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2013 Supreme(UK) 108
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UTTARAKHAND, DEHRADUN
Hon'ble Mr. Justice B.C. Kandpal, Hon’ble Mr. C.C. Pant and Hon’ble Mrs. Kusumlata Sharma, Members
NATIONAL INSURANCE COMPANY LIMITED – Appellant/Opposite Party
Versus
SH. VISHNU BHAGWAN AGGARWAL – Respondent/Complainant
First Appeal No. 238/2007
Decided on : 13.03.2013
For the Appellant : Mr. Rajiv Kakkar, Learned Counsel
For the Respondent: Mr. Arun Himani, Learned Counsel
Headnote:Consumer Protection Act, 1986, Sec. 15 — Insurer’s appeal under — Against the order to pay sum of Rs. 17,061/- to the respondent - complainant @ 9% p.a. and Rs. 1,500/- towards litigation expenses — The facts of the case are that Complainant purchased a mediclaim policy from O.P. for insured sum of Rs. 1,00,000/- — On 25.09.2005, complainant suffered a disc slip for which doctor advised physiotherapy and prescribed medicines — But, this facility was not available at the referred hospital — Therefore, complainant underwent physiotherapy at his home and spent a sum of Rs. 21,832/- in his treatment — Thereby, claim which was repudiated by the O.P. — Held — Cl. 2.4 of the said policy provides that, “medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing home but actually taken whilst confined at home in India if the patient can not be removed to hospital/nursing home for lack of accommodation therein — In the instant cases there was no facility of physiotherapy in the said hospital, therefore, the complainant was not admitted in the said hospital and he took physiotherapy at his home — Thus, the treatment taken by the complainant falls u/Cl. 2.4 of the said policy — Further that the insurance company had clearly made deficiency in service by repudiating the legitimate claim of the complainant — Compensation awarded by the District Forum perfectly justified. (Paras 1, 2, 6 to 8)
miHkksDrk laj{k.k vf/kfu;e] 1986 & chekdrkZ dh vihy] izfroknh@f’kdk;rdrkZ dks #- 17]061@& dk Hkqxrku @ 9% p.a. vkSj #- 1500@& eqdnes ds [kpZ djus ds vkns’k ds fo#) & f’kdk;rdrkZ us ,d Medi Claim policy O.P. ls [kjhnh #- 1]00]000@& dh chfer jkf’k ds fy, & 25-9-2005 dks f’kdk;rdrkZ disc slip ls ihfM+r gks x;k] ftlds fy, fpfdRld us mls nok,¡ nh vkSj physiotherapy dh lykg nh & ijUrq ;g lqfo/kk izLrkfor vLirky esa miyC/k ugha & blfy, f’kdk;rdrkZ us ?kj ij gh physiotherapy djkbZ vkSj vius bykt ij #- 21]832@& [kpZ fd, & blfy, nkok] ftls O.P. us fujkÑr fd;k & /kkfjr ikfylh ds Cl. 2.4 ds vuqlkj fpfdRlk mipkj dh vof/k tks 3 fnu ls vf/kd gks mu chekfj;ksa ;k gkfu ds fy, ftuesa lkekU; rkSj ij ns[kHkky vkSj bykt dh vko’;drk gksrh gS vLirky ;k ufl±x gkse esa ijUrq og Hkkjr esa gh jg dj ?kj ij gh mipkj djk ldrk gS D;ksafd ejht dks ogk¡ jgus dh lqfoèkk u gksus ds dkj.k vLirky ;k ufl±x gkse ugha ys tk;k tk ldrk & izLrqr okn esa dfFkr vLirky esa physiotherapy dh lqfo/kk ugha Fkh & blfy, f’kdk;rdrkZ dks izLrkfor vLirky esa HkrhZ ugha djk;k x;k vkSj mlus bykt ?kj ij gh djk;k & bl izdkj f’kdk;rdrkZ }kjk bykt U/Cl. 2.4] dfFkr ikfylh & vkSj ;g fd chek dEiuh dh Li”Vr% lsok esa deh] f’kdk;rdrkZ ds tk;t nkos dks fujkÑr djuk & ftyk Qksje }kjk iznku izfrdj U;kf;dA ¼izLrj 1] 2] 6 ls 8½
(Per: Justice B.C. Kandpal, President):
This is insurer’s appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 28.06.2007 passed by the District Forum, Nainital in consumer complaint No. 127 of 2006. By the order impugned, the District Forum has partly allowed the consumer complaint and directed the appellant – opposite party to pay sum of Rs. 17,061/- to the respondent – complainant together with interest @9% p.a. from the date of filing of the consumer complaint till payment and Rs. 1,500/- towards litigation expenses.
2. Briefly stated, the facts of the case as mentioned in the consumer complaint, are that the complainant had purchased a mediclaim policy from the opposite party – National Insurance Company Limited (appellant before this Commission) for insured sum of Rs. 1,00,000/-. The policy was valid for the period from 03.02.2005 to 02.02.2006. On 25.09.2005, the complainant suffered a disc slip and consulted Dr. Ashok Kumar of S.S. Nursing Home, Moradabad on 27.09.2005, who prescribed x-ray and MRI and referred him to Sai Hospital, Moradabad. On 27.09.2005, the doctor of Sai Hospital, Moradabad prescribed some medicines to the complainant and advised rest for 15 days. On 15.10.2005, the complainant again went to the doctor and at that time, the doctor advised physiotherapy and rest for three months and also prescribed medicines. The complainant underwent physiotherapy at his home through Ashna Physiotherapy & Rehabilitation Centre, Kashipur for the period from 17.10.2005 to 30.01.2006 and spent a sum of Rs. 21,832/- in his treatment. The complainant lodged the claim with the insurance company, but the same was repudiated by the insurance company on 14.06.2006. Alleging deficiency in service on the part of the insurance company, the complainant filed a consumer complaint before the District Forum, Nainital.
3. The insurance company filed written statement before the District Forum and pleaded that the complainant was suffering from backache, for which he had taken OPD treatment. It was also pleaded that the claim submitted by the complainant was referred to Paramount Health Services (Pvt.) Ltd., New Delhi, who repudiated the claim vide their letter dated 17.05.2006 and there has not been any deficiency in service on their part.
4. The District Forum, on an appreciation of the material on record, partly allowed the consumer complaint vide impugned order dated 28.06.2007 in the above terms. Aggrieved by the said order, the insurance company has filed this appeal.
5. We have heard the learned counsel for the parties and have also perused the record.
6. It is an admitted fact that the complainant did not remain admit in any hospital/nursing home for his treatment and he underwent physiotherapy at his home through Ashna Physiotherapy & Rehabilitation Centre, Kashipur for the period from 17.10.2005 to 30.01.2006. The claim of the complainant was repudiated under Clause 2.3 of the policy, which states that, “expenses on hospitalisation for minimum period of 24 hours are admissible …………” However, Clause 2.4 of the policy provides that, “medical treatment for a period exceeding three days for such illness / disease / injury which in the normal course would require care and treatment at a hospital / nursing home but actually taken whilst confined at home in India under any of the following circumstances namely-
(i) The condition of the patient is such that he / she can not be removed to the hospital / nursing home or
(ii) The patient can not be removed to hospital / nursing home for lack of accommodation therein.
7. The complainant, first of all, consulted Dr. Ashok Kumar of S.S. Nursing Home, Moradabad on 27.09.2005, who referred him to Sai Hospital, Moradabad, where he was advised physiotherapy and rest for three months. As there was no facility of physiotherapy in the said hospital, therefore, the complainant was not admitted in the said hospital. When the complainant was not in a position
