DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: BHADRAK
Dated the 29th day of February, 2020
C.D Case No. 57 of 2017
Present 1. Shri Raghunath Kar, President
2. Shri Basanta Kumar Mallick, Member
3. Afsara Begum, Member
Sri Gadadhar Panda
S/o Sanatan Panda
Vill: Hasinpur,
Po: Ganijanga,
Ps: Bhadark (R), Near Neheru UP School,
Dist: Bhadrak, Odisha, 756114
……………………. Complainant
(Versus)
1. The Branch Manager,
Bajaj Allianz General Insurance Company Ltd.
2nd Floor, OT Road, Near ITR, Balasore,
Odisha, Pin- 756001
2. The General Manager, Bajaj Allianz General Insurance Company Ltd.
Bajaj Finserv 1st Floor, Survey 208/1-B,
Behind Weikfield IT Park, Viman Nagar, Pune- 411014
……………………..Opp. Parties
Counsel For Complainant: Sri C. R. Sahoo, Adv & Others
Counsel For the O.Ps: Sri A. Chand, Adv & Others
Date of hearing: 13.08.2019
Date of order: 29.02.2020
BASANTA KUMAR MALLICK, MEMBER
This dispute arises out of the complaint filed by the complainant alleging deficiency of service and unfair trade practice against the O.Ps.
The facts of the this case as described in the complaint are to the effect that the complainant is the father of Sri Sanjay Kumar Panda whose life has been insured with the O.Ps under Group Personal Accident Insurance Scheme vide policy No. OG-16-9999-9960-00000003 and child certificate No. OG-17-1000-6401-00658739 for a sum assured of Rs 3,00,000/-. The said policy was commenced from 28.12.2016 and was veiled up to 27.12.2017 midnight. During currency of the policy, the policy holder met an accident with a bull on dt. 09.02.2017 at about 9:30 PM, while returning from Bhadrak to his house by his own motorcycle with another person seating behind him where he sustained severe bodily injury and also lost his sense on the spot. Some passersby witnessed the accident and immediately rescued him and took him to D.H.H Bhadrak for treatment. The treating doctors of D.H.H Bhadrak when found the condition of the patient is going more critical the attendants of the patient including the complainant were advised to shift the patient to Cuttack for batter treatment. The patient was taken to Ashwini Hospital Cuttack where he was admitted on 02.02.2017 necessary treatment was provided for a prolonged period of nearly 25 days. In course of treatment the complainant, being the father of the insured, spent a sum of Rs 4,17,686/- excluding the cost incurred for Ambulance and also for the attendants. As the life of the accident victim is insured with the O.Ps, the complainant intimated the insurer through a claim proposal requesting them to directly make payment to the Hospital Authorities so as to enable him to carry on the treatment till full recovery which was not responded by the O.Ps. The complainant was facing acute financial crisis for treatment of his son and therefore he was compelled to move the office of OP No. 1 and requested for disbursement of claim amount towards medical expenses incurred during the period of treatment but the said O.Ps did not pay any heed to the request as well as claim of the complainant. Inspite of repeated requests and persuasions the O.Ps did not pay the claim of medical expenses incurred for treatment as a result of which the treatment of accident victim could not be carried on for his recovery. Finding no other way the complainant is constrained to file this case in the Forum for deficiency in service and unfair trade practice.
O.Ps objected the allegations of the complaint and contested the case. The written version filed by the O.Ps raised the question of cause of action, no deficiency service and all the allegations against the O.Ps are baseless, misconceived and unsustainable in law. The O.Ps denied all the allegations only other than the fact of the accident of insured person. The complainant’s son is an insured person under G.P.A policy on payment of the required premium of Rs 500/- on 31.12.2016 and accordingly policy certificate was issued covering the period from 28.12.2016 to 27.12.2017 midnight. In explaining the fact, the complainant has not opted for temporary total disability cover while taking up the policy. Further the O.Ps submitted that the alleged injured Sanjay Kumar Panda has submitted claim document to avail temporary total disability benefit for road traffic accident with severe head injury and Subdural Hemorrhage- Post Craniotomy Status which is not at all covered under the scope of policy. Hence the said claim was repudiated as the scope of the policy is only for wider coverage such as Death, permanent total disability and permanent partial disability. As per the document submitted by the complainant confirm that the accident victim sustained total temporary disability which is not covered under G.P.A policy. In the above premises the claim preferred by the complainant on behalf of his son lacks merit and therefore liable to be dismissed and the repudiation of claim is absolutely just and proper.
Admittedly the son of the complainant is an insured under G.P.A policy commencing from 28.12.2017 and the claim has been preferred for temporary total disability by the complainant, being the nomine of the policy, for and on behalf of his son.
Gone through the facts of the compliant and written version submitted by the O.Ps, perused the materials on record, heard both the parties of this case and observed as detailed below.
