By Sri. K. Gheevarghese, President:-

The complaint filed against the Opposite Parties under Section 12 of the Consumer Protection Act 1986.

2. The complaint in brief is as follows:- The complainant is a member in Panavally Ksheerolpadaka Sahakarana Sangham, the Third Opposite Party informed the complaint of a scheme which is promoted by the Fourth Opposite Party. The scheme was solemnly based for the promotion of the members of Ksheera Farmers who included in the concerned society, the complainants name was also included in the Insurance Schemes commencing from 11/08/2006 to 10/08/07. The Insurer covered the risk basing on the terms of the policy to the knowledge of complainant. On 16/03/2007 complainant fell down from a tree while engaged in plucking of pepper from pepper wines. The complainant had undergone continuous treatment from different centers and the shock resulted in the fall made the complainant absolutely bed ridden.

3. On 22/10/2009 the complainant submitted a Personal Accident Insurance Claim Form to the office of the Third Opposite Party. The claim submitted by the complainant was rejected on technical reasons, mainly based on that the complainant had the disability of 60% of permanent partial disability. The request of the complainant to the service providers and insurer found to be no use and all of them repudiated the claim of the complaint for one or other reasons. The denial of the claim of the bedridden complainant is anything short of deficiency in services, there may be an order directing the Opposite Parties to compensate complainant with Rs.2,00.000/- along with the interest of 12% from the date of accident till realization along with cost and compensation.

(Contd...3)

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4. The Opposite Parties Filed Version. The sum up of the version filed by First and Second Opposite Parties are as follows:- The First and Second Opposite Parties are unnecessary parties in this case. The Ksheera Karshaka Suraksha Padhathi is a Insurance Scheme by OP No 4 and the implementing the agency of the scheme is OP No 5. The claim of the complainant was forwarded by the Second Opposite party on request of the Third Opposite Party to the Fifth Opposite Party for the settlement of claim on 05/11/2007. whereas the inability of the OP No 5 to consider the

claim on the reason that the claim is only 60% permanent partial disability, the scheme envisages 100% permanent partial disability for the sanction of the claim amount. This Opposite Parties are not responsible for the repudiation for the claim by the OP No.4 and 5. In the above circumstances the complaint is dismissed with cost.

5. The Third Opposite Party Filed Version:- According to them there is no deficiency in service. The claim of the complainant was repudiated by the insurer. The Insurer is only liable to compensate the complainant for the risk coverable under the scheme.

6. The sum up of the version Filed by Fourth Opposite Party is as follows:- The members of various milk producers of Malabar Regional Co-operative Milk Producers are insured for the period from 11-08-2006 till 10-08-2007. The sum insured as per the Group Janatha Personal Accident Policy is limited to Rs.1,00,000/-, the terms and conditions of the policy is that the case of personal accident Opposite Party is liable to pay compensation to the insured. The policy covers the risk only if the injury belongs to the category as such, irrecoverable loss of sight of both eyes, or actual loss by physical separation of the 2 hands or 2 entire foot of 1 entire hand and 1 entire foot or of such loss of sight of 1 eye and such loss of 1 entire hand or 1 entire foot. The

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capital sum insured as stated in the schedule is applicable to the insured person as per the P.A. Policy table 1 A 100% of the sum assured is given in case of death, loss of 2 limbs, 2 eyes or 1 limb, 1 eye, loss of 1 eye or 1 limb 60% and permanent total disablement from injuries other than named above 100%. In the case of these complainant the disability is only 60% and there is no Permanent Total Disablement. Hence the insurer is not liable to compensate the complainant for this reason the complaint is to be dismissed with cost.

7. The 5^th Opposite Party`s Version in sum up as follows:- The 5^th Opposite Party is a

service provider for the customers in respect of the insurance. The services provided by this Opposite Parties is in too responsible PA and JPA policy, the policy period of said policy 1 year from 11-08-2006 to 10-08-2007. The PA policy covers the death, loss of 2 limbs, 2 eyes or 1 limb or 1 eye(100%), loss of 1 limb or 1 eye 60% and 100% Permanent Total Disablement from other injuries then those stated earlier. The JPA policy covers death due to accident and 100% Permanent Total Disablement due to accident. The 5^th Opposite Party is not aware of any

circular issued by MRCMPU bearing MRU/P&1/310/KKSP/2006 dated 29/08/2006. This Opposite Party is not aware of any circular.

