State Consumer Disputes Redressal Commission
Apolo Munik Health Insurance Co Ltd vs Mohit Choupra on 13 September, 2023
jkT; miHkksDrk fookn izfrrks"k vk;ksx] lfdZV cSap] tks/kiqj ¼jkt0½ vihy la[;k 34@2018 1- viksyks E;wfud gsYFk bU';ksjsal dEiuh fyfeVsM] jftLVMZ dk;kZy; viksyks gkWLihVy dkWEiysDl] tqcyh fgYl iksLV gSnjkckn ¼vka/kzizns'k½ 2- viksyks E;wfud gsYFk bU';ksjsl a dEiuh fyfeVsM] f}rh; o rhljk ekyk] vkbZ ysCl lsaVj IykV uacj 404&405 m|ksx fogkj] r`rh; pj.k] xqMxkao& 122016 3- viksyks E;wfud gsYFk bU';ksjsl a dEiuh fyfeVsM] 'kk[kk dk;kZy;
rhljk ekyk] IykV ucj 17] ds-ih- Vkoj ckWEcs eksVj lfdZy ds ikl] vij pkSikluh jksM] iksLV tks/kiqjA && vihykFkhZx.k@foi{khx.k &cuke& eksfgr pkSiMk iq= dkUrhyky tkfr& vksloky fuoklh& egkohj dkyksuh] iksLV ckyksrjk ftyk ckMesjA &&izR;FkhZ@foi{kh le{k% ekuuh; U;k;kf/kifr Jh nsosUnz dPNkokgk] v/;{k ekuuh; Jh vrqy dqekj pVthZ] lnL; ¼U;kf;d½ euuh; Jh lat; Vkd] lnL;
mifLFkr%& vihykFkhZZx.k@foi{khx.k dh vksj ls Jh vuh"k vgen] vf/koDrkA izR;FkhZ@ifjoknh dh vksj ls Jh vfuy Hk.Mkjh]] vf/koDrkA cgl lqus tkus dh fnukad% 11-09-2023 fu.kZ; dh fnukad% 13-09-2023 }kjk%& Jh vrqy dqekj pVthZ] lnL; ¼U;kf;d½ 1- vihykFkhZx.k@foi{khx.k viksyks E;wfud gsYFk bU';ksjsal dEiuh fyfeVsM us ;g vihy izR;FkhZ@ifjoknh eksfgr pkSiMk ds fo:} fo}ku ftyk miHkksDrk vk;ksx] ckMesj ds }kjk ifjokn la0 184@2017 cmuoku ^^eksfgr pkSiMk cuke viksyks E;wfud gsYFk bU';ksjsal dEiuh fyfeVsM^^ esa ikfjr fu.kZ; fn0 10-11-2017 ds fo:} izLrqr dh gS] ftlds }kjk fo}ku ftyk miHkksDrk vk;ksx us ifjoknh dk ifjokn Lohdkj dj fuEu vkns'k fn;k gS%&& ^^vr% ifjoknh }kjk miHkksDrk laj{k.k vf/kfu;e] 1986 dh /kkjk 12 ds vUrxZr izLrqr ifjokn Lohdkj djrs gq, foi{khx.k dks vkns'k fn;k tkrk gS fd os ifjoknh dks esfMDyse ds :i esa 2]25]195@& :i;s vkSj bl jkf'k ij fnukad 08-08-2017 ls vnk;xh rd 9 izfr'kr okf"kZd nj ls C;kt dk Hkqxrku djsA blds vykok ifjoknh dks gqbZ ekufld {kfr ds fy, 20]000@& :i;s vkSj ifjokn O;; ds fy, 5]000@& :i;s dh jkf'k dk Hkqxrku fd;k tkosA bu nksuksa jkf'k;ksa dk ,d ekg esa Hkqxrku ugha gksus ij bu ij vkns'k dh fnuakd ls vnk;xh rd 9 izfr'kr okf"kZd nj ls C;kt ns; gksxkA^^ 2- ifjoknh eksfgr pkSiMk us foi{khx.k ds fo:} fo}ku ftyk miHkksDrk vk;ksx ds le{k ,d ifjokn bl vk'k; dk is'k fd;k Fkk fd mlus foi{kh la- 3 ds ckyksrjk fLFkr ,tsUV Jh feFkys'k ftUny ds ekQZr foi{kh chek dEiuh ls fn0 31-03-2012 ls fn0 30-03-2013 rd dh vof/k ds fy, chek/ku 5]00]000@& :i;s dk esfMDyse chek djok;k Fkk] mlds ckn izfro"kZ izhfe;e vnk dj fn0 31-03- 2015 ls 30-03-2016 rd dh vof/k ds fy, fujUrj esfMDyse chek ikWfylh izkIr dh tkrh jgh gSA chfer vof/k esa izFke ckj ekg vxLr] 2014 esa is'kkc