CONSUMER DISPUTES REDRESSAL COMMISSION – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110016
Case No.257/2016
Sh. KRISHAN KUMAR
S/O Sh. BANWARI LAL
R/O A-88, SARAI KALE KHAN,
NIZAMUDDIN, DELHI -110013…..COMPLAINANT
Vs.
THE ORIENTAL INSURANCE CO. LTD.
THROUGH ITS DIRECTOR
AT 2, CENTRAL ROAD, JANGPURA ROAD,
BHOGAL, NEW DELHI- 110014.…..OPPOSITE PARTY
Date of Institution-16.08.2016
Date of Order- 31.10.2022
O R D E R
MONIKA SRIVASTAVA - PRESIDENT
The complainant has filed the present complaint seeking compensation of Rs.83433/- along with 12% interest. The complainant is also seeking Rs.25,000/- towards legal expenses and mental harassment caused to him.
- It is stated by the complainant that he had taken two policies from the OP being personal accident policy number 212703 /48/2015/2913 from the period 25.10.2014 to 24.10.2015 and second policy being happy family floater policy number 212703/48/2015/2914.
- It is stated by the complainant that these policies were renewed by the complainant on expiration and the renewed policies are annexed along with the complaint.
- It is stated by the complainant that under the personal accident policy the sum assured is Rs.5,00,000/- and the complainant is entitled to weekly compensation for accident cover at the rate of 1% of capital sum insured. Under the Happy Family Floater Policy, the complainant is entitled to hospitalization benefits and post hospitalization benefits subject to conditions under the said policy.
- It is stated by the complainant that he had met with an accident after falling from the ladder on 12.08.2015 and was admitted at Chiranjiv Medical Centre, Jhansi, U.P from 12.08.2015 till 15.08.2015 and thereafter from 15.08.2015 till 01.09.2015 at Kailash Hospital and Heart Institute, Noida, U.P.
- It is further stated by the complainant that he was not able to work due to injury and as per the advice of the doctors, was taking rest. He has filed all his bills of physiotherapy from October 2015 till January 2016 and that he is entitled to weekly compensation under the Personal Accident policy as per its terms and conditions however, the OP has only paid Rs. 45,000/- for 6o days from 12.08.2015 till 13.10.2015 whereas the complainant is entitled to minimum Rs.55,000/- on this account.
- It is stated by the complainant that had filed 3 claims before the OP however they were rejected on the ground that the same were beyond the permissible post hospitalization period of 60 days in spite of the complainant submitting all his medical records.
- It is stated by him that the OP has not relied on the report of the doctor of the complainant and in fact have chosen to rely on the report of another panel doctor of the OP who is not an expert in the field of orthopaedics, but is a physician
- It is further stated by the complainant that he is the sole bread earner of the family and due to the accident, his right elbow is permanently damaged and he is not able to work with his right hand.
- It is stated by him that the entire purpose of taking on insurance is which is to provide indemnity to the insured is defeated in his case.
- On the other hand, in the reply, the OP has not denied the policies of the complainant neither have they denied that 3 claims were filed with them however it is stated by them that the claim number 556221516320565 and 5562215163190844 were repudiated as these pertained to OPD, physiotherapy, investigation and consultation expenses from 19.12.2015 to 23.01.2016.
- It is further stated by the OP that claim number 556221516334693 was repudiated as it pertained to physiotherapy expenses from 01.02.2016 to 18.02.2016 as they were also beyond the permissible post hospitalization period of 60 days. All these claims were validly rejected as they violated clause 3.7 of the policy.
- Clause 3.7 of the policy is reproduced as under:
“reasonable and necessary medical expenses incurred for the treatment of disease/injury for a period UP to 60 days from the date of discharge from hospital shall be considered as part of claim covered under the policy”
- It is further stated by the OP that the claim of the complainant under the personal accident policy was found to be exaggerated for the total amount claimed but the same was allowed for the period from 12.08.2015 to 13.10.2015(60 days) which totals to Rs. 45,000/- and which has been duly paid as full and final settlement of the claim to the complainant.
- On merits, it is denied that the complaint suffered great loss to himself or his family members or that he is the only earning member or that his entire family is facing hardship due to sudden stoppage of the family income on account of the accident of the complainant.
- It is stated by the OP that there is no deficiency in service on their part as the claim of the complainant have been denied in consonance with the insurance policy
- It is further stated by the OP that it is wrong on the part of the complainant to state that terms and conditions of the policy were not provided to him and even otherwise the same are available on the website of the OP and it is a public document for everyone to access and see.
The OP had filed an amended reply which was duly taken on record. Rejoinder has been filed by the complainant. Evidence affidavits and the written submissions have been filed by both the parties.
This Commission has carefully gone through the material on record and it is noticed that the complainant has filed his claim under the Personal Accident Policy and the report of the panel doctor of the OP annexed with the reply as Annexure B records “therefore it is recommended that he should be compensated under TTD clause for the period 12.08.2015 to 13.10.2015 (63) days plus medical expenses…….. Detail of valid medical expenses during the period of TTD: no original bills/receipts submitted.”
Considering this report, the amount payable is to be calculated as per the schedule provided in the policy which is 100% CSI (Capital Sum Insured) in case of Temporary Total Disablement (TTD). The sum insured in the present case is Rs.5,00,000/- therefore the amount payable by the OP to the complainant would be CSI for 63 days of TTD which comes to Rs. 86,301.36/- whereas the OP has paid to the complainant sum of Rs. 45,000/- Accordingly, the OP is directed to pay to the complainant a sum of Rs. 41301.36/- towards TTD. The OP is also liable to pay a sum of Rs. 10,000/- towards mental harassment caused to the complainant. This entire sum would be payable by the OP within a period of three months from the date of the order failing which the said amount would be payable with interest @ 7% p.a.
Parties be given copy of order to the parties as per rules. File be consigned to the record room. Order be uploaded on the website.
