State Consumer Disputes Redressal Commission
Naresh K. Duahare vs Icici Lombard Gic on 29 June, 2022
e0iz0 jkT; miHkksDrk fookn izfrrks"k.k vk;ksx] Hkksiky ¼e-iz-½ IykV uacj 76 vjsjkfgYl Hkksiky ¼izLrqr vihy ftyk miHkksDrk vk;ksx f'koiqjh }kjk iz-Ø- 336@09 esa ikfjr vkns'k fn- 27-04-2010 ls mn~Hkwr½ vihy Øekad % 1402@2010 ujs'k dqekj nksgjs iq= Jh jkeyky nksgjs fu0 fl)s'oj esyk xzkm.M] ftyk f'koiqjh ------------------vihykFkhZ@ifjoknh fo:) 1-izca/kd] vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsal da-fy- tsfuFk gkml] dslojko [kkM+ds ekxZ] egky{eh eqEcbZ&400034 2- izca/kd] vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsal da-fy- jft0vkfQl& vkbZlhvkbZlhvkbZ cSad VkWolZ] ckaUnzk dqykZ dkEiysDl] eqEcbZ 400051 3-izca/kd] vkbZlhvkbZlhvkbZ cSad fy0] vkj-,-ih-th-& izFke eafty gksVy lsUVj fcfYMax] 'kkL=h pkSd iM+ko Xokfy;j 4-eqds'k xks;y iq= dSyk'k ukjk;.k xks;y] ÝsapkbZth vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsl a da-fy-
egy dkyksuh f'koiqjh ------------------ izfrvihykFkhZx.k@foi{khx.k
%% le{k %%
ekuuh; MkW0 Jherh eksfudk efyd % ihBklhu lnL;
ekuuh; MkW0 JhdkUr ik.Ms; % lnL;
ekuuh; Jh Mh0ds0 JhokLro % lnL;
%% i{kdkjx.k }kjk %%
vihykFkhZ ds fy, Jh vt; nqcs vf/koDrkA
izfrvihykFkhZ Ø- 1 o 2 ds fy, Jh vfer frokjh vf/koDrkA izfrvihykFkhZ Ø- 3 ds fy, Jh lqHkk"k /kksVs vf/koDrkA izfrvihykFkhZ Ø-4 vuqifLFkrA vkns'k ¼ fnukad 29@06@2022 dks ikfjr ½ -2- ekuuh; lnL; Jh Mh0ds0 JhokLro vuqlkj %& 1- ;g vihy vihykFkhZ@ifjoknh ujs'k dqekj nksgjs¼la{ksi esa ^vihykFkhZ^½ }kjk miHkksDrk laj{k.k vf/kfu;e 1986 dh /kkjk 15 ds vUrxZr ftyk miHkksDrk fookn izfrrks"k.k vk;ksx f'koiqjh¼^la{ksi esa ^^ftyk vk;ksx^½ ds izdj.k Øekad 336@2009 esa ikfjr vkns'k fnukad 27-04-2010 ds fo:) izLrqr dh x;h gS] ftlds }kjk fo}ku ftyk vk;ksx }kjk ifjoknh dh vksj ls izLrqr ifjokn dks fujLr fd;k x;k gSA 2- fo}ku ftyk vk;ksx ds }kjk vihykarxZr vkns'k esa ;g ys[k djrs gq, fd vukosnd dh vksj ls lacfa /kr fpfdRldksa ls izkIr tkudkjh ^izn'kZ vkj&6^ yxk;r vkj&13^ is'k dh x;h gS] mlds vuqlkj vihykFkhZ dks iSjkykbfll dh chekjh dsoy 50 izfr'kr gh vafdr gS] ,slh fLFkfr esa vkosnd dk ekeyk vukosnd dh vksj ls izLrqr chek ikfylh dh 'krksZa ds v/khu _.k ekQh dh Js.kh esa ugha vkrk gSA ,slh n'kk esa vukosndx.k chek daiuh dh vksj ls vkosnd }kjk Hkou gsrq izkIr fd;k x;k _.k] ekQ fd;s tkus ;ksX; ugha gksus ls chek daiuh }kjk lsok esa fdlh