IN THE CONSUMER DISPUTES REDRESSAL COMMOSSION, ALAPPUZHA Tuesday the 14th day ofDecember, 2021 Filed on 09.10.2020 Present 1. Sri.S.SanthoshKumar.BSc. LLB(President) 2. Smt. C.K.Lekhamma. BA,LLB(Member) In CC/No.253/2020 Between Complainant:- Opposite party:- Sri.RamaSundharam The Divisional Manager Kanniyakonithara, House United India Insurance Co. Ltd Pulinkunnu, Kainadi.P.O Divisional Office Alappuzha-688538 Sarada Shopping Centre (Adv. Korah Jimmy) Mullackal, Alappuzha (Adv. T.S.Suresh) O R D E R SMT. C.K.LEKHAMMA(MEMBER) The brief facts of the complainant’s case are as follows:- The complainant had taken a Personal Accident Insurance Policy No.009044217P112406 from the opposite party. The sum insured was Rs.5,00,000/-.On 6.11.2018 while the complainant was working on a construction site, he had a fall from the first floor of the building and sustained disability of his right shoulder. He consulted a doctor at General Hospital, Kottayam. As a part of the treatment, he had taken an X-ray and after diagnosis, his arm was placed in an immobilization bag as recommended by the doctor. So he was undergone rest up to 28.12.2018(7.5 weeks). On the above-mentioned period, he was unable to do any work and the opposite party is liable to pay weekly compensation. Thereafter he submitted the claim, after proper endorsement by his doctor, to the opposite party. After a long delay opposite party sent a letter asking for proof of his income certificate and bank account statement. The complainant sent a reply stating that he is not permanently employed and not working under anybody hence he didn’t maintain an account with any bank. So does not file any income tax returns. After which there was no reply from the opposite party. The complainant filed a complaint with the grievance cell of the opposite party and later with the Insurance Ombudsman. But the Ombudsman rejected his complaint on baseless grounds. Hence this complaint was preferred and sought the following reliefs against the opposite party. 1. To direct the opposite party to pay a sum of Rs.16,000/-towards weekly compensation for 7.5 weeks with interest and cost to the complainant. 2. The Version of the opposite party is as follows:- The complainant has approached before this Commission with utmost unclean hands by suppressing the material facts. There is absolutely no bonafides and merit in the above case. More over there is absolutely no deficiency of service as alleged by the complainant. This opposite party admits policy No.100904/4217P112406106 Wef. 29.11.2017 to 28.11.2018 issued to the complainant. When the policy is issued the terms and conditions were explained and served by this opposite party to the complainant. The benefit under the policy is strictly subject to conditions clauses, warranties, exclusions etc. Averments in the complaint to the effect that the disability is due to fall from the first floor of the building is not correct, hence denied. Ombudsman order is correct, the contra allegations are not correct, hence denied. Though the alleged accident happened at Pulinkunnu, but the complaint has treated in hospital at Kottayam ignoring the Taluk hospital Pulinkunnu. This will leads a suspicious circumstance regarding the bonafides of the complainant. This opposite party never done anything to hurt the complaint. the actual facts is that when the opposite party received the claim from the complaint the same was examined by the opposite party and as per the documents submitted by the insured company found the following inconsistency. - Insured has stated that the accident happened at construction site. But till date insured has not provided any statement from the employer to substantiate the accident.
- As per the claim form insured is treated at general hospital Kottayam. Insured has not provided any documents to substantiate his treatment at the above hospital. The accident as per the insured has occurred at kainnady, Alleppey district and the nearest government hospital from the accident site is Taluk head quarters hospital, Pulinkunnu.
- Insured has not provided the discharge summary to substantiate his condition of post accident, the kind of injury sustained by him and also what are the treatment taken by him.
- Insured has provided a medical bill dated 08.11.2018, 2 days after the accident. The medicines are purchased from Nithya Medicals, Manipuzha, Kottayam. The location is neither near the insured residence nor near the hospital where he had undergone treatment. Insured has not provided any other medical bills to substantiate the treatment that he had taken (medical bills enclosed Ext.)
- The medicines which are purchased as part of the claimed treatment are
- Amitryn- Used for prevention of migraine attacks.
- Etornext ER – Used for treatment of osteoarthritis and Rheumatoid arthritis.
- Nucoxia- Used for treatment of gout and arthritis
- OCID- Used to remove the amount of acid produced in the stomach.
