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.37 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. Shriram General Insurance Co. Ltd., Rep: by its Authorized Signatory, O/o. D.No.52-1/1-1, Ring Road, Veterinary Colony, Vijayawada – 8.
2. Shriram General Insurance Co. Ltd., Rep: by its Authorized Signatory, O/o. E-8, EPIP, RIICO Industrial Area, Sitapura, Jaipur – 302022 (Raj.)
. … 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 T. Veerabhadra 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 a sum of Rs.4,80,000/- under personal accident policy, a sum of Rs.50,000/- towards compensation and to award costs.
2. The averments of the complaint in brief are as follows:
The complainant took a personal accident (individual/family) policy No.417055/48/12/000145 for assured sum of Rs.4,80,000/-. The policy period was 11.8.2011 to 10.8.2012. The complainant paid Rs.1,059/- towards gross premium. The complainant met with an accident on 20.3.2012 and suffered injuries including fractures. The accident was reported to police and an FIR in Crime No.52/2012 was registered by Kankipadu PS. The complainant took treatment in Nagarjuna hospital, Kanuru and Time hospital, Ashoknagar, Vijayawada for 17 days as inpatient. The complainant suffered permanent disablement due to accident and he lost employment. He became deaf and dumb, blind and physical handicapped. The certificates were issued by competent authority. The complainant made a claim to the 1st opposite party and the 1st opposite party sent a letter dated 3.5.2012 stating that the policy provides for benefits in the event of permanent total disablement or permanent partial disablement. The 1st opposite party did not process the application and sent a letter dated 14.8.2012 repudiating the claim of the complainant. The opposite parties did not examine the documents submitted by the complainant and no personal verification was done. The complainant got a legal notice issued on 31.12.2012 to the opposite parties. They received notice and kept quiet. There is deficiency in service on the part of the opposite parties therefore this complaint is filed.
3. The opposite parties 1 and 2 filed their version generally denying the allegations made in the complaint and further stating as follows:
The complainant had taken conservative treatment at Time hospital on 20.3.2012. The patient was conscious and oriented at the time of admission in the hospital and also at the time of discharge. The medical certificates produced by the complainant refer to 38% disability in the eye sight, 32% disability in the hearing and 33% disability due to orthopedically handicap. The certificates do not show that the complainant suffered permanent partial disability. The disability certificates are not admissible in evidence. The opposite parties after examining the claim addressed letters to the complainant on 21.3.2012, 3.5.2012 and 20.4.2012 asking the complainant to submit some documents. The complainant did not respond till 2.6.2012 then the opposite parties had informed that the complainant presumed to have no interest to pursue the claim and the claim file was closed. In case of permanent partial disability other than loss of limbs and eyes the doctor would assess percentage of capital sum insured payable under the policy. The complainant has not suffered permanent disablement. Therefore the complainant is not entitled to any amount. The complainant made excess claim. There is no deficiency in service on the part of the opposite parties.
4. The complainant filed his affidavit and it is received as deposition of PW.1. The Manager of the opposite parties filed affidavit and it is received as evidence of DW.1. Exs.A1 to 14 are marked on behalf of the complainant.
5. Heard the arguments advanced by the learned counsel for both the parties. The complainant has filed written arguments.
6. The points that fall for determination are:
- Whether the complainant had suffered permanent partial disability and is entitled to benefits under the policy?
- Whether there is deficiency in service on the part of the opposite parties?
- 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 11.8.2011 to 10.8.2012. 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. No doctor of opposite party seems to have seen the complainant and examined him before sending repudiation letter.
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 in another CC.39/2013 sent the complainant to Superintendent, Government General Hospital, Vijayawada for examination and report. Copy of the record sent by the Superintendent, Government General Hospital, Vijayawada marked as Ex.A14 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 that 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 stated the complainant has hearing loss of 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 certificate they issued is 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.4,80,000/-. It does not have the details. Terms of policy not filed either party. Hearing loss falls within the category of permanent partial disablement. If there is loss of hearing in both ears, it is not known how much percentage of sum assured, would be allowed. The complainant is not shown to any panel doctor and the opposite parties did not get the disability assessed. 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% the benefit for partial loss shall be 32% of sum assured. That means the complainant is entitled to Rs.1,53,600/- for permanent partial loss of hearing. He is not entitled to any other amount under the policy.
12. The learned counsel for the opposite parties objects the admissibility of documents No. the doctor certificates. He relies on Sudhir Bhuiya Vs. National Insurance Co., Ltd., 2005 ACJ 509 for the proposition that medical certificates cannot be weighed as evidence without examining the doctor concerned. In Kunal Saha case 2006 (3) CPJ 142 (NC) the Supreme court has state that Evidence Act is not applicable to Consumer complaints before the Forum. So we give weight to the certificates issued by the medical officer, a government officer.
19. 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.39/2013 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 a decision of Delhi State 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.
14. A proposer to take life insurance policy has no restriction in choosing the assured sum. 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 chosen as 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:
15. 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.
16. In view of the answer on points 1 and 2 the complainant shall be entitled to a sum of Rs.1,53,600/- 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.1,53,600/- at the rate of 9% p.a. from 2.6.2012 the date of repudiation.
17. In the result the complaint is allowed in part and the opposite parties are directed to pay jointly and severally a sum of Rs.1,53,600/- (Rupees one lakh fifty three thousand and six hundred only) towards benefits under the policy with interest at the rate of 9% p.a., from 2.6.2012 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 Manager – OPs
(by affidavit) DW – 1,(by affidavit).
Documents marked
On behalf of the complainant:
Ex.A1 Photocopy of policy schedule.
Ex.A2 21.03.2012 Photocopy of FIR.
Ex.A3 09.04.2012 Photocopy of discharge summary.
Ex.A4 Photocopy of medical certificate in respect of orthopedically handicapped candidate.
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 20.04.2012 Photocopy of letter issued by Op to complainant.
Ex.A8 03.05.2012 Photocopy of letter issued by Op to complainant.
Ex.A9 02.06.2012 Photocopy of letter issued by Op to complainant.
Ex.A10 14.08.2012 Photocopy of mail.
Ex.A11 31.12.2012 Photocopy of legal notice got issued by complainant to OPs.
Ex.A12 Postal acknowledgement.
Ex.A13 Photocopy of wound certificate.
Ex.A14 Photocopy of medical certificates issued by Professors, Govt. General Hospital, Vijayawada.
On behalf of the opposite parties: - Nil-
PRESIDENT