izdkj dh =qfV dkfjr fd;k tkuk nf'kZr ugha gS] vr% ifjokn dks fujLr fd;k x;k gSA mDr vkns'k ls NqC/k gksdj] vkosnd }kjk ;g vihy fuEu vk/kkjksa ij izLrqr dh x;h gSA 3- v/khuLFk ftyk vk;ksx dk vihykarxZr vkns'k fof/k ,oa rF;ksa ds foijhr ikfjr fd;k x;k gS rFkk v/khuLFk vk;ksx ds }kjk bl egRoiw.kZ rF; ij /;ku ugha fn;k x;k gS fd izfrvihykFkhZ chek daiuh }kjk vihykFkhZ dks chek ikfylh ds rgr _.k ekQ ugha fd;k x;k gSA v/khuLFk ftyk vk;ksx ds }kjk bl egRoiw.kZ rF; ij Hkh /;ku ugha fn;k x;k fd vihykFkhZ iSjkykbfll jksx ls xzflr gks x;k gS rFkk mDr lanHkZ esa lHkh fpfdRldksa ds izek.k i= Hkh izLrqr fd;s x;s gSa] ftu ij /;ku fn;s cxSj ftyk vk;ksx viuk vkns'k ikfjr fd;k x;k gS] QyLo:i vihykFkhZ dh -3- vihy dks Lohdkj dj] vihykarxZr vkns'k fnukad 27-04-2010 dks vikLr dj ifjokn i= ds vuqlkj mls lgk;rk fnyk;s tkus dh izkFkZuk dh xbZ gSA 4- ifjokn esa ifjoknh ds }kjk gkse lsQ Iyl flD;ksj ekbaM ikWfylh Øekad 4065@0000001@vkbZlhvkbZlhvkbZ@,p,y@0009050 ds vuqlkj gkse yksu :- 3-85 yk[k tks fnukad 22-08-2006 dks Lohd`r fd;k x;k Fkk] mDr _.k dks ekQ djus rFkk ekufld ,oa 'kkjhfjd ijs'kkuh gsrq foi{khx.k ls :- ,d yk[k rFkk izdj.k dk O;; :- 20 gtkj fnyk;s tkus dh izkFkZuk dh x;h FkhA 5- mHk;i{k ds fo}ku vf/koDrkx.k ds rdZ Jo.k fd;s x;sA 6- vihykFkhZ ds fo}ku vf/koDrk }kjk ;g rdZ fd;k x;k gS fd mlds }kjk izfrvihykFkhZ Ø- 1] 2 o 3 ds ,tsaV izfrvihykFkhZ Ø-4 ds ek/;e ls Hkou gsrq _.k izkIr djus gsrq mijksDr gkse lsQ Iyl flD;ksj ekbaM ikfylh izkIr dh x;h Fkh rFkk mls gkse yksu :- 3-84]132@& fnukad 22-08-2006 dks Lohd`r fd;k x;k Fkk rFkk izfrvihykFkhZx.k }kjk vihykFkhZ ls :- 14]132@& tek djkdj chek ikfylh Øekad ,y-ch-,l-ch-@00001368901 Hkh iznku dh x;h Fkh] ftlds vuqlkj ikfylh /kkjd dks fdlh Hkh izdkj dh ?kkrd chekjh tSls iSjkykbfll vkfn gksus ij mldk lEiw.kZ _.k jkf'k ekQ fd;s tkus dk izko/kku Fkk rFkk gkse yksu dh ekfld fd'rsa izfrekg :- 4]100@& dh fu/kkZfjr dh x;h FkhA tuojh 2007 esa vpkud vihykFkhZ ujs'k dqekj nksgjs dh rfc;r [kjkc gqbZ] rc mls ftyk fpfdRlky;] f'koiqjh esa MkW0 ,-,y- 'kekZ dks fn[kkus ij muds }kjk iSjkykbfll dh chekjh gksuk crk;k x;k rFkk mls izkFkfed bykt mijkUr Xokfy;j fpfdRlky; esa bykt gsrq jsQj fd;k x;kA rRi'pkr~ mls Xokfy;j esa t;kjksX; fpfdRlky; esa U;wjks ltZu izks- ,l-,u- vk;axj dks fn[kk;k x;k] tgka ij mls HkrhZ dj mldk mipkj fd;k x;k rFkk mldh ,evkjvkbZ djk;h x;h] ftlesa mls iSjkykbfll ls xzflr