BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 30th day of April 2012 Filed on : 07/02/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member
Smt. C.K. Lekhamma, Member
C.C. No.76/2011
Between
Jayachandran R. Vaishnavam, : Complainant
Manickamangalam P.O., (Party in person)
Kaladay, Ernakulam.
And
The Oriental Insurance : Opposite party
Company Ltd. (By Adv. Lakshmanan T.J, )
Divisional Office No. 1,
Jewel Arcade,
Post Box No. 1010,
Layam road, Kochi-682 011.
O R D E R
A Rajesh, President.
The facts of the complainant’s case are the following:
The complainant is an employee of Appolo Tyres, Chalakudy. The employer Appolo Tyres insured their employees with the opposite party. While so on 23-09-2010 the complainant met with a bike accident and sustained injuries. He underwent treatment in L.F Hospital Angamaly. He had to avail leave for 43 days for the rest due to the accident. The opposite party rejected the insurance claim of the complainant stating that at the time of accident he had consumed alcohol and there was smell of alcohol at the time of admission was due to the regular consumption of Homoeo medicines. The complainant is entitled to get insurance claim from the opposite party. This complaint hence
2. The version of the opposite party.
The opposite party issued a group personal accident policy to M/s. Appolo Tyres and being an employee the complainant was covered under the policy subject to the terms and conditions of the same. The opposite party processed the claim application of the complainant and the same was rejected by letter dated 05-01-2011. It is evident from the discharge summary that the complainant was under the influence of alcohol at the time of accident. As per clause 5 of the policy condition the opposite party is not liable to pay insurance amount when the injury was caused under the influence of alcohol. There is no deficiency in service on the part of the opposite party. The complainant incurred only Rs. 17,543/- towords treatment expenses instead he claimed Rs. 60,000/- from the opposite party. The opposite party requests to dismiss the complaint.
3. No oral evidence was adduced by the complainant. Exts. A1 and A2 were marked on his side. The witness for the opposite party was examined as DW1 and Exts. B1 and B2 were marked on their side. Heard the complainant who appeared in person and the counsel for the opposite party.
4. The only point that arises for consideration is whether the complainant is entitled to get insurance claim from the opposite party?
5. Admittedly the opposite party issued an insurance policy in favour of the employer of the complainant in which he is a beneficiary. It is not in dispute that the complainant met with an accident and was taken to L.F. Hospital, Angamaly. The opposite party vehemently relies on Ext. B1 discharge summary issued from the hospital, in which it is stated that “alcoholic breath smell ++”. The doctor also treated the complainant and issued Ext. B1 was examined as DW1, he deposed that the above observation in the record does not mean that the patient was alcoholic and was under the influence of alcohol. According to the Hon’ble National Consumer Disputes Redressal Commission mere presence of alcohol even above usually prescribed limits is not a conclusive proof of intoxication (Life Insurance Corporation of India & Anr. V. Ranjith Kaur 2011 (3) CPR 266). The opposite party herein has failed to substantiate their case to the contra.
6. In the above circumstances the opposite party is liable to pay Insurance claim of the complainant with 12% interest p.a. from the date of receipt till realization. However in this case the complainant has failed to prove any evidence to prove the quantum of expenses incurred by him. Therefore we direct the opposite party to pay the insurance claim of the complainant together with interest @ 12% p.a. from the date of complaint till realization provided the complainant submits necessary documents to prove the claim application. Ordered accordingly.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order
Pronounced in the open Forum on this the 30th day of April 2012.
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits:
Ext. A1 : Copy of letter dt. 05-01-2011
A2 : Copy of certificate dt. 08-07-2011
Opposite party’s exhibits:
Ext. B1 : Case summary and discharge record
Depositions:
PW1 : Dr. Saji P.O. Thomas
Copy of order despatched on :
By Post : By Hand:
