By Sri. Jose. V. Thannikode, President:
This complaint is filed to get the sum assured for the injury caused due to an accident from the Opposite Party.
2. Brief of the complaint:- The complainant was the policy holder of traffic accident insurance policy No.570309148/11/2165000011 of Opposite party for the period 03.01.2012 to 02.01.2013. As per the policy conditions all the expenses incured due to any accident is liable to be paid by the Opposite party up to an amount of Rs.1,00,000/-.
3. The Complainant met with an accident while traveling on his motor bike on 25.08.2012 at about 10.30 AM. He had sustained injury and the elbow ligament was broken. Immediately he was admitted to Vinayaka Hospital Sulthan Bathery. Then he was advised for MRI Scan and hence he was admitted in Ortho I Specialty Hospital, Coimbatore on 30.08.2012 and had undergone surgery to his shoulder. He was discharged on 02.09.2012. The Complainant had to spend about Rs.1,50,000/- for his treatment. Thereafter the Complainant submitted claim application with all relevant document to the Opposite Party. As per the policy condition he is entitled to get up to Rs.1,00,000/- for the expenses he incured for the same.
4. But the Opposite party has not settled the claim for the amount till now. Then the Complainant cause to send a lawyer notice to the Opposite party but Opposite Party replied alleging untenable contentions. The Opposite Party has alleged that the Complainant had not produced any document to prove the accident . The complainant along with a letter, copy of GD entry, from Sulthan Bathery Police Station, Medical Bill etc to prove the accident. More over the Complainant sent the certificate issued by the Doctor who treated him on the day of accident from the Vinayaka Hospital.
5. As per the term of policy a report from police alone is sufficient for granting claim and the Complainant further says that there is a clear deficiency of service from the part of Opposite party and prayed before the Forum to direct the Opposite party to pay Rs.1,00,000/- with 12% interest with cost and compensation.
6. Notice was served to Opposite Party and Opposite party appeared and filed version, stating that this Opposite Party admits that the Complainant has taken policy No.570309/48/11/2165000011, but the allegation that as per the policy, all the expenses incurring for the treatment of the policy holder for the injuries sustained in an accident up to Rs.1,00,000/- is not fully correct as the same is subject to the terms and conditions of the policy. It is also admitted that the Complainant has submitted a claim form to the company.
7. This Opposite Party does not admit the allegations regarding the admission in the hospital, and the expense incurred therein. This Opposite Party submits that the documents submitted by the Complainant are not sufficient to prove the accident alleged by the Complainant. This Opposite Party is not admitting the allegation that the Complainant met with an accident while he was traveling on his Motor cycle on 25.08.2012. The Complainant has to prove the accident. The medical certificate submitted by the Complainant, is insufficient to prove the accident in the above matter. The Opposite Party has requested vide letter dated 11.12.2012 to the complainant to produce authoritative records to prove the accident. But instead of submitting the documents to substantiate the accident, the Complainant had only forwarded copy of RC, policy and driving license etc only. Though the Complainant asserts that he was treated at Vinayaka Hospital Sulthan Bathery , no documents were produced to substantiate the same. Since the documents submitted by the Complainant are contradictory as far as the date of accident is concerned the production of an FIR in the above case is very much essential to process the claim.
8. This Opposite Party admits the receipt of lawyer notice dated 08.11.2013. Thereafter this Opposite party has sent reply stating the true state of facts. Instead of producing the treatment records the Complainant has produced a certificate issued from Dr.Randheer Krishnan K, of Vinayaka Hospital, Sulthan Bathery, which in its face is sufficient to prove the falsity of the case put forwarded by the complainant. The allegation that this Opposite party is making untenable contention in order to escape from payment of claim amount and that even as per the conditions in the policy, a report from the Police alone is required for granting the claim amount as per the Policy and that the Opposite party deliberately evading the payment of the Policy amount etc are false and are made only for the purpose of the case. The further allegation that there is deficiency of service on the part of the Opposite Party and that therefore the Complainant is entitled to get interest at 12% per annum is devoid of any merit. The Complainant is not entitled to get Rs.1,00,000/- or interest or cost from the Opposite Party.
9. The Complainant has to prove that he had already spent Rs.1,00,000/- towards medical bills. The Complainant has to prove the same. There is no deficiency of service on the part of the Opposite party in processing the claim of the Complainant. This Opposite party has rendered adequate and proper service to the Complainant in the matter of settling the claim made by the Complainant. Without necessary documents the Opposite Party could not settle the claim made by the Complainant.
10. The allegation that there was negligence and deficiency of service on the part of this Opposite party in considering the claim application and that the complainant has sustained loss and damage on account of the same etc are false and hence denied. Hence prayed before the Forum to dismiss the complaint with compensatory cost to the Opposite Party.
