This Complaint coming up before us for hearing on 11-10-11 in the presence of Sri Sk. Habibulla, advocate for the complainant and of Sri S.A. Khadar, advocate for opposite party, upon perusing the material on record after hearing both sides and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao,  President:-

        The complainant filed this complaint under section 12 of the Consumer Protection Act seeking assured amount of Rs.1,10,000/- plus interest @24% p.a., and Rs.50,000/- as damages and Rs.10,000/- as costs.

2.   In brief the averments of the complaint are these:

        The complainant obtained individual personal accident policy bearing No.550507/42/07/8100000311 from the opposite party covering the period from 07-03-2008 to 06-03-2009 for Rs.1,00,000/- plus cumulative bonus of Rs.20,000/-.   The complainant also obtained Janatha Personal Accident policy bearing No.550507/47/04/9660283 from the opposite party for Rs.1,00,000/- commencing from 03-03-05 to 02-03-10.    On 15-07-08 at 9.00 a.m. while going from his house one piece of kitchen wood accidentally hit the left eye of the complainant and caused injury.   The complainant took treatment from Dr. Bolla Nageswara Rao as out-patient.   Due to the above accident the complainant lost his total eye sight of left eye.    The Medical Board of Government General Hospital, Guntur issued disability certificate.    The complainant submitted claim forms on 27-02-09 regarding Janatha Personal Accident policy and on 28-02-09 regarding individual personal accident policy with all required documents.   The opposite party on 12-04-10 issued a letter to the complainant stating that the record in respect of the claim under policy No. 550507/42/07/8100000311 was closed without paying any amount and did not respond to the other policy.    As per the terms and conditions of the policy 550507/42/07/8100000311 the complainant is entitled to an amount of Rs.50,000/- plus Rs.10,000/- while in respect of other policy a sum of Rs.50,000/-.   In all the complainant is entitled to Rs.1,10,000/-.   The complainant suffered a lot mentally and financially.   The opposite party is liable to compensate the complainant towards damages also.    The complaint therefore be allowed.

3.  The contention of the opposite party in brief is hereunder:

        The complainant took Janatha personal accident policy bearing No. 150804/42/07/01/029 from M/s United India Insurance Company Limited for the period from 14-03-08 to 13-03-09 and another policy bearing No.150804/47/07/51/44 for the period from 01-01-08 to            31-12-12.    The complainant is in the habit of taking different policies from different companies with an intention to have wrongful gain.     The opposite party shall not be liable to make any payment under this policy in respect of any claim be in any manner fraudulent statement or device by the insured or by any person on behalf of the insured policy as per condition No.3 of Personal Accident insurance policy and 4 of Janatha Personal Accident policy.   As per condition No.6 of Janatha Personal Accident policy the maximum liability is Rs.1,00,000/- only to be shared among different insurers.    The complainant already received the compensation payable for the loss of one eye from M/s United India Insurance Company Limited.    The complainant did not respond to the several reminders issued by the opposite party.    The opposite party did not commit any deficiency of service.   The complaint therefore be dismissed.

4.  Exs.A-1 to A-13 on behalf of complainant and Exs.B-1 to B-9 on behalf of opposite party were marked.

5.  Now the points that arose for consideration in this complaint are:

1. Whether the opposite party committed deficiency of service?
2. Whether the complainant is entitled to compensation?        
3. To what relief?

6.   Admitted facts in this case are these:-

        1. The complainant obtained Janatha Personal Accident Policy                    (Ex.A-2) and Individual Personal Accident Insurance Policy                     from the opposite party (Exs.A-1).

        2. The complainant submitted claim forms to the opposite party.

        3. The opposite party addressed letters to the complainant                                Exs.A-12 (=B-6) and A-13 (=Ex.B-4).

7.   POINT No.1:-   In this case the complainant made claim with the opposite party under Janatha Personal Accident Policy as well as Individual Personal Accident Policy.  The opposite party under                Exs.A-12 (=B-6) and A-13 (=Ex.B-4) sought certain clarifications from the complainant.    Under Ex.A-13 dated 05-06-09 the opposite party sought the following clarifications:

“1.   It is noted from the certificate of Dr. Balla Nageswara Rao that you have been referred to the higher centre for further treatment.   Please provide the particulars of the treatment along with case sheet, medical reports, etc.

2.    It is mentioned in the claim form for col.9 as N.A. Please                   provide the specific answer for ‘Is a claim being made under                any other insurance?  If so, please give particulars’

3.   It may be noted from the medical certificate issued by Chairman, Physically Handicapped Board, Guntur district. Vide col.7 (b) that “30% BLIND” from which it may be interpreted that there is no total loss of sight.

4.      You have submitted the photocopies of medical bills &                       prescriptions.  Please send originals for the same”.    

8.   Ex.B-7 letter dated 07-05-10 addressed by the opposite party to the complainant revealed that the complainant did not answer clause 2 as detailed supra.   Ex.B-9 letter dated 12-08-10 addressed by M/s United India Insurance Company Limited to the opposite party revealed that that the complainant approached M/s United India Insurance Company also for similar relief.

9. The complainant claimed Rs.50,000/- only regarding  Janatha Personal Accident policy.     Clause 6 of Ex.B-1 conditions of JPAP says

            “If the insured shall at any time during the continuance of policy be insured against similar Janatha Personal Accident Insurance policy with one or more insurers then the maximum liability of the insurers irrespective of the number of such policies in force with one or more insurer shall be limited to a maximum sum of Rs.1,00,000/- only”.

