State Consumer Disputes Redressal Commission
Mr. Captain Jangam Raghunath Gowd vs 1.The Oriental Insuranceco. Ltd., on 19 November, 2024
1
BEFORE THE TELANGANA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION: HYDERABAD.
CC.NO. 86 OF 2020
Between:
1) Mr. Captain Jangam Raghunath Gowd,
S/o Late Sri J.M.Goud,
R/o. Plot No.21 &23, Santho shimaa Colony,
Near AOC Gate, west Marredpally,
Secunderabad-500026.
....... Complainant
And
1.The Oriental Insurance Company Ltd., Rep by its Divisional Manager, Aviation Underwriting Cell, Oriental House, 2nd Floor, #7, Tata Road, Churchgate, Mumbai, Maharashtra. India - 400020.
2.M/s Jet Airways (India) Limited, Rep by its Director, Address at Soriya Centre, Sahar Airport Road, Andheri (E ), Mumbai, Maharashtra. India.
Pin 400099.
... Opposite parties 1 & 2 Counsel for the Complainant : M/s. KRR Associates Counsel for the Opposite Party No.1 : Mr. S.Satyananada Rao Counsel for the Opposite Party No.2 : [Paper Publication filed] QUORUM: Hon'ble Sri K.Ranga Rao - Presiding Officer-
Member- (Judicial).
& Hon'ble Smt.R.S.Rajeshree, M ember (Non Judicial).
TUESDAY, THE NINETEENTH DAY OF NOVEMBER, TW O THOUSAND TWENTY FOUR ***** Order : (Per Hon'ble Sri K.Ranga Rao- Presiding Officer-
Member - (Judicial).
1). This complaint is filed on 29.12.2020by the Complainant namely Mr.Captain Jangam Raghunath Gowdu/s. 47(1) of Consumer Protection Act,2019 praying this State Commission to direct opposite party No.1Insurnace company :2
(a )To pay TOP-UP Policy amount of Rs.1,15,00,000.00(Rupees one crore fifteen lakhs only) with interest @ Rate of 24% p.a. from the date of payment till realization.
(b) To pay balance amount of Rs.57,50,000/-. Towards the base policy and to pay compensation of Rs.10,00,000/- with interest @ 24% p.a. from the date of payment till realization.
(c) To pay a sum of Rs.10,000,00/- towards mental agony and unfair trade practice with interest @ 24% p.a. from the date of payment till realization.
(d) To pay damages and costs of Rs.1,00,000/-with interest @ 24% p.a. from the date of payment till realization.
And to pass such other relief or reliefs as this State Commission deems fit and proper in the circumstances of the case.
The brief averments of complaint are as follows:
2). The complainant was an Airline Pilot and having the Airline Transport Pilots Licence (ALTP) vide No.1485, issued on 08.09.1989 by the Director General of Civil Aviation, Government of India.
The complainant was employed by the opposite party No.2 M/s. Jet Airways ( India) Limited from 21.11993 and was Designated as Senior Commander and was flying Air Bus Airplanes A330/300 all over the World with an impeccable record of about 20,000/- Hours of Flying time experience till the last operated flight on 21.01.2016, which the complainant had flown the International Flight from Brussels to Mumbai. The complainant has worked with the opposite party No. 2 during his entire service period and was operating flights(Flying) till the last day of his ALTP Licence was cancelled.
The opposite party No.2 Jet Airways has obtained a Group Insurance Policy in the year 2009 from opposite party No.;1 Oriental Insurance Co. Ltd and the said policy was in existence till 2018. The policy is named as wad tailor made and was called "Aviation Lose of License Insurance Policy (Group) vide Policy 3 No.112400/43/2016/65 (LOL) by paying premium amount of Rs.1,06,01,973/-. The policy was issued to all the employees of about one thousand members of opposite party No.2, by opposite party No.1 upon agreed terms and conditions. The complainant was also member of the group (LOL) Policy since 2009 and was also a member of the National Aviators Guild (NAG) Pilots union since inception. As per the terms and conditions of policy, in case of any claim, the policy is covered for an amount of Rs.1,15,00,000/- (Rupees one crore fifteen lakhs only).
The complainant further submits that opposite partyNo. 1 insurance company along with Oppositeparty no.2 Jet Airways and the Pilot Association (NAG) after vide consultations since the year 2013, have come up with the Tailor made additional "TOP UP"
Insurance Policy along with the existing primary policy for the staff of about 1000 Employees of Opposite party No. 2 Jet airways. The complainant has also opted for the Additional Top UP Policy vide No.1124000/43/2016/159, and apart from primary insurance LOL policy the "ADD ON TOP UP" policy was also taken and additional top up policy which is also loss of license (LOL). Premium amounts were deducted from the salary of the complainant. The Additional Top UP Policy which is also obtained for the first year from 07.12.2015 to 06.12.2016 for which premium was deducted from the salary of the complainant from November 2015 salary by Opposite party No.2 (Employer) and paid the same to the Opposite party No.1 insurance company. The premium for the second year of TOP UP Policy,covering from 05.01.2017 to 04.01.2018 was deducted from the salary of complainant of November/December 2016 Month. As such both the polices are covered for any eventuality. The liability of the Insurance Company shall be Limited to ONE HUNDRED PERCENTUM OF THE CAPITAL SUM ISNURED. In the present policy, in case of loss of licence by the Pilot/complainant herein, the amount payable for the pilot/complainant is Rs.1,15,00,000/- (Rupees one crore fifteen lakhs only). Apart from the loss of licence policy, Mediclaim policy was also issued to the Employees of the opposite party No.2 by Opposite party No.1, covering the family members as well, for which the premium was deducted from the salary of the complainant. The Medi-Claim Policy was also issued along with 4 LOL Polices. The Medi-claim policy covers all the pre-existing diseases of the insured and his family members. The same is mentioned to bring the Dual Nature of Insurance Company but the same cannot be construed as making any admission that the complainant was diabetic prior to taking the policy, nor the same is known to the complainant.
