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