ORDER

(Per: Mrs. Veena Sharma, Member):

This appeal, under Section 15 of the Consumer Protection Act, 1986, has been preferred by appellant-opposite party No. 1-insurance company against the order dated 19.04.2011 passed by the District Forum, Haridwar in consumer complaint No. 63 of 2011, whereby the District Forum has allowed the consumer complaint against the opposite party No. 1 and directed the opposite party No. 1-insurance company to pay to the complainant a sum of Rs. 99,430/- together with interest @ 9% per annum from the date of filing the consumer complaint till the date of payment and also to pay a sum of Rs. 5,000/- towards cost of litigation to the complainant, within one month from the date of order, whereas the District Forum has dismissed the consumer complaint against the opposite party No. 2.

2.       Briefly stated the facts of the case, as mentioned in the consumer complaint, are that the complainant-Sh. Gaurav Kumar Thakur is the registered member of the opposite party No. 2-District Bar Association, Haridwar and his registration number is 5550/04.  The opposite party      No. 2-District Bar Association had insured their members through a Group Personal Accident Policy under risk Table 1-B without medical extension from the opposite party No. 1-The New India Assurance Co. Ltd., which was valid from 17.12.2009 to 16.12.2010 for a premium of Rs. 39,002/- and the policy number is 321900/42/09/03/00000142, the complainant was also insured under this scheme.  The complainant is at serial No. 117 of the list of this Group Personal Accident Policy. The complainant met an accident on 11.08.2010 and the insurance company-opposite party No. 1 was intimated about this accident.  The insurance company has appointed its surveyor. In August, 2010, the surveyor of the insurance company came to complainant house and took his photographs and gave a claim form to him to fulfill the formalities.  The knee bone of the complainant was damaged in this accident and he was operated by      Dr. Mukesh Jain at Muzaffarnagar on 13.08.2010. From 12.08.2010 to 10.12.2010, the complainant was at bed rest. On 10.12.2010, doctor gave fitness certificate to the complainant. With all the medical expenditure bill and fitness certificate, the complainant submitted the claim form to the opposite party No. 1-insurnace company, but the insurance company has not considered his claim form and has not paid any amount to the complainant and has repudiated his claim.  This act of the opposite parties comes under unfair trade practice.  Due to this, the complainant has suffered physical and mental agony, therefore, the complainant has filed a consumer complaint against the opposite parties before the District Forum, Haridwar.

3.       The opposite party No. 1- The New India Assurance Co. Ltd. has filed written statement and has pleaded that the consumer complaint has been filed on false and frivolous grounds and could not be accepted. The answering opposite party has denied to take any other charges except the insured amount under Group Personal Accident Policy, so the complainant does not fall under the definition of ‘consumer’, therefore, the consumer complaint is not maintainable before the District Forum.  It is wrong to say that the opposite party No. 2-District Bar Association had assured their members that they will get all the medical expenses by the answering opposite party-insurance company, occurred due to accident. All conditions and exclusions about Group Personal Accident Policy were discussed from the opposite party No. 2.  After accepting all the conditions, the insurance was issued in favour of the members of the opposite party No. 2.  Despite of other condition main compensation about Group Personal Accident Policy benefits were specifically mentioned in Table 1-B of Sl. No. 125 of policy conditions. The answering opposite party is liable to pay the claim according to the policy condition.  It is accepted that the complainant met with an accident on 11.08.2010 and he intimated the answering opposite party by submitting the claim form.  The answering opposite party has appointed a surveyor, who submitted survey report on 27.01.2011. In this report, it was mentioned that the complainant met with an accident and his injuries were not under Table 1-B of insurance policy. Therefore, the answering opposite party has not liable to pay any medical expenses incurred into this accident.  The answering opposite party has closed the complainant’s claim file, as it was not covered under the insurance policy.  There is no deficiency on the part of the answering opposite party, therefore, the consumer complaint filed by the complainant against the answering opposite party is liable to be dismissed.

4.       The opposite party No. 2-District Bar Association has filed written statement before the District Forum and accepted that the complainant is a member of the association.  The answering opposite party has further pleaded that they assured the complainant at the time of insurance that he will get the insurance cover in case of any accident during insurance period.  He will get all the expenses occurred in his treatment by the opposite party No. 1-insurance company.  So answering opposite party is not responsible to give any claim (medical expenses) to the complainant. The complainant has made the answering opposite party a formal party. 

5.       The District Forum, on an appreciation of the material on record, has allowed the consumer complaint No. 63 of 2011 vide order dated 19.04.2011 in the above manner.  Aggrieved by the said order, the opposite party No. 1-insurance company has filed the present appeal.

6.       We have heard Smt. Anjali Gusain, learned counsel for the appellant-insurance company and gone through the entire record of the District Forum and also perused the material placed on record. None appeared on behalf of the respondent Nos. 1 & 2.

7.       There is no dispute with regard to the fact that the complainant-respondent No. 1-Sh. Gaurav Kumar Thakur is a member of respondent No. 2-District Bar Association and insured by the appellant-New India Assurance Co. Ltd. vide policy No. 321900/42/09/03/00000142 under Group Personal Accident Policy. There is no dispute with regard to the fact that the respondent No. 1 met with an accident on 11.08.2010.  There is also no dispute that as a result of said accident, knee bone of respondent No. 1 was damaged and his knee was operated by Dr. Mukesh Jain at Muzaffarnagar.  All concerning authorities including insurance company were duly informed by respondent No. 1 about the said accident and expenses occurred in the treatment due to this accident. The dispute is mainly regarding about the conditions and exclusions of the Group Personal Accident Policy which was taken by the complainant-respondent No. 1.  After perusal of the record, it is evident that the complainant was insured under Group Personal Accident Policy.  The policy condition is filed on record at paper Nos. 53 to 56.  We have gone through this policy condition and specially Clause-B of the policy. The claim of the respondent No. 1 was repudiated under the terms and conditions of Clause-B of the policy.  Clause-B reads as under:-

          “(b) If such injury shall within Twelve calendar months of its occurrence be the sole and direct cause of the total and Irrecoverable loss of – i) sight of both eyes or the actual loss by physical separation of two entire hands or two entire feet or one entire hand and one entire foot, or of such loss of sight of one eye and such loss of one entire hand or one entire foot, the Capital Sum Insured in the Schedule hereto.

          ii) Use of two hands or two feet, or of one hand or 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 stated in the Schedule hereto.” 

8.       According to the terms and conditions of the policy, it is observed that the claim of respondent No. 1 regarding expenditure in terms of injuries, is not within the purview/scope of Group Personal Accident Policy.  So there is no deficiency in service on the part of the appellant-insurance company to repudiate the claim of the respondent No. 1-complainant.

9.       In view of the above position and the material available on record, we are unable to sustain the impugned order passed by the District Forum and the same is liable to be set aside.  As such, the appeal is fit to be allowed.

10.     Appeal is allowed.  Impugned order dated 19.04.2011 passed by the District Forum, Haridwar is set aside and consumer complaint No. 63 of 2011 is dismissed.  The statutory amount deposited by the appellant at the time of filing the appeal be released in appellant’s favour.  No order as to costs.