Haryana

Yamunanagar

CC/609/2012

Karan Singh S/o Maya Ram - Complainant(s)

Versus

M/s National Insurance Company Ltd. - Opp.Party(s)

Y.C.Tyagi

08 Dec 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                             Complaint No. 609 of 2012.

                                                                                             Date of institution: 8.6.2012.

                                                                                             Date of decision:8.12.2015

Karan Singh aged about 40 years son of Shri Maya Ram, resident of village Dhanora, P/o Dayalgarh, Tehsil Bilaspur, District Yamuna Nagar, Haryana.   

                                                                                                                                                             …Complainant.

                                    Versus

 

1. National Insurance Company Limited, having its Divisional Office at 141-142,, Navyug Market, Hapur Road, Ghaziabad (U.P.) 201001, through its Senior Divisional Manager.
2. National Insurance Company Limited, having its Local Office at Yamuna Nagar Jagadhri Road, Distt. Yamuna Nagar through its Branch Manager/Authorized Signatory.
3. Sanjiv Kumar son of Shri Ram Lal r/o Village & Post Office-Haripur Khol, Tehsil Ponta Sahib Distt. Sirmour, H.P.                                                                                                                                                                    …Respondents.

 

Before:             SH. ASHOK KUMAR GARG…………….. PRESIDENT.

                        SH. S.C.SHARMA………………………….MEMBER.

 

Present:  Sh. Y.C.Tyagi, Advocate, counsel for complainant.  

               Sh. Parmod Gupta, Advocate, counsel for OPs No.1 & 2.

               OP No.3 ex-parte vide order dated 10.9.2015.          

             

ORDER

 

1.                     Complainant Sh. Karan Singh has filed the present complaint under section 12 of the Consumer Protection Act. 1986, praying therein that respondents ( hereinafter referred as OPs) be directed to make the balance payment of compensation after deducting an amount of Rs. 25823/- from the sum insured of Rs. 4,00,000/- on account of amputation of right hand suffered by the complainant in an accident alongwith compensation as well as litigation expenses.  

2.                     Brief facts of the complaint, as alleged by the complainant, are that the complainant obtained an insurance policy NIC/GPA bearing policy No. 361200/42/ 11/8200000099 w.e.f. 1.12.2011 to 20.11.2012 for a sum insured for personal accident of Rs. 3,20,000/- and for hospitalization Rs. 80,000/- from the OP No.1. i.e. National Insurance Company Limited Divisional Office, Gaziabad (U.P.)

3.                     On 9.1.2012, complainant met with an accident and his right hand was cut down in Power Machine of Chara Cutting installed at his house in village Dhanora, District Yamuna Nagar. Immediately after this accident the complainant was shifted to Gaba Hospital Yamuna Nagar where his treatment was done and the complainant spent more than Rs. 30,000/- on his treatment and medical expenses. Besides this, the complainant had spent Rs. 20,000/- on transportation and diet etc. Due to this accident the complainant suffered 60% disability as the right hand of the complainant had cut down in this accident and he become unable to do any work for his livelihood. A written intimation was given to the OP No.2 vide application dated 11.1.2012 and requested for providing insurance benefits. Information to this effect was also given to the local police on which DDR No. 34 dated 13.1.2012 was lodged in the Police Station Bilaspur, District Yamuna Nagar. Thereafter, the complainant submitted all the required documents and completed all the formalities as per requirement of OP No.1 & 2. The claim of the complainant was considered by the Op No.1 & 2 but only an amount of Rs. 25823/- was paid vide cheque No. 006897 dated 8.5.2012 against the claim of Rs. 4,00,000/-. The complainant asked the officials of the OPs No.1 & 2 in this regard i.e. to pay full insured amount but no response was given to the complainant by the OPs and since then the complainant is running from pillar to post. As the OPs No.1 & 2 refused to listen and pay the genuine claim of the complainant on account of amputation of the right hand, which shows malafide intention and gross negligence and deficiency in service on the part of OPs. Hence, this complaint.

4.                     Upon notice, OPs No.1 & 2 appeared and filed their written statement jointly whereas OP No.3 filed his written statement separately and thereafter he remained absent and was proceeded ex-parte vide order date 10.9.2015.

5.                     OPs No.1 & 2 while filing the written statement took some preliminary objections such as complaint is not maintainable, no territorial jurisdiction, complicated question of law and facts is involved. Ops have already made a payment of Rs. 25823/- and complainant had issued discharge voucher on 28.5.2012 and on merit, it has been admitted that the complainant obtained a group insurance accident policy through M/s Dauhin Touch Network Private Ltd. but it was never a GPA policy. It has been further stated that M.s Dauhin Net Work Private Ltd. took a policy known as Group Personal Accident Policy and the said company lodged a claim with the OPs company and the claim was processed and a total bill of Rs. 26523/- was sent and all the documents were sent by the National Insurance Company to Dr. Vinod Gandotra, M.B.B.S. FCGP an independent expert doctor of New Delhi who after taking into consideration the above aspect hospitalization etc. assessed a sum of Rs. 25,823/- and the same amount was released to the complainant, which stands received by him through his bank PNB Ranjitpur , District Yamuna Nagar and he issued clear discharge voucher under his signature and as such complaint is false and frivolous and is not maintainable. It has been further submitted that there is no clause of compensation of disability as alleged under the said policy and lastly prayed that a correct and calculated amount, which was found payable was paid to the complainant. Hence, there is no deficiency in service and complaint is liable to be dismissed.

6.                     OP No.3 filed written statement separately and admitted that complainant was introduced with the insurance policy provided by OPs No.1 & 2 but the Op No.3 have no concern whatsoever with the dispute between the complainant and OPs No.1 & 2.

7.                     To prove his case, counsel for complainant tendered into evidence his affidavit as Annexure CX and documents such as Photo copy of Certificate of insurance as Annexure C-1, Photo copy of discharge card alongwith treatment file of Gaba Hospital as Annexure C-2 to C-8, Photo copy of bill of Gaba Hospital as AnnexureC-9 and C-10, Photo copy of medical bills as Annexure C-11 to C-23, Snap showing amputation of right hand as Annexure C-24, Photo copy of disability certificate as Annexure C-25, Intimation letter dated 11.1.2012 as Annexure C-26, Photo copy of DDR as Annexure C-27, Photo copy of letter submitting documents dated 16.1.2012 as Annexure C-28, Claim form as Annexure C-29, Photo copy of claim form verified by Doctor as Annexure C-2\30, Blank receipt and cancel cheque as Annexure C-31, Details of expenses of medical bills amounting to Rs. 26523/- as Annexure C-32, Miscellaneous applications as Annexure C-32 to C-25, Photo copy of ration card as Annexure C-36, Photo copy of election commission card as Annexure C-37, Photo copy of bank pass book as Annexure C-38, Photo copy of cheque received amounting to Rs. 25823/- as Annexure C-39 and closed the evidence on behalf of complainant.

8.                     On the other hand, counsel for the OPs No.1 & 2 tendered into evidence affidavit of Parveen Arora Administrative Officer, NIC, Yamuna Nagar as Annexure RW/A and documents such as Photo copy of GPA claim sheet as Annexure R-1, Photo copy of disbursement voucher of amounting to Rs. 25823/- as Annexure R-2, Photo copy of list of persons covered under GPA as Annexure R-3, Photo copy of certificate of compliance of section 64 of Insurance Act alongwith terms and conditions as Annexure R-4 and affidavit of Dr. Vinod Gandotra as Annexure R-5 and photo copy of assessment of medical bills as Annexure R-6 and closed the evidence on behalf of OPs No.1 & 2.

9.                     We have heard the counsels of both the parties and have gone through the pleadings as well as documents placed on the file carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs No.1 & 2 reiterated the averments made in the reply and prayed for dismissal of complaint.

