DOF.22.9.2003

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 23^rd  day of   April   2010

CC.313/2003

Kumaran Pallichalil,

Maniyoor,

P.O.Chekkikulam                                             Complainant

(Rep. ByAdv.B., P.Saseendran)

The Divisional Manger,

National Insurance Co.Ltd.,

Kannur Dist. Office,

P.B.No.40, Bank Road, Kannur 1.                   Opposite party

(Rep. by Adv.V.K.Rajeev)

O R D E R

Sri.K.Gopalan, President

            This is a complaint filed under section 12 of consumer protection act for an order directing the opposite party to pay Rs.52, 000/- as policy amount with interest @12% p.a from 27.4.04 till the date of realization and an amount of compensation for mental agony Rs.15, 000/- together with the cost of these proceedings.

            The case of the complainant in brief are as follows: ‘the complaint a toddy tapper had taken personal accident policy along with  27 other persons for a sum of Rs.1,00,000/- by remitting Rs.252/- for the period from 12.7.002 to 11.7.03. As per the terms and conditions of the policy the complainant is entitled to get a sum  at  the rate of 1% of the capital sum insured per week together with the cost of medical bills complainant was hospitalized  following a snake bite on 27.4.03 and undergone treatment from  27.4.03  to 24.5.03. Complainant continued his treatment even after discharge. Doctor advised him to take bed rest since his injury was not completely cured. Complainant cannot do any job till this day and tapping has been done by a toddy worker. Complainant submitted claim before the opposite party with all documents and medical bills. But opposite party offered only Rs.8, 400/-. At the time of Hospitalization period itself the complaint had spent Rs.28, 000/- for his medical treatment only. As per the terms and conditions of the policy the opposite party has to pay Rs.52, 200/-. Due to the injury caused by snake bite the complaint has been totally disabled from engaging in his employment and become a burden to his family. The amount offered by the opposite party is far away from the expenses and loss caused to the complainant. Legal notice was sent. But opposite party offered only Rs.8, 400/- in the reply. Non payment of amount as per terms and conditions is a deficiency in service on the part of opposite party. Hence this complaint.

            Pursuant to the notice opposite party entered appearance and filed version denying the main allegations of complainant. Opposite party has issued standard insurance policy to a group of persons and the complainant is one among them. But opposite party denies their liability to reimburse the full medical expenses incurred by the complaint and also for the 25% of the temporary partial disability as averred in the complaint. Complainant hospitalized for 18 days and concerned doctor issue certificate showing that he was having temporary partial disability of 25% for the period of confinement in the hospital. Therefore as per the specific conditions of the policy the complainant is not entitled to claim any amount. But if claim is admitted medical expenses only up to40% or 10% of the sum assured which ever is less need only be granted to the insured. Therefore the claim for Rws.52, 000/- put forward by the complaint is not maintainable. On receipt of the claim from the complainant, this opposite party had intimated their  willingness to settle the claim by taking 6 weeks as the period of confinement due to temporary partial disability instead of 18 days which will come to Rs.6000/- and also granted 405 of the medical bills, i.e. Rs.2,400/-.  Hence a total amount of Rs.8, 400/- offered on10.7.03 itself. But the complaint declined to accept the offer. There is no deficiency on the part of opposite party. Hence to dismiss the complaint.

            On the above pleadings the following issues have been taken for consideration.

1. Whether there is any deficiency on the part of the opposite party?

2. Whether the complainant is entitled for the remedy as prayed in the complaint?

3. Relief and cost.        

            The evidence consist of oral testimony of complainant as PW1,PW2 and Exts.A1 to A5 on the side of the complainant and oral evidence adduced by DW1 with documentary evidence Exts.B1 to B7 marked on the side of opposite party.

Issue No.1to 3

            It is an admitted case that complaint is a policy holder of opposite party. There is no dispute with respect to the period or the sum assured. The date of incident and hospitalization is also admitted. The real dispute existing only with regard to the amount for which complainant is entitled for. The complainant’s case is that he is entitled to get a sum of Rs.52,000/- that is at the rate of one percent of the capital sum insured per week together with the cost of medical bills. At the same time opposite party contended that as per clause (f) of the insurance policy “if such injury be sole and direct cause of the temporary total disablement then so long as the insured person shall be totally disabled from enjoying in any employment or occupation of any description what so ever, a sum @ one percent of the capital sum insured stated in the scheduled hereto per weeks, but in any case not exceeding Rs.5000/- per week in all”. More over, if the claim is to be admitted, the insured is entitled for only 40% of the admissible amount or 10% of the capital sum insured as medical expenses. Opposite party further contended that they have taken the period of confinement as 6 weeks instead of 18 days and  arrived at a figure Rs.6000/- as compensation for the hospitalization and had granted 40% of the medical bills produced by the complainant and granted Rs.2400/- towards the same. But complainant refused to accept this offer.

