SMT. RAVI SUSHA  : PRESIDENT

         This complaint has been   filed  for getting an order directing opposite party to pay sum of Rs.16,00,000/- to the complainant with  interest  and  to pay  cost of the proceedings of this case.

   Briefly the fact of the complaint is that  the complainant was the registered owner of the car KL-59P/4286  having valid  driving license, and the car was having valid insurance coverage at the time of accident.  On 22/4/2019, the complainant was driving the car met with an accident.  In the accident the complainant ahs his wife sustained grievous injuries.  He had type 2 Thompson Epstein posterior hip dislocation and fracture of acetabulam.  His right lower limp fluxed, adduced and internally rotated with shortening.  Then he was taken to Aster MIMS  hospital, Kannur and admitted  there for treatment on the same day.  He was discharged from the hospital on 27/4/2019.  The complainant became permanently disabled.  At present , the complainant  is having more than 75% permanent disability considering the body as a whole.  His occupational disability will be 100%.  As the car  was validity insured with the OP vide policy No.11203219, they are bound to pay compensation under the head of personal  accident coverage to the complainant in proportion to the percentage of permanent disability he had.  The OP failed to disburse the amount entitled to the complainant.  As per the norms of the policy issued by the OP, they are liable to pay proportionate amount of the sum of Rs.15,00,000/- to the complainant.  100% of the above sum will come to Rs.15,00,000/-.  In addition , the complainant spent more than Rs.1,00,000/- towards medical expenses and treatment expenses.  The total amount entitled for the complainant will come to Rs.16,00,000/-.  The OP defaulted in the service to be tendered to the complainant.  Hence this complaint.

   Opposite party  admits  that the  vehicle  was insured in the name of complainant  on the date of alleged accident dtd.22/4/2019.  But the coverage  under the said policy is limited as per the endorsements , conditions and limitations of the policy.  It is submitted that the complainant  prefer this  complaint for the claim as if he is entitled for a personal accident  claim, under the guise  that the OP is liable to pay the same.   But even as  per the  policy copy produced by the complainant  it is seen that the OP has not collected any premium for PA coverage, hence the OP is  not liable to pay any compensation and the complainant is not entitled to  claim under the PA coverage. As per the complaint it is stated that the above alleged accident was happened while he was driving  his vehicle No.KL-59-P-4286.  The complainant neither informed the alleged accident to the OP nor registered a claim  as per the terms of the policy.  So the complainant is  not  entitled to  claim any amount  from the OP.  Hence prayed for the dismissal of the  complaint.

   At the evidence stage, complainant has filed his proof affidavit and documents. Examined as PW1, marked Extrs.A1 to A10 and the disability certificate  as Ext.X1.  On the side of OP, the Legal manager  of OP insurance company filed  his proof affidavit .  Examined as DW1 .  Marked policy with terms and condition as Ext.B1.  After that the learned counsel of OP made argument.  Learned counsel of complainant filed written argument note.

  The undisputed facts in this case are that the complainant was the owner-driver of the insured vehicle  No.KL/59/P/4286, that he had taken a policy of the vehicle with accident  benefit that during the policy period, he was involved in an accident and as result of that  accident Lacerated wound over Right side of posterior dislocation® Hip and he had 16% disability of right lower limb.  These points are admitted by OP but it is contended that the disability  from which the complainant suffered  did not entitle him to claim any benefit under the personal accident cover clause mentioned in the policy of insurance because it was not  permanent and as specified in that clause.  The relevant provision of that clause is as follows:- Personal Accident cover for owner-Driver “ the company undertakes to pay compensation  as per the following scale  for  bodily injury/death sustained by the owner-driver of the vehicle in direct connection with the vehicle insured or  whilst mounting into/dismounting  from or traveling in the insured vehicle as a co-driver ,caused by violent, accidental, external and visible means which  independently of any other cause shall  within six calendar  months of such injury result in  Death -100%, Loss of two limbs or sight of two eyes or one limb and sight of one eye-100%, Loss of one limb or sight of one eye-50%, Permanent total disablement from injuries other than named above -100%  compensation provided.”

   It is contended that as the disability suffered by the complainant was not permanent total disability it is not covered by the personal accident cover.  In the instant case as per Ext.X1 issued by the Medical Board percentage of disability stated  as 16% disability of right lower limb”.  Further it is not mentioned that  as a result of the disability caused by the accident, he would not be able  to earn his livelihood.  The above two findings are material facts and were not disputed.  It is to be noted that though the disability was caused due to accident, the nature of injury does not come under any of the category as mentioned in the terms and conditions  of the  policy and hence  was outside the  purview of the personal accident cover.

  The complainant deposed that  he has no dispute regarding the policy and its terms and conditions(Ext.B1).  Further the point to be noted is that though complainant has informed and given FIS on 10//6/2019(ie after 1 ½ months after the accident) and taken FIR, no intimation and claim had been preferred to the insurance company.  In the conditions it is very clearly mentioned that ”Notice shall be given in writing to the company immediately upon the occurrence of any accident or in the event of any claim.”

   Here the complainant  failed to do so.  So there is no question of repudiation of the claim.

   As per the circular Ext.A10, the complainant is eligible to get personal accident benefit, even if not remitted premium, but the complainant has violated the mandatory condition of giving intimation and submit claim form to OP Insurance  company.  Moreover, due to accident no disability happened which would become unable  him  from doing livelihood.  Hence he is not eligible to get the policy benefit.

   Under the circumstance  as stated above, complainant fails to establish his case.  Hence it is dismissed.  No order as to cost.

Exts:

A1-copy of  FIR in crime No.424/19

A2- copy of charge sheet

A3- copy of RC

A4- Insurance policy

A5-copy of driving license

A6-Accident register cum wound certificate

A7-Discharge summary

A8(series)- prescriptions( 5 in Nos.)

A9- IRDA circular copy

X1- Disability certificate( marked subjected to proof )

B1- Policy terms and conditions

PW1-Siju.P.B- complainant

DW1-shyju-M.V-OP

Sd/                                                                  Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                         MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                       /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR