IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM
Dated this the 29th Day of October 2019
Present: - Sri.E.M.Muhammed Ibrahim, B.A, LL.M. President
Smt.S.Sandhya Rani, BSc,LL.B, Member
Sri.Stanly Harold, B.A,LLB, Member
CC No.193/16
Soman.K.N : Complainant
Kariyattu rahul Nivas,
Perumpuzha P.O
Kundara
Punukkannoor, Kollam.
[By Adv.George Varghese]
V/s
The Divisional Manager : Opposite party
The Oriental Insurance Co.Ltd.
LIC Building, Chinnakkada,
Kollam-1.
[By Adv. S.Dileep Kumar]
FAIR ORDER
Sri.Stanly Harold, B.A,LLB, Member
this is a case based on a consumer complaint filed u/s 12 of the Consumer Protection Act.
The averments in the complaint in short are as follows:-
Complainant is the policy holder of the opposite party and took policy from opposite party from 20.08.2015 for the vehicle bearing Reg.No.KL02 AV 4871 scooter. As the premium with PA coverage for the owner also Policy No.411700/31/2015/52967. On 26.08.2015 at Ananthapally the complainant met with an accident taken to Government Hospital Adoor. The injuries were comminuted fracture of left foot and treated at KIMS hospital Kollam and still continuing the treatment and almost 2 lakh rupees were spend for the treatment.
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Complainant paid consideration as premium including premium for personal coverage. Even then the opposite party had not complied with the contract of service there by the opposite party committed gross deficiency deliberately for flimsy reasons. The complainant is a consumer under the Consumer Protection Act and Rules.
Opposite party entered appearance and filed version denying the averments in the complaint. Opposite parties would content that policy given to the complainant is a personal accident coverage policy, and additional risk of owner /driver is covered to a maximum sum of Rs.1,00,000/- given in the policy subject to the specific terms given under Section 3 of the policy. As per section 3 of the policy condition, accident injuries sustained is classified into 3 different heads, disclosing quantum of percentage for each of the injuries. The opposite parties further contend that complainant had not made any attempt to inform the above accident before their office as stipulated in condition No.1 of the policy. Instead of that the complainant appeared before this Forum directly without giving an opportunity to the opposite parties deciding the admissibility of claim as per the terms and conditions of policy. So the complaint is to be dismissed inlimini.
In the light of the above pleadings the points that arise for consideration are:-
- Whether there is any deficiency in service on the part of the opposite party in respect of disbursing insurance claim for the complainant for the sustained injuries?
- Whether the complainant is entitled to get any amount as per the policy conditions?
- Relief and costs.
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Evidence on the side of the complainant consists of oral evidence of PW1 and Ext.P1 to P9 documents. No oral evidence has been adduced by the opposite party but Ext.D1 policy conditions.
Heard both sides.
The learned counsel for the complainant and opposite parties have filed notes of argument.
Point No. 1&2
For avoiding repetition of discussion of materials these 2 points are considered together. PW1 is the complainant in this case. He filed affidavit in lieu of chief examination by re-iterating the averment in the complaint and got marked Ext.P1 to P9 documents.
The complainant’s case is that he had approached the opposite party for the injuries sustained apart from the damages sustained to the vehicle KL-02 AV 4871 for which the opposite parties had already paid Rs.6589/- and asked the complainant to file an application for disbursing the claim amount after 3 months based on the investigation. But inspite of repeated request the opposite parties have not paid any amount but told the complainant that as per Section 3 of the policy the claim is only applicable for Permanent total disablement and the injury sustained by the complainant would not come within that category. In the circumstance complainant holds the opposite party are acting in a unilateral manner which is opposed to public policy and natural justice.
The opposite parties would admit insurance coverage, ownership and damage of vehicle and the alleged accident. The contention of the opposite parties is that the complainant had failed to inform the accident before the opposite parties as stipulated in condition No.1 of the policy instead of it he directly approached
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the Forum without giving an opportunity to opposite parties for deciding the admissibility of the claim as per the terms and conditions of the policy.
The learned counsel for the opposite parties had canvassed the relevant Section III of Ext.D1 policy that the complainant is entitled to claim 50% of the sum assured if he sustained total and irrecoverable loss at one limb or sight of one eye and 100% of the sum assured, if the complainant suffered permanent total disablement from the injuries suffered to him. However the opposite parties would contend that the complainant is entitled to get the benefit under this policy only if he proves he had sustained permanent total disability as envisaged in Section III of the policy conditions. It is also brought out in evidence that the complainant had not produced any disability certificate to substantiate his claim under the policy conditions.
The second condition which is to discussed is whether the complainant is entitled to make any claim as stipulated u/s Section III Ext.D1 policy? It is crystal clear that the fact regarding the permanent disablement is a matter which requires conclusive medical evidence and not a matter of guess work or inference at all. The complainant failed to establish any evidence to prove that he had suffered permanent total disablement as defined in Section III of policy. The opposite parties would rely on the dictum laid down in the decision of National Commission reported in 2007 CPJ Page 113 in 2006 CPJ Vol 2 page No.137 and in 2003 CPJ Vol 2 page 103. The Hon’ble National Commission had interpreted the policy terms as such it had mentioned in the policy by the National Commission by explaining and interpreting the terms of policy and conditions as such found that the respective complainants are not eligible to get compensation under the policy for the injury sustained to them resulting in partial disability when
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the policy conditions stipulate total and permanent disability. The points answered accordingly.
In the light of the settled position upheld by the Hon’ble National Commission we are of the view that the complainant is not eligible to claim any benefits or compensation under the Personal Accident Coverage given in Ext.D1 policy for the injury sustained to him without resulting any permanent disability as stipulated in the policy.
Therefore the complainant is not entitled to any claim for the injuries sustained to him. We are also found that there is no deficiency in service on the part of opposite parties. The points answered accordingly.
In the result we find no merit in the complaint and the same stands dismissed. Parties are directed to suffer their respective costs.
Dictated to the Confidential Assistant Smt. Deepa.S transcribed and typed by her corrected by me and pronounced in the Open Forum on this the 29th day of October 2019.
E.M.MuhammedIbrahim:Sd/-
S.SandhyaRani:Sd/-
Stanly Harold:Sd/-
Forwarded/by Order
Senior Superintendent
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INDEX
Witnesses Examined for the Complainant:-
PW1 : Soman.K.N
Documents marked for the complainant
Ext.P1 : OP Ticket dated 26.08.15
Ext.P2 : OP Ticket dated 26.08.15
Ext.P3 Series : Service invoice
Ext.P4 : Copy of driving license and RC Book
Ext.P5 : Copy of driving license
Ext.P6 : Copy of Insurance package policy
Ext.P7 : Photograph
Ext.P8 : X-Ray
Ext.P9 : Copy of statement of account
Documents marked for the opposite party
Ext.D1series : True copy of the insurance policy with condition.
E.M.Muhammed Ibrahim:Sd/-
S.Sandhya Rani:Sd/-
Stanly Harold:Sd/-
Forwarded/by Order
Senior Superintendent
