BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 4^TH DAY OF MARCH 2022

ORDER

SRI.K.S.BILAGI, PRESIDENT

1. The complaint has been filed under Section 12 of C.P.Act, 1986(herein under referred as an Act) for the following reliefs against the OPs:-

Direct the OPs to pay compensation of Rs.1,50,000/- with interest at 18% p.a. from the date of intimation till the date of payment along with exemplary cost of Rs.15,000/- towards cost of litigation and such other reliefs.    

2. The case set up by the complainant in brief is as under:-

The complainant while working as production helper under OP No.1 met with an accident on 13.07.2011 and sustained eye injury on duty on 15.04.2016.  He had taken treatment in Narayana Nethralaya hospital by spending Rs.3,20,000/-.

3 The OP No.1 has settled sum of Rs.1,80,000/- towards medical expenses and other incidental expenses.  But, OP Nos.2 and 3 failed to extend insurance benefit to the complainant.  Sum of Rs.1,50,000/- is required for further treatment and further medical expenses.  The OPs are liable to pay this amount. Hence, this complaint.

4. In response to the notice, all the OPs appear and file separate versions.  The OP No.1 admits that the complainant was working as production helper.  The complainant to prove that due to accident he suffered injury on 12.07.2011.  In fact, the complainant met with an accident on 15.04.2016 and he was on leave.  The complainant submitted his resignation and his terminal benefit have been settled.  In fact, the OP No.1 has paid Rs.2,07,130/-.  The OP No.1 is not aware of closure of claim of complainant by OP Nos.2 and 3.  No amount is due from OP No.1.  OP No.1 requests to dismiss the complaint.

5. OP No.2 contends that the complaint is not maintainable.  The complainant has been tried to play fraud by making false claim.  OP No.3 issued Tailor made group mediclaim policy benefit for the period from 14.08.2015 to 13.08.2016 and complainant is one of the holder of said policy.  The OP No.2 denies that the complainant sustained injury while working in OP No.1 on 15.04.2016 and complainant is not entitled to balance amount of Rs.1,50,000/- towards further treatment, further on medical expenses, mental agony and mental stress.  In fact, the complaint is not maintainable as complainant has received full and final settlement of Rs.2,07,130/- from OP No.1.  OP No.2 requests to dismiss the complaint.

6. OP No.3 submits that the complaint is not maintainable.  The issue involved in this case is of civil in nature and complicated.  Therefore, this Forum has no power to decide such issue. OP No.3 admits that tailor made group mediclaim policy for the period from 14.08.2015 to 13.08.2016 issued including the complainant.  OP No.3 denies that complainant spent Rs.3,20,000/- and OP No.1 has paid only Rs.1,80,000/-.  OP No.3 denies that the complainant need Rs.1,50,000/- towards further treatment, further medical expenses, mental agony, mental stress and loss of income.  The OP No.3 is not liable to pay any amount.  As per the terms and conditions of the policy, complainant is not entitled to any reliefs.  OP No.3 requests to dismiss the complaint.

7. The complainant files affidavit evidence and relies on certain documents.  Affidavit evidence of the partner of OP No.1 has been filed with two documents. The affidavit evidence of official of OP No.2 has been filed.  The affidavit evidence of official of OP No.3 has been filed.  OP No.2 and 3 have filed seven documents.  Heard the arguments of advocate for OP Nos.2 and 3 only.  No oral argument has been advanced on behalf of complainant and OP No.1. 

8. The following points arise for our consideration:-

1. Whether the complainant proves deficiency of service on the part of OPs?
2. Whether the complainant is entitled to relief mentioned in the complaint?
3. What order?

9. Our answers to the above points are as under:

       Point Nos.1 and 2:  In the negative.

