THE KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACADU, THIRUVANANTHAPURAM

APPEAL No. 56/2022

JUDGEMENT  DATED : 15.04.2024

(Against the order in C.C.22/2020 of DCDRC, Kannur)

PRESENT:              

APPELLANT:

(by Adv. A.K. Pradeep Kumar)

Vs.

RESPONDENTS:

(by Adv. Saji Issac K.J.)

JUDGEMENT

SRI. K.R. RADHAKRISHNAN  : MEMBER

          This is an appeal filed by the complainant against the order in C.C.No.22/2020 on the file of the District Consumer Disputes Redressal Commission, Kannur (the District Commission for short). As per the order dated 29.11.2021 the District Commission partly allowed the complaint and directed the opposite parties to pay the balance claim amount of Rs.45,000/-(Rupees Forty Five Thousand only) and a compensation of Rs.10,000/-(Rupees Ten Thousand only) for the mental agony within one month from the date of the order, failing which the amount of Rs.45,000/-(Rupees Forty Five Thousand only) shall carry interest @9% per annum from the date of the order till realisation. As the complaint was allowed only in part the complainant has filed this appeal for the balance amount of claim as per his complaint.

          2.       The complaint is briefly as follows:

          The complaint pertains to a dispute regarding the claim payable under the personal accident policy issued to the appellant complainant. The complainant has taken a personal accident policy No.331720178685 5200000 from the opposite parties for the period from 23.05.2017 to 22.05.2019 for a sum insured of Rs.15,00,000/- (Rupees Fifteen Lakhs only).  As per the policy, the complainant is entitled for weekly benefit @Rs.3750/- (Rupees Three Thousand Seven Hundred and Fifty only) per week for the period of temporary total disablement (TTD for short) for a maximum of period of 52 weeks.  Besides he is eligible for hospital cash @Rs.1000/-(Rupees One Thousand only) per day for the period of inpatient treatment.  He is also eligible for Rs 50,000/-(Rupees Fifty Thousand only) in case of ‘broken bones’ (BB).   The complainant met with an accident on 05.03.2018 and suffered multiple fractures on his right toe finger. He was admitted in the AKG Memorial Hospital and discharged on the next day.  Initially the complainant was advised to take rest for three weeks which was revised on various subsequent reviews, extending the period of rest to 36 weeks. He was given fitness certificate from 03.12.2018.  According to the complainant he was eligible for Rs.1,35,000/-(Rupees One Lakh Thirty Five Thousand only) towards weekly benefit for TTD for 36 weeks (Rs.3,750 x 36 weeks) and Rs.50,000/-(Rupees Fifty Thousand only) for ‘broken bones’ and Rs.1,000/-(Rupees One Thousand only) as hospital cash for 1 day.  However, he was given weekly benefit of Rs.90,000/- (Rupees Ninety Thousand only) for 24 weeks (Rs.3,750 x 24 weeks) plus Rs.8,000/-(Rupees Eight Thousand only) for ‘broken bones’.  Aggrieved by the short payment of the compensation amount, the complainant filed the complaint claiming Rs.87,000/-(Rupees Eighty Seven Thousand only) being the balance amount of Rs.45,000/-(Rupees Forty Five Thousand only) towards weekly benefit for the balance 12 weeks (i.e. Rs.3,750x12 weeks) plus Rs.42,000/-(Rupees Forty Two Thousand only) in respect of broken bones (Rs.50,000-Rs.8,000), with interest @9% and compensation of Rs 50,000/-(Rupees Fifty Thousand only) for mental agony and harassment.

          3.       Notice was issued to the opposite parties and they filed their version.   According to the opposite parties the complainant is entitled for weekly benefit for 24 weeks @Rs.3,750/-(Rupees Three Thousand Seven Hundred and Fifty only),  for the ‘broken bones’ Rs.4,000/-(Rupees four Thousand only) and for hospital cash Rs 1,000.  They have already disbursed the eligible amount as per policy to the complainant. They are not liable to pay any further amount.  There is no deficiency in service and hence, they prayed for the dismissal of the complaint.

          4.       The evidence in the complaint consists of oral evidence of the complainant as PW1 and Exhibits A1 to A4 documents marked on his side.  The senior Manager of the opposite party was examined as DW1 and Exhibits B1 and B2 were marked on the side of opposite party. On the basis of the evidence adduced, the District Commission passed the impugned order. Though the District Commission allowed weekly benefit for a further period of 12 weeks (making the total to 36 weeks as per the complaint) and hospital cash of Rs.1000/-(Rupees One Thousand only), the claim for the ‘broken bones’ was not allowed in full. Aggrieved by the said order Complainant has filed this appeal.

5.       Heard both sides.  The learned counsel for the appellant/complainant submitted that the respondent Insurance Company did not give the eligible claim as per the policy.  They have violated the terms of the contract by arbitrarily reducing the eligible amount of the claim under the head ‘broken bones’. The policy produced by them is a fabricated document. He is eligible for Rs.50,000/-(Rupees Fifty Thousand only) whereas they have paid Rs.8,000/-(Rupees Eight Thousand only).   He is eligible for the balance amount of Rs.42,000/-(Rupees Forty two Thousand only).  He also submitted that the compensation awarded is only
Rs.10,000/-(Rupees Ten Thousand only) which is low. Hence, he prayed for allowing the appeal with costs.