djus esa nnZ gksus ij ifjoknh us izkjfEHkd bykt ds ckn fn0 08-09-2014 dks MkW- izrhd xxZ dks fn[kk;k rks mlus VsfLVax ds ckn Pelvi-Ureteric Junction obstruction of the lower pole moiety on left side appears likely with normal excerting left Kidney vafdr fd;kA ifjoknh us bl ij cksEcs gkWfLiVy ,.M esfMdy fjlpZ lsUVj] eqEcbZ esa fn0 15-09-2014 ls fn0 17-09-2014 rd HkrhZ jgdj viuk bykt djok;k o bykt ij O;; jkf'k 1]05]401 :- dk ds'kysl gksfLiVykbZts'ku ,izqoy ds fy, foi{kh chek dEiuh ds le{k Dyse is'k fd;kA foi{kh chek dEiuh us mijksDr Dyse dh jkf'k esa ls 70]000@& :i;s dk Hkqxrku fd;kA blds i'pkr~ ifjoknh us MkWDVj dh jk; ds vuqlkj fn0 17-12-2014 ls fn0 18-12-2014 rd dkWyksuh uflZax gkse esa HkrhZ jgdj viuk bykt djok;k vkSj bykt ij O;; gqbZ jkf'k 14]700@& :i;s dk foi{kh chek dEiuh ds le{k Dyse is'k fd;k ysfdu foi{kh chek dEiuh us bl Dyse isVs fn0 19-03-2015 dks bl Dyse isVs 10]121 :- dk Hkqxrku fd;kA 3- blds i'pkr~ iwoZ dh rjg ifjoknh ds is'kkc djus esa nnZ gksus dh f'kdk;r gksus ij fn0 26-04-2015 dks viuh iqu% tkap djokbZ] rks mls ;g crk;k x;k fd cka, xqnZs ls tqM+h gqbZ uyh ds ikl iqu% ekal c<+ x;k gSA bl ij ifjoknh iqu% cksEcs gkWfLiVy ,.M esfMdy fjlpZ lsUVj] eqEcbZ esa fn0 11-05-2015 ls 16-05-2015 rd HkrhZ jgdj Lower Moiety PUJ Obstruction dk bykt djok;k] ftl ij 2]25]195@& :i;s [kpZ gq;sA bl jkf'k dk Dyse chek foi{kh chek dEiuh ds le{k is'k fd;k ysfdu foi{kh chek dEiuh us ;g dgdj ifjoknh dk chek nkok [kkfjt dj fn;k fd mldh chekjh CONGENITAL DISEASE dh Js.kh esa vkrh gS vkSj chek ikWfylh dh 'krksZa ds v/khu bl rjg dh tUetkr chekjh ds fy, dksbZ Dyse ns; ugha gSA ifjoknh ds vuqlkj mlds ;g chekjh u rks tUetkr gS vkSj u gh lu~ 2014 ls igys mlus bl chekjh dk dksbZ bykt djok;k gS vkSj u gh blls igys mlds dksbZ is'kkc dh dksbZ rdyhQ gqbZ FkhA bl izdkj foi{kh chek dEiuh us ifjoknh dk chek nkok vuqfpr :i ls fujLr fd;k gSA vr% ifjoknh us chek Dyse jkf'k e; C;kt] {kfriwfrZ ,oa ifjokn O;; fnykus dh izkFkZuk dh gSA 4- foi{khx.k us tokc ifjokn esa ifjoknh }kjk fn0 31-03-2012 ls fn0 30-03- 2013 rd dh vof/k ds fy, vius LokLF; dk chek djokuk ,oa bl esfMDyse chek ikWfylh dk fnuakd 30-03-2016 rd fujUrj uohuhdj.k djokuk Lohdkj fd;k gSA foi{khx.k dk dguk gS fd mUgksaus ifjoknh ds Dyse dk fjO;w fd;k rks ;g Kkr gqvk fd ifjoknh ftl chekjh ds fy, gkWfLiVy esa HkrhZ gqvk gS] mldk bykt CONGENITAL DISEASE dh Js.kh esa vkrk gS] bl dkj.k ds'kysl lqfo/kk dks fjtsDV fd;k x;k gSA foi{khx.k us ;g Hkh dgk fd ,DliVZ dh lykg Hkh yh xbZ gS vkSj mlus ;g dUQeZ dj fn;k fd ifjoknh dh chekjh CONGENITAL IN NATURE gSA ,slh fLFkfr esa ifjoknh dk Dyse [kkfjt dj foi{khx.k us dksbZ lsok nks"k dkfjr ugha