State Consumer Disputes Redressal Commission
Ajay Goyal vs Icici Lombard Gic on 11 April, 2022
e/;izns'k jkT; miHkksDrk fookn izfrrks"k.k vk;ksx] 76] vjsjk fgYl] Hkksiky-
izdj.k Øekad % 47@2014
1& vt; xks;y vkRet LoxhZ; Jh egs'k panz xks;y]
2& Jhefr vukfedk xks;y iRuh LoxhZ; Jh johUnz xks;y]
Øekad&1 o 2 fuoklh nky cktkj] eq[; xyh] y'dj]
Xokfy;j ¼e-iz-½
3& vpy xks;y vkRet LoxhZ; Jh johUnz xks;y] vo;Ld]
4& rstl xks;y vkRet LoxhZ; Jh johUnz xks;y] vo;Ld]
Øekad&3 o 4 }kjk vfHkHkkod Jhefr vukfedk xks;y] fuoklh nky cktkj] eq[; xyh] y'dj] Xokfy;j ¼e-iz-½ &&&&&&& ifjoknh fo:) 1& vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsl a dEiuh fyfeVsM+] jftLVMZ vkfQl vkbZlhvkbZlhvkbZ cSad VkWoj] ckUnzk&dqykZ dkEiysDl] eqEcbZ ¼egkjk"Vª½ dkiksZjVs vkfQl&vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsl a dEiuh fyfe-] vkbZlhkvkbZlhvkbZ yksEckMZ gkml] 414] ohj lkojdj ekxZ] flf) fouk;d eafnj ds ikl] izHkknsoh] eqEcbZ ¼egkjk"Vª½ }kjk eSustj 2& vkbZlhvkbZlhvkbZ cSad fyfeVsM+] 'kk[kk dk;kZy; flVh lsaVj] Xokfy;j ¼e-iz-½ }kjk eSustj &&&&&&& vukosndx.k %% le{k %% ekuuh; MkW- eksfudk efyd % ihBklhu lnL;
ekuuh; Jh ,l-,l- clay % lnL;
%% i{kdkjx.k }kjk %%
ifjoknhx.k }kjk Jherh dYiuk oekZ] vf/koDrk mifLFkrA vukosnd Øekad&1 }kjk Jh vkfnR; 'kekZ] vf/koDrk mifLFkrA vukosnd Øekad&2 }kjk Jh vfer frokjh] vf/koDrk mifLFkrA -2- vkns'k ¼fnuakd 11&04&2022 dks ikfjr½ ekuuh; lnL; Jh ,l-,l- caly vuqlkj %& 1& ifjoknhx.k }kjk ;g ifjokn vukosndx.kksa ds fo:) miHkksDrk laj{k.k vf/kfu;e] 1986 dh /kkjk 12 ds varxZr izLrqr dh xbZ gSA ifjoknh Øekad&1 vt; xks;y e`rd Jh johUnz xks;y dk HkkbZ gS] ifjoknh Øekad&2 Jhefr vukfedk xks;y e`rd Jh johUnz xks;y dh iRuh gS rFkk ifjoknh Øekad&3 ls 4 e`rd Jh johUnz xks;y ds iq=x.k gSaA 2& Jh johUnz xks;y us edku gsrq vukosnd Øekad&2 ls _.k fy;kA _.k dh jkf'k ds fy;s vukosnd Øekad&1 vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsal dEiuh fyfeVsM+ dh chek ikWfylh izkIr dh FkhA 3& ifjokn esa ;g crk;k fd johUnz xks;y dks chekjh gksus ls fnuakd 19&6&2012 dks funku gkVZ ,.M esVsjfuVh gkfLiVy] Xokfy;j esa HkrhZ fd;k x;k Fkk] ml le; HT, D.M.2, T, Hypertension Type II DM Thromobytopenia Hepatorenal dysperation, UTI septicarive, virax crk;k FkkA 4& fnuakd 18&6&2012 dks _.kxzfgrk dk CyM ,Dtkfefu'ksu gqvk FkkA _.kxzfgrk dks fnuakd 21&06&2012 dks lj xaxkjke vLirky esa f'k¶V fd;k x;kA 5& ifjoknhx.k us ifjokn esa crk;k fd _.kxzfgrk dhe`R;q fdMuh QSy gksus ls chek daiuh dks ikWfylh vuqlkj Dyse izLrqr gksus ij chek daiuh us Dyse fujLr fd;kA bldk dkj.k crk;k fd e`r eysfj;k dh chekjh ls xzflr FkkA eysfj;k dh chekjh ds ckn vU; tfVyrk,a gkus ls e`R;q gqbZA Øksfud fdMuh dh chekjh fl) ugha ekuhA -3- 6& ifjokn esa ;g crk;k fd _.kxzfgrk dh e`R;q Øksfud fdMuhdh chekjh ls gh vFkkZr~ fdMuh QSy gksus ls gh gqbZ gSA chek daiuh ds }kjk Dyse fujLr fd;s tkus ls ;g ifjokn izLrqr fd;kA 7& ifjokn izLrqr gksus ij vukosnd ds }kjk mRrj izLrqr dj crk;kfd e`rd dks tks chek