Chandigarh

DF-I

CC/393/2023

SUBHASH RANA - Complainant(s)

Versus

UNITED INDIA INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

06 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/393/2023
Date of Institution	:	16/08/2023
Date of Decision	:	06/03/2024

 

Subhash Rana son of Sh. Baldev Singh R/o House No.2946/2, Sector 47-C, Chandigarh.

… Complainant

V E R S U S

United India Insurance Company Limited Regional Office through its Regional Manager, SCO No.123-124, Sector 17-B, Chandigarh.

… Opposite Party

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Ashwani Arora & Devinder Kumar, Advocates for complainant
	:	Sh. Shubham Jain, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Subhash Rana, complainant against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that complainant is the registered owner of Innova car bearing registration No.CH-02-AA-3599 (hereinafter referred to as “subject car”) and got the same insured with the OP for commercial purpose vide policy, which was valid w.e.f. 6.1.2022 to 5.1.2023 (hereinafter referred to as “subject policy”). Copies of registration certificate and insurance policy are Annexure C-1 and C-2.  On 25.3.2023, the subject car was hired by one Davinder Sharma for Mata Vaishno Devi Shrine in J&K and back to Panchkula.  On the night of 27.3.2022 at around 11:30 p.m. when the complainant was coming back to Panchkula from Jammu and reached near Randhawa Sugar Mill, Dasuya, District Hoshiarpur, the subject car struck against a tractor trolley, which was loaded with sugarcane and was parked in the middle of the road by its driver, as a result of which all the occupants of the subject car sustained injuries, including the complainant, who suffered serious injuries on his left eye, nose and other parts of body.  Immediately after the accident, complainant was taken to the Civil Hospital, Dasuya from where he was referred to Shriram Hospital, Jalandhar and from there he was shifted to PGI, Chandigarh. The complainant remained admitted at PGI, Chandigarh w.e.f 28.3.2022 to 30.3.2022. The matter was also reported to police regarding which DDR No.47 dated 31.3.2022 was also recorded and copies of driving licence, DDR and medical record are Annexure C-3 to C-5.  Complainant had lodged two separate claims with the OP i.e. one for own damage claim of his car and the other for injuries sustained by him covered under the head of Compulsory Personal Accident (CPA), being owner–driver of subject car, by submitting all the documents required for processing the claim.  OP settled the own damage claim with the intervention of Ombudsman, but, has repudiated the personal accident claim of the complainant vide letter dated 28.2.2023 (Annexure C-7) on the ground that the disablement of eye is only 30% Permanent Partial Disablement.  The complainant obtained the disability certificate from the Hospital on 28.6.2023 (Annexure C-9) in which even the combined permanent disability was assessed to the extent of 48%.  Moreover, as per terms and conditions of subject policy, complete loss of vision in one eye means there is visual disability of 50% and even on that account OP was required to settle the claim of the complainant in view of the terms and conditions of the subject policy and is liable to pay sum of ₹7,50,000/- to the complainant since the coverage for the personal accident claim was to the tune of ₹15.00 lacs. As the OP had wrongly repudiated the claim of the complainant, he sent a legal notice dated 1.7.2023 (Annexure C-10) to the OP alongwith the disability certificate dated 28.6.2023, but, with no result.  In this manner, the aforesaid act of the OP amounts to deficiency in service and unfair trade practice. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, jurisdiction, concealment of facts and cause of action.  However, the factum of issuance of the subject policy to the complainant and the accident of the subject car has not been disputed. It is alleged that the claim of complainant was rightly repudiated since as per scale of compensation payable to owner–driver mentioned under Section IV (iii) of the terms and conditions of the subject policy, compensation @ 50% of sum insured payable under this cover is admissible in case of loss of sight of one eye on permanent total basis.  However, in the case in hand, as per the disability certificate provided by the complainant, as he is suffering from 30% Permanent Partial Disability, he is not covered under the subject policy and the claim was rightly repudiated by the OP. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant is the registered owner cum driver of the subject car, as is also evident from copy of RC as well as driving licence (Annexure C-1 & C-3), and the same was got insured by the complainant w.e.f. 6.1.2022 to 5.1.2023, as is also evident from the copy of subject policy (Annexure C-2/R-1) and the same met with an accident on 27.3.2022, which resulted in causing damage to the subject car as well as injuries to all the occupants, including the complainant who suffered multiple injuries on his nasal bone, left eye and other parts of the body and was firstly shifted to Civil Hospital, Dasuya from where he was referred to Shriram Hospital, Jalandhar and finally to PGI, Chandigarh, where he remained admitted from 28.3.2022 to 30.3.2022, the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in repudiating the genuine claim of the complainant and he is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP has rightly repudiated the claim of the complainant and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OP.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy and the medical record, having been relied upon by the parties, and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of copy of the subject policy (Annexure R-1) clearly indicates that the subject car was insured for own damage as well as for personal accident for owner–driver covering the risk of ₹15.00 lacs. Section IV of the subject policy contains the terms and conditions, which specifically provide coverage for personal accident of owner–driver and the relevant portion of the same is reproduced below for ready reference :-

