SMT. RAVI SUSHA : PRESIDENT
Complainant has filed this complaint U/S 12 of the Consumer Protection Act 1986, for getting an order directing the Ops to pay an amount of Rs.23,000/- to the complainant with an interest of 9% from the date of payment till realization with Rs.50,000/- towards compensation for the mental agony and harassment suffered by the complainant due to the deficiency in service on the part of OPs.
The facts according to the complainant are that he was a beneficiary of personal accident individual policy scheme for an amount of Rs.15,00,000/- which providing monetary security in case of accident. On 5/3/2018 the complainant met with an accident and suffered multiple fractures on his right toe finger and after he was taken to AKG Hospital Kannur and discharged on 6/3/2018. The complainant was advised to take rest for 3 weeks. Again on 26/3/2018 advised rest for eight weeks, on 2/5/2018 for four weeks , on 30/5/2018 for 12 weeks and on 29/8/2018 the doctor has advised him to take rest continued for 3 months. On 3/12/2018 the doctor has given fitness certificate to the complainant . The complainant has informed the accident to the Ops on next day itself through claim intimation. As per the conditions of the policy the complainant is entitled to compensation payable in the event of loss of employment due to total disablement will be at 1% of the sum insured under table three of the policy or 15,000/- whichever is less. Even though the complainant is entitled to get an amount of Rs.36,000/-, the OP has credited an amount of Rs.13,000/- to the complainant and he has to get balance amount of Rs.23,000/- from the Ops. The complainant has sent a registered letters to OPs for which no reply was sent. There is deficiency on the part of OP and they have rejected the claim of the complainant illegally and against the terms of the policy. Hence filed this complaint.
Opposite parties challenged the above contentions of the complainant. According to the Ops the complainant had taken a personal accident policy for a sum of Rs.15,00,000/- with table III benefit for Rs.1,00,000/- with policy NO.441600/48/2018/327 covering the period from 13/8/2017 to 12/8/2018. But this OP honored the policy as per Sec.1(f) of the policy condition. The complainant is entitled to get only table III benefit as stipulated in the policy, it is calculated and disbursed a sum of Rs.13,000/- to the complainant . There is no bases to get 23,000/- more than what is paid to him and Rs.50,000/- as compensation with cost. There is no deficiency in service on their part and no scope for compensation and cost of litigation to the complainant . Hence prayed for the dismissal of complaint.
Complainant filed affidavit for evidence and documents. He was examined as PW1 and the documents were marked as Exts.A1 to A7. The Deputy Manager of 1st OP Mr.Anoop .B Tilak filed his chief affidavit and documents. He was examined as DW1 and Exts.B1 to B10 were marked as documents on the side of OPs. Both witness were cross-examined for the rival parties. After that both learned counsels for the complainant and OPs made oral argument.
The learned counsel for the OPs argued that the claim amount of complainant is calculated as per the policy condition and disbursed the eligible amount of Rs.13,000/- to the complainant. According to OP complainant is not entitled to get any more amount than Rs.13,000/- as claimed by him. The learned counsel of OPs further submitted that as per policy condition section No.1(f) complainant is entitled to get benefit of 1% for total disablement period. According to Ops complainant has lost the salary for 13 weeks due to total disablement so Rs.13000/- has been given . For substantiating OPs’ contention, they produced and relied Exts.B4 to B7. Ext.B4 is letter issued by the complainant on 12/3/2018. Ext.B5 is the claim intimation of complainant dtd.5/3/2018, Ext.B6 is the claim form of complainant dtd.11/4/2018 and Ext.B7 is the letter issued by the complainant to OP dtd.4/6/2018. OP contended that as per Exts.B4 to B7 the complainant’s intimation and claimed benefit from 7/3/2018 to 4/6/2018. As per Ext.B6 OP has disbursed claim benefit for 13 weeks ie Rs.13,000/-.
On the other hand complainant contended that due to the accident he suffered multiple fracture on his right toe finger which was proved through Ext.A6 discharge summary from AKG Hospital ,Kannur and the doctor who treated him advised to take rest for total 36 weeks . Further contended 36 weeks doctor has given fitness certificate to rejoin his duty. So as per policy condition 1(f) he is entitled to get Rs.36000/- as benefit. For proving 36 weeks rest advised by the treating doctor complainant has produced the discharge summary form AKG Hospital. On perusal of Ext.A6 it is seen that the treating doctor Dr.Vinod Kumar advised to take rest for 36 weeks and after 36 weeks on 26/10/2018 suggested united and issued fitness certificate for rejoining duty.