8. The MRCMPU Limited sent a letter on 05/11/2007 NO. MRU/P&1/310/KKSP/2006/986 along with PA claim form of P. Gopi and it was forwarded to Branch Manager, National Insurance Company. The claim form detailed that Sri. Gopi fell down from a tree while plucking pepper and suffered injury to the spinal cord, the 5^th opposite Party did all the efforts to process the claim. However the claim of the injured was not considered by the insurer on the ground that the disability of the insured is only 60% and no Permanent Total disability has been caused to him

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and the claim was not considered. The repudiation of the claim of the complainant is no way connected to this opposite party and there is no deficiency in their service. Hence the complaint is to be dismissed with cost.

9. The points in consideration are:-

1. Is there deficiency in service on the part of the Opposite Parties in repudiation

of the claim?

2. Relief and Cost.

10. Point 1 and 2:- The evidence in this case consist of the testimony of the witness and proof of affidavit of the 4^th opposite party, Exhibits A1 to A9 and X1 are the documents produced. The Orthopedic Surgeon in District Hospital Mananthavady is the expert witness who is examined as PW2.

11. The complainants case is that due to fall from tree the complainant sustained transection of the Spinal Cord and he has sustained Permanent Total Disablement and he is in a position not get up from the bed, the injury sustained by the complainant is permanent total. The insurer is liable to compensate the complainant, the scheme of insurance of Ksheera karshaka Suraksha Padathi during the period 11/08/2006 to 10/08/2007 is admitted by the Opposite Party, the risk that has undergone by the insured is not coverable according to the

Opposite Party. Exhibit X1 is the case record of the complainant`s treatment in Medical College Hospital Calicut, the certificate of Permanent Disablement is issued to the complainant assessing Permanent Disablement of 60%, and this certificate is issued by the Medical Board. The illness of

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the complainant is stated as Traumatic Paraplegia it is admitted by the insurer that as per the Policy Table 1A risk covers only if satisfied the conditions that are death, loss of 2 limbs, 2 eyes or 1 limb or 1 eye(100%), loss of 1 limb or 1 eye(50%) the Permanent Total Disablement from injuries other than named above 100%. The aspect which is to be considered in this case is that whether the injury of the complainant amount to Permanent Total Disablement that is categorized in the policy. The witness expert who is examined as PW2 is the Consultant Orthopedic Surgeon in District Hospital Manathavady. The exhibit X1 details the injuries and treatment of the complainant from Medical College Hospital Calicut. According to the witness expert Paraplegia is the illness of the complainant that means complete loss of power of both lower limbs. The spinal cord of the injured is transected, the consequences of the paraplegia loss control of Bladder and Bowl, both legs would also be lost sensation. The case sheet also shows that since cord is transected there is no possibility for the recovery of the patient, the disability of the injured is non curable and permanent the injury can be considered 100% disability. The repudiation of the claim is on basing upon the percentage of the disability. According to PW2 basing on records the patient is having Total Paraplegia up to 100%. The disability of the injured in this case is to be considered total and permanent.

12. The Circular issued by the Union Limited that is marked as exhibit A1 details the amount of compensation claimable for the injuries sustained in accident. The complainant is in such a condition that he lost the power of his legs and totally bed ridden. The amount claimable by the insured in such condition is Rs.2,00,000/-, it is also admitted by the Opposite Parties that the complainant belonged to the Group Insurance Scheme remitting the premium amount. The Fourth Opposite Party is the insurer of the Janatha Personal Accident Policy. The claim of the

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complaint is to be considered 100% Permanent and Total Disability and the amount considerable in this case is to be given to the complainant by the Fourth Opposite Party the Insurer.

In the light of above inferences the Fourth Opposite Party is directed to give Rs.2,00,000/- to the insured along with interest at the rate of 12% from the date of filing this complaint till realization of the amount. The complainant is also entitled for the cost of Rs.500/- from the Fourth Opposite Party this to be complied by the Fourth Opposite Party within 1 month from the date of the receipt of this order.

Pronounced in Open Forum on this the day of 21^st July 2011.

Date of filing:02.11.2009.