State Consumer Disputes Redressal Commission
The Oriental Insurance Company Ltd vs Gopal Krishan Mundhada on 26 November, 2021
jkT; miHkksDrk fookn izfrrks"k vk;ksx] lfdZV cSap] chdkusjA vihy@278@2013 fn vksfj;aVy bU';ksjsl a dEiuh fy- iathd`r dk;kZy; vksfj;aVy gkml ,&25@27] vklQ vyh jksM+] ubZ fnYyh & 'kk[kk fn vksfj;aVy bU';ksjsal dEiuh fy- vuwix<+] ftyk Jhxaxkuxj foLrkj iVy 11 iqjkuh /kku e.Mh jk;flaguxj] tfj;s e.Myh; izcU/kd] e.Myh; dk;kZy; iap'krh lfdZy] lknqZyxat] chdkusjA vihykFkhZ&foi{kh &cuke& xksiky d`".k ewanM+k iq= Jh fd'ku yky eqanM+k] tkfr ekgs'ojh] fuoklh iqjkuh /kku e.Mh] JhxaxkuxjA izR;FkhZ&ifjoknh vihy vUrxZr /kkjk 15 miHkksDrk laj{k.k vf/kfu;e]1986 le{k% Jh vrqy dqekj pVthZ] lnL; ¼ U;kf;d ½ Jh lat; Vkd] lnL; ¼ xSj U;kf;d ½ m Ik fLFk fr %& 1- Jh ,u-ds-xk¡/kh& vf/koDrk vihykFkhZA 2- izR;FkhZ vf/koDrk vuqifLFkrA fu.kZ; fnukad 26-11-2021 }kjk%Jh vrqy dqekj pVthZ] lnL; ¼U;kf;d ½ ;g vihy fo}ku ftyk miHkksDrk eap ¼ orZeku esa ftyk miHkksDrk ¼ vk;ksx ½] Jhxaxkuxj }kjk vius ifjokn la- 352@2012 xksiky d`".k ewanM+k cuke fn vksfj;aVy bU';ksjsl a d-fy- esa ikfjr fu.kZ;kns'k fnukad 27-11-2013 ds fo:) vihykFkhZ&foi{kh chek dEiuh }kjk bl vk;ksx ds le{k is'k dh x;h gS] ftlds }kjk izR;FkhZ&ifjoknh dk ifjokn Lohdkj fd;k x;k gSA 2 ifjokn ds laf{kIr o lqlaxr rF; bl izdkj ls gSa fd ifjoknh us foi{khx.k ls gSIih QSfeyh Q~yksVjk esMhDyse ikWfylh Lo;a o vius ifjokj ds fy, fu/kkZfjr izhfe;e vnk djds lu~ 2008 esa izkIr dh FkhA fnukad 02-01- 2011 dks tc og vius llqjky esa Hkkjh lkeku mBk jgk Fkk rks vpkud jkT; miHkksDrk fookn izfr-vk;ksx]l-cS- chdkusj vihy la- 278@13 fu.kZ; fn-26-11-21 mldh dej esa nnZ gksus yxk ftl ij mlus MkW-'kf'kdkUr vxzoky dks fn[kkdj ,e-vkj-vkbZ- djok;h rks ;g ik;k fd fMLd fgy x;h gS rFkk mDr fpfdRld us ifjoknh dk mipkj izkjEHk fd;kA ifjoknh us mDRk ds lEcU/k esa MkW-v'kksd iu?kfM+;k dks Hkh fn[kk;k ftUgksua s Hkh fMLd fgyus dh iqf"V dhA ifjoknh us mDr fjiksVZ vkfn fn[kkdj foi{kh ls lEidZ fd;k rks foi{kh us ifjoknh dks esDkl ds;j gkWLihVy] fnYyh esa bykt djokus dk dgk] ftl ij ifjoknh us viuh mDRk chekjh dk bykt esDl ds;j gkWLihVy fnYyh esa djok;k x;k tgka 1]77810@&:- [kpkZ gqvkA ifjoknh us mDr mipkj O;; ds iquHkZj.k gsrq foi{kh chek dEiuh ds ;gka Dyse izLrqr fd;k ysfdu foi{kh us Dyse bl vk/kkj ij nsus ls bUdkj dj fn;k fd mDr chekjh dk bykt ikWfylh ysus ds nks lky ds Hkhrj doj ugha gksrkA ifjoknh us ifjokn izLrqr dj bykt ijk [kpZ gqbZ dqy jkf'k 1]93]603@&:- e; C;kt fnykus ds lkFk lkFk ekufld ijs'kkuh ds fy, izfrdj jkf'k ,oa ifjokn O;; fnykus dk vuqjks/k fd;kA 3 foi{kh chek dEiuh us tokc izLrqr dj ifjokn dk