Jharkhand

Bokaro

CC/17/113

Aftab Alam - Complainant(s)

Versus

HDFC ERGO General Insurance Co. Ltd. - Opp.Party(s)

Annu Mishra

29 Mar 2022

ORDER

1. Complainant has filed this case with prayer for direction to O.Ps. to pay insured amount Rs. 12,50,000/- on account of death of insured Zulekha Khatoon with interest and for payment of Rs.20,000/- and Rs. 10,000/-  as compensation and litigation cost respectively to the complainant.
2. Complainant’s case in brief is that his mother Zulekha Khatoon purchased Sarva Suraksha-Personal Accident Policy No. 2952201005938901000 valid from 15.03.2016 to 14.03.2017 for sum assured Rs. 10,000,00/-. Further case is that said Zulekha Khatoon got injured on 12.08.2016 due to burn and fall on floor causing disablement of her both legs. Further case is that thereafter complainant visited Shivam Hospital on 10.11.2016 with his mother who was treated there and Civil Surgeon, Bokaro also issued disablement certificate for her. Further case is that claim form was submitted with O.P. No.1 with documents related to treatment but it was repudiated on 21.12.2016 on the ground that case is not related to accidental in nature, hence this  case has been filed before this Commission.
3.  O.P. Insurance co. has filed W.S. mentioning therein that as per papers submitted the insured was suffering from Paraparesis that is partial paralysis of limbs and weakness of limbs caused due to ailments but suppressing this fact claim has been made in breach of the policy. Further reply is that the policy was issued in respect to personal accident subject to terms and conditions, exceptions and limitations. Further reply is that claim is baseless which is very much apparent from the prescription dt. 10.11.2016 that treatment for “weakness of both leg, difficulty to standing, poor sensation, unable to flex” was done for her case which is not accidental in nature. Further reply is that as per policy the loss under accidental injury has been covered but here in this case treatment for medical ailment has been done hence it is not covered under the policy.
4.  In light of pleadings of the parties following points are to be decided by this Commission which are as follow:-

1. That whether treatment of the insured was done for accidental injury ?
2. That whether the complainant is entitled to get relief as claimed ?

5. Following facts are admitted facts:-

1. That Zulekha Khatoon has obtained Sarv Suraksha-Personal Accident Policy.
2.  That said policy was valid from 15.03.2016 to 14.03.2017.

6. On perusal of the papers submitted by the complainant it is apparent that Annexure 1 is the photo copy of policy bond which is not in dispute. Annexure 2 is the prescription dt. 10.11.2016 prepared by the Doctor of Shivam Hospital, Bokaro on which basis claim has been raised but it is not containing any word related to accidental injury. Annexure 3 is disablement certificate of Zoolekha Khatoon issued by the Office of CMO, Bokaro, accordingly Zulekha Khatoon is having 65% disablement. This documents is also not in dispute. Annexure 4 is terms and conditions  of the Sarv Suraksha Policy, accordingly this policy is related to the benefit of accidental bodily injury caused to the insured by accident only. Annexure 5 is claim repudiation latter in which it is mentioned that as per documents submitted it has been observed that insured has taken treatment related to weakness of both leg, difficulty to standing, poor sensation unable flex, diagnosed with paralysis which are medical element and not accidental in nature, hence there shall be no claim in the case.

7   On careful perusal and scrutiny of the papers submitted in the case by the complainant it is very much clear and apparent that no paper to prove that the insured sustained any injury due to accident resulting in permanent disablement. Therefore, we are of the opinion that the papers submitted by the complainant are in consonance with the conclusion drawn by the O.Ps. hence complainant has failed to establish his case against the O.Ps. We are also of the opinion that complainant is not entitled to get any relief because there is no deficiency in service by the O.Ps.

8   Accordingly, the prayer made by the complainant is  

         being dismissed with cost.