By Smt. Padmini Sudheesh, President: The facts of the case are as follows. The petitioner has taken a Janatha Personal Accident Insurance policy from the United India Insurance Company on 17.7.2000. The period of the policy was from 17.7.2000 to 16.7.2005 and the sum assured was Rs.1,00,000/- and the policy number is 101202/47/51/11/7909/2000. The petitioner was met with an accident on 12.10.2002 and sustained injuries to head and eyes and was admitted in the Elite Mission Hospital. He was in the I.C.U. for 1½ month. The sight of right eye has lost and the left eye was partially damaged. The petitioner claimed for insurance benefits with all required documents. But the respondent Company refused to provide the benefit. Hence this complaint. 2. The averments in the counter is as follows: This respondent admits that the policy is issued for a period from 17.7.00 to 16.7.05 and the sum assured under the policy was Rs.1,00,000/-. The limit of liability is as per the terms and conditions of the policy. As per condition No. b, c, d of the policy this respondent is liable to pay compensation only if the complainant has sustained total and irrecoverable loss of right of both eyes or total and irrecoverable loss of sight of one eye. The discharge summary issued from the Elite Mission Hospital shows the injuries and disability. The medical certificate issued by the Department of Ophthalmology, Medical College Hospital, Thrissur dated 1.1.03 shows that the petitioner is visually handicapped to 40% due to optic atrophy right eye. Disability is said to be partial and not permanent in nature. Petitioner is not entitled to get any amount and the claim does not come under the purview of policy. Petitioner is entitled to claim compensation only if the petitioner sustain injuries as described in the policy. The claim is repudiated for genuine reasons. There is no deficiency in service. Hence dismiss the complaint. 3. The points that arise for consideration are the following. (1) Is there any deficiency in service? (2) If so, reliefs and costs. 4. The evidence consists of Exts. P1 to P9 and Exts. R1 to R9. 5. Points-1 & 2: The definite case of the complainant is that being the policyholder of Janatha Personal Accident Insurance, he is eligible for the capital sum assured for the bodily injury sustained to him by the accident. On 12.10.02 he was met with a motor accident and he has sustained injuries to his head and eyes. He was admitted in Elite Mission Hospital, Thrissur and was in the I.C.U. for 1½ month. According to the complainant, due to the accident he has lost his right eyesight and partially the sight of left eye. In the counter the respondent company denied the version of complainant. Ext. P7 is the policy issued by the company in which it is stated in Condition No. C that if such injury shall within six calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of sight of one eye, or total and irrecoverable loss of use of a hand or a foot, fifty percent (50%) of the capital sum insured stated in the schedule hereto. So the loss of sight of one eye amounts the payment of 50% of the capital sum insured. Here the complainant has stated that the vision of his right eye lost forever. He has produced nine documents and which are marked as Exts. P1 to P9. Ext.P4 is the certificate issued by the Medical Board of Medical College Hospital, Thrissur. From this certificate it can be seen that he is having disability of 40% due to optic atrophy. Ext. P8 is the copy of discharge summary in which it is stated that after patient recovered his right eye vision was found to be impaired. The word impaired is used in the certificate and it doesnt mean that total damage is happened. It only means that not functioning normally. We say someone is speech impaired it doesnt mean that that person is dumb. The word impaired indicates only some kind of abnormality and also not functioning normally. It doesnt mean total loss. In this case as per the records the sight of right eye is not lost. Ext. P1 is a certificate issued by Dr. Suneethy in which it is stated that the right eye of petitioner is blind due to optic atrophy. Ext. R8 is another certificate issued by the same doctor on 1.1.03 in which she is certified that this person is visually handicapped 40% due to optic atrophy right eye. Ext. P1 is the certificate issued by her on 2.8.03 after retirement from service. In that certificate (Ext. P1) she has not mentioned about the reference of Ext. R8. Since she has retired from service I am not making any comments regarding these contradictory views. From the documents it is clear that the eyesight has not lost fully. As per the conditions of the policy he is entitled for the capital sum only if sight of both eyes are lost. If sight of one eye has lost the person is entitled for 50% of the capital sum. Here the disability stated is 40%. So the complainant is not entitled for the capital sum or half of the capital sum. The disability even if 40% is caused due to the accident and the respondent company is not denied this aspect. They clinch on the policy conditions. Almost half sight of the right eye is lost and damage caused to the left eye also. So taking into considering the circumstances we are inclined to allow this complaint. A young person became handicapped in a morning without the fault of his own. The accident, disability etc are admitted by the respondent company and they are not willing to provide the insurance claim due the conditions stated in the policy. The right eyesight of a person has partly lost due to the accident is an admitted fact and 40% disability is certified. As per the policy conditions he is not eligible for the capital sum. Here half eyesight has lost. So we arrive at a conclusion to allow Rs.25,000/- as policy benefits. The respondent company failed to honour the claim by not taking into consideration the special circumstance of the case. So there is service deficiency on the part of Company. So they are liable to provide the insurance benefit as directed by the Forum. 6. In the result, complaint is allowed and the respondent Company is directed to pay Rs.25,000/- (Rupees twenty five thousand only) to the complainant with interest at the rate of 12% per annum from 12.10.03 till realization. The Company is further directed to pay Rs.1000/- (Rupees one thousand only) as costs. Comply the order within two months. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 29th day of September 2008.