gksuk ik;k x;kA -4- 7- izfrvihykFkhZx.k }kjk fnukad 28-04-2008 dks vihykFkhZ ls leLr dkxtkr Dyse gsrq izkIr fd;s x;s rFkk mls _.k jkf'k dh fd'rksa dks tek djuk cUn dj nsus gsrq Hkh dgk x;kA rRi'pkr~ fnukad 01-07-2008 ls vihykFkhZ ds }kjk fd'r tek djuk cUn dj fn;k x;k] ijUrq fnukad 12-03-2009 dks izfrvihykFkhZ chek daiuh }kjk mldk Dyse fujLr dj fn;k x;k] tcfd vihykFkhZ xaHkhj chekjh ds dkj.k vlguh; ihM+k ,oa nnZ ls xzflr jgk gS rFkk mls dkQh ekufld ijs'kkuh dk lkeuk Hkh djuk iM+k gSA bl izdkj izfrvihykFkhZx.k }kjk vuqfpr :i ls mldk Dyse fujLr djrs gq, lsok esa =qfV dh x;h gSA QyLo:i mldk _.k ekQ djrs gq, mls ekufld ,oa 'kkjhfjd {kfr gsrq :- ,d yk[k rFkk ifjokn O;; :- 20 gtkj izfrvihykFkhZx.k ls fnyk;s tkus dh izkFkZuk dh x;h gSA ;gh rF; vihykFkhZ us vius 'kiFk i= fnukad 15-10-2009 esa mYysf[kr fd;k gS rFkk ^izn'kZ lh&1 yxk;r lh&19^ rd ds nLrkost izLrqr fd;s x;s gSaA 8- izfrvihykFkhZx.k dh vksj ls fo}ku vf/koDrk }kjk rdZ djrs gq, ;g O;Dr fd;k x;k gS fd vihykFkhZ dh chekjh mlds }kjk Ø; dh x;h ikfylh esa ifjHkkf"kr chekjh dh izd`fr dh ugha jgh gSA ikfylh ds lsDlu 2-1 esa iSjkykbfll ds laca/k esa fuEukuqlkj ifjHkkf"kr fd;k x;k gS %& "Complete and permanent loss of function of two or more limbs as a result of injury of illness of the brain or spinal cord. Permanent loss of function of two or more limbs shall be deemed to have occurred if.
The condition has persisted for at least 6 month from the date it was first suffered in spite of the insured properly implementing all medical advice related to its cure, and A Doctor of Central or State government hospital confirms complete, irreversible and permanent loss -5- Paralysis resulting directly or indirectly or as a consequence of any self- inflicted injury is excluded.
9- izfrvihykFkhZx.k dh vksj ls ;g dgk tk jgk gS fd mDr 'krZ dh n'kk esa vihykFkhZ dks {kfriwfrZ dh ik=rk ugha jgh gS] D;ksfa d mldh chekjh fjdoj gksus ;ksX; gS] QyLo:i ftyk vk;ksx }kjk mldk ifjokn mfpr :i ls fujkd`r fd;k x;k gSA 10- mDr lanHkZ esa mHk;i{k dh vksj ls izLrqr lk{; ij fopkj fd;k x;kA ^izn'kZ lh&1^ gkse yksu laca/kh vkosnu gS] ftlesa fnukad 22-08-2006 dks vihykFkhZ dks :- 3]84]132@& dk gkse yksu Lohd`r fd;k x;k gSA ^izn'kZ lh&2^ mDr _.k laca/kh fd'rksa dh Hkjik;h gsrq nLrkost gS] ftlds vuqlkj fy;s x;s _.k dks 240 eghus esa :- 14]132@& dh fd'r esa Hkjik;h djuh FkhA ^izn'kZ lh&4^ vihykFkhZ dk _.k [kkrk laca/kh fooj.k gS rFkk ^izn'kZ lh&5^ vihykFkhZ }kjk izfrvihykFkhZx.k ls Ø; dh x;h flD;ksj ekbaM ikfylh Øekad 4065@0000001@vkbZlhvkbZlhvkbZ@,p,y@0008050 gS] ftlesa fnukad 22-08-2006 ls fnukad 21-08-2011 rd dh vof/k ds fy, chek jgk gSA ^izn'kZ lh&6 o lh&7^ vihykFkhZ }kjk Hkjk x;k Dyse QkeZ gS rFkk izn'kZ lh&8 vihykFkhZ ds bykt dk ipkZ ftyk fpfdRlky; f'koiqjh dk gS] ftlesa mlds nksuksa yksoj fyaCl esa detksjh gksuk crk;k x;k gS rFkk mldk bykt gqvk gSA ^izn'kZ lh&9^ jksxh dY;k.k lfefr ftyk fpfdRlky; f'koiqjh dk fMLpktZ fVfdV gS ftlesa fnukad 26-04-2008 ls 01-05-2008 rd ujs'k dqekj nksgjs dks HkrhZ jguk crk;k x;k gS rFkk ^izn'kZ lh&10^ esa Spastic paraplegia ls ihfM+r gksus rFkk 50 izfr'kr dh fu;kZsX;rk crk;h x;h gSA ^izn'kZ lh&11 yxk;r lh&16^ rd ds nLrkost ftyk fpfdRlky; f'koiqjh ds fpfdRld MkW0 ,-,y-'kekZ ds bykt ls lacfa /kr nLrkost gSa rFkk ^izn'kZ lh&17^ t;kjksX; fpfdRlky; lewg Xokfy;j ds bykt ls lacfa /kr nLrkost gS rFkk ^izn'kZ lh&19^ vihykFkhZ dh ,evkjvkbZ fjiksVZ gSA ^izn'kZ lh&19^ esa -6- lokZbdy ofVZczk] ^izn'kZ lh&5 ,oa lh&6^ esa daizsflo ek;yksiSfFkd psatsl gksuk crk;k x;k gSA 11- izfrvihykFkhZ chek daiuh dh vksj ls fo}ku vf/koDrk ds }kjk rdZ ds nkSjku ^izn'kZ vkj&5^ dh chek ikfylh ds dkWye uacj 2-1 lsDlu 1 MAJOR MEDICAL ILLNESS & PROCEDURES dh vksj /;ku vkdf"kZr djk;k x;k gS] ftlds dkye C esa Paralysis dh chekjh Hkh mYysf[kr gSA fo}ku vf/koDrk ds }kjk vkxs ;g rdZ fd;k x;k gS fd ^izn'kZ vkj& 5^ esa chek dh tks 'krsaZ jgha gSa mlds vuqlkj daiyhV ,oa ijekusaV ykl nks vFkok vf/kd vaxksas dk gksuk pkfg, rHkh mls {kfriwfrZ izkIr gksxh rFkk vkxs ;g Hkh rdZ fd;k x;k gS fd dsUnzh; o jkT; ljdkj ds vLirky ds }kjk ejht dks complete, irreversible and permanent loss gksuk pkfg, rHkh mls {kfriwfrZ izkIr gksxhA 12- mDr lanHkZ esa ujs'k dqekj nksgjs dh fcekjh dh fpfdRldksa ls tks tkap djk;h x;h mlesa ejht dk loZizFke ftyk f'koiqjh esa bykt djus okys MkWDVj ,-,y- 'kekZ ds ^izn'kZ vkj&11 o vkj&12^ ds nLrkost gSa] ftlesa iz'u Øekad 26 esa mlds nksuksa yksoj fyaCl esa detksjh gksuk crk;k x;k gS vkSj ;gh fLFkfr iz'u Øekad 27 esa Hkh crk;h x;h gS ftlesa nksuksa yksoj fyaCl esa detksjh] >qu>quh rFkk laosnuk&'kqU; ,oa nksuksa yksoj fyaCl esa detksjh crk;h x;h gS vkSj iz'u Ø- 28 esa Spastic paralysis crk;k x;k gS rFkk iz'u 41 esa ;g iwNk x;k gS fd D;k mDr chekjh permanent(irreversible) or