Karnataka

Gadag

CC/29/2014

Mr. Anand L dumvat - Complainant(s)

Versus

The Manager ICICI Lambord Health Care PA Claims, - Opp.Party(s)

S.R.Gorpode

31 Dec 2015

ORDER

JUDGEMENT DELIVERED BY SMT.SAMIUNNISA.C.H., PRESIDENT:

The complainant has filed this Complaint against the Opposite Parties (herein after referred in short as OPs) u/s 12 of Consumer Protection Act, 1986 alleging deficiency in service the Ops be directed to pay a sum of Rs.2,00,000/- towards the payment of Insurance Coverage for owner/driver clause along with interest at the rate of 12% p.a. and pray to pay special and general damages to the Complainant Rs.2,00,000/- along with litigation expenses. 

 

2.    The brief facts of the case are that the Complainant owns a MARUTI RITZ Car for which he had insured from Ops-Insurance Company by paying a premium of Rs.7,330/- on 10.08.2012. The policy was inforce from 10.08.2012 to 09.08.2013, bearing the Policy No.3001/MI-00716977/00/000. The Policy was issued through its representative at RNS Motors Ltd., Vanakal, Hubli. The said policy certificate contains certain Terms and Conditions under which the Complainant/ Consumer is entitled for Insurance Coverage/Claim. The Complainant was on the way to Hubli from Gadag on 14.05.2013 along with his wife in his own vehicle MARUTI RITZ KA-26 M-3652 on the way near Sasvihalli Cross, all of a sudden the front right side tyre of the car got puncture and the vehicle has beyond the control, the Complainant cum driver tumble down on the right side of nalha along with the car. In this mishap the Complainant and the wife got simple and grievous injuries. The wife of the Complainant lodge a Complaint at Annigeri Police station the same was registered by the Policy authorities in Crime No.0053/2013 dated: 16.05.2013. The relatives of the Complainant shifted the Complainant and his wife to SDM Hospital from the spot in the 108-Ambulance. The Complainant got treated at Sri. Balaji Institute of Neuro Science, at Vidyanagar, Hubli as in-patient, 14.05.2013 to 25.05.2013 and got operated for “# D 12 e Commuvicted # Lek lower end of Raows and Uinail Stylous pivousis”. After the discharge of the Complainant he is on regular treatment for severe injuries on his spinal card.

 

3.  After the accident, Complainant got a letter from OP No.2’s Office as M0T03105 682/01, dated: 23.05.2013 in which the OP No.2 informed the Complainant to submit the claim form along with the mention documents. The Complainant’s still under treatment in hospital at Hubli, the OP No.2 wrote a letter similar letter quoting as reminder letter on 09.06.2013. Again on 25.06.2013 the OP No.2 wrote another letter quoting as reminder cum closure letter in which it was asked to submit the documents within a period of 15 days of receipt of the said letter, for which the Complainant had replied through email and also wrote a letter informing the OP that “since the treatment is going on, the doctor treating told that the disability certificate came only be issued after six months on completion of treatment, in this case and inability to get X-ray, scan report from the hospital authority”. Further, the Complainant informed that claim only be submitted after getting disability certificate from the Doctor treating, the OP-Insurance Company not considered the request of the Complainant and sent a closure letter” dated: 29.07.2013 in which the OP had stated that “we regret to inform you that till date we have not received any information/documents from your end, we are constrained close this claim in our records for lack of information and documents related to the claim.” And the said letter also mentioned that kindly get back to us in eight weeks of the time failing which we would considered the same a close/accepted rejection.

 

4.     After the series of correspondence the OP again wrote a letter bearing No. M0T03105 682/01, dated: 16.08.2013 in which the Complainant was directed to submit the claim within 15 days of receipt of above letter with the documents quoted. The reminder letter dated: 03.09.2013 was also followed above letter.

