Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 302
Instituted on : 06.07.2018.
Decided on : 04.07.2022.
Vinod Kumar age 29 years s/o Sh. Krishan R/o Village-Baroda, Teh. Gohana, District Sonipat. .
......................Complainant.
Vs.
HDFC ERGO General Insurance Company Ltd., 5th Floor, Tower-1 Stellar I.T. Park, C-25, Sector-62, Noida(UP) through its Director/Manager.
...........…….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. SHYAM LAL, MEMBER
Present: Sh. Puneet Chahal, Advocate for the complainant.
Sh.Gulshan Chawla Advocate for the opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the complainant had availed individual personal accident policy vide no.3317100153475800000 from the respondent which was valid from 04.11.2016 to 03.11.2017 and he has paid premium of Rs.1124/-. On 08.01.2017, the complainant met with an accident and suffered injuries and he was got admitted in PGIMS, Rohtak and his MLR was conducted vide No. MV/03/2017. Thereafter, complainant was admitted in Sir Ganga Ram Hospital, New Delhi and Goyal Hospital Jaipur and he became permanent disabled and he had spent Rs.2,50,000/- on his treatment. The complainant had applied for insurance claim to the opposite party vide claim No.331716000335 and submitted all the relevant documents to the opposite party. The complainant requested the opposite party many times to disburse his amount but the opposite party had not given any heed to the request of complainant. Hence, there is deficiency in service on the part of opposite party and it is prayed that opposite party may kindly be directed to pay an amount of Rs.5,00,000/- alongwith interest at the rate of 18% p.a. till the date of actual realization of whole of amount, compensation and litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that the policy certificate bearing no. 3317100153475800000 namely individual personal accidental policy was being availed by the complainant for the period of 04.11.2016 to 03.11.2017, subject to the terms and conditions of the policy. That the complainant had opted for the below detailed benefits namely Accidental death, dependant child education benefit, medical insurance premium indemnity and permanent disablement:
Coverage Sum assured
Accidental death 10,00,000/-
Dependent Child Education Benefit 1,00,000/-
Medical Insurance Premium Indemnity 1,00,000/-
Permanent Disablement 1,00,000/-.
It is further submitted by the opposite party that complainant met with an accident on 08.01.2017, registration of the DDR No.4 on 25.01.2017 and having suffered injury is correct as per the information provided by the complainant. On the receipt of the claim intimation, the claim of the complainant was registered vide claim No. C331716000335 and claim number was shared with complainant/informer for better communication in regard to the present claim. It is wrong and denied that the complainant submitted entire document required for adjudication/settlement of claim of merits. It is hereby submitted that letters dated 08.02.17 and 05.04.2017 were served upon the complainant requesting him to provide the documents as per check list for the settlement of claim but getting no response, answering respondent were left with no other option except to close the claim of the complainant for want of documents. Hence, there is no deficiency in service on the part of insurance company. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. Counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C-1 to Ex.C-57 and has closed his evidence on dated 13.02.2019. Ld. counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.RW1/1 to Ex.RW1/3 and closed his evidence on 27.08.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case, the contention of opposite party is that the complainant has not submitted required documents i.e. original discharge summary, all original medical investigation report, KYC form alongwith self signed KYC documents and original cancelled cheque alongwith bank passbook copy of insured. On the other hand, the complainant placed on record so many documents in his evidence i.e. Ex.C1 to Ex.C57 . During the pendency of the complaint, one more application has been moved by the complainant on dated 14.06.2021 for submitting the documents and placed on record the DDR Report, M.LṚ., Disability Certificate and X-Ray report, Treatment Record, discharge chard of Goyal Hospital Jaipur, Treatment bills/medicine bills, cancel cheque and copy of bank pass book, Copy of Aadhar Card & PAN Card. The reply of the application has also filed by the respondent on dated 02.08.2021 and as per reply they again demanded the documents from the complainant.
6 We have minutely perused the documents placed on record. The bare perusal of MLR and treatment record itself shows that complainant suffered multiple fractures in his left hip i.e. dislocation of joint with vascularity below knee and he took treatment from the various hospitals i.e.Ganga Ram Hospital, New Delhi, Goel Hospital and also purchased medicines and equipments from other medical stores. To prove this fact he placed on record so many bills and copy of treatment record. As per Ex.C5 disability certificate issued by the Medical Board, PGIMS, Rohtak, complainant has suffered 50% disability. We have minutely perused the cover note Ex.C1/Ex.RW1/1 Individual Personal Accident Policy and as per this policy the complainant was covered under the policy for an amount of Rs.10 lac for accidental death, Rs.1 lac for Dependent Child Education, Rs. 1 lac for medical Insurance Premium Indemnity and Rs. 10 lac permanent disablement. However opposite party in their reply has wrongly submitted the amount of permanent disablement Rs.100000/-. The respondent insurance company also placed on record terms and conditions of the policy which is part of Ex.RW1/1. In the terms and conditions of the policy- word permanent disability has been described in section 2 on page no.5 : “If during the Period of Insurance an insured person sustains bodily injury which directly and independently of all other causes results in disablement within twelve(12) months of the date of loss, then the company agrees to pay to the insured person the compensation stated in the specific Table of benefit below which is shown as the Table of benefits in the schedule. From the perusal of medical report, treatment record and disability certificate, it has been established that the complainant suffered multiple fracture and disability in the accident in question and as per policy, the complainant was covered under the head permanent disablement for Rs.10 lacs. As the complainant suffered 50% permanent disablement so he is entitled for Rs.5 lac as per the policy.
7. In view of the fact and circumstances of the case we hereby allow the compliant and direct the opposite party to pay Rs.500000/-(Rupees five lac only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 06.07.2018 till its realization and shall also pay a sum of Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. 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:
04.07.2022.
........................................................
Nagender Singh Kadian, President
……...........................................
Tripti Pannu, Member.
……………………………….
Shyam Lal, Member
