As per Hon’ble President Mr. Atul Alshi.
1. The complainant filed complaint case against arbitrary rejection of his medical expenses claim of Rs.2,12,765/- for the temporary disablement due to accident and thereby claiming interest and cost of litigation.
2. The complainant No. 1 is employee of the complainant No.2, M/s. GTN Industries Limited Nagpur and complainant No. 2 insured the employees of industry under the Group Personal Accident policy and secure employees from accidental injury like Accidental Death, Loss of two Limbs, Loss of one limb, Permanent Total Disability and Medical Expenses (Arising out of Accident) against the premium paid for sum insured Rs.7,35,56,086/- for the period from 01/04/2018 to 31/03/2019 for the policy bearing No. 181100/48/2019/59.
3. The complainant No.1 met with an accident on 29/09/2018 when he was going towards store department and he suddenly fall down and therefore caused injury to right leg. The complainant No. 2 referred him RHN Hospital Nagpur where he was diagnosis as cellulitis and injured leg was infected with lot of puss and the doctor had given treatment for the injury caused due to accident in the premises. The complainant No. 2 lodged claim with OP but the OP repudiated insurance claim for the reason injury and accident does not matched. The rejection of claim holding that the treatment was given to control sugar and hypertension does amounts to deficiency in service. Therefore, the complainant filed present complaint against repudiation of legitimate claim of Rs.2,12,765/- with interest, compensation for mental and physical agony and litigation expenses.
4. The OP filed reply and denied the allegations and submitted that the insurance claim is payable for the accidental injury resulted in partial permanent disability to the organs described in list mentioned in policy conditions. The OP further submitted that medical expenses for the treatment of accidental injury is payable to the extent of 25% of claim. Therefore, the rejection of insurance claim for the injury caused is not accidental injury does not amounts deficiency in service.
5. Both the parties argued the case on merit at length. After hearing of case the following points arose for consideration.
POINTS FINDINGS
- Whether the complainant is consumer? Yes.
- Whether there is deficiency in service on the part of OP? Yes.
- 3) What order? As per final order.
REASONING
6. Point No. 1 to 3 – It is admitted fact that the complainant No. 2 has industry and employee of industry insured under the Group Personal Accident policy bearing No. 181100/48/2019/59 for the period 01/04/2018 to 31/03/2019. The complainant insurance claim came to the rejection for the reason that the injury is not accidental injury and treatment was given to the complainant to control diabetes and hypertension. The complainant No. 2 has issued certificate certifying that the complainant No. 1 met with an accident on 29/09/2018 and was on leave from 30/09/2018 to 15/04/2019 at page no 18 as per list of documents filed by counsel for the complainant alongwith complaint. As per repudiation letter issued by OP on 02/07/2019 the cause of hospitalization is diabetes and hypertension which is not cover under the policy. As per certificate issued by Dr. Dilip Rathi, doctor of Rathi Nursing Home dtd.23/07/2019, certifying that the complainant No. 1 was admitted in the hospital from 05/10/2018 to 18/10/2018 with history of traumatic injury to left leg followed by pain and swelling with fever. On examination the patient was diagnosed as Cellulitis left leg with infection with sepsis hence surgical management debridement + VAC application done and rest of medical management done for infection and sepsis alongwith blood sugar management done for control of infection. The complainant No. 1 has caused injury his left leg sudden and unfortunate act by external and visible and violent, therefore it is an accident. The injury has been caused due to suddenly fall down is accidental physical harm excludes illness or disease which is evident as per certificate issued by RNH Hospital dtd. 23/07/2019 and discharged summary file at page No,. 73 as per list of documents dtd.12/08/2021. The injury is traumatic injury which is certainly caused due to accident and which developed Cellulitis, infection, septic and the treatment was given to control injury by antibiotics medicine and also the treatment to control diabetes and hypertension to early recover from injury and disablement. Therefore, the complainant No. 1 is liable for compensate the temporary total disablement as per clause (f) of terms and conditions of policy for reimbursement of medical expenses. As per medical expenses subject clause of policy that in case of total amount of medical expenses claimed under policy the complainant No. 1 entitled to receive only the amount of Rs. 25% out of total medical expenses claimed of Rs.2,12,765/- amounted to Rs.53,191/- alongwith Rs.10,000/- towards compensation for the metal torture and Rs,10,000/- for the cost of litigation.
ORDER
- The complaint is partly allowed.
2. The OP is hereby directed to pay 25% of claimed amount that is Rs.53,191/- to the complainant towards total medical expenses claim of Rs.2,12,765/-.
3. The OP is further directed to pay compensation of Rs.10,000/- for mental agony and Rs.10,000/- towards litigation cost to the complainant.
4. Copy of the order shall be supplied to all the parties free of cost.
