DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/9/2022

Date of Institution   : 04.01.2022

Date of Decision    : 22.05.2024

Pardeep Kumar Gupta, aged about 62 years, son of Sham Lal resident of # B-XI/436, Street No. 10-B, K.C. Road, Ward No. 22, Barnala, Tehsil and District Barnala, Punjab.           

                          …Complainant Versus

1. IFFCO TOKIO General Insurance Company Limited, Ch. Sobha Ram Complex, Garg Tyre Emporium, Bathinda, Punjab, through Branch Manager. 

2. IFFCO TOKIO General Insurance Company Limited, IFFCO TOKIO Plot, 2B&C, Sector 28-A, Madhya Marg, Chandigarh, through Branch Manager. 

                             …Opposite Parties

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. Dhiraj Kumar counsel for complainant.

Sh. A.K. Jindal counsel for opposite parties.

Quorum:-

1. Sh. Jot Naranjan Singh Gill : President

2.Smt. Urmila Kumari : Member

3.Sh. Navdeep Kumar Garg : Member

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1. The complainant namely Pardeep Kumar Gupta has filed the present complaint under Section 35 of the Consumer Protection Act 2019, (amended upto date) against IFFCO TOKIO General Insurance Company Limited & others (hereinafter referred as opposite parties).  

2. The facts leading to the present complaint are that the complainant obtained individual personal accident policy valid from 24.8.2019 to 23.8.2020 bearing No. 54534008 from the opposite party No. 1 through Bhushan Kumar Garg agent of opposite parties. As per policy temporary total disablement (TTD) sum insured was Rs. 5,00,000/- and as per policy weekly benefit of 1% of sum insured mentioned under TTD benefit was agreed by the opposite parties with the complainant. It is further alleged that the complainant met with an accident on 10.10.2019 and first aid was given by Dr. Pardeep Sharma to the complainant and he was referred by the said doctor to DMC & Hospital Ludhiana on same day and the complainant was admitted in DMC & Hospital Ludhiana on 10.10.2019 and was discharged on 19.10.2019. The complainant was preventing from attending to his business and temporary totally disabled from 10.10.2019 to 16.2.2020 and in this regard medical certificate was issued by Dr. Rajneesh Garg, MS Ortho, DMC & H Ludhiana. It is further alleged that as per terms and conditions of the policy claim No. 51094561 was applied by the complainant before the opposite parties and required documents were also supplied by complainant to the opposite parties, but the opposite parties failed to pay the claimed amount to the complainant without any reason. However, letter/reminder was wrongly issued by the opposite parties to the complainant for supply of some documents on 12.12.2019, which were already supplied by complainant at the time of applying of claim and thereafter reply of the same was given by the complainant to the opposite parties on 22.4.2021 alongwith required documents, but the claim of the complainant is not cleared/payment of the claim is not made by opposite parties to the complainant. The above said act of the opposite parties suffered a lot of harassment and mental agony to the complainant, as such there is deficiency in service and negligence on the part of opposite parties. The complainant has also issued a legal notice on 16.12.2021 to the opposite parties but they did not bother to reply the same. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To make the payment of Rs. 92,857/- alongwith interest.  

ii)To pay Rs. 30,000/- as compensation of humiliation and harassment of the complainant and Rs. 10,000/- as litigation expenses.   

3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking legal objections interalia on the grounds that the complainant has concealed material facts and documents from this Commission as well as the opposite parties. The complainant did not provide required documents i.e. 1) claim form duly filled & signed by beneficiary, 2) detailed narration of incident i.e. how accident happened in relation to time, place and date, 3) History of Alcohol intake at the time of accident, certified by treating doctor, who attended the patient immediately after injury, 4) Original discharge summary of the hospital, 5) original Total Treatment Papers like Discharge summary, Doctor's prescription advising test, X-ray/pathology report alongwith films etc., 6) Original medical bills (if medical extension provided), 7) Original Fitness certificate issued by Doctor, 8) Original Leave Certificate issued by Employer, 9) Copy of Attendance Register, 10) Copy of Photo ID Proof and 11) Copy of Pan, Adhaar Card & cancelled cheque/NEFT details required for processing and decision of claim although it was mandatory on the part of insured to provide all relevant documents for processing and decision of claim as per terms and conditions of the policy. The opposite parties wrote letters 23.11.2019, 12.12.2019 and Final reminder letter dated 24.1.2020 but the complainant failed to submit the complete documents, as such claim of the complainant closed as “No Claim” on account of non-compliance of above said letters. 

