DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA
CC.No.479 of 30-10-2013
Decided on 12-02-2014
Rajwinder Singh aged about 35 years S/o Gurtej Singh R/o Village Goniana Kalan, P.O. Harraipur, Tehsil & District Bathinda.
........Complainant
Versus
1.Tata AIG General Insurance Company Limited, Registered Office: 15th Floor, Tower-A, Peninsula Business Park, G.K Marg, Opp. Senapati Bapat Marg, Lower Parel, Mumbai-400013, through its M.D/Chairman.
2.Tata AIG General Insurance Company Limited, The Mall, Bathinda, through its Manager.
3.Axis Bank Ltd. Faridkot Road, Kotkapura, District Faridkot, through its Branch Manager.
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM
Smt.Vikramjit Kaur Soni, President.
Smt.Sukhwinder Kaur, Member.
Sh.Jarnail Singh, Member.
Present:-
For the Complainant: Sh.A.S Shergill, counsel for the complainant.
For Opposite parties: Sh.Naresh Garg, counsel for the opposite party Nos.1 and 2.
Opposite party No.3 ex-parte.
ORDER
VIKRAMJIT KAUR SONI, PRESIDENT:-
1. The instant complaint has been filed by the complainant under section 12 of the Consumer Protection Act, 1986 as amended upto date (Here-in-after referred to as an 'Act'). Briefly stated the case of the complainant is that he purchased one accident guard policy bearing No.0200114697 00 of the opposite party Nos.1 and 2 with client ID No.6554431, w.e.f 28.12.2012 to 27.12.2013 against the principal sum assured of Rs.25 lacs, in his name, from the opposite party No.3 and deposited the premium of Rs.3170/-. As per the terms and conditions of the abovesaid policy, the complainant is entitled to the compensation in case of any accident. After the purchase of the abovesaid policy, the complainant continued paying the premium amount of Rs.3170/- per month with the opposite parties against the proper receipts. The complainant met with an accident while cutting the fodder for the cattle, due to this his right hand came in the fodder cutting machine, resulting in crushing of his middle finger and ring finger of the right hand on dated 6.3.2013. The complainant admitted in Sukhmani Nursing Home, Goniana Mandi, Tehsil & District Bathinda and has been attended by Dr.Bija Mall. The treating doctor operated the complainant for the injuries and amputated/cut his half portion of both middle and ring finger of his right hand and after that done the surgery and stitches. As per the disability certificate issued by Dr.Dhiraj Goyal, MBBS, MS (Ortho), Civil Hospital, Bathinda, the complainant has become a disabled person upto the extent of 8%. As the half portion of both the middle and ring finger of the right hand of the complainant has been amputated/cut including the first joint of both the aforesaid fingers, as such the complainant is entitled for the compensation from the opposite party Nos.1 and 2 atleast 10% of the principle sum assured amount of Rs.25 lacs (5% for one joint each) as per Coverage C-3 (Section: Permanent Total Loss of us), mentioned at Pages No.11 and 12 of the terms and conditions of the abovesaid policy. The complainant lodged the claim with the opposite party Nos.1 and 2 through the opposite party No.3 and submitted all the requisite documents for the payment of the accidental insurance claim as per the terms of the abovesaid policy, but they have paid him the claim amount of Rs.30,000/- only without any basis and criteria, although as per the terms of the abovesaid policy, as the complainant has suffered the loss of two joints i.e. one joint of each middle and ring finger of his right hand, as such he is entitled for the compensation @ 5% per joint i.e. total 10% of the basic/principal sum assured of Rs.25 lacs and 10% of the same comes out to Rs.2.50 lacs. The complainant requested the opposite parties many times to make the payment of the insurance claim, but to no avail. Hence the present complaint filed by the complainant to seek the directions of this Forum to the opposite parties to pay him the balance amount of the accidental claim to the tune of Rs.2,20,000/- alongwith cost to the tune of Rs.5500/- and compensation to the tune of Rs.50,000/-.
2. The opposite party Nos.1 and 2 after appearing before this Forum have filed their joint written statement and pleaded that the claim of the complainants towards weekly indemnity (Temporary Total Disability) @ Rs.5000/- per week has already been paid taking into account that the complainant was temporary disabled for 42 days (6 weeks) based on the documents submitted by him as such the amount of Rs.30,000/- was assessed and paid to him as per the terms and conditions of the abovesaid policy. The opposite parties further pleaded that the abovesaid policy provides coverage @ 25% of the principle sum for the accidental dismemberment of thumb and index finger only and that too of the same hand. In the present case the complainant has himself alleged that he has suffered from injuries and dismemberment of middle and ring finger of the right hand, so he is not entitled to the loss/disability of it as per the terms and conditions of the abovesaid policy. The complainant has not paid the premium/not opted the cover under Permanent Total Loss of Use. The complainant has opted only for the accidental death & Dismemberment and weekly indemnity upto 52 weeks cover and has paid the premium in this regard to the tune of Rs.3170/- including the service tax of Rs.348.71/-. The accidental dismemberment provides cover only for the loss of thumb and index finger and not for the middle and ring finger.
