Haryana

Kurukshetra

171/2018

Vishal Saini - Complainant(s)

Versus

Reliance gen Ins - Opp.Party(s)

Ravi Kumar

11 Feb 2020

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KURUKSHETRA.

 

                                                Consumer Complaint No.171/2018.

                                                        Date of instt.:09.08.2018. 

                                                Date of Decision:11.02.2020.

 

Vishal Saini s/o Shri Sheesh Ram Saini, r/o H.No.481/5, Mohan Nagar, Kurukshetra.

                  ….…Complainant.      

                                           Versus   
 

1. Reliance General Insurance Co. Ltd., Krishe Sapphire Krisjhe Block, III Floor South Wing, Survey No.88, Hi Tech City Main Road, Madhapur, Hyderabad-500081 through its Authorized Signatory.
2. Reliance General Insurance Co. Ltd., Pipli-Kurukshetra Road, near Pooja School, Pipli through its Branch Manager.

 

                                                        ….…Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.

                                                                                               

Before       Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member.       

                   Shri Issam Singh Sagwal, Member.                

 

Present:     Shri Ravi Kumar, Advocate for the complainant.

                Shri V.K. Garg, Advocate for the OP No.1.

                OP No.2 ex-parte.

 

ORDER

 

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by the complainant Vishal Saini against Reliance General Insurance Co. Ltd., the opposite parties.

2.             It is stated in the complaint that the complainant is having a motorcycle bearing No.HR-07R-0910 Chassis No.MBLJA05EGB9H06595 Engine No.JA05EBB9H06543 and got insured the same with the OPs in the year 2016, 2017 & 2018. That at the time of renewing the policy, the OPs had given option to him to get the Personal Accident Insurance worth Rs.2 lacs on additional amount of Rs.212/-. That he opted to chose the said option and get the accident insurance and renwed the same online with Personal Accident Policy No.920221729130129414 with Transaction ID No.C508091756995 and valid for 16.09.2017 to 15.09.2018. That on 28.05.2018, he went to Manali for vacations and on 30.05.2018 he met with an accident and badly injured and his major surgery was done and admitted in Lady Willingdon Hospital, Manali, Kullu, District Manali, HP for 6 days and got treated from Shri Balaji Aarogyam Hospital, Kurukshetra. That at the time of accident, he was having a DL bearing No.HR0720120059651. That he spend Rs.2,00,000/- on his treatment and suffered the loss of work for more than 60 days. That he informed the same to the OPs on their website i.e. https://www.reliancegeneral.co.in on 01.06.2018 via email and got it confirmed by call and got message from “AX-RELGEN” that your claim Ref. No. is 2181005205. That he got email on 31.07.2018 that he has to sent the documents to them via post within 15 days and very next day, he sent the same and same was delivered to them on 07.08.2018 at 09:40. That now the OPs have refused to release the insured amount to him on the ground that insurance is not covered in the policy itself so we cannot provide you the claim. On 09.08.2018, he received reply that your claim is rejected on the ground that it is not covered under the policy. He approached the OPs many times, but all in vain. This way, the OPs are deficient. Hence, this complaint.

3.             Upon notice, opposite party No.1 appeared and filed written statement stating therein that the complainant is claiming for loss of employment of 60 days and medical reimbursement bills of alleged accident under temporary total disability benefit without any such coverage of benefits under insurance contract. That as per policy schedule, Table of Benefit of B, was opted by the complainant at the time of purchasing the policy coverage after understanding all the terms and conditions and exceptions of insurance contract. That the personal accident policy is not a policy of health insurance policy which covers all the medical reimbursement of patient. This policy is a different kind of policy in which a very small amount of premium i.e. Rs.212/- is charged from the consumer by giving coverage in accordance with the terms and conditions of the insurance contract. On merits, the rest of the contents of the complaint were denied and Prayer for dismissal of the complaint was made.