fojks/k djrs gq, vafdr fd;k fd ifjoknh us ikWfylh lu~ 2008 esa ugha yh x;h Fkh cfYd fnukad 09-01-2009 ls ,d o"kZ ds fy, ikWfylh yh x;h Fkh] ftls fjokbZo ugh djok;k vkSj fQj mlus fnukad 06-02-2010 dks ,d ikWfylh yh FkhA ifjoknh }kjk llqjky esa otu mBkus ls nnZ gksus o fpfdRld dks fn[kkus ds rF; ls tkudkjh ds vHkko esa vLohdkj fd;k x;k rFkk ;g dgk fd foi{kh us ifjoknh dks ,slk ugha dgk Fkk fd og esDl gkWLihVy fnYyh esa viuk mipkj djok;sA ;g dgk x;k fd PIVD (PROLAPSED INTER VERTEBRAL DISK ) dk vkWijs'ku chek ikWfylh tkjh gksus ds nks lky ds Hkhrj doj ugha gksrk gS] blfy, chek ikWfylh dh 'krZ la- 4-3 ds vuqlkj lgh izdkj ls lmldk Dyse fujLr djds lwfpr dj fn;k x;k FkkA vr% foi{kh us ifjokn fujLr ;ksX; cryk;kA 4 fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ us nksuksa i{kksa ds vfHkopuksa ,oa lk{; ij fopkj djrs gq, vkykSP; fu.kZ; ikfjr fd;k] ftlds }kjk ifjoknh dk ifjokn Lohdkj fd;k x;kA vkykSP; fu.kZ; ls O;fFkr gksdj vihykFkhZ&foi{kh chek dEiuh us ;g vihy izLrqr dh gSA 5 ;ksX; vf/koDrk vihykFkhZ&foi{kh us vihy esa n'kkZ;s vk/kkjksa dkas rdkaaZs ds :i esa nksgjkrs gq, fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ ds vkykSP; fu.kZ; dks vfof/klEer o xyr gksuk crkrs gq, vihy Lohdkj fd;s tkus ;ksX; gksuk 2 jkT; miHkksDrk fookn izfr-vk;ksx]l-cS- chdkusj vihy la- 278@13 fu.kZ; fn-26-11-21 crk;kA vius rdksZa ds leFkZu esa ;ksX; vf/koDrk vihykFkhZ&foi{kh chek dEiuh us fuEu fyf[kr U;k; n`"VkUr is'k fd;s %& 1- II(¼2020½lhihts 287 ¼,u-lh-½ jkW;y lqUnje ,fyvkal bU';ks-d-fy-
cuke lqfer jkepUnkuh 2- II(¼2015½lhihts 661 ¼,u-lh-½ vksfj;aVy bU';ks-d-fy- cuke rkjk 3- I(¼2016½lhihts 699 ¼,u-lh-½ ;wukbZVsM bf.M;k bU';ks-d-fy- cuke dsujk cSad o vU;
6 cgl ds nkSjku izR;FkhZ&ifjoknh dh vksj ls dksbZ mifLFkr ugha gqvk] blfy, mudh vksj ls fdlhs dks ugha lquk tk ldkA 7 geus ;ksX; vf/koDrk vihykFkhZ ds mi;qZDr rdksaZ ij euu fd;kA fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ ds vkykSP; fu.kZ; dk v/;;u fd;kA ;ksX; vf/koDrk vihykFkhZ dh vksj ls izLrqr mi;qZDr U;k;n`"VkUrksa dk llEeku v/;;u djrs gq, lEiw.kZ vfHkys[k dk /;kuiwoZd voyksdu fd;kA 8 bl ekeys esa vihykFkhZ&foi{kh chek dEiuh }kjk izR;Fkh&ifjoknh }kjk izLrqr Dyse] tksfd izR;FkhZ&ifjoknh }kjk vihykFkhZ&foi{kh chek dEiuh ls Lo;a ds rFkk ifjokj ds fy, yh x;h esMhDyse ikWfylh ds vUrxZr PIVD (PROLAPSED INTER VERTEBRAL DISK ) ds vkWijs'ku esa O;; gqbZ jkf'k ds Dyse dks bl vk/kkj ij vLohdkj fd;k x;k fd mDr ikWfylh dh 'krZ la - 4-3 ds vuqlkj ikWfylh izHkko esa vkus ds nks o"kZ dh vof/k ds e/; fy;s x;s mipkj dk iquHkZj.k ikWfylh ds vUrxZr fd;s tkus ;ksX; ugha FkkA