Chandigarh

DF-I

CC/175/2024

OM PARKASH KHULLAR - Complainant(s)

Versus

ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

03 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/175/2024
Date of Institution	:	1/4/2024
Date of Decision	:	3/12/2024

 

Om Parkash Khullar son of Sh. Telu Ram Khullar, Aged 66 Years, R/o H.No.3175, Sector 21-D, Chandigarh.

Complainant.

VERSUS

ICICI Lombard General Insurance Company Limited, Branch Office through Branch Manager, Plot No.149, 4th Phase-I, next to Hometel Hotel, Industrial Area, U.T. Chandigarh.

2nd Address: 9th Floor, Flat No.12, ICICI Bank Towers Financial District Nanakramguda, Hyderabad (Telangana).

Opposite Party

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Ashwani Arora and Sh. Devinder Kumar, Advocate for complainant
	:	Sh. Sahil Abhi, Advocate for OPs (through VC)

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant against the opposite parties  (hereinafter referred to as the OP). The brief facts of the case are as under :-
   1. It transpires from the averments as projected in the consumer complaint that the complainant had obtained a loan to the tune of Rs.3,99,99,993/- from ICICI Lombard  and  in order to secure the loan the complainant obtained Group Safeguard Insurance policy  (hereinafter to be referred as subject policy) Annexure C-2 valid w.e.f. 29.6.2018 to 28.6.2023.  On 15.3.2022, when the complainant was walking towards the housing side at village Nirhali located on Dotehi-Kasauli  road,  which was a sloppy area, he accidently slipped and fell on the road and received serious injuries i.e. facture right trimallcolar closed W/o DNVD. Immediately, the complainant was taken to PGI where he was admitted and was operated  on 25.3.2022 and was discharged on 29.3.2022  with the advice to follow up in the OPD. The copy of medical treatment card is annexed as Annexure C-3. During stay in the hospital the complainant had intimated the OP through email dated 25.3.2022 regarding the accident which was duly acknowledged by the OP vide email 26.3.2022. The complainant got registered his claim with OP and relevant documents were also supplied to the OP by the complainant by sending mail, which was acknowledged by OP and copies of email exchanged between the parties are Annexure C-4 to C-6.  The OP has raised objection with regard to non submission of documents and the complainant had intimated the OP that he was still under medical treatment and the required medical documents cannot be provided at that stage. However, the claim of the complainant was rejected by OP vide rejection letter Annexure C-10 dated 13.7.2022, on  the ground of non submission of documents and clarification  having been supplied by the complainant.  Thereafter few communications were exchanged between the parties on 15.11.2022. The complainant was examined by the Orthopedics Department of PGIMER Chandigarh whereby he  was issued with Certificate Annexure C-12, by declaring the complainant as permanent partial disabled and the said certificate  was duly given to the OP on 16.11.2022. Thereafter various reminders were sent to OP to process his claim under the head of permanent partial disability but with no result. Ultimately the complainant was examined by the Medical Board of PGIMER whereby he had been issued with permanent disability certificate Annexure C-14 dated 21.3.2024  The complainant again submitted the relevant documents to OP but nothing has been done by the OP. In this manner, the aforesaid act amounts to deficiency in service and unfair trade practice on the part of OP. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
   2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action and also that the complainant has not approached this Commission with clean hands. It is further admitted that the subject policy was issued to the complainant which was valid w.e.f. 29.6.2018 to 28.6.2023  and the copy of the subject policy alongwith terms and conditions are annexed as Annexure OP-1. However, it is alleged that the claim of the complainant is not covered under the subject policy  since the  same does not fall in any category of the disability mentioned in the terms and condition of the policy at sr. No.1 to 27  as there is no actual loss by physical separation  of body part  as per table given  in the policy.  Not only this, beyond that any disability certificate given by any hospital does not fall in ambit of the policy coverage which is a contract itself. Hence, the claim of the complainant neither falls under the definition of “Accident or injury  or under the permanent partial disablement benefits.” Accordingly on finding that as the claim of the complainant was not falling under the ambit of policy coverage, the same was repudiated by the OP vide letter OP-2. Thereafter on obtaining permanent disability by the complainant, the complainant again made request to the OP for processing the claim but since again it was found that as there was no loss of any body part and the disability  was on account of stiffness, the claim was again repudiated on 26.3.2024 vide Annexure C-17 especially when the OP has taken expert opinion from Dr. Ninad P. Mohite  who examined the patient through video call and examined his records and had opined the aforesaid fracture   as temporary disability and the report of the medical expert is annexed as Annexure C-5. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
   3. In rejoinder, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.
2. In order to prove their respective claims the parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments on record.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy Annexure C-2/OP-1 covering the loan liability as well as structure of building alongwith accidental injury benefits valid w.e.f. 29.6.2018 to 28.6.2023  on payment of premium of Rs.10,38,400/-   with sum insured to Rs.3,99,99,993/-  and on  15.3.2022, the complainant  suffered traumatic ankle stiff right trimalleolar fracture and the claim of the complainant has been repudiated by the OPs vide repudiation letter Annexure C-10 dated 13.7.2022  on the ground that the claim of the complainant is not covered under the terms and conditions of the subject policy,  the case is reduced to a narrow compass as it is to be determined if the aforesaid act of the OP amounts to deficiency in service and the complainant is  entitled for the relief as prayed for, as is the case of the complainant or if the claim of the complainant being not falling within the ambit of policy coverage was rightly repudiated by the OP and the same is liable to be dismissed as is the defence of the OP.
   2. As per case of the complainant  he has suffered 20% permanent disability in relation to his right ankle and as the case of the complainant covered under the subject policy, the complainant is entitled for 20%  of the sum insured under the subject policy  and the OP has wrongly repudiated the genuine claim of the complainant whereas the defence of the OP is that the complainant has suffered permanent partial disability and since there is no separation of body part as covered under the permanent disability benefit under head A.1.3 of the terms and conditions of the policy, the claim  of the complainant was rightly repudiated as per terms and conditions of the policy. 

 

3. In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around the documentary evidence led by both the parties including the subject policy, terms and conditions and repudiation letter, which are  required to be scanned carefully to determine the real controversy between the parties.
4. Annexure C-2 is the subject policy and the  relevant details given in  tabulated form are reproduced as under:-

 

 

 

5. Annexure C-3  is the medical treatment card which clearly indicates that  the complainant has suffered fracture in the right ankle and remained admitted at PGI, Chandigarh. Annexure C-14  is the disability certificate issued by the   PGI  which indicates that the injury suffered by the complainant was declared to be 20% permanent disability by the said medical authority  of PGI  in relation to the right ankle  of the complainant. The relevant portion of the same is reproduced as under:-

“Certificate No.: CH0170619580107799

This is to certify that I/we have carefully examined Om Parkash Khullar, Son of Shri Telu Ram, Date of Birth 05/06/1958, Age 65, M, Registration No. 0401/00000/2307/0177326, resident of House No. House No. 3175 Sector 21 D Chaandigarh - 160022, Sub District Chandigarh, District Chandigarh, State / UT Chandigarh, whose photograph is affixed above, and I am/we are satisfied that:

A)    He is a case of Locomotor Disability

(B) The diagnosis in his case is Post Traumatic Ankle Stiff Right Trimalleolar fracture

C) He has 20%(in figure) Twenty percent(in words) Permanent Disability in relation to his Right Ankle as per the ( guidelines (Guidelines for the purpose of assessing the extent of specified disability in a person included under RPWD Act, 2016 notified by Government of India vide S.O. 76(E) dated 04/01/2018)”.

6. Thus one thing is clear on record that the complainant has not suffered permanent partial disability rather he has suffered permanent disability to the extent of 20%  in relation to his right ankle  on account of trimalleolar fracture.
7. As per defence of the OP the case of the complainant is not covered under any benefit given under the head A.1.3 of the policy schedule and the relevant portion of the same is reproduced as under:-

8.  As per case of the complainant his case is covered under clause A.2.6 of the policy and  the relevant portion of the same is reproduced as under:-

 

9. The learned counsel for the OP contended that as the loss suffered by the complainant i.e. permanent partial disability, is not covered under any of the benefits given head A.1.3 and  the claim of the complainant was rightly repudiated by the OP.
10. However, there is no force in the contention of the learned counsel for the OP as it stands proved on record that the complainant  had suffered 20% permanent disability  in relation to his right ankle which is squarely covered under Sr. No. 9 clause A.2.6 of the policy schedule  according to which for injury in lower leg, clavicle ankle the insured is entitled for 20% of the total sum insured and for that no permanent or partial permanent disability is required as is the defence of the counsel for the OP rather the benefit of the policy has also been extended for the fractured bones  under clause A.2.6 and as it is an admitted case of the parties as well as supported  with medical record including disability certificate that the complainant has suffered permanent disability  to the his right ankle, the complainant is entitled for benefit under the said clause.
11. In view of the foregoing discussion we are of the view that the OP is unjustified in repudiating the genuine claim of the complainant and there is deficiency in  service and unfair trade practice on the part of the OP.
12. So far as the quantum of relief is concerned, as held above the OP is liable to pay 20% of the total sum insured i.e. Rs.3,99,99,993/- x 20%= 79,99,999/- alongwith compensation and litigation cost.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-
   1. to pay ₹79,99,999/- to the complainant(s) alongwith interest @ 9% per annum (simple) from the date of repudiation till onwards
   2. to pay ₹20,000/- to the complainant/s as compensation for causing mental agony and harassment;
   3. to pay ₹10,000/- to the complainant/s as costs of litigation.
5. This order be complied with by the OP within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 3/12/2024			[Pawanjit Singh] President
mp
			[Surjeet Kaur] Member
			[Suresh Kumar Sardana] Member