State Consumer Disputes Redressal Commission
Mrs. Kusum Bansal vs United India Insurance Company Limited on 7 June, 2013
2nd Addl. Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 616 of 2008
Date of institution: 17.6.2008
Date of decision : 7.6.2013
Mrs. Kusum Bansal wife of Sh. Punit Bansal, resident of 2450/II-34, Kesri
Bagh, Amritsar.
.....Appellant
Versus
United India Insurance company Limited having Branch Office at 11-A,
Lawrence Road, Amritsar through its Senior Branch Manager.
.....Respondent
First Appeal against the order dated 9.5.2008
passed by the District Consumer Disputes
Redressal Forum, Amritsar.
Before:-
Shri Piare Lal Garg, Presiding Member
Shri Jasbir Singh Gill, Member Present:-
For the appellant : Sh. Akhilesh Vyas, Advocate and Sh. Pankaj Sharma, Advocate For the respondent : Sh. Munish Goel, Advocate PIARE LAL GARG, PRESIDING MEMBER This is an appeal filed by the appellant/complainant-Mrs. Kusum Bansal(hereinafter called 'the appellant') against the order dated 9.5.2008 of the District Consumer Disputes Redressal Forum, Amritsar(hereinafter called the 'District Forum') vide which the complaint of the appellant was dismissed by the District Forum.
2. Brief facts of the case are that the appellant was regularly obtaining the insurance policies from the respondent. The appellant also insured herself for an amount of Rs. 3 lacs for the 5th year from 10.5.2001 to 9.5.2002 and bonus was also given by the respondent to the appellant First Appeal No. 616 of 2008 2 in the premium of the policy. The appellant also paid Rs. 90/- to cover benefit of medical expenses upto 50% of the claim amount and 10% of the Capital Sum Insured i.e. Rs. 3 lacs, whichever will be less vide cover note No. 42/01/2801. The appellant was also insured under death benefit, permanent disablement and temporary total disablement arising out of the accident.
3. It was further alleged that the appellant fell down through "mug" of her house on 30.3.2002 and suffered fracture on her right leg and right knee joint and was admitted in Madan Hospital, Majitha Road, Amritsar on the same day. She was operated upon in the said hospital and was discharged on 5.4.2002. It was also advised by the Doctor to remain on Bed for three months and to undergo physiotherapy alongwith prescribed medicines. The intimation regarding the incident was given to the respondent on 1.4.2002 by the appellant.
4. There was no improvement in the movement of the appellant and then she consulted Dr. Vishal Verma (M.S. P.T.), Consultant Physiotherapist, who after examining recommended rest for nine months, who give physiotherapy to the appellant at her residence. When there was no proper relief particularly to knee joint and movement then she decided to shift Bombay where she was admitted in Ashmi Arthroscopy and Sports Medicine Institute, Bombay on 3.1.2003 and Dr. Anant Joshi of Ashmi Arthroscopy and Sports Medicine Institute, Bombay operated on 3.1.2003 and discharged on 4.1.2003. It was advised by the Doctor to take physiotherapy continuously for 3 to 6 months and as per the advice of the doctor, she remained under treatment of physiotherapy of Dr. Vishal Verma upto 30.6.2003.
First Appeal No. 616 of 2008 3
5. The appellant submitted the claim on 12.2.2004 alongwith certificates, prescriptions of the Doctors and bills of the medicines to the respondent. Details of the same are given in para No. 7.
6. Only a cheque of Rs. 36,000/- bearing No. 024252 on 19.7.2005 was received by the appellant against the claim of Rs. 2,02,600/-. No consent or discharge voucher was executed or signed by the appellant for the acceptance of Rs. 36,000/-. The appellant vide letter dated 22.7.2005 lodged the protest with the respondent against the payment of Rs. 36,000/- only but no reply of the same was received by the appellant from the respondent. It was further pleaded that the appellant was also having medi-claim insurance with the respondent regarding the hospitalization. The appellant claimed the same under mediclaim policy and the amount was received including the physiotherapy charges for the month of April, 2002 and May, 2002 which were paid by the appellant to Dr. Vishal Verma.
7. The present claim relates to claim under Personal Accident Policy and requisite documents and bills etc. were submitted by the appellant with the respondent. Alleging deficiency in service, the complaint was filed by the appellant with the prayer that the respondent may be directed to pay Rs. 1,70,600/- alognwith the interest @ 12% p.a. as well as compensation to the tune of Rs. 20,000/- due to mental pain, agony and harassment.
