Date of filing: 07.03.2013.
Date of disposal: 26.02.2014.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:
VIJAYAWADA, KRISHNA DISTRICT
Present: Sri A. M. L. Narasimha Rao, B.Sc., B. L., President
Smt N. Tripura Sundari, B. Com., B. L., Member
Sri S. Sreeram, B.A., B.Com., B.L., Member
Wednesday, the 26th day of February, 2014
C.C.No.39 of 2013
Between:
Adapa Taraka Rama Prasad, S/o Pandu Ranga Rao, Hindu, Aged about 32 years, R/o.D.No.10/88E, Kankipadu Post, Kankipadu Mandal, Krishna District.
….. Complainant
And
1. Royal Sundaram Alliance Insurance Co. Ltd., Rep: by its Authorized Signatory, O/o M.G. Road, Vijayawada – 10.
2. Royal Sundaram Alliance Insurance Co. Ltd., Rep: by its Authorized Signatory, O/o Sundaram Towers, 45 & 46, White Road, Chennai – 600014.
. … Opposite Parties.
This complaint coming on before the Forum for final hearing on 10.02.2014, in the presence Sri K. Rama Chandra Rao, advocate for complainant; Sri Ch. Sreepathi Rao, advocate for opposite parties and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble President Sri A. M. L. Narasimha Rao,)
1. This complaint is filed under Section 12 of Consumer Protection Act, 1986 for a direction to the opposite parties to pay Rs.10,00,000/- the amount payable under the policy, to pay Rs.50,000/- towards deficiency in service and mental agony and to award costs.
2. The averments of the complaint in brief are as follows;
The complainant took a personal accident shield online-schedule policy No.PY00012573000100 dated 22.10.2011 valid up to 21.10.2012. The sum assured is Rs.10,00,000/- under the policy. The complainant paid premium of Rs.1,080/-. On 20.3.2012 the complainant met with an accident and sustained injuries and fractures. The accident was reported to SHO, Kankipadu PS and FIR in Crime No.52/2012 was registered. The complainant was treated in Nagarjuna hospital, Kanuru and Time hospital, Ashoknagar, Vijayawada as inpatient for 17 days. Thereafter he continued to take follow up treatment. Due to injuries the complainant had suffered permanent disability and he lost his employment. He became deaf and dumb, blind and he became permanently handicapped. The competent authority had issued certificates in that regard. The complainant made a claim to the 1st opposite party. The 1st opposite party repudiated the claim through a letter dated 26.10.2012 without examining the documents submitted by the complainant and without personal verification. Thereafter the complainant got issued a legal notice dated 31.12.2012. The opposite parties received the notice and kept quiet. There is deficiency in service on the part of the opposite parties. Therefore the present complaint is filed for the policy amount and compensation.
3. The opposite parties filed their version admitting the policy and denying the liability and further stating as follows:
The complainant made a claim on 12.9.2012 stating that he met with an accident on 20.3.2012 as some vehicle hit him while he was riding motor cycle. The opposite parties found that the complainant did not suffer any total or partial permanent disability. The medical record submitted by the complainant shows that he did not suffer either total permanent disability or partial permanent disability. The policy covers life and total or partial permanent disability. The complainant therefore is not entitled to any amount under the policy. There is no deficiency in service on the part of the opposite parties. The opposite parties are not liable to pay any amount.
4. The complainant filed his affidavit and it is received as evidence of PW.1. The Assistant Manager - legal of the opposite parties filed his affidavit and it is received as evidence of DW.1. Exs.A1 to A10 are marked on behalf of the complainant and Exs.B1 to B5 are marked on behalf of the opposite parties.
5. Pending enquiry in this complaint the complainant was referred to medical board for examination and accordingly the Superintendent, Government General Hospital, Vijayawada got the complainant examined in the departments of Orthopedics, Ophthalmology and ENT. Three certificates are filed by the Superintendent, Government General Hospital, Vijayawada. The record received from the Superintendent, Government General Hospital, Vijayawada is marked as Ex.X1.
6. Heard the arguments advanced by the learned counsel for both the parties. The complainant and opposite parties filed written arguments.
7. The points that fall for determination are:
- Whether the complainant had suffered permanent partial disability in an accident and if he is entitled to any amount under the policy issued by the opposite parties?
