KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
VAZHUTHACAUD, THIRUVANANTHAPURAM
APPEAL No. 559/2016
JUDGMENT DATED: 25.05.2023
(Against the Order in C.C. 286/2011 of CDRF, Thrissur)
PRESENT:
SRI. AJITH KUMAR D. : JUDICIAL MEMBER
SRI.RADHAKRISHNAN K.R : MEMBER
APPELLANT:
Paul A. Sebastian, Aiswarya Gardens, Chiyyaram P.O., Thrissur-680 026.
(By Adv. Unnikrishnan V.)
Vs.
RESPONDENTS:
- Manager, United India Insurance Company Ltd., Thrissur-680 001.
- Manager, United India Insurance Co. Ltd., Micro Office, Amballur, Thrissur.
(By Adv. R. Jagadish Kumar)
JUDGMENT
SRI. RADHAKRISHNANK.R.: MEMBER
This is an appeal filed by the complainant in C.C. No. 286/2011 on the file of the District Consumer Disputes Redressal Commission, Thrissur (District Commission for short). As per the order dated 31.05.2016 the complaint was dismissed by the District Commission. This appeal is filed against the said order.
2. The pleadings of the complainant in brief are as follows: The complainant had taken two personal accident policies from the opposite party insurer - the first policy bearing No. 100682/42/09/01/00000004 was issued for a sum insured of Rs 3,00,000/- for a period of one year from 07.05.2009 to 06.05.2010 and the second policy bearing No. 100682/42/09/01/00000009 was issued for a sum insured of Rs. 2,00,000/- for the period from 09.07.2009 to 08.07.2010. The policy provides for payment of weekly benefit for the period of Temporary Total Disablement (TTD for short) resulting from an accident. The complainant had an accidental fall on 24.06.2009 and he was admitted in the Elite Mission Hospital from 25.06.2009 to 27.06.2009. As per the certificate issued by the doctor he was advised to take complete rest for six weeks. Hence he claimed Rs. 30,000/- as weekly benefit @ 1% of the sum insured of both the policies together (ie. Rs 5,00,000/-) for a period of six weeks. However, the opposite party approved the weekly benefit for a period of two weeks only @ Rs. 3,000/- per week and paid an amount of Rs. 6,000/-. Hence the complaint was filed before the District Commission claiming the balance amount with compensation and costs.
3. Opposite parties filed version stating that they have paid the claim as per the terms and conditions of the policy. As per clause 1(f) of the policy issued to the Complainant the maximum weekly benefit payable for TTD is Rs. 3,000/- per week. As per the discharge summary issued by the Elite Mission Hospital where the complainant was treated, he was advised to take rest for two weeks only. Hence the complainant is eligible for weekly benefit @ Rs. 3,000/- per week for two weeks. Accordingly Rs. 6,000/- was paid to him. No further amount is payable to the complainant as per the terms and conditions of the policy. Hence they prayed for dismissal of the complaint.
4. Complainant filed proof affidavit and produced three documents which were marked as Exts. P1 to P3. Opposite parties produced seven documents which were marked as Exts. R1 to R7. On the basis of the evidence adduced the District Commission passed the impugned order. Aggrieved by the said order the complainant has filed this appeal.
5. Heard both sides.
6. The learned Counsel for the appellant submitted that as per the medical report submitted to the insurer the appellant/complainant was advised to take complete rest for six weeks. He is eligible to get Rs. 30,000/- as weekly compensation ie. @ Rs. 5,000/- per week for six weeks. The respondents have paid Rs. 6,000/- for a period of two weeks only @ Rs. 3,000/- per week. They are liable to pay the balance amount of Rs. 24,000/-. In the Ext. P3 medical report the treating Doctor has certified that the appellant requires confinement to bed/house for six weeks. It is not disputed by the respondents. Hence the appellant prayed for allowing the appeal/complaint by directing the respondents/opposite parties to pay the balance amount of Rs. 24,000/- with interest, compensation and costs.
7. The learned Counsel for the respondents submitted that as per clause 1(f) of the policy (Ext R6) the maximum weekly compensation payable for TTD under all policies taken together is Rs 3,000/- only. As per the discharge summary issued by the hospital, the appellant/complainant was advised to take rest for two weeks only and the amount payable is Rs. 6,000/- being the weekly benefit payable under the policy for two weeks. This amount is already paid to him. Moreover they have no liability under the second policy as it was taken after the accident. They submitted that they have already settled the claim as per terms and conditions of the policy and so they have no further liability. Hence they prayed for dismissal of the appeal with costs.