ikWfylh tkjh dh Fkh ml ikWfylh vuqlkj Cancer, End Stage Renal Failure Multiple Sclerosis, stroke, Paralysis and Myocardial Infarction dh chekjh fMMsDV gksus ij] ?kVuk gksus ij gh Dyse ns; gSA bl izdj.k esa _.kxzfgrk dh e`R;q eysfj;k dh chekjh ls gqbZ gS vr% chek ikWfylh ds rgr mYysf[kr medical illness ugha gksus ls Dyse fujLr fd;k x;k gSA 8& okn fo"k; & D;k vukosnd }kjk _.kxzfgrk dh e`R;q gksus ij ifjoknhx.k dks chek ikWfylh vuqlkj Dyse dh ik=rk gS\ 9& mHk;i{k dks lqukA 10& ifjoknhx.k ds fo}ku vf/koDrk us rdZ esa crk;k fd e`rd dh e`R;q eysfj;k dh chekjh ls ugha gqbZ gSA chek ikWfylh esa fdMuh ds QSy gksus ij e`R;q gksus] fdMuh QSy gksus ij chek ikWfylh ds rgr Dyse ns; gSA eysfj;k dh chekjh ls e`R;q gksuk fl) ugha gSA e`R;q lejh esa Hkh _.kxzfgrk dh e`R;q fdMuh ds QSy gksus ls gh crk;k x;k gSA MkWDVj dh lejh fjiksVZ ls _.kxzfgrk dh chekjh Øksfudy fdMuh fMlht dh chekjh fl) gS vkSj Øksfudy fdMuh fMlht dh chekjh ls gh chek/kkjd dh e`R;q gqbZ gSA chek ikWfylh esa Multiple Sclerosis, stroke, paralysis, myocardial infarction lHkh chekfj;ka dOgj dh gqbZ gSA _.kxzfgrk dh chekjh bu lHkh chekfj;ksa dh Js.kh dh gh chekjh fMMsDV gqbZ gS vr% chek daiuh us eysfj;k ls e`R;q gksuk dgk gS] og lgh ugha gSA -4- 11& vukosnd ds fo}ku vf/koDRkk us rdZ esa crk;k fd _.kxzfgrk eysfj;k dh chekjh ls xzflr FkkA eysfj;k dh chekjh dh tfVyrk gksus ls fdMuh QSy gqbZ gSA ;g Øksfud fdMuh fMlht dh chekjh ugha gSA ;g Hkh crk;k fd e`rd eysfj;k ls xzflr Fkk vkSj e`R;q dk dj.k Septic Shock with multi organ failure and acute kidney injury gSA lj xaxkjke gkfLiVy dh MsFk lejh esa acute kidney injury alongwith Hypertension, Type II DM, Pyrexia with Thrombocytopenia with GTCS with ARDS with metabolic andrespiratory acidosis with shock? viral? dengue? complicated malaria dk Li"V mYys[k gSSA MsFk lejh esa ;g Hkh Li"V mYys[k gS fd Nil Urine Output Sepsis (Infection) dk dkj.k fu"df"kZr fd;k gS tks Chronic Kidney Disease dks ifjHkkf"kr ugha djrkA lj xaxkjke gkfLiVy ds mipkjdrkZ MkWDVj us iz'ukoyh eas ;g Lohdkj fd;k fd chfer Chronic Kidney Disease ls ihfMr ugha FkkA ;g stage renal failure dh ifjf/k esa ugha gksus ls Dyse ns; ugha gSA vius i{k esas U;k; n`"Vkar II ¼2019½ lhihts 81 ¼vlke½ ,pMh,Qlh bjxks tujy ba';ksjl sa dEiuh fyfeVsM+ fo:) dey fVEcjsoky rFkk I ¼2017½ lhihts 123 ¼,ulh½ deys'k xqIrk fo:) vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsal dEiuh fyfeVsM o vU; izLrqr fd;sA 12& rdksZa dk euu fd;kA vfHkys[k dk voyksdu fd;kA 13& vfHkys[k vuqlkj chek ikWfylh ¼izn'kZ lh&1½ esa fuEukuqlkj chekfj;ka dOgj dh gqbZ gS%& No. Coverage Section Insured Event Applicable Sum Insured I Major a) Diagnosis of the following illnesses, Medical namely: of covered illness: Cancer, End Illness & Stage Renal Failure Multiple Sclerosis Procedures
b) Undergoing of the following surgical Procedures: of Major Organ Transplant, Heart Valve Replacement or Coronary Rs.3427042/- Artery Bypass Graft.
