West Bengal

Paschim Midnapore

CC/141/2015

Sri Udita Kumar Pradhan - Complainant(s)

Versus

National Insurance Co.Ltd. - Opp.Party(s)

07 Apr 2016

ORDER

                                                          DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

Mrs. Debi Sengupta, Member

and

Kapot Chattopadhyay, Member.

   

                                                  Complaint Case No.141/15                         

                                       

                                   Sri Udita Kumar Pradhan…………..………...……Complainant.

Versus

1)National Insurance Co. Ltd.,

2)The Business Centre Head, National Insurance Co. Ltd.,

3)The Regional Manager, National Insurance Co. Ltd.

                                                   .,..………...........…..Opp. Parties.

 

 

              For the Complainant: Mr.  Surajit Dutta, Advocate.

              For the O.P.               : Mr.   Anath Bandhu Ghosh, Advocate.

 

Decided on: - 07/04/2016

                               

ORDER

                          Bibekananda Pramanik, President – Facts of the case, in brief, is as follows :-

                  The present petition of complaint was at first filed before the Ld. District Consumers Disputes Redressal Forum, Purba Medinipur and said complaint was numbered as CC/84/2015. Subsequently,  vide order dated 28/10/2015,  passed by the Hon’ble State Consumers Disputes Redressal Commission, West Bengal, in Transfer Application No.TA/5/2015, said petition of complaint has been transferred to this Forum for disposal and accordingly the petition of complaint was a registered and numbered as CC/141/2015.

                    Complainant’s case in brief is that he is the owner of the one two wheeler

Contd………………..P/2

 

 

 

 

( 2 )

 Honda Motorcycle bearing registration no.WB-30-K-0839 and his said motor cycle was duly insured under a ‘Two Wheeler Package Policy’ along with personal accident policy with the opposite party vide policy no.156034311310000344 covering the period from 14/08/2013 to 13/08/2014 and the I.D.V of the vehicle was Rs.32,900/- and personal accident coverage is Rs.1,00,000/-.  During the policy period, the complainant met with an accident on 12/12/2013 at about 6.45 a.m. while he along with his son started from his residence at Madhakhali and then one Tata ACE Vehicle being registration no.WB-31-6567 dashed him from back side.   Due to such accident, the complainant sustained injuries and became senseless.  He was at first admitted in Bhupatinagar P.H.C. for treatment and therefrom he was referred to Tamluk Hospital after primary treatment.  Few days thereafter, he was admitted in Ekbalpur Nursing Home at Kolkata and he had to incurr  medical expenditure  of Rs.1,25,400/- for recovery from such accidental injury.  Over that accident, Bhupatinagar P.S. started a case vide FIR no.05/2014 dated 08/01/2014.  Complainant submitted claim form on 25/03/2014 before the opposite party -Insurance Company for remibursement of medical expenditure of Rs.1,25,000/-.  In spite of receipt of the claim under that policy, the opposite party-Insurance Company did not settle the claim and due to such non- settlement of claim, the opposite party- Insurance Company has committed gross deficiency in service as well as unfair  trade practice causing financial hardship to the complainant. Hence this complaint, praying for directing the opposite parties to pay the claim amount of Rs.1,25,000/- with interest, an award of compensation to the tune of Rs.3,00,000/- and litigation cost of  Rs.20,000/-.

                               Opposite parties- Insurance Company have contested this case by filing a joint written objection. Denying and disputing the case of the complainant, it is the specific case of the opposite parties that  the policy in question is only payable in case of claim of death and permanent disablement of owner - driver according to policy terms and conditions of personal accidental insurance policy (Individual) and according to terms and conditions of the policy, the policy in question is not covered under any kind of medical reimbursement caused by an accident in time of driving of the insured motor cycle and reimbursement is  only covered under mediclaim policy.  This policy is also issued for liability to cover third  party risk, own damage of the insured vehicle risk and including another facility i.e. coverage of personal accident benefit within one insurance policy according to coverage of different head as stated above in a policy of two wheeler policy.  So this policy is in the nature of package but it is not covered for any medical benefit and so there is no question of medical reimbursement.  Since the complainant has prayed for reimbursement of medical expenses and not for his disablement, so the opposite party-

Contd………………..P/3

 

 

 

( 3 )

Insurance Company is unable to settle or entertain the claim of the complainant under this policy.  It is stated that the complaint is not maintainable and as such it is liable to be dismissed.

Point for decision

                             Is the complainant entitled to get the reliefs, as sought for?    

                   

Decision with reasons

In this case,  neither the complainant nor the opposite parties have adduced any sort of evidence,  either oral or documentary but they have relied upon some documents,  so filed by them.

It is not denied and disputed that the complainant is the owner of one two wheeler Honda Motorcycle bearing registration no.WB-30-K-0839 and his said motor cycle was duly insured with the opposite party- Insurance Company under a two wheeler package policy being no.156034311310000344 covering the period from 14/08/2013 to 13/08/2014 and the sum assured for personal accident coverage was Rs.1,00,000/-.  According to the complainant,  during the said policy period, he met with an accident on 12/12/2013 while he was riding his said motor cycle and due to such accident the complainant sustained injuries. He was at first admitted in Bhupatinagar P.H.C and thereafter he was referred to Tamluk Hospital after primary treatment.  Subsequently, he was admitted in Ekbalpur Nursing Home at Kolkata and he incurred medical expenditure of Rs.1,25,400/- for his such treatment.  Further according to the complainant, he submitted claim under that policy before the opposite party no.2 for reimbursement of medical expenditure of Rs.1,25,000/- under that policy but in spite of that,  the opposite party did not settle the claim.  As against this, it is the case of opposite parties as we find from their written objection that  any claim under the aforesaid policy is only payable in case of death and permanent disablement of the owner cum driver and this policy is not covered under any kind of medical reimbursement caused by an accident at the time of driving of the insured motor cycle.

  From the petition of complainant we find that the complainant submitted claim before the opposite party under that policy for medical reimbursement of Rs.1,25,400/-.  Referring the said policy paper which has been filed in this case, Ld. Lawyer for the complainant drawn our attention at the time of hearing of argument that  there is clear note  about personal accident coverage  of Rs.1,00,000/-  and the complainant is therefore entitled to the said sum of Rs.1,00,000 under that policy due  to such accident.  As against this, Ld. Lawyer for the opposite party submitted before us the papers relating to terms and conditions of TWO WHEELER PACKAGE POLICY of National Insurance Company and

Contd………………..P/4

 

 

 

( 4 )

pointed out that it would be found from the terms and conditions of this policy that compensation under this policy is allowed in case of death, loss of two limbs or sight of two eyes or one limb and  sight of one eye or  permanent total disablement from injuries other than named above.  From this document regarding terms and conditions of  TWO WHEELER PACKAGE POLICY  of National Insurance Company we find that Section III provides that compensation under this policy is payable in case of death or loss of two limbs or sight of two eyes or one limb or sight of one eye or in case of permanent total disablement from injuries other than named above. Admittedly, the policy in question is not a mediclaim policy and the complainant did not sustain  injuries as provided under section – III , as stated above.  So under the said terms and conditions of the policy in question the complainant is not entitled to get any reimbursement of medical expenditure under that policy.

  The petition of complaint is therefore liable to be dismissed.

                                                  Hence, it is,

                                                     Ordered,

                           that the complaint case no.141/2015  is hereby dismissed on contest but in the circumstances without cost.

                               Let plain copy of this order be given to the parties free of cost.

 

          Dictated & Corrected by me

             

                      President                            Member              Member                      President

                                                                                                                           District Forum

                                                                                                                        Paschim Medinipur