The complainant submits that as per the Guidelines/Procedure of the Director General of Civil Aviation (DGCA), Civil Aviation, Government of India, which follows the Guide Lines of the International Civil Aviation Authority (ICOA), the DGCA does a routine Medical Assessment of the Pilots every six months for the Renewal of Pilots of ALTP Licence of each individual Pilot. The Medical Tests are conducted by the Air Force Central Medical Establishment (AFCME) Government of India, Civil Aviation Department, Accordingly the Complainant has appeared for the Medical Tests by the DGCA, Civil Aviation Department Government of India on 24.07.2015. The complainant was Medically examined on 24.07.2015 by the Department and was recommended for Medical Examination for LIPID Profile, OTTT, HBAIC and cure certificate was advised on recommendations for the next medical examination after six months and was also advised to reduce weight and wear corrective spectacles. After the entire medical check-ups were done and after being satisfied with the present Medical tests, the DGCA has Renewed the ALTP Pilots Licence of Complainant without any restrictions or limitations. The DGCA, Government of India has renewed the Pilot License of the complainant only after being satisfied with the medical and health condition of complainant. The pathology reports were issued by Doctors concerned are filed along with this complaint for the perusal of the State Commission. The Said pathologyreports clearly illustrate that the tests were satisfactory as such the ALTP License was renewed as per the guidelines governed by the ICOA and DGCA.
The Complainant further submits that he was filing flying Airbus A 330/300 Aircrafts Internationally, carrying about more than 300 passengers in a Plane, World over, with about 20,000 5 hours of Flying time experience e without any remarks . The complainant was a senior commander and he was flying passenger Aircraft till 21.01.2016.
The Complainant further submits that as per the guidelines of Civil Aviation, every pilot has to under routine Medical Test to prove their fitness from the DGCA certified Aviation Medical Specialist Doctors for the renewal of their ALTP License. Basing on the test results, the DGCA renews the license by grading as FIT,FIT WITH LIMITATION, TEMPORARY UNFIT AND PERMANENT UNIFIT. Basing on the same the pilot is permitted to fly the Airplanes.
The Complainant further submits that apart from the Medical test every pilot has to undergo series of other tests to renew their ALTP License. The names of the said test are mentioned below:-
a)Medicals every six Months.
b)Simulator Every Six Months.
c)Instrument rating renewal every 12 months including low visibility practice test checked conducted without external visual reference.
d)Simulator every six Months four hours of practice of emergencies and base training procedures.
e)4 Hours of proficiency check including Instrument rating.
f). On Line Route Check every 12 months.
g) Ground Refresher every 12 months for five days of 7 hours each day including following subjects.
h) Airplane specific performance.
i) Air plane technical systems.
j)SEP Safety and emergency procedures
k)CRM Crew Resources Management.
l)LVO Low Visibility operation cat 2/3 procedures.
m)RVSM Reduce Vertical Separation Minimum.
n)Adverse weather including Monsoons.
o)Safety Management system SMS Accidents/Incidents Review. P)Change in regulations/Change in the operational Manual.
q)Dieting and anti-Icing Procedures.
r)DGR Dangerous goods regulations every 24 months.6
s)Aviation Security training every 24 months AVSEC Aviation security for two days.
t)Route and regulation competency qualification. u)SOP Jet Air Ways standard operation procedures.
All these tests are conducted for the renewal ALTP License of each Pilot and then the Pilot is graded as FIT, FIT WITH LIMITATIONS TEMPORARY UNFIT AND PERMANENT UNFIT, basing on the reports by the Central Authority DGCA. As such the Complainant appeared before the Medical Assessment team as per the procedure of DGCA for renewal of the Pilots License on 24.07.2015 and was cleared of the Test without any restrictions. The Authorities have made some recommendations for the next Medical tests after six months. The pathology reports dated 24.07.2015 shows that the Complainant was fit and cleared the tests.
The Complainant submits that after flying the International Aircraft from Brussels to Mumbai on 21.1.2016, the Medical Examination mandatory every months was conducted and the Licence was not renewed by the DGCAand recommended to get fit and clear the Medical tests and his ALTP License was kept under Temporarily unfit (TMU) category and will be given three 90 days to clear the tests conducted by certified Doctors of AFCME, but the same could not happen as the Complainant was aged about 62 years by then, as such the Licence was declared Permanent Unfit PMU and license was Lost/cancelled on 05.09.2017 after 28 years Long Service of Pilot of International Passenger Aircraft Flying Experience with unblemished Record. Complainant further submits, that had it been that the Complainant was not medically fit on 24.07.2015, why would the DGCA allow the Pilot to fly the Plane and why would Jet Air ways risk the Aircraft worth crores of rupees and lives of about 300 passengers by allowing an unfit Pilot to fly the Plane The Insurance Company has repudiated the rightful claim without any concrete proof.
The Complainant submits Policy covered for the Loss of Licence Group Policy obtained by his Employer Opposite party No. 2 and made a claim dated 14.05.2018 for both the Policy amounts of Rs. 2,30,00,000.00 (Rupees two crores thirty lakhs only) as the 7 Complainant was covered under both the Policies for the LOSS OF LICENCE(LOL) POLICIES.
The Complainant submits that the Opposite Party No. 1 has made payment of Rs. 57,50,000.00 on 14.04.2018 towards the Primary Policy No. 112400/43/2016/65 balance amount were not paid by the insurance company and repudiated the claim the claim for the Top Up Policy No 112400/43/2016/159 vide letter dated 05/11/2019,citing lame excuse that the Complainant was Diabetic at the time of obtaining the TOP UP Policy in December 2015, without any concrete Documentary evidence for the same. The Repudiation letter dated 05.11.2019 sent with all baseless allegations of Complainant suffering with Diabetes Disease and was known to the Complainant and the same was not disclosed and that the ALTP License is cancelled because of the same. The Medical Test are conducted by the certified Professionals approved by the DGCA, at the Premier Institute of AFCME, which is serving the Nation from about last 80 years and above with AVIATION Medicine, Specialist Doctors. The DGCA follows the guidelines of International Monitoring organization ICOA. The AFCME Doctors have cleared the medicals of the Complainant with some recommendations for the Next Medical Test after six months. It is astonishing that the Doctors of the Insurance Company Opposite party No.1 are questioning the reports of the AFCME. The Complainant was not suffering with any disease much less Diabetes prior to 24.07.2015 and the same was not known to the Complainant The Complainant submits that the in the mean time the Complainant M/s Jet Airways (India) Limited, has closed its operations on 17.04.2019.The Complainant was made to run from pillar to post for the gathering the documents and Policy Documents and various communications with the Opposite party No.1for the claim with the Opposite Party Insurance Company. The Complainant was mentally traumatized for the Loss of License and for delay of the payment of Policy amounts by the Opposite Party No. 1 Insurance Company.
