IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Prethakumari: Member Smt.M.D.Jessy: Member Dated this, the 12th day of October 2009 OP.71/2005 P.V.Valsalan, Puthanveedu, P.O.Pappinissery Complainant (Rep.by Adv.K.K.Balaram) M/s.Oriental Insurance Company, P.B.No.437, South Bazar, Kannur 2. Opposite party (Rep. ByAdv.K.C.Santhoshkumar) O R D E R Sri.K.Gopalan, President This is a complaint filed under section12 of consumer protection act for an order directing the opposite party to pay an amount of Rs.75, 000/- with interest, compensation and cost. The case of the complainant in brief is as follows: The complainant is a policy holder for the period from 26.8.02 to 25.8.03 and renewed twice from26.8.03 to 25.8.05. Complainant sustained injury on 10.3.03 due to accident fall. He was then taken to ESI dispensary at Pappinisseri. After two days he was admitted in Thottada ESI Hospital and treated there till 26.3.03. Thereafter, the complainant was referred to Head quarters Hospital, Kannur. Complainant was given Physiotherapy also from the District Hospital. Since there was no relief complainant was taken to Kozhikode Medical College on 29.7.2003 for treatment. The complainant, as an insured person under the individual personal accident policy entitled to get insured sum. The matter was informed to the opposite party through the Agent and also by a written letter dt.10.3.03 and 15.7.2003. Subsequently when he contacted opposite party he was advised that the claim form can be filed after the treatment. Since there was no reply to his letter, the complainant sent a letter again on 15.7.03 requesting to send claim form. But there was no reply. Another letter also send on 18.11.04 and finally sent a lawyer notice on 29.1.2005 for which opposite party sent reply giving false allegations denying the claim. The complainant is entitled to get a mediclaim benefit for an amount of Rs.75, 000/- on the basis of the accident policy. Hence this complaint. Pursuant to the notice the opposite party entered appearance and filed version denying the main allegations. The brief contentions of the opposite party are as follows: complainant is a policy holder bearing No.488dated 26.8.02 and on expiry two other new policies were issued on 26.8.03 and 26.8.04. The opposite party received intimation on 8.11.04 in respect of an incident alleged to have been taken place on 10.3.03. There was no explanation for the unreasonable delay in submitting the claim. The averment that the delay was occasioned as the complainant was laid up in a bedridden stage is false. Complainant has to give written notice immediately upon the event. The claim made by the complainant is bogus. Even the highly belated claim of notice sent on his b behalf contains any data to suggest that the complainant has sustained any injury that make him eligible for the compensation. The claim is vexatious and frivolous. Hence to dismiss the complaint. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency in service on the part of opposite party? 2. Whether the complainant is entitled for the remedy as prayed in the complaint? 3. Relief and cost? The evidence consists of the oral testimony of PW1, DW1, and Ext.A1 to A11and B1 to B3. Issue Nos. 1 to 3 Admittedly complainant is a policy holder. The case of the complainant is that he has sustained injury due to fall on 10.3.03. He was then taken to ESI Hospital, Thottada and then to Head quarters Hospital, Kannur and thereafter Kozhikode Medical College. Complainant filed chief affidavit in tune with the pleadings. He has stated that he had been in treatment under the doctors of Kozhikode Medical college. It is also stated that his treatment had been continued thereafter from Pariyaram Medical College. He is not fully recovered even now. Complainant gives evidence by chief affidavit that he had intimated the accident by way of a letter dt. 18.3.03 but there was no reply. Then again send letter dt. 15.7.03 requesting to send him a claim form. Since no reply was sent complainant contacted the opposite party through telephone and opposite party told him that he can apply after the treatment is over. Meanwhile complainant renewed his policy twice. Complainant states in chief affidavit that