UNITED INDIA INSURANCE CO LTD Vs. SURINDER NATH

JUDGEMENT

(1.) Brief facts of this case are that the respondent who is the complainant purchased a medi-claim insurance policy from the petitioner OP. On 10.10.1997 at about 9.00 a.m., the complainant slipped in the bathroom and got injury in the region of left hip. He was unable to move and hence first aid was given to him for a period of 2 to 3 days. Then, X-ray was got done by him through a portable machine through Tarlok Hospital, Ferozepur in which the fracture of neck of left femur was found for which operation was considered necessary. Surgical operation was got done at Nayyar Hospital, Amritsar. He remained in the hospital for about a week and an artificial hip, namely, Polar Hip was implanted. The complainant paid medical treatment expenses amounting to Rs.10,000/- and Rs.29,000/- for the artificial hip implanted by the doctor. The implant was stated to have been supplied by Perfect Surgical, New Delhi. According to the complainant, M/s Perfect Surgical, New Delhi was supplying medical equipment to Baghi Hospital Ferozepur where the son of the complainant was working as doctor and since the complainant had once objected to the Proprietor of the said firm for not supplying the good material to the Hospital and a complaint in this regard was made to the Chief Medical Officer of Baghi Hospital, Ferozepur. Due to this reason, the Proprietor of Perfect Surgical got annoyed with the son of the complainant and hence during the investigation carried out by the OP Insurance Co. in regard to the supply of the artificial hip, the firm did not cooperate which led to the repudiation of the claim of the complainant by OP Insurance Co. The complainant, therefore, filed a complaint before the District Forum seeking direction to the OP to pay medical claim bill of Rs.80,000/- and damages to the tune of Rs.3 lakh totaling Rs.3,80,000/- along with interest @ 18% p.a. On appraisal of the issues and evidence adduced by the parties, the District Forum partly allowed the complaint and directed the OP to pay a total sum of Rs.50,300/- to the complainant which included cost of the artificial hip and other expenses on the treatment. Aggrieved by the order of the District Forum, an appeal was filed by the OP Insurance Co. before the State Commission which dismissed the appeal vide its impugned order. The revision petition has been filed against this order of the State Commission.

(2.) We have heard counsel for the petitioner but none has appeared on behalf of the respondent in spite of service of the notice. It is submitted that the claim of the complainant was got investigated through a surveyor to verify the genuineness of the bills submitted by him through his son who is a doctor. It is alleged that the bill of Perfect Surgical was found to be bogus and it was confirmed by the Proprietor of Perfect Surgical Co. that he never supplied Bipolar Hip and received no amount in this regard. It is also alleged that the bills in respect of Tarlok Hospital and Baghi Hospital were arranged by the son of the complainant because of his influence and hence the claim was rejected on genuine grounds by the petitioner Co. The contract of insurance being based on the principle of utmost good faith hence the claim put up by the complainant could not be accepted because of its bogus nature. The petitioner Co. has placed on record copies of the proforma invoice for Rs.28,300/- purported to have been issued by Zodiac Surgicals, New Delhi and also the chit dated 14.02.1998 said to have been issued by Perfect Surgical Co. for Rs.29,500/-. We have seen the two documents placed on record in respect of the alleged claim of the complainant in respect of the purchase of the Bipolar Hip. While the claim in respect of this has been upheld by both the District Forum and the State Commission while accepting the total claim of Rs.50,300/-, there is no doubt that the proforma invoice for Rs.28,300/- on the basis of which the claim in respect of the purchase of Bipolar Hip has been accepted by the fora below is not a proper bill for the sale of the item nor can it be regarded as a cash memo. It is simply a proforma invoice indicating the price of the item along with certain terms and conditions subject to which the same could be supplied. It does not indicate that the item was actually supplied by the firm or paid for by the complainant. In view of this and the report of the surveyor, we find substance in the submissions made by the petitioner. To this extent, fora below erred in accepting the claim of the petitioner and hence the same will have to be excluded from the total claim of Rs.50,300/- allowed by the fora below. Consequently, in modification of the impugned order, the petitioner Company is directed to pay a sum of only Rs.22,000/- to the complainant. The revision petition stands partly allowed and disposed of in terms of this direction.