8The Complainant had with great difficulty has obtained the Documents from the Insurance Company Opposite party No.1 and the his Employer Opposite party No. 2 who no more operating any air services. And Replied through various E mails and letters to theOpposite party No. 1 Insurance Company and provided all the documents as required requested for the claim amounts to be settled as per the Policy. But the Opposite Party No. 1 has denied the same on the ground that the Complaint was Diabetic prior to 24.07.2017, which is false and baseless nor supported by any documentary evidence.
It is further submitted that Opposite Party No.1, Insurance Company, has written a letter dated 16.08.2018 with Information to the Complainant, to the Government of India, DGCA for the Medical Reports dated 24.7.2015 Conducted by AFCM. The Government of India, DGCA has replied through letter dated 17.09.2018 replying to the letter along with the medical reports dated 24.07.2015.
The Opposite Party No. 1 after the receipt of the letter dated 17.09.2018 from the Government of India, has requested the Complainant to provide medicaltest reports conducted in December 2015. The Pathology reports were also submitted to the Opposite Party No 2. Those reports also clearly illustrates that the Blood sugar levels as on December 2015 were under permissible limits only. Butthestill Opposite party No. 1 Insurance Company has erroneously repudiated the claim without basis, as the Complainant was flying the Aircrafts till 21.01.2016, had it been the care the Civil Aviation Authorities, would not have permitted to fly the Aircraft and even the Employee Jet Air ways would not risk the lives of passenger and crores of worth Air craft to be at risk.
The Complainant submits that that ALTP Licence was Lost/cancelled only in 05.09.2017, almost more than two years from the date of Pathology 24.07.2015, which also shows no conclusive evidence of any ailment more Particularly Diabetes to the Complainant. The Opposite party No. 1 Insurance Company has failed to appreciate that the Pathology reports of July 205 and 9 December 2015 have normal findings and no other document shown to the Complainant to disprove the same.
The Complainant submits that the Opposite Party No. 1 has illegally denied the rightful claim of the Complainant, as such they have denied the claim in spite of many communications directly with them along with all the required documents. The Opposite Party No. 1, based on the report of their own Medical team have rejected the reports and assessment of Aviation Medical experts of the AFCME Governed by the Government of India, DGCA, just to deny the lawful claim of the Complainant. The same is unlawful and the Authorities concerned should hone the right full claim of the Complainant.
The Complainant being Senior Commanders and Pilot by Profession have lost his income through the same and made to run from pillar to post for the Policy amounts to take care of his retired life and his family members and made to visit their offices in this PANDEMIC COVID-19 situations almost from last one year The Complainant have lost his monthly income and also being denied the Policy benefit of Rs 1,15,00,000.00 thereby causing lot of mental agony to the Complainant and his family members, who are going through lost of mental pressure.
It is further submitted that the acts of the Opposite parties are illegal and there is a negligence and deficiency of service and unfair trade practice on their part. Hence the complainant is entitled for the Policy amounts of Rs. 1,15,00,000.00 and Rs10,00,000/- (Rupees Ten Lakhs only) towards Mental agony and Rs 10.00.000 Compensation for Deficiency in service and unfair trade Practice., together with "interest @24% per annum from the date of claim till payment realization, apart from costs of Rs 1,00,000/-. Hence the complaint.
3). Written version is filed by the opposite party no.1 contenting and submitting as follows:-
10The complaint is neither maintainable in law nor on facts on record as such the same is liable to be rejected in limine. This opposite party categorically and emphatically deny each and every averment made in the complaint except those which are specifically admitted to hereinafter and put the complainant strict proof thereof.
The Opposite Party submits that it has issued Group Aviation Loss of License insurance Policy bearing No. 112400/43/2016/159 for the period of one year commencing from 07.12.2015 to 06.12.2016 to Opposite party No.2 Jet Airways (Indialtd.),covering various pilots as mentioned in the policy. The insured have taken this additional policy for the first time apart from the main group Aviation loss of license insurance policy under which the complainant was covered from the year 2009.
The opposite party submits that the complainant is one of the employees covered under the above stated policy for a sum insured of Rs.1,15,00,000/- as per the terms and conditions of the policy. The copy of the said Insurance policy is herewith filed.
The complainant submitted a claim form Dt.23.08.2017 duly signed by him and questionnaire/Form forming part of claim form duly completed and signed by complainant's medical attendant Dr. Sreedevi Patnala on 30.11.2017 wherein the said Doctor sated that the complainant was examined by her for the first time in January, 2016 for the illness of "Diabetes Mellitus Type II.The same is herewith filed.
The complainant appeared for medical Examination at AFCME at New Delhi on 17.02.2017 and subsequent tomedical examination, the complainant was found temporarily unfit for flying duties for 12 weeks on account of diabetic Mellitus grade iii control. Subsequently on 06.06.2017, the complaint had undergone medical Examination at AFCME, New Delhi wherein he was again found temporarily unfit for flying duties for 12 weeks on account of 11 Diabetes Mellitus Grade iii Control and again on 05.09.2017, the complainant had under gone medical examination at AFCME, New Delhi, where he was declared permanently unfit for flying on account of Diabetes Mellitus Type II.
Based on the above examinations by AFCME, the Director General Of Civil Aviation vide their medical assessment Dr. 03.10.2017 had finally assessed and declared that the complainant was found permanently unfit for flying on account of 1. Diabetes Mellitus
2.TMT positive for inducible Ischemia.The same is herewith filed.
The insured videE.Mail Dt.06.09.2017 informed to the Opposite Party No.1 that his flying license was cancelled in terms of permanently unfit by AFCME. The upon which Opposite Party No.1 requested the complainant to submit the claim form and all necessary documents including all medical reports in support of his claim vide their E.mail Dt.06.09.2017.
The Opposite party also deputed M/s. RISKalyze, Insurance Surveyors to investigate and submit their report in regard to the investigation report of the Blood Sugar profile &HbAlc Dt.22.07.2015 and it was confirmed that as Per the DGCA Record they did not have the report of Lipid Profile and OGIT and same is herewith filed.
