KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD THIRUVANANTHAPURAM FA.28/2009 JUDGMENT DATED.30.1.2010 PRESENT JUSTICE SHRI.K.R.UDAYABHANU -- PRESIDENT SRI.M.K.ABDULLA SONA -- MEMBER The Senior Branch Manager, National Insurance Co.Ltd., Branch Office, Ambika Arcade, -- APPELLANT M.G.Road, Trissur. (By Adv.S.Rajeev) Vs. M.K.Damodharan, Manakkalath House, Chakkaramkandam, -- RESPONDENT Mundoor P.O, Trissur. (by Adv.C.S.Rajmohan & Ors.) JUDGMENT SRI.M.K.ABDULLA SONA,MEMBER This appeal prefers from the order passed by the CDRF, Thrissur in the file of OP.No.626/03 dated 24.10.08. The appellant is the opposite party. In short the complainant was a member of Automobile Workshop Association and was a worker in the workshop. He has also a policy holder of Jeevan Raksha Insurance Policy of the opposite parties in the group Insurance scheme. This policy had coverage from 2.2.01 to 1.2.02. On 24.11.01 the appellant had fallen from a tree and sustained serious injuries and had treated as inpatient in the hospital of West Fort Hospital, Thrissur and Medical College Hospital, Thrissur. After the accident he cannot walk without others help. As per the group insurance policy One lakh rupees had assured for permanent total disability. Due to the accident the complainant was not in a position to move easily the body parts below the waste. He cannot walk without crutches. He cannot do the workshop jobs or any other jobs. The treatment is still continuing. The respondent had given Rs.9546/-towards disability and medical expenses. He had applied for the insurance benefit with all the concerned documents. He examined by the Medical Board and certificate was issued. Even after the claim has not settled. On 14.2.03 the complainant again requested through the telephone to appear before the Medical Board and no certificate had issued. Again on 17.1.03 he had asked to present for the Medical Board and no examination was conducted. They also told that they will send the certificate to the Insurance Company directly. But no certificate issued to him by the Company or the Board. Subsequently on 6.5.03 the respondent Company had intimated the non settlement of the claim. It is stated in the letter are denied. So, the complainant had sent a lawyer notice on 14.7.03 and it was replied by the company stating untrue matters. But the deserved amount has not received so far. Hence this complaint. 2. The opposite parties appeared and filed their written version. They contended that the complaint is false and hence denied. According to the opposite parties after receiving Rs.9546/- in March 2002 the complainant has subsequently submitted a claim for permanent total disability under the PTD Section of the policy, which covers only total and irrecoverable loss of limbs/eyes as per table IA of P.A Policy. The maximum sum insured being rupees one lakh for total and irrecoverable loss of 2 eyes/limbs and Rs.50,000/- ie; 50% for total and irrecoverable loss of one eye/limb. In addition to this coverage the insured has also obtained Table III cover for Rs.20,000/- which means the petitioner has a temporary total disability coverage of Rs.200/- per week for the period, the petitioner is totally bed ridden. In this case the opposite party has also settle the said claims what has been mentioned in the certificate dated 4.12.02 of Medical Board is that the petitioner is having moderate disability of 60%. The said certificate was unacceptable to the respondent company as it contained some qualifications and was ambiguous. What the respondent wants for processing the claim is the percentage of permanent total disability suffered by the petitioner as a result of the accident on 24.11.01. This respondent company has taken the initiative in sending a letter to the Chairman of Medical Board, Medical College Hospital, Thrissur for getting an unequivocal certificate confirming the percentage of PTD suffered by the petitioner. As per respondent’s request the Medical Board examined the petitioner on 5.3.03. The certificate sent to this respondent company by the Medical Board shows that the petitioner has no otorhinolaryngological disability. More over, in the certificate issued by the Board after examining the petitioner what the Board has stated is that the petitioner is suffering from Benign Hyperplasia of the prostrate which everyone knows is a disease. The Superintendent of Medical College hospital has sent the copy of the letter dated 23.4.03 to the petitioner also. In the certificate it is stated that the petitioner has no PTD of any kind and this respondent had informed the inability to entertain the claim. There is no cause of action. There is no breach of any policy conditions. Complainant is not entitled to get an amount of Rs.1 lakh with costs and compensation. Hence dismiss the complaint. 