3. Registered notice has been sent to the opposite party No.3 on dated 3.12.2013 vide postal receipt No.A RP338825164IN but despite receiving the summons, none appeared on behalf of the opposite party No.3 before this Forum, hence ex-parte proceedings are taken against it.
4. The parties have led their evidence in support of their respective pleadings.
5. Arguments heard. The record alongwith written submissions submitted by the parties perused.
6. The undisputed facts of the parties are that the complainant has purchased one accident guard policy bearing No.0200114697 00 of the opposite party Nos.1 and 2 with client ID No.6554431, w.e.f 28.12.2012 to 27.12.2013 against the principal sum assured of Rs.25 lacs, in his name, from the opposite party No.3 and deposited the premium of Rs.3170/-. As per the terms and conditions of the abovesaid policy, the complainant is entitled to the compensation in case of any accident. The complainant met with an accident while cutting the fodder for the cattle, due to this his right hand came in the fodder cutting machine, resulting in crushing of his middle and ring finger of the right hand on dated 6.3.2013. The complainant lodged the claim with the opposite parties Nos.1 and 2 through the opposite party No.3, they have paid him the claim amount of Rs.30,000/- only.
7. The disputed facts of the parties are that as per the disability certificate issued by Dr.Dhiraj Goyal, MBBS, MS (Ortho), Civil Hospital, Bathinda, the complainant has become a disabled person upto the extent of 8%. The complainant is entitled for the compensation from the opposite party Nos.1 and 2 atleast 10% of the principle sum assured of Rs.25 lacs i.e. 5% for one joint each. The complainant is entitled for the accidental claim of Rs.2.50 lacs, out of Rs.2.50 lacs, the opposite party Nos.1 and 2 have paid him the claim amount of Rs.30,000/- and withheld the amount of Rs.2,20,000/-. As per the terms and conditions of the abovesaid policy the complainant is entitled for the compensation to the tune of 7.5% of the sum assured for two joints as per Clause No.12 under heading Coverage C-3, Permanent Total Loss of Use.
8. A perusal of Ex.C4 shows that the second and third finger of right hand cut by sharp; stitching and dressing done'. Vide Ex.C8, Disability Certificate (Obvious Disability) i.e. a valid certificate has been issued to the complainant, the columns No.B and A of this certificate shows 'The diagnosis in his/her case is Amputation of Right middle and ring finger and He/She has 8% (in figures) eight percent (In words) permanent physical impairment/blindness/hearing in relation in his/her (Part of body) as per guidelines notified by Ministry of Social Justice and Empowerment No.16-18/97-NI, I, New Delhi dated 1st June 2001 and amended from time to time'. The opposite party Nos.1 and 2 have placed on file Accident Guard-5L Schedule of Insurance, Ex.OP1/2. While settling/paying the claim to the complainant, the opposite party Nos.1 and 2 have relied upon Coverage C-2:- Accidental Dismemberment, whereas as per the version of the complainant, he falls under Permanent Total Loss of Use i.e. Coverage C-3, in this coverage Clause 12 is mentioned as:-
“Permanent Total Loss of Use of Fingers of either hand
a) Three Joints 10%
b) Two Joints 7.5%
c) One Joint 5%”
A perusal of medical record placed on file shows that the complainant has suffered the loss of two joints i.e. one joint of each middle finger and ring finger of his right hand, meaning thereby his two joints of right hand have been cut. The disability certificate shows that 8% disability has been suffered by the complainant, thus he is covered under Clause 12 of Permanent Total Loss of Use of Fingers of either hand, which shows 'Two Joints:-7.5%'. The policy so issued to the complainant is of the principal amount of Rs.25 lacs and he has suffered the loss of two joints. As per the Coverage C-3 of 12(B), he is entitled for the amount of Rs.1,57,500/-(7.5% of Rs.25 lacs=Rs.1,87,500/- minus Rs.30,000/- as the amount of Rs.30,000/- has already been paid to the complainant) from the opposite parties.
9. Therefore in view of what has been discussed above there is deficiency in service on the part of the opposite parties in not paying the claim amount to the complainant well within time. Hence this complaint is accepted with Rs.20,000/- as cost and compensation against the opposite parties. The opposite parties are directed to pay the amount of Rs.1,57,500/- to the complainant.
10. The compliance of this order be done within 45 days from the date of receipt of the copy of this order.
11. In case of non-compliance the interest @ 9% per annum will yield on the amount of Rs.1,57,500/- till realization.
12. A copy of this order be sent to the parties concerned free of cost and file be consigned to the record room.
Pronounced in open Forum:-
12-02-2014
(Vikramjit Kaur Soni)
President
(Sukhwinder Kaur)
Member
(Jarnail Singh)
Member