4).The opposite party No.1 further submits that the documents submitted by the Director General of Civil Aviation were not sufficient to determine the date of commencement of the illness.The opposite party vide their letters Dt. 20.08.2018 and 06.12.2018 requestedthe insured/opposite party No.2, (Jet Airways) to submit medical reports of the complainant so as to determine the admissibility of the claim under loss of license Policy No.112400/43/2016/159 and same are herewith filed.
Finally as advised by the higher office of the opposite party, the subject case was referred to Dr.C.H. Asrani of Inches Health Care Team for his opinion on commencement of illness to determine the admissibility of the claim of the complainant under the insurance policy. Dr. Asrani upon the review of the case opined vide certificate 12 Dt. 28.02.2019 that the complainant had Diabetic Mellitus prior to 24th July 2015 and his opinion was elaborated as under for the conclusion.
"As per report of class I Medical Examination Report By AFCME, Civil Aviation Department, Government of India New Delhi Dt. 24.07. 2015, the investigation/compliance for next review at AFCME/ I am was only with Lipid Profile, OGTT & HbA1C and cured certificate by Endocrinologist. As defined HbA1c is test to evaluate blood sugar control in preceding 2-3 months and the fact a cure certificate is demanded, implies that the insured had an ailmentoféndocrine system which is concluded by other battery tested. This establish that insured was known case of Diabetes Prior to 24th July 2015."and the same is here with filed.
The Opposite Party submits that as per Exception No.2 of the Loss of license Insurance policy No. 112400/43/2016/159 issued to the Insured Jet Airways Ltd, wherein the complainant is one of the group members) clearly mentions that the "Policy does not cover any claim for incapacity resulting directly or indirectly from any personal injury, illness, disease, or disability including natural deterioration existing prior to the inception of this insurance, except where such personal injury, illness, disease or disability including natural has been declared in writing to the company and accepted by them without any additional exclusion.
The Opposite Party submits that on careful scrutiny and observation of the documents submitted by the complainant and in pursuance of medical opinion obtained from Dr.C.H.Asrani, of M/s. Inches Health Care clearly indicating the complainant as a known case of Diabetes prior to 24 July 2015. Since the commencement of illness which leads to cancellation of flying license is prior to inception of the policy(07.12.2015) and accordingly the subject claim is falling under the exceptions of the policy.
It is submitted that the Opposite Party by following the principles of natural justice, has given reasonable opportunity to the complainant vide letter Dt.05.11.2019 to substantiate his claim 13 before a final decision is taken by this opposite party is annexed as Annexure R-8.
It is most respectfully submitted that except making bald averments, the complainant has not chosen to make a single sentence as to what is the deficiency as to the settlement of the claim of the complainant and that as to how present complaint is maintainable before this Hon'ble Commission and that as to what basis the complainant is entitled to compensation.
It is further submitted that this Opposite Party is not liable to pay any amount to the complainant as there is no deficiency of the service on their part as no delay is caused from the date of submission of the claim form/papers toll the date of repudiation of the claim i.e. 29.01.2019 as per terms and conditions of the policy. Hence the complaint is liable to be dismissed ab initio. Annexture-
9. The averments made in prayer clause of the complaint are wrong and false and hence denied. It is humbly submitted that the complainant is not entitled to get any relief as the claim of the complainant was repudiated as per terms and conditions of the policy.
The answering Opposite Party reserve its right to add, amend, alter or delete in this version as and when it is so required.
It is therefore prayed that this Hon'ble Forum be pleased to dismiss the complaint with costs in the interest of justice.
Opposite party No. 2 is set expartee.
5). During the course of enquiry.The complainant filed his evidence affidavit and got marked Exs.A1 to A14 on his behalf. On behalf of opposite partyNo.1insurance company, one P.BallaGopal, the Regional Manager of Opposite party No.1, filed his evidence affidavit and got marked Exs.B1 to B8.
Heard arguments of the counsel for complainant and counsel for Opposite party No.1 insurance company who by and large have 14 reiterated their respective versions pressed in the complaint and the written version.
Opposite party No. 1 filed written arguments also.
In view of the rival pleadings, contentions, evidence and arguments, the points that arise for consideration are:
i. Whether there is any deficiency in service on the part of the opposite party No.1 Insurance company ?
ii. Whether the complainant is entitled for the reliefs sought for in the complaint?
iii. If yes, to what extent?
To decide the points for consideration we have carefully examined the whole material borne by record and the same would manifest that the following is the specific case of the complainant that he was Air Line Pilot, having Ex.A1 Air Line Transport Pilot Licence ALPT Vide No.1485, issued on 08.09.1989 by the Director General of Civil Aviation, Government of India.
Further the complainant was employed by opposite party No.2 M/s. Jet Air Ways (India limited) from 21.10.1993 and was Designated as Senior Commander and was flying Air Bus Airplanes A330/300 all over the World with an Impeccable record of about 20,000/- (Twenty Thousand) hours of Flying time Experience till the last flight wasoperated by him on 21.01.2016, wherein the complainant had flown the International Flight from Brussels to Mumbai.
Opposite party No.2 Jet Airways, obtained Ex.A2 Primary Policy i.e. Group Insurance Policy in the year 2009 with opposite party No.1 oriental Insurance Company Ltd, and the same was in Existence till 2018. The policy is named as wad tailor made and was called "Aviation Loss of License Insurance Policy (Group) vide Policy NO.112400/43/2016/65(LOL) by paying premium amount of Rs.1,06,01,973/-. The Said Ex.A2 Primary Group Insurance Policy/Base Policy was issued to all the employees of about 1000 members of opposite party No.2, upon agreed terms and conditions.15
The complainant was also member of the Group (LOL) since 2009 and was also a member of National Aviation Guild (NAG) Pilots Union since inception. As per the terms and conditions of Ex.A2 Primary/Base Policy, in case of any claim, the said policy is covered for a amount of Rs.1,15,00,000.00/- (Rupees one crore fifteen lakhs only).
