::BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BIDAR::
C.C. No.11/2024.
Date of filing: 02.02.2024.
Date of disposal:16.11.2024.
P R E S E N Ts:-
(1) Shri. Mabu Saheb H.Chabbi, B.Com.,LL.B.,(Spl.),
President.,
(2) Kum. Kavita,
M.A.,LL.B.,(Spl.),
Member.
COMPLAINANT/S Suresh S/o Mallanna Guttedar,
Age:62 years,Occ:Contractor (now Nil),
R/o H.No.10-1-146, Mangalpet Road
Behind P.W.D. Office, Bethany Colony Bidar.
Through his wife and Nominee.
Smt.Prabha W/o Suresh Guttedar,
Age:55 years,Occ:Household,
R/o H.No.10-1-146, Mangalpet Road
Behind P.W.D. Office, Bethany Colony Bidar.
(By Sri.Rajkumar K.Advocate.)
V/s
OPPONENT/S The Branch Manager,
TATA AIG General Insurance Company Ltd.,
1st Floor, Unit No.F6 and F8 Business Park
Akkamahadevi Colony, Kalaburagi 585103.
(By Sri.S.Wilson Advocate).
:: J U D G M E N T ::
By Shri. Mabu Saheb H.Chabbi, President.
The complaint is filed by the complainant under section 35 of the Consumer Protection Act 2019, against the opponent for the deficiency in service caused by not settling the claim of the insurance of the complainant. Hence, passed the following judgement.
Brief facts of the complaint.
The brief facts of the complaint are as follows: -
2. The complainant was a contractor by profession he has purchased Group Accident Guard Policy from OP through India Post Payments Bank Ltd., under certificate of insurance policy No.0239461184 certificate No.04532160 covering period from 03.11.2022 to 02.11.2023 by covering health problems, hospitalization and accidental medical expenses including accidental disablement and paralysis. The wife of the complainant Smt.Prabha is the nominee for the said policy. The assured would be entitled for an amount of Rs.10,00,000/- in case of permanent partial disability for any kind of ailment, paralysis etc. On 08.07.2023 while complainant Sri.Suresh S/o Mallanna Guttedar was stepping down the stairs from the roof of his house he slipped down and caused internal head injury , immediately taken him to Gurunanak Hospital Bidar and conducted MRI Scan and diagnosed that, the complainant suffered with paralypitic/paralysis stroke, the right said body become paralyzed, after providing with conservative treatment he was discharged. The complainant approached medical board of BRIMS Hospital Bidar for evaluation of disability and after examination issued disability certificate No.KA2045191960186235 dt:09.10.2023, stating that it is a case of multiple disability diagnosed Rt Hemiplegiya and he has 75% permanent disability in relation to his right side body. The policy issued by the OP covers the above said disability and as such complainant submitted the claim form for the assured amount with relevant medical document but, the OP repudiated the claim on 20.11.2023 through letter to the complainant based on untenable grounds and hence, the complainant filed this complaint against the OP for the claim of assured amount based on the policy.
Written Version of OP.
3. The notice issued by this commission to the OP was served upon it and the OP appeared through its counsel before this commission and filed its W.V. and the gist of the W.V. is as below.
The OP has admitted the fact of purchase of policy by the complainant from the OP under policy bearing No.0239461184 covering the period from 03.11.2022 to 02.11.2023 and the said policy covers any risk arising out of accident. To underwrite any risk, the vital requirement is that, the risk should have been caused due to accident. The accident must be a sudden, unforeseen and involuntary event, caused by external, visible and violent means but, in the present case of the complainant the complainant has not produced any documents to prove that, his condition of paralyses was due to accident as per the history of medical report the weakness in RT upper limb and lower limb since 1 month with tingling sensation and further diagnosed with CVA Stroke with RT Hemiplegia meaning that, the present unfortunate condition of the complainant is due to stroke (illness) and not by accident and hence the repudiation of the claim is accordance with the terms of the policy and there is no deficiency of service caused by the OP to the complainant. It is denied that the complainant is entitle for assured amount of Rs.10,00,000/- from the OP, the policy covers only to the risk caused due to accident and not for illness. The allegation regarding the stepping down through stair case from the roof of his house and slipped down and caused internal head injury is false and denied by the OP. The assessment of disability at 75% is wrong and the same is denied by the OP, the paralysis as alleged by the complainant is due to sickness ailment and not caused due to any accident and hence, the policy does not covered the claim of complainant. In view of the above said facts and circumstances of the case the OP prayed to dismiss the complaint.
