Complaint filed on: 07-11-2017

                                                      Disposed on: 28-05-2018

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM,

OLD DC OFFICE COMPOUND, TUMAKURU-572 101

CC.No.100/2017

DATED THIS THE 28^th DAY OF MAY 2018

PRESENT

SMT.PRATHIBHA. R.K. BAL, LLM, PRESIDENT

SRI.BALAKRISHNA V.MASALI, MEMBER

Complainant: -

Muralidhar.B,

S/o. late Badappa,

Aged about 62 years,

Residing at Ojugunte,

Kotta post, Kasaba hobli, Sira taluk, Tumakuru district  

(In person)

V/s

Opposite parties:-    

1. HDFC ERGO General Insurance Co. Ltd, Registered and corporate office, 6^th floor, Leela Business park, Anderi, Kurla road, Anderi (East), Mumbai -59
2. The Sr. Manager, Service centre, (Health Claims Services) HDFC ERGO General Insurance Co. Ltd. No.25/1, 2^nd floor, building no.2, Shankaranarayana building, MG Road, Bengaluru
3. The Manager,

HDFC Bank, BH Road, Tumakuru

(OP No.1 and 2 by advocate Sri.B.K.Chandrashekaraiah)

(OP No.3- Exparte)

ORDER

SMT.PRATHIBHA. R.K.  PRESIDENT

        This complaint is filed by the complainant against the OP No.1 to 3, under section 12 of the Consumer Protection Act, 1986. The complainant prays to direct the OP No.1 to 3 to pay compensation of Rs.15,00,000=00 along with 18% interest per annum and grant such other relief as prayed in the complaint, in the interest of justice and equity.

2. The brief facts of the complaint is as under.

          The complainant has obtained Personal Accident policy No.52097069 from the OPs Insurance Company by paying premium amount of Rs.6,200=00. The above said policy was valid from 28-9-2015 to 27-09-2017.

          The complainant submitted that, on 6-11-2015 he met with an accident and he was admitted to the Forties Hospital, Nagarabhavi, Bengaluru for 15 days. And thereafter obtaining six months treatments in the said hospital as out-patient. The complainant further submitted that, for the above said treatment he has spent nearly Rs.10,00,000=00. The complainant further submitted that, after taken treatment, the complainant submitted a claim form before the OPs Insurance Company by claiming 100% compensation for the complete removal of lower jaw as per the personal accident table benefits-A. Further the complainant claimed 75% of compensation as per the table benefits-A as he has lost 100% of the hearing loss. The complainant further submitted that, he has lost hearing 96.62% of his left ear and 30% of his right ear.

          The complainant further submitted that, the OPs Insurance Company have not paid the full amount of hospital charges. In this regard, the complainant has approached the OPs on several times, but the OPs have paid only Rs.1,72,400=00 to the complainant’s account No.7402500100043601 in Karnataka Bank, Sira branch. The complainant further submits that, the OPs have not paid the full amount of the insured amount of Rs.15,00,000=00 to the complainant. Hence, the complainant has come up with the present complaint.

3. After service of the notice, the OP No.1 and 2 have appeared through this counsel and filed common objection. The OP No.3 did not appear before the form and he was called out absent and he has been placed ex-parte.

          4. In the version, the OP No.1 and 2 contended that, the complaint is not maintainable either in law or on facts and it is liable to be dismissed in limine. The OPs denies allegations made in the complaint, except those which are expressly admitted.

          The OP No.1 and 2 submitted that, the policy bearing No.52097069/00001 is a personal accident policy and the said policy was valid from 28-9-2015 to 27-9-2017 which was issued to the complainant. The OPs undertakes to pay the claim subject to accident death/injuries. The sum payable for death/injury as per the benefit chart mentioned as under

The above said policy only covers the table of benefits–Table-(B):

Table-B:

The OPs further submitted that, the insured had made a claim on 28-1-2016 under the said policy. After scrutiny of the medial documents, it was observed that, the insured has undergone treatment for bilateral maxillary facture anterior wall, bilateral infra-orbital rim facture, as per the table (b) covers only 100% disability. As per the

 Aesthetic loss due to soft issue/skeletal damage – 7.5%, 

Functional loss (Malocclusion & Mastication) – 22.5%

Both aesthetic + Functional loss included = 30%

Total – PPI (Permanent Physical Impairment) = 30%

          The OP No.1 and 2 further submitted that, after scrutiny of the documents issued a repudiation letter dated 12-2-2016 stating that;