Opposite party No.1 Insurance company along with Opposite party No.2 Jet Airways and the Pilots Association (NAG) after vide consultations since the year 2013, have come up with Ex.A3 the Tailor made additional "TOP UP" Insurance Policywith the existing Ex.A2 Primary/base Policy for the staff of about 1000 employees of Opposite party No.2 Jet Airways including the complainant herein. The complainant also obtained Ex.A3 additional TOP UP Policy vide No. 1124000/43/2016/159, apart from Ex.A2 Primary Insurance (LOL) policy. Ex.A3 ADD ON TOP UP Policy was also for Loss of Licence (LOL). The Additional TOP UP Policy was obtained for the first year from 07.12.2015 to 06.12.2016 for which the premium was deducted from November 2015 salary of complainant by opposite party No.2 Employer and paid the same to opposite party No.1 Insurance company.
The Premium for the second year covering from 05.01.2017 to 04.01.2018 of Ex.A3 TOP UP Policy was deducted from Salary of the complainant from November/December 2016, as such both the polices are covered for any eventuality.
The liability of Opposite party No.1 insurance company shall be limited to ONE HUNDRED PERCENTUM OF THE CAPITAL SUM INSURED,in case of Loss OF License by the Pilot/Complainant and the amount payable for the complainant is Rs.1,15,00,000.00/.
Apart from the Loss of Licence of Policy, Mediclaim Policy was also issued to the Employees of the Opposite party no.2, by opposite party No.1, covering the family members as well, and the premiums were deducted from the salary of the complainant. So Mediclaim Policy was also issued along LOL Polices. The Mediclaim Policy covers all the Pre-existing diseases of the insured and his 16 family members. The same is mentioned to bring the dual nature of the Insurance company and same cannot be construed as making any admission that the complainant was diabetic prior to taking of the policy, nor the same was known to the complainant.
As per Guidelines/Procedure of Director General of Civil Aviation (DGCA), Civil Aviation, Government of India, which follows the Guidelines of the International Civil Aviation (ICOA), the DGCA does a routine Medical Assessment of the Pilots every six months for the Renewal of Pilots ALTP Licence of each individual pilot.
The Medical Tests are conducted by the Air Force Central Medical Establishment (AFCME), Government of India, Civil Aviation Department. The complainant accordingly appeared for the Medical Test by the DGCA, Civil Aviation Department. Government of India on 24.07.2015. The Complainant was Medically examined on the said date i.e.24.07.2015 by the Department and was recommended for the Medical Examination for the LIPID Profile, OTT, HBAIC and cure certificate was advised on recommendations for the next Medical Examination after six months and was also advised to reduce weight and wear corrective spectacles.
After entire Medical Check-ups were done and after being satisfied with thesaid Medical tests, the DGCA Renewed the ALTP pilots Licence of the complainant without any restrictions or limitations.
Ex.A10 and A11 Pathology reports dt.22.07.2015 and 26.12.2015 respectively issued by the Doctors concerned show that the blood sugars of the complainant are normal and under the control and satisfying by the said report, the ALTP Licence of the complainant was Renewed as per guidelines governed by ICOA and DGCA.
Apart from the Medical Test every Pilot has to undergo series of other tests for renewal of his ALTP License. The names of said tests are mentioned below:-
17a)Medicals every six Months.
b)Simulator Every Six Months.
c)Instrument rating renewal every 12 months including low visibility practice test checked conducted without external visual reference.
d)Simulator every six Months four hours of practice of emergencies and base training procedures.
e)4 Hours of proficiency check including Instrument rating.
f). On Line Route Check every 12 months.
g) Ground Refresher every 12 months for five days of 7 hours each day including following subjects.
h) Airplane specific performance.
i) Air plane technical systems.
j)SEP Safety and emergency procedures
k)CRM Crew Resources Management.
l)LVO Low Visibility operation cat 2/3 procedures.
m)RVSM Reduce Vertical Separation Minimum.
n)Adverse weather including Monsoons.
o)Safety Management system SMS Accidents/Incidents Review. P)Change in regulations/Change in the operational Manual.
q)Dieting and anti-Icing Procedures.
r)DGR Dangerous goods regulations every 24 months.
s)Aviation Security training every 24 months AVSEC Aviation security for two days.
t)Route and regulation competency qualification. u)SOP Jet Air Ways standard operation procedures.
The above tests are conducted by the DGCA Certified Aviation Medical Specialist Doctors for the renewal of ALTP License of each pilot. After conducting the above tests, the pilot is graded as FIT, FIT WITH LIMITATIONS TEMPORARY UNFIT AND PERMANENT UNFIT, basing on the reports by the Central Authority of DGCA. The complainant appeared before the Specialist Doctors of DGCA on 24.07.2015 and cleared the said tests without any restrictions, for the renewal of his license. The Authorities have made some recommendations for the next Medical tests after six months.
18The complainant after flying the International Aircraft from Brussels to Mumbai on 21.01.2016,the Medical Examination which is mandatory for e very six months, was conducted but the Licence of the complainant was not renewed by DGCA and recommended to get FIT and clear the Medical Tests, until then his ALTP License was kept under Temporarily unfit (TMU) category and given Three 90 days to clear the tests conducted by certified Doctors of AFCME, but the same could not happen as the complainant was aged about 62 years by then, as such the License of the complainant was declared permanent unfit (PMU) and therefore the license was lost/cancelled on 05.09.2017, after 28 years of Long service as Pilot of International Passenger Aircraft Flying Experience with unblemished Record.
It is the vehement submission and empathic case of the complainant that had it been that the complainant was not medically fit on 24.07.2015, why could the DGCA allow the complainant to fly the plane and why would opposite party No.2 Jet Airway risk the Aircraft worth of crores of rupees and lives of about 300 passengers, by allowing an unfit pilot (complainant) to fly the plane. opposite party No.1 insurance company has repudiated the legal and rightful claim of the complainant without any concrete proof/ evidence, basing on conjectures and surmises .
The complainant for the loss/Cancellation of his ALTP License, made claim vide Ex.A4 to Opposite party no.2 insurance company, claiming the amounts under Ex.A2 and A3 Primary and TOP UP Insurance policies respectively for an amount of Rs.2,30,00,000./- (Rupees tow crores thirty lakh only) as the complainant was covered under both the said polices. But opposite party No.1 insurance company paid only Rs.57,50,000 (Rupees fifty seven lakhs fifty thousand only) on 14.04.2018 to the complainant towards Ex.A2 Primary Policy and the balance amount of the said policy was not paid to the complainant and repudiated the claim under Ex.A3 additional TOP UP Policy vide Ex.A8 repudiation letter dt.05.11.2019, citing lame excuse that the complainant was Diabetic at the time of obtaining Ex.A3 TOP UP Policy in December 2015 without any Documentary Evidence for the same.