During hearing the complainant raised that due to a Road Traffic Accident the insured sustained severe head injury and was under the treatment for a period of more than 25 days in Ashwini Hospital, CDA Cuttack and incurred huge financial expenses for the purpose. When the complainant faced financial crunch, submitted a claim proposal to the O.Ps with the bills issued by the said Hospital requesting the insurer to transfer the claim amount to the account of the Hospital where the insured is under treatment. The said claim was stacked against temporary total disability which was drastically turned down and repudiated by the O.Ps stating that the claim for temporary total disability is not covered under the scope of policy being totally false. Such act of repudiation of the O.Ps inflicted serious mental agony to the complainant as he was in dire need of money to continue the treatment of his injured son. On the other hand O.Ps have denied the claim of the complainant in stating that the sub clause 1, 2 & 3 of clause “A” discloses that the claim can be settled for accidental death, permanent total disability and permanent partial disability but the complainant has claimed compensation for medical expenses against temporary total disability. In reply to the objection raised by the O.Ps complainant stated that the O.Ps have covered only sub clause 1, 2 & 3 of clause “A” issued by insurance company leaving aside the relevant provision which is distinctly mentioned in sub clause 3 (a, b) and sub clause 4 of clause A where it is mentioned as:-
a.“If the Permanent Partial Disability is not listed in the table, then we will pay a proportion of the sum assured shown under the schedule headings wider and comprehensive. You agree that the amount payable by us will be decided by our medical advisors according to the degree to which the normal functional physical capacity of the insured person(s) has been impaired permanently”.
b. “If the insured person(s) was already suffering from Permanent Partial Disability before the date the insured person(s) met with accidental bodily injury, then the amount we pay will be reduced by that extent. You agree that the reduction will be decided by our medical advisors according to the degree of Permanent Partial Disability from which the insured person(s) was already suffering”.
4. Temporary Total Disability (Available if the schedule shows opted for it) if the insured person(s) suffers accidental bodily injury during the policy period which completely prevents the insured person(s) from engaging in his/her occupation, then we will make a weekly payment of the lower 1% of the sum assured shown under the schedule heading comprehensive (of the insured person(s)) and Rs 5,000/-.
a. We will make the first payment when you satisfy us that accidental bodily injury has completely prevented the insured person(s) from engaging in his/her occupation.
b. We will stop making payments when we are satisfied that the insured person(s) can engage in his/her occupation again, or when we have made payments for a maximum period of 100 weeks from the date the insured person(s) met with the accidental bodily injury, whichever is earlier.
5 (c) Hospital Confinement Allowance (Available if the schedule shows you opted for it) if we accepted a claim under 1) to 4), then we will pay Rs 1,000/- for each complete calendar day that the insured person(s) had to be hospitalized for medical reasons because of the accidental bodily injury he/she met with. However the amount we pay will be limited to Rs 30,000/- during the policy period even if there is more than one claim for the insured person(s).
d. Medical Expenses Reimbursement (Available if the schedule shows you opted for it) if we have accepted a claim under 1) to 4), then we will reimburse the costs of necessary medical treatment the insured person(s) had to obtain from a doctor because of the accidental bodily injury the insured person(s) met with. However our payment will be limited to 40% of the value of the claim we accepted under 1) to 4) or Rs 5,00,000/- whichever is lower.
In view of the above provisions of clause A sub clause 4 & 5 (c, d) this Forum observed that there is provision for payment of compensation to reimburse the medical expenses incurred during treatment period. But on the other hand the O.Ps objected in stating that the insured person has not opted for temporary total disability without adducing any evidence to their contentions. The O.Ps were also instructed, in course of hearing, to furnish the original proposal application submitted by the insured person for opening of the policy under G.P.A scheme. Non production of original proposal form by the O.Ps leads to believe that the O.Ps have taken false plea to avoid settlement of claim.
After perusal of policy condition as mentioned above there is no way for the O.Ps other than to settle the claim within the scope of sub clause 4 of clause A. Besides, the O.Ps have caused gross negligence in not deputing their medical advisors to observe the condition of the insured person and progress made in course treatment. In addition to that the burden of proof rests on the O.Ps to prove that the insured person has not opted for temporary total disability which is not proved by the O.Ps. Therefore it is believed that the O.Ps are hiding the actual facts not to settle the claim for their own interest. Further the complainant has explained that the insured person has not yet recovered from the bodily injury as he is not capable of moving and talking clearly and also the insured person has not resumed his occupation till yet as a result of which his family members are passing through financial crunch.
As analyzed above and from the facts and circumstances the Forum holds that the O.Ps have caused deficiency of service and adopted unfair trade practice for settlement of the claim. In this situation the O.Ps are liable to pay less 1% of sum insured to partially augment the total expenditure incurred for treatment purpose as laid down at sub clause 4 of clause A of policy condition. Therefore it is ordered;
ORDER
The complaint be and the same is partly allowed against OP No. 1 & 2. OP No. 1 & 2 are directed to settle the claim as per sub clause 4 of clause A along with compensation of Rs 5,000/- and Rs 2,000/- as cost of litigation. This order must be complied by OP No. 1 & 2 within a period of 30 days from the date of receipt of this order.
This order is pronounced in the open Forum on this day of 29th February, 2020 under my hand and seal of the Forum.