3. The Forum below raise to issues whether there is any deficiency in service and in sought reliefs and costs. Evidence adduced by the complainant and marked as Exts.P1 to P25 and Exts.R1 o R14 respectively. 4. The Forum below after adducing the evidence found that document dated 10.5.07 is not marked but they perused. As per the policy conditions capital sum is assured for permanent total disability. As per the document dated 10.5.07 the complainant has 50% permanent disability. So, he entitled to get half of the capital sum. The respondent company stated in the counter that as the company has received the certificate dated 23.4.03 which clearly shows that the petitioner has no PTD of any kind and this respondent has informed the petitioner vide letter dated 6.5.03 of their inability to entertain the petitioners claim. The complainant is only entitled for half of the capital sum. According to the complainant Rs.9546/- was accepted by him towards disability and medical expenses. But, in the complaint there is no relief for expenses incurred for medical treatment. He claims for capital sum, compensation and costs. According to the company, the amount paid is the only amount due to the petitioner as per the terms and conditions of the policy. As per the policy he is not entitled for the medical expenses. He is entitled only for disability. Hence he is not entitled for a separate compensation and the amount already received by him shall be adjusted towards compensation. There is deficiency in service on the part of the respondent company in not allowing a genuine claim. 5. The Forum below directed the opposite party is to pay Rs.50,000/- to the complainant towards disability within two months and the amount already accepted by the complainant shall be adjusted towards compensation and costs. 6. The opposite party prefers this appeal from the above impugned order passed by the forum below. On this day this appeal came before this Commission, the counsel for the appellant vehemently argued on the grounds of appeal memorandum that the order passed by the forum below is not accordance with law and evidence. The counsel for the appellant submitted that Forum had appreciated the fact that Medical Board Certificate dated 5.3.03 which clearly shows that the petitioner has no permanent total disability. Hence the order passed is against the terms of the policy which is illegal and liable to be set aside. 7. This Commission heard both sides and perused the records, it is seeing that the complainant who already received an amount of Rs.9546/- towards disability and medical expenses. It is also seeing that there are so may medical certificate produced both from complainant and opposite party. The forum below directed the medical board to examine the complainant and file a medical certificate. The medical certificate issued by the West Fort Hospital is not sufficient. But the medical Board certificate issued by the Medical Board of the medical College, Thrissur is one different from another. How the statutory Medical Board taken different assessment in views in a same person on two assessments? I is different to say that which medical certificate is legally sustainable. The World Health Organization issued norms for percentages of disability of a person. It is an acceptable criteria to assess the percentage of total disability of a person by any Medical Board or any Doctor. The second medical board is consisting most competent medical experts and their medical certificate is most reliable and evidence. Policy condition is a very important criteria and guidelines to pass compensation and award. It is a statutory provision. But the complainant who is totally disabled due to his accident. He is a worker in his profession he lost his entire life. He is nothing but a question mark of his future life. The counsel for the appellant submitted that they disbursed an amount to the complainant for the same accident in another policy issued by the very same Insurance Company. It is a mere submission of the counsel and there is no supporting evidence with the appellant. This Commission is seeing that the order passed by the forum below is to pay Rs.50,000/- to the complainant towards disability is legally sustainable. It is accordance with law and evidence. This Commission is not interfering in the impugned order passed by the forum below. It is a relief to the unfortunate victim complainant. This is the social object of the insurance policy. In the result, this appeal is dismissed and confirmed the order passed by the Forum below. We appreciate the consumer friendly attitude of the forum below. Both parties are directed to suffer their own respective costs. The points of the appeal are answered accordingly. M.K.ABDULLA SONA -- MEMBER JUSTICE K.R.UDAYABHANU -- PRESIDENT | 