 

5.    Finally, on 15.09.2013 the Complainant submitted the documents, the OP acknowledge the receipt of the documents along with the claim form and wrote a letter No. M0T0 3105 682/01. In which the OP has stated that “we would like to inform you that you had perused information and documents provided to us and regret to inform you that the claim is not payable as temporary disablement is not covered as per Policy Terms and Condition, after receiving such a blunt reply from the OP the Complainant requested the OP through a letter dated: 17.12.2013 to return all the documents forwarded by the Complainant, on the receipt of this letter the OP only return a bunch of summary of medical bills and prescription through a Courier, but P.A. claim form, attested copy of policy, certified copy of FIR and Complaint and hospital admission and discharge summary, R.C., D.L., two passport size photos, photograph of the Complainant reflecting disablement and indemnity cum detoriation bond duly signed by the Complainant/claimant had been not returned to the Complainant”. Hence, the Complainant had approach the Forum to claim the insured amount as per the Clause mentioned in the Certificate of Insurance Bond.

 

6.  The Complainant had sought Rs.2,00,000/- towards the Insurance Coverage along with the 12% interest per annum and the general damages of Rs.2,00,000/- and other reliefs.

 

7.  Case was registered and notice was ordered by the predecessor on the seat. After service of the notice, the OPs appeared through his counsel and filed his version.

8.   Brief facts of chief defence of OP No.1 and 2:

The OP had denied the contents of the Complaint, the OP had alleged that the Complainant had narrated a story to gain the illegal monetary benefits from the Ops. Further, the OP had alleged that the Complainant was on the way to Hubli from the Gadag on 14.05.2013 along with his wife in his own car MARUTI RITZ KA-26 M-3652 all of a sudden the vehicle punctured and tumble down in this mishap the Complainant and his wife got simple and grievous injuries had alleged that the Complainant had been lodged a Complaint after one year which is belated Complaint lodge before the Police and also alleged that the averment of the Complaint shows that on the date of alleged accident the above said car did not met with an accident, hence the Complainant is not liable for any compensation, further OP had alleged that the MVC Petition No.258/2014 of District and Session Judge and MACT Gadag filed by the wife of the Complainant disclosed that the Complainant was not driving the said car on that day the Complainant’s wife in her Complaint lodged before the Police, she has stated that due to rash and negligent driving by the driver after car the alleged accident occurred. Further, the OP had alleged that the Complainant’s wife in her Complaint stated that the Complainant was admitted at SDM Hospital Hubli as per the MVC Petition filed by her discloses that he was shifted to Balaji Hospital, Hubli and thereafter to Mahakoteshwara Hospital, Badami and also OP had denied that the Complainant was an indoor patient as alleged in the Complaint, the OP in his defence submitted that the temporary disablement is not covered under the Policy, moreover owner/driver is not covered but only paid driver is covered, the Complainant is not a paid driver hence, sought for the dismissal of the Complaint, there is no breach of policy conditions from the OP side and hence the Complainant is not entitled for any compensation as sought for in the Complaint. Further, the Ops stated without the prejudice to the above contention even if the Complainant proves that the contention of the Complaint, if the Complainant is entitled for compensation, production of valid insurance policy of alleged vehicle and a valid driving licence of the driver is to be produced.     

9.      In the background of the above sets of pleadings, the Complainant himself examined before this Forum as CW1 and produced 07 documents along with 46 prescription and Medical Bills. On the other hand, the Manager, Legal in the OP No.2’s Company examined as OP No.1 and swear on behalf of Op No.1 also and produced the Booklet of the Terms and Conditions of the Policy. On the basis of the above said pleadings, oral evidence and documentary evidence, Forum has raised following points for adjudication of this case which are hereunder:  

1.     2.	Whether the Ops prove that Complainant had violated the condition of the Policy?   Whether the complainant proves that the deficiency in service on the part of the Ops as alleged in the Memorandum of the Complaint?
3.   4.	Whether the Complainant is entitled for the relief sought for?   What Order?

