Smt. K.P. Padmasree (Member – I):
Complainant Smt. Sheeja S. Kumar, W/o. Sasikumar residing at Narayaneeyam, Thumpamon, Pandalam filed this complaint against the opposite parties for getting a relief from the Forum.
2. Brief facts of the complaint is as follows: Complainant is an account holder of the 1st opposite party bank. Her husband is working abroad and she usually dealing banking transactions with the 1st opposite party. 2nd opposite party compelled her to join the personal accident policy namely SBT UNI Suraksha issued by the 1st and 2nd opposite party jointly. Complainant joined the scheme and remitted the premium for 18.08.2010 to 17.08.2011 and policy certificate was issued to the complainant.
3. As per Clause (C) of the policy certificate it is mentioned that if the accident leads to loss of one leg, loss of one hand and loss of one eye the insured is entitled to get Rs.5 lakhs.
4. On 26.12.2010, while the complainant with her son and neighbour travelling from Pandalam to Pathanamthitta met with an accident and she seriously injured and hospitalized in Pushpagiri Medical College, Carithas Hospital, Amrutha Hospital and Specialist Hospital for long time. Due to the accident complainant’s lost her left leg and vision of left eye completely.
5. As per the terms and conditions of the insurance policy complainant is entitled to get Rs. 5 lakhs and complainant demanded the same from the 2nd opposite party several times. But the 2nd opposite party informed her that she is entitled to get Rs.2,50,000/- only. Complainant send a legal notice to the 1st and 2nd opposite party and the 2nd opposite party sent a reply notice by saying that she is entitled only for Rs.2,50,000/- and it was paid to her and with regard to the loss of eye sight there was no medical evidence. Even though the complainant has submitted all the medical records for proving loss of vision the opposite party has not paid Rs.5,00,000/- to the complainant and it is falsely stated that they have paid Rs.2,50,000/- to the complainant. The above said act of the opposite party is a clear deficiency in service and opposite parties are liable to the complainant for the same. Hence this complaint for getting the policy amount of Rs.5,00,000/- along with bank interest from 26.12.2010.
6. In this case, opposite parties entered appearance and filed their versions separately.
7. 1st opposite party filed version with the following contentions: 1st opposite party admitted that they have issued a Personal Accident Policy to the complainant for the period from 18.08.2010 to 17.08.2011. On 18.06.2013 1st opposite party received a letter from the complainant intimating that she had met with an accident in December 2010. 1st opposite party forwarded the letter to 2nd opposite party for immediate action. 2nd opposite party demanded certain documents and records from the complainant. After verification 2nd opposite party intimated the complainant that she would be entitled only for Rs. 2,50,000/- and the disbursement of claim amount is strictly in accordance with the procedural formalities fixed by the 2nd opposite party insurance company. Hence there is no deficiency in service from the part of the 1st opposite party.
8. 2nd opposite party filed version with the following contentions: 2nd opposite party also admit that Personal Accident Policy for Rs.5 lakh was insured to the complainant for a period of one year. The alleged accident taken place on 26.12.2010 within the validity period of policy. As per the policy conditions once the accident leading to death or loss of limb/eye takes place the insured/heirs are duty bound to report the matter immediately to the insurer with documents and records to prove the accident, injuries suffered. So that the insurer can fix the applicable amount after due verification. In this case, matter was brought to 2nd opposite party’s knowledge on 2013. From the records it is seemed that complainant lost a leg in the accident. 2nd opposite party called records and on the basis of the records sanctioned Rs.2,50,000/- towards loss of leg. The claim for alleged loss of left eye was not allowed since there was no medical evidence to that effect. Applicable amount was offered to the complainant without any delay which is refused by her. Hence there is no deficiency in service from the 2nd opposite party. With the above contentions, 2nd opposite party prays for the dismissal of the complaint.
9. On the basis of the complaint and versions we have framed the following issues:
- Whether there is any deficiency in service from the opposite parties?
- Reliefs & Costs?
10. The evidence of this case consists of the oral evidence of the complainant who has been examined as PW1, PW2 and Ext.A1 to A11. Opposite party has not produced any oral or documentary evidence. But they cross-examined PW1 and PW2. After closure of the evidence, both sides were heard.
11. On the basis of the proof affidavit, complainant was examined as PW1 and documents produced were marked as Exts.A1 to A11. Ext.A1 is the policy certificate in the name of the complainant in the period of 18.08.2010 to 17.08.2011. Ext.A2 is the final report of Pandalam Police Station dated 27.12.2010. Ext.A3 is the Accident-cum Wound Certificate issued from Pushpagiri Medical College dated 26.12.2010. Ext.A4 is the discharge summary of Caritas Hospital dated 24.01.2011. Ext.A5 is the discharge summary of Amritha Institute of Medical Science dated 05.02.2011. Ext.A6 is the discharge summary of Specialists Hospital, Ernakulam. Ext.A7 is the Standing Disability Assessment Board Certificate issued from District Hospital, Kozhencherry. Ext.A8 is the Medical Certificate dated 10.09.2014 from Amrita Institute of Medical Science. Ext.A9 is the copy of legal notice dated 10.11.2014 issued by the complainant’s counsel to the opposite parties. Ext.A10 is the reply notice issued by the 2nd opposite party to the complainant’s counsel. Ext.A11 is the photograph of the complainant before and after the accident. As discussed earlier, the opposite parties did not adduce an oral evidence in this case. After the closure of evidence, we heard both sides.
12. Point Nos. 1 & 2:- For the sake of convenience, we would like to consider Point No.1 & 2 together. On the basis of the contentions and arguments of the parties, we have perused the entire materials on evidence and found that parties have no dispute with regard to the issuance of policy, insured amount, alleged accident and the amount already allowed to the complainant. The only dispute is with regard to the loss of the left eye vision and denial of insurance amount for the same. According to the complainant even though she had lost her left eye sight completely she did not get the insured amount completely. For proving her loss of left eye sight she produced Ext.A3, A4, A7 and A8 documents before us. On the other hand, the contention of the opposite parties is that complainant has not produced any document before them for proving loss of her vision. Regarding this aspect, the conclusive evidence before us is Ext.A7 and A8 document. On going through these documents, we can see that complainant had lost her left vision completely. An accident can be either a sudden happening or a slowly evolving process like percolation of harmful substances affecting human body. In this case under consideration it appears after the accident gradually she lost her left eye vision completely. Ext.A7 is the standing disability assessment board certificate. The medical board had given its opinion that, “permanent Ophthalmic handicapped by ‘Traccaeabe Optic Atrophy”. We cannot discard the document of medical board. In this connection Dr. Kuruvilla George, Consultant Ophthalmology, District Hospital, Kozhencherry was examined before us as PW2, who is a member of the medical board. He categorically stated that, “ Ext.A7 documentþൽ ഞാൻ ഒപ്പിട്ടിട്ടുണ്ട്. ഇടതു കണ്ണൻറെ കാഴ്ച ഒരിക്കലും തിരിച്ചു കിട്ടില്ല എന്നാണ് ഞങ്ങളുടെ പരിശോധനയിൽ മനസ്സിലായത്. വാദിക്ക് ഉണ്ടായ അപകടത്തിൻറെ സ്വഭാവം അനുസരിച്ച് ഇത്തരത്തിൽ ഒരു പരിക്ക് ടി അപകടത്തിൽ നിന്നും ഉണ്ടാകാം”. So we can rely upon the document Ext.A7 and A8 and deposition of PW1 and PW2. Hence we are of the view that complaint is allowable and Point No.1 and 2 found in favour of the complainant.
13. In the result, this complaint is allowed against 2nd opposite party. Being an agent of the 2nd opposite party 1st opposite party is exonerated from their liability thereby the 2nd opposite party is directed to pay Rs.5 lakhs (Rupees Five Lakhs only) insured amount to the complainant along with cost and compensation of Rs.50,000/- (Rupees Fifty Thousand only) to the handicapped/poor policy holder for dragging in litigation, failing which complainant is allowed to realise the said amount ordered herein above with 10% interest from the date of order.
Declared in the Open Forum on this the 30th day of July, 2016.
(Sd/-)
K.P. Padmasree,
(Member – I)
Sri. P. Satheesh Chandran Nair (President) : (Sd/-)
Smt. Sheela Jacob (Member – II) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : Sheeja S. Kumar
PW2 : Dr. Kuruvilla George
Exhibits marked on the side of the complainant:
A1 : Policy certificate in the name of the complainant in the period of
18.08.2010 to 17.08.2011.
A2 : Copy of Final report of Pandalam Police Station dated 27.12.2010.
A3 : Copy of Accident-cum Wound Certificate issued from Pushpagiri Medical
College dated 26.12.2010.
A4 : Copy of Discharge summary of Caritas Hospital dated 24.01.2011.
A5 : Copy of discharge summary of Amritha Institute of Medical Science
dated 05.02.2011.
A6 : Copy of discharge summary of Specialists Hospital, Ernakulam
dated 24.02.2011.
A7 : Copy of Standing Disability Assessment Board Certificate issued
from District Hospital, Kozhencherry dated 17.05.2013.
A8 : Copy of Medical Certificate dated 10.09.2014 from Amrita Institute
of Medical Science.
A9 : Copy of legal notice dated 10.11.2014 issued by the complainant’s
counsel to the opposite parties.
A10 : Copy of reply notice dated 21.11.2014 issued by the 2nd opposite party
to the complainant’s counsel.
A11 : Photograph of the complainant before and after the accident.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties: Nil.
(By Order)
Copy to:- (1) Sheeja S. Kumar, Narayaneeyam, Mootheril, Thumpamon.P.O.,
Pandalam Thekkekara Village, Adoor Taluk.
(2) Manager, State Bank of Travancore,
Thumpamon Branch, Thumpamon.P.O.,
Pandalam, Pathanamthitta.
(3) Divisional Manager, United India Insurance Co. Ltd.,
Divisional Office No.II, P.B.No.5521, Malankara Building,
V.J.T. Hall Road, Thiruvananthapuram.
(4) The Stock File.