19Opposite party No. 1 insurance company made baseless allegations in Ex.A8 letter that the complainant was suffering with Diabetic Disease and the same was known to him due to which his ALTP License was cancelled. The Medical Tests are conducted by the Certified professional specialist Doctors approved by the DGCA, at the Premier Institute of AFCME, which is serving the Nation from about last 80 years, with AVIATION Medicine, Specialist Doctors. The DGCA follows the guidelines of International Monitoring organisation ICOA.
The AFCME Doctors have cleared the Medicals of the complainant with some recommendations for the Next Medical Test after six months. It is astonishing that the Doctors of Opposite party No.1 insurance company, are questioning the reports of AFCME, by the panel Doctor of opposite party No.1 Insurance Company, who is not an expert as like the expert Specialist Doctors of AFCME. The so called opinion of Doctor Ansari who works for the Insurance Companies such as opposite party No.1 and who is not a qualified Endocrinologist, shall not be basis for repudiating the Genuine and legal/rightful claim of the complainant.
It is the consistent and emphatic version/evidence of the complainant that he was not suffering with any disease much less the alleged Diabetes Miletus Type-II prior to 24.07.2015 and the same was not known to the complainant as alleged by the insurance company without any authenticated evidence/proof.
In the meantime, the opposite party No.2 Jet Airways closed its operations on 17.04.2019. The complainant was made to run form pillar to post for gathering the documents and Policy Documents for which he addressed various E-mails and letters and with great difficulty, he obtained the documents from opposite parties No.1 and 2 and then he provided all the Documents to opposite party No.1 Insurance Company as required by it for the claim amounts under Ex.A2 and A3 polices but opposite party No.1 denied the same on the ground that the complainant was Diabetic prior to obtaining Ex.A3 Additional TOP UP Policy. Even with regard to Ex.2 primary/base policy, though it is very clearly stated in the said policy that in case of cancellation of the ALTP Licence of the 20 complainant, he is entitled to hundred present amount of the sum assured i.e. 1,15,00,000/- (Rs. One crore fifteen lakhs), the complainant is not paid the same but was paid only a part of the same, which is mentioned supra and the same is not sustainable under law as per Ex.A2 Base/Primary Group Insurance Policy.
Opposite party No.1 Insurance company addressed a letter dt.16.08.2018 to the Government of India DGCA for the Medical Reports of complainant dt.24.07.2015 conducted by AFCME,by marking a copy of the same to the complainant, for which the DGCA replied through Ex.A7 letter dt.17.09.2018.
After receipt of Ex.A7 letter from Government of India, opposite party No.1 Insurance Company requested the complainant to provide Medical Test reports conducted in December 2015, for which the complainant submitted Ex.A10 and A11 Pathology reports which clearly indicate that the Blood Sugar Levels of the complainant were under permissible limits only. Yet opposite party No.1 erroneously repudiated the claim of the complainant without any basis though the complainant was flying the Aircraft till 21.01.2016 i.e. he had flown the International Aircraft from Brussels to Mumbai on that day.
Had really the allegations of opposite party/insurance company that he (the complainant) has been suffering from Diabetes Miletus, the Civil Aviation Authorities would not have permitted him to fly the Aircraft and even the Employer opposite party No.2/ Jet Air ways would not risk the lives of 300 passengers and the Aircraft Worth of Crores of Rupees.
The ALTP Licence of the complainant was lost/cancelled only on 05.09.2017 which is almost more than 2 years from 24.07.2015 the date of Medical examination by AFCME Government of India, Civil Aviation Department New Delhi, as per which there is no conclusive evidence of any aliment more particularly Diabetes Miletus Type-II to the complainant. Opposite party No.1 Insurance company has failed to appreciate Ex.A10 and A11 Pathology reports which have normal findings.
21Opposite party No.1 has illegally denied the rightful claim of the complainant basing on the report of their own Medical team which have got vested interest towards opposite party No.1 insurance company and in fact the said medical team of opposite party No.1 is not as that of the expert specialist Doctors of AFCME as such the self-serving opinion of the panel Doctor of opposite party No.1 Insurance company shall not be basis to reject the reports of expert Doctors of AFCME.
The complainant has lost his monthly income and further the denial of claim of the complainant by opposite party No.1 caused a lot of mental agony to the complainant and his family members and same amounts to deficiency of service and unfair trade practice on the part of opposite party No.1 Hence the complainant knocked the doors this State Consumer Commission for justice by seeking the reliefs mentioned in the complaint.
To prove his case, at the cost of the repetition, the complainant filed his evidence affidavit and got marked Exs.A1 to A14.
We have scanned the evidence affidavit of the complainant and the same shows that the complainant on oath has reiterated his case which is mentioned supra.
Ex.A1 is the copy of Airline Transport Pilots License (ALTP) Vide No.1485 of the complainant issued by the Director General Civil Aviation Government of India on 08.09.1989. The Photograph of the complainant is on the said A1 License. The said EX.A1 License shows that the same was renewed from year to year by DGCA.As per Ex.A1 licence, the complainant being a Pilot/Sr. Commander, was given licence by DGCA to fly Air Bus Air planes A330/300/A340CCR/300 all over the world.
At this juncture we feel it relevant to mention that a letter dt.17.05.2018 borne by record, was addressed to the complainant 22 herein, by one. Vanitha Avasthi, the Deputy General Manger of Human Resource of opposite party No.2 Jet Airways wherein the complainant is addressed as "Capt. Jangam Goud, Sr. Commander, 10102010/VOM, Flight Operations, Mumbai. Thus Ex.A1 the copy of the ALTP Pilot Licence of the complainant, coupled with the above letter establishes the fact that the complainant is a Pilot and he was employed as such by op2 Jet Airways and was designated as Sr. Commander. Thus the complainant proved that he is a pilot and he was employed as such in opposite party No.2 Jet Air ways and he was designated as, Sr. Commander, to fly Aeroplanes Air Bus Air planes A330/300/A340CCR/300 all over the world.
