SRI. K. ANIRUDHAN (MEMBER)<br /> <br /> Sri. Santhosh J. Mathew has filed this complaint before the Forum alleging deficiency in service on the part of he opposite party. The main contentions of the complainant is that he had taken an individual personal Accident policy bearing No.101500/42/023 for a period of one year from 29.12.2004 to 28.12.2005 for Rs.1 lakh with table of benefits IV/+Medical expenses from the opposite party. The premium amount was of Rs.204/-. The benefit conditions are clearly stated in the policy certificate. The opposite party was also collected premium for additional benefits. It is stated that the complainant met with a road accident (fall from bike) on 1.12.2005. Initially he was treated at the Medical College Hospital, Alappuzha for his serious injuries with fracture of right leg. Later he was shifted to District Hospital, Alappuzha and was treated by Dr. V.S. Ajithkumar who is expert in orthopedic surgery. The complainant was in plaster till 22.1.2006. It is further stated that the complainant was in non-weight bearing for 4 weeks and partial weight bearing for additional 4 weeks and was on bed rest. As such the concerned doctor recommended the complainant 14 weeks for temporary total disability and for the complainant incurred Rs.3,774/- as Medical expenses. The complainant further contended that as per policy document he was legally eligible for an amount of Rs.17,774/-. But the opposite party has settle the amount to Rs.9,000/- only. Hence the complaint for the balance amount of Rs.8,774/- and for other relief. <br /> 2. Notice was issued to the opposite party. They entered appearance and filed version together with the documents in evidence. In the version it is stated that as per the policy condition the complainant is entitled to get 1% of the sum/insured for temporary total disability and 5 % of the admissible claim for actual medical expenses which ever is less for medical expenses. It is started that as per the documents the complaint had temporary total disablement up to the date of removal of plaster ie. on 22.1.06 and the same was arrived on Rs.6000/- and the medical bills submitted is Rs.3031/- but 50% of the admissible claim is Rs.3000/- hence Rs.9000/- was arrived. It is further stated that the said amount of Rs.9000/- was offered and it was accepted by the complainant in full and final settlement of the claim and that the complainant had executed discharge voucher in favour of the opposite party. Hence there was no deficiency in service on the part of the opposite party.<br /> 3. Considering the rival contentions of the parties this Forum has raised the issues:- <br /> (1) Whether there is any deficiency in service on the part of the opposite party?<br /> (2) Relief and costs. <br /> <br /> 4. Issue No. (1) & (2):- On the side of the complainant he has produced 4 documents - Ext.A1 to A4 marked. Ext.A1 is the original policy certificate showing the policy period – 29.12.04 to 28.12.2005; details of premium amount and policy conditions. Ext.A2 series are the personal accident insurance medical report and claim form. Ext.A3 is the letter of the complainant dt. 7.6.2006 to the opposite party requesting to release the balance amount. Ext.A4 series are the photo copy of the cheque for Rs.9000/- issued to the complainant by the opposite party and photo copies of medical bills. On the side of the opposite party they have produced 8 documents – Exts.B1 to B8 marked. Ext.B1 is the policy certificate. Ext.B2 is the claim form. Ext.B3 is the medical request. Ext.B4 is the OP ticket of Medical College Hospital, Alappuzha. Ext.B5 is the Ticket of the MCH., Alappuzha. Ext.B6 is the fitness certificate issued by the doctor. Ext.B7 is the Medical bills and B8 is the discharge voucher dt. 2.6.06. On a careful readings of the documents submitted by the parties, it cab be seen that the opposite party had duly entertained the claim of the complainant as per the terms of the policy. As per the policy, the complainant is eligible to get a weekly compensation of 1% of the of the total sum insured, during the period of treatment and for reimbursement of the amount spent for purchase of medicines subject to a maximum of 50% of the weekly compensation. As per records, the complainant was under treatment for 6 weeks as per the advice of the concerned doctor and the total amount comes to Rs.3031/-. As such the opposite party sanctioned a sum of Rs.6000/- after calculated 6 weeks compensation, and total amount for medicine items calculated for Rs.3000/-. So considering the conditions of the policy it cannot be say that there is any latches on the part of the opposite party in releasing the insured amount to the complainant. The contentions of the complainant cannot be accepted as valid ground to state that the was under treatment for 14 weeks, since the concerned doctor has stated that the complainant was on treatment for the accident injury only for 6 weeks ie. during the period of plaster and the same was removed after 6 weeks on schedule and there is nothing to show that the complainant had continued the treatment was under a plaster treatment again. The certificate of the doctor – Ext.B8 shows that it is certificate for resuming his job was allowed only after 14 weeks. The period of 8 weeks after removal of plaster advised for resumption of his duty cannot be considered as the complainant was under treatment. So the contentions of the complainant regarding the above matter cannot be accepted as valid ground. On a careful readings of the documents given in evidence by the complainant and the opposite party and depositions of both parties and after a detailed hearing, we are of the view that there is no deficiency in service on the part of the opposite party in calculating the insured amount. The issues are found in favour of the opposite party. Since there is no deficiency in service on the part of the opposite party, the complainant is not entitled to get any relief. <br /> In the result, the complaint is to be dismissed. No orders as to costs.<br /> Complaint dismissed.<br /> Pronounced in open Forum on this the 30th day of July, 2008.<br /> Sd/- SRI. K. ANIRUDHAN:<br /> Sd/- SRI. JIMMY KORAH:<br /> Sd/- SMT.N.SHAJITHA BEEVI:<br /> <br /> APPENDIX<br /> Evidence of the complainant:-<br /> PW1 - Santhosh J. Mathew (Witness)<br /> Ext.A1 - Original Policy Certificate<br /> Ext.A2 series - Personal accident insurance medical report and <br /> Claim form <br /> Ext.A3 - Letter of the complainant dt. 7.6.06 to the opposite<br /> party<br /> Ext.A4 series - Photo copy of the cheque for Rs.9000/- issued to the complainant and photo copy of the medical bills<br /> <br /> Evidence of the opposite party:-<br /> RW1 - Asokan K.P. (Witness)<br /> Ext.B1 - Policy Certificate<br /> Ext.B2 - Claim Form<br /> Ext.B3 - Medical Report<br /> Ext.B4 - OP ticket of MCH., Alappuzha<br /> Ext.B5 - OP ticket of MCH., Alappuzha <br /> Ext.B6 - Fitness certificate of the doctor<br /> Ext.B7 - Medical Bills<br /> Ext.B8 - Discharge voucher dt. 2.6.06.<br /> Ext.B9 - Policy conditions<br /> <br /> // True Copy //<br /> <br /> By Order<br /> <br /> <br /> Senior Superintendent<br /> To<br /> Complainant/Oppo.party/S.F.<br /> <br /> Typed by:-pr/-<br /> Compared by:-<br /> <br />