4. On merits, it is submitted that the policy is strictly subject to its terms and conditions. The complainant not produced any certificate from the concerned hospital/doctor for advising him for complete bed rest for the huge period of 10.10.2019 to 16.2.2020 as claimed. As per discharge summary of complainant he was advised bed rest for 4 weeks from 10.10.2019, hence the amount claimed by complainant in the present complaint is exorbitant and hence should not be considered. Moreover, as per insurance policy Temporary Total disablement benefit at the rate per week is 1% CSI (available under TTD benefits) or Rs. 25,000/- whichever is lower is only payable (refer Table benefits at page No. 4 & 5 of the policy conditions). Further, no treatment papers, X-ray reports, and original medical bills were provided by the complainant to enable respondent to decide admissibility of the claim under the terms and conditions of the insurance policy. It is wrong to state that the complainant was preventing from attending his business or temporary totally disabled from 10.10.2019 to 16.2.2020 as alleged. All other allegations of the complainant are denied and prayed for the dismissal of complaint.  

5. Ld. Counsel for the complainant has filed rejoinder to the written version filed by opposite parties and denied the averments as mentioned in the reply.  

6. To prove the case the complainant tendered into evidence copy of policy schedule Ex.C-1, copy of prescription slip Ex.C-2, copy of discharge summary Ex.C-3 (containing 2 pages), copy of medical certificate Ex.C-4, copy of reminder letter Ex.C-5, copy of letter dated 22.4.2021 Ex.C-6, copy of legal notice Ex.C-7, postal receipts Ex.C-8 & Ex.C-9, his own affidavit Ex.C-10 and closed the evidence. 

7. To rebut the case the opposite parties tendered into evidence copy of request letter Ex.OPs-1, copy of reminder letter Ex.OPs-2, copy of final reminder letter Ex.O.Ps-3, copy of policy schedule Ex.O.Ps-4 (containing 12 pages), affidavit of Devendra Kumar Ex.OPs-5 and closed the evidence. 

8. We have heard the learned counsel for the parties and have gone through the record on file. Written arguments filed by complainant.

9. Ld. Counsel for the complainant argued that the complainant obtained individual personal accident policy valid from 24.8.2019 to 23.8.2020 bearing No. 54534008 (Ex.C-1) from the opposite party No. 1 through Bhushan Kumar Garg agent of opposite parties and as per policy temporary total disablement (TTD) sum insured was Rs. 5,00,000/- and as per policy weekly benefit of 1% of sum insured mentioned under TTD benefit was agreed by the opposite parties with the complainant. It is further argued that the complainant met with an accident on 10.10.2019 and first aid was given by Dr. Pardeep Sharma to the complainant (Ex.C-2) and he was referred by the said doctor to DMC & Hospital Ludhiana on same day and the complainant was admitted in DMC & Hospital Ludhiana on 10.10.2019 and was discharged on 19.10.2019 (Ex.C-3). It is also argued that the complainant was preventing from attending to his business and temporary totally disabled from 10.10.2019 to 16.2.2020 and in this regard medical certificate was issued by Dr. Rajneesh Garg, MS Ortho, DMC & H Ludhiana (Ex.C-4). It is further argued that as per terms and conditions of the policy claim No. 51094561 was applied by the complainant before the opposite parties and required documents were also supplied by complainant to the opposite parties, but the opposite parties failed to pay the claimed amount to the complainant without any reason and a letter/reminder dated 12.12.2019 (Ex.C-5)  was wrongly issued by the opposite parties to the complainant for supply of some documents, which were already supplied by complainant at the time of applying of claim and thereafter reply of the same was given by the complainant to the opposite parties on 22.4.2021 (Ex.C-6) alongwith required documents, but the claim of the complainant is not cleared/payment of the claim is not made by opposite parties to the complainant. 

10. Ld. Counsel for the opposite parties argued that the complainant did not provide required documents which were demanded by the opposite parties vide letter dated 12.12.2019 (Ex.O.Ps-2) which are as under;-1) claim form duly filled & signed by beneficiary, 2) detailed narration of incident i.e. how accident happened in relation to time, place and date, 3) History of Alcohol intake at the time of accident, certified by treating doctor, who attended the patient immediately after injury, 4) Original discharge summary of the hospital, 5) original Total Treatment Papers like Discharge summary, Doctor's prescription advising test, X-ray/pathology report alongwith films etc., 6) Original medical bills (if medical extension provided), 7) Original Fitness certificate issued by Doctor, 8) Original Leave Certificate issued by Employer, 9) Copy of Attendance Register, 10) Copy of Photo ID Proof and 11) Copy of Pan, Adhaar Card & cancelled cheque/NEFT details. It is further argued that it was mandatory on the part of insured to provide all relevant documents for processing and decision of claim as per terms and conditions of the policy and the opposite parties wrote letters 23.11.2019 and Final reminder letter dated 24.1.2020 (Ex.O.Ps-1 & Ex.O.Ps-3) but the complainant failed to submit the complete documents, as such claim of the complainant closed as “No Claim” on account of non-compliance of above said letters. It is further argued that the complainant not produced any certificate from the concerned hospital/doctor for advising him for complete bed rest for the huge period of 10.10.2019 to 16.2.2020 as claimed and as per discharge summary of complainant he was advised bed rest for 4 weeks from 10.10.2019, hence the amount claimed by complainant in the present complaint is exorbitant and hence should not be considered. It is also argued that as per insurance policy (Ex.O.Ps-4) Temporary Total disablement benefit at the rate per week is 1% CSI (available under TTD benefits) or Rs. 25,000/- whichever is lower is only payable (refer Table benefits at page No. 4 & 5 of the policy conditions) and no treatment papers, X-ray reports, and original medical bills were provided by the complainant to enable respondent to decide admissibility of the claim under the terms and conditions of the insurance policy. Further, in the arguments it is denied by Ld. Counsel for the opposite parties that the complainant was preventing from attending his business or temporary totally disabled from 10.10.2019 to 16.2.2020.