Ex.A2 is the copy of the Prime/Base Policy of Aviation Loss of License Insurance Policy (Group) Vide Policy No.112400/43/2016/65 (LOL) which is for a period from 01.08.2015 to 31.07.2016 issued by opposite party No.1 Oriental Insurance Company limited for the employees/pilots including the complainant herein.
On the first page of Ex.A2 Primary/Base policy it is mentioned that, " Now this is to certify that subject to the terms, limitations, exceptions and conditions, contained herein or endorsed hereon in the event of Insured person during the period of insurance (as stated in the schedule) suffering any bodily injury whatsoeve r or suffering any illness whatsoever resulting at any time whether during or after the period of insurance (but not beyond of TWO Years after the expiry of this insurance) in his incapacity (as hereinafter defined) then compensation will be paid to the Insured person through the Insured as follows by the company."
The above is certification by opposite party no.1 insurance company in favour of the employees/ Pilots including the complainant of opposite party No.2 Jet Airways.
The schedule of compensation and provisos to the same are mentioned on second page of Ex.A2 Prime Policy. Under Schedule of compensation, items 1 to 5 and under the provisos 1 to 4 are mentioned out of which the first proviso is relevant and same is extracted below for the ready reference:-
23Proviso No.1) The liability of the Insurance company shall be limited to ONE HUNDRED PERCENTUM OF CAPITAL SUM INSURED At page No.3 of Ex. A2 prime policy under the heading "
"DEFINITIONS",the words " INCAPICITY", " PERMANENT TOTAL DISABLEMENT" are defined as follows:-
INCAPACITY :- Any incapacity causing Permanent Total Disablement or Temporary Total Disablement of the person insured.
PERMANENT TOTAL DISABLEMENT: -Any disablement due to personal injury or due to illness, disease of disability including natural deterioration of the person insured which entirely prevents him from attending to the occupation and which appears beyond reasonable doubt to be of a permanent nature.
At page No. 9 of Ex.A2 policy the details of policy Number and Premium computation under Group Loss of Licence and the period of the insurance are mentioned in a Tabular Form and same is extracted below for ready reference.
Policy No.112400/43/2016/65 PREMIUM COMPUTATION UDNER GROUPP LOSS OF LICENCE INSURANCE FOR THE PEROID:01/08/2015 TO 31/07/2016 A/C JET AIRWAYS/JET LITE (INDIA) LTD.
SR.No. CATEGORY OF No OF Premium SUM
PILOT PILOTS Rate INSRUED
Per Pilot
(Rs.)
1. Pilot, First Officer, Below55 807 0.06138% 8,500,000
Tr. First Officer, Above 5 0.07892% 8,500,000
Co-Pilot. 55
2. Captain, Below 607 0.06138% 11,500,000
Examiner, Fleet 55
Manager
Above 85 0.07892% 11,500,000
55
Total 1504
24
Total sum Insured : Rs.14,860,000,000/-
Premium : Rs.92,99,976/-
Add:14% Service Tax : Rs.13,01,997/-
_________________
Total :Rs.1,06,01,973/-
Now let us look at Ex.A3 additionalTopupPolicy provided by opposite partyno.1 orientalinsurance company to the employees of Opposite party no.2 Jet Airways including complainant herein.
A perusal of Ex.A3 Additional Top upPolicy shows that the policy Number is:-112400/43/2061/159 (LOL) and the period of insurance is from 07.12.2015 to 06.12.2016. Ex.A3 Top Up Policy also is similar to Ex.A2 base policy and the same also was issued in favour of the complainant herein namely Mr.Gowd JR ID No.10102010 Member of Jet Airways India Limited who is covered under Group Health Insurance Policy. Ex.A3 Top up Policy also shows the coverage of policy period for the second year i.e. from 05.01.2017 to 04.01.2018. It is the consistent version and evidence of complainant that for both Ex.A2 Base policy and Ex.A3 TOP up Policy the premium amounts were deducted from his salary by his employer opposite party no.2 Jet Airways and paid the same to Opposite party no.1 Insurance Company. We have already referred to the number and contents of Ex.A2 Base Group Insurance policy for which the premium amount of Rs.1,06,01,976/- was paid through Opposite party no.2 to Opposite party no.1 Insurance company. For Ex.A3 Additional Top UP policy the premium amounts were deducted from the salary of the complainant from November 2015 by Opposite party no.2 being the employer and the paid the same to Opposite party no.1 Insurance company. It is also categorically averred and deposed by the complainant that the premium amount for the second year of the TOP Up Policy the period of which mentioned supra were deducted from the salary November/December 2016 month.
The above details with regard to payment of premium under Ex.A2 base policy and Ex.A3 Top Up policy were admitted byOpposite party no.1 Insurance company under Ex.A3 Top Up policy also in case of any eventuality / cancellation of ALTP Licence 25 of the complainant he is entitled to the Insurance amount of 100 % i.e. Rs.1,15,00,000/-.
As Opposite party no.1 insurance company admitted issuance of Ex.A2 primary and base policy and Ex.A3 Top Up policy after receiving the premium amounts from the salary of the complainant, we hold that the complainant has proved/established that he is entitled for the insurance amounts under both Ex.A2 and Ex.A3 policy in case of loss/cancellation of his ALTP License No.1485 issued by the Director General Civil Aviation Government of India on 08.09.1989.
As seen from the specific case of complainant which is mentioned supra that on 05.09.2017 his ALTP license was declared permanent unfit which is after 28 years long service of Pilot of International Passengers Aircraft flying experience with unblemished record. In view of the same his submitted Ex.A4 claim form on 23.08.2017 to Opposite party no. 1 Insurance company under Ex.A2 and A3 primary and TOP Up policies respectively for an amount of Rs.2,30,00,000/- as he his covered under both the polices. But Opposite party no.1 Insurance company paid only Rs.57,50,000/- on 14.04.2018 to the complainanttowards Ex.A2 primary policy and balance amount of the said policy was not paid to the complainant and further repudiated the claim under Ex.A3 additional Top Up Policy vide Ex.A8 repudiation letter dt.05.11.2019, citing lame excuse that complainant was diabetic at the time of obtaining Ex.A3 Top Up Policy in December 2015 without any documentary evidence for the same.