“SECTION - IV: PERSONAL ACCIDENT COVER FOR OWNER-DRIVER

Subject otherwise to the terms exceptions conditions and limitations of this policy, the Company undertakes to pay compensation as per the following scale for bodily injury/death sustained by the owner-driver of the vehicle in direct connection with the vehicle insured or whilst mounting into/dismounting from or traveling in the insured vehicle as a co-driver, caused by violent accidental external and visible means which independent of any other cause shall within six calendar months of such injury result in:

Nature of injury	Scale of compensation
(i) Death	100%
(ii) Loss of two limbs or sight of two eyes or one limb and sight of one eye	100%
(iii) Loss of one limb or sight of one eye	50%
(iv) Permanent total disablement from injuries other than named above	100%

Provided always that

1)     compensation shall be payable under only one of the items (i) to (iv) above in respect of the owner-driver arising out of any one occurrence and the total liability of the insurer shall not in the aggregate exceed the sum as per schedule during any one period of insurance.

2)     no compensation shall be payable in respect of death or bodily injury directly or indirectly wholly or in part arising or resulting from or traceable to (a) intentional self injury suicide or attempted suicide physical defect or infirmity or (b) an accident happening whilst such person is under the influence of intoxicating liquor or drugs.

3)     Such compensation shall be payable directly to the insured or to his/her legal representatives whose receipt shall be the full discharge in respect of the injury to the insured.

This cover is subject to

(a)    the owner-driver is the registered owner of the vehicle insured herein;

(b)    the owner-driver is the insured named in this policy.

(c)    the owner-driver holds an effective driving licence, in accordance with the provisions of Rule 3 of the Central Motor Vehicles Rules, 1989, at the time of accident.”

 

4. Annexure C-9 is the copy of disability certificate dated 17.4.2023 issued by the Govt. Multi-Speciality Hospital Sector 16, Chandigarh which indicates that the VA of the complainant was found - right eye 6/6, left eye nil and the permanent partial disability was assessed 30% whereas the combined disability was assessed 48% only.
5. The learned counsel for the complainant contended with vehemence that as it is provided under Section IV of the subject policy that the loss of sight of one eye is covered under 50% of the scale of compensation, the claim of complainant is squarely covered under the subject policy and the complainant is entitled for 50% of the PA cover of ₹15.00 lacs i.e. ₹7.50 lacs. 
6. On the other hand, learned counsel for the OP contended with vehemence that since as per the terms and conditions of the subject policy, insured is entitled for the claim in case he suffers 50% disability and since in this case complainant has suffered only 48% disability, he is not entitled for any claim, therefore, his personal accident claim was rightly repudiated.
7. There is no force in the contention of learned counsel for the OP as even Section IV of the terms and conditions of the subject policy specifically provides the scale of compensation to be provided to the insured in case of loss of one limb or sight of one eye.  In the case in hand, as it stands proved from the disability certificate (Annexure C-9) that the patient/insured was having vision of right eye of 6/6 and that of left eye NIL, making clear that the insured had completely lost sight of one eye i.e. left eye, therefore, as per the afore-extracted scale of compensation provided under Section IV, OP/insurer was certainly liable to pay 50% of the sum assured to the complainant i.e. ₹7,50,000/-.  Hence, it is unsafe to hold that the OP is justified in repudiating the claim of the complainant.
8. So far as the defence of the OP that the complainant has not suffered 50% permanent disability and his case is not covered under the terms and conditions of the subject policy is concerned, same is of no help to the OP in the light of Section IV of terms and conditions of the policy, which specifically deals with the personal accident cover for owner-driver.
9. In view of the aforesaid discussion, it is safe to hold that complainant has successfully proved the cause of action set up in the consumer complaint.  Hence, the present consumer complaint deserves to succeed and OP is liable to pay the aforesaid amount of ₹7,50,000/- to the complainant alongwith interest and compensation etc. for the harassment suffered by the complainant.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-

1. to pay ₹7,50,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 28.2.2023 onwards.
2. to pay ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

06/03/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Suresh Kumar Sardana] Member