BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD, THIRUVANANTHAPURAM.

PRESENT

SRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENAKUMARI. A : MEMBER

SMT. S.K.SREELA : MEMBER

O.P. No. 407/2001 Filed on 06.10.2001

Dated : 16.08.2010

Complainant:

K. Sureshkumar, residing at Kuzhivila Puthen veedu, Pananvila, Nalanchira P.O, Thiruvananthapuram.

(By adv. B. Vasudevan Nair)

Opposite party :

United India Insurance Co. Ltd., represented by its Senior Divisional Manager, Divisional Office No. 1, Vettukattil Building, Jose Junction, M.G. Road, Ernakulam.

(By adv. R. Jagadishkumar)

This O.P having been heard on 31.05.2010, the Forum on 16.08.2010 delivered the following:

ORDER

SMT. BEENAKUMARI.A: MEMBER

Complainant is a young man and was engaged in plumbing works for earning his daily bread. He used to carry out plumbing works in various private firms and other buildings and was earning money from the same for his livelihood. In the meanwhile, an agent of the opposite party approached the complainant and explained to him about the possibility of facing accidents in his daily work. The agent also explained to the complainant about the benefits of joining an insurance scheme namely Janatha Personal Accident Insurance Policy. As per the terms of the policy the policy holder is to pay a single premium and the policy shall cover death and other losses due to the accidents. Brochures showing the details of the conditions of the policy was also issued to the complainant. The complainant entered into a contract of insurance with the opposite party and a policy certificate was also issued to him. The complainant remitted the required premium as per the conditions of the policy and policy issued to the complainant bears No. 100104/47/97/E.S.E/13312. On 25.11.1999 the complainant met with an accident and as a result he was seriously injured. The accident was caused due to electric shock while carrying out plumbing work, which resulted in permanent partial disability to the complainant. His right hand has become motionless in addition to other disability and the medical board has certified that he is having 60% permanent partial disability. Now the complainant is not in a position to carry out his profession and earn for his livelihood. The complainant issued a letter to the opposite party claiming the amount covered by the JPA policy on 22.06.2001 along with the disability certificate issued from the Medical College Hospital, Thiruvananthapuram by registered post, but to the surprise of the complainant no reply was given to the said letter by the opposite party. Complainant issued a reminder to the opposite party and on 07.08.2001 a letter was received by the complainant from the opposite party wherein the opposite party denied their liability of paying the policy amount stating that the disability caused to the complainant will not come under the conditions covered by the policy.

The opposite party in this case is United India Insurance Company Ltd. They filed version stating that they repudiated the claim of the complainant on the ground that temporary partial disability is an exclusion under the policy and since the petitioner is lodging the claim under the same, the opposite party has no other alternative than to repudiate the claim. Complainant and opposite party have filed affidavits in this case. Examined the complainant as PW1 and 7 documents were marked as Exts. P1 to P7 from his side. The opposite party produced the specimen copy of policy with conditions.

Points that arise for consideration are:-

1. Whether there is deficiency in service from the side of opposite party?

2. Whether the complainant is entitled to get the reliefs and costs?

    

Points (i) & (ii):- Complainant is a Janatha Personal Accident policy holder (policy No. 100104/47/97/E.S.E/13312). As per the terms of the policy, the policy holder is to pay a single premium and the policy shall cover death and other losses due to the accidents. Ext. P1 is the receipt issued by the agent of the opposite party for the acceptance of insurance premium from the complainant. Ext. P3 is the policy certificate of the complainant. There is no dispute regarding the validity of policy. This policy covers Accidental death and permanent total disability of the insured. In this case the complainant sustained injury due to electric shock on 25.11.1999. The complainant stated that the accident caused permanent partial disability to him, his right hand became motionless and the medical board has certified that he is having 60% permanent partial disability. The complainant has produced the disability certificate issued by the Medical Board, Trivandrum as Ext. P2. As per Ext. P2 the medical board certified that he has 60% permanent partial disability. But as per the policy conditions the insurance cover is for permanent total disability i.e; 100% disability. Ext. P6 is the copy of letter issued by the complainant to the opposite party to award compensation to him on the basis of the disability certificate issued by the Medical Board. Ext. P7 is the copy of reply issued by the opposite party to the complainant stating that as per the disability certificate the disability is assessed as 60%. Under Janatha Personal Accident Policy, the policy holder shall have 100% permanent total disability to get benefit under the scheme. The policy copy produced by the complainant itself shows that only the insured person having total permanent disability is entitled to get the benefit under this scheme. In this case the complainant produced a decision reported in II (1999) CPJ 20 (NC) in Bhag Chand Jain Vs. LIC of India & another. In that case National Commission has found that “the State Commission failed to consider the opinion of the Board wherein it was specifically mentioned that the petitioner sustained multiple fractures of both lower extremities and there was no possibility to improve and he had developed permanent disability in totality”. But in this case the complainant himself admitted that he has only 60% permanent partial disability. And the complainant did not produce any document stating that he is totally disabled to do any work. And moreover there are various Appellate Court Judgements that the terms of the contract have to be construed strictly without altering the nature of the contract as it may affect the interest of parties adversely. Insurance is a contract. In IV (2004) CPJ 49 (SC) Polymat India Pvt. Ltd. & another Vs. National Insurance Co. Ltd. & others the Hon'ble Supreme Court's finding is that in interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable if the parties have not made it themselves. In this case as per the policy certificate it is clearly stated that the policy cover is for accidental death, permanent total disability. But the complainant in this case is having 60% permanent partial disability and moreover in this case the complainant did not produce any medical certificate showing that he is disabled for doing any work.

From the above mentioned discussions we find that the claim of the complainant has been repudiated by the opposite party in accordance with the terms and conditions of the Janatha Personal Accident Policy. Hence the complaint is dismissed.

In the result, the complaint is dismissed.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 16^th day of August 2010.

BEENAKUMARI. A : MEMBER

G. SIVAPRASAD : PRESIDENT

S.K. SREELA : MEMBER

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O.P. No. 407/2001

APPENDIX

I COMPLAINANT'S WITNESS :

PW1 - Suresh Kumar

II COMPLAINANT'S DOCUMENTS :

P1 - Original receipt issued by the agent of the opposite party for

the acceptance of insurance premium from the complainant.

P2 - Copy of disability certificate issued by the Medical Board,

Tvpm.

P3 - Copy of Janatha Personal Accident Policy Certificate

duplicate.

P4 - Copy of Disability Certificate

P5 - Copy of Janatha Personal Accident Insurance.

P6 - Copy of letter from complainant

P7 - Copy of reply issued by the opposite party to complainant.

III OPPOSITE PARTY'S WITNESS :

NIL

IV OPPOSITE PARTY'S DOCUMENTS :

D1 - Copy of policy with conditions

PRESIDENT

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