BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
VAZHUTHACAUD : THIRUVANANTHAPURAM
PRESENT:
SHRI. G. SIVAPRASAD : PRESIDENT
SMT. BEENA KUMARI. : MEMBER
SMT. S.K. SREELA : MEMBER
C.C.No. 97/2007 Filed on 04/04/2007
Dated : 31..05..2011
Complainant:
R. Satheesan, Roadarikathu Veedu, Anappara, Vellarada, Kudappanakkunnu – P.O., Thiruvnanthapuram.
(By Adv. Suresh Kumar. S)
Opposite party:
M/s. The New India Assurance Co. Ltd., T.C 42/82, Second Floor, Govt. Press Road, Thiruvananthapuram – 695 001.
(By Adv. P.A. Sadhika)
This O.P having been heard on 27..04..2011, the Forum on 31..05..2011 delivered the following:
ORDER
SMT. S.K.SREELA, MEMBER:
The pleadings in the complaint are as follows: The complainant was a quarry worker getting a salary of Rs.350/- per day and the sole bread winner of his family consisting of his wife, children and age old parents. On 17/01/2006 about 9.15 P.M the complainant was walking along the Kattakkada – Anthiyoorkonam public road from Kattakkada side to Anthiyoorkonam side. When he reached at Kottappuram junction along the above said road he was knocked down by an Auto Rickshaw bearing Reg. No. KL.01/AL.335 and sustained serious injuries. In the above said accident the complainant sustained fracture lower third of radius of left forearm, multiple lacerated wounds and contusion all over the body. Immediately after the accident the injured was taken to Medical College Hospital, Thiruvananthapuram. He was treated in casualty vide O.P.No. 17894/06 and admitted in observation ward. During this time closed manipulative reduction and long arm slab was applied to his left hand. All other wounds were sutured and medicated and send him to Primary Health Centre, Malayinkil. He was admitted and treated there from 18/1/2006 to 12/3/2006 vide IP No.69. During this period the condition of the injured became worsened and on 31/1/2006 he was send back to Medical College Hospital, Thiruvananthapuram and admitted there as an inpatient vide IP No. 413336 from 31/1/2006 to 4/2/2006. On 31/1/2006 he was subjected to a major operation of open reduction and internal fixation and bone grafting under general anaesthesia. On 4/2/2006 he was discharged from Medical College Hospital, Thiruvananthapuram and readmitted in Primary Health Centre, Malayinkil on the same day. He continued his inpatient treatment there and discharged on 12/3/2006 with an advice to take follow up treatment. In this connection it is submitted here that the complainant is a holder of a personal insurance claim including medical expenses as policy No. 760502/42/05/00228 of the opposite party for an amount of Rs.2,00,000/- valid from 28/12/2005 to 27/12/2006. After getting discharge from the hospital complainant preferred a claim to the opposite party for Rs. 1,50,000/- with all supporting documents as prescribed in the claim petition form. The opposite party without considering the complainant's claim in correct perspective and without any basis rejected complainant's claim, and fixed it as Rs.4,000/-. The act of the opposite party amounts to deficiency in service rendered to the complainant. Hence this complaint for claim amount along with compensation and costs.