because of financial stringency due to continuous treatment he was compelled to send letter on 18.11.04. It was not replied by oppoiste party. So complainant sent lawyer notice dt.29.1.05. Complainant in his chief affidavit says that it was for getting his Insurance claim that he contacted opposite party through letters dt.18.3.03 and 15.7.03 apart from several telephone calls. But opposite party consoled the complainant telling him not to hurry but to submit the claim form after the treatment is over. Complainant alleged that opposite party dealt the matter in this manner only to deny the insurance claim for which complainant is legally entitled. Opposite party on the other hand filed affidavit in tune with their contentions stating that complainant is a policy holder and he has renewed his policy on 26.8.03 and 26.8.04. But complainant had not disclosed anything about the incident or his difficulties. Opposite party contended that the incident was communicated only when the lawyer notice dt.18.11.04 was sent to opposite party. Opposite party stated the same in the chief affidavit also. Opposite party contended that the case of the complainant is totally false.It can be seen that the alleged accident fall had taken place on 10.3.03 complainant pleaded that the mater was intimated to the opposite party through the insurance agent and by a written letter sent by the complainant on 10.3.03 and 15.4.03”. In the chief affidavit he has stated that “:” Fsâ A]-I-S-hn-h-cT FXnÀI-£n tFPân-s\- A-dn-bn-¨-t¸mÄ Hcp Fgp¯v aptJ\ FXnÀI-£n-sb-A-dn-bn-¡p-¶-Xp-T-X-¶m-bn-cn-¡p-T-F-¶p-Ft¶mSv]-d-ªn-cp-¶p. Rm³18.3.03\p A]-I-S-hn-h-cT FXnÀI-£n-sb-F-gp-¯-ap-tJ-\-A-dn-bn-¡p-I-bpT sNbvXn-cp-¶p “Complainant has not stated in his complaint that he has written letter to opposite party on 18.3.03. It is seen stated that complainant send another letter on 15.7.03. In the chief affidavit he has stated “18.3.03se Fsâ Fgp¯n\p FXnÀI-£n-bnÂ\n¶p adp-]Sn In«m-¯-Xn-\mÂ15-.7-.03-\p-Rm³ hoWvSpT FXnÀI-£n¡v Fgp-¯-A-b-¡p-I-bpT Hcp Ivsfbn-T- t^m-d-T-A-b-¨p-X-cp-hm³ -B-h-i-y-s¸-Sp-I-bpT sNbvXp.. He has not stated that the letter send on 15.7.03 was one registered. But he has produced Ext.A3 acknowledgement bearing the date 16.7.03 on the seal of the opposite party. Ext.A4 a postal receipt which carries no date also produced. The letter sent on 18.1.04 was the letter mentioned as registered letter in the complaint. The copy of the letter marked as Ext.A5.The original has been produced by opposite party. This letter is relevant since it is the first admitted document of intimation of the alleged incident. There is no wisper about the letter of 18.3.03 and that of the letter 15.7.03 .What he has written with respect to the intimation of incident is thus: “As I was in a bedridden stage it was not possible for me to appear before you in order to file claim form. So the matter was intimated to you through the agent and over phone and I was asked to file claim form after the treatment. Meanwhile, the policy issued to me was renewed twice” The letter of 18.3.03 and 15.7.03 has not been mentioned anywhere in the letter. And there was also no mention about intimation of letter whatever maybe, alleged to be sent on 10.3.03, in the complaint. Ext.A7 is the lawyer notice sent on 29.1.05. This is the valid document wherein the foundation of the case of the complainant laid down. The case of the complainant therein is nothing but mere repletion of what has been written in Ext.A5 above mention letter of 18.11.04. It is thus: As my client was seriously laid up it was not possible for him to be present before you in order to file claim form. So the matter was intimated to you through the agent and over phone and my client was told to file claim form after the treatment. So he addressed to you on 18.11.04for getting the claim form so as to make a claim.” It is very clear that as per this notice complainant addressed to opposite party on 18.11.04 for getting the claim form. No other letter of intimation before 18.11.04 has been mentioned in Ext.A7. If there was any such communication earlier to 18.11.04 that would have been found place in ext.A7. No wisper about any such letters of communication anywhere in the notice. Ext.A8 is the reply