By Smt. Padmini Sudheesh, President: The complainant’s case is that he was a Janatha Personal Accident Insurance Policyholder of respondent from 28.11.1997 to 27.11.2007. As per the policy the disability was caused due to an accident and the insured is eligible for compensation according to the disability caused. In addition to that the insured will be entitled for medical expenses also. On 21.4.02 a motor accident was occurred to complainant and he had sustained injuries. He had occurred fracture to his right leg and right hand palm also. He was admitted in West Fort Hospital, Thrissur and an amount of Rs.62,564/- was the medical expenses. The accident was intimated to the Company on the very next day of the accident. The respondent refused to honour the claim of complainant by stating motor accident. Hence the complaint. 2. The counter of respondent is that the respondent denies that the respondent had issued to the complainant Janatha Personal Accident Insurance Policy with medical expenses for the period 28.11.1997 to 27.11.2007. So this respondent denied the liability to pay any compensation to the complainant. The complainant or his son have not requested for any claim application form from this respondent. This respondent denies the averments in the complaint that the son of the complainant approached this respondent and told to the complainant’s son that this respondent will not give the claim form since the accident was a motor accident. The complainant also has not approached this respondent for the claim form or demanded any amount. The complainant has not approached this respondent in time. The complainant has not produced any medical bills or hospital records before this respondent. This respondent denies the alleged accident on 21.4.02. No police records are produced to prove the accident. The drivers of both the vehicles had no valid driving licence at the time of the alleged accident. The respondent denies that the complainant had sustained any total permanent disability in the alleged accident. Hence this respondent is not liable to pay Rs.25,000/- with interest. The accidental policy is covered only if there is accidental death or permanent total disability. If there is loss of one eye, 2 limbs and one limb or 2 eyes full sum insured is assured. If there is loss of one eye or one limb due to accident, half the sum insured is assured. The complainant had no such permanent total disability and hence this respondent denies the liability. 3. The respondent filed an additional counter by stating that this respondent admits the Janatha Personal Accident Insurance Policy issued to the complainant. In the counter filed on 13.9.04 this respondent had denied the policy since it was not traceable being issued to Unicare Marketing as a Group Insurance Policy. Now since the complainant had produced the policy copy this respondent was able to trace out the policy. Though a policy is issued in the name of the complainant, it is subject to the terms, conditions, exclusions and limitations stipulated therein. The scope of cover of Janatha Personal Accident Insurance Policy is death, total and irrecoverable loss of sight of both eyes or losses of use of two hands or feet or loss of sight of one eye and loss of use of one hand or foot, total and irrecoverable loss of sight of one eye or loss of use of one hand or foot and permanent total disablement due to accident. As per the terms and conditions of the policy, the respondent is not at all liable to indemnify the complainant since the complainant is not covered by none of the things stated above. The complainant has not produced any documents or medical records to prove that he has permanent total disablement due to accident. Hence dismiss. 4. The points for consideration are: (1) Was there any deficiency in service on the part of respondent? (2) If so, reliefs and costs. 5. The evidence adduced consists of Exts. P1 to P8 and Exts. R1 and R2. 6. Points: The complaint is filed to get reimbursement of the medical expenses occurred to the complainant and also for compensation. According to the complainant, he is holding a Janatha Personal Accident Insurance Policy issued by the respondent for a period of 28.11.97 to 27.11.07 and during the pendency of the policy he had met with a road traffic accident on 21.4.02. According to him, the accident was happened due to the negligence of the driver of offending vehicle KRM-74 Jeep and had sustained grievous injuries out of the accident. 7. The respondent denied the allegations in the complaint and they are admitting the policy. According to the respondent this is a very low premium policy intended to help insured in case of unaccepted tragedies like death, total loss of sight of both eyes or one eye or total loss of both hands or feet, loss of one hand or one foot and permanent total disablement due to accident. They stated that this aspect is very clearly borne out from Ext. R2 policy schedule. Ext. R1 is the policy certificate and Ext. R2 is the terms and conditions of the policy. The Counsel for complainant argued that even though Ext. R2 is produced by respondent it is not the terms and conditions applicable to Janatha Personal Accident Insurance Policy issued to complainant and the facts stated in Ext. R2 are not applicable to complainant. According to him, the policy number is different in terms and conditions of the policy. Ext. R1 the copy of certificate produced by respondent would show that the master policy number is 100600/47/01/11/1893/97. In Ext. R2 the policy number is stated as 100600/47/61/11/1893/97. There is difference in two figures and according to the complainant Ext. R2 is not the terms and conditions applicable to complainant. Even though the conditions stated in the counter are common in Ext. R2 this cannot be taken into consideration in support of Ext. R1. Since the numbers are different it cannot be said that Ext. R2 is the policy terms and conditions applicable to Janatha Personal Accident Insurance Policyholder. The Counsel for complainant argued that since the terms and conditions are not applicable to this policy, it cannot be looked into. 8. The respondent filed an additional counter on 24.2.05 along with the application to accept the same. In the additional counter it is stated that in the counter filed on 13.9.04 this respondent had denied the policy since it was not traceable being issued to Unicare Marketing as a Group Insurance Policy. It is also stated that since the complainant had produced the policy copy this respondent was able to trace out the policy from the details given therein. The complainant produced Ext. P1 the original policy certificate and it show that the master policy number as 100600/47/01/11/1893/97. The complainant filed I.A.621/05 to direct the respondent to produce the original of terms and conditions applicable to master policy No.100600/47/11/01/1843/97 and also the original of master policy etc. Even if there was direction it is not seen produced. The respondent produced Ext. R2 but it is different in policy number. So the terms and conditions are not aware. 9. The claim of complainant is that a motor accident was occurred to him on 21.4.02 which was within the insurance policy period and so he is entitled to get the medical expenses incurred to him. Since there is no document to show that the complainant is not eligible for medical expenses we have no other way except to honour the claim of complainant. There are documents to show the occurrence of accident and the complainant is entitled to get the expenses claimed. Since there is no permanent total disability he is not entitled for the claim amount of Rs.25,000/-. The disability certificate would show that he had only 20% permanent disability as per Mc bride scale. So he is not deserving the disability claim. 10. In the result, the complaint is partly allowed and the respondent is directed to pay the Ext. P8 series bills amount and Rs.2500/- (Rupees two thousand five hundred only) as compensation with cost Rs.500/- (Rupees five hundred only) within two months from the date of receipt of copy of this order. If the payment is not made within the stipulated time the complainant will be eligible to get interest at the rate of 12% from the date of order till realization for the medical expenses amount. Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 18th day of September 2010.
| | [HONORABLE Rajani P.S.] Member[HONORABLE Padmini Sudheesh] PRESIDENT[HONORABLE Sasidharan M.S] Member | | 
