-::BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT BIDAR::
C.C. No.63/2018.
Date of filing: 18.09.2018.
Date of disposal: 26.07.2019.
P R E S E N T:-
(1) Shri. Ashok Hanamath Malaghan B.Com., LL.B.,( Spl.)
President. ( I/C )
(2) Shri. Shankrappa (Halipurgi),
B.A.LL.B. (Spl.)
Member.
COMPLAINANT/S Sri Vishwanath, S/o Gangadhar
Sajjanshetty, Age: 50 years,
Occ: Agriculture,
R/o H.No. Madkatti,
Now at Basveshwar Colony, Bhalki,
Tq. & Dist.Bidar.
( By Sri. Sanjay Kumar S. Patil ,Adv.)
VERSUS
OPPONENT/S: The Branch Manager,
National Insurance Co.Ltd.,
Branch Office, 2nd Floor,
Veerbhadreshwar Chambers,
Opp. Neharu Stadium,
Bidar-585401.
( By Smt. Shakuntala Patil, Adv.)
:: J UD G M E N T ::
By Shri. Ashok Hanamant Malaghan, President.
This is a complaint filed by the complainant U/s.12 of the C.P.Act., 1986 against the O.P claiming compensation to the tune of Rs.2,00,000/- with interest from the O.P.
2. Brief facts of the case of the complaint are:
The complainant is a resident of village Madkatti,Tq.Bhalki, Dist.Bidar. complainant states that, he is a member of Pradhan Mantri Bhima Yojana customer of respondent company under scheme of personal accident insurane scheme renewable year to year by offering protection against death, disability or partial disability due accident launched by Pradhan Manthri Suraksha Bhima Yojana scheme of Govt. of India. Under this scheme respondent assured to pay the compensation of Rs.2 lakhs for death and partial or permanent disability and Rs. 1 lakh for irrecoverable loss of sight of one eye or loss of use of one hand or foot. Accordingly he has paid the premium amount of Rs.12/- on 31.05.2015 through state Bank of India Branch at Bhalki vide saving Bank account no. 30856090215 hence, respondent has issued the policy vide no. 37020442158200000 said policy was in force at the time of accident i.e. up to 31.05.2016.
3. Further complainant submits that on 30.06.2015 at about 00.35 hours when he was returning towards his house after completing his agricultural works at his field at village Madkatti when he was near punyashrama on his motor bike bearing regd.no.KA-39 E-6991 on proper side with normal speed at that time one driver of car bearing regd no. KA-39 M-1708 came from Ambedkar ciorcle side in rash and negligent manner violently dashed to the complainant due said accident complainant sustained grievous injuries on his head and occipital region started bleeding from ear consequently become unconscious, one Kiran Khandre looking the complainant and informed to his son namely Sangmesh, then son rushed to the spot and brought his father to Govt. hospital Bhalki after giving primary treatment, referred to higher centre at Hyderabad. Accordingly shifted to Malla Reddy Narayan hospital at Hyderabad wherein, he was in patient from 30.06.2015 to 10.08.2015 he was undergone several surgery like craniotomy and tracheotomy done by said hospital with huge amount of medical and hospital expenses, in spite of that, complainant could not feeling well he is suffering from neuro problem become disable of his left side body which are left eye, left hand left leg are not working, he is unable to walk stand on both leg thus Govt. hospital Bidar BRIMS competent department has issued disablement certificate has issued the disablement certificate starting that his permanent disability is 60% to 70%.
4. Further the complainant has applied the claim through branch Manager at Bidar and also to it’s Office at Bengaluru for paying compensation under above scheme as he is member of entitled to get the Rs.2,00,000/- as he has become disablement of loss of sight of one eye and loss of use of one hand of foot i.e. table B. But, respondent in order to escape from it’s liability returned the claim as not tenable on 03.07.2018 to Hubli and same returned to complainant. Under the above scheme respondent is liable to pay the compensation of Rs.2,00,000/- to the complainant but, giving false reasons returned the claim. Hence the complainant filed this complaint before this Forum for claiming compensation and cost from the O.P.
