Haryana

Ambala

CC/297/2016

Surjeet Singh - Complainant(s)

Versus

OIC Ltd. - Opp.Party(s)

Dinesh Sharma

26 Feb 2018

ORDER

FBEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

AMBALA.

                                                     Complaint Case No.:   297 of 2016.

                                                     Date of Institution:     27.07.2016.

                                                     Date of order:                    26.02.2018.

 

Surjeet Singh son of Shri Banta Singh resident of village Barara District Ambala.

                                                                          ….. Complainant.

                                          Versus     

 

1.The Oriental Insurance Company Limited Division Office No.03, Code No.272200, 4 =E/14, Ajad Bhawan, 2^nd Floor, Jhandewla Extension, New Delhi through its Divisional Manager.

2.Punjab National Bank, Barara District Ambala through its Manager.

 

….Opposite parties.

 

Complaint U/s 12 of the Consumer Protection Act

                                                                                

BEFORE:       SH. D.N. ARORA, PRESIDENT    

                   MS. ANAMIKA GUPTA, MEMBER                                                         SH.PUSHPENDER KUMAR, MEMBER.         

 

Present:          Shri Dinesh Sharma, Advocate for the complainant.

                      Shri R.K.Vig, Advocate for OP No.1.

                      Shri Munesh Sharma, Advocate for the OP No.2.     

 

ORDER

 

                   Briefly stated the facts of the present complaint are that he is having saving bank account No.7497000100008949 with Op No.2 which had deducted Rs.12/- from his account as a premium amount under Prime Minister Surkasha Bima Yojna on 03.06.2015 duly received by Op No.1. The complainant has been insured under PMSBY scheme to the tune of Rs.2 lacs i.e. sum assured which is payable in case of accidental injury. On 04.07.2015 the complainant was cutting fodder by an electric machine/Toka machine and unfortunately his right hand came into the machine and crushed upto elbow, therefore, he was taken to MM Medical College and Hospital, Mullana and his arm was amputated. The complainant was declared 80 % disabled as per disability certificate dated 05.08.2015 issued by Medical Board, Ambala City. The Op No.1 was intimated through Op No.2  regarding accident and request was also made to make the insured amount but the Op No.1 wrongly and illegally rejected the claim on the ground that FIR was not lodged by the complainant which was essential for settlement of the claim. Thereafter the complainant got recorded DDR regarding this in police station Barara vide GD No.25 dated 30.11.2015 and requested the Op No.1 to pay the amount of compensation but it did not make the payment of sum assured. The complainant got served legal notice upon the OP No.1but despite that the Ops did not pay any heed.  The act and conduct of the Ops clearly amounts to deficiency in service on their part. In evidence, the complainant has tendered affidavit Annexure C1 and documents Annexure C2 to Annexure C22.

2.                 Upon notice, OPs appeared and filed their separate replies. OP No.1 in its reply has submitted that complainant himself is liable for the incident which took place on 04.07.2015 and the matter was received in the office on 24.08.2015 by Op No.2 regarding accident but no FIR was lodged regarding this which was essential to settle the claim under PMSBY. Since the complainant himself has not fulfilled the terms and conditions of the accidental scheme of the policy, therefore, his claim was rightly repudiated vide letter dated 21.10.2015 duly intimated to the complainant. The complainant got the DDR registered only on 30.11.2015 i.e. after 5 months from the date of accident therefore, his claim was not liable for re-consideration. There is no deficiency in service and unfair trade practice on the part of Op No.1 and the repudiation of claim of the complainant is justified and there is no illegality in the same. Other contentions have been controverted and prayer for dismissal of the claim has been made.

                   Op No.2 in its reply has taken many preliminary objections such as cause of action, concealment of material facts, locus standi and maintainability etc. Under the said scheme the sum assured to the complainant was Rs.2 lac in case of death and Rs.2 lac in case of total and irrecoverable loss of both eyes or loss of use of both hands or feet or loss of sight of one eye and loss of use of hand or foot and Rs. 1 lac in case of total and irrecoverable loss of sight of one eye or loss of use of one hand or foot. The claim so submitted by the complainant was immediately sent to Op No.1 for settlement but the same was cancelled when the complainant had not fulfilled all the terms and conditions of the policy.  There is no deficiency in service and unfair trade practice on its part. Lastly, prayer for dismissal of the claim has been made. In evidence, the Ops have tendered affidavits Annexure RA, Annexure RB and documents Annexure R1 to Annexure R21.

