Ld Advocate for the complainant is present. Judgement is ready and pronounced in open Commission in 6 pages 3 separate sheet of paper. 

BY - SRI.SAURAV CHANDRA, MEMBER

1. Brief facts of the Complainant’s case are that the Opposite Party is an insurance company from whom the Complainant being a Senior Citizen–cum–Fisherman Member of the Digha Fishermen & Fish Traders Association, took a Group Insurance Policy No.0317014221P101817266 for the period 01.06.2021 to 31.05.2022 with a Sum Assured of Rs.2,00,000.00.

2. Sudden on 13.02.2022 during dusting ice in the Ice Breaking Machine at the trawler in Rasulpur Ferry Ghat, the Complainant made an accident for which his right hand was amputated.

3. The Complainant has obtained Certificate of Disability from the Contai Sub-Divisional Hospital on 02.06.2022 and accordingly informed to the Op with an Insurance Claim of Rs.2,00,000.00 vide Claim No.0317014222C050003001/1 but, the said claim has been repudiated by the Op on the ground of Loss of Single Limb covered only where Permanent Partial Disablement (PPD) is taken in the policy. As the Group PA Policy has taken for the fishermen under Risk Group – III covering Table Benefit – II (Death, PTD), the claim cannot be processed and is repudiated under Table Benefit – II.

4. Therefore, the Complainant being aggrieved filed the instant case before this Commission.

5. The cause of action of this case arose on and from 20.03.2023 when the Op repudiated the Complainant’s genuine claim.

The Complainant, therefore, prays for:-

1. To pay the Insurance Claim amount of Rs.2,00,000.00 by Op with Interest @10% p.a. from 13.02.2022 till realization.

2. To pay Compensation of Rs.1,50,000.00 for mental agony.

3. To pay Litigation Cost of Rs.20,000.00 to the Complainant for conducting the case.

4. Any other reliefs.

6. Notice was duly served upon the Op but, the Op has preferred to see the case be decided ex-parte against it.

7. Under the above circumstances, the Complainant has prayed for an ex-parte order against the Op.

8. Points for determination are:

1. Is the case maintainable in its present form and in law?
2. Is the Complainant entitled to the relief(s) as sought for?

9. Decision with reasons

1. Both the points I and II, being inter related to each other, are taken up together for discussion for sake of brevity and convenience.

2. We have carefully perused the Complaint, Complainant’s Fishermen Registration Card issued by the Department of Fisheries (Govt. of West Bengal), Fishermen Group Insurance Policy, Discharge Summary, Enquiry Report of the Contai Police Station, Claim Disposal Request Letter issued by the Digha Fishermen & Fish Traders Association, Certificate of Disability, Insurance Claim Form duly filled by the Complainant and Insurance Claim Repudiation Letter by the Op. along with all receipts and other documents.

3. Having regards had to the facts and circumstances of the case in the light of evidence, it is evident that there is no dispute that Complainant is a consumer having grievances against the Op, as such the case is maintainable in its present form and in law.

4. In the Repudiation Letter issued by the Op has mentioned about the Table Benefit – II (Death, PTD) under which the Complainant is covered. Loss of single limb covered only where PPD is taken in the policy. As the loss of single limb of the Complainant (amputation of right hand below the elbow), the claim could not be processed under Table Benefit – II.

5. In the above context this Commission is defining the terms of PTD and PPD as under :-

Permanent Total Disability (PTD) – It means when insured is permanently totally and absolutely unable to engage in any occupation or employment of any description whatsoever. Total Disablement means such disablement whether of a temporary or permanent nature, as incapacitates workman for all work which he was capable of performing at the time of the accident resulting in such disablement.

Permanent Partial Disability (PPD) – It means the permanent loss of use or function of any portion of your body resulting from your accepted conditions. PPD is based on a formula set by law and administrative rule.

6. Now, the only question which is required to be decided is whether the Complainant suffered from the total disablement or not ?

As per the observation of this Commission, the injured Complainant in this case is a fisherman by profession. By loss of the Right Hand above the elbow, he has evidently been rendered unfit for the work of fisherman as the work of fisherman cannot be done by one hand only. Therefore, this is not a Permanent Partial Disablement but, a fit case for Permanent Total Disablement in nature. Although in the Certificate of Disability issued by the Govt. of India, the percentage of disability is mentioned as 65% but, keeping in view the complete disablement of the work by the Complainant, it should be treated as Permanent Total Disablement (PTD).

The Hon’ble Supreme Court of India has also held the similar judgment in the following three cases:-

1. Pratap Narain Singh Deo - Vs. - Srinivas Sabata & Anr. [Civil Appeal No.1536 of 1970]
2. K. Janardhan - Vs. - United India Insurance Co. Ltd. [Civil Appeal No.5831 of 2002]
3. Arjun S/o. Ramanna @ Ramu - Vs. - IFFCO Tokio General Insurance Co. Ltd. & Anr. [Civil Appeal No.1555 of 2022 @SLP(C) No.26384 of 2019]

7. Therefore, it is clearly transpires, there are not only elements of Negligence and Gross Deficiency in Service but also forced the Complainant to suffer a severe economic loss, harassment and mental agony by the whimsical act of the Op.

8. Now, coming to the matter of reliefs, the Op can’t get absolved from the mischief of Negligence, Harassment and Gross Deficiency in Service. The Personal Accident Group Insurance Claim for Rs.2,00,000.00 should be entertained by the Op for necessary settlement by treating this case as Permanent Total Disablement - (PTD) and dispose in accordance with the Insurance Regulatory & Development Authority (Protection of Policyholders’ Interest) Regulations, 2002; within 30 days from the date of this order in default the Op will have to pay a simple interest @10% per annum in addition to the settled amount for non-compliance from the date of this order. So, we think it would just and proper if we direct the Op to pay a sum of Rs.20,000.00 towards Compensation and Rs.5,000.00 as Litigation Cost to the Complainant within 30 days from the date of this order in default the Op will have to pay @ Rs.100.00 per diem (day)  in addition to the said amount for non-compliance from the date of this order.

1.  Accordingly, both the points are decided in favour of the Complainant.

10.  Thus, the complaint case fully succeeds.

Hence, it is

        O R D E R E D

That the CC-34 of 2023 be and the same is allowed ex-parte against the Op.

The Op is hereby directed to entertain the claim of the Complainant amounting to Rs.2,00,000.00 for necessary settlement by treating this case as Permanent Total Disablement - (PTD) and dispose in accordance with the Insurance Regulatory & Development Authority (Protection of Policyholders’ Interest) Regulations, 2002; within 30 days from the date of this order in default the Op will have to pay a simple interest @ 10% per annum in addition to the settled amount for non-compliance from the date of this order.

The Op is also directed to pay a sum of Rs.20,000.00 towards Compensation for Gross Negligence and Deficiency in Service and Rs.5,000.00 as litigation costs to the Complainant within 30 days from the date of this order in default the Op will have to pay @ Rs.100.00 per diem (day) in addition to the said amount for non-compliance from the date of this order.

The Complainant would be at liberty to put the order into execution u/s 71 of the Consumer Protection Act, 2019 and to initiate a proceeding u/s 72 of the Consumer Protection Act, 2019.

Let a copy of this judgment be provided to the Complainant free of cost.

The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.

File be consigned to record section along with a copy of this         judgment.