sent by opposite party to the said lawyer notice sent by the complainant. It has written that the insured is under legal obligation to give a written notice with full particulars, immediately upon happening of any event which may give rise to a claim under this policy. Ex.B1 shows that it is the first condition. Complainant has not produced copy of any letter sent to opposite party prior to 18.11.04. Ext.A8 specifically pointed out that the intimation with respect to the alleged accidental fall was intimated only on 8.11.2004, in the complaint it has alleged that intimation sent on 10.3.03 and 15.7.03. It is seen that the date 10.3.03 has been added by way of correction resulting in confusion with respect to the date. That confusion could have been avoided if the copy of the letter has been produced which complainant failed to do. Complainant in the first time stated in the affidavit, that he has sent a letter of intimation on 18.3.03. But in this case also copy of the letter has not been produced. Neither the registered letter sent on 18.11.2004 and lawyer notice Ext.A8 nor the complainant mentioned about the letter of information allegedly sent on 18.3.03.Such a letter if sent, it is difficult to understand, why the complainant ignored to mention about these letter in Ext.A5, A7and in complaint. The absence of earliest communication stands as the basic reason for rejecting the claim. Under such circumstances the case, in any way cannot be determined basing only on Ext.A2 & A3. Moreover the complainant renewed the policy twice after the alleged incident. These new policies were issued on 26.8.03 and 26.8.04. It can be seen that Ext.A5 registered letter and Ext.A7 lawyer notice has been sent only after these renewal. Herein also the crucial point arose whether or not the complainant informed the opposite party at this juncture about the incident and his health condition. Complainant has no case that, on both occasion, informed the opposite party anything neither about the incident nor of his heath condition. Whereas, the opposite party has specific case and stated in chief affidavit thus: tFsX¦n-ep-T-tcm-K-ap-s-¦n-ep-T-im-cn-cn-I-ssh-I-e-y-§-fps¦n-epT IqSm-sX- I-gnª policy bnÂ-F-s´-¦n-epT Xc-¯n-ep-ff t]mcm-bva-I-fp-s-¦n-epT t]mfnkn ]pXp-¡p¶ ka-b¯ IT-]-\nsb And-bn-¡m³ lc-sP#n-¡m-c³_m-[-y-Ø-\m-Wv. He has also stated in the affidavit that “ F¶m policy ]pXp-¡p¶ ka-b-s¯m-¶p-T-A-]-I-S-s¯-]-äntbm hnj-a-X-I-sf-]-äotbm A\-ym-b-¡m-c³ Cu FXnÀI-£nsb And-bn-¡p-I-bp-m-b-nà . “Complainant could very well inform the existing health condition and the alleged incident to the opposite party which, he even legally bound to do at the time of removing the policy. This is a very material question which the complainant ignored to answer. In the usual course it has been expected to be informed. Complainant in anyway could not succeeded in establishing his case. The available evidence does not permit to hold that there is deficiency in service on the part of opposite party in rejecting the claim of the complainant. In the light of the above discussion and perusal of the documents on record we hold that the complainant failed to prove his case, establishing deficiency of service on the part of opposite party. The available evidence does not show reasons to reject the repudiation of claim by the opposite party. The issues 1 to 3 found against the complainant. In the result, the complaint is dismissed. No order as to costs. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1.Copy of the policy schedule issued by OP A2.Certificate of posting receipt A3 & A4.Postalreceiptand AD card A5.Copy of the letter dt.18.11.04sent to OP A6.Postal AD card A7.Copyof the lawyer notice dt.29.1.05 sent to OP A8.Reply notice sent b y OP A9 & 10.Medical prescriptions and bills A11.Travelling taxi bills Exhibits for the opposite party B1.Copyof the policy schedule issued to complainant B2.Conditions B3.Copy of the reply notice sent to complainant Witness examined for the complainant PW1.Complainant Witness examined for the opposite parties DW1.K.Sreedharan /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur.
......................GOPALAN.K
......................JESSY.M.D
......................PREETHAKUMARI.K.P | | 