Evidence of complainant.
4. The wife of the complainant Smt. Prabha W/o Suresh Guttedar and the P.A. holder has been examined as P.W.1 and another witness by name Dr.Lingaraj Kadadi S/o Vishwanath Kadadi has been examined by filing his evidence affidavit as P.W.2 and got marked documents Ex.P.1 to Ex.P.9 which are as follows,
- Ex.P.1-Copy of Group Accident Guard policy certificate.
- Ex.P.2-Copy of certificate issued by Gurunanak Hospital dt:11.07.2023.
- Ex.P.3-Copy of disability certificate issued by department of Empowerment of persons with disabilities, Ministry of Social Justice and Empowerment, Government of India dt:09.10.2023.
- Ex.P.4- Copy of claim form dt:10.10.2023.
- Ex.P.5-Copy of repudiation letter dt:20.11.2023.
- Ex.P.6-Copy of photo.
- Ex.P.7-Oiginal special power of attorney.
- Ex.P.8-Copy of MRI Brain Plain Study dt:08.07.2023. (2 pages)
- Ex.P.9-Copy of case sheet issued by Shubham Neuro Center dt:24.08.2023.
Evidence of Opponent.
5. One, Manjunath G. S/o Govindaiah Associate Vice President legal claims of OP Company, has been examined as R.W.1 by filing his evidence affidavit on behalf of OP and 3 documents got marked as per Ex.R.1 to Ex.R.3 on behalf of OP Company which are as below.
- Ex.R.1-Copy of Group Accident Gaurd policy certificate.
- Ex.R.2-Copy of terms and conditions of policy.
- Ex.R.3-Copy of repudiation letter dt:04.12.2023.
Points/Issues.
6. The OP has submitted its written argument. Heard the arguments advanced by the parties. On perusal of the pleadings and the documents of the parties, this commission raised the points for consideration as below;
- Whether the complainant proves that, he is consumer to the OP and further proves the deficiency of service is caused by the OP in not settling his claim of insurance?
- Whether the complainant is entitled for any relief as sought in his complaint?
- What orders?
7. Our answers to the points raised above are as follows: -
- In the affirmative.
- In the affirmative.
- As per the final order.
Points No 1 and 2.
8. In order to decide the complaint issues, this commission discussed points/issues No.1 and 2 together, as each points are inter related to each other- as follows.
9. In order to prove the case of the complainant the complainant has lead his evidence as P.W.1 by way of reiterating the complaint facts and another witness by name Dr.Lingaraj Kadadi S/o Vishwanath Kadadi has been examined by filing his evidence affidavit as P.W.2, got marked Ex.P.1 to Ex.P.9 documents on his behalf. One, Manjunath G. S/o Govindaiah Associate Vice President legal claims of OP Company, has been examined as R.W.1 by filing his evidence affidavit on behalf of OP and 3 documents got marked as per Ex.R.1 to Ex.R.3 on behalf of OP Company and got reiterated the facts of W.V. in his evidence affidavit.
