Sri S.K.Sahoo,President.
The complainant has filed a petition U/s. 12 of C.P.Act, 1986.
2. The case of the complainant is that he is an account holder of UCO Bank Talmul Branch, having account No. 13123211001362. An amount of Rs.12.00 was deducted from his account each year towards Pradhan Mantri Surakhya Yojana, for policy No. 1518962945669631. The left leg of the complainant was not functioning properly which was reported to opp.party No.1. The complainant has also submitted his claim by letter dtd.22.11.2016 bearing claim No.2171010784. A letter was also submitted to the opp.party No.3 on 07.10.2017. The complainant also submitted reply to such letter by his letter dtd.12.10.2017 through Regd. post with A.D. A copy of the said letter was sent to C.D.M.O,Angul vide Memo No. 555 dtd.18.07.2017.No reply was received by the complainant relating to the aforesaid communication. As there was a defect in the disable certificate, the complainant approached the C.D.M.O,Angul by his letter dtd.01.02.2017. On 24.12.2018 a fresh certificate was issued to the complainant. The complainant failed to get his insurance amount, for which he reported opp.party No.1 by his letter dtd.04.12.2017 but no reply has been received from him. Hence this case.
3. Notice was issued to all the opp.parties through Regd. Post with A.D on 08.04.2019. During hearing the complainant wants to delete opp.party No.2 and accordingly he has been deleted vide order dtd.01.11.2019. Opp.party No.1 filed show cause where as opp.partyNo.2 to 4 filed separate show cause signed by the authorised signatory of Reliance General Insurance Corporation Ltd.
4. The case of opp.party No.1 is that the case filed by the complainant is not maintainable either in law or in facts. It is barred by law of limitation in view of Section-24 A of C.P. Act, 1986. There is no cause of action to file this case against opp.party No.1. The complainant is not a consumer. The complaint is barred for non-joinder for necessary party and mis-joinder of unnecessary parties. There is no specific allegation regarding the deficiency in service as defined U/s.2(g) of the C.P. Act, 1986. It is admitted that an amount of Rs.12.00 was deducted from the account of the complainant with his active consent for PMSBY. The complainant has not intimated about the accident dtd.22.11.2016 to opp.party No.1 within 30 days as stipulated by the policy. Only on 04.12.2017 the complainant intimated the fact to the opp.party. After receipt of the said complaint dtd.04.12.2017 from the complainant immediately opp.party No.1 referred the matter to other opp.parties within a period of 30 days. The opp.party No.1 has received the claim form from the complainant only on 15.07.2017. He has neither filed the FIR copy nor the preliminary treatment report/ prescriptions of his treatment. On the other hand he has filed the copy of OPD documents of AIIMS ,Bhubaneswar dtd.25.04.2017. The opp.party No.1 duly intimated the complainant that his claim is not admissible by the higher authority due to barred by limitation. Absolutely there is no deficiency in service on the part of the opp.party No.1.
5. Opp.party No.2 to 4 in their joint written statement alleged that the case filed by the complainant is not maintainable in law or in facts. The dispute raised by the complainant is not coming under the ambit of C.P.Act, 1986. He is not a consumer as defined U/s. 2 (d) of the Act. The complainant took a policy bearing No. 1518962945669634 under Pradhan Mantri Surkhya Yojana, covering the risk from 01.06.2016 to 31.05.2017. The alleged occurrence took place on 22.11.2016 i.e within the policy coverage. The complainant alleged that he has sustained disability in an accident by which his knee was affected. As per the disability certificate submitted by the complainant, disability assessment was done for right leg by the Medical Board,Angul. Since the part of the body which was allegedly affected in the accident as has been stated in the claim form submitted by him, the claim of the complainant was rightly repudiated. The repudiation of the claim of the complainant was duly intimated to him on 07.09.2017 and the reasons of repudiation was written in it. He was also advised to contact the opp.parties within a period of two weeks in case of any query. The complainant did not made any query and remained silent for about seventeen months. Only thereafter he has approached the Consumer Forum/Commission. There is no deficiency in service by the opp.party No.2 to 4. The complaint filed by the complainant be dismissed.
6. Admittedly the complainant is a policy holder under Pradhan Mantri Surkhya Yojana with policy No. 1518962945669634 .It is also admitted that the risk period under that policy was 01.06.2016 to 31.05.2017. Although the complainant in his complaint petition has not mentioned about the date of accident relating to his claim, from the documents filed by opp.party No.1, it appears that in his application the complainant has mentioned that accident took place on 22.11.2016 due to a mutual fight in between a cow and the ox on the village road. The opp.party No.1 has also filed the photo copy of the claim procedure relating to Pradhan Mantri Surkhya Bima Yojana. It is clear from the said procedure that the claim form shall be completed by the insured or at the case may be by the nominee and be submitted to the Bank within 30 days of the occurrence giving rise to the claim under the policy. It further appears that the said claim form shall be supported with all other documents along with a disability certificate issued by the Civil Surgeon. The complainant has not filed any documents relating to the alleged accident dtd.22.11.2016. From letter dtd.07.09.2017 of the Claim Manager (opp.party No.3) addressed to the complainant, it appears that as per the claim documents and the disability certificate it is observed that the disability assessment is done for right leg where as the injury occurred in the above incident on the left leg. There was no amputation/disability occurred. Under benefit-C total and irrevocable loss sight of one eye or loss of the use of one hand or foot is covered under the policy. So the claim of the complainant was repudiated by the insurance company, as the complainant is not entitled to any amount under insurance policy. As it appears the complainant has relied on a certificate for the persons with disability issued by the then CDMO-cum-Chairman, District Medical Board, Angul dtd.10.05.2013. As it appears to be manipulated one, by this Office letter No.577/dtd.13.05.2023 the Commission sent a copy of such certificate to the CDMO & Public Health Officer,Angul for his report. In pursuance of such letter the CDMO,Angul by his letter No.475/dtd.18.05.2023 sent the copy of the register maintained by his Office. On perusal of the said letter, it appears that certificate No.944/dtd.10.05.2013 having 60% permanent disability was issued in favour of the complainant but the complainant tampered the said certificate making it 20% permanent disability. I also verified the said disability certificate filed by the complainant which appears to be manipulated and tampered one. The present certificate has been issued only on 01.06.2017 bearing certificate No.OD1510619550042961 in view of the Govt. guidelines. So it is clear from the materials from the record that the complainant was permanent disable of 60% on 10.05.2013 but he tried to manipulate the document in support of the present claim.
From the documents filed by the opp.party No.1, it is also clear that the claim raised by the complainant is barred by limitation, as the complainant failed to submit the claim form along with documents to the opp.party No.1 within 30 days from the date of alleged accident i.e on 21.11.2016. There is no deficiency in service by the opp.parties.
7. Hence order :-
: O R D E R :
The complaint filed by the complainant is dismissed on contest against opp.party No.1,3 & 4.