5. After the notice issued by the Forum the O.P appeared before this Forum through his counsel and has filed his written version contending that, the complaint filed by the complainant claiming compensation under the Pradhan Mantri Suraksha Bhima Yojana” (PMSBY) against the insurance Company is wrong and in correct and not maintainable. In reply to para no.1 of the complaint it is true that, the complainant is a member of PMSBY of respondent company under the scheme of personal accident insurance scheme. It is further admitted that, the respondent assured to pay the compensation of Rs.2,00,000/- for death. But, further contents of the complaint i.e. partial or permanent disability etc. are wrong and incorrect and the respondent is not liable to pay the compensation under the head of partial or permanent disability as per the A.B.C. of PMSBY coverage. The contents of para no.2 of the complaint, the complainant has met with an accident and he sustained injuries to the left ear, occipital region as per the wound certificate produced by him. It may be true that, the complainant after sustaining injuries in the accident was taken to Govt. Hopistal, Bhalki, Mallareddy Hospital Hyderabad etc. But, the injuries sustained by the complainant not covered under a.b.c. table of benefits of PMSBY policy. Therefore the respondent is not liable to pay the compensation. In reply to para no.3 of the complaint, the claim of complainant against the respondent through branch office, Bidar to it’s office at Bangalore for paying compensation is rightly rejected by the respondent office as injuries sustained by the complainant not covered in PMSBY coverage. The respondent has denied the contention taken by the complainant about the respondent is liable to pay the compensation for Rs.2,00,000/-. Further it is falsely alleged that, the respondent company by giving false reasons returned the claim of the complainant. The disability certificate of the complainant is not covering the injuries mentioned in the said policy coverage. The falsely alleged in para no.5 & 6 of the complaint about the compensation of Rs.25,000/- payable by the respondent due to carelessness, negligence, inefficient service by the respondent in dealing the application of the complainant. Therefore the complaint filed by the complainant is not maintainable.
6. The respondent further states that, the complainant sustained injuries on left ear and occipital reason as per the would certificate filed by him. The disability certificate produced by the complainant not covering injuries mentioned in the policy. As per PMSBY coverage the claimant/complainant shall sustained injuries as under:
- Total & irrecoverable loss of both eyes or loss of use of both hands or feet a loss of sight of one eye and loss of use of hand or foot.
- Total & irrecoverable loss of sight of one eye or loss of use of one hand or foot.
If the complainant sustained above said injuries, he is entitled to get compensation of Rs.2,00,000/- under ‘ b ‘ injuries and Rs.1,00,000/- under ‘c’ injuries, but the complainant sustained any of the above said injuries. Therefore, the respondent company is not liable to pay the compensation.
7. The complainant met with an accident on 30.06.2015 and claim application filed before the respondent office on dt.20.12.2017 i.e. after laps of two year 5 months and 20 days. The present complaint filed before this Forum on 18.08.2018 i.e. after laps of three years, which is barred by limitation. The complainant even not filed any application for condoning the delay in filing the complaint. Hence, the complaint barred by limitation and deserves to be dismissed with compensatory cost of Rs.25,000/-.
8. The complainant has filed his evidence affidavit in support of this case and his documents are noted as annexure P.1 to P.22. On the other hand the O.P. has also filed his evidence affidavit in support of his case but documents are filed as Annexure.R.1 to R3. The written arguments filed by the both parties. Heard the oral arguments.
9. Considering the above said facts and circumstances and on the basis of pleadings of both the parties the following points arose for our consideration.
- Whether the complainant proves that, there is a deficiency of service on the part of the Opponent in settling his claim?
- Whether the complainant is entitled any reliefs claimed ?
- What orders?
10. Our answers to the above points are as follows:-
- In the affirmative.
- Partly in the affirmative.
- As per the final order owing to the following:-
11. Point No.1
Considering the pleadings of the both parties, it is not in dispute that, complainant is a member of Pradhan Mantri Bhima Yojana Scheme which was covered by the Opposite party. Insurance policy which was valid and effective as on the date of accident caused on 30.06.2015 while he was riding his motor cycle bg.no. KA39 E 6991. Further it is also not in dispute that, the manner of accident caused to the complainant as narrated in the complaint.
12. It is a specific case of the complainant that, he has sustained grievous injuries in an accident caused on 30.06.2015 on his head, occipatal region with bleeding from ear and then he was shifted to Govt. hospital, Bhalki and then reffered to Mallareddy Narayan hospital, Hyderabad wherein, the complainant was admitted from 30.06.2015 to 18.08.2015 and attended various tests and investigation and operations as suggested by the Doctors and has spent huge amount for medical and other expenses and presently the complainant has suffering the neuro problems on his left side body including left eye and leg and thereby the complainant is permanently disabled person and unable to works anything as before. In this regard the Govt. hospital, Bidar (BRIMS) has issued a disability certificate after examining the complainant holding that, the complainant has sustained disability to the extent of 60 to 70%.
13. The complainant has submitted his claim form to the opposite party for settlement of his claim. But, O.P. has repudiated his claim on a filmsy ground without considering the real fact of the case to achieve the main object of the policy. Hence such act of the O.P. is nothing but deficiency in service in the eye of law and as such the O.P. is liable to answer the claim of the complainant.