-5-c) Occurrence of the following Medical Events: of covered events: Stroke, Paralysis and Myocardial Infarction II Personal a) Death of the Insured on account of an Accident Accident;
b) Permanent Total Disablement of the Insured on account of Accident;
III EMI 3EMI's
Loss of Loss of employment of the Insured
Job
14& chek ikWfylh vuqlkj Cancer, End Stage Renal Failure Multiple
Sclerosis, Heart Valve Replaement, Stroke, Paralysis and Myocardial Infarction dh chekjh gksuk ;k bl chekjh ls e`R;q gksus ij le ba';kssM :i;k 34]27]042@& ns; gksuk mYysf[kr gSA bl ikWfylh vuqlkj ,DlhMsaV esa e`R;q gksus ij ;k LFkk;h :i ls fu'kDr gksus ij Hkh :i;k 34]27]042@& dh chek jkf'k dh ik=rk crk;h gSA 15& chek ikWfylh vuqlkj chek ikWfylh esa mYysf[kr chekjh ikWfylh ds 90 fnu ckn chekjh dk irk yx tkus ij chekjh ikbZ tkus ij chek Dyse ns; gksxkA bl ikWfylh esa ,slh dksbZ 'krZ ugha gS fd ek= ,d gh chekjh ,d le; gksuk t:jh gSA ;fn ,d le; ,d ls vf/kd chekjh Hkh Kkr gksrh gS@ik;h tkrh gS rks Hkh chek Dyse ns; gksxkA chekjh dSlh gksxh] dSls ugha gksxh] blds ckcn Hkh dksbZ mYys[k ugha gSA blls Li"V gS fd fdlh Hkh dkj.k ls fdlh Hkh fLFkfr ls chfer O;fDr dks chekjh gksrh gS rks Hkh chek Dyse ns; ekuk tkosxkA 16& ifjoknh dk CyM dk VsLV fnukad 18&6&2012 dks gqvk Fkk ¼CyM fjiksVZ izn'kZ lh&4 ij gS½A blesa WBC 3300 crk;s x;s gS] lkekU;r% WBC 4500 ls 11000 gksuk pkfg;sA fnuakd 20 twu 2012 dks Hkh _.kxzfgrk ds VsLV gq;s Fks ftlesa SGOT 10&35 ds LFkku ij 238] SGPT 09&43 ds LFkku ij 118] Gamma G.T. 9- 52 ds LFkku ij 110 fjiksVZ esa n'kkZ;s gS fjiksVZ izn'kZ ¼lh&5½A chek ikWfylh esa -6- Multiple Sclerosis dks Hkh dOgj fd;k gSA Multiple Sclerosis dh chekjh izfrj{kk iz.kkyh detksj gksus ij Multiple Sclerosis dh fLFkfr gksrh gSA Multiple Sclerosis chekjh ds y{k.k esa ns[kus esa vlqfo/kk] lapkyu esa deh] vfLFkjrk] cksyus esa vlqfo/kk] flgju eglwl djuk] 'kkjhfjd vaxksa esa detksjh vkrh gSA 17& Øksfud fdMuh fMlht ¼End-stage, Kidney Renal failure½ vFkkZr~ fdMuh ,slh fLFkfr esa [kjkc gksuk tc mlds Bhd gksus dh laHkkouk cgqr gh de jgrh gSA 18& fdMuh dh chekjh ds y{k.k 'kjhj esa nnZ] lkal ysdus esa rdyhQ] ewag esa esVfyd dk Lokn] LØhu gsjhVs'ku] FkaM yxuk] pDduk vkuk] gkFk ikao esa lwtu ;wfj;u esa cnyko] gkbZ CyM izs'kj] otu vf/kd de gksuk] flj nnZ bR;kfn fdMuh dh chekjh gksus ls Hkh ;s y{k.k chekjh ds ekus tkrs gSA fdMuh [kjkc gksus ds dkj.k esa izk;% Mk;fcfVt] mPp jDrpki] nnZ fuokZj.k nokvksa dk lsou djuk] fny dk nkSjs iMuk] e`= dh leL;k,a bR;kfn ds dkj.k fdMuh [kjkc gksuk ekuk x;k gSA 19& ifjoknh dh tc fnuakd 