Haryana

StateCommission

A/1097/2016

BAJAJ ALLIANZ GEN.INSURANCE CO. - Complainant(s)

Versus

RAJESH KUMAR - Opp.Party(s)

VARUN CHAWLA

18 Aug 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

HARYANA PANCHKULA

 

 

First Appeal No.1097 of 2016

Date of the Institution:02.11.2016

Date of Decision: 18.08.2017

 

1.      Bajaj Allianz Life Insurance Company Limited, GE Plaza, Yerwada, Pune-Maharashtra, 411006 through its General Manager Regd. And Head Office.

2.      The Manager, Bajaj Allianz Life Insurance Company Limited, Pehowa Chowk, Kaithal Near Mithlesh Hotel, Kaithal, Tehsil and District Kaithal.

(Through Sh. Rajinder Singh Kalsi, Zonal Legal Manager, Bajaj Allianz Life Insurance Company Limited, SCO 215-217, Sector-34, Chandigarh).

                                                                             .….Appellants

Versus

Rajesh Kumar aged about 22 years, S/o Gora Lal, R/o village Kangthali, Tehsil and District Kaithal.

                                                                             .….Respondent

CORAM:    Mr.R.K.Bishnoi, Judicial Member

                    Mrs. Urvashi Agnihotri, Member

 

Present:-    Mr.Varun Chawla, Advocate for the appellants.

                    Mr.C.P.Tiwana, Advocate for the respondent.

 

O R D E R

URVASHI AGNIHOTRI, MEMBER:

1.      Bajaj Allianz Life Insurance Company Limited and Anr. – OPs are in appeal against the Order dated 22.07.2016 passed by the learned District Consumer Disputes Redressal Forum (for short ‘District Forum’), Kaithal, whereby the complaint of Sh.Rajesh Kumar - Complainant has been allowed with the direction to the OPs, to pay Rs.81,789/- to the complainant being the sum assured for permanent partial disability benefit as per policy No.0300152626 dated 28.04.2013 and also to pay Rs.3300/- as lumpsum compensation on account of harassment, mental agony and costs of litigation charges.

2.      In brief, according to the Complainant, he got insured with the OPs vide policy bearing No.0300152626 on 28.04.2013 with accidental permanent total partial disability benefits and also deposited an amount of Rs.8633/- on 28.04.2013. The complainant alongwith his father namely Gora Lal was going from Kanghali to Patiala at 6.00 A.M. on 22.03.20174 in their car and they met with an accident. They both were admitted at Amar Hospital, Patiala while the father of the complainant was referred to P.G.I., Chandigarh and the complainant spent Rs.5,00,000/- on his treatment. The complainant lost one eye permanently in the accident for which he claimed from the OPs the disability benefit of Rs.81,789/-, but the OPs refused to pay the same. Aggrieved against the same, the complainant approached the District Forum for the redressal of the grievances.

3.      Justifying their action, the OPs pleaded that the complainant failed to submit the requisite documents, despite repeated demands. As the diagnosis stated that the prescription of light was present in the injured eye, hence the same was not covered under the benefit of terms and conditions of policy, therefore, the claim of the complainant was rightly rejected and there was no deficiency in service on the part of the OPs. However, the learned District Forum, agreeing with the complainant allowed the complaint on 22.07.2016 by granting him the aforesaid relief. 

4.      Against the impugned order dated 22.07.2016, the OP / appellant have filed appeal before us reiterating their pleas as raised before the District Forum. We have heard the learned counsel for the parties and have thoroughly gone through the record, from the perusal whereof, it is evident that though the aggregate claim of the complainant is for a much higher amount yet in substance the real claim is only for an amount equal to 50% of the sum assured which was Rs.81,789/-. This is evident from para 4 of his complaint, as reproduced below:-

“4. That the claimant has lost permanently one eye in the accident. The claimant is entitled 50% of the Sum Assured that is rupees 81789/-“.

5.      Similarly, in their written statement, the OPs appellant have taken number of pleas technical as well as on merit, yet their real defence is that instead of allowing a higher claim the complainant was entitled only to 59% of the sum assured, as claimed by him in para No.4 of his complaint mentioned above. This will be evident from para 5 of their written statement reproduced below:-

“5.xxxx Even if it is presumed for the sake of arguments that the partial disability suffered by the respondent complainant was permanent (though not proved), the maximum benefit admissible is to the extent of 50% of the Sum Assured. The Ld. Forum has acted with material irregularity & has failed to appreciate this aspect of case and order passed by Forum is against agreed terms and conditions of insurance contract”.

6.      In view of the aforesaid factual position the appeal of the OP Company is partial accepted and we modify the Order passed by the learned District Forum by reducing the amount of compensation to the extent of 50% of the Sum Assured i.e. Rs.81789/- plus Rs.3300/- as litigation expenses. It is further directed that if the aforesaid  amount is not paid within 30 days from the receipt of the certified copy of this Order, the complainant shall be entitled to interest @18% P.A. from the date of this order till its payment.

7.      The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellants against proper receipt and identification in accordance with rules.

 

August 18th, 2017

Mrs.Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench

 

R.K.