Research › Search › Judgment

Uttarakhand High Court · body

2013 DIGILAW 126 (UTT)

NATIONAL INSURANCE COMPANY LIMITED v. SH. VISHNU BHAGWAN AGGARWAL

2013-03-13

B.C.Kandpal, C.C.Pant, Kusumlata Sharma

body2013
ORDER (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. 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 or able to go to the hospital, he took physiotherapy at his home from Ashna Physiotherapy & Rehabilitation Centre, Kashipur for the period from 17.10.2005 to 30.01.2006. Thus, the treatment taken by the complainant falls under Clause 2.4 of the policy and the same should not have been repudiated by the insurance company. 8. Learned counsel for the insurance company cited a decision of Maharashtra State Consumer Disputes Redressal Commission, Mumbai in the case of Ramesh Inderchand Kothari and another Vs. New India Assurance Co. Ltd.; 2011 (1) CPR 320. In the said case, the complainant underwent root canal treatment. 8. Learned counsel for the insurance company cited a decision of Maharashtra State Consumer Disputes Redressal Commission, Mumbai in the case of Ramesh Inderchand Kothari and another Vs. New India Assurance Co. Ltd.; 2011 (1) CPR 320. In the said case, the complainant underwent root canal treatment. It was held that whenever dental surgery is required because of disease or injury as explained with hospitalization, then case can be considered for mediclaim, otherwise it can not be considered. It was further held that as there was no hospitalization for correction of injury and, as such, the repudiation of the claim was justified. In the said case, the appellant – complainant was not admitted in the hospital for root canal treatment. The State Commission held that the complainant was not entitled to mediclaim because he was not hospitalized for dental surgery, as required under the provisions of the policy. In other words, for mediclaim, surgery and hospitalization both are necessary. But the instant case falls under Clause 2.4(ii) of the policy. As stated above, there was no facility of physiotherapy in Sai Hospital,Moradabad and when the condition of the complainant deteriorated and he was not in a position to go to the hospital, he took the treatment of physiotherapy at his home from Ashna Physiotherapy & Rehabilitation Centre, Kashipur for the period from 17.10.2005 to 30.01.2006. Thus, the said case law can not be applied to the facts and circumstances of the present case and the insurance company has clearly made deficiency in service by repudiating the legitimate claim of the complainant. No dispute has been raised by the insurance company with regard to the quantum of compensation awarded by the District Forum. Even otherwise, we find that the quantum of compensation awarded by the District Forum is perfectly justified and the same is not on the higher side. The interest @9% p.a. and litigation expenses of Rs. 1,500/- awarded by the District Forum, are also fully justified. Thus, appeal lacks merit and is liable to be dismissed. 9. For the reasons aforesaid, appeal is dismissed. No order as to costs.