18&6&2012 dks [kwu dh tkap djk;h xbZ mlesa WBC 3300 ik;k x;k FkkA WBC de gksus ls Li"V gS fd 'kjhj esa bUQsD'ku fnuakd 18&6&2012 dks FkkA 'kjhj esa bUQsD'ku fdlh fdMuh dh chekjh ls u gksdj fdlh vU; vax dh chekjh dh otg ls gqvk gks]a ,slk Hkh izek.k vfHkys[k ij ugha gSA 19& Gamma G.T. izk;% yhoj ds vykok xkWy CysM] Lizhu isufØ;k] fdMuh esa ekStwn jgus ij c<+s gq;s SGPT, Gamma G.T. vkrh gSA 20& SGOT fnuakd 20&6&2012 dh fjiksVZ esa dkQh c<k gqvk ik;k x;k] ;g dsoy yhoj dh chekjh ls gh c<+s gks]a 'kjhj ds vU; vax lgh gks] ,slk Hkh dksbZ izek.k vfHkys[k ij ugha gSA -7- 21& fnuakd 19&6&2012 dks tc funku vLirky esa ifjoknh x;k Fkk vkSj fnuakd 20&6&2012 dks fMLpktZ fd;k Fkk] ml fMLpktZ fVfdV esa SGPT, SGOT bR;kfn c<s gq;s crk;s x;s gSA STDM2 bR;kfn tks chekjh bl fMLpktZ fVfdV esa crk;h og fdMuh ls lacfa /kr ugha gksa o 'kjhj ds vU; vax dh chekjh ls gh gks]a ,slk Hkh mYys[k ugha gSA fnuakd 23&6&2012 dh e`rd dh lejh fjiksVZ esa lj xaxkjke gkfLiVy }kjk ,slk vksfifu;u ugha fn;k x;k fd e`rd eysfj;k dh chekjh ds dkj.k e`r gqvk gSA lj xaxkjke vLirky dh fjiksVZ esa eysfj;k dk VsLV fuxsfVo vk;k gSA blls Li"V gS fd e`rd eysfj;k ls ugha ejk gSA vukosnd vf/koDrk dk rdZ fd eysfj;k dh chekjh ds dkj.k _.kxzfgrk dh e`R;q gqbZ gS] ;g lgh ugha ekuk tk ldrkA bl fjiksVZ esa eysfj;k dk VsLV fuxsfVo gksuk crk;kA 22& lj xaxkjke gkfLiVy dh lejh fjiksVZ esa ;wfju dk vkmViwV fuy crk;kA blls Hkh ;gha fu"d"kZ fudyrk gS fd _.kxzfgrk Øksfud fdMuh dh chekjh ls xzflr FkkA lj xaxkjke vLirky esa ØsVsfuu c<kus ds fy;s Mk;fyfll Hkh fd;k gSA blls Hkh Li"V gS fd _.kxzfgrk dh fdMuh bruh {kfrxzLr gks xbZ Fkh fd mls Mk;fyfll dh t:jr iMhA eysfj;k ;k 'kjhj dh vU; vax dh chekjh fcxM tkus ls gh fdMuh dh chekjh gqbZ gksa ;k QSy gqbZ gks]a ,slk bl fjiksVZ esa mYys[k ugha gSA bl fjiksVZ vuqlkj _.kxzfgrk dks dkfMZ;d vjsLV Hkh gqvk gSA fny dh chekjh Hkh eysfj;k ;k yhoj dh chekjh ds dkj.k gqbZ gks]a ,slk Hkh mYys[k ugha gSA Strock ¼gkVZ vVSd½ dh ?kVuk Hkh chek ikWfylh esa dOgj dh gqbZ gSA lj xaxkjke vLirky dh fgLVªh 'khV esa IysVjsV de gksuk Hkh crk;k gSA ;g IysVjsV eysfj;k dh chekjh ds dkj.k de gq;s gks]a ,slk Hkh dksbZ mYys[k ugha gSA IysVjsV fdMuh dh chekjh esa Hkh de gksrs gSA 23& vfHkys[k vuqlkj _.kxzfgrk dh izfrjks/kd {kerk] detksj gksuk fl) gSA Multiple Sclerosis, Myocardial Infarction ;g Hkh ikWfylh esa dOgj fd;k gqvk gSA vfHkys[k vuqlkj _.kxzfgrk dks fØfVdy fdMuh fMlht] gkVZ vVSd] izfrjks/kd {kerk de gksus ls Multiple Sclerosis, Myocardial Infarction dh chekjh o bu chekjh -8- ls e`R;q gksuk fl) gSA chek ikWfylh