SMT. RAVI SUSHA : PRESIDENT
Complainant filed this complaint under sec.35 of the Consumer Protection Act 2019 seeking to get an order directing opposite party to pay sum of Rs.5,50,000/- to the complainant with interest @12% per annum from 4/1/2020 till realization and also to cost of the proceedings of this case.
The case of the complainant in brief is that the complainant has taken personal accident cover in the motor insurance policy of the motor cycle KL59/U7839. On 4/1/2020 the complainant was riding the vehicle, suddenly the vehicle capsized and complainant fell down from the vehicle and thereby he was grievously injured. He had sustained fracture of right distal tibia and fracture shaft of fibula. At the time of accident the complainant is having valid driving license. As the vehicle was validly insured with the OP vide policy No.98000031190950013733, they are bound to pay compensation under the head of personal accident coverage to the complainant in proportion to the percentage of permanent disability he had. The OP failed to disburse the amount entitled to the complainant for the expenses incurred for his future treatment , incidental and transportation expenses. As per the norms of the policy issued by the OP, they are liable to pay proportionate amount of the sum of Rs.15,00,000/- to the complainant 15% of the above sum will come to Rs.2,25,000/-. In addition the complainant spent more than Rs.1,00,000/- towards medical expenses and treatment expenses at present. The complainant issued a registered lawyer notice to the OP for claiming Rs.5,50,000/- , but the OP belated the claim. Hence the complaint.
Notice of this complaint was sent to the OP, and after receiving the notice OP entered appearance and filed version stating that the OP is not liable to pay the insurance amount to the complainant since the complainant committed fundamental breach of the insurance policy and he failed to intimate regarding the accident along with the FIR from the police station immediately after the accident and failed to furnish the vehicular documents and his driving license before this OP, which he is specifically bound to do as per the insurance policy and its condition. The OP is not liable to pay the insurance amount to the complainant, since he was knowingly driving the vehicle at the time of the accident without a driving license, which amounts to the fundamental breach of the insurance policy and its conditions. As per Sec.III of the policy condition the company undertakes to pay 100% of the sum insured as compensation to the insured only if the insured owner-driver , dies due to the injury, loss of two limbs or sight of two eyes or loss of one limb and sight of one eye, or for permanent total disablement from injuries sustained in the accident. The insured is entitled for 50% of the sum insured only if he sustains loss of one limb or sight of one eye. In fact the complainant is entitled for compensation under the policy, only if he sustain 100% disability or other injuries mentioned in the schedule and scale shown in the section III of the insurance policy. There is no deficiency of service or unfair trade practice on the part of OP. Hence prayed for the dismissal of the complaint.
At the evidence stage, complainant has filed his chief affidavit and documents. Examined as PW1 and marked Exts.A1 to A12. On the side of OP, the Manager of OP insurance company filed chief affidavit and was examined as DW1. Insurance policy with conditions is marked as Ext.B1. After that the learned counsel of complainant filed argument notes.
The undisputed facts in this case are that the complainant has taken personal accident cover in the motor insurance policy of the motor cycle KL59/U7839. It is also a fact that the complainant was driving the vehicle at the time of accident and he is having valid driving license.
Complainant’s case is that on 4/1/2020, due to accident to the insured motor cycle while he was riding, he had sustained fracture of right distal tibia and fracture shaft of fibula. It is submitted that due to the fracture, he became permanently disabled and now he is having more than 15% permanent disability considering the body as a whole.
As per Ext.B1 policy sum insured is Rs.15,00,000/-. Period of policy is from 31/8/2019 to 30/8/2020. Further section III-personal accident cover for owner-Driver (i) death scale of compensation -100%, (ii) loss of two limbs or sight of two eyes or one limb and sight of one eye-100% (iii) loss of one limb or sight of one eye-50%, permanent total disablement from injuries other than named above -100%.
OP contended that as per the above said scale of the policy, the complainant(insured) is not having any of the injuries or disability, is not entitled to claim for the compensation under the personal accident insurance policy.
According to complainant, the percentage of total disability assessed by the doctors is 22%, so he is entitled to the proportional amount of sum assured.
A bare perusal of the policy shows that the scale of compensation specifically stated that permanent, total disablement from injuries other than , death, loss of both limb or one limb, loss of eye sight.
Here the complainant has not sustained permanent total disablement from injuries. Hence complainant is not entitled to get policy benefit.
In the result, complaint is dismissed.
Exts:
A1- Copy of RC
A2- Copy of insurance policy
A3- Driving license
A4-copy of lawyer notice
A5-postel receipt
A6-acknowledgment card
A7- Reply notice
A8-Discharge summary issued by Tejaswini Hospital
A9-Prescription( 2 in Nos)
A10(series) –Medical Bills
A11(series)-Ambulance bills( 4 in Nos)
A12- Disability certificate
B1- policy with conditions
PW1- Ayyoob- complainant
DW1- Haridasan.K- OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew. Sajeesh K.P
eva
/Forwarded by Order/
ASSISTANT REGISTRAR
