The ICICI Lombard General Insurance Company Limited V/S Sri.Govindappa - Consumer Court Case

Karnataka

Kolar

CC/13/2016

Sri.Govindappa - Complainant(s)

Versus

The ICICI Lombard General Insurance Company Limited - Opp.Party(s)

Sri.N.Manjunath

03 Jan 2017

ORDER

Date of Filing: 30/03/2016

Date of Order: 03/01/2017

BEFORE THE KOLAR DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, D.C. OFFICE PREMISES, KOLAR.

Dated: 03^RD DAY OF JANUARY 2017

PRESENT

SMT. PRATHIBHA.R.K., BAL LLM, PRESIDENT

SRI. R. CHOWDAPPA, B.A., LLB….. MEMBER

SMT. A.C. LALITHA, BAL., LLB …… LADY MEMBER

CONSUMER COMPLAINT NO :: 13 OF 2016

Sri. Govindappa,

S/o. Seethappa,

Aged About 37 Years,

R/at: Doddrahalli Village,

Hunakunda Post, Bangarpet Taluk,

Kolar District.

(Rep. by Sriyuth. N.Manjunath, Advocate) …. Complainant.

- V/s -

The ICICI Lombard General Insurance

Company Limited, No.89, 2^nd Floor,

S.V.R. Complex, Hosur Main Road,

Madivala, Koramangala,

Bangalore-68.

(Rep. by Sriyuth. B.Kumar, Advocate) …. Opposite Party.

-: ORDER:-

BY SMT. PRATHIBHA.R.K, PRESIDENT

01. The complainant has filed this complaint Under Section 12 of the Consumer Protection Act, 1986 seeking directions against the OP to pay Rs.6,00,000/- towards sum assured amount and Rs.50,000/- towards damages along with interest at the rate of 18% per annum from the date of repudiation of the claim till realization with costs of the proceedings.

02. The facts in brief:-

(a) It is the contention of the complainant that, the complainant is an insurance policy holder of OP - Insurance Company by making payment of monthly premium of Rs.2,340/- vide policy bearing No.4111/MPM/99778357/00/000 covering from 20.02.2015 to 19.02.2018 for an assured sum of Rs.6,00,000/-. The said policy covers the risk of (i) Death resulting from accident, (ii) Permanent total disablement resulting from accident, (iii) Temporary total disablement resulting from accident.

(b) On 09.06.2015 at about 6.15 am, the complainant while walking on the outskirts of his village Doddarahalli, Bangarpet Taluk, Kolar District, he came in contact with a live electric wire, that were hanging from the electricity transformer, due to negligence of concerned electricity authorities. As a result of which, he sustained severe burn injuries to his left hand and left leg. Immediately complainant was shifted to M.S. Ramaiah Hospital, Bangalore, for treatment. But the efforts made by the doctors went in futile and complainant’s left upper limb was amputated above the elbow level. Hence complainant lost his left hand totally and permanently.

(c) On 16.09.2015 complainant claimed assured sum from OP for sustaining permanent total disablement due to accident. But OP repudiated the claim vide letter dated: 03.11.2015 stating that, the injury sustained by him was inadmissible as the loss suffered by the complainant falls outside the purview of the policy coverage. Further OP in the said letter makes reference to Section 2.2, part-II of policy wordings and states that, to claim compensation under the policy for permanent total disability, the insured should have lost one entire hand.

(d) The complainant further contends that, since he lost his left hand above elbow level, he is permanently and totally disabled and he cannot perform any kind of work with the help of remaining amputated stump present at left shoulder joint and hence he is entitled for the sum assured by the OP. By making repudiation the OP has done great injustice to the complainant. The OP has treated complainant’s claim as “temporary total disablement claim” as per the letter dated: 03.11.2015 issued to the complainant. So contending, the complainant has filed this complaint seeking above set-out reliefs.

(e) Along with the complaint the complainant has submitted following documents:-

(i) Copy of the FIR along with complaint

(ii) Copy of ICICI Lombard General Insurance Company Policy

(iii) Copy of Temporary total disability claim

(iv) Copy of Letter

(v) Copy of claim form for personal Accident Insurance

(vi) Copy of Discharge Summary issued by M.S. Ramaiah Memorial Hospital, Bangalore.

(vii) Copy of Medical Certificate/Fitness Certificate

(viii) Copy of disability certificate

(ix) Copy of Election Card

(x) Copy Aadhar Card

(xi) Copy of Ration Card

(xii) Copy of policy wording personal protect

03. In response to the notice issued, counsel for OP appeared and filed its version by resisting the claim of the complainant in toto.

(a) In the version the OP contended that, the complainant took “Family Health Protector Insurance Policy” bearing No.4111/MPM/99778357/00/000 from the OP for himself which is valid from 20.02.2015 to 19.02.2018 subject to the terms and conditions of the said policy. The complainant submitted a claim to the OP on 16.09.2015 in respect of hospitalization as a result of burn injuries sustained to his left hand while he came into contact with a live electrical wire which was hanging from an electricity transformer. Due to the said incident the complainant has taken treatment in M.S. Ramaiah Hospital, Bangalore, and in spite of best efforts of doctors therein, his left upper limb was amputated to above elbow level.

(b) The OP in its version further submitted that, as per the terms and conditions of policy certificate Part 1 the coverage is for death and permanent total disablement and for Temporary Total disablement due to accident as per Part-II of the policy wordings section 2.2. is as under:-

(a) I Loss of sight of both eyes

(b) II Actual loss by physical separation of both hands/both feet or “one entire hand” and one entire foot or,

(c) III Loss of use of both hands feet or “of one hand” and one foot without physical separation.

