DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM
Dated this the 5th day of October, 2023
Filed on: 30/06/2021
PRESENT
Shri.D.B.Binu President
Shri.V.Ramachandran Member
Smt.Sreevidhia.T.N Member
CC NO. 221/2021
Between
COMPLAINANT
Anil, S/o. Bhaskaran, Kanakuzhi Puthenpurayil, Pandappilly, Aarakkuzha, Muvattupuzha 686672.
(Rep. by Adv. Jain Jacob, Court Road, Muvattupuzha)
VS
OPPOSITE PARTIES
- Manager, The New India Assurance Company Ltd., Kavikunnel Chambers, MC Road, Muvattupuzha 686661.
- Manager, The New India Assurance Company Ltd., Neha Towers, Near Govt. Hospital, KH Iyer Road, Perumbavoor 683542.
(Rep. by Adv. Joy Jeseph, J&J Associates, MRRA-82, New JNDJA Lane, Kochi 682023)
FINAL ORDER
Sreevidhia T.N., Member:
- A brief statement of facts of this complaint is as stated below:
The complainant is a taxi driver. The complainant had taken a Mediclaim policy from the 1st opposite party. The complainant had also taken an insurance policy from the 2nd opposite party for getting insurance coverage for his vehicle KL-07S-4364 Mahindra & Jeetho.
On 18-01-2021 the complainant had met with an accident at Muvattupuzha and subsequently he was admitted to Muvattupuzha Medical Centre and as it was the covid season he was treated and was sent home in the evening. The doctor who treated the complainant at Muvattupuzha Medical Centre suggested that he should consult a doctor at a dental hospital. Since the doctor found that the complainants 4 teeth were loose and hanging and the complainant has been treated accordingly. Due to the hit of the complainants face and left rib area at the steering part of the vehicle caused pain and dizziness to the complainant in the next day. Therefore the complainant had seen a doctor named James Mani at Koothattukulam. The complainant has been scanned and taken meditation as per the instructions of Dr. James Mani. The doctor has suggested the complainant that it is enough to take rest at home as it is the time of covid. But on 05-02-2021 the pain in the left side of the rib was more than usual and dizziness also occurred. So the complainant consulted the doctor at Nirmala Medical Centre again. On X-ray the surgeon saw fractures in the left portion of the ribs, therefore the complainant was admitted at Nirmala Medical Centre from 05-02-2021 to 07-02-2021.
The complainant had to spent an amount of Rs.66,127/- towards medical expenses at Muvattupuzha Medical Centre . The 1st opposite party has transferred Rs.20,273/- only to the complainants account as Mediclaim policy. The complainant states that the opposite party shall reimburse the full amount of the claim. The complainant also states that he had spent Rs.64,219/- for his treatment and he is liable to get the balance amount Rs.43946/- from the 1st opposite party.
The complainant states that he had spent Rs.72,500/- for the repair works of his vehicle but the 2nd opposite party has transferred only Rs.26,766/- and he is liable to get the balance amount of Rs.45,734/- .
The complainant had also sent a legal notice to the opposite party on 27/04/2021 to get balance amount.
Hence the complainant approached this Commission to readdress his grievances and to get Rs.1,14,680/- including the balance amount Rs.43946 from the 1st opposite party with respect to the Mediclaim policy of the complainant, Rs.45734/- with respect to the vehicle repair claim from the 2nd opposite party, Rs.25,000/- towards compensation for mental agony and hardships suffered by the complainant along with 12% interest.
2 Notice :
Notice was issued to the ops from this Commission on 16/08/2021 and the ops appeared and filed their joint version.
3 Version:
The Complaint is not maintainable either under law or facts. The vehicle is a Commercial vehicle insured with a commercial vehicle package policy.The Complaint is not maintainable as multiple causes of action and reliefs under different policies issued from different offices are clubbed together in one Complaint and hence liable to dismissed on this ground alone.
The Complainant had submitted a mediclaim under the mediclaim policy as above for IP treatment from 5.2.2021 to 7.2.2021; admitted with pain left chest with h/o road accident 15 days back; Straping done; Dental Consultation for loose tooth. The Complainant submitted bills for Rs.66727/. Out of the above bills, one bill for Rs.42, 000/dated 16.2.2021, after the above IP Treatment from a Dental Clinic, is for ceramic crown -dental cap- done which was not paid as it does not fall under medical expenses required towards Reasonable and Customary and Medically Necessary Expenses as covered in the policy. Bills amounting to Rs.433/ were also not paid as those bills were for non-medical items. Further Rs.2,716/ was not paid as there was no bills for the same. Rs.800/ towards X-ray charges was not paid as X-ray Report was not attached along with the claim. After deducting the above non payable amount totaling Rs. 45,949/, this Opposite Party paid Rs.20,273/ towards settlement of the claim under the policy
The Opposite Party, under the Terms & Conditions of the Policy, is liable only to the actual medical expenses Reasonable and Customary and Medically Necessary Expenses admissible under the Policy. Hence the nonpayment of the amount as above is legal and valid under the Policy. The Complainant is not entitled for any further amount in this regards towards medical expenses under the policy.