izR;FkhZ&ifjoknh] fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ ds le{k ;g dg dj vk;k fd fnukad 01-11-2011 dks uoo"kZ dh c/kkbZ nsus ds fy, og vius ifjokj ds lkFk chdkusj fLFkr llqjky x;k Fkk] rc fnukad 02-11-2011 dks izR;FkhZ&ifjoknh }kjk llqjky esa Hkkjh lkeku mBkus ds dkj.k vpkud mldh dej esa nnZ gks x;k rks llqjky okyksa us izR;FkhZ&ifjoknh dks MkW-'kf'kdkUr vxzoky dks dks fn[kk;k ftUgksusa izR;FkhZ&ifjoknh dks ,e-vkj-vkbZ- djokus dh lykg nhA ,e-vkj-vkbZ dh fjiksVZ ds vuqlkj MkW-vxzoky }kjk izR;FkhZ&ifjoknh dh fMLd fgyuk crk;kA izR;FkhZ&ifjoknh us fnukad 07-01-20 nqckjk ,e-vkj- vkbZ- djok;hA izR;FkhZ&ifjoknh ds vuqlkj mlus fo'ks"kK fpfdRld MkW-v'kksd iu?kfM+;k dks Hkh fn[kk;k rFkk MkDVjksa dh fojks/kkHkklh fjiksVZ nsus ds dkj.k vUrr% ifjoknh us fnYyh fLFkr esDl gSYFk ds;j gkWLihVy esa mipkj djok;k] tgka ij mldk vkWijs'ku fd;k x;k ,oa vkWijs'ku ij 1]77]810@&:- dk [kpkZ 3 jkT; miHkksDrk fookn izfr-vk;ksx]l-cS- chdkusj vihy la- 278@13 fu.kZ; fn-26-11-21 vk;kA fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ us ikWfylh dh 'krZ la - 4-3 dh O;k[;k djrs gq, mDRk 'krZ ds vUrxZr n'kkZ;h lwph esa dze la- 20 esa Surgery for Prolapsed inter vertebral Disk unless arising from accident -2 years ds vuqlkj ;g ekuk fd ;|fi lkekU;r;k ikWfylh izHkko esa vkus ds nks o"kZ dh vof/k esa Prolapsed inter vertebral Disk Surgery gsrq mipkj esa [kpZ jkf'k mDr 'krZ ds vuqlkj ns; ugha gS] fdUrq ;fn nq?kZVuk ds dkjk.k mDRk chekjh gqbZ gks rks Hkys gh ikWfylh izHkko esa vkus ds nks o"kksa ds Hkhrj chekjh gqbZ gks ,oa mipkj djok;k x;k rks mldk fpfdRlk O;; ikWfylh ds vUrxZRk iquHkZj.k ;ksX; gSA fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ us vkykSP; fu.kZ; esa izR;FkhZ&ifjoknh }kjk ftl izdkj dfFkr rkSj ij llqjky esa Hkkjh lkeku mBkus ds dkj.k vpkud dej esa nnZ gksuk crk;k gS] mls nq?kZVuk gksuk ekuk gSA bls vihy esa vihykFkhZ chek dEiuh us iqjtksj <ax fookfnr fd;k gSA ;ksX; vf/koDrk vihykFkhZ chek dEiuh dh vksj ls mi;qZDr U;k; n`"VkUr m)fjr djrs gq, vk;ksx dk /;ku vfHkys[k ij miyC/k izR;FkhZ&ifjoknh }kjk izLrqr esMhDyse QkWeZ ,oa blds lkFk layXu esDl gSYFk ds;j gkWLihVy] fnYyh dh fMLpktZ lejh fnukad 30-01-2011 dh vksj fnykrs fgq, rdZ fn;k fd mDr fMLpktZ lejh esa CHIEF COMPLAINT esa izR;FkhZ&ifjoknh }kjk foxr rhu ekg ls cka;s ikao ds fupys fgLls esa nnZ ,oa Hkkjhiu dh f'kdk;r gksuk n'kkZ;k gSA muds vuqlkj blls ;g tkfgj vkrk gS fd okLro esa izR;FkhZ&ifjoknh lEHkor;k vDVwcj] 2010 ls gh cka;s ikao ds fupys fgLls esa nnZ ,oa Hkkjhiu dh ihM+k ls ihfM+r FkkA mUkdk ;g Hkh dguk gS fd fMLpktZ lejh esa n'kkZ;h x;h History of illness esa fnukad 02-1-2011 