- Whether there is deficiency in service on the part of the opposite parties in settling the claim?
- Whether the complainant is entitled to the amounts claimed?
Point No.1:
8. The complainant and opposite parties do not dispute as to the existence of policy covering the period from 22.10.2011 to 21.10.2012. The complainant said to have met with an accident on 20.3.2012. The complainant filed a copy of FIR in that connection. He also filed discharge summary from Time hospital in which it is noted that the complainant met with an accident on 20.3.2012. The complainant filed medical certificates issued by Chairman, Superintendent, Government General Hospital, Vijayawada showing partial blindness, partial deafness and partial disability due to multiple fractures. They do not show if the disability was permanent or temporary. Only permanent disabilities are covered by the policy. Temporary disabilities are not covered by the policy.
9. The complainant made a claim under Ex.B2 noting 38% disability in the right eye, 32% disability in the right ear and 33% disability in multiple fractures. These are percentages of disability shown by the complainant himself. The opposite parties have repudiated the claim on the ground that the complainant did not suffer permanent disability. They relied upon the certificate issued by Dr. S. Prem Kumar, Orthopedic Surgeon stating that the fractures the complainant suffered did not cause permanent disability and that the complainant dose not suffer from permanent partial disability. This doctor is not shown to have seen the complainant and examined him before issuing the certificate under Ex.B3.
10. As the material placed by the parties found to be insufficient and as there is no reference to permanent disability in the certificate issued by the medical board this Forum sent the complainant to Superintendent, Government General Hospital, Vijayawada for examination and report. Ex.X1 sent by the Superintendent, Government General Hospital, Vijayawada contains a letter issued by the Professor, Department of Orthopedics, a letter issued by the Professor, Department of Ophthalmology and a letter issued by the Professor, Head of the Department, ENT. The Professor of Department of Orthopedics had stated there was no permanent disability. Similarly the Professor of Ophthalmology opined that the complainant may be normal in both eyes. So permanent disability in the vision is also not certified. As regards hearing loss the Professor & Head of the Department ENT had assessed hearing loss at 80 db in the right ear and 60 db in the left ear. At the end of letter he stated that after detailed examination and audiometric tests the certificates they issued are correct. That means the certificates earlier issued as to the hearing disability is confirmed. That certificate is the one filed by the complainant under Ex.A5. In this certificate it is stated the complainant was disabled to the extent of 32%, the complainant was handicapped by 32%. It is this percentage that is noted by the complainant in his claim Ex.B2. The Professor of ENT has not stated that it is only a temporary disability. Therefore it must be taken as a permanent partial disability in hearing. The percentage of disability is 32.
11. From the above discussion we hold that the complainant had suffered permanent partial loss of hearing to an extent of 32%. He did not suffer other permanent disability. The policy issued by the opposite parties under the original of Exs.A1 and B1 shows that maximum sum assured is Rs.10,00,000/- and covers the percentage of benefit for death, permanent total disablement and permanent partial disablement. Hearing loss falls within the category of permanent partial disablement. If there is loss of hearing in both ears, the benefit will be 75% of the sum assured. If there is loss hearing in one ear it is 30% of the sum assured. In case of any other partial disability the percentage is as assessed by the panel doctor of the company. The complainant is not shown to any panel doctor and the opposite parties did not get the disability assessed. They simply relied upon a certificate issued by Dr.Prem Kumar whom seem to have not examined the complainant. Therefore we have to take the percentage of loss assessed by the medical board and claimed by the complainant as the percentage of loss of hearing. When the percentage of loss of hearing is 32% and when the benefit for total loss is 75%, the benefit for partial loss shall be 32% of 75%. That means the complainant is entitled to Rs.2,40,000/- for permanent partial loss of hearing. He is not entitled to any other amount under the policy.
12. The learned counsel for the opposite party had raised an objection to the maintainability of the complaint on the ground that the complainant had taken another policy from Sriram General Insurance Company Limited and filed another complaint in CC No.37/2013 in this Forum claiming compensation for the same cause and injury as claimed in the present complaint, that the complainant is not entitled to double benefit and therefore this complaint is not maintainable. The learned counsel for the complainant submits that the contract of life insurance and personal accident insurance are not contracts of indemnity and so the restrictions as to double insurance is not applicable to the present case. He relied upon a decision of National Commission in Mohan Singh Vs National Insurance Company Limited 2013 (2) CPR 709 and and ruling of Delhi Commission in Narayan Simandas Munbh Vs Oriental Insurance Company 2013 (1) CPR 150 (Delhi). These two decisions are not applicable to the facts of present case as one case pertains to vehicle damage and other case pertains to declaration as to health condition of the insured.
