Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 485.
Instituted on : 21.08.2017.
Decided on : 29.07.2019.
Sh.Kuldeep Singh s/o Sh. Ram Chander R/o H.No.65/2, J.P.Colony, Rohtak, Haryana.
………..Complainant.
Vs.
- The Managing Director,. HDFC ERGO General Insurance Company Ltd., 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E) Mumbai-400059.
- Branch Off:-
HDFC ERGO General Insurance Company Limited, HDFC Bank, 401, 402, Model Town, Main Delhi Road, Haryana.
- Also At:-
HCS Noida, HDFC ERGO General Insurance 5th Floor, Tower 1, Steller IT Park, C-25, Sector 62, Noida-201301.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
SH. VED PAL, MEMBER.
DR. RENU CHAUDHARY, MEMBER.
Present: Sh.Satender Nara, Advocate for complainant.
Sh. Gulshan Chawla, Advocate for opposite party No. 1 & 3.
Opposite parties No. 2 given up.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the wife of the complainant had purchased “Sarva Suraksha” policy no.2950201071882800000 on dated 21.05.2015 and policy no.2950201295685400000 on dated 14.01.2016. That complainant has met with an accident and lost his right leg knee permanently and now permanently depends upon walker to walk and also suffered with medical expenses of Rs.350000/- on his treatment in Govt. and private hospital. That as per opposite party’s policies, complainant is liable to get benefits of Permanent Total Disability/Permanent Partial Disability as well as accidental hospitalization. That as per policy no. 2950201071882800000 dated 21.05.2015 complainant has right to charge from opposite party a sum of Rs.400000/- as permanent total disability/permanent partial disability and Rs.160000/- as accidental hospitalization. That complainant is also liable to get the benefits of the policy no.2950201295685400000 dated 14.01.2016 and Rs.500000/- as Permanent total Disability/Permanent Partial Disability and Rs.100000/- as Accidental Hospitalization. That complainant supplied all the necessary documents regarding the reimbursement of his benefits. That complainant requested the opposite parties many times orally as well as telephonically to reimburse the benefits under the policies but no attention has been paid by the opposite parties. That the act of OPs is illegal and there is deficiency in service on the part of O.Ps. As such, it is prayed that opposite parties may kindly be directed to make the payment of Rs.1360000/- as per terms and conditions of the policies and also to pay Rs.100,000/- as compensation on account of mental agony and harassment and Rs.22,000/- as litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite party No. 1 & 3 in their reply has submitted that the contents regarding the issuance of policies with terms and conditions of the policies are correct. It is also correct that as per information provided by the complainant, he met with an accident. It is denied that complainant has provided permanent disability certificate allegedly issued by PGIMS Rohtak in favour of the complainant to the answering respondent. That answering opposite parties severed several letters w.e.f. 21.11.2016 to 18.11.2017, requesting the complainant to supply the copy of disability certificate from Government hospital to evaluate the compensation. That the complainant has alleged to have been provided disability to answering respondent but has not provided even after filing of the present premature complaint. That the complainant failed to submit the requisite documents, therefore, the claim of the complainant cannot be considered. All the other contents of the complaint were stated to be wrong and denied and opposite party No. 1 & 3 prayed for dismissal of complaint with cost. However, opposite party No.2 was given up by the complainant being unnecessary as per his statement dated 03.10.2017.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.CW1/1 to Ex.CW1/11 and has closed his evidence on dated 28.01.2019. Ld. counsel for the opposite party No. 1 & 3 has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R24 and closed his evidence on dated 18.12.2018.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. As per the complaint, complainant has sought relief for loss of job, permanent partial disability, accidental hospitalization and credit shield insurance. But the claim of the complainant has not been settled by the opposite parties on the ground of non submission of documents. As per para no.6 & 7 of the complaint, the complainant has demanded an amount of Rs.400000/- as permanent total disability/permanent partial disability and Rs.160000/- for medical hospitalization under policy no. no.2950201071882800000. Complainant has also demanded Rs.5 lacs for permanent total disability/partial disability and Rs.100000/- as accidental hospitalisation under policy no.2950201295685400000. As per policy Ex.R1, period of insurance is 14.01.2016 to 13.01.2018 and as per policy Ex.R2, period of insurance is 21.05.2015 to 20.05.2018. In both the policies Ex.R1 & Ex.R2, the coverage under the head accidental hospitalisation is Rs.1 lac each and the complainant has submitted the bills approximately Rs.160000/-. Meanaing thereby, the demand under the head of accidental hospitalization is less than the sum assured. Complainant has also demanded an amount of Rs.100000/- for loss of job at the time of arguments. But perusal of the document Ex.CW1/10 itself shows that complainant was only absent from the services on medical grounds from 21.08.2016 to 21.1022016. As per section 4 of terms and conditions of the policy, it is submitted that : “In the event of the insured person losing his job due to retrenchment from his employer in view of mergers and acquisitions the policy will pay a maximum of 3 EMI towards his loan account or lesser if he gets re-employed earlier”. But in the present case, complainant has not lost his job and he was only on leave on medical grounds. Hence he is not entitled for any relief on this ground. Complainant has also sought relief under permanent disability and has placed on record disability certificate Ex.CW1/8 and Ex.CW1/9. As per which, complainant has 45% disability. Perusal of the disability certificate shows that the same was issued on 03.01.2019 i.e. after filing of the present complaint, meaning thereby, the same was not served to the opposite parties. As per condition no.2.3.2.2 of the policy Ex.R3 under the head Coverage of Permanent Partial Disability, it is submitted that “In the case of the Insured’s Permanent Partial Disability of a nature not detailed in the PPD Table, the Company will pay a proportion of the Sum Insured by reference to the degree to which the insured’s normal functional physical capacity has been impaired, as advised by the Company’s medical advisors”.
6. In view of the facts and circumstances of the case, it is observed that complainant is entitled for a sum of Rs.160000/-(Rupees one lac sixty thousand only) on account of accidental hospitalization under both the policies, which shall be paid by the opposite parties alongwith interest @ 9% p.a. from the date of filing the present complaint till its realization and shall also pay Rs.5000/- as compensation and litigation expenses to the complainant within one month from the date of decision.. However, complainant is also directed to submit the alleged certificate of permanent disability to the opposite parties and thereafter, the opposite parties shall settle the claim of the complainant on the basis of disability certificate. However, complainant is at liberty to file the fresh complaint, in case he is not satisfied with the decision of the opposite parties, regarding the claim assessment upon the disability certificate submitted before the opposite parties by the complainant.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
29.07.2019.
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Nagender Singh Kadian, President
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Ved Pal Hooda, Member.
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Renu Chaudhary, Member.