            In short complainant’s case is that he had spend  Rs.28,000/- for  treatment at the time of hospitalization period itself and as per terms and conditions he is entitled for an amount of Rs.52,000/-. Complainant adduced evidence by way of proof affidavit and stated thus: t]mf-kn-bpsS \n_-Ô-\-IÄ {]Im-cT F\n¡v BgvN-tXm-dpT t]mf-kn-Xp-I-bpsS Hcp iX-am-\-hpT saUn-¡Â _nÃp-I-fpT In«m³ AÀl-am-Wv.       “But complainant did not explain which is the condition in the policy that empowers the complainant for such a claim. The affidavit is a repetition of the pleadings in the complaint. Complainant states that opposite party has to pay Rs.52, 000/- but he has not given explanation how did he arrived to such a calculation.

            It can be seen that clause (f) of the policy condition Ext.B1 reads “If such injury shall be the sole and direct cause of temporary total disablement then so long as the insured person shall be totally disabled from engaging in any employment or occupation of any description whatsoever, a sum at the rate of one percent(1%) of the capital sum insured stated in the schedule hereto per week but in any case not exceeding Rs.5000/- per week in all, under all Policies,  Provided that the compensation payable under the foregoing clause(f) shall not be payable for more than 104 weeks in respect of any one injury calculated from the date of commencement  of  the disablement and in no case shall exceed the capital sum insured.…”. So it makes clear that complaint is entitled for a sum @1% of the capital sum insured per week as compensation. In other words he is entitled for Rs.1000/- per week as compensation. It has come in evidence that complainant had been admitted in hospital and undergone treatment of a period form 27.4.03 to 24.5.03. It comes only 28days for which only an amount of Rs.4000/- can be expected. But opposite party has considered the period six weeks instead of 28days and offered Rs.6000/-. Opposite party’s stand in considering the period can only be treated as one which is favourable to complainant. Now the next point is the calculation of the Medical bills. Ext.B4 reveals that the complainant has produced inpatient and medical bills 17 in nos. for Rs.7240/- before the opposite party. The case of the opposite party is that of the claim is admitted medical expenses only up to 40% or 105 of the sum insured whichever is less need only be granted to the insured. Complainant did not challenge this pleading of the opposite party. Complainant has not pleaded the basis upon which he depended to calculate the medical expense. He did not even try to establish whether he is entitled for medical expenses and if so, the amount for which he is entitled for. He did not point out anywhere the conditions or rules by which he is entitled for the medical expenses. Ext.A3 goes to show opposite party has made clarification with respect to the medical expenses which reads that “The medical expenses payable only if the claim is admitted and the limit is 40% of the admissible claim or 10% of the sum insured as per the terms and conditions of the claims”.

            On going through the evidence on record and documents it is found that the complainant is miserably failed to prove his case, though incident and hospitalization is true and admitted. However, the opposite party has the obligation to pay the promised amount, even if complainant could not succeed in establishing his case. Issue No.1 is found against complainant and issue No.2 and 3 are found infavour of complainant to the extent of promised amount of the offer already made by the opposite party

            In the result, complaint is disposed of directing the opposite party to pay an amount of Rs.8400/- (Rupees Eight Thousand four hundred only) to the complainant  within one month from the date of receipt of this order, failing which the complainant is allowed to execute the order as per the provisions of consumer protection Act. However there is no order as to costs.

                                    Sd/-                                 Sd/-                 Sd/-

President                      Member           Member

APPENDIX

Exhibits for the complainant

A1.Copy of disbursement voucher

A2.Copy of the layer notice sent to OP

A3.Replynotice sent by OP

A4.Medical certificate issued by Dr.P.M.Gopinath

A5.Certificate dt.11.8.04 issued by Kannur Range chethu thozhilali union

Exhibits for the opposite party

B1.Copy of the personal accident group insurance policy issued by OP

B2,Medical certificate form attending doctors report

B3.Claim form submitted by complainant

B4.IP Bill issued from AKG hospital, Kannur

B5.Copy of the reply notice sent to complainant

B6.Claim settlement note

B7.Letterdt.10.7.03 sent to complainant

Witness examined for the complainant

PW1.Complainant

PW2.P.V.Ravindran

Witness examined for the opposite party

DW1.T.A.Sankarankutty         

                                                                        /forwarded by order/

                                                                        Senior Superintendent

Consumer Disputes Redressal Forum, Kannur