SMT. RAVI SUSHA: PRESIDENT
Complainant filed this complaint U/S 12 of Consumer Protection Act 1986 against Opposite Parties seeking to get an order directing Opposite Parties to pay an amount of Rs.87,000/- to complainant with interest 9% from the date of payment till realization and Rs. 50000 towards compensation for the mental agony and harassment occurred alleging deficiency in service on the part of Opposite Parties.
Briefly stated the facts of the complaint are that the complainant had taken a personal accident policy from OP having policy No.331720178685 5200000 for a sum of Rs.1500000. During the currency of the insurance policy period, complainant met with an accident on 05/03/2018, resulting multiple fractures on his right toe finger. Complainant was admitted in A K G memorial Hospital on 05/03/2018 and discharged on 06/03/2018 and was advised to take rest for 3 weeks. Again on 26/03/2018 the doctor has advised him to take rest for eight weeks more and also for review after one month. On 02/05/2018 also the doctor has advised him to take rest for four weeks and on 30/05/2018 the doctor has advised to take rest for 12 weeks. Again on 29/08/2018 when the complainant consulted the doctor complainant was advised to take rest for three months. After the three months on 03/12/2018 the doctor has given fitness certificate to the complainant. The complainant has informed these facts of accident to the respondents next day itself through claim intimation. As per the conditions of the policy the complainant is entitled to compensation payable in the event of broken bones is Rs.50000 (fifty thousand only) and also Rs. 3750 per week for temporary total disablement. But the OP has credited an amount of Rs. 8000 only. The complainant is entitled to get Rs. 135000 (one lakh thirty five thousand only) for 36 weeks on the ground of temporary disablement but the OP has paid only Rs. 90000(ninety thousand only) to the complainant and the complainant is entitled to get Rs. 87000 (eighty seven thousand only) as balance as per the terms and conditions of the policy. The complainant has sent a registered letters to the OP on 31/08/2018 for which no reply was sent by the OP to the complainant. Hence filed this complaint.
The complaint was resisted by the OP. The contentions raised by OP are that they admitted the personal Accident policy of complainant. According to OP they calculated claim amount to the complainant as per terms and conditions stipulated in the policy. It is submitted that as per medical record the complainant was admitted as impatient for 1day hence Hospital cash was given as Rs. 1000/-. Towards Broken bone, the fractures was for 2,3rd toe right foot, hence as per policy paid towards multiple fracture. As per section 10, table 9 © for multiple fracture, the percentage of sum maximum insured relates to broken bones is 8%. Hence the complainant is entitled for Rs. 4000 ie 50000 x 8% = 4000 towards Temporary total Disability Rs. 3750 for 12 weeks 45000/-. According to OP as per the above said calculation, they arrived total claim amount entitled to complainant comes to Rs. 50000. It is submitted by OPs that there is no deficiency in service on their part and complaint is not entitled to any further amount than Rs. 50000 and prayed for the dismissal of this complaint.
Complainant filed his chief affidavit. He was examined as pw1 and marked Ext A1 to A4 on his side. Ext. A1 is certified copy of policy. Ext. A2 is discharge summary Ext A3 letter sent by complainant to OP and Ext. A4 is letter of Maithra commodities (marked subject to proof). The senior manager Legal of OP filed his chief affidavit and was examined as Dw1. Ext. B1 policy with terms and conditions and Ext B2 claim form submitted by the complainant were marked as documents on the side of OP.
After that the Learned counsels of complainant and OP filed written argument notes. We have perused the records of the case carefully and considered the submissions of both learned counsels.
Admittedly, complainant obtained personal accident policy, which was issued by the OP. The fact of the complainant having met with an accident causing multiple fracture on his right toe finger is not in dispute. The only dispute is whether he would be entitled to claim amount as alleged by the complainant?
Here complainant produced Ext. A1 policy certificate and OP produced Ext B1 policy certificate of complainant with terms and conditions. On thorough perusal of Ext A1 and Ext B1 coverage for broken bones, sum insured is Rs. 50000. Section 10(9©) states as under “If during the Period of Insurance an Insured Person sustains Bodily injury which directly and independently of all other causes results in a broken bone as specified in this Section, then the company agrees to pay to the Insured person the compensation stated in the table of benefits up to the total sum insured in the schedule 9 © multiple fracture, at least one complete 8% of sum insured.
It may be noted that as per this clause the amount arrived by OP as Rs. 4000/- is correct for the payment for broken bones because it is an admitted fact that the complainant sustained multiple fracture on his right toe finger.
With regard to other clause for temporary total disablement sum insured comes Rs.3750/week, no dispute between parties. Here the dispute is about in calculating the number of weeks.
According to OP complainant was under rest for 23 weeks. On the other hand complainant claimed that due to temporary disablement he was under rest for 36 weeks as per the advise of treating doctor. Complainant produced Ext. A2 for substantiating the said averment. On perusal of Ext. A2 discharge summary of complainant, we can reveal that the version of complainant is correct. Then the sum Insured stated in the policy schedule would be Rs. 3750x36 = Rs. 135000. It is further admitted that complainant was admitted as impatient in hospital for one day ie entitled Rs. 1000/- as hospital expense. From the facts of this case we came to know that OP paid Rs. 90000 to the complainant as claim amount. Hence as per the terms and condition of policy Ext. A1 and B1 complainant is entitled to get the remaining amount of Rs. 45000/- from OP.
As per the facts and circumstances we find that there is deficiency in service on the part of OP in calculating the claim amount (Sum insured) of complainant in respect of Temporary disablement coverage.
In the result complaint is allowed in part. OPs are directed to pay Rs. 45000 to the complainant as the remaining amount. OPs are further directed to pay Rs. 10000 as compensation for the mental agony happened to the complainant. OPs shall comply the order within one month from the date of receipt of this order failing which the amount Rs. 45000 carries interest @ 9% per annum from the date of order till realization. Complainant can recover the award amount through execution proceedings as per provisions of consumer Protection Act 2019.
Exts.
A1 - Certificate copy of policy
A2 - Discharge summery
A3 - Letter dated 31/08/2018
A4 - Letter of Maithra Commodities (subject to proof)
B1 - Policy certificate with terms and conditions
B2 - Claim form
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(min)
/Forward by order/
Senior Superintendent
