DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 391

 Instituted on:   18.09.2018

                                                                         Decided on  :   23.02.2023      

1. Rajeev Kumar Kansal aged about 42 years son of Sh. Sham Lal, resident of Jain Colony, Bhawanigarh, Tehsil Bhawanigarh, District Sangrur.                                                                                     

    ….Complainant. 

                                          Versus

1. United India Insurance Company Limited, Divisional Office: Railway Station Road, Sangrur, through its Divisional Manger.
2. Punjab Health System Corporation, Civil Secretariat Chandigarh, through its Managing Director.
3. State of Punjab, through Deputy Commissioner, Sangrur.

                                                                ...Opposite parties. 

QUORUM                                       

JOT NARANJAN SINGH GILL : PRESIDENT

SARITA GARG                          : MEMEBR

KANWALJEET SINGH              : MEMBER

For the complainant  : Shri Sanjeev Goyal & Udit Goyal,  

  Adv.              

For the Op.1             : Shri G.S. Sibia, Adv.

For the Op.2 & 3       : Shri Vinay Jindal, Adv.

ORDER BY

JOT NARANJAN SINGH GILL, PRESIDENT

1. Complainant has alleged in the complaint that complainant was the member of Bhagat Puran Singh Sehat Bima Yojna, which is being run by the Ops number 2 & 3. The Ops number 2& 3 issued a card bearing number 6305-3181-9901-1585-5 to the complainant. Under the scheme beneficiary and his family can get the medical reimbursement for an amount of Rs. 50,000/- and also entitled to get Rs. 5,00,000/- on account of accidental death and permanent disability of the card holder and his family members. No separate terms and conditions of the policy were supplied to the complainant. On 15.02.2017 complainant's car met with an accident with truck bearing registration number PB-13AB-4399 at about 11 PM when they reached near Fun Square Mall, Village Akoi Sahib. Thereafter, complainant and other were immediately taken to Civil Hospital, Sangrur. Where, the doctors referred him to the DMC Hospital, Ludhiana. FIR number 15 dated 02.03.2017, U/S. 279/337/338/427 IPC was registered at Police Station, Sangrur. Complainant remained admitted in the hospital from 16.02.2017 to 14.03.2017. Complainant spent a sum of Rs. 5,00,000/- on his treatment including transportation and follow up treatment and Rs. 5,00,000/- is more required for further treatment. The complainant sustained head injuries and due to that the complainant totally lost the vision of his right eye and left side body of the complainant is not working properly and thus, the complainant became permanent 100% disable due to said accident. After recovering from the injury, the complainant lodged the claim with the Ops on their customer care number 104. The surveyor of the Op number 1 visited the house of the complainant and demanded Several documents from the complainant and the complainant supplied all the documents to the surveyor for releasing the claim. But till date, Ops failed to release the claim amount to the complainant and lastly, prayed that the Ops may kindly be directed to make the payment of Rs. 5,00,000/- as compensation to the complainant on account of permanent disability along with interest @18% p.a. from the date of accident till the realization and to pay Rs. 1,00,000/- on account of mental tension, agony and physical harassment and 22,000/-as litigation expenses.
2. Upon notice, Ops appeared and filed written reply separately. Op number 1 filed written reply by taking preliminary objections that complainant is not maintainable qua the Op.1. Complainant is not a consumer of the Ops. Complainant has no locus standi and cause of action to file the present complaint against the Op.1. On merits, it is admitted that Complainant was the member of Bhagat Puran Singh Sehat Bima Yojan, However all the terms and conditions of the policy were duly supplied to the complainant. The Op.1 appointed investigator and the investigator conducted thorough investigation and submitted his report dated 22.05.2017. The Op.1 on the basis of report of the surveyor, repudiated the claim of the complainant vide letter dated 05.11.2018 on the ground that the disability of the complainant is partial disability and not covered as per the terms and conditions of the policy. However, the disability of the complainant is having 65% as per disability certificate number 337 dated 18.04.2017 which is partial disability and the remaining allegation are denied by the Op.1 and lastly prayed that the complaint may kindly be dismissed with costs qua the Op.1.
3. Written reply filed by Op number 2 & 3 by taking legal objections which are similar to preliminary objections of Op number 1. So, there is no need to retreat the same to avoid repetition. On reply on merits, it is admitted that Op number 2 & 3 issued a health card bearing number  6305-3181-9901-1585-5 in the name of complainant. Complainant was insured vide policy number 11210048161800000106 issued by the Op number 1, which was valid from 01.11.2016 to 31.10.2017. Op number 2 & 3 wrote a letter dated 11.07.2017 to the Op number 1 to extend the policy upto 31.03.2018 and made the necessary payment as insurance premium to Op number 1 and Op number 1 must have extended the period of the Policy. As per this policy, on the death in personal accident of any insured was covered for Rs. 5,00,000/- to the head of the family and if the insured is suffering from 100% disability due to accident then the insured is liable to get the claim. The Complainant has produced the disability certificate in which the disability is shown as 65% which is partial disability and is not covered under the terms and conditions of the scheme. Hence, the claim of the complainant is repudiated. The remaining allegation are denied by Op. 2 & 3 and prayed that the complaint may kindly be dismissed with costs.
4. Complainant has submitted his documents in evidence Ex. C-1 affidavit alongwith documents Ex.C-2 to Ex.C-8. Similarly, Ops submitted in evidence Ex. Op-1/1 affidavit of Sh. Harmeet Singh Chahal, Senior Divisional Manager of Op number 1 alongwith documents Ex.Op.1/2 to Op.1/4 and Op number 2 & 3 also submitted self attested affidavit in evidence Ex.Op 2 & 3/1 alongwith documents Ex. Op 2 & 3/2 to Ex.Op 2 & 3/5.
5. We had heard the learned counsel of both the parties and gone through the record file carefully with the valuable assistance of the learned counsel for the parties. During arguments the contentions of the learned counsel of both the parties are similar to their respective pleadings. So, there is no need to reiterate the same to avoid repetition. Now come to major controversy whether the complainant is liable for relief as claimed by him in his prayer?
6. No doubt, it is admitted fact that the complainant availed the health policy/scheme from the Ops. Undisputedly, policy in question was issued by Ops. Ops admitted this factum as per Ex.Op.2 & 3/2 that they firstly issued policy to the complainant which was valid from 01.11.2016 to 31.10.2017, the same was extended upto 31.03.2018 as per Ex. Op2/2 & Op3/3. The Car of the complainant was met with an accident on 15.02.2017 with the truck. Ex. C-4 is the photocopy of the FIR. It transpires from the document Ex.C-3 which is a discharge slip that the date of admission was 16.02.2017 and the date of discharge was 14.03.2017. We observed from the perusal of record Ex.C-2, Ex.Op.2 & 3/3 that the complainant having the valid health insurance policy at the time of occurrence of accident i.e. 15.02.2017. According to the document Ex.C-3 complainant was diagnosis as under:-

Alleged case of road side accident with comminuted depressed fracture right frontal bone with multiple fractured skull with fracture right zygoma and maxilla with multiple RIB fractures right side with fracture right clavicle with soft tissue injury with traumatic optic neuritis right eye with left hemiplegia with? Dissection right ICA.