8. We have considered the submissions on both sides and carefully perused the records. The respondent/insurance company admitted having issued two personal accident policies to the appellant/complainant, with a sum insured of Rs. 3,00,000/- and Rs. 2,00,000/-. They further submitted that the weekly benefit payable is 1% of the sum insured and it is limited to Rs. 3,000/- per week under all policies taken together as per clause 1(f) of the policy (Ext. R6) which reads under:
“If such injury shall be sole and direct cause of temporary total disablement, then so long as the insured shall be totally disabled from engaging in any employment or occupation of any description whatsoever, a sum at the rate of one percent (1%) of the Capital Sum Insured stated in the schedule as existing at the inception of the policy hereto per week, but in any case not exceeding Rs. 3,000/- per week in all, under all policies.
In view of the above condition in the policy, we agree to the contention of the respondent that their maximum liability for TTD is limited to Rs 3,000/- per week.
9. We observe that the coverage under the second policy commenced on 09.07.2009, which is after the date of accident. This policy was not produced by either side. Obviously the insurer has no liability under this policy. Another contention of the respondent is that the insured is a retired person and so he has not lost any income during the period of TTD. The occupation of the insured is shown as lawyer in the policy. The first policy is having a cumulative bonus of 15% which shows that it is continuous renewal for three years. After having issued the policy, there is no point in arguing that the insured is not eligible for the policy. Once the policy is issued, the insurer is bound by the contract of insurance and duty bound to honour the claims as per terms and conditions of the policy
10. The main point in this case is regarding the number of weeks for which the appellant/complainant is eligible for weekly benefit. As per the repudiation letter dated 14.02.2011 (Ext. R2) the respondent informed the appellant/complainant that he was eligible for the weekly benefit for two weeks only. According to them as per the discharge summary of Elite Mission Hospital, the appellant/complainant was advised to take rest for two weeks only. This is a vital document in the custody of the respondent. It was not produced for examination before the District Commission. Ext. P3/R5 is the medical report in the format of the respondent/insurance company issued on 16.09.2009 by the treating doctor of the appellant/complainant. As per the answers to question No. 7, Doctor certified that the injured person/appellant/complainant requires complete rest for six weeks and that he will not be able to do any portion of his duties during this period. There is nothing on record to contradict the period of confinement recommended by the doctor as per Ext. P3/R5 medical report. In their letter dated 13.05.2011 (Ext. R4), the respondent stated as under:
“3. As per medical certificate produced by your client your client was advised to take 2 weeks rest followed by the incident”.
Ext P3/R5 is the medical report issued by the doctor and produced by the appellant/complainant. Doctor has recommended rest for six weeks and ‘two weeks’ is not mentioned anywhere in the said report. Hence the period of TTD taken by the respondent is arbitrary and without any basis. The appellant /complainant is eligible for weekly benefit for six weeks @ Rs. 3,000/- per week totalling Rs. 18,000/-. The amount due to him after deducting the amount of Rs 6,000/- already paid is Rs. 12,000/-.
11. In view of the aforesaid reasons and findings, we find that there is deficiency in service on the part of the respondent insurance company. The District Commission erred in properly appreciating the evidence on record and dismissing the complaint and hence their order is liable to be set aside. Accordingly the order dated 31.05.2016 of the District Commission is set aside.
Considering the facts and circumstances of the case we are of the view that an amount of Rs. 5,000/- is just and reasonable towards the compensation for the mental agony and hardships of the appellant/complainant. A further amount of Rs. 5,000/- is allowed as costs.
In the result, the appeal/complaint is allowed as follows:
- The respondents/opposite parties are directed to pay the appellant/ complainant an amount of Rs. 12,000/- with interest @ 9% per annum from 14.07.2011, the date of filing the complaint till realization.
- The respondents/opposite parties are also directed to pay Rs. 5,000/- as compensation towards the mental agony and hardships suffered by the complainant with interest @ 9% per annum from the date of filing the complaint till date of realization.
- The respondents/opposite parties shall further pay an amount of Rs. 5,000/- as costs of the proceedings.
All the above amounts shall be paid within a period of one month from the date of receipt of a copy of this judgment failing which the amounts shall carry interest @ 12% per annum.
AJITH KUMAR D. : JUDICIAL MEMBER
jb RADHAKRISHNAN K.R. : MEMBER