fd;k gSA 5- ;ksX; vf/koDrk vihykFkhZx.k@foi{kx.k dh vksj ls vihy esa n'kkZ;s vk/kkjksa rFkk fyf[kr cgl esa rF;kaas dks rdksZ ds :i esa nksgjkrs gq, fo}ku ftyk miHkksDrk vk;ksx] ckMesj ds vkyksP; fu.kZ; fn0 10-11-2017 dks fookfnr fd;k gSA mudh vksj ls vius rdZ ds leFkZu esa ekuuh; mPpre U;k;ky; }kjk flfoy vihy la[;k 2776@2002 ^^lroar dqekj la/kq cuke U;w bf.M;k ,';ksjal dEiuh fyfeVsM^^ easa ikfjr fu.kZ; fn0 10-07-2009 is'k fd;k x;k gSA 6- blds foijhr ;ksX; vf/koDrk izR;FkhZ@ifjoknh us mijksDr rdksZ dk fojks/k djrs gq, fo}ku ftyk miHkksDrk vk;ksx] ckMesj }kjk ikfjr vkyksP; fu.kZ; dks vius vfHkdFku vkSj lk{; ds ifjis{; esa rF;kRed ,oa fof/kd n`f"V ls iw.kZr% ;qfDr;qDr gksus dk rdZ nsrs gq, blesas gLr{ksi dh xqatkb'k ugha gksuk crk;kA mUgksusa gekjs le{k Hkkjrh; chek fofu;ked vkSj fodkl izkf/kdj.k ¼IRDA½ }kjk tkjh ifji= la[;k IRDAI/HLT/REG/CIR/046/03/2018 fn0 19-03-2018 dh izfr izLrqr djrs gq, rdZ fn;k gS fd mijksDr ifji= esa ekuuh; fnYyh mPp U;k;ky; ds fu.kZ; ds ifjis{; esa chek dEiuh }kjk Genetic disorders laca/kh viotZu 'krZ dks ekuuh; fnYyh mPp U;k;ky; }kjk Hkkjrh; lafo/ku ds vuqPNsn 14 dk mYya?ku gksuk n'kkZrs gq, ekuuh; fnYyh mPp U;k;ky; ds fu.kZ;kuqlkj lHkh chek dEifu;ksa dks ;g vkns'k fn;k gS fd Genetic disorders dks chek ykHk izkIr djus gsrq viotZu dh 'krksZ ds :i esa ugha ns[kk tkosA 7- geus fo}ku vf/koDrkx.k dh cgl lquh ,oa i=koyh ij miyC/k lk{;] fof/k fofu'p; ,oa vihykFkhZ@foi{kh chek dEiuh }kjk izLrqr fyf[kr cgl dk voyksdu fd;kA 8- iz'uxr ekeys esa Lohd`r rkSj ij izR;FkhZ@ifjoknh us ifjokn esa n'kkZ;s vuqlkj izFke ckj vxLr] 2014 esa is'kkc djus esa nnZ gksus dh f'kdk;r ij fn0 08-09-2014 dks MkW- izrhd xxZ dks fn[kk;k ,oa ijh{k.k ds i'pkr~ Pelvi-Ureteric Junction obstruction of the lower pole moiety on left side appears likely with normal excerting left Kidney ik;k tkuk crk;kA blds i'pkr~ ifjoknh }kjk fn0 15-09-2014 ls fn0 17-09-2014 rd cksEcs gkWfLiVy ,.M esfMdy fjlpZ lsUVj] eqEcbZ esa HkrhZ jgdj bykt djok;k]] ftl ij 1]05]401@& :i;s [kpZ gq, ,oa chek nkok is'k djus ij chek dEiuh }kjk 70]000@& :i;s dk Dyse Lohdkj fd;k x;kA blds i'pkr~ fn0 17-12-2014 ls fn0 18-12-2014 rd dkWyksuh uflZax gkse esa HkrhZ jgdj viuk bZykt djok;k] ftlesa 14]700@& :i;s dk foi{kh chek dEiuh ds le{k Dyse is'k fd;k] ftl ij 10]121@& :i;s dk Hkqxrku fd;kA iqu% is'kkc djus esa nnZ gksus dh f'kdk;r gksus ij fn0 26-04-2015 dks tkap djokbZ] ftlds i'pkr~ cksEcs gkWfLiVy ,.M esfMdy fjlpZ lsUVj] eqEcbZ esa fn0 11-05-2015 lsfn0 16-05-2015 rd HkrhZ jgdj Lower Moiety PUJ Obstruction dk bykt djok;k] ftlesa 2]25]195@& :i;s dh jkf'k [kpZ gqbZA bl jkf'k dk tks chek nkok is'k fd;k x;k] mls