D.O.F:29/08/2018
D.O.O:10/01/2022
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.146/2018
Dated this, the 10th day of January 2022
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
R. Gangadharan aged 59 years
S/o Ramadas,
R/at Adkathbail Beach,
Kasaragod. P.O, Kasaragod Taluk – 671121 : Complainant
Kasaragod – Dist
(Adv: U.S.Balan)
And
1. The Director of Insurance,
Kerala State Insurance Department,
Insurance Directorate, Trans Tower,
Vazhuthakad, Thykkad P.O
Thiruvanathapuram – 695014 : Opposite Parties
(Adv: Addl. Govt. Pleader)
2. The Regional Executive,
Kerala Fisherman Welfare Fund Board,
Mopla Bay, Kannur – 670017
3. Fisheries Officer
Kerala Fisherman Welfare Fund Board,
Kasaragod, Kasaba Beach,
P.O Kasaragod 671121
ORDER
SRI.KRISHNAN.K :PRESIDENT
The Complaint filed under section 12 of Consumer Protection Act.
The case of complainant in short is that on 08/01/2016 while taking bath at about 5.30pm, due to slippery nature of floor, he fell down and sustained injuries. He was removed to Govt General Hospital Ernakulam and treated as outpatient. Later he moved to Hospital Kannur and continued treatment by Dr. Maya up to 13/01/2016. Thereafter he was admitted at specialty hospital on 14/01/2016 and discharged on 21/01/2016, he submitted claim to Opposite Party No:3, forwarded through Opposite Party No:2, recommended Rs. 25,000/- for payment by Opposite Party No:1. Opposite Party No:1 repudiated the claim by letter dated 28/09/2016. Grievances is that repudiation is not justifiable and thus claimed Rs. 50,000/- and Rs. 10,000/- for pain and suffering, , Rs. 20,000/- towards cost of litigation.
2. The Opposite Party No:1 filed written version, Opposite PartyNo:1 admitted having a group personal Accident insurance agreement with Kerala Fisherman Welfare fund board Opposite PartyNo:2 . It covers risk to the registered fisherman who suffers accident, hospitalization for not less than 24 hours, subject to producing discharge certificate with bills. In claim form date of accident shown as 08/01/2018 but documents not support it but shows admission in hospital as 14/01/2016, complainant is not entitled to the claim since injury is not caused by accident as per advice of United India Insurance company
3. The Opposite Party No:2 filed their written version. The Opposite Party No:2 contended that they recommended payment of Rs. 25,000/-, but ultimately repudiated by Opposite Party No:1 and intimated to complainant.
IA 153/2018 to condone the delay in filing the complaint is allowed.
4. Both parties not adduced oral evidence. Complainant produced Ext A1 to A11 documents and marked. Ext X1 medical board report. Opposite Party No: 1 filed argument notes.
5. Considering the averments in the complaint, written version and documents produced following points arise for consideration in the case.
a). Whether the injury suffered by complainant on 08/01/2016 followed by and resultant claim for medical treatment for medical treatment from 14/01/2016 comes within the term accident and whether complainant is entitled to the claim for treatment covered by insurance policy for fisherman?
b) Whether there is any deficincy in service repudiating the claim? And whether complainant is entitled for compensation? If so for what reliefs.
All the issues discussed together and findings is recorded accordingly for convenience.
6. Ext A1 the enquiry report by Opposite Party No:2 clearly shows that complainant is fisherman with ID No: 1346. Report recommended payment for Rs. 26921/- Opposite Party No:2 sent Ext A5 letter dated 18/06/2016 recommending payment of Rs. 26921/- since it is found that claim come within the insurance policy conditions Ext A6 dated 28/09/2016 is repudiation letter by Opposite Party No:1 for the three reasons, accident on 08/01/2016, reported for treatment on 14/01/2016 for back pain thus not due to accident and not eligible for benefits.
7. The reason stated for repudiating the claim is not legally or factually justifiable . Ext A8 is the causality registration card 08/01/2016 shows injury suffered due to fall in bathroom backwards, backache pain. Ext A9 is the medical bills. Ext A10 shows medical report, issued by Radiologist and Ext A11 medical bills. Ext X1 is the certificate issued by medical board. So from the documents it is very clear that complainant suffered injury due to fall inside the bathroom reported treatment in Eranakulam Hospital. Treatment continued at Kannur admitted in the hospital on 14/01/2016 and discharged on 21/01/2016.
8. Document revels that complainant suffered injury on 18/01/2016 followed by resultant claim for medical treatment from 14/01/2016 comes within the term accident and admission treatment on 14/01/2016 is a continuation of treatment for resultant injury caused on 08/01/2016 and hence complainant entitled to the claim for the treatment covered by insurance policy for fisherman. There is no need to produce documentary evidence to prove that he has taken a room in guest house on 08/01/2016.No specified pleadings by way of defence denying the residence and even injury caused on 08/01/ 2016 for reporting for treatment but defense is that treatment by admission from 14/01/2016 is not due to any accident injury cause but only a back pain.
9. Medical records and documents produced by complainant are marked even without any objection from the side of Opposite Party. They were duly proved Opposite Party No:2 recommended payment of Rs.25000/- the said amount is payable by Opposite Party No:1 to the complainant. Repudiation of the claim is not legally justifiable but not in accordance with law and is thus set aside.
Therefore Opposite Party No:1 is directed to pay a sum of Rs.25,000/-being the insurance benefits to the complainant as per coverage of group insurance policy with 8% interest from date of filing the complaint till repayment.
Since repudiation is found to be unjustified there is deficiency in service of Opposite Party No:1 since insurance benefits are rejected not on valid grounds for which Opposite Party No:1 directed to pay Rs. 10,000/- towards compensation for deficiency in service to the complainant. Which amount is fair and reasonable under the circumstances of the case. Complainant is entitled to litigation cost fixed at Rs. 5000/- payable by Opposite PartyNo:1. Claim against this Opposite Parties are rejected.
In the result complaint is allowed in part directing Opposite Party No:1 to pay Rs. 25,000/- (Rupees Twenty five thousand only) as insurance benefits with 8% interest from date of filing complaint till payment and Rs. 10,000/- (Rupees Ten thousand only) for deficiency in service and also Rs. 5000/- (Rupees Five thousand only) as cost of the litigation within in 30 days of the receipt of the order.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
A1- Enquiry report
A2- Passbook
A3- Ration Card
A4- Family data
A5- A letter Dt: 18/06/2016
A6- A letter Dt: 28/09/2016
A7- A letter Dt: 14/10/2016
A8- Causality registration card
A9- Bill
A10- Report, department of medical imaging
A11- Tax invoice
X1- Medical certificate
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
