IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 11th day of October, 2011.
Present : Sri. Jacob Stephen (President).
Sri. N. Premkumar (Member)
C.C. No. 145/2010 (Filed on 18.10.2010)
Between:
Sri. J.S. Sigmond Raj @ Rajan
Kanan House, Noorommavu Muri,
Mallappally Taluk. … Complainant.
And:
1. National Insurance Company Ltd.,
Changanassery represented by its
Manager.
2. The Manager,
National Insurance Co. Ltd.,
Pathanamthitta.
(By Adv. Sam Koshy) … Opposite parties.
ORDER
Sri. N. Premkumar (Member):
Complainant filed this complaint for getting a relief from the Forum.
2. Fact of the case in brief is as follows: Complainant met with an accident on 10.06.2008 while riding in a scooter. Due to the accident, he sustained fracture on both hands and leg and admitted in Thiruvalla Medical Mission Hospital in an unconscious stage. He has undergone 2 major operations there. Complainant had taken a Yatra Suraksha Policy for ` 1 lakh by remitting ` 150 as premium.
3. Complainant has incurred about ` 1 lakh as treatment expenses. For getting the said amount, he filed C.C. 26/2009 before this Forum. This Forum observed that the complaint is premature and disposed the case by directing to file proper claim form before the opposite parties within 15 days. Accordingly, complainant filed claim form with records before the opposite parties. But they repudiated it by stating that F.I.R. has not been produced.
4. According to the complainant, at the time of accident, he was in an unconscious stage and he was undergone surgery and treatment. Thereafter, he informed the police authorities by stating that he falls from scooter and he has no complaint against anyone. So the police did not register any case. It is recorded in the wound certificate and treatment certificate that complainant’s case is road traffic accident. So the repudiation of the claim is deficiency of service and the opposite parties are liable to the complainant. Hence this complaint for realizing ` 1 lakh with 12% interest along with cost.
5. Opposite parties entered appearance and filed version stating that the complaint is not maintainable either in law or on facts. They have no dispute regarding the policy and its validity and the order in C.C. No.26/2009 of this Forum. But the complainant slept over the order and never turned up with any claim form as stipulated in it. At last, on the basis of opposite parties’ reminders, complainant produced documents on 09.06.2010. Opposite parties processed the claim and found that the claim is not payable. The claim is not supported by relevant documents as per the terms and conditions of the policy. There is no F.I.R. or G.D. entry in this case, which is a vital document to prove the claim.
6. As per condition No.3 of the terms and condition, “proof of satisfactory to the company shall be furnished of all matters upon which the claim is based. Any representative of the company shall be allowed to examine the insured on the occasion of any alleged injury or disablement or any claim for hospitalization expenses. First Information Report given to the police, postmortem report and inquest report in the event of death, record of admission, discharge, treatment taken in the hospitals, nursing home, bills for medical expenses incurred and certificate from medical board or authorized medical practitioner authorized by the company certifying permanent total disablement or loss of use of hand or foot shall be submitted to the company along with duly filled claim form”. “No sum payable under this policy shall carry interest”. The complainant has not complied with the above requirements and has not proved to be entitled to claim any benefit under the policy. Therefore, they rightly repudiated the claim. Moreover, complainant is chronic diabetic patient and any expenses incurred in that regard is not cover under the policy. Hence opposite parties canvassed for the dismissal of the complaint with their cost.
7. From the above pleadings, following points are raised for consideration:
(1) Whether the complaint is maintainable before the Forum?
(2) Whether the reliefs sought for in the complaint are allowable?
(3) Relief and cost?
8. Evidence of the complaint consists of the proof affidavit and Exts. A1 to A6 and Exts. B1 and B1(a). After closure of evidence, both sides were heard.
9. Point Nos. 1 to 3: In order to prove the complainant’s case, complainant filed proof affidavit along with certain documents vide separate memo. The documents produced were marked as Exts.A1 to A6. Ext. A1 series are the medical bills of complainant. Ext.A2 is the medical certificate issued to the complainant from Thiruvalla Medical Mission Hospital. Ext. A3 is the wound certificate issued from Thiruvalla Medical Mission. Ext. A4 is the disability certificate issued by General Hospital, Pathanamthitta. Ext. A5 series are the discharge summaries. Ext. A6 is the repudiation letter issued by opposite parties.
