Haryana

Jind

413/11

Dayanand - Complainant(s)

Versus

United India Insurance - Opp.Party(s)

Sh. Rajnish Garg

31 Mar 2015

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, JIND.

                                                              Complaint No. 413 of 2011

                                                    Date of institution:-3.10.2011

                                                    Date of decision:-31.3.2015

Daya Nand Jain s/o Sh. Shiv Dhan Jain aged 66 years r/o Gurudwara Colony, ward No.12 Safidon Mandi, Safidon, Jind.  

                                                                           ..Complainant.

Versus

United India Insurance Company Branch Safidon District Jind through its Manager.

                                                                          …Opposite party.

Complaint under section 12 of

 

Before:      Sh. Hari Singh Khokhar, President.

                Smt. Bimla Sheokand, Member.

 

Present:-    Sh. Rajnish Garg, Adv. for the complainant.

                Sh. Vikas Sharma, Adv.for the opposite party. 

Order:-

                In nutshell, the facts of the complaint are that the complainant took the Medical Insurance Policy titled as ‘Janta Personal Accident Insurance’ vide policy No.452801 dated 10.9.2004 for the period of 5 years i.e. 11.9.2004 to 10.9.2009 and paid the premium of Rs.240/- p.a. regularly. The complainant is Ex. Govt. employee. It is stated that on 6.9.2009 when the complainant was going to market then  one motor-cycle rider hit the complainant very rashly and dangerously. After accident the complainant fall down and his right foot/leg was injured  and the blood was falling down on the road. The complainant admitted in the hospital of Phool Singh Memorial, Gohana for treatment. Due to infection in the leg of

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complainant the doctor advised him to cut the leg and operated the right leg of complainant on 18.9.2009. The complainant got the disability certificate from the Medical Superintendent, General Hospital, Safidon which shows 70% disability. The complainant informed the opposite party regarding the accident and demanding his personal accidental claim  but the opposite party repudiated the claim of the complainant vide letter dated 7.4.2010 which is illegal null and void and the same be set aside.  Deficiency in service on the part of the opposite party is alleged. It is prayed that the complaint be accepted and opposite party be directed to pay the claim amount of Rs.50,000/-,  a sum of Rs.20,000/- as compensation on account of mental pain and agony as well as to pay a sum of Rs.11,000/- as litigation expenses to the complainant.

2.     Pursuant to notice, the opposite party appeared and filed written reply stating in the preliminary objections i.e.  the complainant has got no cause of action and locus-standi to file the present complaint;  the complaint is not maintainable in the present forum and the complaint is false and frivolous. On merits, it is contended that the complainant has violated the terms and conditions of the policy while he has not furnished the required papers/documents in support of his claim despite letter and reminders. The complainant was a patient of chronic disease diabetes and due to this reason his right leg has been amputated. As the cause of amputation of the leg of complainant is not covered under the insurance policy, hence claim of the complainant has rightly been repudiated by the opposite party vide letter dated 7.4.2010. The intimation of alleged accident was sent to the police after a delay of 54 days.   All the other allegations have been denied by the opposite party. Therefore, there is no deficiency in service on

 

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the part of the opposite party. Dismissal of complaint with  special cost of Rs.10,000/- is prayed for.  

3.     In evidence, the complainant has produced  the copy of ration card Ex. C-1,  copy of disabilities certificate Ex. C-2, copy of policy Ex. C-3, copy of cover note Ex. C-4, copy of application Ex. C-5, copy of  discharge slip Ex. C-6, copies of  OPD slips Ex. C-7 to C-10, copy of application Ex. C-11, copy of letter dated 7.4.2010 Ex. C-12 and  his own affidavit Ex. C-13 and closed the evidence. On the other hand, the opposite party has produced the affidavit of  Mahender Pal, Sr. Divisional Manager Ex. OP-1, copy of claim form Ex. OP-2 and copy of letter dated 7.4.2010 Ex. OP-3 and closed the evidence.