14. On the other hand the learned counsel for the O.P. has vehemently argued that the claim of the complainant is not payable because the injuries sustained by him are not covered as per the policy a.b.c. table coverage under PMSBY scheme. So, considering above all aspect, the concerned authority of O.P. has taken a right decision by rejecting the claim of the complainant on the basis of terms and conditions of the policy which are binding on both the parties. Hence, the claim of the complainant is not payable under law. Therefore, lawful action taken by the O.P. based upon the terms and conditions of the above said scheme does not constitute any deficiency in service, as contended by the complainant.
15. The learned counsel for the O.P. further argued that, the present claim of the complainant is barred by limitation and as such the complainant has not filed any separate application for condonation of delay. Hence, on this account also the claim of the complainant is liable to be rejected.
16. In order to prove their respective cases both the parties have produced documents coupled with their evidence affidavits.
17. The complainant has produced the documents Annexure 1 to 22 including the treatment records of both the hospitals and the criminal case papers of the police station wherein the case was registered against the Driver of the vehicle for causing the accident. In the said accident, the complainant has sustained grievous injuries over his head and occipital region and said injuries are noted in the wound certificate Annexure.P.10 as grievous in nature and the documents Annexure.P.11 is the discharge summary sheets issued by Mallareddy Narayana Multispeciality hospital are clearly shows that, the complainant was attended various tests and investigations and also operations as suggested by the Doctor including the surgery of Craniotomy/Evacuation done on 30.06.2015 and Tracheostomy done on 30.06.2015 and then the patient was discharge on 10.08.2015 with a advise to attend the follow of treatments. So, it shows that, the patient has sustained grievous injuries over his head and other neurological effect on account of said accident. In view of the said fact the complainant has claimed his left side body including the eye, hand and leg were completely senseless and thereby he was unable to work anything as before, which has resulted into a permanent disability to do works. The learned counsel for the complainant has drawn the attention of the Forum on Annexure.P.9 the disability certificate issued by BRIMS Teaching hospital, Bidar wherein, the disability of the patient was assessed to the extent of 60 to 70%, but the learned counsel for the O.P. has strongly objected to consider the said disability saying that, the said injuries are not covered by the insurance policy a.b.c schedule. Further argued that insurance policy is a beneficial scheme under PMIRY yojana for those who are sustained injuries over the both eye or amputation of particular limb but not to any other injuries now shown by the complainant. Hence, the learned counsel submits that, the claim is not payable under the above said scheme of policy.
18. The learned counsel for the O.P. has drawn the attention of the Forum, on the documents produced by the O.P.under Annexure R.1 to R.3. On perusal of the said documents the conditions of the scheme have been narrated. But, nothing on record to show that, these conditions were made known to the complainant while issuing the policy or subsequently before the date of the accident caused to him as per the rule of IRDA. So, in the absence of the same the members of the said scheme are unable to know the alleged terms and conditions of the policy, of which now relied by the opposite party in deciding the claim. Since it is mandatory on the part of the opposite party to supply the copy of the terms and conditions of the policy to it’s members concerned. But, in this case no such documents produced by the O.P.
19. Considering the facts and circumstances of the case and on perusal of medical certificates produced under Annexure P. 9 to 11 are evident that, the complainant has sustained grievous injuries in the said accident, though the said injuries are not scheduled injuries as contended by the O.P. But, the effect of the said injuries on the complainant are severe in nature and has caused partial disablement on his limbs and thereby the complainant was unable to works hard due to above said disablement. As per Annexure P.9 the disability certificate issued by the group of Doctors is shown 60 to 70% disability but, the said Doctors has not specified whether the said disability is as to whole body or to a particular limb of the complainant. In the absence of the same, we are of the view that, the said disability cannot be taken as to whole body disability in the absence of any scientific method specified in the said certificate. However, considering the real problems of the complainant, even in the absence of any other proofs we are of the view that the complainant has suffered disability of a particular limb including the effect of the injuries on his eyes and hands, it is just and proper to consider only to the extent of 30% as to whole body. We further noticed that, the above said insurance scheme is a beneficial scheme to the effected persons of an accident and who sustained injuries. It is further observed that, in this case the complainant has sustained injuries on his vital organs of head and occipital regions and the effect of the injuries are grievous in nature and may be effects even on the eye of the complainant including his other limbs, thereby naturally the complainant is unable to work as before and thereby loose his working capacity on account of the said injuries. Under the circumstances without going into strict proof of terms and conditions of the policy, we have considered the main purpose of the policy for which, policy was issued. It is not the case of the O.P. that, there is a primary violation and breech of policy conditions in any manner. Therefore, rejection of claim by O.P. on mere technicalities of the policies schedule does not fulfil the main object of the policies since the said policy has been issued for the benefits of the poor people who are unable to maintain their lives under above situations. Therefore considering the said aspect the rejection of claim of the complainant is unjust and improper. At least the O.P. could have consider the just claim of the complainant on non standard basis looking to the grievous injuries suffered by the complainant. But, rejection of total claim is not justified in the eye of law. Hence, the repudiation action of the O.P. is liable to be quashed, for the discussion made above.