vihykFkhZ@foi{kh chek dEiuh us ;g dgrs gq, [kkfjt dj fn;k fd mldh chekjh CONGENITAL DISEASE dh Js.kh esa vkrh gS vkSj chek ikWfylh dh 'krksZa ds v/khu bl rjg dh tUetkr chekjh ds fy, dksbZ Dyse ns; ugha gSA 9- mijksDr foospu ls ;g Li"V gS fd izFke nks ckj chekj gksus ij vihykFkhZ@foi{kh chek dEiuh us izR;FkhZ@ifjoknh ds mipkj ds [kpZ dk ikWfylh ds vUrxZr iquHkZj.k fd;k gS fdUrq r`rh; volj ij 2]25]195@& :i;s ds iquHkZj.k ds fy, CONGENITAL DISEASE crkrs gq, viotZu esa 'kkfey gksuk ekurs gq, Dyse vLohdkj fd;k gSA izFke rks ;g fLFkfr Lohd`r gS fd ifjoknh ds is'kkc laca/kh chekjh izkjfEHkd Lrj ij vihykFkhZ@foi{kh chek dEiuh ls mDr chek ikWfylh ysus ls iwoZ fo|eku ugha Fkh vFkkZr bls Pre-Existing chekjh ugha ekuk tk ldrkA tgkWa rd CONGENITAL DISEASE dk laca/k gS] ekuuh; fnYyh mPp U;k;ky; }kjk ^^;wukbVsM bf.M;k bU';ksjsal dEiuh fyfeVsM cuke t;izdk'k rk;y vihy la0 610@2016 ,oa CM Nos. 45832@2017 ¼ftldk lUnHkZ ifjoknh }kjk izLrqr ifji= fn0 19- 03-2018 esa fn;k x;k gS½ esa Genetic disorders ¼CONGENITAL DISEASE½ dks Hkkjrh; lafo/kku ds vuqPNsn 14 dk mYya?ku gksuk ekurs gq, bl vk/kkj ij Dyse fujLr fd;k tkuk lgh ugha Bgjk;k x;k gS ,oa blh vk/kkj ij Hkkjrh; chek fofu;ked vkSj fodkl izkf/kdj.k ¼IRDA½ }kjk Genetic disorders ds ekeyksa dks Dyse viotZu dh ifjf/k esa ugha ekurs gq, Dyse fn;s tkus gsrq funsZf'kr fd;k x;k gSA 10- fo}ku ftyk miHkksDrk vk;ksx] ckMesj dk Hkh ;gh ekuuk gS fd izR;FkhZ@ifjoknh ds is'kkc lac/kh chekjh] ftldk bykt ckWEcs gkWLihVy ,.M fjlpZ lsUVj] eqEcbZ esa djk;k x;k og CONGENITAL DISEASE Fkh rks ekuuh; fnYyh mPp U;k;ky; ds fu.kZ; ,oa blds lac/a k esa Hkkjrh; chek fou;ked vkSj fodkl izkf/kdj.k }kjk tkjh ifji= esa n'kkZ;s vuqlkj vihykFkhZ@foi{kh chek dEiuh }kjk ifjoknh dk Dyse vLohdkj fd;k tkuk fof/klEer Bgjk;s tkus ;ksX; ugha gSA vr% fo}ku ftyk miHkksDrk vk;ksx }kjk vius fu.kZ; esa izR;FkhZ@ifjoknh dk chek nkok Lohdkj fd;s tkus ;ksX; ekurs gq, ifjokn Lohdkj fd;k gS blesa ge fdlh izdkj dh dksbZ fof/kd folaxfr ugha ikrs gSa uk gh vihykFkhZ@foi{kh chek dEiuh }kjk vihy esa mBk;s x;s vk/kkjkssa ij bl vihy dks Lohdkj ;ksX; ikrs gSA ifj.kkeLo:i vihykFkhZ@foi{kh chek dEiuh dh vihy vLohdkj fd;s tkus ;ksX; gSA vkns'k 11- vr% vihykFkhZx.k@foi{kh chek dEiuh viksyks E;wfud gsYFk bU';ksjsl a dEiuh fyfeVsM )kjk fo)ku ftyk miHkksDrk vk;ksx] ckMesj }kjk ifjokn la0 184@2017 cmuoku ^^eksfgr pkSiMk cuke viksyks E;wfud gsYFk bU';ksjsal dEiuh fyfeVsM^^ esa ikfjr fu.kZ; fn0 10-11-2017 ds fo:} izLrqr vihy [kkfjt dh tkrh gS vkSj fo)ku ftyk miHkksDrk vk;ksx] ckMesj dk fu.kZ; fn0 10-11-2017 iq"V fd;k tkrk gSA ¼lat; Vkd½ ¼vrqy dqekj pVthZ½ ¼nsosUnz dPNkokgk½ lnL; lnL; ¼U;kf;d½ v/;{k