BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

O.P. No. 357/2002 Filed on 13.08.2002

Dated : 15.12.2008

Complainant:

P. Murukan, T.C 49/2621, Neela Nilayam, Kesava Dev Road, Thamalam, Poojappura, Thiruvananthapuram.

(By adv. R. Jagadish Kumar)

Opposite parties:

1. National Insurance Company Ltd., Divisional Office, Vazhuthacaud, Thiruvananthapuram.

    

2. Senior Divisional Manager, National Insurance Company, Divisional Office, Vazhuthacaud, Thiruvananthapuram.

(By adv. M. Nizamudeen)

This complaint is disposed of after the period so specified under the Consumer Protection Act, 1986. Though the case was taken up for orders by the predecessors of this Forum on 29.11.2006, the order was not prepared accordingly. This Forum assumed office on 08.02.2008 and re-heard the complaint. This O.P having been heard on 10.11.2008, the Forum on 15.12.2008 delivered the following:

ORDER

SRI. G. SIVAPRASAD: PRESIDENT

The facts leading to the filing of the complaint are that complainant is an auto driver by profession and he had taken a special contingency policy No. 570200/46/00 39000151 as a member of Thiruvananthapuram District Transport Workers Union and receipts were issued by opposite parties. The policy covers risks in case of injuries suffered by the insured when the policy is live. Complainant met with an accident on 26.05.2001 at Kothayar in Kanyakumari District when the policy was valid. He stopped from a rocky part and got injury. Immediately complainant was brought to Thiruvananthapuram by car at PRS Hospital for treatment. Complainant was treated initially at PRS Hospital and subsequently at M/s Johnson's Clinic, Karamana. Complainant lodged medicalim insurance to opposite parties on 27.06.2001 with documentary proofs. Opposite parties repudiated the claim on flimsy grounds by letter dated 30.07.2001. The repudiation was on the ground that complainant had no permanent disablement. Complainant issued a lawyer's notice on 01.11.2001 for which a reply was sent by 2^nd

opposite party stating that the complainant's claim was outside the scope of the policy. Complainant had fracture in the knee and below down wards and was treated with plaster of paris for a period of one month followed by surgical bandaging. Complainant was treated with oral drugs also. The repudiation of the genuine claim is illegal and opposite parties are duly bound to compensate the complainant with the policy was live at the time of accident. There is clear deficiency on the side of opposite parties. Hence this complaint claiming an amount of Rs. 10000/- with interest as per the special contingency policy, Rs. 5000/- towards compensation and Rs. 1000/- towards costs.

Opposite parties entered appearance and filed version contending that complaint is not maintainable either on law or on facts. The claim submitted by the complainant was repudiated as it was found on perusal of documents that the complainant has undergone treatment for injuries only as an outpatient while the policy covered only hospitalization expenses incurred as an inpatient, permanent total disability and death. The inability of the opposite parties to allow the claim was intimated to the complainant vide letter dated 03.07.2001. The said contingency policy only covers death, permanent total disability for a capital sum insured of Rs. 50000/- and inpatient hospitalization expenses of Rs. 10000/-. Complainant had fracture in the knee and below downwards are absolutely false and hence denied. The claim was repudiated for valid and cogent reasons and according to the terms and conditions of the policy issued to Thiruvananthapuram District Transport Workers' Union. Opposite parties have not committed any deficiency in service. Complainant is not entitled to get any of the reliefs prayed for. Opposite parties prayed for dismissal of the complaint.

The points that would arise for consideration are:-

1. Whether opposite party is liable to pay an amount of Rs. 10000/- as per the special contingency policy?

2. Whether there has been deficiency in service on the part of opposite parties?

3. Other reliefs and costs.

In support of the complaint, complainant has filed affidavit and marked Exts. P1 to P17. In rebuttal, the Assistant Divisional Manager of the 2^nd opposite party has filed counter affidavit and marked Exts. D1 to D3.

