Order by:

Sh.Mohinder Singh Brar, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that the complainant had purchased Liberty Individual Personal Accident policy bearing no.4111-200504-22-7000970-00-000 dated 22.07.2022 for the period of one year i.e. 22.072022 to 21.07-2023 from the opposite parties. Unfortunately, the complainant met with an accident on 19-11-2022 and he was admitted in Dayanand Medical College & Hospital Ludhiana on the same day i.e. 19-11-2022 and he remained under treatment and got discharged on 26-11-2022. Alleged that the complainant suffered head injury with right temporal Edh with Hemorrhagic contusions with fracture right Zygomatic Arch. The complainant underwent Orif  Plating right Zygomatic on 24-11-2022 and his Plastic Surgery was also conducted by the doctors. Alleged further that the complainant spent Rs.1,55,000/- for his treatment, misc. expenses i.e. Taxi charges, Diet and other expenses. After discharge from the hospital, the complainant remained under regular medical treatment and he has to purchase medicines etc. worth more than Rs.50,000/-, besides the amount mentioned above. Alleged that Opposite Parties was duly intimated about the accident and after discharge from the hospital, the complainant approached opposite parties for payment of expenses spent by him, but they refused to pay the claim amount. The complainant also issued a legal notice dated 20.04.2023 to the Opposite Parties, but to no effect. Due to such act of Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay Rs.1,55,000/- spent by complainant for the treatment and misc. expenses and Rs.50,000/- spent by complainant after discharge from the hospital.

b)      To pay Rs.2,95,000/- as compensation on account of mental tension and harassment.

c)       Interest @ 18% p.a. from the date of accident till realization.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under C.P. Act and appropriate remedy, if any, lies only in the Civil Court; the complainant has concealed material facts and documents from this Commission as well as from the opposite parties, therefore, the complainant is not entitled to any relief. The complainant has concealed the fact that the complainant lodged the claim under the Individual Personal Accident Policy claiming the expenses incurred towards hospitalization as the Insured had met with a road accident, sustained injuries and was diagnosed for head injury with right temporal EDH with hemorrhagic contusions. As per policy the complainant/ insured had opted for only primary covers of Accidental Death, Permanent Total Disability and Permanent Partial Disability. The said diagnosis does not fall under any of the opted category under the insurance policy. Accordingly, the claim has been denied for want of coverage as per policy terms and conditions. The complainant/ insured was also claiming for add on cover i.e. accidental hospitalization expenses, however, as per policy terms and conditions, if claim is not admissible for primary cover, the claim will not be admissible for add on cover either. There is a specific exclusion for pre & post hospitalization expenses as well. Hence no amount is payable to the complainant. Averred that the complainant is not the consumer of the opposite parties; complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       The complainant has also filed replication to the written reply of Opposite Parties denying the objections raised by it in its written reply.

4.       In order to prove his case, complainant has placed on record his affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to C5.

5.       On the other hand, Opposite Parties have placed on record copies of documents Ex.OP1/1 to Ex.OP1/3 and affidavit of Shraddha Kinare, AVP & Corporate Legal Manager, Liberty General Insurance Ltd. as Ex.OP1/4.

6.       We have heard the ld. counsel for both the parties, gone through the written arguments submitted on behalf of the Opposite Parties and gone through the record.

7.       Ld. counsel for the complainant contended that complainant purchased ‘Liberty Individual Personal Accident Policy’ for the period of 22.072022 to 21.07-2023 from the opposite parties. During the policy coverage, the complainant met with an accident on 19.11.2022 and was admitted in Dayanand Medical College & Hospital Ludhiana on the same day i.e. 19.11.2022, where he was diagnosed as ‘RSA- Head injury with Right Temporal Edh with Hemorrhagic contusions and fracture right Zygomatic Arch’ and got discharged on 26.11.2022. After discharge from the hospital, the complainant lodged the claim with Opposite Parties, but they denied it.

8.       Ld. counsel for the Opposite Parties contended that as per policy the complainant had opted for only primary covers of Accidental Death, Permanent Total Disability and Permanent Partial Disability. The said diagnosis does not fall under any of the opted category under the insurance policy. Accordingly, the claim has been denied for want of coverage as per policy terms and conditions. The complainant also claiming for add on cover i.e. accidental hospitalization expenses, however, as per policy terms and conditions, if claim is not admissible for primary cover, the claim will not be admissible for add on cover either.

9.       We have considered the rival contentions of ld. counsel for both the parties and gone through the record. The perusal of policy document Ex.OP1/1 reveals that the complainant purchased ‘Liberty Individual Personal Accident Policy’ for the period of 22.072022 to 21.07.2023 from the opposite parties and in the said document Accident Benefits are mentioned as under:-

From the above table, it is clear that in case of Permanent Total Disability and Permanent Partial Disability, the insured is entitled for the benefit ‘as per the table of benefits’ and in case of ‘Accidental Hospitalization Expenses’, the insured is entitled for ‘Maximum up to Rs.100000/-‘. However, in the case of the complainant, there is no document on record to show that complainant suffered Permanent Total Disability, Permanent Partial Disability, but he remained admitted in the hospital on account of road side accident injury for the period from 20.11.2022 to 26.11.2022 as per discharge summary Ex.C2 and expenses incurred by him on his treatment are more than one lakh, so he is entitled for maximum upto Rs.1,00,000/-.

10.     In view of the above discussion, the instant complaint is partly allowed and Opposite Parties are directed to pay Rs.1,00,000/- (Rupees One Lakh only) to complainant. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost Rs.5000/- (Rupees Five Thousand only) to be paid to the complainants for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission