National Consumer Disputes Redressal
New India Assurance Co. Ltd. vs Jyoti B. Mehta on 22 December, 2023
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 1403 OF 2018 (Against the Order dated 27/04/2018 in Complaint No. 564/2013 of the State Commission Maharashtra) 1. NEW INDIA ASSURANCE CO. LTD. DELHI LEGAL HUB-RO-820000, CORE-3, FIRST FLOOR, SCOPE MINAR, LAXMI NAGAR DELHI ...........Appellant(s) Versus 1. JYOTI B. MEHTA THROUGH HER C.A/SON MR. NISHITH B.MEHTA,
R/O. 1/1, BHAVESHWAR SIKHAR NO 1,
R.B. MEHTA ROAD, GHOTKOPAR (E) MUMBAI 400 077 ...........Respondent(s)
BEFORE: HON'BLE MR. SUBHASH CHANDRA,PRESIDING MEMBER HON'BLE AVM J. RAJENDRA, AVSM VSM (Retd.),MEMBER
FOR THE APPELLANT : FOR THE APPELLANT : MR. J. P. N. SHAHI, ADVOCATE, FOR THE RESPONDENT : FOR THE RESPONDENT : MR. DINESH PRAKASH GUCHIYA, ADVOCATE
Dated : 22 December 2023 ORDER
AVM J. RAJENDRA, AVSM, VSM (RETD.), MEMBER
1. The present First Appeal has been filed under Section 19 of the Consumer Protection Act, 1986 (hereinafter referred to as "the Act") against the Order dated 27.04.2018 passed by the learned State Consumer Disputes Redressal Commission, Maharashtra (hereinafter to be referred as "the State Commission"), in Consumer Complaint No. 564 of 2013, wherein the Complaint filed by the Complainant (Respondent herein) was partly allowed.
2. For the sake of Convenience, the parties in the present matter being referred to as mentioned in the Complaint before the State Commission. "Mrs. Jyoti B. Mehta" is identified as the Complainant who is a legal heir/wife of Life Assured/Insured Mr. Bhogilal Mehta (Since deceased). "The New India Assurance Co. Ltd." is referred to as the Opposite Party / Insurer (OP in short).
3. Brief relevant facts of the case as per the Complainant are that her husband Mr. Bhogilal Mehta ("the Deceased or Insured") had two life insurance policies, viz. No. 110600/42/09/01/00003039 (from 27.03.2010 to 26.03.2011) and 11060042100100201257 (from 27.03.2011 to 26.03.2012) covering personal accident insurance for both for Rs.20 lakhs, along with bonus accrued.
4. The unfortunate incident occurred in Indonesia on 29.09.2010 when the deceased was on a personal trip. During this visit, he suffered a fall on a staircase, resulting in injuries. He was promptly transported to a hospital with the assistance of people on-site. Upon returning to Mumbai, the complainant notified the insurance company via a letter dated 14.10.2010, informing them of the deceased's accidental fall and submitted a claim along with relevant documentation.
5. The insured/deceased was discharged from the Indonesian Hospital on 29.09.2010. But, due to his inability to endure extended travel, he returned to India on 08.10.2010 via Singapore, where he received medical attention. His fall from the staircase had caused severe internal injuries. Based on the recommendation of attending physicians, he was hospitalized. On 12.10.2010, the deceased was admitted to P.D. Hinduja Hospital in Mumbai and underwent major surgery for the evacuation of a 'Sub-Dural Hematoma'. Following this surgery, he was discharged from the hospital on 21.11.2010 and was advised to continue domestic care at home. He incurred expenses totaling Rs.14,03,559. Further, due to the gravity of his internal injuries, the deceased required round-the-clock care from attendants and nurses, even after being discharged from PD Hinduja Hospital. Based on the hospital recommendation, the Complainant engaged the services of Bina Nurses Bureau, incurring an expense of Rs.3,80,500. Subsequently, his health continued to deteriorate, and he was readmitted to Fortis Hospital from 21.12.2010 to 13.01.2011. Following medical assessments, it was confirmed that the step-fall accident had left lasting effects on his health, necessitating ongoing domestic hospitalization. For this second hospitalization incurred Rs. 3,79,131 as expenses. Despite discharge, the deceased's condition warranted intensive post-hospitalization treatment. To ensure his well-being, two attendants and two permanent nurses were appointed. Due to injuries sustained from the step-fall, he underwent another hospitalization at Jaslok Hospital, incurring expenses of Rs.4,75,484. Thus, in total, they incurred Rs.23,43,660 as expenses. Unfortunately, he did not recover from the injuries sustained in the step-fall accident and remained entirely disabled and passed away on 09.01.2013.
6. Consequently, the Complainant, who is the deceased's wife, claimed Rs.27,50,000, towards paid hospitalization expenses. The deceased had been insured for a decade, and this was his first claim, entitling for accrued bonus.
7. On submission of the claim, the Complainant maintained regular contact with the insurance company. On 19.04.2012, the insurer communicated with her, acknowledging the deceased's disability but offered only Rs.25,200 as compensation without any justifiable reason for this meager amount. The deceased was permanently disabled, and according to the policy's terms, the appellant was obligated to pay the entire compensation for permanent disability, as claimed by the complainant. The failure to honor this claim amounts to a deficiency in service on the part of the insurance company.
8. Being aggrieved by the repudiation of claim and deficiency in service by the OPs/Insurer, the Complainant filed a Consumer Complaint (No. 564 of 2013) before the learned State Commission and sought Rs.27,50,000 along with interest @18% per annum from the date of filing of the complaint till realization of the amount and also claimed costs of the proceedings.
9. The OP/Insurer resisted the claim, filed a written statement and denied all adverse allegations. The OP specifically denied any deficiency in service on their part but admitted to issuing a policy for personal accident coverage to Shri Bhogilal Mehta, as stated by the Complainant. The OP sought the medical expert opinion of Dr. AV Patil, a qualified medical professional with expertise in forensic medicine, regarding the case. Dr. Patil reviewed the medical reports from Indonesian Hospital, Hinduja Hospital, and consulted with various specialists in neurology and radiology. Based on this comprehensive evaluation, Dr. Patil prepared a report dated 19.03.2013, which was subsequently received by the OP. The OP/Insurer contended that the alleged injury, a "Sub-Dural Hematoma," resulting from the purported accident on 29.09.2010, did not immediately, permanently, totally, and absolutely disable the insured from any form of employment or occupation. In accordance with clause 1(d) of the policy terms, the claimants were not entitled to claim 100% of the sum assured. However, the OP/insurer admitted that the insured was temporarily totally disabled from the date of the accident until his first discharge from Hinduja Hospital on 21.11.2010, which amounted to 6 weeks. Therefore, the OP conceded that the claim was admissible for temporary total disablement under clause 1(f) of the policy @ 1% of the sum insured from Table A, equaling Rs. 3,000 per week for six weeks, resulting in a total of Rs. 18,000. Further, the hospital records indicated that the first and second hospitalizations in Indonesia and Hinduja Hospital, until 21.11.2010, respectively, were primarily for managing the Sub-Dural Hematoma and its effects, which were directly linked to the alleged fall. The OP contended that the Craniotomy performed on 13.10.2010 during hospitalization was aimed at reducing pressure on the brain due to the accumulated hematoma in the closed skull cavity. The post-operative CT scans demonstrated that the decompression had been successful, relieving the brain of hematoma-induced pressure. Upon insured's discharge on 21.11.2010, the final diagnosis indicated "left-sided Sub-Dural Hematoma," with no mention of "Cerebral Infarction" in the discharge records Based on these facts, the OP contended that the injuries arising from the alleged fall and Sub-Dural Hematoma had been effectively treated during the hospitalizations in Indonesia and Hinduja Hospital until 21.11.2010. Any subsequent hospitalization related to epilepsy was unrelated to or a consequence of the initial Sub-Dural Hematoma or decompression surgery. Therefore, the insured had only experienced temporary disability until 21.11.2010, and the alleged permanent disability and subsequent death were not a direct consequence of the head injury sustained on 29.09.2010. Thus, the complainant was not entitled to the reliefs sought but qualified only for payment of Rs. 18,000 as calculated by the OPs.