3.                We have heard learned counsel for the parties and have perused the case file carefully.

4.                Before going further it is desirable to discuss about PMSBY, which reads as under:

 Pradhan Mantri Suraksha Bima Yojana (PMSBY) which is an accidental death and disability insurance scheme. Today, if an earning member of a family becomes permanently disabled or dies an accidental death, his or her family faces a life in penury and hardship, with no protection or support from any institution or group. By joining the PMSBY scheme and by paying a nominal premium of Rs. 12/- per person per year, he or she will get an insurance cover for a sum of Rs. 2,00,000/- (two lakh) in case of accidental death or permanent full disability or a sum of Rs. 1,00,000/- (one lakh) in case of partial but permanent disability.

 

5.                Undisputedly, the complainant was insured with OP No.1 under PMSBY through OP No.2 (Annexure C9).  As per version of the complainant mentioned in the FIR (Annexure C4) on 04.07.2015 when he was cutting fodder through an electric machine/Toka machine unfortunately his right hand came into the machine and crushed upto elbow, therefore, he was taken to MM Medical College and Hospital, Mullana and his arm was amputated. The complainant was declared 80 % disabled as per disability certificate dated 05.08.2015 issued by Medical Board, Ambala City (Annexure C5) but the OP No.1 wrongly and illegally repudiated his claim.

6.                The OP No.1 has come with the plea that regarding accident but no FIR was lodged which was essential to settle the claim under PMSBY, therefore, his claim was rightly repudiated vide letter dated 21.10.2015. The complainant got the DDR registered on 30.11.2015 and that too has been lodged after a considerable delay in order to fill the lacuna therefore, the claim as also not found fit for re-consideration.

7.                          The complainant had firstly lodged the claim under PMSBY, therefore, the OP No.1 vide letter dated 19.08.2015 (Annexure C10) demanded the copy of FIR alongwith other documents. Thereafter, the Op No.1 further asked the complainant to submit copy of FIR/Panchnama and MLC vide letter dated  22.09.2015 (Annexure C11)  and when the complainant did not submit the requisite document then finding no alternative his claim was repudiated by the insurance company vide letter dated 21.10.2015 (Annexure C14). Perusal of the case file reveals that the complainant had requested the insurance company for settlement of claim and also submitted copy of FIR which could not be lodged in advertently. It is established on the case file that the DDR was got lodged by the complainant on 30.11.2015. We have gone through the list Annexure R9 requisite document for claim process under PMSBY are that FIR/panchnama/PMR/Death Certificate by a Govt.Doctor Clearly giving cause of death listed at Sr.No.5. In the present case none of the document could be prepared as the complainant is alive and only his arm has been amputated. So PMR/Death Certificate/Panchnama/ FIR could not have been got issued. There is no allegation against any person about amputation of arm of the complainant so FIR could not be lodged. There is no requirement of DDR as per Annexure R9 and furthermore no time for lodging the DDR has been mentioned in the  terms and conditions. It is established that the arm of the complainant was crushed and lateron amputated as it had come under the Toka Machine while he was cutting fodder. DDR has also been placed on the record and it is also not disputed that the same has further been submitted with the OP No.1 alongwith application for reconsideration of the claim of the complainant duly recommended by the Op No.2 but it is strange that the Op No.1 did not pay any heed to the genuine claim of the complainant which has been proved on the case file. As per medical certificate Annexure C6 it is clear that the complainant has undergone operation for Toka injury and remained admitted in the hospital from 04.07.2015 to 15.07.2015 and disability certificate Annexure C5 has also been issued by the Civil Surgeon Ambala City wherein permanent disability to the tune of 80 % has been mentioned. The sole ground for repudiation of the claim of the complainant is not lodging any FIR qua the incident which could not lodged due to discussion made above. When it is proved on the case file that the arm of the complainant was amputated due to incident which took per chance without any fault, therefore, not lodging of DDR by the complainant qua the incidence is not fatal to his case.

8.                Keeping in view the above discussion we are considered view that the complainant has able to prove his case against the Op No.1 only by leading cogent and reliable evidence. Accordingly, repudiation letter dated 21.10.2015 is hereby quashed and the present complaint is allowed against Op No.1 only with costs which is assed at Rs.5,000/-.  Although the complainant has claimed Rs.2 lac as compensation but as per scheme PMSBY he is only entitled for Rs.1 lac as per Clause C which says that Total and irrecoverable loss of sight of one eye or loss of use of one hand or foot.  Since in the present case only one hand is amputated, therefore, the complainant is eligible for the claim to the tune of Rs. 1 lac only to be paid by the Op No.1 alongwith interest @ 9 % per annum from the date of filing of the complaint till its realization. Complaint Op No.2 stands dismissed. Compliance of this order be made within one month from the date of receiving of the copy of this order.  Copy of this order be supplied to both the parties free of cost. File be consigned after due compliance.

 

Announced on: 26.02.2018

         

                                                                                      

(Pushpender Kumar)             (Anamika Gupta)              (D.N.Arora)

 Member                                  Member                         President                                                                                         District Consumer Disputes                                                                        Redressal Forum, Ambala.