DOF.29.11.2005 DOO. 12 /7/2010 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 12th day of July 2010 CC.306/2005 N.Anil Kumar, ‘Govindapuram’Chemmadam, P.O.Chekkikulam, Kannur Dt. Complainant (Rep. by Adv.B.P.Saseendran) The Divisional Manager, National Insurance Company Ltd., Bank Road, Kannur1. Opposite party (Rep. by Adv.V.K.Rajeev) O R D E R Smt.K.P.Preethakumari, Member This is a complaint filed under section12 of consumer protection act for an order directing the opposite party to pay Rs.34, 000/- with 12% interest and Rs.5000/- as compensation. The case of the complainant is that he is a toddy taper and has subscribed in group insurance policy of Individual personal Accident scheme of opposite party having policy No.571100/42/04/8100481 for a sum of Rs.1,00,000/- and the period of policy was from 14.7.04 to13.6.05 and the premium of Rs.3370/- was paid. As per the terms and conditions of the policy the complainant is entitled to get a sum at the rate of one percentage of the capital sum insured per week together with the cost of medicinal bills. On21.1.05 the complainant fall from height and injured grievously and was taken to AKG hospital and admitted there from 21.1.05 to26.1.05 with I.P.No.862. The complainant sustained fracture at his left L 2,3,4 and 5 and had undergone surgery and put on catheter and after the discharge also complainant continued treatment for 6 months as out patient and he was reviewed on several occasions. The doctor advised physiotherapy on7.2.05 and absolute bed rest for six months and had undergone 6 months bed rest by putting his body in belts applied by the doctor at the time of discharge. So he cannot do any job and had spent Rs.10, 000/- as medical bills. In order to get the benefit under the policy, the complainant approached the opposite party and submitted all medical bills and other documents. But the opposite party has forwarded a cheque for a sum of Rs.6, 627/- only to the complainant. At the time of hospitalization itself the complainant had spent Rs.10, 000/- for his medical treatment. As per the terms and conditions of the policy opposite arty has to pay Rs.24, 000/- as compensation and Rs.10, 000/- as medical bills. Due to the accident the complainant has been totally disabled and become a burden to his family. The amount offered by opposite party is very low and hence the complainant has issued a lawyer notice. But instead of giving the amount opposite party has issued a reply stating false allegations. Hence this complaint. Upon receiving the notice from the Forum the opposite party appeared and filed their version. The opposite party admits the insurance policy issued to the complainant. But as per the policy conditions, they are bound to pay 1% of the sum insured for 1 week period, which is period of hospitalization due to temporary total disablement of 100%. Upon receiving the claim form and l medical certificate of Dr.Subash Chandran, who treated the complainant from 21.1.05 to26.1.05, opposite party preceded the claim and sent disbursement voucher for Rs.6, 627/- which the complainant is entitled as per the policy and its conditions. The complainant is entitled to get only Rs.1000/- i.e. 1% of sum insured for one week and medical expenses of40% of the admissible claim amount. The medical expenses allowable will be only Rs.400/- and hence the complainant is entitled to get Rs.1400/- . But considering the nature of injuries and out of humanitarian consideration, the opposite party inclined to accept one month has the period of confinement and allowed the claim of Rs.6,627/-. But the complainant refused to accept the same and hence there is no willful default on the part of opposite party. The claim of Rs.10, 000/- towards the treatment expense and the claim for Rs.24, 000/- as per policy are not sustainable and there is no cause of action as alleged and there is no deficiency on the part of the opposite party and hence the complaint is liable to be dismissed. On the above pleadings the following issues have raised for consideration:- 1. Whether there is any deficiency on the part of opposite party? 2. Whether the complainant is entitled to any relief? 3. Relief and cost. The evidence in this case consists of the oral testimony of PWs1 to 4 and DW1 and Exts. A1 to A5 and B1 to B7 marked. Issue Nos. 1 to 3 The case of the complaint is that he had suffered fracture at left nibs 2,3,4, and 5 due to fallen from height and unable to do his job for six months and the opposite party was unwilling to give compensation for that period by saying that he was hospitalized only for 6days. In order to prove his case PWs 1 to 4 were examined and produced and marked documents such as photo copies of discharge summary as Ex.A1, lawyer notice, A2., reply notice A3, certificate issued by PW3, A4, personal accident medical certificate A5, and in order to prove the contention of opposite party they have also produced the documents, such as B1 personal accident insurance policy schedule and conditions, B 2 claim form, B3 medical certificate by