10. The learned State Commission upon hearing the parties, and considering the facts and the circumstances, of the case allowed the complaint and ordered the following: -
ORDER
Consumer complaint is partly allowed.
Opponent/Insurance company is hereby declared as guilty for deficiency in service and unfair trade practice.
Opponent/Insurance company do pay Rs.18,000 to the complainant towards disability sustained by the deceased for claim under the policy.
Opponent/Insurance company do pay Rs.14,06,196 i.e. amount towards medical expenses to the complainant.
Opponent/Insurance company do pay Rs.40,000 towards accrued bonus to the complainant.
Opponent/Insurance company do pay to the complainant Rs.1,00,000 and Rs.30,000 towards costs of litigation.
The complainant is entitled to claim above due amount with interest @ 9% p.a. from the date of filing of the consumer complaint i.e. since 01/11/2013.
Opponent/Insurance company is directed to pay the above amount as per direction within two months from the date of order, otherwise, said amount will carry interest @ 12% p.a. from the date of filing of consumer complaint.
Copies of the order be furnished to the parties.
11. In the Appeal, the Appellants contended that the learned State Commission failed to consider the Expert Medico Legal Consultancy report dated 19.03.2012. The compensation awarded towards mental agony is legally unsustainable. To be eligible for insurance claim, in terms of Clause Section 1(d) of the Personal Accident policy, the insured should be immediately, permanently, totally, and absolutely disabled from engaging in any employment or occupation for a lump sum of 100% of the Capital Sum Insured to be applicable. However, in the instant case, the insured was temporarily totally disabled from the date of the accident until his first discharge from Hinduja Hospital after six weeks on 21.11.2010 making the claim admissible for temporary total disablement under clause 1(f) of the policy. This entailed a rate of 1% of the Capital Sum Insured under Table A @ Rs.3,000 per week for six weeks totalling Rs.18,000. The State Commission failed to understand that medical expense reimbursement is admissible up to 40% of the valid claim amount or 10% of the Capital Sum Insured or actual expenses, whichever is lower. Thus, Rs. 7,200 was admissible. The subsequent treatments at Fortis Hospital from 21.12.2010 to 13.01.2011 and the associated expenses, disability, and eventual death on 09.01.2013 do not fall within the scope of the policy. The insured's death did not result solely and directly from the accidental fall but from a separate episode that occurred after decompression surgery, performed to address the insured's Cerebral Infraction/ epilepsy, which was unrelated to or a consequence of the Sub-Dural Hematoma solely and directly caused by the head injury sustained on 29.09.2010.
12. Upon notice on the memo of Appeal, the Respondent/ Complainant has not filed any reply or objection.
13. In his arguments, the learned counsel for the Appellant reiterated the grounds of appeal and forcefully argued that the State Commission failed to consider the provisions of the Personal Accident Clause, Section 1, Para 'd', which states that if an insured is disabled by any injury immediately, permanently, totally and absolutely from engaging in any employment or occupation, it would entitle them to a lump sum equal to 100% of the Capital Sum Insured. The insured was temporarily totally disabled from the date of the accident till his first discharge from Hinduja Hospital on 21.11.2010 after six weeks. As per policy's terms, this constituted a claim for temporary total disablement, amounting to 1% of the Capital Sum Insured under Table A, equaling Rs.3,000/- per week for six weeks, amounting to Rs.18,000. The reimbursement of medical expense is admissible up to 40% of the valid claim amount or 10% of the Sum Insured or actual expenses, whichever is lower. Thus, Rs.7,200 was admissible and was paid. The State Commission erred in attributing his death solely and directly to the accidental fall. Death had occurred due to a separate episode after his decompression surgery for Cerebral Infraction/epilepsy. It had no direct relation to sub-dural hematoma caused by the head injury on 29.09.2010.
14. On the other hand, the learned Counsel for Respondent/ Complainant reiterated the facts asserted in the complaint and argued that according to the policy, the total calculated claim was Rs. 50,93,660, but it was restricted to Rs. 27,50,000 due to the sum assured. However, the Appellant/Original Opponent paid only Rs. 25,200 with mala fide intention, rejecting the substantial part of the claim, without providing a valid and justifiable breakdown, completely ignoring the claim, even though the deceased had consistently paid an additional premium for such coverage and the accident occurred within the policy period. The accidental fall had resulted in severe injuries to the deceased. The hospitalization documents and medical expenses were genuine and admissible. The State Commission admitted the hospitalization expenses of Rs.23,43,660 and allowed 60% of this amount, in addition to granting Rs.18,000 for temporary disability as per policy. This decision correctly acknowledged the impact of the accidental fall, the temporary disability that was caused, and the entitlement to Rs.18,000, along with 60% of the medical expenses, amounting to Rs.14,06,196, plus a bonus of Rs. 40,000, as well as costs and compensation of Rs. 1,30,000. He further argued that the order of the State Consumer Disputes Redressal Commission in Mumbai be upheld and the present Appeal be dismissed with costs.
15. We have examined the pleadings and associated documents placed on record and rendered thoughtful consideration to the arguments advanced by the learned Counsels for both the Parties.
16. The primary issue and objection raised by the Appellants is whether the insurance company appropriately assessed and settled the Appellant's claim following her husband's accident.
17. In the present case, it is an admitted position that the Appellant issued policy No.110600/42/09/01/00003039 valid from 27.03.2010 to 26.03.2011 and Policy No.11060042100100201257 valid from 27.03.2011 to 26.03.2012 for personal accident of the deceased and his wife Mrs. Jyoti B Mehta, the Complainant. The sum insured was Rs.20 lakhs. The insured was entitled for accrued bonus also. The incident of the insured sustaining injuries due to fall from staircase in Indonesia is undisputed. He was immediately taken to the hospital. The information of the incident was given to the Appellant on arrival at Mumbai vide letter dated 14.10.2010. It is also admitted fact that the insured was discharged from the Indonesian Hospital. He returned to India via Singapore and at Singapore also he was treated in a hospital. The medical papers are also undisputed. On return, the insured was admitted in PD Hinduja Hospital and he underwent surgery at PD Hinduja Hospital on 12.10.2010 for Subdural Hematoma and was discharged on 21.11.2010. He was admitted to Fortis Hospital from 21.12.2010 to 13.01.2011 and thereafter to Jaslok Hospital. The Complainant made her claim vide letter dated 19.04.2012. However, the Appellant agreed to pay only Rs.25,200. Rs.18,000 was granted towards disability and Rs.7,800 was granted for medical expenses.
18. Towards substantiating the claim, the Complainant relied on the insurance policies, copies of premium receipts, Indonesian treatment papers, correspondence with the Appellants, discharge summaries and bills of PD Hinduja Hospital, Fortis Hospital, Jaslok Hospital etc. On the other hand, to disprove the claim, the Appellant relied on the insurance policy and opinion of Expert Medicolegal Consultancy Pvt Ltd dated 19.03.2012 by Dr. AV Patil and the records of the Fortis Hospital that the insured never sustained permanent disability due to the said fall at Indonesia.
19. The relevant portion of Personal Accident Policy issued by the Appellant in favour of the insured states that:-
"1. If at any time during currency of policy, insured person shall sustain any bodily injury solely and directly from accident caused by external, violent and visible mean, the company shall pay to the insured or his legal personal representative, as the case may be, the sum or sums hereinafter set forth, that is to say
a)............. b)............ c)............
d) If such injury shall, as a direct consequence thereof, immediately permanently and absolutely disable the insured person from engaging in any employment or occupation of any description whatsoever, then Lumpsum sum equal to hundred percent (100%) of Capital Sum Insured".
20. It is admitted position that on 12.10.2010 Shri Bhogilal Mehta was admitted to Hinduja Hospital and was diagnosed as a case of Left Sided Subdural Hematoma. He underwent a surgery and was discharged on 21.11.2010. At that stage, there here was no mention of "Cerebral Infraction". The Cerebral Infraction was first noticed in the CT Scan on 21.12.2010 which showed a wedge shaped left middle artery territory infarction and he was diagnosed as a case of status epileptics and thereafter his condition did not improve. Thus, clearly, the sub-dural haematoma caused due to accidental fall was treated successfully in Indonesian Hospital and Hinduja Hospital. The second hospitalization was for epilepsy, which was due to Cerebral Infraction, which is altogether a separate episode and not related to sub-dural haematoma or decompression surgery. The injury he suffered due to fall did not result any total permanent disability. As per the expert opinion of Dr. VK Patil, the disability sustained cannot be considered as a direct consequence of head injury and cannot be said to have arisen immediately, as required by the Personal Accident policy.