temporary(reversible) gS] rc fpfdRld dk mRrj permanent jgk gS rFkk iz'u Ø- 42 ,oa 43 ds mRrj esa fu;ksZX;rk dk izfr'kr 50 crk;k x;k gSA ^izn'kZ vkj 12^ esa Hkh iz'u Ø- 65 ,oa 67 ds mRrj esa Hkh mDr fLFkfr crk;h x;h gS rFkk iz'u 51 esa nksuksa yksoj fyaCl esa detksjh ,oa Spastic paralysis crk;k x;k gS] ftldk rkRi;Z ;g gS fd nksuksa iSj mlds laosnuk'kwU; gks x;s FksA -7- 13- MkW0 izks0 ,l-,u- vk;axj] U;wjks ltZu] t;kjksX; fpfdRlky;] Xokfy;j dk ipkZ ^izn'kZ vkj&6^ izLrqr fd;k x;k gS] ftlesa iz'u Ø-3 esa mDr fLFkfr n'kkZ;h x;h gS ftlesa Numbness] Timbling & weekness both LL crk;h x;h gS rFkk dkWye uacj 8 esa chekjh dh vof/k 1 o"kZ 6 ekg ls gksuk crk;k x;k gSA iz'u 17 esa iSjkykbZfll dks permanent ,oa irreversible ds laca/k esa fpfdRld ds }kjk permanent crk;k x;k gS rFkk disability ds laca/k esa iz'u 18 o 19 esa 50 izfr'kr gksuk crk;h x;h gSA 14- izfrvihykFkhZx.k chek daiuh dh vksj ls fo}ku vf/koDrk us O;Dr fd;k fd pafw d 'kkjhfjd vleFkZrk 50 izfr'kr Fkh] blfy, vihykFkhZ dks _.k ekQh dh ik=rk ugha Fkh] vr% ftyk vk;ksx us mfpr fu"d"kZ fudkyk gS rFkk ifjokn dks fujLr fd;k gS rFkk blh vk/kkj ij chek daiuh }kjk Hkh vihykFkhZ dk Dyse nkok fujLr fd;k x;k gSA 15- izfrvihykFkhZ ds fo}ku vf/koDrk ds mijksDr rdksZa ij fopkj fd;k x;kA bl lanHkZ esa chek daiuh dh vksj ls izLrqr ^izn'kZ vkj&5^ ftlesa dkye uacj 2-1 ds lanHkZ esa ;g mYysf[kr gS fd Complete and permanent loss of function of two or more limbs as a result of injury or illness of the brain or spinal cord. crk;k x;k gSA bl lanHkZ esa tks nksuksa iSjksa esa Numeness & Tingling vkSj detksjh crk;h x;h gS] mldh vof/k 1 o"kZ 6 ekg dh gksuk fpfdRldksa us crk;h gS rFkk mldk uspj ijekusaV crk;k gS rFkk 50 izfr'kr fu%'kDrrk tks crk;h xbZ gS] og mDr fo'ks"k vax ds laca/k esa u gksdj iwjs 'kjhj ds eku ls gksuk izdV gks jgk gS vkSj tc fpfdRld ds }kjk vihykFkhZ ds nksuksa yksoj fyaCl esa detksjh ,oa fVaxfyax crk;h x;h gS rFkk fpfdRld ds }kjk 1 o"kZ 6 ekg ls vf/kd mlds ihfM+r gksus dk rF; Hkh crk;k x;k gS\ ,slh n'kk esa gekjs er -8- esa 50 izfr'kr fu%'kDrrk fpfdRld }kjk ys[k djus ls vihykFkhZ dks] mDr ikfylh dh lafonk ls izkIr gksus okys ykHk ls oafpr ugha fd;k tk ldrk Fkk] D;ksfa d mlesa nks vFkok vf/kd fyaCl fu%'kDrrk dh chekjh dk Hkh mYys[k gS] ftlesa fpfdRldksa ds }kjk mlds nksuksa yksoj fyaCl esa fVaxfyax ,oa uEcusl esa detksjh crk;h x;h gS] vkSj mldh vof/k Hkh 1 o"kZ ls vf/kd