10.  Clause 4 of Ex.B-1 conditions of JPAP says that the company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent statement or device whether by the insured person or any person on behalf of the insured.    Clause 3 of Ex.B-2 conditions says that the company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent statement or device whether by the insured person or any person on behalf of the insured.    It is to be noted here clause 6 of Ex.B-1 conditions of JPAP was silent in personal accident insurance (individual) policy. 

11.   The assured amount under JPAP as seen from Ex.A-2 is Rs.1,00,000/-.   Ex.B-3 claim form submitted by the complainant was on 28-02-09. Ex.B-9 was silent when the complainant submitted claim forms to M/s United India Insurance Company Limited.    Under those circumstances it cannot be said that the complainant preferred claim with M/s United India Insurance Company earlier to Ex.B-3.    Therefore, the contention of the opposite party that the complainant made fraudulent claim is devoid of merit.   The complainant claimed Rs.50,000/- in respect of JPAP but not the assured amount of Rs.1,00,000/-.   Therefore the claim of the complainant is justified. 

12.     The sum assured under Individual Personal Accident Policy as seen from Ex.A-1 is Rs.1,00,000/- plus Rs.20,000/- as claim bonus.    The relevant clauses in Ex.B-2 policy is extracted below for better appreciation:

“a) If such injury shall within twelve (12) calendar             months of its occurrence be the sole and direct   cause of the death of the insured the Capital         Sum Insured stated in the schedule hereto.

1. 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. sight of both eyes or the actual loss by physical separation of the two entire hands or the two entire feet or one entire hand and one entire foot or of such loss of sight of one eye and such loss of one entire hand or one entire foot of the insured the capital sum insured stated in the schedule hereto.
   2.  Use of two hands or two feet or of one hand and one foot or of such loose of sight of one eye and such loss of use of one hand or one foot of the insured the capital sum insured stated in the schedule hereto.
2. 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 fifty percent (50%) of the capital sum insured stated in the schedule thereto.
   2. Total and irrecoverable loss of use of a hand or a foot without physical separation of the insured fifty percent (50%) of the capital sum insured stated in the schedule thereto”.    

13.   To prove that the complainant lost his sight on left eye relied on Ex.A-4 dated 15-09-09 and Ex.A-6 dated 09-02-09.        In Ex.A-5 dated 07-01-2009 Dr. Bolla Nageswara Rao mentioned that the complainant had no vision in left eye and right eye is normal.   But in Ex.A-9 the Medical Board attached to GGH, Guntur it was mentioned as 30% blind.   In column No.7 of Ex.A-7 the following was mentioned:

   7.   Onset of blindness (Please state

whether blindness in from birth

or acquired later, if it has been

issued afterwards the age and                       RE  6/6

cause of blindness may be indicated) : UN  -

                                                                LE No.P2

The blind are those who suffer from

  Either of the following:

(a)  Total absence of sight:   LE/ Corneal degeneration    

                                                Coloboma Iris

                                             Complicated cataract

(b) Visual acuity not exceeding (6/E)

      (or) 20/200 (snellen) in the better

      eye with correcting lenses                       30% blind

                                                      thirty percent blind

            (c) Limitation of the field of vision

            As per Workmen Compensation Act the disability in respect of eye is as follows:   

14.     Since Ex.B-2 revealed the disability as 30% it can be inferred that there was loss of vision of one eye.   The case of the complainant falls under clause ‘C’ (I) of Ex.B-2 and as such is entitled to 50% of the capital sum insured.    The claim regarding 50% of the bonus cannot be split up in our considered opinion and as such is not entitled to 50% of Rs.20,000/-. 

15.    The opposite party keeping the claim pending neither allowing nor repudiating it amounted to deficiency of service.     The opposite party has to pay Rs.50,000/- under JPAP and sum of Rs.50,000/- under Personal Accident (Individual) Policy.   We therefore answer this point accordingly in favour of the complainant. 

16.   POINT No.2:-   Ex.A-9 letter dated 19-03-10 clearly established that it is the complainant who did not furnish particulars to the opposite party as he went Karnataka states for agricultural works.  Under those circumstances awarding a sum of Rs.5,000/- towards compensation will meet ends of justice.   We therefore answer this point in favour of complainant.

17.  POINT No.3:-    In view of above findings the complaint is allowed in part as indicated below:

1. The opposite party is directed to pay Rs.1,00,000/- (Rupees one lakh only) towards JPAP and Personal Accident Individual policy together with interest @9% p.a., from the date of complaint till realisation.  
2. The opposite party is directed to pay Rs.5,000/- (Rupees five thousand only) towards compensation and Rs.1000/- (Rupees one thousand only) towards costs.
3. The amounts ordered above shall be paid within a period of six weeks from the date of receipt of the copy of the order.

Typed to my dictation by Junior Stenographer, corrected by me and pronounced in the open Forum dated this the 18th day of October, 2011.

MEMBER                                  MEMBER                                  PRESIDENT

APPENDIX OF EVIDENCE

  DOCUMENTS MARKED

For Complainant:

For opposite party:        

                                                                                            PRESIDENT