dh ?kVuk dk ftdz ugha gSA 9 gesa bl vihy esa ;g ns[kuk gS fd ftl izdkj ls fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ us izR;FkhZ&ifjoknh ds vfHkopuksauqlkj dfFkr rkSj ij fnukad 02-11-2011 dks llqjky esa vpkud Hkkjh lkeku mBkus ds dkj.k nnZ gksus dks nq?kZVuk ekuk gS] og izdj.k ds rF;ksa ,oa ifjfLFkfr;ksa esa lgh Bgjk;s tkus ;ksX; gS vFkok ugha \ bl lEcU/k esa foospu djus ij ge ;g ikrs gSa fd gkykafd izR;FkhZ&ifjoknh us vius vfHkopuksa ,oa lk{; esa ;gh rF; izdV fd;k gS fd mldh dej dh ihM+k vpkud fnukad 02-1-2011 dks Hkkjh lkeku mBkus ds dkj.k gqbZ Fkh] fdUrq vfHkys[k ij Lo;a izR;FkhZ&ifjoknh }kjk Dyse QkWeZ ds lkFk izLrqr fMLpktZ lejh ds rF; izR;FkhZ&ifjoknh ds mDRk ekeys dks lkfcr djrs gSa ;k ugha] bl n`f"V ls egRoiw.kZ ik;s tkrs gSA ge mDr fMLpktZ lejh 4 jkT; miHkksDrk fookn izfr-vk;ksx]l-cS- chdkusj vihy la- 278@13 fu.kZ; fn-26-11-21 ds voyksdu ij ikrs gSa fd blds vuqlkj izR;FkhZ&Ikfjoknh fnukad 27-01-2011 dks esDl gSYFk ds;j gkWLihVy] fnYyh esa HkrhZ gqvk ,oa fnukad 30-01-2011 dks mls ogka ls fMLpktZ fd;k x;k ,oa bl e/; fnukad 28-01-2011 dks vLirky esa ifjoknh dh Decompression and discoctomy L5S1 done on 28-01-2011 n'kkZ;h x;h gS vFkkZr mDr 'kY; fpfdRlk izfdz;k vLirky }kjk viuk;h x;h gSA bl fMLpktZ lejh esa Mk;Xuksfll PIVD L5S1 n'kkZ;k x;k gS rFkk CHIEF COMPLAINT esa Mr. GOPAL KRISHAN MUNDHRA 50 YEAR OLD MALE PRESENTED WITH COMPLIANT OF PAIN AND HEAVINESS LEFT LOWER LIMB SINCE 3 MONHTS n'kkZ;k x;k gSA mYys[kuh; gS fd ftl izdkj izR;FkhZ&ifjoknh us fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ ds le{k vius vfHkopuksa o lk{; esa dfFkr rkSj ij fnukad 02-1-2011 dks vpkud Hkkkjh lkeku mBkus ds dkj.k nnZ gksuk crk;k gS] og rF; mDRk fMLpktZ lejh esa vafdr CHIEF COMPLAINT ,oa izR;FkhZ&ifjoknh dh History of illness dk lfEefyr :i ls voyksdu djus ij ge ;g ikrs gSa fd izR;FkhZ&ifjoknh foxr rhu ekg iwoZ lEHkor;k vDVwcj] 2010 ls gh cka;s ikao ds fupys fgLls esa nnZ ,oa Hkkjhiu eglwl dj jgk FkkA rhu eghus iwoZ ifjoknh lkekU;r% LoLF; Fkk] fdUrq rhu eghus iwoZ ifjoknh dks cka;s ikao ds fupys fgLls esa cgqr rst nnZ ¼ Accute Pain ½ eglwl gqvk ftldh otg ls ifjoknh dks csM jsLV ysuk iM+k] ftldh otg ls nnZ rks de gks x;k fdUrq nnZ iwjh rjg ls lekIr ugha gqvkA izR;FkhZ&ifjoknh ds cSBus ij mldh dej ds fupys fgLls esa nnZ dh f'kdk;r Hkh vafdr dh x;h gS ,oa mDRk fjiksVZ ds vuqlkj vLirky esa ys tkus ds le; izR;FkhZ&ifjoknh NksVh&NksVh nwjh gsrq iSny py ldrk Fkk fdUrq mlds cka;s ikao esa nnZ eglwl gksrk FkkA blds vfrfjDr ejht dh cka;h ,M+h esa lwukiu ¼ numbness ½ S1 ,fj;k Hkh gksuk n'kkZ;k x;k ,oa ejht dks Further