CONSUMER DISPUTES REDRESSAL COMMISSION-VII
DISTRICT: SOUTH-WEST
GOVERNMENT OF NCT OF DELHI
FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN
SECTOR-20, DWARKA, NEW DELHI-110077
CASE NO.CC/73/22
Date of Institution:- 27.05.2022
Order Reserved on:- 12.02.2024
Date of Decision:- 07.03.2024
IN THE MATTER OF:
Rakesh Kumar
S/o Sh. O.P. Swami,
R/o D-184, Shyam Vihar, Phase-1,
Goyla Road, Road No.6, Najafgarh,
New Delhi - 110043
.….. Complainant
VERSUS
The New India Assurance Co. Ltd.
S-1 to S-6, Manish Link Road,
Plaza I, Plot No. 9, IInd Floor
Sector-5, Dwarka, New Delhi - 110075
.…..Opposite Party
ORDER
Suresh Kumar Gupta, President
- The complainant has filed the complaint under section 35 of Consumer Protection Act, 2019 (hereinafter referred to as Act) with the allegations that he has purchased a personal accident claim policy No.31150342190100000123 valid from 16.07.2019-15.07.2020 from OP by paying a premium of Rs.15576/-. On 01.10.2019, at the intersection of Pune-Mumbai Road, Near Tale Gaon, Dabhade, an accident has taken place when he tried to avoid another motor bike as a result he sustained injuries. His family members reached on the spot and removed him to Pawna Hospital where he was given medical treatment and advised bed rest form 01.10.2019-13.10.2019. The bed rest was further extended by Amar Hospital, Delhi till 19.10.2019. He has on bed rest for 19 days. He was unable to sit on chair to do official work. The company did not grant leave due to exigency of work and allowed him to attend business calls from home at his request. The said permission has caused loss of annual rating points, loss of variable components of 30% in salary in addition to incentive, bonus etc. which amounted to Rs.3 lakhs. The loss of rating points led to cessation of promotion and increment up to next two years whereby he has suffered immediate and long terms losses. The medical prescriptions along with income tax return were submitted to the OP but his claim was rejected as he has not suffered any temporary total disablement. The complaint was sent to grievance officer of the OP but in vain. He has approached Insurance Ombudsman on 18.01.2021. His claim was partly allowed. The OP insisted to produce leave certificate and ignored the medical record. Hence, this complaint.
- The OP has filed the reply with the averments that the claim is payable under clause 1 (F) of the policy in case of total absence of the complainant from the employment. The complainant has admitted that he was working from home. The claim regarding reimbursement of professional charges of the doctor/medical expenses has already been settled as bills were submitted by the complainant. The complainant has failed to show total disablement from engaging any kind of employment/occupation. Mere physical absence of work will not make the claim payable as there has to be absence from the duties and accordingly claim was rejected. The insurance ombudsman has also upheld the rejection of claim under clause 1 (F) of the policy. The parties are bound by the terms and conditions of the polices. There is no deficiency of service on the part of OP.
- The complainant has filed the rejoinder wherein he has denied the averments of the written statement and reiterated the stand taken in the complaint.
- The parties were directed to lead the evidence.
- The complainant has filed his own affidavit in evidence wherein he has corroborated the version of the complaint and relied upon the documents Ex.CW1/A to I though exhibits are not put on the documents.
- The OP has filed affidavit of Sh. Atul Mehrotra in evidence wherein he has corroborated the version of the WS and placed relied upon the documents Ex.OP1/1 to 5 though exhibits are not put on the documents. Ex.OP-1/1 is the policy. Ex.OP-1/2 is the payment vouchers, Ex.OP-1/3 is the emails dated 09.12.2019 and 20.12.2019 from the OP to complainant, Ex.OP-1/4 is the emails dated 20.12.2019 and 03.02.2020 of the complainant to the OP and Ex.1/5 is the emails dated 17.02.2020 of the OP to the complainant whereby complainant was informed where his claim has repudiated.
- We have heard Ld. Counsel for the complainant and the OP and perused the entire material on record.
- It is clear from the pleadings on record that issuance of the personal accident claim policy is not in dispute. The accident of the complainant is nowhere disputed by the OP. The medical rest prescribed by the doctor to the complainant is also not disputed by the OP. The professional charges are paid by the OP to the complainant on the claim lodged by him.
- The question is whether complainant is entitled for the claim on account of loss of income due to an accident as well as due to temporary total disability has both of them are allegedly covered in the personal accident insurance plan.
- The complaint as well as evidence led by the complainant shows that he was allowed to do the work from home by his company by keeping in view the medical rest advised by the doctor. It further shows that leave was not sanctioned by the company.
- It is clear from the pleading as well as evidence led by the complainant that he was on medical rest with pay. He has got the salary for the period during which he has remained on medical rest. He has done the work from home. It all shows that there was no loss of salary due to medical rest.
- The complainant has alleged in the complaint and in the evidence that his medical rest has caused loss of annual rating point, loss in promotion and variable components of 30%of the salary in addition to bonus etc. amounting to Rs.3 lakh and further there was loss of promotion and increments up to next two years.
- It was for the complainant to lead evidence to this effect. The complainant has not led any document to show that there was loss of any rating point or variable component due to the accident which led to the loss of income. It was for the complainant to lead the evidence in any form that work during medical rest has affected his ratings and thereby reduced the benefits of variable components. No previous pay slip regarding the variable components is placed on record. The complainant has not placed on record the last pay slip to show that the income due to variable components stands reduced due to accident which tantamount to loss of income. The evidence to this effect is missing. The alleged future promotional avenues and increments facts cannot be taken into consideration.
- The complainant has failed to lead the evidence in support of the allegations as set out in the complaint. The claim was rightly rejected by the OP under clause 1 (f) of the terms and conditions of the policy. There is no deficiency of service on the part of the OP.
- In view of the above stated discussion, we do not find any merit in the complaint of the complainant and accordingly the complaint of the complainant is dismissed without any order as to the cost.
- A copy of this order is to be sent to all the parties as per rule.
- File be consigned to record room.
- Announced in the open court on 07.03.2024.
