Judgment & Order dt. 05.12.2017
Repudiation of the complainant’s claim for insurance money by the OP i.e. National Insurance Company Ltd. has galvanized the complainant to file the instant case u/s 12 of the CP Act, 1986, alleging deficiency in service on the part of the OP. The quintessence of the facts leading to the filing of the instant case by the complainant may be described as follows:
The complainant faced an accident on 11.4.2014 in his own motorcycle bearing No.WB 62-C/9498 while driving in between the state highway Chakvrigu and Jalghar under Balurghat police station. The complainant being a personal accident policyholder of the OP bearing No.150703/31/13/6200008760 which remained valid upto 29.10.2014 submitted a claim for Rs.1,00,000/- (Rupees One lakh) only for his accident from the OP. The OP has willfully repudiated the bona-fide claim and has violated the terms and conditions of the package insurance policy illegally and it is alleged to be the deficiency in service made by the OP.
The OP has filed a written statement of them to contest in the case, wherein it is submitted inter alia that the complainant Ranab Das has an insurance policy namely ‘Personal Accident Policy’, that the complainant faced an accident on 11.4.2014 as stated by the complainant and the accident took place within the valid period of the policy. But, he is not entitled to get any claim as the terms & conditions of the insurance policy does not cover the claim of the petitioner. So, repudiation of the claim being lawful, the case should be dismissed.
Upon the averments of both the parties the following points are formulated for proper adjudication of the case.
Issues:
- Whether the OP is liable for deficiency in service by repudiating the claim of the complainant for policy amount?
- Is the complainant entitled to get policy amount as claimed for?
Evidence of the parties
The affidavit-in-chief has been filed on behalf of the complainant and same is kept in record. The documents filed by him as per firisti are also kept in the record. On the other hand, the OP has also filed affidavit-in-chief with some documents as per firisti and these are also kept in the record for consideration.
DECISION WITH REASONS
Point Nos.1 & 2:
Both the points are taken up for consideration at a time for the sake of convenience.
It is contended on behalf of the insurance company that the insured or his / her heir is entitled to get 100% of sum assured i.e. Rs.1,00,000/- if the insured suffers death due to accident or loses two limbs, vision of the two eyes. But, when he loses one limb or vision of one eye, he is entitled to get 50% of sum assured. The Ld. Lawyer appearing for the insurance company has also filed the copy of certificate of Insurance cum Policy Schedule issued in favour of Ranab Das, the complainant. The complainant has also submitted the documents of his 45% disability and the documents regarding his treatment and nature of injury in government & non-government hospitals.
Perused the evidence on record and also documents filed on behalf of the parties. Considered all these along with submission on behalf of the parties.
In the instant case, a disability certificate dt. 9.1.2015 (photocopy) and a discharge certificate (photocopy) dt. 10.5.2014 issued by the TRA General Hospital, are filed by the complainant. Nowhere in the certificate is mentioned that the complainant sustained any grievous hurt of permanent nature. The disability certificate does never disclose the nature of disability, although, it discloses that the percentage of disability is 40%. Apart from that, it is also mentioned at Sl No.3 of disability certificate thus, “his / her percentage of partial disability is calculated as 45% and having chances of variation the case requires review after 5 years”. From the disability certificate, it is proved that the disability of the complainant is partial and not permanent. Now to see whether such kind of disability is covered by the insurance policy or not.
There is a chapter titled “standard form for two wheelers package policy” in India Motor Tariff. Sec.III thereof deals with personal accident cover for owner-driver and it lays down that the insured owner-driver (OD) is entitled to get compensation for bodily injury from the insurer company, according to the table provided below :
| Nature of injury | Scale of compensation |
(i) | Death | 100% |
(ii) | Loss of two limbs or sight of two eyes or one limb and sight of one eye. | 100% |
(iii) | Loss of one limb or sight of one eye. | 50% |
(iv) | Permanent total disablement from injuries other than named above. | 100% |
From the above table, it is found that the partial disablement of the insurer is not covered by the insurance. The insurance covers permanent disablement from injuries other than death and loss of limbs. Coming to the facts of the instant case it is found that the complainant did not sustain any injury of permanent nature. He did not sustain any permanent disablement; he sustained only partial disablement, which is not covered by his insurance policy. This being so, the repudiation of the complainant’s claim for compensation by the OP insurance company appears to be lawful and therefore no deficiency in service is seen to have been committed by the insurance company.
In the result, the complaint fails.
Hence,
O R D E R E D
That the complaint case be and same is dismissed on contest without any costs.
Let a free copy of this order be supplied or sent to the parties concerned free of cost at once.
