DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC. No. 224 of 25-08-2008<br /> Decided on : 19-06-2009 <br /> <br /> Baljit Kumar S/o Sh. Jagdish Rai, aged bout 35 years, R/o V.P.O. Maur Khurd, Tehsil Talwandi Sabo, District Bathinda. <br /> .... Complainant<br /> Versus<br /> <br /> 1.Life Insurance Corporation of India, Divisional Office, Urban Estate, Phase I, Dugri, Luhiana through its Senior Divisional Manager.<br /> 2.Senior Branch Manager, Life Insurance Corporation of India, Branch Office Jiwan Jyoti Building, Bibiwala Road, Bathinda.<br /> <br /> ... Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM <br /> <br /> Sh. George, President<br /> Dr. Phulinder Preet, Member<br /> Sh. Amarjeet Paul, Member<br /> <br /> For the Complainant : Sh. Sunder Gupta, Advocate.<br /> For the Opposite parties : Sh. Sanjay Goyal, Advocate.<br /> <br /> O R D E R<br /> <br /> GEORGE, PRESIDENT<br /> <br /> 1. Sh. Baljit Kumar, complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as the 'Act') with the assertions that he vide Proposal Form No. 2356 dated 23-11-2003 applied for purchase of Insurance Policy under Table and Term 75-20 for a sum Insured of Rs. 2,00,000/- and the opposite parties issued Money back policy with profit plus accidental benefits vide policy No. 300128908 effective from 28-11-2003 for a period of twenty years. The complainant was to deposit half yearly installments of Rs. 6,544/- which he is regularly depositing. The complainant runs a Flour Mill to earn his livelihood and while operating the same on 23-08-2007 at about 3.00 p.m., he met with an accident as his left leg was entangled in pulley of the Atta Chaki in which his left leg was badly injured and he was referred to D.M.C. Ludhiana where attending doctor amputated his left leg below knee. The complainant remained admitted in D.M.C. Ludhiana from 24-08-2007 to 12-09-2007 where he has incurred more than Rs. 1,00,000/- and certificate dated 25-09-2007 to this effect was issued by D.M.C. Ludhiana. He was examined by the Board of Doctors constituted by Civil Surgeon, Bathinda, who has issued disability certificate to him to the tune of 70%. He alleges that he has to work by standing before the Flour Mill to perform his duty, so his disability qua his job is 100%. The complainant gave an intimation regarding his accident to the opposite parties dated 22-02-2008 and submitted all the documents required by them, but the opposite party No. 2 vide its letter dated 10-04-2008 has repudiated his claim against law and facts and provision of Insurance policy. As per 'clause 10.4' of the Insurance policy, the opposite parties are liable to pay Insurance amount for any permanent disability regarding amputation of both feet and above the ankle or regarding the amputation of one foot at or above the ankle. He has also suffered amputation of his left leg above the ankle, but below the knee and in this way, he is fully entitled for the benefit under the said policy. Moreover, as per terms and condition of the policy, he is not required to submit further installments after he suffered permanent disability, but the opposite parties are still getting regular installments. He claimed that he is entitled for an amount of Rs.2,00,000/- alongwith accidental benefits and interest @ 15% P.A. from the date of loss till realisation plus Rs. 1,00,00/- on account of medical bills and exemption of further installments. He has also claimed an additional amount of Rs. 50,000/- as compensation on account of pain and sufferings besides Rs. 11,000/- as litigation expenses.<br /> 2. The allegations contested by the opposite parties by raising legal objections that; the complainant has not approached this Forum with clean hands; he has no cause of action to file the present complaint; complaint is false and frivolous and it is not maintainable as there is no deficiency in service on their part. <br /> On merits, it is denied that the disability of the complainant qua his job is 100% . However, it is submitted that complainant has suffered amputation of one foot only and his disability is 70%, so as per clause 10.4 of the Insurance policy his claim is not covered under the accident policy and has rightly been repudiated vide letter dated 10-04-2008. The complainant is not entitled to benefit of accident clause under policy and the terms and conditions of the policy are binding on the parties. They deny that the complainant is entitled to premium waiver benefit and there is any deficiency in service on their part.<br /> 3. The complainant in order to prove his assertion, has brought on record in evidence his affidavit Ex. C-1, photocopy of policy Ex. C-2, photocopy of DDR Ex. C-3, photocopy of letter dated 27.2.07 of the complainant Ex. C-4, photocopy of letter dated 27.2.07 of the opposite parties Ex. C-5, photocopy of letter dated 10.4.08 Ex. C-6, photocopy of medical certificate Ex. C-7, photocopy of Disability certificate Ex. C-8, photocopy of discharge summary Ex. C-9 and photocopy of letter dated 22.2.08 Ex. C-10.