management ds fy, HkrhZ djuk crk;k x;k gSA gekjs fouez er esa Lo;a izR;FkhZ&ifjoknh }kjk izLrqr mDr nLrkost fMLpktZ lejh ds rF; izR;FkhZ&ifjoknh ds bu vfHkdFkuksa ds iw.kZr% foijhr gksuk ik;s tkrs gSa ftlds vuqlkj ifjoknh }kjk dfFkr :i ls fnukad 02-01-2011 dks vpkud Hkkjh lkeku mBkus ds dkj.k dej esa nnZ gksuk crk;k x;k gSA blds vfrfjDr mDr fMLpktZ lejh ds rF; ;g Hkh n'kkZrs gSa fd izR;FkhZ&ifjoknh dh ftl chekjh dh 'kY; fpfdRlk mDr vLirky esa dh x;h] og rhu ekg iwoZ ifjoknh dks eglwl gq, cka;s ikao ds fupys fgLls ds nnZ ,oa cka;h ,M+h ds lwusiu ds 5 jkT; miHkksDrk fookn izfr-vk;ksx]l-cS- chdkusj vihy la- 278@13 fu.kZ; fn-26-11-21 ifj.kkeLo:i mRiUu gqbZ chekjh dh otg ls dh x;h Fkh o vLirky ds fjdkMZ es ,slk dgha ugha n'kkZ;k x;k gS fd vpkud fnukad 02-1-2011 dks Hkkjh lkeku mBkus ls izR;FkhZ&ifjoknh dh 'kkjhfjd voLFkkk [kjkc gqbZ gksA 10 blds vfrfjDr ;fn rdksaZ dh lqfo/kk dh n`f"V ls ;g eku Hkh fy;k tkos fd izR;FkhZ&ifjoknh ;g lgh dg jgk gS fd fnukad 02-1-2011 dks mlus vious llqjky esa Hkkjh lkeku mBk;k rks Hkh gekjs fouez er esa bls nq?kZVuk ugha ekuk tk ldrk] cfYd ftl izdkj dk o`rkar ifjoknh dh 'kkjhfjd fLFkfr@chekjh ds lEcU/k esa fMLpktZ lejh esa crk;k x;k gS] mlds vuqlkj izR;FkhZ&ifjoknh ekg vDVwcj] 2010 ls gh cka;s ikao ds fupys fgLls esa nnZ eglwl dj jgk FkkA ,slh fLFkfr edsa ;fn ;g eku Hkh fy;k tkos fd fnukad 02-01-2011 dks izR;FkhZ&ifjoknh }kjk Hkkjh lkeku mBk;k rks ;g ekuk tkosxk fd ,slk djds Lo;a izR;FkhZ&ifjoknh us LosPNkiwoZd tksf[ke mBk;h gSA gekjs fouez er esa ftl izdkj izR;FkhZ&ifjoknh viuk ekeyk ysdj vk;k gS og vid`R; fof/k ds loZekU; fl)kUr ** volenti non fit injuria vFkkZr voluntary assumption of risk dk ekeyk gS ,oa bls ftl izdkj fo}ku ftyk miHkksDrk eap }kjk nq?kZVuk gksuk n'kkZ;k x;k gS] og gekjs fouez er esa lgh ekus tkus ;ksX; ugha gSA 11 mijksDr foospukuqlkj ge ;g ikrs gSa fd fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ us xyr vk/kkjksa ij ekeys dks nq?kZVuk dk gksuk ekudj chek ikWfylh dh 'krZ la- 4-3 ls ijs gksuk fu/kkZfjr fd;k gSA vr% fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ dk fu.kZ; fo|eku Lo:i esa ;Fkkor~ dk;e j[ks tkus ;ksX; ugha gksus ls vikLr fd;s tkus ;ksX; ik;k tkrk gSA %% vkns'k %% vihykFkhZ&foi{khx.k dh vksj ls izLrqr vihy Lohdkj dh tkrh gSA fo}ku ftyk miHkksDrk eap ¼ vk;ksx ½ }kjk ifjokn la- 352@2012 xksiky d`".k ewanM+k cuke fn vksfj;aVy bU';ksjsal d-fy- esa ikfjr fu.kZ;kns'k fnukad 27-11-2013 vikLr fd;k tkrk gS rFkk izR;FkhZ&ifjoknh dk ifjokn fujLr fd;k tkrk gSA vihy dk [kpkZ i{kdkj Lo;a viuk&viuk ogu djsaxsA ¼ lat; Vkd ½ ¼ vrqy dqekj pVthZ ½ lnL; lnL; ¼ U;kf;d ½ 6