20. The criminal case papers produced by the complainant under Annexure. 12 to 22 are confirms that the above said injuries have been sustained to him in an RTA. Therefore, for the reasons stated above, we are of the view that, repudiation of the claim is not sustainable in the eye of law and same is amounts to deficiency in their service towards complainant and as such the claim is payable by the O.P. based on the facts and circumstances.
21. The O.P.has raised the point of limitation in this case but, in our view the said point has not been substantially proved by the O.P. Since, the present complaint has been filed within two years from the date of repudiation letter dt.03.07.2018 which is in our view was the date of cause of action to file this complaint. Because, before repudiation of claim there was no cause of action for the complainant to file this case. Hence in our view the present complaint is not time barred in any manner.
22. Therefore, looking to any angle, in our view the complainant has proved the point no.1. Hence the same is answered AFFIRMATIVELY.
23 Point No.2.
The complainant has claimed a sum of Rs. 2,00,000/- as compensation shown in the scheduled of policy. But, as discussed in above paras while answering the point no.1. In our view the complainant is entitled to receive Rs.30,000/- on the basis of 30% of disability as against Rs.1,00,000/- shown in policy schedule ‘c’ table for Rs.1,00,000/- (which is awardable only in case of 100% disability on the said schedule injuries). But, now as stated above, in our view the complainant has sustained only 30% disability as to whole body. Hence same disability is considered for computation of above said amount as against the total claim of Rs.2,00,000/-towards loss caused to complainant. In addition to above claim the complainant is entitled Rs.5,000/- towards his pain and sufferings including cost of the litigation from the O.P. Hence, O.P. in all liable to pay Rs.30,000/- + Rs.5,000/- total Rs.35,000/- to the complainant. Thus, the point no.2 is answered partly in the Affirmative. Resultantly the following order is passed.
::ORDER::
The complaint filed by the complainant U/Sec. 12 of C.P.Act. against O.P. is partly allowed with costs.
Consequently the O.P. is liable to pay Rs. 35,000/- as stated above to the complainant along with interest at the rate of 8% p.a. from the date of complaint, till realisation of the entire amount. The O.P. shall comply the above said orders within one month from the date of this order.
Intimate the parties accordingly.
(Typed to our dictation then corrected, signed by us and then pronounced in the open Forum on this 26th day of July 2019).
Sri. Shankrappa H. Sri. Ashok Hanamanth Malaghan
Member. President.
Documents produced by the complainant
- Annexure.1 Repudiation Letter issued by the O.P. to the
- complainant
- Annexure.2– Letter of correspondence issued by O.P.to
Hubli-Bengaluru Branch.
- Annexure.3 Xerox copy of Letter issued by the
complainant to the O.P. Dt. 20.12.2017.
- Annexure.4– Xerox copy of Letter issued by the
complainant to the O.P,Dt. 20.12.2017
- Annexure.5- Xerox copy of Claim form dt.20.12.2019.
- Annexure.6- Xerox copy of Copy of Consent-cum
Declaration form.
- Annexure.7- Xerox copy of Bank statement of account of
complainant
- Annexure 8- Xerox copy of Bank statement of account
of complainant
- Annexure.9- Xerox copy of Disability certificate.
- Annexure.10- Xerox copy of wound certificate.
- Annexure.11- Copy of Discharge Summary.
- Annexure.12- Xerox copy of Charge sheet.
- Annexure.13- Xerox copy of FIR.
- Annexure.14-Xerox copy of Statement
- Annexure.15 & 16 -Xerox copy of Panchanama
- Annexure.17- 20 Xerox copy of statement of witnesses
- Annexure. 21- Copy of Motor Vehicles Accident Report.
- Annexure.22- e-Stamp.
Document produced by the Opponent.
- Annexure R.1- True copy of letter from regional office
Hubli to branch office Bidar.
- Annexure R.2- Attested copy of rules of PMSBY
- AnnexureR.3- Attested copy of Letter from Regional
office to branch office Bidar in respect
of claim of Viswanath repudiated
dt.03.07.2018.
Witness examined.
Complainant.
- P.W.1- Vishwanath, S/o Gangadhar Sajjanshetty
(Complainant )
Opponents.
- R.W.1. Natraju Malraju, S/o Gopalraju (O.P. )
Sri. Shankrappa H. Sri. Ashok Hanamanth Malaghan
Member, President.