esa chfer chekfj;ksa dh otg ls gh _.kxzfgrk dh e`R;q vfHkys[k vuqlkj gksuk fl) gSA vr% ;g lc End-stage, Kidney failure Multiple Sclerosis, Myocardial Infarction dh chekjh _.kxzfgrk dks chek ikWfylh ysus ds 90 fnu ds ckn fMMsDV gqbZ gS] bu chekjh dh otg ls chek/kkjd dh e`R;q gqbZA ;g chekjh chek ikWfylh esa dOgj dh gqbZ gSA 24& vukosnd us tks U;k; n`"Vkar izLqr fd;s mlesa U;k; n`"Vkar II ¼2019½ lhihts 81 ¼vlke½ ,pMh,Qlh bjxks tujy ba';ksjsal dEiuh fyfeVsM+ fo:) dey fVEcjsoky esa e`rd yhoj dh chekjh ls xzflr FkkA gastroenterities and sepsis dh chekjh gksus ls ey dkyk gks x;k FkkA _.kxzfgrk dk mDr chekjh gks tkus ;k chekjh c< tkus ls fdMuh dh rjQ ls [kwu vk;k rFkk dkys dkys nLr gksuk rFkk gastroenterities and sepsis dh chekjh ls gh dkys&dkys ey gksus ls e`R;q gqbZ gSA bls jkT; vk;ksx us Øksfud fdMuh fMlht ugha ekuk gSA U;k; n`"Vkar I ¼2017½ lhihts 123 ¼,ulh½ deys'k xqIrk fo:) vkbZlhvkbZlhvkbZ yksEckMZ tujy ba';ksjsal dEiuh fyfeVsM o vU; esa e`rd Masxw chekjh ls xzflr FkkA Msaxw dh chekjh ds dkj.k mlds IysVjsV de gq;s vkSj mlds dkj.k fdMuh bR;kfn izHkkfor gqbZA blls Øksfud fdMuh fMlht ugha ekukA 25& iz'uk/khu izdj.k esa e`rd dks eysfj;k dh chekjh gksuk fl) ugha gS] eysfj;k fcxMuk Hkh fl) ugha gS] fdMuh ds vykok fdlh nwljs vax dh chekjh ls fdMuh QSy gksuk Hkh fl) ugha gSA fdMuh esa gq;s bUQsD'ku ds dkj.k gh gkbZ cq[kkj dh chekjh gqbZ] MCY;wchlh de gksus] IysVjsV de gq;s] ;gha fu"d"kZ vfHkys[k ls ekuk tk;sxkA vr% vukosnd }kjk tks U;k; n`"Vkar izLrqr fd;s mlds rF; fHkUu gksus ls iz'uk/khu izdj.k esa mldk ykHk izkIr ugha gSA 26& mijksDr foospuk ds izdk'k eas vfHkys[k ls ;g ekuus dk i;kZIr vk/kkj gS fd e`rd _.kxzfgrk dh e`R;q eysfj;k dh chekjh ls ugha gqbZA fdMuh ds vykok dksbZ vU; chekjh ds dkj.k vax {kfrxzLr gq;s gks]a ,slk Hkh fl) ugha gSA vr% fdMuh -9- dh otg ls gh e`R;q gqbZ] ekuk tkosxkA vfHkys[k vuqlkj _.kxzfgrk dh fdMuh dh chekjh Øksfud fMlht ekuus dk i;kZIr vk/kkj gSA 27& vr% mijksDr foospuk ds izdk'k esa ifjokn Lohdkj dj vkns'k fn;k tkrk gS fd chek ikWfylh vuqlkj vukosnd Øekad&1 le ba';ksM jkf'k :i;k 34]27]042@& _.kxzfgrk dh e`R;q fnuakd ls 6 izfr'kr okf"kZd C;kt lfgr ifjoknhx.k dks Hkqxrku djsaA izFker% bl jkf'k esa ls _.kiznkrk vukosnd Øekad&2 dks Hkqxrku dh tkosA _.kiznkrk dks jkf'k iznku djus ds i'pkr~ tks jkf'k cprh gS mls ifjoknhx.k dks nh tk,A lkFk gh ekufld ,oa 'kkjhfjd d"V ,oa ihMk ds fy;s {kfriwfrZ jkf'k :i;k 5]000@& ,oa okn O;; :i;k 2]000@& dk Hkqxrku Hkh vukosnd Øekad&1 ifjoknhx.k dks djsaA ¼MkW- eksfudk efyd½ ¼,l-,l- clay½ ihBklhu lnL; lnL;
nqQkjs