IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 20th day of December, 2012.
Present : Sri. Jacob Stephen (President)
Sri. N. Premkumar (Member)
Smt. K.P. Padmasree (Member)
C.C. No. 128/2012 (Filed on 13.07.2012)
Between:
George. P.D.,
Sine Nivas,
Parakkara P.O.,
Thattayil, Adoor,
Pathanamthitta Dist. … Complainant.
(By Adv. C.V. Jyothi Raj)
And:
The Branch Manager,
ICICI Prudential Life Insurance-
Company Ltd.,
Thellirethu Arcade, Chittoor,
Pathanamthitta. … Opposite party.
(By Adv. Joseph. K.)
ORDER
Sri. Jacob Stephen (President):
The complainant has filed this complaint against the opposite party for getting a relief from the Forum.
2. The complainant’s case is that he is the policy holder of the opposite party under Life Time Gold Benefit Scheme along with the benefit of Accident Death and Disability Rider Scheme. As per the Accident Death and Disability Rider Scheme, opposite party assured ` 1,00,000 in the event of accident death or in the event of sustaining permanent disability. The policy of the complainant is valid from 18.10.2008 to 18.10.2018. While so, on 20.04.2011 at about 12 noon, the complainant met with an accident by collusion with another vehicle while the complainant was riding his motor cycle. Due to the accident, complainant sustained serious injuries and he was immediately taken to Muthoot Medical Centre and thereafter he was shifted to Pushpagiri Medical College Hospital, Thiruvalla and undergone treatment there as an inpatient for a period of one month. During the said treatment and part of the said treatment, his right hand ring finger was amputed. The amputation of the ring finger and other injuries put the complainant in a condition of permanent disability. As per the terms and conditions of the policy, the complainant’s permanent disability is indemnified by the opposite parties. On the strength of the said policy, the complainant approached the opposite party for getting the policy benefits assured by the opposite party by submitting the required documents for processing the complainant’s claim. But the request made by the complainant was rejected by the opposite party through their letter dated 17.11.2011 saying that any benefit under the policy become payable provided the disability suffered is ‘total and permanent’ as specified in the policy terms and conditions. According to the complainant, the complainant losses his right ring finger and suffered crush injury on the right hand associated with scaphoid and it is a permanent disability as defined in the policy. For the treatment, he had spent ` 1,00,000 in the hospital and also he had suffered total disablement due to the said accident and hence opposite party is liable to pay the policy benefits. The non-payment of the policy benefits ignoring the complainant’s disability is a deficiency in service and the opposite party is liable to the complainant for the same. Hence this complaint for the realization of ` 75,000 with 12% interest per annum as the benefit under the policy along with cost of ` 10,000 and ` 15,000 as compensation for the mental agony.
3. Opposite party filed their version with the following main contentions: According to the opposite party, insurance policy is a contract between the insured and the insurer and the terms and conditions of the contract is binding on the parties. As per the terms and conditions of the policy in question, opposite party is liable to pay any amount under the Accident Death and Disability Rider Scheme only when there is any accident death or in a case of sustaining permanent disability to the insured. As per the terms and conditions of the policy, permanent disability means – permanent loss of limbs or total loss of eye sight or totally disabled to resume his job or to attend any gainful employment. In the case of the complainant, there is no such disablement to the complainant as per the terms and conditions of the policy. The complainant’s disability is only the amputation of his right hand ring finger. Amputation of a finger did not come under the policy condition. In the circumstances, opposite party is not able to allow the complainant’s claim and hence the claim was rejected. Apart from the above contentions, opposite party raised certain other contentions with regard to the maintainability of this complaint, violation of the policy conditions etc. which are not considered by this Forum as that matters are not relevant in the circumstances of this case. With the above contentions, opposite party prays for the dismissal of the complaint as they have not committed any deficiency of service.
4. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
5. The evidence of this complaint consists of the oral deposition of the complainant as PW1 and Exts. A1 to A4. There is no oral or documentary evidence from the side of the opposite party. But they have cross examined the complainant. After closure of evidence, both sides were heard.
6. The Point: The complainant’s allegation is that, due to an accident during the policy period, his right hand ring finger was amputed, thereby he had sustained permanent disability and his claim for the policy benefits assured by the opposite party under the Accident Death and Disability Rider Scheme was rejected by the opposite party which is a clear deficiency in service and the opposite party is liable to the complainant for the said deficiency in service.
7. In order to prove the case of the complainant, the complainant had filed a proof affidavit in lieu of his chief examination along with 4 documents. On the basis of the proof affidavit, complainant was examined as PW1 and the documents produced were marked as Exts. A1 to A4. Ext. A1 is the policy certificate and the terms and conditions of the policy issued by the opposite party in the name of the complainant. Ext. A2 is the repudiation letter datetd 17.11.2011 issued by the opposite party in the name of the complainant. Ext. A3 is the disability certificate dated 02.11.2012 issued by the District Medical Board, Pathanamthitta. Ext. A4 is the copy of the discharge summary datetd 14.05.2011 issued from Pushpagiri Medical College Hospital, Thiruvalla in connection with the treatment of the complainant from 20.04.2011 to 14.05.2011.
8. On the other hand, the contentions of the opposite party is that, as per the terms and conditions of the policy in question, the complainant is not entitled to get any policy benefits as the alleged disability of the complainant will not come under the policy conditions. As per the policy conditions, the benefits are available only to the policy holders who sustains total loss of limbs or eye sight or permanently disabled to resume work or attend any gainful employment. In the case of the complainant, no such casualties were occurred as he had sustained only the amputation of his right hand ring finger. Opposite party further contended that, insurance is a contract between the parties and the terms and conditions in the contract are binding on the parties. Since the complainant’s disabilities are beyond the scope of the said contract, the complainant is not entitled to get any policy benefits for his disability and hence opposite party is not liable to the complainant.
9. In order to prove the contentions of the opposite party, opposite party filed their version and cross examined the complainant on the basis of the contentions raised in the version. No other evidence either oral or documentary is adduced by them.
10. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record and found that there is no dispute between the parties with regard to the policy in question. The only dispute is with regard to the policy benefits offered by the opposite party. According to the complainant, he had sustained a permanent disability due to the accident and the consequent amputation of his ring finger and hence he is entitled to get the policy benefits offered by the opposite party under the disability rider scheme. But according to the opposite party, the complainant has not sustained any permanent disability as defined in the policy conditions and hence he is not entitled to get any policy benefits.
11. In view of the contentions of the parties, we have perused the policy conditions. As per the policy conditions, total disability means – loss of 2 limbs or loss of sight of both eyes or the loss of one limb accompanied by the loss of sight in one eye (and the limb means – the entire hand or foot) or the permanent incapacity to resume work or to attend any gainful employment. But in the present case, the complainant has not sustained any of the aforesaid disabilities or he has not adduced any evidence to show that he had sustained a permanent disability as defined in the policy conditions. The only piece of evidence relying by the complainant for establishing his disability is Ext. A3 disability certificate issued by the District Medical Board, Pathanamthitta. As per Ext. A3, the complainant had 7% of permanent disability due to the loss of his ring finger. 7% disability is a mild disability as per Ext. A3 disability certificate itself. A mild disability cannot be treated as a permanent disability as defined in Ext. A1 policy conditions. So we find that the complainant’s disability is not a permanent disability as defined in the policy conditions and hence the rejection of the claim is legal. Therefore, there is no deficiency of service from the part of the opposite party and this complaint is not allowable.
12. In the result, this complaint is dismissed. No cost.
Pronounced in the Open Forum on this the 20th day of December, 2012.
(Sd/-)
Jacob Stephen,
(President)
Sri. N. Premkumar (Member) : (Sd/-)
Smt. K.P. Padmasree (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : P.D. George.
Exhibits marked on the side of the complainant:
A1 : Policy certificate and the terms and conditions of the
policy issued by the opposite party in the name of the
complainant.
A2 : Repudiation letter datetd 17.11.2011 issued by the
opposite party in the name of the complainant.
A3 : disability certificate dated 02.11.2012 issued by the
District Medical Board, District Hospital, Kozhencherry.
A4 : Copy of the discharge summary dated 14.05.2011 issued
from Pushpagiri Medical College Hospital, Thiruvalla in
connection with the treatment of the complainant from
20.04.2011 to 14.05.2011.
Witness examined on the side of the opposite party: Nil.
Exhibits marked on the side of the opposite party: Nil.
(By Order)
(Sd/-)
Senior Superintendent
Copy to:- (1) George. P.D., Sine Nivas, Parakkara P.O.,
Thattayil, Adoor, Pathanamthitta Dist. (2) The Branch Manager, ICICI Prudential Life Insurance
Company Ltd., Thellirethu Arcade, Chittoor,
Pathanamthitta.
(3) The Stock File.