10.                    It is not disputed that complainant was covered under the Group Personal Accident policy w.e.f. 1.12.2011 to 30.11.2012 vide policy bearing No. 361200/42/11/8200000099 (Annexure C-1) issued by OPs No.1 & 2 covering the risk of under Personal Accident Section 80% i.e. Rs. 3,20,000/- and under Hospitalization Section 20% i.e. for Rs. 80,000/- totaling Rs. 4,00,000/-. It is also not disputed that the complainant met with an accident and his right hand was cut down in the power machine of chara cutting installed at his house in village Dhanora, district Yamuna Nagar which is evident from the hospital record of Gaba Hospital Annexures C-2 to C-8. It is also not disputed that complainant suffered disability to the tune of 60% on account of amputation of right hand through wrist which is evident from disability certificate Annexure C-25 and photo of complainant Annexure C-24. It is also not disputed that OPs insurance company had made a payment of Rs. 25823/- on 8.3.2012 through cheque of AXIS Bank to the complainant on account of medical expenses. The only plea of the complainant is that the complainant is also entitled to get the claim amount on account of amputation of the right hand from wrist as per terms and conditions of the insurance policy and the genuine claim of the complainant has been illegally withheld by the OPs No.1 & 2 and referred the case law titled as Vinod Kumar Nagrah vs. United India Insurance Company Limited, 1996(1) CPC page 237, Oriental Insurance Company Limited Versus Dev Raj, 2000(1) CPC page 98 wherein it has been held that Consumer Protection Act, 1986- Sections 14 & 2-Insurance Claim- Total disability-Loss of eye sight-Complainant took personal accident policy for Rs. 1 lac- As per terms of policy 50% amount was payable for total loss of any limb of the body- Complainant lost total sight of his right eye due to an accident as reported by Civil Surgeon- Insurer offered to pay 40% of total claim i.e. Rs. 20,000/- only- Order of District Forum accepting the claim of Rs. 50,000/- with 18% interest is well reasoned-Appeal stands dismissed with costs decided by the Hon’ble State Commission, Punjab, Chandigarh and also referred the case law titled as United Insurance Company Limited and others versus Kewal Singh and others, 2005(1) CPC page 681, Oriental Insurance Company Ltd. & Others versus Government Tool Room and Training Centre, 2008(1) CPC page 495 wherein it has been held that Consumer Protection Act, 1986- Sections 2(1)(g) and 14- Final settlement of claim- Discharge voucher- Discharge voucher got signed by applying wrong practice of coercive method of bargaining- Complainant cannot be stopped simply on the ground that he had accepted insurance claim by executing discharge voucher- Order passed by State Commission upheld- Appeal dismissed.

11.                   On the other hand, counsel for OPs No.1 & 2 hotly argued at length  that there is no clause of compensation of disability as alleged under the said policy and further complainant has accepted an amount of Rs. 25823/- and had executed a discharge voucher with his signature Annexure R-2. So, the complainant is not entitled to get any compensation on account of disability/ amputation of right hand and there is no deficiency ins ervice on the part of OPs.

12.                   To decide the issue between the parties we have minutely perused the terms and conditions of the insurance policy Annexure R-4 which is reproduced as under:          

                        Group Personal Accident Policy

                        Whereas the insured named in the schedule hereto (hereinafter called the ‘insured’) has applied to National Insurance Company limited (hereinafter called the ‘Company) for the insurance hereinafter set forth in respect of persons detailed in the Schedule of insured persons (hereinafter called the insured ‘persons).

                        NOW THIS POLICY WITNESSETH that subject to and in consideration of the payment made or agreed to pay to the Company the premium for the period started in the Schedule or for any further period for which the company may accept payment for the renewal of the policy and subject to the terms, provisions, exceptions and conditions herein expressed or contained or hereon endorsed, the Company shall pay to the insured to the extent and in the manner hereinafter provided that if any of the Insured Persons shall sustain any bodily injury resulting solely and directly from accident caused by external violent and visible means, the sum, hereinafter set forth in respect of any of the insured persons specified in the schedule:-

1. If such injury shall within twelve (12) calendar months of its occurrence be the sole and direct cause of the death of the insured person, the capital sum insured stated in the schedule hereto applicable to such insured person.
2. If such injury shall within twelve (12 ) calendar months of its occurrence be the sole and/or direct cause of the total and irrecoverable loss of

1. The sight of both eyes or of the actual loss by physical separation of the two entire hands or two entire feet or one entire hand and one entire foot or sight of one eye and such loss of one entire hand or one entire foot of the        insured person the capital sum insured stated in the schedule hereto applicable to such insured person.
2. Use of two hands or two feet or one hand and one foot or of such loss of sight of one eye and such loss of use of one hand or one foot of the insured person the capital sum insured stated in the Schedule hereto applicable to such insured person.

