IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM
DATED THIS THE 30TH DAY OF JANUARY 2018
Present: - Sri. E.M.Muhammed Ibrahim, B.A, LLM. President
Sri. M.Praveen Kumar,Bsc, LLB ,Member
CC.No.280/2015
Aswathy .N : Complainant
W/o Santhoshkumar
Thekkethazhathu Veedu
Naduvilakkara
Thevalakkara P.O
Kollam – 690524
[By Adv.N.Muraleedharan Pillai, Kollam]
V/S
HDFC ERGO General Insurance Co.Ltd: Opposite party
1st Floor, 165-166 Bakbay Reclamation
H.T.Parekh Marg, Church gate
Mumbai – 400020
Represented by
The Branch Manager
HDFC ERGO General Insurance Co.Ltd
5th Flore , Bishop Jerom Nagar
Kollam – 691001
[By Adv.S.Dileep Kumar, Kollam]
ORDER
SRI. M. PRAVEEN KUMAR, MEMBER
Complainant’s case is that she had taken a Sarv Suraksha Policy from opposite party on 24/08/2015 by paying a total one time premium amount of Rs.1,114/- . As per the terms of the policy the opposite party is liable to pay the insured Rs.1,50,000/- for permanent disability , Rs.25,000/- for the loss of earning for three months , Rs.1,00,000/- for the loss of articles, Rs.50,000/- for the accidental hospitalization and Rs.25,000/- for critical illness. On 31/08/2015 at
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about 8.45 AM when the complainant was riding her scooter bearing Reg.No.KL 23-K 9380. a cat crossed the road all on a sudden and when she applied brake the petitioner fell down on the road from the scooter and as a result the complainant sustained the following injuries, namely:-
- loss of one tooth in the lower jaw
- Class II fracture of one tooth in lower jaw
- concession of more than 3 teeth in both upper and lower jaw
- Abrasion on upper lip
- Abrasion on nose
- Abrasion on face below left eye
- Abrasion on right leg and knee
After the accident the complainant was taken to the Government Taluk Head Quarters Hospital, Karunagappally where she was treated as outpatient for many days. More than Rs.15,000/- is expended for the treatment. A huge amount is still to be expended for further treatment.
Due to the loss of teeth, fracture of tooth and concession of a number of teeth and other injuries the complainant has sustained permanent disability. Hence the complainant is entitled to get Rs.1,00,000/- from the opposite party for the permanent disability sustained by the complainant. Further in the accident the complainants helmet worth Rs.1500/- is totally damaged in the accident. She working as a accountant in a private firm named Abyes Mobile Priority, Bishop Jerome Nagar, Kollam earning a monthly salary of Rs.8500/-. But after the accident due to the injuries sustained the complainant was compelled to take leave for one month in loss of pay and thereby she sustained a loss of income of Rs.8500/-. On 15/10/2015 the complainant approached the opposite party for getting damages as per the terms of the policy. But the opposite party refused the
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complainants claim and informed the complainant that without the order of a court the opposite party could not pay any amount to the complainant. The said acts of the opposite party of refusing the claim of the complainant and the failure on the part of the opposite party in paying compensation to the complainant as per the terms of the policy amount to deficiency in service on the part of the opposite party. The amount of compensation claimed is Rs.1,75,000/- (Rupees One Lakh and Seventy Five Thousand Only) for which a fee of Rs.200/- is payable and a demand draft for Rs.200/- is produced . It is therefore most humbly prayed that the Hon’ble Forum be pleased to pass an order Under Section 14 of the Consumer Protection Act granting the following.
Hence the complainant approached the Forum for relief:-
- Directing the opposite party to pay a compensation of Rs.1,75,000/- (Rupees One Lakh and Seventy Five Thousand Only ) to the complainant.
- Directing the opposite party to pay the cost of proceedings to the complainant and
- Grading such other relief which the Hon’ble Forum considers fit and proper.
Opposite party filed version contending that as per the specific condition 3.1 of the policy , the insured is under an obligation to give written notice to the opposite party immediately upon the happening of any event, giving rise to a claim under the policy. It is also made clear in the above policy condition, the insured shall intimate the claim in writing to this opposite party within 14 days , in any event, with respect to a claim arising under the policy. In the instant case , the complainant failed to comply with the above mandatory conditions of the policy, who had never informed the claim in writing this opposite part, at any point of time
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prior to the filing of this complaint before this Hon’ble Authority. The complainant therefore violated 3.1 of the policy condition and as such, the opposite party is not at all liable to consider the claim of the complainant on that score itself.
As per the specific condition in the policy, the coverage given under the policy is only for a claim arising out of death of the insured or the event of causing permanent total disability or permanent partial disability as specified in 2.1, 2.2 and 2.3 of the policy condition. The nature of the permanent total disability and permanent partial disability arising out of an accident, which enabling the insured to arise a claim under the policy is also specifically mentioned in the table given under the policy. In the instant case the complainant has suffered only some superficial injuries for which she took OP treatment alone from Government Taluk Hospital, Karunagappaly as per the pleading stated in the complaint itself and from the documents produced by the complainant before this Hon’ble Forum. Since the injuries suffered to the complainant are very much trivial in nature , the complainant has not even intimated the incident to the police within a reasonable time as evident from the FIR registered by the police in this case.
Complainant in this case is not entitled to claim accidental hospitalization benefits specified Under Section 3 any benefits towards loss of job defined Under Section 4 of the policy condition, for the insignificant injuries sustained to her. The minor injury sustained to the complainant was effectively managed by outpatient treatment and she had resumed to normal health within days from the accident. The complainant is therefore not entitled to get any claim towards loss of salary as claimed in para 3 of the complaint for the leave alleged to have taken by the complainant due to the alleged accident. It is submitted that there is no provision in the policy for payment of any benefits towards loss of income as claimed in the complaint on account of the leave alleged to have taken by the complainant. As per
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the specific condition in Section 4 of the policy, the insured is entitled to claim a maximum of Rs.25,000/- towards his loan account, in the event of losing the job due to retrenchment from his employer in view of merger and acquisitions . The complainant has not incurred any medical expenses for the OP treatment taken by her from the Govt.Taluk Hospital for a claim under that head. It is submitted that the policy holder is entitled to claim medical expenses only on production of detailed bills and receipts from the hospital for the inpatient treatment expenses incurred by the policy holder, for the injury suffered resulting permanent total disability and permanent partial disability due to the accident. In the present case the complainant has not taken any inpatient treatment and has not incurred any medical expenses for the OP treatment taken by her for the simple injuries sustained .
The claims advanced by the complainant under various heads are not admissible and are against the basic terms and conditions of the policy and are liable to be dismissed. The complaint has no manner of the right to attribute any kind of deficiency against this opposite party and to raise any grievance against this opposite party under the provisions of the Consumer Protection Act.
The Points
1. Whether there is any deficiency in service on the part of the opposite party?
2.Whether there is any unfair trade practice on the part of the opposite party?
3.whether the complainant is entitled to get compensation as claimed?
4.Reliefs and costs
Evidence on the side of the complainant consists of the oral testimony of PW1 and documentary evidence P1 to P4. Opposite party have not adduced any
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oral evidence but got marked Ext.D1 policy conditions. Heard Learned Counsel for the parties and perused records.
The Points :-
Admitted case of the parties is that complainant had taken a Sarv Suraksha Policy from the opposite party by paying a total one time premium amounts of Rs.1114/- on 24/08/2015 which covers Rs.1,50,000/- for permanent disability , Rs.25,000 for the loss of earning for three months , Rs.1,00,000/- for the loss of articles, Rs.80,000/- for the accidental hospitalization and Rs.25,000/- for critical illness.
Here the crucial question to be considered is whether the claim repudiated by the opposite party is justifiable or not?