Here OP’s contention is that the insured will get benefit only to total disablement. Both parties relied the same policy condition ie, condition (f) of Ext.A1and condition No.1(f) of Ext.B2. The said condition states that ‘ If at any time during the currency of this policy, the insured shall sustain any bodily injury resulting solely and directly from accident then the company shall pay to the insured, the sum or sums herein after set forth, that is to say(f)” If such injury shall be the sole and direct cause of temporary total disablement , then so long as the insured shall be totally disabled from engaging in any employment , a sum at the rate of one percentage(1%) of the capital sum insured stated in the schedule here to per week but in any case not exceeding Rs.3,000/- per week in all, under all policies.’
On a thorough analysis of this condition it is stated that the insured gets benefit ‘ if the injury shall be the sole and direct cause of temporary total disablement , then so long as the insured shall be totally disabled from engaging in any employment ‘. Here during the period on which the treating doctor advised the complainant to take rest ie, 36 weeks, he was totally disabled from engaging in employment. So the complainant has occurred total disablement due to injury for temporary period of 36 weeks. Hence the complainant is entitled to get the benefit as per condition No.1(f). Here there is no dispute that complainant is entitled to get Rs.1000/- per week as claim benefit.
The learned counsel of Ops further raised a contention that the complainant obtained certificate from treating doctor illegally. We cannot taken into consideration of that contention . Here the original discharge summary from the treating hospital is produced and it is evident that the doctor who treated the complainant had given advise to take rest till 3/12/2018 ie 36 weeks and instructed to rejoined the duty after 3/12/2018 since the bones united. In addition to that the witness of OP(the Deputy Manager) admitted that as per medical records complainant has taken best rest for 36 weeks and also admitted the fact that treating doctor issued fitness report to rejoin duty from 3/12/2018.
It is to be noted that in Ext.B6 the personal accident claim form submitted by complainant before OP was on 11/4/2018 in which he reported that as a result of injury he confined to bed from 7/3/2018 to 4/6/2018. The treating doctor also reported like that. But in column No.8: the doctor answered to the question(a) Has he been able to attend to any portion of his business or occupation? Answer No.(b) If so from what date? Shall (c) If so please state probable date(i) of his being able? (ans) Assess later on (ii) of his complete recovery? (A) assess later. Further column No.9- Is there now any disability ? If not please give date of recovery? (Ans) can be assessed later. It is seen that from the above said report of treating doctor connected with the entries regarding advise given by doctor in Ext.A6 discharge summary, we can come to a conclusion that the complainant has been as the direct and sole consequence of the injuries sustained confined to his house for 36 weeks. There is no dispute regarding per week is Rs.1000/-,so complainant is entitled to get total benefit as Rs.36,000/-. Further OP does not have a case that complainant is a defaulter in paying the premium amount and is a habitual litigant. Hence though the complainant submitted letter on 30/8/2018 with final report of doctor, the rejection of payment of actual monetary benefit to the complainant as per section 1(f) of policy condition amounts to deficiency in service on the part of Ops Insurance company. So complainant is entitled to get relief.
In the result complaint is allowed in part. Opposite parties are directed to pay an amount of Rs.23,000/- to the complainant with an interest of 4% from the date of complaint till realization. Opposite parties are further directed to pay Rs.10000/- as compensation and cost of the proceedings. The opposite parties shall comply the order within one month from the date of receipt of this order otherwise complainant is entitled to get Rs.23,000/- with an interest @9% from the date of complaint till realization. Complainant is at liberty to file execution application against opposite parties for realization of the awarded amount as per provisions envisaged in Consumer Protection Act 2019.
Exts:
A1to A3 -Policy dtd.13/8/2004, 10/8/2017,8/8/2018
A4- letter dtd.4/6/2018
A5-letter issued by complainant
A6-Dischgarge summary
A7- Certificate issued by Maitra commodities(Subject to proof)
B1& B2-Policy
B3-Accident claim security form
B4-letter issued by the complainant dtd.12/3/2018
B5-claim intimation dtd5/3/18
B6-Personal Accident claim form dtd.11/4/18
B7&B8-letter dtd.4/6/18,30/8/18
B9-Copy of PLC No.3405/2019
B10- letter issued OP to legal service committee KNR dtd.29/11/19
PW1-B.Viswanath- complainant
DW1-Anoop B Tilak-witness of Ops
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew. Sajeesh K.P
eva /Forwarded by Order/
ASSISTANT REGISTRAR