13. There is no restriction on a proposer to take life insurance policy for any fixed amount. While taking the policy the proposer may take policy from one insurer for certain amount and another policy from another proposer for some more amount. When there are no limitations on the amount payable on the death or loss of limb of the insured the limitation as to double insurance cannot be applied. In cases of contract of indemnity there are restrictions contained in IMT for double insurance. We find relevant text in M.N. Srinivasan’s ‘Principles of Insurance Law’ 8th Edition. The text at Pg.14 of the book reads as follows:
“Double or multiple insurance is insurance of same risk with more than one insurer, for instance, a person taking insurance on his life with many insurers or more than one policy with same insurer. Life and personal accident insurances are not contracts of indemnity and hence the insured can realize the sum assured from all the policies.
But other insurances are all contracts of indemnity and so nothing more than the actual loss can be realized from all the insurances that have been affected. In non-life insurance, therefore, the over-insurance by multiple insurance is of no particular advantage”.
Since personal accident insurance is not a contract of indemnity, there is no restriction on insured claiming amount from all the policies. He is entitled to the benefit under all the policies. Therefore the objection raised by the opposite parties is overruled.
Point No.2:
14. In view of the answer point no.1 it must he held that the opposite party is not justified in total repudiation of the claim made by the complainant for the benefits under the policy. The failure of the opposite parties to get the complainant examined by panel doctor to assess partial disability is also deficiency on their part. Therefore we hold that there is deficiency in service on the part of the opposite parties.
15. In view of the answer on points 1 and 2 the complainant shall be entitled to a sum of Rs.2,40,000/- as benefit under the policy as regards permanent partial loss of hearing. Since the repudiation is not justified the complainant shall also be entitled to compensation of Rs.10,000/-, the complainant shall also pay costs assessed at Rs.2,000/-. The complainant is entitled to interest on the amount of Rs.2,40,000/- at the rate of 9% p.a. from 26.10.2012 the date of repudiation.
16. In the result the complaint is allowed in part and the opposite parties are directed to pay jointly and severally a sum of Rs.2,40,000/- (Rupees two lakhs and forty thousand only) towards benefits under the policy with interest at the rate of 9% p.a., from 26.10.2012 the date of repudiation, and to pay Rs.10,000/- towards compensation and to pay Rs.2,000/- towards costs to the complaint within one month from the date of this order. The complaint for rest of the reliefs is dismissed.
Dictated to steno, N. Hazarathaiah, transcribed by him, corrected by me and pronounced by us in the open Forum, this the 26th day of February, 2014.
PRESIDENT MEMBER MEMBER
Appendix of evidence
Witnesses examined
For the complainant: For the opposite party:
Adapa Taraka Rama Prasad – PW.1 The Assistant Manager - legal of (by affidavit) OPs DW – 1,(by affidavit).
Documents marked
On behalf of the complainant:
Ex.A1 Photocopy of policy.
Ex.A2 21.03.2012 Photocopy of FIR.
Ex.A3 09.04.2012 Photocopy of discharge summary.
Ex.A4 24.04.2012 Photocopy of medical certificate for the blind.
Ex.A5 07.05.2012 Photocopy of medical certificate for the deaf and dumb.
Ex.A6 Photocopy of medical certificate in respect of orthopedically handicapped candidate.
Ex.A7 26.12.2012 Photocopy of letter issued by Op to complainant.
Ex.A8 31.12.2012 Photocopy of legal notice got issued by complainant to OPs.
Ex.A9 Postal acknowledgements.
Ex.A10 Photocopy of wound certificate.
On behalf of the opposite parties:
Ex.B1 Photocopy of policy.
Ex.B2 Photocopy of personal accident disablement claim form.
Ex.B3 04.07.2013 Photocopy of letter issued by Dr S. Prem Kumar, to OPs.
Ex.B4 Photocopy of wound certificate.
Ex.B5 26.12.2012 Photocopy of letter issued by Op to complainant.
PRESIDENT