Learned counsel for the complainant submitted that on 31/08/2015 at about 8.45 AM complainant met with an accident while she was riding her scooter bearing Reg.No..KL-23. K 9380 a cat crossed the road and she fell down and sustained injuries namely
1.loss of one tooth in the lower jaw
2.Class II fracture of one tooth in lower jaw
3.concession of more than 3 teeth in both upper and lower jaw
4.Abrasion on upper lip
5.Abrasion on nose
6.Abrasion on face below left eye
7.Abrasion on right leg and knee
and was taken to the Government Taluk Head Quarter Hospital, Karunagappally and she was treated as OP for many days and paid more than 15,000/- as treatment
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expenses. Loss of teeth , fracture of tooth and concession of a number of teeth and other injuries the complainant sustained permanent disability and hence she is entitled to get Rs.1,00,000/- from opposite party.
Counsel for the opposite party submitted that complainant has not suffered any injury causing Permanent disability and Permanent Partial Disability as mentioned in the policy and as such the complainant is not entitled to claim any benefits for the injury. The counsel for the opposite party vehemently argued that there is a specific condition in the policy regarding permanent partial disability and it is the duty of the complainant to prove that she suffered Permanent Partial Disability as mentioned in the policy condition and that there is absolutely no evidence to show that the complainant had suffered any Permanent Partial Disability or Partial Disability.
We have perused Ext.D1 document (Policy and policy condition) and it is seen that injuries sustained by the complainant would not come under the purview of the policy condition 2.2 and 2.3 ie coverage part, Permanent Partial Disability, coverage part B- Partial Disability. Hence the denial of the claim for permanent disability of the complainant is justifiable .
Learned counsel for the complainant has further argued that the complainant is entitled to get Rs.15,000/- for the expenses incurred for the treatment Rs.1500 for the loss of helmet Rs.8500/- for the loss of earning.
Learned counsel for the opposite party has drawn our attention that complainant has not produced any documents showing the IP treatment, Medical bills, wound certificate and that the claim preferred by the complainant towards loss of salary/loss or earning etc are also not allowable under the policy terms and conditions . As the complainant has not produced any document to substantiate that
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she had treated as IP, also not produced any medical bill for medical expenses and loss of helmet and complainant also failed to prove that she suffered Permanent disability /Permanent Partial Disability as mentioned in the policy conditions.
Counsel for the complainant has drawn our attention towards pleading in complaint that while complainant is an employee working as an account at Abyes Mobile Priority, Kollam injuries sustained and she was compelled to take leave for one month in loss of pay and thereby she sustained a loss of income of Rs.8500/-, due to the injuries sustained during the accident. But no documentary evidence has been produced showing that the complainant was working at the time of accident. In such circumstances, this pleading is without proof and cannot be relied upon.
On evaluating the entire materials available on record we are of the view that the complainant has failed to substantiate her case.
Since insurance being a contract between the parties, they are bound by the terms and condition s of the policy. It is settled position that nobody can go beyond the terms and conditions of the policy. Here the complainant failed to prove violation of any of the conditions of the policy on the part of opposite party. Hence we are inclined to hold that the opposite party rightly repudiated the claim and we are not in a position to attribute any deficiency in service, negligence or any unfair trade practice on the part of opposite party.
In the result, complaint stands dismissed. Parties are directed to suffer their respective costs.
Dictated to the Confidential Assistant Smt.Vijimole.G transcribed and typed by her corrected by me and pronounced in the Open Forum on this 30th day of January 2018 .
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Dated this the 30th day of January 2018.
E.M .MUHAMMED IBRAHIM:Sd/-
M.PRAVEENKUMAR:Sd/-
Forwarded/by Order
Senior Superintendent
I N D E X
Witness examined for the complainant
PW.1:-Aswathy
Documents marked for the complainant
1.Ext.P.1:- Policy certificate
2.Ext.P.2:- Photocopy of FIR
3.Ext.P.3:-OP. Tickets (2 nos)
4.Ext.P.4:- Photocopy of driving license
Witness examined for the opposite party
Nil
Documents marked for the opposite party
1.Ext.D.1:- Policy schedule and condition
E.M .MUHAMMED IBRAHIM:Sd/-
M.PRAVEENKUMAR:Sd/-
Forwarded/by Order