Dr.Subash Chandra, B 4 discharge summary, B5 details of medical bills, B6 disablement voucher and B7 cheque issued by opposite party on 11.7.05. The opposite party admits that the complainant has sustained fracture at his ribs and there exists a valid policy at that time. But they denied that they are bound to pay 1% of sum insured for 6 months. According to opposite party they are only bound to pay 1% of the sum insured for one week since he was hospitalized only for 6 days and he was having total temporary disability for the period of 6 days only. Even though it is so they have considered 6t week’s period of total disability Rs.627/- was allowed as medical expenses and hence the opposite party issue a disbursement voucher B6. But according to the complainant he was not able to do his job for 6 months and hence he is entitled to get compensation for 6 months instead of 6 weeks. As per Ex.B1 clause (f) says that “if such injury shall be the sole and direct cause of temporary total disablement thus so long as the insured person shall be totally disabled from engaging in any employment or of occupation of any description what so ever, a sum at the rate of one percent (1%) of the capital sum insured stated in the schedule here to per week”. As per this clause, the injured person is entitled to get 1%of the capital sum insured per week until he is able to engage in his employment, provide that the injury shall be the sole and direct cause of temporary total disablement. So the total disability is with respect to the engaging the employment. It is an admitted fact that the complainant is a toddy taper and a person who has sustained fracture at this left 1,2,3,4 and 5 cannot climb coconut tree wihtin6 days of his fall. Ext.B 4 itself shows that KTB was discontinued only on 22.4.05. There after he has undergone physiotherapy. The complainant deposed that tUmIvSsd ImWn-¡p¶ ka-b¯v 6 amkT Rm³Nn-InÕ FSp-¯n-«p-v. BIvkn-Uâp-I-gnªv Hcp-hÀjT Ign-ªmWv Rm³ tPmen¡v t]mb-Xp. Bk-a-b-¯pT ]c-k-lm-b-t¯m-sS-bmWv Rm³ tPmen sNbvX-Xv.The complaint has produced Ext.A1 certificate, which was issued by PW3. He deposed that “ A\n Ipam-dnsâ \s«-Ãn\v £X-am-bn-cp-¶p.The PW2 also proves that the complainant has joined for his employment only after 11 months. The PW2 deposed that A\n Ipam-dn\p ]cn¡v ]änb kT-`-hT And-bmT sX§n \n¶p hoWn-«mWv ]cn¡p ]än-b-Xv. 21.1.05 apX Unk-T-_À hsc A\nÂIp-am-dn\p thn sN¯n-bXp Rm\m-Wv. The PW4. Who has identified the signature of the treated doctor in Ext.A5. deposed that “ he was hospitalized during 21.1.05 to 26.1.05 and was confined to bed during that period. As per column 11 the injury was the sole and direct cause for the temporary total disability. So from the above evidence read along with clause (f) of the policy conditions, it is clear that the complainant is under treatment and hence is entitled to get benefit under clause (f) ie. 1% of the capital sum insured per week for 6 months. So he is entitled to get Rs.24, 000/- as per clause 6. The complaint submitted that he has produced all medical bills to opposite party along with the claim application. The opposite party has produced Ext.B5 which shows the detailed amount as per bills. As per the Ext.B5 the total bill is for Rs.4883.50. So the complainant is entitled to get this amount also. So he is entitled to an amount of Rs.28883.50. So we are of the opinion that there is deficiency on the part of opposite party in deciding the claim amount and hence the opposite party is bound to pay the above amount i.e. Rs.28883.50 (Rounded to Rs.28, 884/-) with 5% interest from 11.7.05 i.e. the date of B6 till realization of the amount. The complainant is also entitled to get Rs.500/- as cost of the proceedings and hence order passed accordingly. In the result, the complaint is allowed directing the opposite party to pay Rs.28884/-(Rupees Twenty eight thousand Eight hundred and eighty four only) with 5% interest from11.7.05 till the date of realizations with Rs.500/-ascost to the complainant within one month from the date of receipt of this order failing which the complainant is at liberty to execute the order s per the provisions of consumer protection act. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1.Copyof discharge summary issued from AKG hospital A2.Copyof the lawyer notice sent to OP A3.Letter dt.28.9.05 sent by OP A4.Certificate dt.24.5.07 isued from Mattannur Range Tody tapers union A5.Personal accident medical certificate Exhibits for the opposite party B1.Copy of the policy Schedule issued by op B2.Claim form submitted bycomplainnat B3.Medical certificate form submitted by complainant B4.Copy of discharge summkary issued byAKG hospital B5 & 6.Copy of medical bills B7.Cancelled cheque Witness examined for the complainant PW1.Complainant PW2.Thijil.K.K. PW3.N.V.Chandrababu PW4.MuraleedhraRao Witness examined for the opposite party DW1.T.K.Sankarankutty /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Froum, Kannur
| | [HONORABLE PREETHAKUMARI.K.P] Member[HONORABLE MR. GOPALAN.K] PRESIDENT[HONORABLE JESSY.M.D] Member | | 