6.       The learned counsel for the respondent submitted that they have already satisfied the eligible amount as per the terms and conditions of the policy.  The appellant is eligible for weekly compensation for 24 weeks only and they have already paid this amount.  The District Commission has allowed weekly compensation for a further period of 12 weeks. As per section 10 of the policy pertaining to broken bones, the sum insured of Rs.50,000/-(Rupees Fifty Thousand only) is the maximum amount payable under the policy. As per the table of benefits the appellant is eligible for 8% of the sum insured for the fracture suffered by him.  They have already paid 8% of the sum insured of Rs.50,000/-(Rupees Fifty Thousand only) i.e. Rs.4,000/-(Rupees four Thousand only) towards broken bones and no further amount is due to him.  There is no deficiency in their service and hence they prayed for dismissal of the appeal.

7.       We have considered the submissions on both sides and perused the records.   The dispute is regarding the claim payable under the personal accident policy issued to the appellant/complainant, consequent to an accident to him. The appellant claimed weekly benefit of Rs.1,35,000/-(Rupees One Lakh Thirty Five Thousand only) for 36 weeks (Rs.3750x36 weeks) plus claim for broken bones Rs.50,000/-(Rupees Fifty Thousand only) and Rs.1,000/-(Rupees One Thousand only) for hospital cash totalling Rs.1,86,000/-(Rupees One Lakh Eighty Six Thousand only).  The respondents initially paid Rs.90,000/-(Rupees Ninety Thousand only) towards weekly compensation for 24 weeks plus Rs.8,000/- for broken bones totalling an amount of Rs.98,000/-(Rupees Ninety Eight Thousand only). The District Commission ordered to pay an additional amount of Rs.45,000/-(Rupees Forty Five Thousand only) towards weekly benefit for a further period of 12 weeks making the total to 36 weeks which is the claim of the appellant/complainant under the head ‘weekly benefit’ for TTD.                                                                               The District Commission awarded Rs.10,000/-(Rupees Ten Thousand only) towards compensation for mental agony and ‘hospital cash’ for Rs 1000 for hospitalisation for one day.

8.       The only remaining grievance of the appellant is regarding the amount paid under the head ‘broken bones’.  The respondent has already paid Rs.8000.  The appellant claimed that he is eligible to get the full sum insured of Rs 50,000 under this head. So he claimed the balance amount of Rs.42,000/-(Rupees Forty two Thousand only).  Appellant has produced the copy of the policy as Exhibit A1 and the respondent has produced the copy of the policy as Exhibit B1.  According to the complainant/appellant the respondent has produced a fabricated policy altering the clause regarding the broken bones. 

9.       Exhibit A1 is the policy produced by the appellant/complainant without the relevant clause. Exhibit B1 is the policy with clauses attached, produced by the respondents.  We do not find any reason to believe that it is a fabricated document.  Clause 10 and 10.9 of the policy (Exhibit B1) reads as under:

10. “if during the period of insurance an insured person sustains bodily injury which directly and independently of all other causes results in a broken bone as specified in this Section, then the company agrees to pay to the insured person the compensation stated in the table of benefits up to the total sum insured in the schedule”

10. 9. Fractures of Rib or Ribs, Cheekbone, Coccyx, Upper jaw, Nose, Toe and toes, finger or fingers:

(a) Multiple fractures (at least one compound and one complete): 16 %

(b) all other compound fractures:12 %

 (c) multiple fracture, at least one complete: 8% of sum insured”.

Evidently, considering the fracture suffered by the appellant the amount payable is limited to 8% of the sum insured of Rs.50,000/-(Rupees Fifty Thousand only).  However, the appellant has admitted having received Rs.8,000/-(Rupees Eight Thousand only) under the section ‘broken bones’, which is 16% of the sum insured as per clause 10.9 (a). 

10.     The District Commission has passed the impugned order by partly allowing the complaint as per the terms and conditions of the policy. As per the order, the appellant has already been awarded the TTD benefit of Rs.1,35,000/-(Rupees One Lakh Thirty Five Thousand only) @Rs.3,750/-(Rupees Three Thousand Seven Hundred and Fifty only) for 36 weeks, hospital cash for one day Rs.1,000/-(Rupees One Thousand only) and claim paid for ‘broken bones’ Rs.8,000/-(Rupees Eight Thousand only), totalling Rs.1,44,000/-(Rupees One Lakh Forty four Thousand only).  The District Commission also ordered Rs.10,000/-(Rupees Ten Thousand only) as compensation for mental agony.  Considering the facts and circumstances of the case we find it just and reasonable and no interference in this regard is required.  Hence, we do not find any infirmity in the order of the District Commission partly allowing the complaint.

On the basis of the foregoing discussion, we do not find any valid ground to interfere with the order of the District Commission and hence the appeal is liable to be dismissed.  Hence, the appeal is dismissed and the order dated 29.11.2021 of the District Commission in C.C.No.22/2020 is confirmed.  No costs.

SL