2.The opposite party, New India Assurance Co. Ltd. has filed their version contending as follows. The complaint is not maintainable. That the complainant be put to strict proof regarding his employment and his present salary status. It is true that the complainant has made a claim before the opposite party, claiming that he has suffered injury to his forearm, namely a fracture in connection with a road accident. The further allegations regarding the depth of the injury, the alleged worsening in his condition etc. are false and hence denied. It can be seen that he was admitted as inpatient in the Medical College for less than 24 hours only. It is only later, as per the complainant himself, due to alleged worsening of the injury that he was admitted to the Medical College again. This itself would reveal that the nature and gravity of the injury has been grossly exaggerated by the complainant himself. The complainant was a policy holder No. 760502/42/05/00228 under Table 'A' with the opposite party during the period from 28/12/2005 to 27/12/2006. It is also true that though a claim for Rs.1,50,000/- was preferred, the opposite party fixed the complainant's claim at Rs.4,000/- as full and final settlement of the claim on standard basis, after assessing and studying in detail the claim. The complainant/insured is also the holder of another policy of the opposite party Assurance Company earlier from Divisional Office-1 at Palayam, Thiruvananthapuram, bearing No. A 760500/42/04/00423 covering almost a common period. During the time of the alleged accident, on 17/1/2006 both policies were in effect. Complainant/insured had preferred a claim form dated 8/8/2006 with copy of two medical certificates with Divisional Office – 1 of the opposite party Assurance Co., for the same accident. That was rejected on reasonable grounds and hence later, the complainant filed the complaint as C.C. No.137/07 before this Forum which is also pending. The claim of the complainant/insured is without any basis whatsoever and is made on an experimental basis for making undeserved benefits and profit from the opposite party. Medical Certificates produced would show that the complainant is suffering from temporary disablement only. That the complainant has also concealed material particulars while submitting the details for the insurance policy for getting coverage. In the proposal form dated 28/12/2005 the insured had claimed his monthly income as Rs.10,000/- whereas in the ration card produced it can be seen that his monthly salary is only Rs. 500/- per month. Thus it can be clearly seen that the complainant had preferred the claim at a belated stage in contravention of the terms and conditions and that there is also discrepancy in the medical certificates. There was no delay in settling the claim and thus no deficiency in service. The claim form itself was received at a belated stage, about 7 months after the alleged accident. None of the reliefs claimed for in the complaint are legally allowable. The claim is only to be dismissed with costs to the opposite party. Hence opposite party prayed for dismissal of the complaint.
3. Both parties have filed affidavits. Complainant has been examined as PW1 and marked Exts. P1 to P7. Exts. D1 to D4 were marked on the part of the opposite party.
4. The points for consideration are:
Whether the act of the opposite party in fixing the amount at Rs.4,000/- is justifiable?
Whether there is any deficiency in service on the part of the opposite party?
Reliefs and costs?
5. Points (i) to (iii): There is no dispute that the complainant holds a policy No. 760502/42/05/00228 of the opposite party valid for a period from 28//12/2005 to 27/12/2006. According to the complainant on 17/1/2006 at about 9.15 P.M he was knocked down by an Auto Rickshaw and sustained serious injuries for which he had claimed Rs.1,50,000/- but the same was not considered and the opposite party fixed the claim at Rs.4,000/- without any basis. The opposite party has contended that the complainant had submitted the claim form after about 7 months after the alleged accident. That this opposite party, taking into consideration of other factors like production of copy of FIR, discharge summary from Medical College Hospital etc..and in good faith accepted the contention of the complainant that he had been involved in an accident on 17/1/2006, though the opposite party was not able to conduct their own investigation at the belated stage. Considering all these aspects, the opposite party had decided to consider eight weeks treatment, as shown in document No. 3 and fixed the amount at Rs. 4,000/-. (Rs. 500 x 8 weeks). This calculation has been arrived at as per document No. 1 (Personal Accident Insurance Policy) under clause (1) sub