O R D E R <br /> <br /> <br /> SRI. D.KRISHNAPPA., PRESIDENT.,<br /> <br /> The grievances of the complainant against the Op in brief is that he is working has a Group D official in RBANMS 1st grade college. On 14-06-2008 at about 8 pm he fell into a sump situated in front of his house and sustained injury to his leg. Then he approached Vijayalakshmi Hospital who on examination told him to had diabetic and blood pressure and he got treatment as inpatient for about 25 days. That he suffered expenditure of Rs.70,000/- and he has taken a group insurance floated by his college from the OP company. That he thereafter gave a claim application with all necessary documents but the Op has not considered his claim but issued a letter on 01-09-2009 as no claim. Therefore stated to had suffered and prayed for a direction to the OP to pay him Rs.1 lakh under different heads. <br /> <br /> OP has filed version through his advocate admitting that the complainant’s employer the college having availed group insurance for the benefit of its employees. It is further contended by them that it is not liable under the policy conditions to pay medical expenses. That the insured is covered with a risk through his employer and the complaint is bad for non-joinder of his employes. It is further stated that the insured will be entitled for reimbursement of hospital expenditure only in case of accidental death, loss of limbs, loss of eyes, permanent and total disablement with permanent partial disablement. That the complainant has given different dates of the injury he suffered once telling that he suffered injury on 14-06-2008 whereas the discharge summary contain date of accident as 13-06-2008. OP further admitting that risk of the complainant is also covered in the group insurance floated by the college of the complainant and stated that the amount could be reimbursed only when there is a death, loss of limbs, eyes, fingers including other organs of the body but in the case of the complainant he has not suffered any loss or cessation of any parts of his body as such stating that he is not liable to compensate the complainant as the complainant having had not suffered the eventualities as relied upon by them as prayed for dismissal of the compliant. <br /> <br /> <br /> In the course of enquiry into the complaint, the complainant and one Chethan a representative of the OP have filed their affidavit evidence by reproducing what they have stated in their respective compliant and version. The complainant alongwith the compliant produced a copy of the risk assumption letter, a copy of the letter containing insurance particulars with copies of letters he had addressed to the OP and list of the beneficiaries on whose behalf the group insurance was taken. OP also produced terms and conditions of group personal accident insurance policy and details of reimbursement of medical expenditure. We have head the complainant who is in person, counsel for the OP and perused the records.<br /> <br /> <br /> On the above contentions, following points for determination arise.<br /> <br /> 1. Whether the complainant proves that the OP has caused deficiency in his service in not reimbursing his medical expenses incurred for treating his fractured leg? <br /> <br /> 2. To what relief the complainant is entitled to ?<br /> <br /> Our findings are as under:-<br /> <br /> Point No: 1 in the negative.<br /> Point No: 2:see the final order.<br /> <br /> REASONS: POINT No:1:: <br /> <br /> The claim of the complainant, that he is one of the beneficiaries of the group insurance floated by his employer with the OP. His further contention is that he accidentally fell into a sump in front of his house suffered fracture, claim to had availed treatment as an inpatient spending Rs.70,.000/- but the OP to whom he had made a claim with necessary documents has refused the claim. <br /> <br /> The OP counsel inviting our attention to the terms and conditions of the policy issued by the OP stated that the complainant though had suffered an injury to his leg but there being no total or partial permanent disablement will not be entitled for reimbursement of the medical expenditure. In this regard the OP relied upon basis on which the insured would become entitle for reimbursement of medical expenditure. On going through these conditions ( exclusions) it is found that these exclusions found to be harsh and defeating the object of taking insurance. The conditions further read that an insured to become entitle to benefit under the policy should have suffered a death or actual loss by physical separation of two entire hands or two entire feet, entire foot or sight of one eye and such loss of entire hand or one entire foot then the capital sum insured and stated that part I of the schedule is applicable to such insured person. Admittedly the complainant has not suffered any such injury of total disablement, partial disablement or eye sight and other injuries which results in total disability of the insured. The complainant as against these conditions of the policy has not brought to our notice the terms and conditions of the policy which would entitled him for reimbursement of medical expenditure he has suffered. We by going through the conditions of the policy find that the complainant under these circumstances is not entitled for reimbursement. With such restrictive conditions, the policy taken by the management of the complainants consumer ended with no benefit to the insured except on extreme injuries falling in the group of death or physical separation of the complainant body organs. We therefore find that the nature and conditions of the policy will not benefit the insured until they reach the extreme events happening. As the result the OP based on the conditions of the policy has repudiated the claim of the complainant which cannot be termed has deficient. Hence we answer point No: 1 in the negative and pass the following order. <br /> <br /> O R D E R<br /> <br /> Complaint is dismissed. Parties to bear their own costs. <br /> <br /> Dictated to the stenographer. Got it transcribed and corrected. Pronounced in the open forum on this the 15th February 2010.<br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT. <br /> <br />