The Complainant submitted a motor claim dated 22.1.2021 for alleged damage to his vehicle KL-17-S-4364 on 18.1.2021 when it lost control and hit on a wall, with an estimate of Rs.72,500/. One passenger in the vehicle also sustained injury in the accident. The accident and damage were reported to this Opposite party after shifting the vehicle to workshop and with a delay of 4 days of the incident. No opportunity was given to this Opposite party to inspect the vehicle on the spot of the accident which is an essential requirement for commercial vehicles met with accident with Third party injury/ property damage for admitting the liability under the policy. However, immediately on getting the intimation, this opposite party deputed a competent and IRDA approved Surveyor to assess the loss and he inspected the vehicle on 23.1.2021 and subsequent dates. The vehicle is a 2018 model commercial vehicle, subject to depreciation @ 15 % for metal parts and 50% for rubber parts. The Policy Excess is Rs.500/. The vehicle was repaired and re inspection of the vehicle was done by the surveyor. The bill amount towards labour and parts replacement of the vehicle is Rs.38,700/. The surveyor after deducting depreciation, policy Excess (Rs.500) and salvage value (Rs.300), assessed the net loss payable under the policy based on the repair bills for Rs.29, 740/ and submitted his Report and Re inspection Report dated 22.2.2021.
The Complainant is not entitled for any further amount in respect of the above two claims from this Opposite party under the above two policies. The averment in the complaint that the complainant is not bound by any conditions of the policy is not true and correct and it is made only out of his ignorance in this regard. It is a settled law of land that Insurance is a Contract and both the parties are bound by the Terms and Conditions of the contract as evident in the Policy. The Insured cannot claim anything more than what is covered in the Policy. There is no deficiency of service or unfair trade practice from the side of this Opposite Party.
4 Evidence:
Evidence in this complaint consists of proof affidavit filed by the complainant and the documentary evidence filed by the complainant which were marked as Exbt A1 to A8. Exbt. A6 series and Exbt A7 marked subject to objection from op’s counsel. Complainant is cross examined by the opposite party’s counsel and his depositions are recorded as Pw1. Opposite party filed 6 documents which were marked as Exbt B1 to B6.
Heard both parties
5. Issues:
- Whether any deficiency in service or unfair trade practice is proved from the side of ops towards the complainant?
- If so, reliefs and compensation?
The case of the complainant is that he had taken one Mediclaim Policy from the 1st opposite party for the period from 29/01/2021 to 25/01/2022 with Policy No. 76160034209500000216. The sum assured for the above said policy was Rs.5,00,000/- as evidenced by Exbt. A1. The complainant had also taken Policy Schedule cum Certificate of Insurance for his vehicle Mahindra & Jeeto KL7-S4364 (Commercial Vehicle Package Policy) from the 2nd opposite party; which has a coverage of insurance from 09/07/2020 to 18/07/2021. The complainant had met with an accident on 18/01/2021 at Muvattupuha and was admitted at Nirmala Medical Centre, Muvattupuzha. The complainant states that the doctor who treated him at the Nirmala Medical Centre, Muvattupuzha suggested to consult a dentist since the complainant’s 4 teeth were found loosening and handing after the accident on 18/01/2021. The complainant was admitted in Nirmala Medical Centre from 05/02/2021 to 07/02/2021. The complainant had spent Rs.66,127/- for his treatment. The 1st opposite party had transferred an amount of Rs.20,273/- to the Bank of India account of the complainant towards the Medical claim of the complainant. The complainant states that he is eligible to get the balance amount of Rs.43,946/- also from the 1st opposite party towards the Mediclaim availed by the complainant from the 1st opposite party.
The complainant had also taken a vehicle insurance coverage policy for his vehicle Mahindra & Jeeto KL 7-S-4364. The complainant states that he had to spent Rs.72,500/- for the repair of the vehicle after the accident on 18/01/2021. But 2nd opposite party has given only an amount of Rs.26,766/- to the complainant towards insurance claim. The complainant had submitted all the documents to the opposite parties for receiving the claim amount of the two policies taken from the opposite parties.
We have verified all the documents and evidence filed from both sides. Exbt. A1 is the Mediclaim Policy of the complainant for the period from 29/01/2021 to 28/01/2022. Exbt. A2 is the vehicle package policy of the complainant’s vehicle. Exbt. A3 is the CT Scan report of the complainant. Exbt. A4 is the discharge certificate of the complainant for his treatment at Nirmala Medical Cetnre, Extbt. A5 is the treatment bills of the complainant.
