichever is less. 5 FIRST APPEAL NO. 3 OF 2013 C. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees D. Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants, infra cardiac valve replacements, vascular stents. E. Hospitalization expenses (excluding cost of organ) incurred for/by donor in respect of organ transplant to the insured.
ND.: The amount payable under 1.2 C & D above shall be at the rate applicable to the entitled room category. In case Insured opts for a room with rent higher than the entitled category as in 1.2 A above, the charges payable under 1.2 C & D shall be limited to the charges applicable to the entitled category.
9. The major surgeries include cardiac surgeries, brain tumour surgeries, pace maker implantation for sick sinus syndrome, cancer surgeries, hip, knee, joint replacement surgery.
10. No doubt for the hysterectomy, the explanation of the complainant will be restricted upto 25% of the sum insured or actual expenses whichever is less. Whereas the complainant had also undergone hospital course for Bilateral salpingo-oophorectomy, which is quite different than the hysterectomy. 6 FIRST APPEAL NO. 3 OF 2013 Salpingitis :- It is the inflammation of fallopian tubes that run from ovary to the tip of uterus.
11. Oophorectomy is surgical procedure to remove the ovaries. Therefore, this hospital course was different from the hysterectomy from which there is no cap. However, the learned District Forum in this order did not consider the fact that there was cap upto 25% or the actual expenses whichever is less in the case of hysterectomy and has not given any bifurcation what about the expenses of hysterectomy and what were the expenses of oophorectomy. In these circumstances, the order so passed by the learned District Forum is not legally sustainable as the preposition in hand is not properly discussed by the District Forum.
12. In view of the above, the appeal is accepted. Impugned order is set-aside with a direction to the District Forum to bifurcate the expenses of hysterectomy and oophorectomy and then to decide according to terms and conditions and Clause No. 1.2 of the policy, which amount the complainant is entitled for hysterectomy and to what amount for oophorectomy.
13. The parties through their counsel are directed to appear before the District Forum on 10.6.2015. Copy of the judgment alongwith record of the District Forum be sent back forthwith.
14. The appellant had deposited an amount of Rs. 55,004/- with this Commission at the time of filing the appeal. This amount of Rs. 55,004/- with interest accrued thereon, if any, be remitted by the registry to the appellant by way of a crossed cheque/demand draft 7 FIRST APPEAL NO. 3 OF 2013 after the expiry of 45 days, from the despatch of the order to the parties; subject to stay, if any, by the higher Fora/Court.
15. The arguments in this appeal were heard on 5.5.2015 and the order was reserved. Now the order be communicated to the parties as per rules.
16. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Gurcharan Singh Saran) Presiding Judicial Member (Jasbir Singh Gill) Member May 8, 2015. (Surinder Pal Kaur) as Member