State Consumer Disputes Redressal CommissionRajani Kant vs The New India Insurance Co. on 17 February, 2009Appeal
No.1252/04
 

 Banwari
Lal Mishra V. United India Insurance Co.Ltd.
 

 


 

Before:
 

 


 

	Mr.Justice
Sunil Kumar Garg-President
 

	Mrs.Vimla
Sethiya-MemberShri
H.S.Khandelwal,counsel for the appellant
 

Shri
Balendra Suman,counsel for the respondent 

 

 


 

 


 

Date of
judgement:					17.2.2009
 

	
 

	
 

	This
appeal has been filed by the  complainant appellant against the order
dated 24.5.04 passed by the District Forum-I,Jaipur in complaint
no.500/01,by which the complaint of the complainant appellant was
dismissed.It
arises in the following circumstances:That
the complainant appellant had filed a complaint against the
respondent insurance company before the District Forum-I,Jaipur on
10.5.01 interalia stating that he and hife both had taken a medicalim
policy from the respondent insurance company in the joint name of
appellant and his wife for a sum of Rs.50,000/- each for the period
1.7.99 to 30.6.2000. It was further stated in the complaint that on
17.5.2000 at about 10 P.M in the night the complainant appellant felt
pain in chest and further felt difficulty in breathing and he
immediately consulted local doctor who gave primary treatment and
thereafter he consulted the doctors of Tongia Heart and General
Hospital,Jaipur,where he was got admitted on 18.5.2000 and was
discharged on 19.5.2000 and while the complainant appellant was
admitted in that hospital,some tests were got2conducted
by the doctors of that hospital and the complainant appellant had
spent a sum of Rs.5673.55 and medicines were also prescribed for
further treatment and he had taken the treatment upto 4.6.2000 as
prescribed by the doctors of that hospital and thereafter the claim
was preferred, but that claim was repudiated by the respondent
insurance company through letter dated 29.12.2000 in the following
manner:"Re:- Mediclaim No.140403/48/7/144/2K
Admission 		18.5.2k DOD19.5.2k.With reference to above claim under mediclaim
		policy,after observation of submitted claim document,it is
	concluded that the admission in hospital was only for 	more
evaluation of health check up. The same is exclused 	under 4.10 of
exclusion of mediclaim policy.As such your claim is not admissible under policy
and not 	payable. The claim file is closed treating No Claim.Thanking you."Thereafter the present complaint was filed.A reply was filed by the respondent insurance company
before the District Forum-I,Jaipur on 27.8.01 and in the reply same
pleas were taken which were taken in the repudiation letter dated
29.12.2000 and apart from that it was stated that as per terms and
conditions of clause 4.10 the claim was not payable at all, as
necessary tests were got conducted by the complainant appellant not
because of the fact that he was ill but for the purpose of health
check up and that was not covered under the terms of the policy and
thus the claim was rightly repudiated and it was prayed that the
complaint be dismissed.3The District Forum after hearing both the
parties,through the impugned order dated  24.5.04 had dismissed the
complaint interalia holding that the claim of the complainant
appellant was hit by clause 4.10 after placing reliance on the report
of the investigator Shri Arun Kumar  dated 14.11.2000 in which he has
held that the admission of the complainant appellant in the Tongia
Hospital was more fore evaluation of health check up only.Aggrieved from that order,this appeal has been filed by
the complainant appellant.In this appeal,the main contention of the learned
counsel for the complainant  appellant is that the District Forum had
erred in placing reliance on the report of the investigator dated
14.11.2000 as since the complainant appellant was admitted in the
hospital and some necessary tests were conducted not only this,and he
was advised of  CAD and further treatment was given,therefore,the
present case was not a case of  simple admission for test but prior
to that the complainant appellant was having a Unstable Angina pain
in heart,for that he was admitted in the hospital and when he was
admitted in the hospital if he had incurred some amount,they are to
be reimbursed and the repudiation of the claim of the complainant
appellant by the respondent insurance company and dismissal of the
complaint by the District Forum could not be justified.On the other hand,the learned counsel for the
respondent insurance company has supported the impugned order.We have heard the learned counsel for the parties and
perused the record.4In this case,so far as the fact that the complainant
appellant after feeling pain in chest was shown to the doctors of
Tongia Hospital,Jaipur on 18.5.2000 and where he was asked to be
admitted in general ward through ex.1 is not in dispute. It is also
not in dispute that from the discharge summary of the Tongia
hospital,Jaipur it is also clear that the complainant appellant was
admitted in Tongia Hospital,Jaipur on 18.5.2000 and discharged on
19.5.2000 and dignosis which was made was unstable angina and for
that some tests were got conducted by the doctor and ultimately he
was advised CAD as early as possible. On file there is a certificate
of Dr.Arun Agarwal,heart specialist dated 11.10.2000,who after seeing
the official record had come to the conclusion that the complainant
appellant was suffering from Coronary Artyery Disease(CAD) and he has
further opined that the same was not a pre-existing disease.When this being the position,the findings recorded by
the District Forum by which the claim was rejected could not be
sustained at all, as the complainant appellant was rightly admitted
in the hospital for getting the check up as he was having an angina
pain and if some expenses had been made and for that bill was given
by the doctors of the hospital for giving the treatment to the
complainant,it could not be said that they were not for any treatment
as the disease of CAD was found and when there was a disease the
expenses incurred on that disease are to be reimbursed and present
case  cannot be covered under the clause 4.10 of the policy.For reasons as stated above,this Commission comes to
the conclusion that the findings recorded by the District Forum by
which the complaint of the complainant appellant was dismissed are
liable to be quashed and set aside as they suffer from basic5infirmity,illegality and perversity and further the
repudiation of the claim of the complainant appellant by the
respondent insurance company could not be justified as the same was
repudiated in an arbitrary manner without any justification and thus
this appeal deserves to be allowed.The result is that this appeal filed by the complainant
appellant is allowed,impugned order dated 24.5.04 passed by the
District Forum-I,Jaipur is quashed and set aside and the complaint
filed by the complainant appellant is allowed in the manner that the
respondent insurance company would pay the amount of Rs.5673.55 with
interest @ 9% p.a from the date of filing of the complaint till the
payment is made alongwith cost of Rs.5000/- to the complainant
appellant.Member						President Appeal No.245/06
 