(c )  If such injury shall within twelve (12) calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of

1. The sight of one eye or of the actual loss by physical separation of one entire hand or one entire foot of the insured person fifty percent (50%) of the capital sum insured stated in the schedule hereto applicable to such insured person.
2. Use of a hand or a feet of the insured person without physical separation, fifty percent (50%) of the capital sum insured stated in the schedule hereto applicable to such insured person.

Note:          For the purpose of clauses (b) and (c) above (physical separation of a hand or foot) means separation of hand at or above the wrist and /or of the foot at or above the ankle.

13.                   After going through the above noted terms and conditions of the insurance policy, we are of the considered view that the complainant has right to get compensation as mentioned in schedule under clause C (i) to the tune of 50% of the sum insured of Rs. 3,20,000/- i.e. Rs. 1,60,000/- from the OPs No.1 & 2 on account of amputation of his right hand from the wrist which is evident from the Annexure C-24 Photo/Snap and further form the disability certificate Annexure C-25 and also from the discharge summary and treatment record of Gaba Hospital Annexure C-2 to C-23.

14.                   We further feel to mention specifically here that the OPs No.1 & 2 Insurance Company has mentioned in para No.4 of its written statement that “ there is no clause of compensation of disability as alleged under the said policy” which is totally against the terms and conditions of the insurance policy as mentioned/reproduced above in this judgment. This act and conduct of the official of the OPs i.e. Insurance Company shows their irresponsibility and malafidely intention due to reason best known to them. Even in the claim papers of the claim of complainant, processed by team of OPs No.1 & 2 Insurance Company, there was a clear cut case of amputation of one hand from wrist but no heed was given by the officials of the insurance company and further even at the time of filing of written statement official of the Insurance Company did not hesitate to mislead/ misguide this Forum by mentioning therein that there is no clause for compensation for disabilities. Mere taking such like plea in the written statement does not give any right to the OPs to escape from the wrong done on their part. As such, the OPs No.1 & 2 have wrongly withheld the aforesaid amount of Rs. 1,60,000/- of the complainant which is a gross negligence and unfair trade practice on the part of OPs No.1 & 2. Hence, the complainant is entitled for relief.

14.                   Resultantly we partly allow the complaint of complainant and direct the OPs No. 1 &2 to pay a sum of Rs.1,60,000/- ( 50% of the insured amount of Rs. 3,20,000/-) to the complainant for amputation of his right hand alongwith interest at the rate of 12% per annum from the date 8.5.2012 i.e. when only medical expenses of Rs. 25823/- was paid till its realization. Further OPs No.1 & 2 are also directed to pay a sum of Rs. 20,000/- as compensation and Rs. 5000/- as litigation expenses to the complainant. Further we impose punitive damages of Rs. 20,000/- upon OP No.1 & 2 and the same will be recovered from the personal salary of the officials of the team who processed the claim file in question of the complainant i.e. Ms. Alka Khattar Administrative Officer, Sh. Satish Baboo Assistant Manager and Sh. Alok Mohan Senior Divisional Manager of Divisional Office 141-142 Navyug Market Gaziabad (U.P) i.e. policy issuing office in the ratio of Rs. 5,000/-, Rs. 5000/- and Rs. 10,000/- respectively which will be deposited by way of demand draft in the name of “District Legal Services Authority, Yamuna Nagar”. However, complaint qua OP No.3 is hereby dismissed.

15.                   Order be complied within 30 days after preparation of copy of this order failing which the complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court.8.12.2015.

                       

                                                                                    (ASHOK KUMAR GARG )

                                                                                    PRESIDENT,

                                                                                     

 

                                                                                    (S.C.SHARMA )

                                                                                     MEMBER.