                Upon notice, none appeared on behalf of OP No.2 and accordingly, he was opted to be proceeded against ex-parte by this Forum vide its order dated 13.11.2018.

4.             The complainant tendered affidavit Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-13. On the other hand, the OP No.1 has tendered affidavit Ex.RW1/A alongwith documents Ex.R1 to Ex.R4.

5.             We have heard learned counsel for the parties and have gone through the record carefully.

6.             The learned counsel for the complainant has reiterated all the averments mentioned in the complaint. He argued that the complainant is having a motorcycle and got insured the same with the OPs in the year 2016, 2017 & 2018. He further argued that at the time of renewing the policy, the OPs had given option to him to get the Personal Accident Insurance worth Rs.2 lacs on additional amount of Rs.212/- and he opted the same and renewed the policy online valid for 16.09.2017 to 15.09.2018. On 28.05.2018, he went to Manali for vacations and on 30.05.2018 he met with an accident and badly injured and his major surgery was done and admitted in Lady Willingdon Hospital, Manali, Kullu, District Manali, HP for 6 days and got treated from Shri Balaji Aarogyam Hospital, Kurukshetra and spent Rs.2,00,000/- on his treatment, but the OPs have refused to release the insured amount to him on the ground that insurance is not covered in the policy itself. He further argued that the OPs have misled him by providing the Accidental Death & Permanent Total Disability policy.

7.             Contrary to it, the learned counsel for the OP No.1 has argued that the complainant is claiming for loss of employment of 60 days and medical reimbursement bills of alleged accident under temporary total disability benefit without any such coverage of benefits under insurance contract. As per policy schedule, Table of Benefit of B, was opted by the complainant at the time of purchasing the policy coverage after understanding all the terms and conditions and exceptions of insurance contract. He further argued that the personal accident policy is not a policy of health insurance policy which covers all the medical reimbursement of patient. This policy is a different kind of policy in which a very small amount of premium i.e. Rs.212/- is charged from the consumer by giving coverage in accordance with the terms and conditions of the insurance contract and Prayer for dismissal of the complaint was made.

8.             There is no dispute that the complainant took Personal Accident Policy Schedule Ex.C-6. There is also no dispute that the complainant got injured in an accident and admitted in the Lady Willingdon Hospital, Manali, HP and thereafter, he took the treatment from Aarogyam Hospital, Kurukshetra. The complainant lodged the claim with the OPs, who repudiated the same on the ground that As per the policy Accidental Death & Permanent Total Disability is covered, whereas claim lodged is under Table D Coverage Temporary Total Disablement (Rib Fracture and spleen laceration), which is not covered under the policy.

9.             Since the OPs have repudiated the claim of the complainant vide letter dated 08.08.2018 (Ex.R-1), therefore, the onus to prove the grounds on which the claim was refused was upon the OPs. To prove the same, the OPs has produced documents Ex.R-4 and its Operative clause column is relevant, which reads as under:-

                Operative clause

                NOW THIS POLICY IS WITNESS that subject to the terms, exclusions and conditions constrained herein or endorsed or otherwise expressed hereon if any at any time during the currency of this policy, the insured person shall sustain any bodily injury resulting solely and directly from accident caused by external, violent and visible means, then the Company shall pay to the insured or his legal representative (s), as the case may be, the sum of sums hereinafter set forth, that is to say-

1. If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of death of the insured person, the Capital Sum Insured stated in the Schedule hereto:
2. If such injury shall within twelve calendar months of its occurrence be the sole and direct cause to the total and irrecoverable loss of:
   1. Sight of both eyes, or of the actual loss by physical separation of two entire hands or two entire feet, or of one entire hand or one entire foot, or of such loss of sight of one eye and such loss of entire hand or one entire foot the Capital Sum Insured stated in the Schedule hereto:
   2. use of two hands, or of one  hand and one foot, or of such loss of sight of one eye and such loss of use of one hand or  one foot, the Capital Sum Insured State in the Schedule hereto.
3. If such injury shall within twelve calendar month of its occurrence be the sole and direct cause of the total and irrecoverable loss of:
   1. The sight of one eye or the actual loss by physician separation of one entire hand or of one entire foot (50%) of the Capital Sum Insured State in the Schedule hereto;
   2. Use of the  hand or a foot without physical separation (50%) of the Capital Sum Insured State in the Schedule hereto

        NOTE: for the purpose of Clauses (b) and (c) above, physical separation of the hand means physical separation at or above the wrist and of the foot means at or above the ankle.