“Insured has taken treatment related to bilateral maxillary fracture anterior wall. Bilateral infra-orbital rim facture. The disability certificate records both aesthetic and functional loss at 30%, but as per the policy terms and conditions (table B) we pay for 100% disablement. Hence, claim is not admissible”

          The OP No.1 and 2 further submitted that, the said personal accident policy only covers permanent total disability, as per the disability certificate, the insured has suffered only partial disability which is not covered as the terms and conditions of the said policy. Hence, the claim is not payable. The claim for partial disability bide claim no.PA/15-16/2551 is not payable under the said policy. However, the OPs have discharged its claim made vide claim no.PA/15-16/1936 for broken bones, hospital cash and temporary total disablement.

The OP No.1 and 2 further submitted that, the OPs have paid towards temporary total disability for Rs.1,08,750=00, Broken bones for Rs.50,000=00 and Hospital cash for Rs.64,000=00 to the complainant’s SB account. AS the said loss claimed under permanent disability is not payable under the said policy and the OPs have paid other claim expenses under broken bones, hospital cash and temporary total disablement.

The OP No.1 and 2 further submitted that, without prejudice, the OPs have denied all other averments made in the complaint as false in toto and the complainant is put to strict proof of the same. Hence the OPs have prayed to dismiss the complaint with cost, in the interest of justice and equity.   

5. In the course of enquiry in to the complaint, the complainant and OP have filed their affidavit evidence reproducing what they have stated in their respective complaint and objection. The complainant has produced document which were not marked. The OP has produced documents which were marked as Ex-R1 to R9. We have heard the arguments of both parties and we have gone through the oral and documentary evidence of both sides meticulously. 

6. Based on the above materials, the following points will arise for our consideration.

1. Whether the complainant has proved there is deficiency in service on the part of the OP?
2. What Order?  

7. Our findings on the above points are;

          Point no.1: In the negative

          Point no.2: As per the final order below

REASONS

8. On perusal of the averments of the complaint, objection of the OP and affidavit evidence of both parties, it is an admitted fact that, the complainant obtained Personal Accident policy No.52097069 from the OPs Insurance Company by paying premium amount of Rs.6,200=00 and the said policy was valid from 28-9-2015 to 27-09-2017. It is also an admitted fact that, at the time of accident, the said policy was in force. The complainant has claimed 100% compensation for the complete removal of lower jaw and loss of hearing 75% as per the personal accident table benefits-A. Further, the OPs have not paid full amount of the hospital charges. To substantiate the above said facts, the complainant has produced Ex-C1 to C9.

          9. Per-contra, the OP No.1 and 2 contended that, personal accident policy covers permanent total disability, as per Table –B. As per the disability certificate, the insured has suffered only partial disability which is not covered as per the terms and conditions of the policy. 

          10.  On perusal of the Ex-C2 table of benefits covers as mentioned below:

11. The Ops submitted that, they have paid the amount temporary total disability for Rs.1,08,750=00 and Broken bones Rs.50,000=00 and hospital cash Rs.14,000=00. The same was not disputed by the complainant. As per the table benefits the OPs have paid the amount to the complainant.

12. Further, on perusal of the Ex-C6/Permanent total disablement certificate issued by Dr.Mahesh.A Consultant surgeon of Fortis hospital, wherein it is clearly stated in the Sl.No.6. Hearing – impaired hearing more on left side.

          13. On perusal of the hearing evaluation report given by the audiologist and speed, Fortis Health Management, it is clearly mentioned that, LTC profound hearing loss and RTL mild sensational hearing loss. On the above said report, it is clear that, the complainant has not lost hearing of his both ears. On perusal of policy condition permanent disablement table-(B) it clearly mentioned that 75% of the compensation for the sum assured if permanent total loss of hearing in both ears. Hence, the complainant is not eligible to claim the loss of hearing on both ears. Further, with regard to complete removal of lower jaw, the complainant has failed to produce any documentary evidence that, the complainant lower jaw was removed completely. Hence complainant is not eligible to claim permanent total loss of hearing in both ears and complete removal of lower jaw as per table- B. Accordingly, we answer this point in the negative. In the result, for the foregoing reasons, we proceed to pass the following order;

ORDER

          The complaint filed by the complainant is hereby dismissed. No cost.          

          Supply free copy of this order to both parties. 

          (Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Open forum on this, the 28^th day of May 2018).

     MEMBER                                                         PRESIDENT