Accordingly the OP has repudiated the claim vide letter dated: 03.11.2015. The insurance being a contract of utmost good faith, the applicant has suppressed the pre-existing condition in the proposal form and hence OP has not committed any deficiency of service or illegality in repudiating the claim. The complaint is not maintainable as the electricity board is a necessary part to the proceedings. As such, the claim is bad for non-joinder of necessary party to the proceedings. So contending OP prayed for dismissal of the complaint.

04. On 06.08.2016 complainant has filed his affidavit evidence along with list of document:-

(i) True copy of FIR along with complaint

(ii) True copy of spot mahazar

(iii) True copy of wound certificate

(iv) Notarized copies of Discharge summaries 02 in nos.,

(v) Notarized copy of Disability Certificate,

(vi) Photos 02 in number along with C.D.

05. On 22.08.2016 Sri.K.L.Venu, Legal Manager of OP has filed his affidavit evidence by way of examination-in-chief on behalf of the OP.

06. On 27.10.2016 counsel for complainant filed written arguments. On 15.11.2016 counsel for OP filed Memo with following citation:-

(i) Revision Petition No.3805/2012 SBI Life Insurance Company Limited –V/s- Sri Kiritchandra B Modi, dated: 07.10.2014 by Hon’ble NCDRC, New Delhi.

07. Heard arguments.

08. Therefore the points that do arise for our consideration in this case are:-

(A) Whether the repudiation of the claim made by the OP is justified?

(B) Whether the complainant is entitled to the reliefs prayed for in the complaint?

09. Findings of this District Forum on the above stated points are:-

POINT (A) & (B):- In the Affirmative.

POINT (C):- As per the final order

for the following:-

REASONS

POINT (A):-

10. On perusing the pleadings along with documents and affidavit evidence produced by both parties, it is an admitted fact that, complainant had obtained Insurance Policy bearing No.4111/MPM/99778357/00/000 from the OP - Insurance Company by making payment Rs.2,340/- towards premium which is valid from 20.02.2015 to 19.02.2018 for an assured sum of Rs.6,00,000/-. It is also an admitted fact that, on 09.06.2015 at about 6.15 am, while he walking on the outskirts of his village Doddarahalli, Bangarpet Taluk, Kolar District, complainant came in contact with live electric wires, that were hanging from the electricity transformer, as a result of which, complainant sustained severe burn injuries to his left hand as well as to his left leg. It is further an admitted fact that, immediately he was shifted to M.S. Ramaiah Hospital, Bangalore, for treatment, but all efforts made by the doctors therein went in futile and complainant’s left upper limb was amputated above the elbow level. The contention of the complainant is that, complainant sustained permanent total disablement due to the said incident. Per contra, OP submitted that, the complainant was suffering from the disability which is partial in nature. Further OP repudiated the claim vide letter dated: 03.11.2015 stating that, the injury sustained by the complainant was inadmissible as the loss suffered by the complainant falls outside the purview of the policy coverage and as per Clause 2.2 Part.11 of the above said policy.

11. On perusal of the policy at Clause 2.2(i) which reads as under:-

(i) Loss of Use of both eyes, or Physical Separation/Loss of Use of two entire hands or two entire feet, or one entire hand and one entire foot, or of such Loss of Use of one eye and such Physical Separation/”Loss of Use of one entire hand or one entire foot”, then the Sum Insured as stated under Benefit 2, Section A in the Part 1 of the Schedule to this Policy hereto as applicable to such Insured Person.

As could be seen from Clause (i) of 2.2 in case any person loses one entire hand or one entire foot, then the sum insured as stated under the benefit 2, Section A in Part-1 of the schedule shall be applicable to the insured person. In the instant case the complainant had lost his hand above the elbow. On perusal of the disability certificate and identity card issued by the Government Of Karnataka it is mentioned that, the complainant Sri.Govindappa had lost his left hand up to the above elbow upper limb i.e., amputation of left hand up to the left upper limb. The percentage of disability is mentioned as 80%.

12. Further on perusal of the doctors discharge summary issued by the M.S. Ramaiah Hospital, Bangalore, dated: 12.09.2015 it is mentioned as “Left upper limb – Entry would, Left hand – In flexion contracture including fingers and thumb. No active movement, Left elbow – Elbow contracture (+), Blackish discoloration of skin around elbow, Left forearm – Black discoloration up to upper 1/3^rd, No sensation, Left arm-Multiple black patches up to shoulder, No bleeding. Hence it is clear that, the complainant has lost his upper limb and the upper limb would not be used anymore though the complainant has not lost his entire hand as claimed by the OP the said loss can be construed as the total loss of the hand. Therefore we came to the conclusion that the repudiation made by the OP is unsustainable. Accordingly, we answered Point (A) in the affirmative.

POINT (B):

13. We proceed to pass the following:-

ORDER

01. The present complaint stands Allowed with costs of Rs.5,000/-.

02. The OP is directed to pay a sum of Rs.6,00,000/- towards insured amount to the complainant along with interest at the rate of 9% per annum from the date of repudiation of the claim i.e., 03.11.2015 till realization.

03. The OP is further directed to pay a sum of Rs.10,000/- as compensation to the complainant.

04. The OP is also directed to submit the compliance report to this forum within 30 days from the date of receipt of this order.

05. Send a copy of this order to both parties free of cost

(Dictated to the Stenographer in the Open Forum, transcribed by him, corrected and then pronounced by us on this 03^rd DAY OF JANUARY 2017)

LADY MEMBER MEMBER PRESIDENT