Points (i) to (iii):- It has been the case of the complainant that complainant, a driver by profession, had taken a special contingency policy vide No.570200/46/00 39000151 as a member of Thiruvananthapuram District Transport Workers Union and receipts were issued by the opposite parties, and that the said policy covers risks in case of injuries suffered by the insured when the policy alive. According to the opposite parties, the said policy would cover only death, permanent total disability for a capital sum insured of Rs. 50000/- and inpatient hospitalization expenses of Rs. 10000/-. Exts. P1 and P2 are the copy of receipts issued by the opposite parties showing remittance of premium towards Misc. TB policy by M/s Thiruvananthapuram District Transport Workers Union. As per Ext. P1 collection No. and date is 6240 dated 07 March, 2001 and as per Ext. P2 collection No. and date is 6364 dated 14 March 2001. Submission by the counsel appearing for the complainant was that during the period when the policy was valid, the complainant met with an accident on 26.05.2001 at Kothayar in Kanyakumari district and he was brought by car to PRS Hospital, Thiruvananthapuram for treatment and subsequently complainant was treated at M/s Johnson's Clinic, Karamana. It has been contended by the complainant that even after lodging the medi-claim stating the full details of his treatment with documents, opposite parties repudiated the same on flimsy grounds by letter dated 03.07.2001. Ext. P3 is the letter dated 03.07.2001 issued by the opposite party to the complainant. It is stated in Ext. P3 that complainant has undergone treatment for injuries only an outpatient, since policy covers only hospitalization expenses incurred as an inpatient and the injuries sustained by the complainant have not resulted in treatment disablement as defined in the policy, and that opposite parties expressed their inability to admit the liability for the said claim. Ext. P4 is the copy of advocate notice dated 01.11.2001 sent to the opposite party by the complainant. Ext. P5 is the postal receipt. Ext. P6 is the acknowledgement card. Ext. P7 is the reply dated 02.11.2001 issued by the opposite party to the counsel of the complainant. Ext. P8 is the copy of treatment bill date 26.05.2001 for Rs. 575/- issued by PRS Hospital to the complainant. Ext. P9 is the copy of pharmacy bill dated 26.05.2001 issued in the name of complainant by the PRS Hospital for Rs. 188/- towards plaster of paris 15 cm. Ext. P10 is the copy of pharmacy bill dated 26.05.2001 issued in the name of complainant by the PRS Hospital for Rs. 128.50 towards medicines. Ext. P11 is the copy of bill dated 26.05.2001 issued in the name of complainant by PRS Hospital for Rs. 180/- towards X-ray. Ext. P12 is the copy of the slip showing medicine prescriptions by PRS Hospital. Ext. P13 is another slip dated 31.05.2001 issued by PRS Hospital. Ext. P14 is the treatment report issued by Johnson's Clinic. In Ext. P14 it is stated that the complainant was treated with a plaster of paris (below knee) cast for a period of one month(27 days) followed by Crepe bandage and that he is deemed to fit to rejoin duty on 30.06.2001. Ext. P15 contains pay bills dated 27.06.2001 issued by Mannadi Medicals for Rs. 89/- towards Crepe bandage. Ext. P16 is the copy of mediclaim insurance policy claim form. Ext. P17 is the letter dated 19.10.2001 issued by the opposite parties to the complainant stating closing of the file and treating the claim as 'No claim' since complainant has not submitted the claim form or any documents. Submission by the counsel appearing for opposite parties was that the claim was repudiated for valid and cogent reasons and according to the terms and conditions of the policy issued to the Thiruvananthapuram District Transport Workers Union and that opposite parties have not committed any deficiency in service. Opposite parties further submitted the bills, receipts, certificates etc. submitted by the complainant were false. Ext. D1 is the photocopy of Ext. P3 and Ext. D2 is the photocopy of Ext. P7. Ext. D3 is the copy of special contingency insurance policy. As per Ext. D3, capital sum insured is Rs. 50000/-, inpatient hospitalization expense is Rs. 10000/-, period of insurance 07.03.2001 to 06.03.2002. As per special contingency insurance policy (Ext. D3) the company will indemnify the insured persons if they shall sustain bodily injury resulting solely and directing from the accidents caused by onward and visible means. As per clause (d) of the policy, expenses incurred on hospitalization as an inpatient due to bodily injury resulting solely and directly from an accident caused by outward violent and visible means. According to the complainant, he met with an accident on 26.05.2001 at Kothayar in Kanyakumari District and complainant stopped from the rocky part and got injured. Opposite parties denied it. Complainant gave evidence of accident by way of affidavit. Complainant has not been cross examined by opposite parties. A perusal of Exts. P8 to P15 would show that complainant was treated at PRS Hospital, Thiruvananthapuram and subsequently at Johnson Clinic at Karamana from 26.05.2001 to 27.06.2001. Hospitalization would mean sending somebody to hospital for treatment. As per clause (d) of the said policy opposite parties would indemnify expenses incurred on hospitalization as an inpatient due to bodily injury resulting solely and directly from an accident caused by outward violent and visible means. Opposite party repudiated the claim on the ground that complainant had undergone treatment only as outpatient. A patient who lives in hospital while receiving treatment is called inpatient. It is pertinent no note that complainant has treated at two hospitals from 26.05.2001 to 27.06.2001. As per Ext. P14 complainant had treated for an injury of the left foot allegedly sustained on 26.05.2001 and preliminarily treated at PRS Hospital and he was treated a plaster of paris (below knee) cast for a period of one month followed by crepe bandage. Considering the nature of treatment, after the application of plaster of paris and serving medicines the patient need not stay in the hospital, which would later saddle the complainant with higher bill. The word inpatient should be interpreted in broader sense. When there can be different interpretations, the interpretation which would be beneficial to consumer is to be given preference. A perusal of Exts. P8 to P15 would reveal that complainant had incurred expenses on hospitalization to the tune of Rs. 1670.45(Rs. 575+ Rs. 188+Rs. 128.45+ Rs. 180+ Rs. 510+ Rs. 89) to which, we find, the opposite parties are liable. Non-payment of the said amount would amount to deficiency in service. Taking into consideration of the totality of circumstances, we think, justice will be well met if complainant is compensated by an amount of Rs. 5000/- against all his claims.