 

Our Answer to the above Points are:-

Point No.1 – Negative,

Point No.2 – Affirmative,

Point No.3 – Partially Affirmative,

Point No.4 – As per the final Order

                         

R E A S O N S

 10.  POINT NO.1:  It is the case of the Complainant that he is a customer of Ops Insurance Company for his vehicle MARUTI RITZ Car and paid a premium of Rs.7,330/- on 10.08.2012 and he had produced the certificate cum Policy Schedule issued by the Ops Company which was valid from 10.08.2012 to 09.08.2013. The Policy bearing No.3001/MI-007169771001000, Complainant become the Consumer to the OP. Unfortunately on 14.05.2013 Complainant was on way to Hubli from Gadag along with his wife in his above said vehicle, on Gadag Hubli Road near Sasvehalli Cross all of sudden the front right side of the tyre was got puncture and said vehicle tumble down on right side of the nahla, in this mishap the Complainant as well as his wife got simple and grievous injuries and Complaint was lodged by his wife at nearest Police station and same was registered as Crime No.53/2013 dated: 16.05.2014 at Annigeri Police Station Navalgund Taluk. But, Ops had contended that the Complainant had violated the condition of the policy, but policy certificate issued by the Ops which was produced before this Forum itself speaks that Complainant is not at all have violated the conditions of the policy. The Ops contention is that the policy was not covered to the paid driver, this Op had taken a contention that the Complainant wife had filed MVC at MACT before District Court at Gadag. As per the Complaint, the wife of the Complainant is that the vehicle was driven by the driver, but while perusing the Complaint given by the wife of the Complainant which was produced by the Complainant there is no such whispering about the driver, it is clear that the above said vehicle was driven by the Complainant by owner/driver. Moreover, the OP had produced the Xerox copy of the Terms and Conditions of the Booklet, MOTOR INSURANCE PACKAGE PRIVATE CAR (Policy wording) in the 2^nd Para in Page No.6, “PERSONAL ACCIDENT COVER TO PAID DRIVER, CLEANER, CONDUCTOR (Applicable to all classes of vehicle)”.

 

       In consideration of payment of an additional premium, it is hereby agreed that the insurer undertakes to pay compensation on the scale provided below for bodily injury as hereinafter defined sustained by the paid driver/cleaner/conductor in the employ of the insured in direct connection with the vehicle insured whilist mounting into dismounting from or travelling in the insured vehicle and caused by violent, accidental, external and visible means which independently of any other cause shall within six calendar months of the accurence of such injury result in:-

Details of Injury	Scale of Compensation
Death	100%
Loss of two limbs or sight of two eyes or one limb and sight of one eye	100%
Loss of one limb or sight of one eye	50%
Permanent Total Disablement from injuries other than named above	100%

     

     But, the above condition does not apply to this specific Complaint filed by the Complainant. Since Complainant himself was driving the vehicle for that Complainant had produced FIR and Medical Bills. Since he is the owner of the vehicle he does not come under the above said condition as like the Complainant had produced the policy bond in that limits of liability Clause. 

“Limits of Liability Clause Under section II-1 (i) of the Policy-Death of or bodily injury. Such amount as is necessary to meet there requirements of the motor vehicle act 1988. Under Section II-1 (ii) of the Policy-Damage to third party property is Rs.7.5 lakhs P.A. Cover under section III for Owner-Driver is Rs.2.0 Lakhs”

 

          Such being the fact, the above Condition is applied to this Complainant. Hence the violation of condition of Policy is not establish by the OP. Hence, answer to Point No.1 in negative.

 

          11.  POINT NO.2:  The Complainant is the owner of the vehicle MARUTI RITZ bearing Registered No.KA-26 M-3652 and had insured his vehicle in Ops-Company. This was undisputed fact. The Complainant met with an accident on 14.05.2013 the wife of the Complainant registered a Complaint concerned Police Station and the same was registered as Crime No.53/2013 FIR dated: 16.05.2013 and injured Complainant was shifted to Balaji Institute of Nero Science and Traum, Hubli and he was treated as inpatient from 14.05.2013 to 25.05.2013. The discharge summary of the Doctor treated discloses the same, along with which the medical bills and prescription had been produced as the documentary evidence before the Forum. The Complaint of the said accident was registered in the Annigeri Police Station, Navalgund taluk is in time. Hence, the belated Complaint as alleged by the OP does not arise.