clause (f). As per the policy schedule attached the policy cover is under Table 'A' (Risk Group III) The benefit under table 'A' are (1) Death (2) Loss of 2 limbs or 2 eyes or limb and 1 eye (3) Loss of 1 limb or 1 eye (4) permanent total disablement (5) permanent partial disablement (6) Temporary total disablement – 1% of C.S.I upto 100 weeks benefit. CSI available under Table A to be limited to 24 times monthly income. That as per the ration card the monthly income as Rs.500/- and so the opposite party has been recommended to revise the income of the complainant / insured as Rs.2,000/- as notional. Thus the C.S.I is calculated as 2000 x 24 = 48,000/- and it is rounded as 50,000/- and thus the maximum entitled CSI is the said amount. As per clause (1) sub clause (f) 1% of the CSI x weeks ie. 500 x 8 weeks. That the sum of Rs. 4,000/- was fixed after taking all these factors and records produced by the complainant into consideration. As per the condition in Ext. D2, it has been stated that 'upon the happening of any event which may give rise to a claim under the policy, written notice with full particular must be given to the company immediately. As per Ext. P1, it could be seen that the complainant has filed the claim form on 22/7/2006. It is very evident from the above that the complainant has not complied with the condition as enumerated in Ext. D2 that the happening of any event must be given to the company immediately. PW1 has deposed to the question put forward by the learned counsel for the opposite party that “Accident നടന്ന് കഴിഞ്ഞ് ഏകദേശം 8 മാസം കഴിഞ്ഞാണ് claim കൊടുത്തതെന്ന് പറഞ്ഞാല് ശരിയല്ലേ (Q) എനിക്ക് ഓര്മ്മയില്ല. (A) Further PW1 has deposed that he had informed the accident to the opposite party but the complainant has not furnished any records to substantiate the same. In the above circumstance, the contention of the opposite party that Insurance Company could not conduct investigation since the accident was not informed immediately stands affirmed. As per Ext. D3 Dr. J.R. Jagajeev has certified that the claimant has been totally prevented from attending to normal duties for 9 months from 17/1/2006. But as per Ext. D1, Column 4 of medical certificate, Dr. Biju. S has certified that the complainant has been totally prevented from attending to normal duties for 8 weeks. These 2 are contradictory statements. As per Ext. D1 dated 8/8/2006 the percentage of disability has been mentioned as below 8% but as per Ext. D3, it has been mentioned as 18% permanent disability. There has been a disparity in the percentage of disability also. Thus it can be clearly seen that the complainant had preferred the claim at a belated stage in contravention of the terms and conditions and that there is also discrepancy in the medical certificates. Clause (1)(f) of Ext.D2 reads as follows: “If such injury shall be sole and direct cause of temporary total disablement, then so long as the insured person shall be totally disabled from engaging in any employment or occupation of any description whatsoever, a sum at the rate of one percent (1%) of the Capital Sum insured stated in the Schedule hereto per week, but in any case not exceeding Rs.3,000/- per week in all, under all policies. The complainant as PW1 has deposed that he earns more than Rs. 500/- per day. But as per Ext. D4, ration card it could be seen that the monthly income of the complainant is Rs. 500/- only.
6. Considering the above facts and evidence, we have no difficulty in concluding that the complainant has miserably failed to establish his claim and the act of the opposite party in offering Rs. 4,000/- is justifiable.
In the result, complaint is dismissed with liberty to the complainant to accept Rs. 4,000/- offered by the opposite party towards full and final settlement of the claim. No order as to costs and compensation.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 31st day of May, 2011.
Sd/- S.K. SREELA, MEMBER.
Sd/- G. SIVAPRASAD,
PRESIDENT.
Sd/- BEENA KUMARI.A, MEMBER.
ad.
C.C.No: 97/2007
APPENDIX
I. Complainant's witness"
PW1 : R. Satheesan
II. Complainant's documents:
P1 : Copy of Personal Accident Insurance Claim Form
P2 : " policy schedule
P3 : " settlement intimation voucher dated 19/7/2006
P4 : " the FIR and FIS in Crime No: 57/06 of Kattakada Police.
P5 : " the OP ticket dated 17/12/06 issued from Medical College Hospital, Thiruvananthapuram.
P6 : " Discharge card dated 4/2/2006 issued from Medical College Hospital, Thiruvananthapuram.
P7 : " discharge card dated 12/3/2006 issued from PHC Malayinkil
III. Opposite party's witness : NIL
IV. Opposite party's documents:
D1 : Copy of the Personal Accident Insurance Claim Form
D2 : " policy schedule
D3 : " Personal Accident Insurance Claim Form
D4 : " Ration Card
Sd/-
PRESIDENT