10. In order to prove the opposite parties contention, opposite party filed proof affidavit along with documents. Documents produced were marked as Exts. B1 and B1(a). Ext. B1 is the terms and conditions of the policy and Ext. B1(a) is the relevant portion in Ext. B1 terms and conditions.
11. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record. Complainant’s case is that he met with an accident while riding in a scooter and sustained fracture and other injuries and incurred treatment expenses. As a policy holder of opposite party, complainant claimed the treatment expenses, but they repudiated it stating that First Information Report is not produced. Opposite parties’ contention is that the claim is not supported by relevant documents as per the terms and conditions of the policy i.e. F.I.R. or G.D. entry. Therefore, they rightly repudiated it as per condition No.3 of the terms and conditions.
12. It is seen that there is no dispute regarding the issuance of policy or its validity, accident and treatment. The only dispute is the non-submission of F.I.R. or G.D. entry along with the claim form. According to the complainant, at the time of accident, he was unconscious and later he had undergone surgery and prolonged treatment. Thereafter, the matter was intimated to the police. But they have not registered the case because the complainant had no allegation against anybody in the accident. Exts. A1 to A5 shows that he was under prolonged treatment due to the accident and sustained 20% permanent disability also. The opposite parties have not challenged the same.
13. On a perusal of Exts. A2 to A4 it is seen that the incident is road traffic accident. In this case, complainant has not informed the police due to his incapacity immediately after the accident. But later it was informed, but police did not register any case as there is no accused for the occurrence. Therefore, he cannot be blamed or denied claim for not producing F.I.R. or other related documents. Non-registering of F.I.R. or G.D. entry does not mean that it is not a road traffic accident. By relying on Exts. A1 to A5, we have no doubt regarding the accident. Therefore, unless and until opposite parties are not challenging the occurrence of road traffic accident, they cannot insist the production of F.I.R. or G.D. register which was actually not yet registered.
14. In this case, the claim of the complainant is filed as per order in C.C. 26/2009 of this Forum. Available materials on record reveal that the complainant met with road traffic accident. But opposite parties repudiated it for non-production of F.I.R. or G.D. entry. It is seen that the said documents were not yet be registered. It is regrettable to view that the opposite parties repudiated the claim only because of the non-production of a document not in existence. But by relying on Exts. A1 to A5 documents, it is crystal clear that the accident occurred while riding the vehicle. Since the cardinal principle of insurance is for the welfare and benefit of the consumers and the interest of justice, we are of the view that the complainant’s claim is maintainable before this Forum and allowable. Considering the facts and circumstances of the case, no amount is allowable for compensation and cost.
15. In the result, this complaint is allowed, thereby the opposite parties are directed to pay the Ext. A1 series bill amount within one month from the date of receipt of this order, failing which the whole amount will follow 10% interest from this date till the realization of the whole amount.
Declared in the Open Forum on this the 11th day of October, 2011.
(Sd/-)
N. Premkumar,
(Member)
Sri. Jacob Stephen (President) : (Sd/-)
Appendix:
Witness examined on the side of the complainant: Nil.
Exhibits marked on the side of the complainant:
A1 series : Medical bills of complainant.
A2 : Medical certificate issued to the complainant from Thiruvalla
Medical Mission Hospital.
A3 : Accident Register-cum-Wound certificate issued from Thiruvalla
Medical Mission.
A4 : Standing Disability Assessment Board Certificate issued by
General Hospital, Pathanamthitta.
A5 series : Discharge summaries issued by Department of Orthopaedic,
Thiruvalla Medical Mission.
A6 : Repudiation letter dated 11.10.2010 issued by opposite parties.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties:
B1 : Terms and conditions of Yatra Raksha Policy.
B1(a) : Relevant portion in Ext. B1 terms and conditions.
(By Order)
Senior Superintendent.
Copy to:- (1) Sri. J.S. Sigmond Raj @ Rajan, Kanan House, Noorommavu Muri,
Mallappally Taluk.
(2) Manager, National Insurance Company Ltd., Changanassery.
(3) The Manager, National Insurance Co. Ltd., Pathanamthitta.
(4) The Stock File.