          12. After the accident owner cum driver (Complainant)/Insured got a letter dated: 23.05.2013 bearing No.MOTO 03105 682/2001 in which Complainant was informed to submit Claim Form along with a documents mentioned. Again the similar letter was written on 10.06.2013 quoting as reminder letter, again on 25.06.2013 the OP wrote another letter quoting reminder cum closure and ask to submit the documents within a period of 15 days, for the said letter the Complainant replied on 01.07.2013 through an email and the same was posted through RPAD which had been acknowledged by the OP on 10.07.2013 in which the Complainant informed the OP that “since the treatment is going on the doctor treating said that this disability certificate can only be issued after six months on completion of treatment and also the doctor had said that X-Ray and Scan Report only be handed over on demand either to court or the Insurance Company concerned” which had informed to the OP by the Complainant through a letter dated: 01.07.2013 which had been acknowledged by the OP on 10.07.2013 in support of this the Complainant had produced a copy of the letter and acknowledgement which had signed by the OP without considering the above said letter the OP on 29.07.2013 sent a closure letter informing that they had not received any information documents, since this Claim is treated as close in our record by lack of information/ documents. Finally on 13.09.2013 the Complainant submitted the claim form along with the attested insurance copy of the insurance policy, certified copy of the FIR, Complaint, admission and discharge summary certificates, attested copy of RC, driving licence, address proof, two passport size of photographer, colour photo of injured reflecting the disability, original Medical Bills along with prescription, Indemnity cum Declaration Bond along with Rs.100 Stamp Paper which had been acknowledged by the OP, after acknowledgement of the documents, the OP simply replied stating that, “we would like to inform that we have perused the information, documents provided to us and we regret to inform that the claim is not payable as temporary disablement is not covered as per Policy Terms and Conditions”. The Complainant/Insured holds a valid driving licence the copy of which had been produced before the Forum, when the Insured/Complainant met with an accident he was in hope that he may get the insurance claim for his better treatment, but even after the submission of the record as required by the OP except Disability Certificate, the OP had simply rejected the claim by saying that the temporary disablement is not covered under this Policy, the doctor treating the Complainant had not issued any Disability Certificate without the Certificate to prove the disability is the temporary or the permanent, the OP cannot decide it as a temporary disablement. Further, the Policy Certificate issued by the OP in the limits and liability column it speaks that, the driver cum owner have the limit of claiming Rs.2,00,000/- if any bodily injury occurred as is necessary to meet their requirements of the motor vehicle Act, 1988, owner cum driver is Rs.2,00,000/-. Since the above said policy was inforce till 09.08.2014 it means that the insurance was inforce that the time of alleged accident. The record furnished by the Complainant clearly transpires that the Complaint lodge was in time. Further, the OP failed to prove that the Complainant was not driving the vehicle. The policy certificate does not disclosed anywhere that the temporary disablement is not covered in the policy. Under Regulation of Insurance Regulatory Development Authority (IRDA), it is mandatory to the Insurance Company to complete the investigation and release the amount within the 30 days, hence there was delay on the part of the OP to settle the claim for nearly two years such an act amounts to willful negligency and deficiency in service. Hence, the Point No.2 is decided in affirmative.

          13.  POINT NO.3:  As decided in the above point No.2 OP had failed to settle the claim of the Complaint in time. Since there was willful negligency and deficiency in service and the Complainant is entitled for compensation as provided in the C.P. Act, 1986. Hence, the Point No.3 is partially affirmative.

          14.  POINT No.3:  In the result of the above findings, we deliver the following:        

 

//ORDER//

          1.   The complaint is partial allowed.

2.  The Ops are directed to pay the Complainant an amount of Rs.2,00,000/- (Rupees two lakh) along with interest at 09% p.a. from the date of this Complaint till the realization towards the amount insured.

3.   The Ops are directed to pay a compensation of Rs.50,000/- (Rupees fifty thousand) towards special and general damages to the Complainant.

4.    Further, the Ops directed to pay Rs.2,000/- (Rupees two thousand) towards the cost of this litigation

5.   Ops are directed to comply this Order within 30 days from the date of this Order, failing which OP had to pay interest at 12% p.a. for the Insured amount.  

6. Send a copy of this Order to both parties free of cost.   

 (Dictated to the Stenographer, transcribed by him, corrected and then pronounced by me in the Open Court 16^th day of January, 2016)

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