21. In view of the above, the claim is admissible for temporary total disablement in terms of clause 1(f) of the policy @ 1% of the sum insured under Table A i.e. Rs.3000/- per week for six weeks amounting to Rs.18,000. The Appellant rightly awarded Rs.18,000 due to accidental injury between 29.09.2010 till his first discharge from Hinduja Hospital on 21.11.2010. However, the Appellants ignored the fact that the insured had also paid additional premium of Rs.552.40 towards medical expenses. The Insured had also paid Rs.3,382 towards additional premium. In spite of this, the Insurer sanctioned only Rs.7500 towards medical expenses.
22. It is undisputed that the insured was required to take medical treatment in hospital at Indonesia. While returning, he was unable to travel for a long and came via Singapore, where he was treated at Singapore, which she established. He was admitted at Hinduja Hospital and paid Rs.14,03,559. Due to certain internal injuries, the deceased required attendant & nurse for 24 hours after discharge from Hinduja Hospital and paid Rs.3,80,500. Towards care from 21.12.2010 to 13.01.2011 he paid Rs.3,79,131 at Fortis Hospital. At Jaslok Hospital he incurred Rs.4,75,484. Records revealed that the policy was for Rs.20 lakhs with accrued Bonus of Rs.75,000. However, while the deceased and complainant incurred expenses of Rs.23,43,660, the Appellant sanctioned only Rs.7500 towards medical treatment.
23. The Appellant Insurance Company was to reimburse 60% of medical expenses to them. 60% of Rs.23,43,660 is Rs.14,06,196. The complainant is entitled to claim said amount towards medical expenses of the deceased, which is covered under the policy when premium for medical treatment is received by the opponent. The complainant is also entitled to Rs.18,000 for temporary disablement of the deceased and Rs.14,06,196 towards medical expenses.
24. It is, therefore, established that the Appellant illegally repudiated the genuine claim of the Complainant. Thus, we find no merit in the present Appeal and uphold the Order of the learned State Commission dated 27.04.2018, except for payment of compensation of Rs.1,00,000 to the Complainant.
25. The Hon'ble Supreme Court in DLF Homes Panchkula Pvt. Ltd. Vs. D.S. Dhanda, in CA Nos. 4910-4941 of 2019 decided on 10.05.2019 has held that multiple compensations for singular deficiency is not justifiable. Therefore, the award of Compensation Rs.1,00,000/- for mental pain, agony and harassment given by the State Commission are not tenable.
26. In view in foregoing deliberations, the order of the learned State Commission in Consumer Complaint No. RBT/CC/15/816 in CC 13/564 is modified as follows:
ORDER I. The Appellant/ Insurance Company shall pay Rs.18,000 to the Complainant towards disability sustained by the deceased for claim under the policy.
II. The Appellant/ Insurance Company shall pay Rs.14,06,196 towards medical expenses to the Complainant.
III. The Appellant/ Insurance Company shall pay Rs.40,000 towards accrued bonus to the Complainant.
IV. The Appellant/ Insurance Company shall pay the above dues along with interest @ 9% per annum from the date of filing of the Consumer Complaint i.e. from 01.11.2013, within a period of one month from the date of this order. In the event of delay, the rate of interest applicable for such period beyond one month shall be @ 12% per annum.
V. The Appellant/ Insurance Company shall also pay Rs.30,000 towards costs of litigation.
27. All pending application, if any, stand disposed of.
28. The Registry is directed to release the Statutory deposit amount, if any in favour of the Appellants after due compliance of this order.
...................................... SUBHASH CHANDRA PRESIDING MEMBER ................................................................................... AVM J. RAJENDRA, AVSM VSM (Retd.) MEMBER