CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM.

Present

 Sri. Santhosh Kesavanath P. President

Smt. Bindhu M. Thomas, Member

                                             Sri. K.N. Radhakrishnan, Member

 

CC No.215/10

 

Saturday the 30^th day of April, 2011

 

Petitioner                                                          : Shaji John,

                                                                         Palliviruthy Kunnel,

                                                                         Pala PO,

                                                                         Kottayam.

                                                                        (Adv. T.G.Sujith Kumar)

                       

                                                                    Vs.

Opposite party                                                 : Divisional Manager,

                                                                         Oriental Insurance Co.Ltd.,

                                                                         Divisional Office, Palakkatt Building,

                                                                         Market Junction, Trippunithura,

                                                                         Kochin

                                                                         (Adv. Sajan A.Varghese)

                                                                       

 

                                                            ORDER

 

 

 

            The case of the complainant presented on 27-8-2010, is as follows:-

 

            He had taken a personal accident policy (PA) from the opposite party on

 10-11-2007. Subsequently on 31-8-2008 the complainant met with an accident at Pala near St.Joseph Church and he was admitted in the Marian Medical Centre Hospital Arunapuram Pala from 31-8-2008 to 2-9-2008. Accordingly he had spent Rs.3443/- as treatment expenses. Then the complainant submitted a claim form before the opposite party with all relevant documents. But the opposite party had sanctioned only Rs.1000/-. The complainant had sent lawyer notice to the opposite party for the balance treatment expenses. But there was no response from the opposite party. The complainant was legally entitled for the treatment expenses as per policy. There was clear deficiency in service on the part of the opposite party. Hence this complaint.

            The notice was served with the opposite party. They appeared and filed their version contending as follows: The policy was admitted by the opposite party. The records produced by complainant shows that he underwent treatment for injuries due to a wound on his left leg on 31-8-2008. The treatment records produced by the complainant shows that he was treated as inpatient at the said hospital up to 2-9-2008 as seen from the records and there was only a temporary total disablement for a period less than a week. Even then while the claim was processed he was sanctioned 1% of the sum insured ie Rs.1000/- in accordance with the policy conditions. The medical expenses for treatment are not covered under Personal Accident Policy. The opposite party has paid Rs. 1000/- to the complainant and he received the claim amount in full and final settlement of the claim without any protest. The claim of the complainant was settled by the opposite party as per the policy terms and conditions of the policy and the amount paid to him. There was no cause of action against the opposite party. There was no deficiency in service on the part of the opposite party. Hence the complaint may be dismissed with costs.

            The complainant filed proof affidavit and documents which are marked as exhibits A1 to A3. The opposite party filed proof affidavit and document which are marked as exhibit B1.

            Heard both sides. We have gone through the complaint version documents and evidences of both sides. The case of the complainant is that the opposite party has not settle the claim of the complainant as per policy.

            According to him he was entitled for entire claim. Opposite party has taken a contention that as per the terms and conditions of the policy complainant was entitled only for Rs.1000/- and the same amount was also received by him. According to them the amount was received by the complainant as full and final settlement of the claim without any protest. The treatment and medical expenses of the complainant was admitted by the opposite party. But only the amount with regard to expense was disputed. The opposite party has submitted that the complainant was entitled only for Rs.1000/- as per policy and the same was received by him. However the opposite party has not revealed the terms and conditions of the policy at the time of taking the policy. The opposite party has not disputed the ailment, treatment and expenses. Hence we have no reasons to dis-believe the case of the complainant. We are of the opinion that the case of the complainant is to be allowed.

            In the result the complaint is allowed as follows: (1) we direct the opposite party to pay the balance claim amount ie Rs.2443/- to the complainant and pay Rs.750/- as costs of these proceedings. The order shall be complied with within a period of one month from the date of receipt of a copy of this order.

Sri. K.N. Radhakrishnan, Member                    Sd/-

Sri. Santhosh Kesavanath P. President Sd/-

Smt. Bindhu M. Thomas, Member                    Sd/-

Ext.A1-is the medical bills

Ext.A2-is the copy of lawyer notice dtd 12/5/09

Ext.A3-is the copy of policy

Ext.B1-is the terms and conditions of Personal Accident Policy.

By Order,

 

Senior Superintendent.