4.     We have heard the arguments of Ld. Counsel of both the parties and also perused the record placed on file. The complainant took the Medical Insurance Policy namely ‘Janta Personal Accident Insurance’ from the opposite party vide policy No.452801 dated 10.9.2004 for the period of 5 years w.e.f 11.9.2004 to 10.9.2009. The complainant met with an accident on dated 6.9.2009 and his right foot/leg was injured. He took first aid from the hospital but due to regular pain he came to Gohana for treatment in Phool Singh Memorial Hospital on 17.9.2009 and the leg of the complainant was amputed due to infection. The complainant obtained the disability certificate from General Hospital, Safidon which shows the 70% disability. The complainant also informed to the police through registered post vide receipt No.7370 dated 30.10.2009 Ex. C-11. The  complainant lodged the claim with the opposite party but the opposite party repudiated the claim of the complainant vide letter dated 7.4.2010 Ex. C-12. Deficiency in service on the part of opposite party is alleged.

5.     On the other hand, the opposite party has averred that the

 

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complainant has violated the terms and conditions of the policy while he has not furnished the required documents in support of his claim despite letters and reminders. The complainant was a patient of diabetes and thus his right foot has been amputed due to this reason which is not covered under the said policy. The claim of the complainant has rightly been repudiated vide letter dated 7.4.2010. All the other allegations have been denied by the opposite party.

6.     We perused Ex. C-3 and C-4 which reads as follow:-

Sum Insured              Rs.1,00,000/-

Premium                    Rs.240/-

Period of insurance     11.9.2004 to 10.9.2009

Special Conditions      As per policy condition.

(1 )  Subject Covered

 

        Persons in the age group of 5-70 years.(No medical Examination)

(2 )  Scope of Cover

        Death of disablement due to accident caused by external violent

 and visible means e.g. fire, drowing, road/rail accidents,

electrocution, snakebide, and attack by wild animals,

sterilization risks and claims arising out of recing on wheels, big

game hunting, mountaineering and whilst engaged in winter

sports like skling of ice hockey are not covered.

(3)  Sum Insured

        In multiples of Rs.25,000/- (upto Rs.1 Lacs)

(3a)   Period of Policy

        Policy cam be taken for a minimum period of 1 year in more but

        maximum upto 5 years. A suitable rebate in premium would be

        allowed for policies taken for 2 years on more.

 

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(4)    Benefits

a)     Death due to accident          100% of sum insured

b)     Permanent total                  100% of sum insurted disablement

c)     Loss of 2 eyes or 2 limbs

        or one eye and one limb      100% of sum insured

d)     Loss of one or one limb      50% of sum insured

Claim Procedure

a)     Immediate notice to be given to the policy issuing office.

b)     Claim form to be submitted with Medical Certificate

c)     For death claim, nominee should submit.

        i) Death Certificate (ii) Original Policy (iii) Claim form (iv)

        Post-mortem Report (v) Policy report. 

Ex.C-2 is medical certificate and it is made clear from the certificate given by Medical Superintendent of General Hospital, Jind that disability is permanent to the extent of 70%. This certificate clearly shows amputation of right leg of complainant.

7.     In view of the facts and circumstances, we have considered this complaint and arrived at the conclusion that the repudiation of claim by the opposite party is not justified. Deficiency in service is established on the part of the opposite party. Therefore, the complaint is allowed and the opposite party is directed to pay Rs.50,000/- to the complainant within a period of 30 days after receiving the certified copy of this order. In case of failure, the opposite party will also pay a simple interest @ 9% p.a. to the complainant w.e.f. filing of the complaint i.e. 3.10.2011 till realization of full amount. The opposite party will also pay Rs.2100/- as litigation charges to the complainant.

 

                       

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Parties will bear their own costs. Copies of order be supplied to the parties under the rule. File be consigned to the record-room after due compliance.

Announced on: 31.3.2015

                                                                President,

Member                                   District Consumer Disputes                                                                  Redressal Forum, Jind