11. Complainant filed proof affidavit and stated as stated in the complaint and he was examined as PW1 and Ext.A1 to A9 is marked. Ext.A1series is the lawyer notice send by the Complainant to the Opposite Party and its receipt and AD card, regarding his claim, Ext.A2 is the reply notice for Ext.A1. Ext.A3 is the certificate issued by Dr. Radheer Krishnan K of Vinayaka Hospital Stating that the Complainant had treated by him for fall on a bike on 25.08.2012. This Exhibits and Ext.A7 series bills issued from Vinayaka Hospital will show that the Complainant treated for his said injury. Ext.A4 is the letter send by the counsel for the Complainant stating that the document ie GD entry, Medical bills along with bills submitted to the Opposite Party. Ext.A5 is reply notice given by the Complainant to the Opposite Party stating that in the case no FIR is registered since no one else is injured. Ext.A6 is the policy certificate which show that the Complainant is the holder of policy. Ext.A7 series are the claim form submitted by the Complainant to the Opposite Party. Wherein it is stated that the date of accident, and the hospital where treated first and subsequent treatment from 30.08.2012 to 02.09.2012, photo copy of Driving License of Complainant, Letter given by the Complainant to Opposite party, the discharge summary of Complainant from ORTHO ONE Spine Arthroscopic and Joint Replacement centre Private Ltd., Coimbatore and the copy of final bill which is given to the Opposite party by the Complainant. The total bill amount is Rs.1,18,520/- which shows the Complainant spend Rs.1,18,520/- towards his treatment expense. Ext.A9 is the salient features of the traffic accident insurance policy therein it is stated that (1) Coverage benefit (2) Hospitalisation expense following Rail/Road accident Rs.1,00,000/- “Note” The police should be informed immediately on occurrence of accident and their report should be submitted to the company at the time of claim. It reveals that the holder of policy is entitled for the Hospital expense up to Rs.1,00,000/- and a report ie a GD entry from the police department is only required for admitting the claim..
12. From the side of Opposite party, Proof affidavit is filed and Opposite Party is examined as OPW1 and in the affidavit he stated as stated in the version and Exts. B1 to B2 is marked. Ext.B1 is the Personal Accident Insurance Policy Claim Form. Ext.B2(A) is the Duplicate Schedule. Ext.B2(B) is Schedule and conditions of Yatra Raksha policy.
13. On considering the complaint, version, affidavit, documents and deposition the following points are taken for consideration.
1. Whether there is any deficiency of service from the part of Opposite Party?
2. Relief and cost.
14. Point No.1:- On perusal of the above evidence we opined that on the contention of Opposite party that accident is to be proved, in which the GD entry of the police and treatment of the Complainant on the same day and medical bill issued from the Vinayaka Hospital on the same day can be believed. For admission to the Hospital the records from the Vinayaka Hospital and records from the Kozhikode Hospital and Coimbatore hospital will prove the hospitalisation, for the expense the bills produced along with the claim form reveals that he spend more than Rs.1,00,000/- and in the deposition of OPW1 also stated that as per the records given along with the claim application an amount of Rs.1,25,520/- is spend by the Complainant and finally Ext.A9 shows that only GD entry is suffered for the alleged claim and also OPW1 deposed that “ the company is liable to pay the treatment expense upto Rs.1,00,000/- as per the policy conditions” and also deposed that Ext.A9 is a apart of policy conditions. On the above findings we came to a conclusion that in this case not allowing the claim is a clear deficiency of service from the side of Opposite Party and complainant is entitled for the claim and Opposite Party is liable to compensate the same. The point No.1 is found accordingly.
15. Point No.2:- Since the point No.1 is found in favour of the Complainant the Opposite Party is liable to pay Rs.1,00,000/- with 12% interest from the date of filing of complaint ie 07.05.2012 and Rs.10,000/- as compensation and Rs.5,000/- as cost of this proceedings.
In the result the complaint is partly allowed and the Opposite Party is directed to pay Rs.1,00,000/- (Rupees One Lakh) only with 12% interest from 07.05.2012 the date of filing of complaint till realisation and Rs. 10,000/- (Rupees Ten thousand) only as compensation and Rs.5,000/- (Rupees Five thousand) only as cost of this proceedings to the Complainant. The Opposite Party shall comply the order within one month from the date of receipt of this order. On default the Complainant is entitled for an interest at the rate of 12% for whole the amount.
Dictated to the C.A transcribed by him and corrected by me and pronounced in the Open Forum on this the 30th day of August 2014.
Date of filing:10.05.2013.
PRESIDENT: Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
A P P E N D I X
Witness for the Complainant:
PW1. Assainar. P.C Complainant.
Witness for the Opposite Party:
OPW1. Mathew Paul. Manager, National Insurance Company, Kalpetta.
Exhibits for the Complainant:
A1(a) Lawyer Notice dt:03.01.2013,
A1(b) Acknowledgment.
A1(c) Postal Receipt. dt:08.01.2013.
A2 Reply Notice. dt:04.02.2013.
A3(a) Copy of Certificate.
A3(b) Acknowledgment.
A4(a) Letter. d:25.02.2013.
A4(b) Postal Receipt. d:22.03.2013.
A5. Copy of Letter. dt:23.11.2012.
A6. Copy of Premium Schedule for Trafic Accident Policy.
A7 Series Documents.
A7A Copy of Certificate. dt:28.08.2012.
A7B Copy of Certificate.
A7C(a) Copy of Cash Bill. dt:26.08.2012.
A7C(b) Copy of Clinical Details.
A8. Brochure.
A9. Copy of Traffic Accident Insurance Policy.
Exhibit for the Opposite Party:
B1. Personal Accident Insurance Policy Claim Form.
B2(A) Copy of Traffic Accident Policy.
B2(B) Road/Rail Accident Cum Hospitalisation Insurance Policy.