10. The case of the complainant is that, The complainant was a contractor by profession he has purchased Group Accident Guard Policy from OP through India Post Payments Bank Ltd., under certificate of insurance policy No.0239461184 certificate No.04532160 covering period from 03.11.2022 to 02.11.2023 by covering health problems, hospitalization and accidental medical expenses including accidental disablement and paralysis. The wife of the complainant Smt.Prabha is the nominee for the said policy. The assured would be entitled for an amount of Rs.10,00,000/- in case of permanent partial disability for any kind of ailment, paralysis etc. On 08.07.2023 while complainant Sri.Suresh S/o Mallanna Guttedar was stepping down the stairs from the roof of his house he slipped down and caused internal head injury, immediately taken him to Gurunanak Hospital Bidar and conducted MRI Scan and diagnosed that, the complainant suffered with paralypitic/paralysis stroke, the right said body become paralyzed, after providing with conservative treatment he was discharged. The complainant approached medical board of BRIMS Hospital Bidar for evaluation of disability and after examination issued disability certificate No.KA2045191960186235 dt:09.10.2023, stating that it is a case of multiple disability diagnosed Rt Hemiplegiya and he has 75% permanent disability in relation to his right side body. The policy issued by the OP covers the above said disability and as such complainant submitted the claim form for the assured amount with relevant medical document but, the OP repudiated the claim on 20.11.2023 through letter to the complainant based on untenable grounds.
11. The complainant has produced Ex.P.1 the copy of Group Accident Guard Policy bearing No.0239461184, purchased in the name of the complainant Suresh for the period 03.11.2022 to 02.11.2023, in which the Accidental Dismemberment and Paralysis covers and the amount shown as Rs.10,00,000/- as an assured amount, for permanent partial disability the assured amount shown as Rs.10,00,000/-. The OP is not disputed Smt.Prabha as nominee to the said policy. The complainant also produced Ex.P.7 the power of attorney executed by the complainant Suresh in favour of his wife Smt.Prabha to conduct the case on behalf of him before this commission which is not disputed by the OP. Hence, the complainant has proved that, he is consumer to the OP and OP is considered as service provider to the complainant.
12. The complainant has produced Ex.P.4 the copy of claim form submitted by the complainant on 10.10.2023 to the OP. The complainant also produced Ex.P.5 the copy of repudiation letter issued by OP to the complainant on 20.11.2023 and OP assigned the reasons for repudiation of the claim that, the cause of paralysis is due to sickness in the subject case, regret for not considering the claim under the policy. The OP has denied the claim of the complainant that, the paralysis to the complainant is due to sickness, but the OP has not produced any such evidence to show that, the complainant suffered paralysis due to sickness only. The complainant has produced Ex.P.2 the diagnosed letter issued by Dr.Lingaraj Kadadi Gurunanak Hospital on 11.07.2023, in which he has certified that, the said Suresh diagnosed with CVA Stroke with right Hemiplegia. The complainant has also produced Ex.P.8 the MRI Brain Plain Study report issued by New Medi Scan dt:08.07.2023, which was referred by Dr.Lingaraj Kadadi. The complainant further examined the said Dr.Lingaraj Kadadi as P.W.2 and the said Dr. Dr.Lingaraj Kadadi stated in his evidence affidavit that, “when the patient Suresh S/o Mallanna was brought to him on 08.07.2023 he was unconscious and his wife told that, the said Suresh fell from their house staircase/steps while getting down from the house roof top and had sustained injury on his head and fainted and after examining his head and body found swelling injury over his head and his right side portion of body was not in proper regular movement and after MRI report found right side Hemiplegia/ right side body paralysis”.
13. The OP called P.W.2 for his interrogatories and in the interrogatories the P.W.2 given an answer that, the injury can cause the Hemiplegia and further answered that, the sufferance of stroke and becoming unconscious, was due to injury, which resulted in swelling over the head. In view of the evidence of P.W.2 he has clearly stated in his evidence that, the complainant sustained injury over his head. This evidence has not been falsified by the OP through his interrogatories or by producing any cogent evidence before this commission. P.W.1 the P.A. holder of the complainant also stated in her evidence that her husband/complainant fell down from the stairs of his house and caused injury to his head, which cover the ingredients of accident.