jgh gS] tcfd vU; tks 'krZ Fkh mlesa de ls de 6 eghus rd mDr fLFkfr gksuk pkfg, FkhA 16- bl izdkj ls vihykFkhZ dk bykt djus okys fpfdRld MkW0 ,-,y- 'kekZ vkSj MkW-izksQslj ,l-,u- vk;axj }kjk Hkh yksoj fyEc esa detksjh ijekusVa crk;h x;h gSA ,slh n'kk esa fu'p; gh tks chek ikfylh ds fu;e o 'krsZa Fkha] mlds vkyksd esa vihykFkhZ _.k ekQh dk ik= jgk gS] ijarq ftyk vk;ksx }kjk mls ek= bl vk/kkj ij fd og 'kkldh; lsok esa gS rFkk viuk drZO; fuokZg dj jgk gS] blfy, mldk ifjokn fujLr fd;k x;k gS] tks gekjs er esa] mDr fu"d"kZ fof/k vuqlkj ugha jgk gS] D;ksfa d chek ikfylh esa tks 'krsZa Fkha] og lafonkRed nkf;Ro gS vkSj tc vihykFkhZ iSjkykbfll dh chekjh ls yxHkx Ms<+ o"kZ ls vf/kd le; ls ihfM+r jgk gS rFkk mlds nksuksa yksoj fyaCl esa detksjh] uEcusl] fVaxfyax iSnk gqbZ gS vkSj fpfdRld ds }kjk mls LFkk;h Hkh crk;k x;k gS] ,slh n'kk esa tcfd ^izn'kZ vkj&5^ ds nLrkost esa 100 izfr'kr fMl,cfYV gksus dh fdlh 'krZ dk mYys[k ugha gS] vkSj u gh VksVy 'kCn dk mi;ksx fd;k x;k gS] blfy, vihykFkhZ gkse lsQ Iyl flD;ksj ekbaM ikWfylh] tks fd mlds }kjk izhfe;e vnk dj Ø; dh x;h Fkh] mldh chekjh dh izd`fr dks ns[krs gq,] og mDr chek ikfylh dh 'krZ ds vUrxZr _.k ekQh gsrq ik=rk vftZr djrk FkkA 17- ,slh n'kk esa izfrvihykFkhZx.k chek daiuh ds }kjk tks ek= 50 izfr'kr dh fu%'kDrrk] fpfdRld }kjk crk;s tkus ij vihykFkhZ dk Dyse fujLr fd;k x;k gS rFkk v/khuLFk vk;ksx }kjk Hkh izfrvihykFkhZx.k dh lsok esa dksbZ deh ugha ikrs gq, mlds ifjokn dks fujLr fd;k x;k gS] og chek dh 'krksZa ds vuq:i ugha jgk gS] -9- D;ksfa d nksuksa yksoj fyaCl esa detksjh rFkk mDr chekjh 1 o"kZ 6 ekg ls vf/kd le; ls vihykFkhZZ ihfM+r jgk gS rFkk mDr chekjh LFkk;h izd`fr dh jgh gS] blfy, ;fn iwjs 'kjhj ds eku ls fu%'kDrrk 50 izfr'kr dh jgh Hkh gS] rks Hkh vihykFkhZ mDr 'krksaZ dh iwfrZ djrk FkkA 18- mi;qZDr foospuk ds izdk'k esa izLrqr vihy Lohdkj dh tkdj] ftyk vk;ksx dk vihykarxZr vkns'k fnukad 27-04-2010 fujLr djrs gq, izfrvihykFkhZx.k chek daiuh dks ;g vknsf'kr fd;k tkrk gS fd os nks ekg dh vof/k ds Hkhrj vihykFkhZ dks gkse lsQ Iyl flD;ksj ekbaM ikfylh Øekad 4065@0000001@ vkbZlhvkbZlhvkbZ@,p,y@0009050 rFkk ikfylh Øekad ,y-ch-,l-ch- @00001368901 ds varxZr mls _.k ekQh dh lqfo/kk iznku djs rFkk vihykFkhZ dks ekufld ,oa 'kkjhfjd ihM+k ds 'kh"kZd ds vUrxZr {kfriwfrZ ds :i esa :- 5]000@& rFkk lEiw.kZ okn O;; 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