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PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Mr. Paramjeet Singh Dhaliwal, President and Mr. Harcharan Singh Guram, Member
LIC OF INDIA - Appellant
Versus
NARINDERPAL SINGH SIDHU - Respondent
First Appeal No. 733 of 2016
Decided on : 02-05-2017
Sh. S.K. Mahajan, Advocate, for the Appellants; Sh. I.S. Dhaliwal, Advocate, for the Respondent
The main legal point established in the judgment is the interpretation of the insurance policy's coverage for major surgery and the entitlement of the complainant to reimbursement of medical expenses.
Headnote:
Consumer Protection Act - Insurance Policy - 1986 - Section 12 - 1, 2 - The court allowed the complaint filed by the respondent under Section 12 of the Consumer Protection Act, 1986, directing the opposite parties to pay reimbursement of medical expenses, compensation for harassment and mental agony, and litigation expenses. The court found that the surgery undergone by the complainant fell under the category of major surgery and was covered under the policy. The court modified the impugned order, holding the opposite parties liable to pay 60% of the principal sum assured to the complainant.
Fact of the Case:
The complainant purchased an insurance policy with the assurance of coverage for any injury resulting from accidents. After sustaining severe injuries and incurring medical expenses, the claim was rejected by the opposite parties, leading to mental tension and harassment for the complainant.
Finding of the Court:
The court found that the surgery undergone by the complainant fell under the category of major surgery and was covered under the policy. The court modified the impugned order, holding the opposite parties liable to pay 60% of the principal sum assured to the complainant.
Issues: The issues revolved around the rejection of the complainant's claim by the opposite parties, the coverage of the surgery under the insurance policy, and the entitlement of the complainant to reimbursement of medical expenses and compensation for mental agony.
Ratio Decidendi: The court held that the surgery undergone by the complainant fell under the category of major surgery and was covered under the policy. The court modified the impugned order, holding the opposite parties liable to pay 60% of the principal sum assured to the complainant.
Final Decision: The appeal was partly allowed, and the impugned order was modified to hold the opposite parties liable to pay 60% of the principal sum assured to the complainant. The remaining part of the impugned order, regarding payment of interest, compensation, and litigation expenses, was upheld.
JUDGMENT
Paramjeet Singh Dhaliwal, President.—The instant appeal has been filed by the appellants/opposite parties against the order dated 12.07.2016 passed by District Consumer Disputes Redressal Forum, Moga (in short, "the District Forum"), whereby the complaint filed by the respondent/complainant, under Section 12 of the Consumer Protection Act, 1986, was allowed and the opposite parties were directed to pay Rs. 3,95,999/- to the complainant as reimbursement of his medical expenses, along with interest at the rate of 9% per annum from 09.03.2015 i.e. the date of repudiation of the claim till final realization, less Rs. 53,860/- (already paid to the complainant). They were further directed to pay Rs. 15,000/-, as compensation on account of harassment and mental agony suffered by the complainant, besides Rs. 5,000/-, as litigation expenses.
2. It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Forum.
3. Brief facts, as averred in the complaint, are that on the assurance of agent of the opposite party No.2 and goodwill of the company, the complainant purchased insurance policy bearing No.132913918 dated 26.08.2009. At the time of issuing the policy, officials of the opposite parties assured that the said policy was for 26 years valid from 26.08.2009 to 26.08.2035 and annual instalments of Rs. 19,500/- were payable. It was also assured that if any injury occurred from any type of mis-happening and accident, then this policy would cover the same and the complainant would get 100% assured claim from the opposite parties. On 01.09.2014 at around 4.00 P.M., the complainant, while standing near a crane, was hit by a pillar carried by the said crane in the street, where house of complainant was situated; as result of which he developed severe pain in bilateral lower limbs and was diagnosed as a case of 'closed fracture left tibia and open fracture lateral malleolus right side with peroneous longus and bravis tendon injury'. He was admitted at Dayanand Medical College & Hospital, Ludhiana, (in short, "DMC"), where he was operated on 02.09.2014. He spent a total amount of 3,95,999/- on his treatment. On 18.09.2014, after discharge from the hospital, the complainant submitted all the relevant documents, relating to his operation, to opposite party No.2. However, the claim was rejected by the opposite parties, vide letter dated 09.03.2015, on the ground that surgery performed on the complainant is not listed in the allowed surgery (1-49). However, in the column No.9 'Surgical Benefit Annexure' it is clear that accidents were covered under the policy, in question. He visited and requested opposite party no.2 to settle the claim, but it refused to pay the same. He served a legal notice upon the opposite parties on 3.12.2015, but to no effect. The complainant suffered mental tension, agony and harassment. Accordingly, the complainant approached the District Forum, seeking the following directions to the opposite parties:
i) to pay Rs. 3,95,999/- (Rs. 1,86,904/- on account of hospitalization charges and Rs. 2,09,095/- on account of medical bills and expenses), along with interest;
ii) to pay Rs. 20,000/- on account of deficiency in service;
iii) to pay Rs. 20,000/- on account of mental tension, agony and physical harassment suffered by the complainant; and
iv) to pay Rs. 22,000/- as litigation expenses.
4. Upon notice, opposite parties appeared before the District Forum and filed written reply, raising preliminary objections that there is no deficiency in service on the part of opposite parties. The complainant has concealed the material facts. The present complaint is not maintainable and is liable to be dismissed, as the same has been knowingly filed on false and frivolous facts. The policy opted by the complainant is purely 'Health Insurance Plan', governed by terms and conditions as printed on the policy bond and handbook. The benefits are payable, as per the terms and c