These medicines do not indicate the possibility of insured being treated for an accident after a fall at construction site. Based on the documents submitted by the insured, we had requested the insured to submit the salary slip to ascertain his monthly salary. This is as per the clause of policy as stated below. If such injury shall be the sole and direct cause of temporary total disablement, then so long as the insured person shall be totally disabled from engaging in any employment or occupation of any description whatsoever a sum at the rate of 1% of capital sum insured stated in the schedule herein per week, but in any case not exceeding Rs.5,000/- per week in all under all policies per week in any case not exceeding 25% of the monthly salary. There are several inconsistency in the claim made by the insured which are enumerated above. Further insured has failed to submit the proof of income due to which we are unable to ascertain his monthly salary. Insured has made several self declarations which are false and contradictory in nature. Insured claims that he earns Rs.900/- and works on an average 25 days a month as a construction worker. Still he is not permanently employed. Insured states about his co-worker Mr.Siji Chandran and Mr.Das. Both insured and his co-worker Mr.Siji Chandran have raised claim for weekly compensation during the same period. Both their grievance letters and ombudsman letter are drafted similarly. From the points above it can be conclusively proves that the complainant is making a planned attempt to take undue benefit out of the policy in violation of the conditions laid down in the policy and without complying with the terms of the policy. In the above circumstance this opposite party has not processed the claim. Hence there is absolutely no foul play, fraudulent act, misrepresentation and deficiency of service from the part of this opposite party. The complainant approached insurance ombudsman in the above matter. After considering the evidence and hearing both parties the ombudsman dismissed the complaint of the complainant herein. Stating that the case of the complainant is a clear case of fraudulent claim. Hence in the above circumstance the complainant has no locus standi to file the above case. Hence the complaint herein is not entitled for any relief, compensation interest and cost. 3. The points that came up for the determination are as follows:- 1. Whether the complainant is entitled to get the insurance claim from the opposite party? 2. Compensation and cost if any? 4. The complainant was adduced oral evidence and documentary evidence, Exts.A1 to A4 were marked. The opposite party was examined as Rw1 and Ext.B1 to B5 were marked. Both sides appeared through counsel and we have heard the counsel for both sides. 5. Admittedly Ext.B1was issued by the opposite party. The validity of the policy is not disputed. The accident of the complainant is disputed by the opposite party since they have found inconsistency in the claim submitted by the complainant. The opposite party produced Ext. B5, the medical certificate the same was filled up, signed and sealed by the doctor, who was treating him. In which the nature of his disability is mentioned. As per the said records, the nature of the ailment doesn’t require any admission to the hospital. In addition to that, the doctor found the partial dislocation of his right shoulder and which is in consequence of the accident and the disablement will last 10 weeks.It is pertinent to note that is the discretion of the doctor what kind of treatment is to be administered to the patient and also whether the patient is to be admitted or not. So we are only considering what the doctor suggested in Ext. B5 document. Moreover, one of the document in Ext. A1 dt.6.11.2018 is the bill of X-ray revealed that which was taken on the day of the alleged accident and it can be considered said X-ray was taken for the part of treatment. During re-examination of the PW1, the complainant deposed that the reason for choosing G.H. Kottayam is that his wife’s house is near to the said hospital and in the cross-examination, he deposed that the reason for avoiding Taluk Hospital at Kainady,is that there is no facility for taking X-rays. According to us, we do not find any fault in choosing the hospital for the treatment because it depends upon the decision of the patient to select a doctor and the hospital. The contention about the distance and location of the medical store that the complainant purchased the medicine is also not relevant. So considering the above mentioned aspects it can be concluded that the complainant has sustained the injury as stated inExt.B5, medical certificate and was not in a position to do any work due to the impact of the fall. So we are of the opinion that the claim application is to be processed and the amount is to be disbursed to the complainant. At the same timeit is to be noted that one of the inconsistencies found by the opposite party in complainant’s claim is that he did not submit the salary slip to ascertain his monthly salary. The complainant contented that he is a daily wage worker and he is not working under any employer hence he is unable to submit salary slips or vouchers. But in Ext. A1, the copy of the claim form (B3), in which the complainant filled up his occupation is PWD Contractor, so it is unbelievable that he is not submitting ITR and is not depositing any amount in his account or not madeany money transactions through his account. Otherwise, he could have to submit his account details for verification. As per the above-mentioned reasons, we find that the complainant can submit said documents to the opposite party for fixing his monthly salary and calculating the disbursal amount. In the circumstances, we are not ordering any compensation but the complainant is entitled to get cost of the proceedings from the opposite party. 6. Point no.2:- In the result, we allowed the complaint in part and direct as follows:_ 1. The complainant shall submit relevant documents for fixing his monthly salary, within one month after the receipt of a copy of this order, before the opposite party. In that event, the opposite party is directed to process the claim application of the complainant as per norms and disburse the amount with interest @8% per annum from the date of complaint till realization. The opposite party is also liable to pay Rs.2,000/- (Two thousand) towards cost of the proceedings to the complainant within one month from the date of receipt of this order. The order shall be complied within one month from the date of receipt of the copy of this order. Dictated to the Confidential Assistant, transcribed by her corrected by me and pronounced in open Commission on this the 14th day of December, 2021. Sd/-Smt. C.K.Lekhamma (Member) Sd/-Sri.S.Santhosh Kumar (President) Appendix:- Evidence of the complainant:- PW1 - Rama sundharam(complainant) Ext.A1 - copy of claim form Ext.A2 - letter dtd. 23/7/2019 Ext.A3 - Reference Letter 20/5/2020 Ext.A4 - Letter Evidence of the opposite parties:- RW1 - Prathish Thomas (Witness) Ext.B1 - Copy of Policy Ext.B2 - Copy of ombudsman order Ext.B3 - Copy of Claim form Ext.B4 - Bill from Nithya Medicals, Kottayam Ext.B5 - Medical Certificate // True Copy // To Complainant/Oppo.party/S.F. By Order Assistant Registrar Typed by:- Sa/- Compared by:- | 