 


 


Smt.Chavali						Appellant
 


				V.1.Development Officer,Panchayat Samiti,Sriganganagar2.Addl.Director,State Insurance & GPF Deptt.,Jaipur.3.Dy.Director,State Insurance & GPF
Deptt.,Sriganganagar 

 


 								Respondents
 

 


 

Before:Mr.Justice
Sunil Kumar Garg-President
 

	Mrs.Vimla
Sethiya-Member
 

 


 

Shri
Ajay Tantia,counsel for the appellant
 

None
for res.no.1
 

Shri
M.L.Vyas,,counsel for the res.2&3 

 

 


 

 


 

Date of
judgement:					17.2.2009
 

	
 

	
 

	This
appeal has been filed by the  complainant appellant against the order
dated 3.1.06 passed by the District Forum,Sriganganagar in complaint
no.458/03,by which the complaint of the complainant appellant was
dismissed.It
arises in the following circumstances:That the complainant appellant had filed a complaint
against
 


the respondent before the District Forum,Sriganganagar 
on 25.8.03 interalia stating that her son,Subhash Jakhar,now deceased
was an employee in the department of res.no.1 and was a member of the
Group  Individual Accident Insurance Scheme and as per2terms and conditions of  the  Scheme,if an employee dies
in an accident during service,his dependents would be entitled  to a
sum of Rs.2 lacs. It was further stated in the complaint that on4.2.98,the deceased became ill and he had taken some medicines
prescribed by Dr.Man Mohan Mittal,who was a medical officer in the
government hospital,Sriganganagar. It was further stated in the
complaint that some poisonous medicines were also kept where the
medicines purchased by the deceased were kept and due to mistake he
had taken some wrong medicines(poisonous),thereafter he had died and
a mug FIR no.5/98 was got registered with the police
station,Jawaharnagaru/s 174IPC and police after investigation had
found the case as a suicidal death. Thereafter a claim was preferred
but the claim was repudiated by res.no.2 & 3 State Insurance &
GPF Department through letter dated  13.6.03 interalia stating
that the claim was not payable as the same was not covered under the
policy. Thereafter the present complaint was filed.A reply was filed by res.no.2 & 3 on  10.10.03 and
in the reply same pleas were taken which were taken in the
repudiation letter dated 13.6.03  and it was further stated that if a
person commits suicide and as per clause 1 of condition no.8 of the
Scheme,in case of suicide claim was not payable and since in the
present case deceased had committed suicide,therefore,claim under the
Group Insurance Scheme was not payable and the same was rightly
repudiated through letter dated  13.6.03 and it was prayed that the
complaint be dismissed.The District Forum after hearing both the
parties,through the impugned order dated 3.1.06 had dismissed the
complaint interalia holding that since the deceased had committed
suicide,therefore,claim was not payable.3Aggrieved from that order,this appeal has been filed by
the complainant appellant.In this appeal,the main contention of the learned
counsel for the complainant appellant is that the present case was
not a suicidal death as the deceased had taken the poisonous drug by
mistake and thus the findings recorded by the District Forum are
erroneous one and be quashed and set aside and appeal be allowed.On the other hand,the learned counsel for the
respondents no.2 & 3 has supported the impugned order.We have heard the learned counsel for the parties and
perused the record.In this case,so far as the fact that after taking the
medicine(poisonous),the deceased had died and a mug FIR was
registered with the police station and the police had come to the
conclusion that the deceased had committed suicide, is not in
dispute. The postmortem report as well as the chemical examination
report further confirms the fact that the drug which was taken by the
deceased had given a positive test for the presence  of 
organophosphorous insecticide.Thus, when the police had come to the conclusion that
the present case of the deceased was a suicidal death,therefore,we
see no reason to differ with the findings recorded by the police.
Apart from that when a person commits suicide as per  clause 1(8) of
the Group Insurance Scheme,the claim is not payable and if on that
ground the claim was repudiated by res.no.2 & 3 State Insurance
and GPF department and if on the same ground the complaint
was dismissed by the District Forum, the District Forum had not4committed any illegality in passing the order as the
findings recorded by the District Forum are based on correct
appreciation of evidence of record and they are liable to be
confirmed one and appeal  filed by the complainant appellant deserves
to be dismissed.For reasons,this
appeal filed by the complainant appellant is dismissed accordingly.Member						President AppealNo.1247/04Rajani Kant V.
The New India Insurance Co.Ltd.
 


       

 

Before:
 

 


 

	Mr.Justice
Sunil Kumar Garg-President
 

	Mrs.Vimla
Sethiya-Member
 

 


 

Shri
Asgar Khan,counsel for the appellant
 

ShriVirendra Agarwal,counsel  for the  respondent 

 

 


 

 


 

 


 

Date of
judgement:					17.2.2009
 

	
 

	
 


	This appeal has been filed by the  complainant
appellant against the order dated 7.5.04 passed by the District
Forum,Rajsamand  in complaint no.64/03,by which the complaint of the
complainant appellant was dismissed on the ground that the District
Forum,Rajsamond had no territorial jurisdiction to try the complaint
as the cause of action had arisen at Udaipur.It may be stated here that the complainant appellant
had filed a complaint against the respondent insurance company before
the District Forum,Rajsamand on  26.8.03 and the address of
respondent insurance company was given Udaipur,interalia stating that
his jeep bearing no.RJ.30.T.0253 was got insured with the respondent
insurance company for the period 16.2.02 to 15.3.03  and due to
accident,the vehicle was damaged and for that  a claim was preferred
at Rajsamand though the accident had neither taken place in the
territorial jurisdiction of Rajsamand nor the jeep in question was
got insured at Rajsamond.2The District Forum after hearing both the
parties,through the impugned order dated 7.5.04 had dismissed the
complaint on the ground that it has no territorial jurisdiction.Aggrieved from that order,this appeal has been filed by
the complainant appellant.The learned counsel for the complainant appellant has
frankly submitted that permission be given to the complainant
appellant to file a fresh complaint before the District
Forum,Udaipur.When this being the position,this appeal is to be
dismissed with permission to file a fresh complaint
before the District Forum,Udaipur and the time spent before the
District Forum as well as before this Commission will be exemptedu/s
14of the Limitation Act.For reasons as stated above,this appeal filed by the
complainant appellant is dismissed and permission is accorded to the
complainant appellant to file a fresh complaint within two months
from today before the District Forum,Udaipur and the time spent by
the complainant appellant before the District Forum,Rajsamand as well
as before this Commission  could be sought to be  exemptedu/s 14of
the Limitation Act in the light of the judgement of the Hon'ble
Supreme Court in the case ofLaxmi Engineering Works V. PSG
Industrial Institutereported in 1995(III)SCC 583.Member						President