(Per : Justice Irshad Hussain, President)

This is insurer’s appeal against the order dated 28.08.2008 passed by the District Forum, Haridwar, whereby consumer complaint No. 120 of 2006 was allowed against the insurer with costs of Rs. 2,000/- and the insurer was further directed to pay sum of Rs. 1,31,282/- with interest @ 9% p.a. and Rs. 15,000/- as damages for bed rest within the stipulated period by way of reimbursement of the expenses incurred in the treatment of the complainant, holding mediclaim policy for himself and his wife. In allowing the consumer complaint, the District Forum accepted the complainant’s claim that he suffered fracture of neck of femur (left) in a road accident on 23.08.2004 at Muzaffarnagar and had thereafter undergone total hip replacement at Vardhman Trauma & Infertility Pvt. Ltd., Muzaffarnagar, where he remained admitted from 23.08.2004 to 06.09.2004 and incurred expenses towards his treatment provided by Dr. Mukesh Jain, M.S. (Trauma & Joint Replacement Surgeon) of the said trauma centre. The District Forum rejected the defence stand taken by the insurer and third party administrator – opposite party No. 2, that the claim preferred under the terms and conditions of the mediclaim insurance policy was not tenable in view of the complainant’s failure to furnish the correct details such as date and time of the accident, how and where the accident occurred, medico-legal papers of the accident including injury report etc. and the necessary details and record of the alleged surgery for total hip replacement such as pre-surgery x-ray, the date on which the surgery was done and other related information and, as such, the claim was not payable and there was no deficiency in service on their part.

2. Submissions of the learned counsel for the parties give rise to the following core question for determination of this appeal on merit:

“Whether the claim of the complainant that he was seriously injured in an accident on 23.08.2004 at Muzaffarnagar, was not sustainable and the District Forum fell in error in recording a finding in favour of the complainant on the basis of evidence of Dr. Mukesh Jain and treatment record of the complainant maintained by trauma centre of the said doctor?”

3. As will appeal from the consumer complaint, it has merely been alleged that the complainant met with an accident at Muzaffarnagar on 23.08.2004 and suffered serious injuries and had his femur bone fractured. Complainant is a resident of town of Haridwar and it has never been brought on record as to why and how the complainant happened to be in Muzaffarnagar on the alleged date of accident. Learned counsel for the insurance company persuasively argued that correspondence made by opposite party No. 2, third party administrator, which was assigned the job of settlement of the claim made it clear that the complainant was required to provide detail as to how and where the accident occurred and to submit medico-legal papers of the accident including injury report etc. Exchange of letters was not disputed by the complainant and despite this, no detail of the accident was given in the consumer complaint. Even if the complainant did not find it necessary to lodge an FIR regarding the accident in which he suffered serious injuries, a preliminary medico-legal report of injuries was required to be prepared, so that the claim of the complainant about the allegation of accident could have been corroborated. The learned counsel for the insurance company, thus, urged that in the absence of corroborative evidence of the accident, the claim preferred was, in the first instance, not tenable. On the other hand, learned counsel for the complainant – respondent No. 1 drew attention to the statement of Dr. Mukesh Jain recorded before the District Forum and submitted that the complainant after the accident having been brought to the trauma centre of the doctor, the decision for getting the medico-legal report prepared was to be taken by the