      Point No.3: As per final orders

REASONS

10. Point Nos.1 and 2:  These two points are co-related to each other.  Therefore, these two points are taken into consideration for common discussion. 
11. It is the admitted fact that the complainant was working under OP No.1 and OP No.1 paid Rs.1,80,00/-, Rs.20,180/- and bonus of Rs.7,000/- to the complainant on 10.06.2016.  The complainant made an endorsement for receipt of Rs.1,80,000/- by means of a cheque.  The complainant also submitted resignation letter on 07.06.2016.  The case of the complainant that he needs Rs.1,50,000/- for future medical expenses, loss of income and mental tension.  When the complainant gave a resignation letter and received an amount from his employer OP No.1, the complaint against OP No.1 is not maintainable.  Moreover, the complainant cannot maintain a complaint for imaginary figure of Rs.1,50,000/- towards future medical expenses and loss of income.
12. OP No.1 admits under letter dated 22.04.2016 that the complainant was working with it since 13.07.2011 and he sustained injury on his left eye while working on the bench grinding machine on 15.04.2016.  OP No.3 repudiated the claim of the complainant by letter dated 30.06.2016 that the claim of the complainant for cataract is excluded as per Clause No.8.  We would like to refer this clause while referring terms and conditions of group personal accident insurance policy certificate with medical expenses.  Document No.5 is the CT scan of the complainant.  Document No.6 indicates that foreign body fell into the left eye which was removed elsewhere and patient was referred for further evaluation.  However, same hospital gave a discharge summary stating that the complainant was admitted in Narayana Nethralaya on 18.04.2016, complainant underwent surgery on 18.04.2016 for cataract and he was discharged on the same day.  It clearly indicates that the complainant underwent surgery due to cataract.  Therefore, clause No.8 of the terms i.e. “any person who is suffering from physical defect/infirmity and or insane/mentally disabled” is not applicable. It is relevant to note that OP No.3 issued a letter to the complainant stating that the death benefit upto Rs.1,00,000/- and medical expenses upto Rs.1,00,000/- extended to the complainant under the head Rasta Aapati Kavach.  It is not the case of the complainant that he sustained injury to his left eye due to road traffic accident.  Even OP Nos.2 and 3 are responsible for this policy.  But, the complainant has not sustained injury in the road traffic accident.  Therefore, the complainant is not entitled to any amount from OP Nos.2 and 3.
13. OP Nos.2 and 3 have produced seven documents, document No.1 is the policy issued by OP Nos.2 and 3 under the group insurance policy.  As per the document No.7, the claim of the complainant is shown at Sl.No.523 and he can claim benefit of Rs.1,00,000/-.  The complainant had submitted a claim petition as per document No.B.2.  It further indicates that the claim was Rs.50,963/- and amount payable was Rs.49,711/-  The medical records under document No.3 to 5 indicate that the complainant underwent surgery of left eye cataract.  Document No.5 indicates that the complainant came with a history of foreign body fall into the left eye which was removed from elsewhere.  But, complainant was not produced on what date, the foreign body was removed from his left eye.  The discharge summary has issued by Narayana Nethralaya indicates that complainant underwent cataract surgery.  The cataract surgery cannot be construed as injury in the accident.  Apart from this injury, the complainant has not sustained any injury in road accident to claim amount from OP Nos.2 and 3.  It is undisputed fact that OP Nos.2 and 3 issued group insurance policy under which the complainant is entitled to certain benefits.  Even though clause No.8 of the terms and conditions of group personal accident insurance policy is not applicable to the present case on hand.  But, policy itself is issued by OP Nos.2 and 3, extended death benefit and medical expenses due to road traffic accident  Therefore, the complainant has utterly failed to prove deficiency of service on the part of OP Nos.1 to 3.  Accordingly, the complainant is not entitled to any of the reliefs from the OPs.
14. Point No.3:- In view of the discussion made in point Nos.1 and 2, the complaint requires to be dismissed.   We proceed to pass the following 

  O R D E R

1. The complaint is dismissed.
2. Parties are directed to bear their own costs.
3. Furnish the copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open Commission on this 4^th day of March, 2022)

Documents produced by the Complainant which are as follows:-

Documents produced by the OP Nos.2 and 3 which are as follows:-

Documents produced by the OP No.1 which are as follows:-