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1. The brief history of the case of the complainant is that he opened an SB A/c bearing No.154510025060026 under AGOGP Scheme with OP.2 under which the life and disability of the complainant is covered by an insurance policy through a tie up with OP.1 for a premium of Rs.45/- per person per annum. It is submitted that the complainant met with a road accident on 18.8.2014 resulting multiple fracture to this left hand and left leg and he was under gone complicated surgery in a private hospital at Visakhapatnam and the fact of accident was reported to Sadar PS, Koraput. It is further submitted that the complainant furnished required document with OP.2 for settlement of claim who forwarded the same to OP.1 on 03.3.2015. The OP.1 insisted disablement certificate issued by District Medical Board and the complainant applied for said certificate with District Medical Board but as the OP.3 did not intimate anything, the OP.3 was reminded but in vain. It is also submitted that the complainant on 17.11.2015 submitted another application before the CDMO and basing on which the OP.3 issued a letter mentioning 25% disability. The complainant submitted the said letter with OP.1 but no action has been taken by it. Thus alleging deficiency in service on the part of the Ops, he filed this case praying the Forum to direct the Ops to settle the claim at Rs.50, 000/- and to pay Rs.4.00 lacs towards compensation besides Rs.50, 000/- towards costs to the complainant.
2. The OP No.1 filed counter denying the allegations and contended that the present case is falling under the jurisdiction of MACT as it is a case of road accident involved with motor vehicle and hence this case is not maintainable under C. P. Act. Denying the allegation of non settlement of claim and non intimation of any information, it is submitted that the OP.1 on 13.01.2016 has repudiated the claim of the complainant specifying reasons and intimated the fact to him by RPAD with copy to OP No.2. Thus denying any deficiency in service on its part, the OP prayed to dismiss the case of the complainant with costs.
3. The OP.2 also filed counter denying the allegations but admitted that the complainant is their customer. It is contended that the duty of OP.2 is to forward insurance claim related documents to OP.1 who after scrutinizing the same is to settle the claim and after forwarding the documents, the role of this OP seizes. Thus denying any fault on its part, the OP also prayed to dismiss the case of the complainant.
4. The OP No.3 filed counter denying all the allegations of the complainant but contended that on 18.8.2014 the complainant was brought to the District Headquarters Hospital (DHH) at Koraput as an outdoor patient and he was admitted in special cabin as an indoor patient. After necessary treatment, the complainant was referred to MKCG Medical College & Hospital, Berhampur for further treatment but it was subsequently learnt that the complainant went to Visakhapatnam for treatment. It is further contended that the complainant registered his name through online vide Registration No.20150500607 and appeared in person before the District Medical Board (DMB), Koraput on 01.06.2015 and the complainant was found disabled to the extent of 25% only. It is also contended that the complainant requested for disability of more than 40% but the Board did not find it suitable to consider the request of the complainant and hence the complainant left the hospital without taking any document with 25% disablement. Considering the RTI application of the complainant dt.27.8.2015, the OP.3 supplied information on 21.9.2015. It is further contended that the complainant again submitted application on 17.11.2015 for issue of disability certificate and on the same day OP.3 issued certificate stating that the complainant has got 25% disability. Thus denying maintainability, the complainant as consumer and also denying any fault on its part, the OP prayed to dismiss the case of the complainant.
5. The parties have filed certain documents along with affidavits in support of their cases. Heard from the complainant and A/R for the Ops and perused the materials available on record.
6. In this case, opening of SB A/c by the complainant with OP.2 under AGOGP Scheme and the life and disability of the complainant covered by the insurance policy through a tie up with OP.1 for a certain amount of premium as well as the accident of the complainant on 18.8.2014 are all admitted facts. From the documents available on record, it is seen that the complainant has undertaken operation to his left hand and left leg fractures and the fact of accident has been intimated to local PS as well as Ops 1 & 2. It is also an admitted fact that the complainant has filed relevant documents with OP.2 bank for settlement of claim and the OP.2 has forwarded the papers to OP.1 for necessary action. Further the OP.1 insisted disability certificate to be issued by DMB, Koraput and the complainant has furnished the said certificate with OP.1 but according to the complainant, the OP.1 has not taken any action.
7. It is seen that the allegation of the complainant is binary in nature. The complainant has alleged about non issuance of disability certificate by OP.3 in time for which he suffered and secondly, the OP.1 has neither settled the claim nor intimated anything to him. For just and proper conclusion of this case, the above two issues inter alia emerge importance for consideration.
8. While deciding the 1st issue, it is seen that the complainant has applied online with OP.3 and appeared on 01.6.2015 before the DMB for issue of certificate. The case of the complainant is that the OP.3 till 27.8.2015 did not issue any certificate. The OP.3 in his counter stated that the Board found 25% disability in case of the complainant but the complainant requested for a certificate of more than 40% of disability. When the Board expressed its inability to issue certificate of more than 40% disability, the complainant left the hospital without taking any document. Baring this issue, the complainant has sought information through his RTI application to which the OP.3 has supplied and on the second application of the complainant, the OP.3 has also immediately issued the certificate. It is seen that the DMB is a body consisting of 5 experts including the CDMO who happens to be the Chairman of the Board and the decision is unanimous. From the rival contentions of the parties regarding issue of certificate and in the availing circumstances, we do not see any malicious abuse of power or deliberate maladministration could be done by the Board.
9. The 2nd issue is whether the OP.1 after receipt of claim document did not settle the claim and also did not supply any information to the complainant. While deciding the issue it is seen that the complainant has submitted documents with OP.2 and it was forwarded to OP.1 on 03.03.2015. The OP.1 insisted disablement certificate on 23.9.2015 and the complainant submitted the said letter with OP.1 on 27.11.2015. The complainant alleges that the OP.1 has neither settled the claim nor passed any information to him but the OP.1 in his counter stated that on 13.1.2016 they have repudiated the claim of the complainant with reasons and has filed the copy of said repudiation letter available on record. In view of the above facts, the allegation of the complainant against the OP.1 regarding such inaction is far from truth.
10. Considering the prayer of the complainant, now it is to be seen whether the repudiation of claim is wrong or right. The OP stated that as per terms and conditions of the policy the claim is entertain able when there is “Total and irrecoverable loss of use 100% of a total hand or total foot without physical separation”. The CDMO, Koraput has issued certificate in favour of the complainant as 25% locomotors disability which is partial, the OP.3 has repudiated the claim. Perused the contents of Insurance Scheme documents and Memorandum of Undertaking signed between the Ops 1 & 2 and found that if total and irrecoverable loss of use 100% of a total hand or total foot without physical separation, 50% of Capital Sum Insured that means, the insured is entitled to get 50% of the sum assured for the above loss.
11. In this case, it was revealed that the complainant has met with road accident and sustained fractures and disability certificate issued by DMB shows that the complainant has got only 25% disability. From the above facts and circumstances, the case of the complainant is not coming under the purview of settlement of claim in his favour by OP.1 and hence they have repudiated the claim. We do not find any irregularity on the part of OP.1 in repudiating the claim corresponding to the terms of the policy. Similarly, the OP.2 bank has committed no deficiency in service in this case.
12. Therefore, we do not find any merit in the case of the complainant which deserves dismissal. In the result, we dismiss the case of the complainant but without costs in the peculiar circumstances of the case.
(to dict.)