4. If such injury shall, as a direct consequence thereof, immediately, permanently, totally and absolutely, disable the insured person from engaging in any employment or occupation of any employment or occupation of any employment or occupation of any description whatsoever, then a lump sum equal to hundred percent (100%) of the Capital Sum Insured.
5. If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and/or partial and irrecoverable loss of use or of the actual loss by physical separation of the following then the percentage of the Capital Sum Insured as indicated below shall be payable.

Loss of – all
Loss of toes great- both phalanges
Loss of toes great- one phalanx
Loss of toes other than great, if more than one toe lost each
Loss of – lose of hearing – both ears
Loss of – lose of hearing one ear
Loss of four fingers and thumb of the hand
Loss of four fingers
Loss of thumb both phalanges
Loss of index finger, three phalanges or two phalanges or one phalanx
Loss of middle finger- three phalanges or two phalanges or one phalanx
Loss of ring finger- three phalanges or two phalanges or one phalanx
Loss of little finger - three phalanges or two phalanges or one phalanx
Loss of metacarpeis- first or second (additional) or third, fourth or fifth (additional)
Any other permanent partial disablement	Percentage as assured by a panel doctor of the Company

 

6. If such injury shall be the sole and direct cause of temporary total disablement, then so long as the insured person shall be totally disabled from engaging in an employment or occupation of any description whatsoever, a sum at the rate of one percent (1%) of the Capital Sum Insured stated in the Schedule hereto per week, but in any case not exceeding Rs.5,000/- per week in all, under all policies.

        Provided that the compensation payable under the foregoing clause (f) shall not be payable for more than 100 weeks in respect of any one injury calculated from the date of commencement of disablement and in no case shall exceed the Capital Sum Insured”

                So, from the above Clause, it is evident that Accidental Death & Permanent Total Disability was covered under the policy in question. The OPs further produced Accident Claim Submission Form as Ex.R-3, wherein, the complainant has filled up the TTD (Temporary Total Disability), but from the perusal of Ex.R4 policy, it is evident that the said policy was for Accidental Death & Permanent Total Disability, but in the present case, the complainant has badly injured in the accident and took the treatment for the same. Neither the complainant died nor he received any permanent disability in the said accident, meaning thereby, the claim of the complainant was not covered in the policy in question. The complainant further alleged that the OPs have misled him by providing the Accidental Death & Permanent Total Disability policy. From the policy, it is evident that the complainant took the policy valid from 16.9.2017 to 15.09.2018 and he got injured in the accident on 28.05.2018. However, if the complainant was not satisfied with the policy in question, then he can return the same or to write the OPs in this regard, but he did not do so and remained mum from 16.09.2017 to 28.05.2018, reason best known to him. It is pertinent to mention here that an insurance policy is a contract between the two parties and as such both the parties are bound by the terms and conditions of the policy. Keeping in view the facts and circumstances of the case, we are of the considered view that the OPs has not committed an error while repudiating the claim of the complainant ‘as per terms and conditions of the policy in question. Hence, we found no deficiency on the part of OPs.

10.            In view of the above discussion, we find no merit in the complaint and the same is hereby dismissed with no order as to costs. A copy of this order be sent to the parties free of costs. File be consigned to the record room after due compliance.

Announced in open Forum:

Dt.:11.02.2020.                                                   (Neelam Kashyap)

                                                                        President.

 

 

(Issam Singh Sagwal),         (Neelam)       

Member                             Member.