7. It is writ large on the file reply on merits of Op number 1 pleaded at para number 3(e) that the disability of complainant is having 65% as per disability certificate number 337 dated 18.04.2017, which is partial disability. Similarly, reply on merits of Op number  2 & 3 pleaded  at para number 3(c) that complainant himself has produced disability certificate in which 65% disability has been shown.
8. The major issue for consideration is "Whether the complainant has suffered the permanent disability sustained due to an accident occurred on  15.02.2017. It is mentioned on the disability certificate number 337 dated 18.04.2017 issued by civil surgeon, Sangrur, which is Ex.C-7 that the complainant is physically disabled/Visual disabled and has 65% disability with regard to whole body. Complainant's condition is not likely to be improved and Reassessment is not recommended. As per Ex.Op.1/2, Op number 1 repudiated the claim of the complainant on this ground that there is 65% disability as per the disability certificate number 337 dated 18.04.2017, which is partial disability and not covered as per terms and conditions of the Bhagat Puran Singh, Sehat Bima Yozna Scheme. This Commission also observed that as per Ex.Op1/4 State Government of Punjab, Department of Health and Family Welfare issued a scheme namely "Bhagat Puran Singh Sehat Bima Yozna". This health and accidental insurance scheme was availed to blue card holders, farmers, traders and construction workers. Under this scheme  State Government has to provide cashless health insurance cover of Rs. 50,000/- p.a. per family on floater basis and personal accidental death and disability insurance cover of Rs. 5,00,000/- to the head of the family. As per the detail of the terms and conditions of the scheme, it is clear cut mentioned that an accidental death and 100% permanent total disability a sum insured Rs. 5,00,000/- shall be granted to the main member. In this complaint the complainant is claiming permanent total disability. To trace out the varsity of truth, we have examined documents Ex.C-6 and Ex.C-8. Complainant had filed claim petition before the motor accident claims tribunal, Sangrur. As per Ex.C-6 complainant produced on record the statement of Dr. Nisha Goyal, M.S, Eye, Rajindra Hospital, Patiala. Dr. Nisha Goyal stated in her statement that patient physically and visually disabled to the extent of 65% to the whole body. The patient was having visually disability in his right eye. In her cross examination she stated that on the basis of WHO formula, the board assessed the disability and came to the conclusion that the disability of patient was 65% with regard to whole body. This Commission also examined in detail the document Ex.C-8 which is an award passed by Motor Accident Claims Tribunal, Sangrur. In para number 25 at page 14, it is specifically mentioned that "In view of the cogent medical evidence, this Tribunal has no hesitation to hold that claimant suffered the permanent disability due to the accident".
9. This Commission observed that the Motor Accident Claims Tribunal, Sangrur rightly held that the patient/complainant was suffered injuries and permanent disability after examined the detailed evidence on oath of the witnesses and documents on record. "A man can lie, but document can't." In the light of above said documents this Commission considered that the complainant suffered the permanent disability. The complainant in para No.3(a) of the complaint specifically mentioned that Except the smart card, no separate terms & conditions of the policy were supplied to the complainant. Despite specific averment, no evidence was produced by the opposite party to prove the fact of supply of terms & conditions. The Hon'ble Supreme Court of India in Civil Appeal Number 1544-1545 of 2022 decided on 21.02.2022 case titled as " Anju Kalsi Vs HDFC Ergo General Insurance Company Ltd and Anr", held that in case of repudiation of insurance claim  unless bank and insurance company were able to establish on cogent basis that special conditions of policy issued by insurance company to bank were drawn to notice of account holder for whose benefit insurance cover extended, claim cannot be rejected.                                                                                                                                                                                                                                                                                                                                                                                                   
10. Resultantly, keeping in view the facts and circumstances of the present complaint in hand and in the light of decision of the Hon'ble Supreme Court of India we partly allow the complaint of the complainant and direct the Op number 1 to make the payment of Rs. 5,00,000/- to the complainant on account of permanent disability. Further the Op number 1 is directed to pay consolidated sum of Rs. 10,000/- as compensation and litigation expenses.
11. This order be complied by Op number 1 within a period of 60 days from the date of receipt of order.
12. The complaint could not be decided within the statutory time period due to heavy pendency of cases.
13. Copy of this order be supplied to the parties free of cost as per rules. File be consigned to the records after its due compliance.   

                                Announced.

                                23 February, 2023.

( Kanwaljeet Singh)    (Sarita Garg)  (Jot Naranjan Singh Gill)

    Member                        Member                  President