As per Exbt. A1 policy, it is evident that the policy is valid from 29/01/2021 to 28/01/2022 and the previous policy period is from 29/01/2020 to 28/01/2021 as per Policy No. 7616003419950000208. The accident was occurred on 18/01/2021. Exbt. A4 is discharge summery the complainant was admitted in the hospital with pain, left chest with h/o road accident 15 days back. Straping was done and dental consultation for loose tooth also done. The complainant had submitted bills for Rs.66,727/-. CT Scan report is produced as Exbt. A3. On 19/01/2021 the complainant had paid Rs.2,500/- as CT Scan charges of Brain at New Amma Scan & Diagnostic Centre. From the available documents filed by the complainant it is evident that Exbt. A1 Mediclaim policy had insurance coverage only from 29/01/2021 and the date of the accident was on 18/01/2021. Exbt. A1 policy also reveals that the complainant had a previous Mediclaim policy from the 1st opposite party for period from 29/01/2020 to 28/01/2021. Exbt. A1, A4 reveals that the complainant is eligible to get his medical expenses of the accident happened on 18/01/2021. PW1 at the time of cross examination admitted that Exbt. A2 Mediclaim policy started after the date of accident. PW1 also added the fact he had taken mediclaim policy from the 1st opposite party in the previous year also and hence he has a valid policy on the date of accident.
The alleged incident was on 18/01/2021. The opposite party argued that there is no mention or treatment for any injury to teeth till 08/02/2021. But Exbt. A4 discharge certificate there is mention about the ‘loose teeth’. The opposite party had paid expenses for root canal treatment relying on Exbt. A4 discharge certificate. The opposite party argued that crowning dental car is not a treatment and it does not fall under medical expenses. Complainant during cross examination admitted that x-ray is available but not produced before the Commission. In the version filed by the opposite party the opposite party stated that the bills amounting to Rs.433/- were not paid as those bills were for non-medical items, Rs.2,716/- was not paid as there was no bills for the same, Rs.800/- towards x-ray charges are not paid as x-ray report was not attached along with the claim. Thus the opposite party had paid Rs.20,273/- towards settlement of the mediclaim policy. The complainant is not entitled for any further amount towards medical expenses under the mediclaim policy taken from the 1st opposite party and hence there is no deficiency in service or unfair trade practice from the side of the 1st opposite party. There was no document to prove that the complainant had occurred dental injury on 18/01/2021 due to the alleged accident.
The complainant vehicle has a insurance coverage for the period from 19/07/2020 to 18/07/2021 and hence the insurance of the vehicle is valid on the date of accident of the vehicle ie. on 18/01/2021. Exbt. A7 is the quotation from Sreelakshmi Automobiles for Rs.72,500/-. Exbt. A8 is a legal notice sent by the complainant to the opposite parties seeking the balance claim amount of two insurance policies. The complainant in his complaint states that he had spent Rs.72,500/- for the repair of the vehicle. Exbt. A7 produced by the complainant is only a quotation issued by Sreelakshmi Automobiles, East Vazhappilly, Olippara, Muvattupuha on 21/01/2021. The complainant has not produced any relevant documents to prove that he had to spent Rs.72,500/- for the repair works of the vehicle.
On produced Exbt. B4 survey report dated 22/02/2021. The motor survey report produced by Saly K.K., Insurance Surveyor & Loss Assessor calculated the net payable loss is as Rs.29,745/-. The opposite party in their version states that they had deducted 10% from the above calculation for not giving opportunity for spot inspection and spot survey and hence the claim is settled for Rs.26,766 (Rs.29,740-Rs.2,974/-). The complainant had deposed in box that he had produced necessary bills regarding the repair of the vehicle. There are no bills produced by him in this regard. Even though the complainant had produced the copy of question showing the cost of some spare parts and repairing charges, the complainant had not produced the bill issued by the service centre to prove that he had paid any such amount for servicing the vehicle of the complainant.
From the available documents filed in this case, the complainant has not produced any relevant documents to prove that he had to spent Rs.72,500/- towards the repair of the vehicle. Since the vehicle is a 2018 model (as evidenced by Exbt. A2) depreciation is to be deducted. In this circumstances the Commission has no other way but to rely on the survey report produced by the Insurance Surveyor. From the available documents filed by the complainant no deficiency in service or unfair trade practice is proved from the side of the opposite party towards the complainant in respect of the above two insurance claim from the opposite parties under the above two policies. Hence Point No. (1) is proved not in favour of the complainant and is found liable to be dismissed and accordingly dismissed.
Pronounced in the Open Commission this the 5th day of October,2023.
Sreevidhia.T.N, Member
D.B.Binu, President
Forwarded/by Order
Assistant Registrar
Appendix
Complainant’s evidence
Exhibit A1: Copy of Policy Schedule
Exhibit A2: Copy of Policy Schedule cum Certificate of Insurance
Exhibit A3: Copy of scanning report
Exhibit A4: Copy of discharge summary
Exhibit A5: Copy of certificate from Nirmala Medical Centre
Exhibit A6: Copy of Receipt (Out patients)
Exhibit A7: Copy of Quotation
Exhibit A8: Copy of lawyer notice
Opposite party’s evidence
Exhibit B1: Copy of Policy Schedule cum Certificate of Insurance
Exhibit B2: Copy of Medi Claim Insurance Policy
Exhibit B3: Copy of Motor Accident Claim Intimation
Exhibit B4: Copy of Motor Survey Report
Exhibit B5: Copy of letter issued to the complainant
Exhibit B6: Copy of letter issued to the complainant
Despatch date:
By hand: By post
kp/
CC No. 221/2021
Order Date: 05/10/2023