14. The complainant has produce dEx.P.3 the disability certificate issued by Department of Empowerment of Persons with disabilities, Ministry of Social Justice and Empowerment, Government of India dt:09.10.2023, in which it is mentioned that, the complainant Suresh has 75% permanent disability in relation to his right side body due to right Hemiplegia. The OP has not challenged this disability certificate issued to the complainant before any competent authority and hence, the disability certificate as per Ex.P.3 is considered as an evidence in favour of the complainant to consider his disability to the extent of 75% permanent disability to his right side body. In view of the above said document Ex.P.3 and the evidence of P.W.2 we find that, there is no such reason to consider the repudiation of the claim of the complainant under law.
15. The complainant produced Ex.P.9 the case sheet pertaining to Shubham Nero Centre dt:24.08.2023 which was diagnosed the right Hemiplegia to the complainant by the said centre which supports the case of complainant. The OP has produced Ex.R.1 and Ex.R.2 the Group Accident Guard policy with the terms of said policy, in which under head B2 Accidental Dismemberment and Paralysis the company is liable to pay the sum insured to the complainant as it covered the cause and the period of policy and hence, the repudiation letter issued by as per
Ex.R.3 =Ex.P.5 is not proper and legal and this commission find it as a deficiency of service caused by the Op towards the complainant in not settling the claim of insurance.
16. In view of the above said discussion we are of the considered opinion that, the complainant has proved his case against the OP for the deficiency of service to the complainant, accordingly we answered the point No 1 and 2 in the affirmative in favour of complainant and proceed to pass the following order.
::ORDER::
The complaint u/s 35 of CP Act 2019, filed by the complainant is hereby allowed in part as against OP.
The OP is hereby directed to pay an amount of Rs.10,00,000/- (Rupees ten lakhs) under Group Accident Guard policy No. 0239461184 as per Ex.P.1=Ex.R.1 with interest at the rate of 9% p.a. from the date repudiation letter Ex.P.5 dt:20.11.2023 till the realisation of entire amount to the complainant within 45 days from the date of this order.
The OP is hereby further directed to pay the compensation of Rs.10,000/- for the sufferance and mental agony caused to the complainant and Rs.5,000/- litigation expenses to be paid by the OP to the complainant.
Intimate the parties accordingly.
(Typed to our dictation then corrected, signed by us and then pronounced in the open Commission on this 16th day of November-2024).
Kum. Kavita, Member DCDRC Bidar. | | Shri.MabuSaheb H. Chabbi, President DCDRC Bidar. | |
Documents produced by the complainant.
- Ex.P.1-Copy of Group Accident Gaurd policy certificate.
- Ex.P.2-Copy of certificate issued by Gurunanak Hospital dt:11.07.2023.
- Ex.P.3-Copy of disability certificate issued by department of Empowerment of persons with disabilities, Ministry of Social Justice and Empowerment, Government of India dt:09.10.2023.
- Ex.P.4- Copy of claim form dt:10.10.2023.
- Ex.P.5-Copy of repudiation letter dt:20.11.2023.
- Ex.P.6-Copy of photo.
- Ex.P.7-Oiginal special power of attorney.
- Ex.P.8-Copy of MRI Brain Plain Study dt:08.07.2023. (2 pages)
- Ex.P.9-Copy of case sheet issued by Shubham Neuro Center dt:24.08.2023.
Document produced by the Opponent.
- Ex.R.1-Copy of Group Accident Gaurd policy certificate.
- Ex.R.2-Copy of terms and conditions of policy.
- Ex.R.3-Copy of repudiation letter dt:04.12.2023.
Witness examined.
Complainant.:-
P.W.1- Smt. Prabha W/o Suresh Guttedar, (P.A.holder) (complainant wife).
P.W.2- Dr.Lingaraj Kadadi S/o Vishwanath Kadadi.
Opponent:-
R.W.1- Manjunath G. S/o Govindaiah Associate Vice President legal claims of OP Company.
Kum. Kavita, Member DCDRC Bidar. | | Shri.MabuSaheb H. Chabbi, President DCDRC Bidar. |