In the result, complaint is allowed. Opposite parties shall pay a sum of Rs. 5,000/- to the complainant within two months from the date of this order, failing which the said amount shall carry interest at the rate of 12% till realization.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the day of 15^th December 2008.

G. SIVAPRASAD : PRESIDENT

BEENAKUMARI. A : MEMBER

S.K. SREELA : MEMBER

O.P. No. 357/2002

APPENDIX

I COMPLAINANT'S WITNESS :

NIL

II COMPLAINANT'S DOCUMENTS :

P1 - Photocopy of receipt dated 07.03.2001 issued by the opposite

parties.

P2 - Photocopy of receipt dated 14.03.2001 issued by the opposite

parties.

P3 - Photocopy of letter dated 03.07.2001 issued to the

complainant by the opposite party.

P4 - Copy of legal notice dated 01.11.2001 issued to the opposite

party.

P5 - Postal receipt dated 01.11.2001.

P6 - Postal acknowledgement card dated 02.11.2001.

P7 - Reply notice dated 02.11.2001 issued to the counsel for the

complainant.

P8 - Treatment slip dated 26.05.2001.

P9 - Photocopy of pharmacy bill No.507670 dated 26.05.2001.

P10 - Photocopy of pharmacy bill No.507672 dated 26.05.2001.

P11 - Photocopy of X-ray bill.

P12 - Photocopy of bill dated 26.05.2001.

P13 - Photocopy of bill dated 31.05.2001.

P14 - Photocopy of treatment report dated 27.06.2001.

P15 - Photocopy of bill dated 27.06.2001.

P16 - Photocopy of mediclaim insurance policy claim form of

complainant.

P17 - Letter reference No. 570200 dated 19.10.2001.

III OPPOSITE PARTY'S WITNESS :

NIL

IV OPPOSITE PARTY'S DOCUMENTS :

D1 - Copy of letter dated 03.07.2001 issued to the complainant.

D2 - Copy of legal notice dated 02.11.2001.

D3 - Copy of special contingency insurance policy dated 07.03.2001.

PRESIDENT