8. Upon notice, reply was filed taking preliminary objections that the complaint was not legally maintainable, the appellant not come to the District Forum with clean hands and suppressed the material facts, the appellant had received Rs. 36,000/- as full and final payment without any protest and the cheque was encashed by the appellant, as such, the appellant was estopped to file the complaint by her own act and conduct. First Appeal No. 616 of 2008 4 On merits, regarding obtaining of policies by the appellant not disputed but it was denied that the appellant suffered any temporary disability. She was discharged from Madan Hospital after recovery and in the discharge certificate some medicines were advised by the doctor. There is no record that the appellant had taken any follow up treatment from Madan Hospital or Madan Hospital recommended the appellant to take physiotherapy treatment. No intimation was given by the appellant to the respondent regarding taking any further treatment from any other hospital. The facts mentioned in para No. 5 of the complaint are false and frivolous one. It was also denied that the appellant was ever admitted in hospital at Bombay and the documents regarding taking treatment from the hospital at Bombay are false, frivolous and procured one. It was further alleged that letter dated 22.7.2005 is an afterthought version only to get the illegal compensation. Dismissal of the complaint was prayed for.
9. The District Forum after hearing the counsel for the parties and going through the record, dismissed the complaint as the same was without any merit.
10. Aggrieved from the order, the appeal is filed by the appellant on the grounds that the District Forum did not consider the evidence placed on record by the appellant, the findings of the District Forum that at the time of admission in the hospital at Bombay on 3.1.2013 the appellant was not covered under the policy are also wrong and incorrect and the findings of the District Forum that the claim stands fully settled by the respondent are also not correct. The alleged amount is claimed due to temporary disablement, as such, the order of the District Forum is liable to be set-aside.
First Appeal No. 616 of 2008 5
11. We have gone through the pleadings of the parties, grounds of appeal, perused the record of the learned District Forum and heard the arguments of the counsel for the parties.
12. The version of the appellant is that there was no proper movement of the knee joint, as such, the appellant had gone to Bombay where she was admitted on 3.1.2003 in Asmi Hospital i.e. Arthroscopy and Sports Medince Institute, Akbar Road, Dadar Mumbai of Dr. Anant Joshi. She was operated in the said hospital on the same day and was discharged on 4.1.2003 vide discharge certificate Ex. C-16. It was advised by Dr. Anant Joshi for Physiotherapy upto 3 to 6 months. The appellant remained under treatment of Physiotherapy of Dr. Vishal Verma upto 30.6.2003. As per the Policy, the appellant is entitled for Rs. 3,000/- per week upto 30.6.2003. The claim of the same was submitted by the appellant with the respondents but the same was not paid/settled.
13. We have perused the terms and conditions of "Personal Accidental Policy" Ex. C-14. As per Condition No. F, the insured is entitled for the sole and direct cause of temporary total disablement for an amount of Rs. 3000/- per week but not more than 104 weeks. The relevant para (f) of the same is reproduced:-
"(f) If such injury shall be the sole and direct cause of temporary total disablement, then so long as the insured shall be totally disabled from engaging in any employment or occupation of any description, whatsoever, a sum at the rate of one percent (1%) of the capitals sum insured in the schedule hereto per week, but in any case not exceeding Rs. 3000/- per week in all under all policies.
Provided that the compensation payment under the foregoing sub-clause
(f) shall not be payable for more than 104 weeks in respect of any one injury calculated from the date of commencement and in no case shall exceed the capital sum insured."First Appeal No. 616 of 2008 6
14. This clause is applicable in the Personal Accidental Policy (Individual). We have perused Personal Accidental Policy Ex. C-12, which is tendered into evidence by the appellant. The policy was for the period of 10.5.2001 to 9.5.2002 but as per the version of the appellant herself, she was admitted in Asmi Hospital on 3.1.2003 and was discharged on 4.1.2003. But at the time of admission she was not covered under the Personal Accident Policy. No copy of the policy or cover note produced or tendered into evidence by the appellant to prove that at the time of taking the treatment from Asmi Hospital, Mumbai, she was under insurance cover of Personal Accident Policy. Even there is no such pleadings in the complaint that the appellant was covered under Personal Accidental Policy at the time of taking the treatment from Asmi Hospital, Mumbai.
15. The respondents paid an amount of Rs. 36,000/- to the appellant as medical expenses under the medical claim policy and not under the Personal Accidental Policy. The appellant tried to mix these two policies under which the different risks were covered. The appellant has not produced any terms and conditions of the Mediclaim policy vide which she was entitled for Rs. 3000/- per week upto 104 weeks when she was unable to do any job/work or she was temporarily disabled at that time.
16. The appellant failed to prove for the entitlement of the claim and there is no positive evidence for the acceptance of the complaint of the appellant. The complaint of the appellant was rightly dismissed by the District Forum.
17. There is no merit in the appeal of the appellant, as such, the same is dismissed. The impugned order of the District Forum is affirmed and upheld. No order as to costs.
18. The arguments in this appeal were heard on 3.6.2013 and the order was reserved. Now the order be communicated to the parties. First Appeal No. 616 of 2008 7
19. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Piare Lal Garg)
Presiding Member
June 7, 2013. (Jasbir Singh Gill)
as Member