<br /> 4. The opposite parties in order to controvert the evidence of the complainant, brought in their evidence affidavit of Sh J P Arya, Manager Ex. R-1.<br /> 5. We have heard the learned counsel for the parties and perused the entire record of the case carefully.<br /> 6. Learned counsel appearing on behalf of the complainant urged that complainant Baljit Kumar got himself insured on 23-11-2003 from opposite party No. 2 under Table and Term 75-20 for a sum of 2,00,000/- for a period of 20 years under LIC Money Back Policy with profit plus accidental benefits and he paid regularly and punctually half yearly installments of Rs. 6,544/- . He urged that complainant met with an accident while operating Flour Mill on 23-08-2007 and remained admitted in DMC Ludhiana from 24-08-2007 to 12-09-2007. The matter was brought to the notice of the Insurance Corporation. The complainant also submitted the details of his treatment and disability certificate Ex. C-8 alongwith discharge summary and other relevant documents to the opposite parties for claim of Rs. 2,00,000/- as per Insurance policy alongwith accidental benefits and medical bills to the tune of Rs. 1,00,000/-. Since he has acquired 100% disability qua his job, therefore he also claims exemption from making any further payment of premium under policy. He urged that as per 'Clause '10.4' of the terms and conditions of the Insurance policy Ex. C-2, he is entitled for the entire claim because he has acquired permanent disability as he has suffered amputation of his one foot as per medical certificate Ex. C-7 and disability certificate Ex. C-8. He has urged that the opposite parties in violation of the terms and condition and in illegal manner, vide letter Ex. C-6, have repudiated his claim on the ground that due to accident, he has acquired disability only to the extent of 70% and as per policy this benefit is applicable if the disability is 100%. He further urged that his claim has been repudiated in violation of the terms and conditions of the policy, therefore he seeks appropriate direction from this Forum,<br /> 7. Learned counsel appearing on behalf of the opposite parties has refuted the claim of the complainant's counsel and he urged that as per medical certificate Ex. C-7 and disability certificate Ex. C-8, the complainant has suffered disability to the extent of 70% and not 100% and therefore, the opposite parties have rightly rejected the claim of the complainant as per 'Clause 10.4' of the Insurance policy Ex. C-2.<br /> 8. We have considered the rival contentions of the counsel for the parties after taking into consideration the entire material available on the record. 'Clause 10.4' is reproduced as under :-<br /> “Clause 10.4 - <br /> The disability above referred to must be disability which is the result of an accident and must be total and permanent and such that there is neither than nor at any time thereafter any work, occupation or profession that the Life Assured can ever sufficiently do or allow to earn or obtain any wages, compensation or profit. Accidental injuries which independently of all other causes and within one hundred twenty days from the happening of such accident result in the irrecoverable loss of the entire sight of both eyes or in the amputation of both hands at or above the wrists or in the amputation of both feet at of above the ankles or in the amputation of one hand at or above the wrist and one foot at or above the ankle shall be deemed to constitute such disability.” <br /> 9. The complainant has suffered amputation of his one foot only whereas 'Clause 10.4' referred to above, clearly reveals that he is entitled for the benefit of his Insurance in case he has acquired 100% disability or in the amputation of both feet at or above the ankles or in the amputation of one hand at or above the wrist and one foot at or above the ankle, is deemed to constitute such disability.<br /> 10. Since the complainant has suffered amputation of his one foot, his case does not fall within the ambit of 'Clause 10.4' referred to above and there appears to be no cause or reason for us to interfere in any manner in the repudiation of claim of the complainant by the opposite parties vide letter dated 10-4-2008 Ex. C-6. Hence, the complaint being devoid of merits, is dismissed leaving the parties to bear their own costs. Copy of this order be sent to the parties concerned free of costs and file be consigned.<br /> Pronounced :<br /> 19-06-2009 <br /> <br /> (George)<br /> President<br /> <br /> <br /> (Dr. Phulinder Preet)<br /> Member <br /> <br /> (Amarjeet Paul) Member