11. It is admitted fact that the complainant obtained individual personal accident policy valid from 24.8.2019 to 23.8.2020 bearing No. 54534008 from the opposite party No. 1 and as per policy temporary total disablement (TTD) sum insured was Rs. 5,00,000/- and as per policy weekly benefit of 1% of sum insured mentioned under TTD benefit was agreed by the opposite parties with the complainant. It is also admitted fact that the complainant met with an accident on 10.10.2019 and first aid was given by Dr. Pardeep Sharma to the complainant and he was referred by the said doctor to DMC & Hospital Ludhiana on same day and the complainant was admitted in DMC & Hospital Ludhiana on 10.10.2019 and was discharged on 19.10.2019. 

12. The allegation of the opposite parties is that the complainant not produced any certificate from the concerned hospital/doctor for advising him for complete bed rest for the huge period of 10.10.2019 to 16.2.2020 as claimed and as per discharge summary of complainant he was advised bed rest for 4 weeks from 10.10.2019, hence the amount claimed by complainant in the present complaint is exorbitant and hence should not be considered. To prove his case the complainant has placed on record Medical Certificate Ex.C-4 which was issued by the treating Doctor Rajnish Garg MS (Ortho) Professor & Head Deptt. of Orthopaedics DMC & Hospital, LDH. vide which in the column No. 3 it is mentioned “Has claimant been totally prevented from attending to any portion of his business? If so for how long? and in this regard date is mentioned as 10.10.2019 – 16.2.2020”. Further, in column No. 6 it is mentioned that How long from the happening of the Accident do you consider a) Total disablement will last from 10.10.2019 – 16.2.2020. It is also mentioned in the medical certificate by the treating doctor that Having personally examined the above named insured. I certify that the above statements are correct and that the insured person is necessarily disabled by the accident referred to. So, from the perusal of above said medical certificate issued by the treating doctor it is proved that the complainant was preventing from attending to his business due to temporary totally disabled from 10.10.2019 to 16.2.2020. The another allegation of the opposite parties is that the complainant has not supplied the history of Alcohol intake at the time of accident, certified by treating doctor, who attended the patient immediately after injury. In this regard the complainant has placed on record copy of prescription slip (Ex.C-2) of first treating Doctor Pardeep Sharma M.S. (Ortho) of Pardeep Sharma Hospital, Kacha College Road, Barnala and the above said doctor in the prescription slip mentioned “No History of Alcohol at the time of injury”. So, this allegation of the opposite parties is not tenable. Further, from the perusal of insurance policy Ex.O.Ps-4 it shows that Temporary Total Disablement (TTD) sum insured was Rs. 5,00,000/- and as per policy weekly benefit of 1% of sum insured mentioned under TTD benefit. Further, at Page No. 5 of Ex.O.Ps-4 it is also mentioned that Temporary Total disablement benefit at the rate per week 1% of C.S.I or Rs. 25,000 whichever is lower. Therefore, we are of the view that the complainant is entitled for the benefit as claimed by him as per policy. So, the days from 10.10.2019 to 16.2.2020 comes to 130 days and the same was divided by 7 means one week (i.e. 130/7 comes 18.57 X Rs.5,000 = amounting to Rs. 92,850/-). 

13. In view of the above discussion, the present complaint is partly allowed and the opposite party is directed to pay Rs. 92,850/- to the complainant alongwith interest @ 7% per annum from the date of filing the present complaint till its realization. The opposite parties are further directed to pay Rs. 15,000/- on the account of consolidated amount of compensation alongwith litigation expenses to the complainant. 

14. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

15. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       22nd Day of May, 2024

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member