BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 119 of 2010
Date of Institution : 9.4.2010
Date of Decision : 23.8.2016
Sunil Kumar son of Sh.Krishan Kumar, c/o M/s Hans Raj Madan Lal, Cloth Merchants, Gandhi Chowk, Mandi Dabwlai, tehsil dabwali District Sirsa.
….Complainant.
Versus.
The New India Assurance Company Ltd., Sirsa through its Divisional Manager, Sirsa.
...…Opposite party.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI S.B.LOHIA ………………………..PRESIDENT.
SHRI RANBIR SINGH PANGHAL ……MEMBER.
Present: Sh.A.K.Gupta, Advocate for the complainant.
Sh.R.K.Chaudhary, Advocate for the opposite party.
ORDER
In brief, the complainant purchased personal accident insurance policy no. 353702/42/000007/09/00000017 w.e.f. 11.6.2007 to 10.6.2008 against risk of Rs.1 lac with benefits under Table-A, including risk of Rs.50,000/- in respect of his wife Ranju. During the period of policy, the complainant and his wife Ranju met with severe road accident on 16.6.2007, in which they received serious and grievous injuries and remained admitted in different hospitals and ultimately suffered permanent partial disablement. Rapat no.11 dt.16.6.2007 regarding the accident was recorded by the police of police station Cantt., Bathinda. The complainant lodged claim no.353/702/42/07/01190000001 with the opposite party and handed over all the requisite documents alongwith treatment record, bills etc. But, the opposite party on 29.10.2009 settled the claim regarding injuries and disablement to the tune of Rs.50,000/- only in respect of injuries to complainant Sunil Kumar and Rs.25,000/- in respect of injuries to Ranju. However, this amount was received by the complainant under protest. In fact, the complainant and his wife were entitled to amount of bills to the tune of Rs.1 Lac and Rs.50,000/- respectively on account of weekly benefits. Hence, the opposite party has not paid the claimed amount of Rs.2,25,000/- in respect of injuries to both the insured, despite repeated requests of the complainant. Hence, the present complaint. .
2. Opposite parties in their reply have admitted the purchase of personnel accident insurance policy by the complainant. Although the sum insured complainant Sunil Kumar was Rs. 2 lakh instead of 1lakh as alleged and sum insured of Smt. Ranju was Rs. 1 lakh instead of Rs. 50,000/- as alleged with table A benefits. It is pleaded that as per record supplied by the complainant, he remained admitted in hospitals i.e. Adesh hospital for five days 15.6.2007 to 20.6.2007 and in Ganga Ram hospital, New Delhi for 13 days from 20.6.2007 to 3.7.2007. Smt. Ranju remained admitted in Adesh hospital from 15.6.2007 to 16.6.2007 and in Ganga Ram Hospital, New Delhi from 17.6.2007 to 19.7.2007. As per record and certificate, complainant and his wife become disable person upto 25%. As per terms of policy the insured is entitled for 1 % of the sum insured per week upto the total sum insured i.e. for hundred weeks or for compensation in terms of the disability i.e. 25 % of the total sum insured in the present case, whichever is higher. In the present case Shri Sunil Kumar remained admitted in the hospital for 2 weeks 4 days and Smt. Ranju remained admitted in the hospital for 3 weeks 3 days and as such the amount of claim has been paid to the complainant alongwith her wife in accordance with the terms of the policy. It is pertinent to mention here they were not entitled for medical expenses, although medical bills have been paid to them as they were also having medi claim policy. The opposite party is always ready to give better services to the customers and to settle the claims in terms of the policy and there is no deficiency in service on their part. Ops also denied the remaining allegations of the complainant.
3. Both the parties have led their evidence in the form of affidavits and documents. The complainant has tendered in evidence Ex.C1-his affidavit, Ex.C2-receipt, Ex.C2-A-handicapped medical certificate, Ex.C3 to Ex.C6-premium receipts, Ex.C7-forwarding letter for payment of claim amount, Ex.C8-request for weekly compensation amount, Ex.C9 to Ex.C11-replies to RTI, Ex.C12-again request for part payment, Ex.C13 and Ex.C21-discharge summary, Ex.C14 – medial report, Ex.C15 to Ex.C20-prescriptions slips, whereas the respondents have tendered Ex.R1-affidavit of Sh.R.K.Indora, Divisional Manager.
4. We have gone through the record of the case carefully and have heard learned counsel for both the parties.
5. To determine the question whether there is any deficiency on the part of the Ops in settlement of the claims of the complainant or not, we carefully gone through the record produced by the parties in support of their version. As per the Ops version, complainant remained in hospital for a period from 15.6.2007 to 20.6.2007 and from 20.6.2007 to 3.7.2007 i.e. for total 20 days in other words two weeks and six days and Smt.Ranju wife of complainant remained in hospital from 15.6.07 to 16.6.07 and from 17.6.07 to 19.7.07 i.e. total 35 days in other words five weeks. As per the policy terms in case of temporary total disablement @ 1% of sum assured upto 100 weeks (maximum weekly benefits not to exceed Rs.3000/-). Further as per the Ops sum assured was Rs.2,00,000/- in case of complainant Sunil Kumar and 1,00,000/- in case of Smt.Ranju, whereas the complainant is claiming sum assured by way of this complaint Rs.1,00,000/- and Rs.50,000/- respectively. In view of disability certificate Ex.C2/A, complainant Sunil Kumar having 25% disablement whereas no disability certificate for Smt.Ranju has been placed on record. As per the allegations of the complaint, complainant and his wife confined to bed for more than one year, but there is no report on the file to support this version of the complainant that he and his wife confined to bed for the period more than one year. There is only discharge summary of Sir Ganga Ram hospital Ex.C13 according to which date of admission of Sunil Kumar is 20.6.07 and date of discharge is 3.7.07. According to discharge summary of Smt.Ranju from of Sir Ganga Ram hospital Ex.C21, her date of admission is 28.7.07 and date of discharge is 28.7.07. Further as per the Ops version, both husband and wife become disable person upto 25%. As per the terms of policy, the insured are entitled for 1% of the sum assured per week upto the total sum assured i.e. for hundred weeks or for compensation in terms of the disability i.e. 25% of the sum assured whichever is higher. Op vide its letter Ex.C11 clearly informed the complainant that his claim case has been settled as per permanent partial disablement certificate and the claim under weekly benefits was not tenable. In case calculation is made on the basis of week, it comes to Rs.2000/- per week on the basis of total sum assured of Rs.2,00,000/- in case of Sunil Kumar complainant and in case of Smt.Ranju, it comes Rs.1,000/- per week on the basis of total sum assured of Rs.1,00,000/-. As such, Ops have already paid 25% of the sum assured to each injured on the basis of their disability which is on the higher side from the calculation of week basis. In our view, Ops have rightly settled the claims of the complainant on higher side and there is no deficiency on their part.
6. As a result of our discussion, we are of the considered view that present complaint deserves dismissal. We order accordingly. No order as to cost. A copy of this order be supplied to the parties free of cost. File be consigned to record room after due compliance.
Announced in open Forum. President,
Dated: 23.8.2016. Member. District Consumer Disputes
Redressal Forum, Sirsa.