6). Now it is to be critically and carefully examinedwhether Opposite party no. 1 Insurance company is justified in paying only a part of the amount of the Insurance Under Ex.A2 primary policy and whether it is justified in repudiating claim under Ex.A3 Top Up Policy.
At this juncture it is to be made clear that it is a settled law in a catena of rulings by various Hon'ble High Courts, Hon'ble Apex Court of this country and even by the Hon'ble National Consumer disputes RedressalCommission, New Delhi that whenever any 26 Insurance Company repudiates a claim under any Insurance policy, the onus is on the said Insurance company to justify the said repudiation of the claim by cogent and convincing evidence, so it is to be seen whether Opposite party no.1 insurance company as placed any cogent and convincing evidence to reject the claims of the complainants under Ex.A2 and A3 insurance policies. It is also settled law an insurance company shall not be permitted to travel beyond the repudiation letter by adding a new case which is not mentioned in the repudiation letter.
Ex.A8 repudiation letter is dt.5.11.2019 but prayer to the same Opposite party no.1 insurance company addressed Ex.A5 letter to Opposite party no.2 Jet Airways who is the employer of complainant. In Ex.A5 letter also Opposite party no.1 Insurance company referred to the aspects of repudiation of the claim of the complainant under Ex.A2 and Ex.A3 polices. So we are considered view that both Ex.A5 letter and Ex.A8 letter are to be examined on contrast.
At Para No.3 of Ex.A5 letter addressed by Opposite party no.1 insurance company to Opposite party no.2 Jet Airways it is mentioned that " Capt. JangamGowd was covered under Loss of Licence (LOL) Insurance Policy No.112400/43/2016/65 for the period from 01.08.2015 to 31.07.2016 (Base Policy) as well as Additional Loss of License Insurance Policy No.112400/43/2016/159 for the period from 07.12.2015 to 06.12.2016 (Additional Policy)."
At Ex.A5 letter reference about Ex.A2 base policy is mentioned by Opposite party no.1 Insurance company and same is extracted below for ready reference:-
Claim No.112400/43/2018/92 under Loss of Licence Policy No.112400/43/2016/65 (Base Policy):-
"Capt. JangamR.Gowd, bearing Licence No.ALTP-1485, was covered under the above Group Loss of Licence Insurance Policy for a capital sum insured of Rs.1,15,00,000/- for the 27 period from 01.08.2015 to 31.07.2016. He had been continuously covered under the subject policy since 2009."
We had settled the claim under the above policy for Rs.57,50,000/- (net of deductible of 50% of sum insured) considering the long continuity of beneficiary's coverage " under the base policy and there was no reason to cause any verification of any medical records of the beneficiary since he had been continuously covered under the base policy since 2009."
Opposite party Insurance also referred to the claim of the complainant under Ex.A3 Additional policy and the same is extracted below for ready reference and for proper discussion.Claim No.112400/43/2018/93 under Loos of Licence Insurance Policy No.112400/43/2016/159 (Additional Policy):"Capt. Jangam R. Gowd, bearing License No. ALTP- 1485, was covered under the above Group Loss of Licence Insurance policy for a capital Sum insured of Rs.1,15,00,000- for the period from 07.12.2015 to 06.12.2016. This policy was taken for the first time and incepted with effect from 07.12.2015.
The subject Additional Policy was incepted on 07.12.15 and incidentally Capt. JangamGowd was examined first time in January, 2016 (24/01/2016) for Diabetes Mellitus Grade III which is a close proximity to the inception of policy."
From the above contents of Ex.A5 letter addressed to opposite party no.2 Jet Air ways who is the employer of the complainant it is cleared that the complainant is covered under both polices i.e. Ex.A2 Base Group Policy and Ex.A3 TOP UP Additional Policy. In the said letter and also in its written version and evidence affidavit opposite party no.1 stated that in case of claim under the above two polices the complainant is entitled to 100% Capital Sum insured of Rs.1,15,00,000/-. But admittedly opposite party no.1 Insurance company paid only half of the above insured amount against its own promise that the complainant is entitled to 100% of Ex.A2 policy. Even for the payment of the above the half of the amount of Rs. 57,50,000/- paid the same by stating that 28 considering the long continuity of the complainant's coverage under the base policy and there was reason to cause any verification any medical records of the complainant since he had been continuously covered under the base policy since 2009.Opposite party no.1 insurance company issued Ex.A2 Group Base Policy to opposite party no.2 Jet Airways, Covering one thousand employees/Pilots of opposite party no.2, including the complainant herein. That Ex.A2 policy was issued basing on the fact that for the fitness of the pilots to fly the Air plane, Medical Assessment of the pilots are conducted by certified experts Doctors of Air Force Central Medical Establishment (AFCME) as per guidelines/procedure of Director General Civil Aviation (DGCA), Civil Aviation, Government of India, which follows the guidelines of the International Civil Aviation and the said tests are conducted for every six months for the renewal of pilots ALTP Licence of each individual pilot. It is a fact borne by record vide Ex.A1 Copy of the Pilot Licences ALTP 1485 of the complainant that the said Licence of the complainant was renewed every year till the complainant was declared permanent unfit and in view of the same his license was lost/cancelled on 05.09.2017.
As seen from Ex.A5 letter the stand taken by insurance company for repudiating the claim of the complainant under Ex.a3 TOP UP Additional policy is very strange and same is based on the guess/conjecture without any concrete documentary evidence its says that the Additional Top up Policy was taken 07.12.2015 by the complainant and incidentally he was examined for Diabetes Miletus-Grade III in January 2016 as such opposite party no.1 Insurance company contents that there is close proximity for the same to Ex.A3 TOP UP Policy. opposite party no.1 Insurance company in Ex.A5 letter further contents that it was observed by the Licencing authority while giving the extension of the Licence on 24.07.2016 pointed out existence of health issues and insisted curing certificate from endocrinologist and advised to reduce weight to acceptable BMI. It was also advised various medic al tests such as Lipid Profile, OGTT HbA1C and submit the reports while appearing for next medical review.
29At this juncture it is to be noted and made clear that the above tests are to be undergone by the complainant after six months.
Ex.A7 is the letter dt.17.09.2018addressed by Sri NJ Katoch, Wg Cdr JDMS (Med) Operation Manager Medical Cell (DGCA) Government of India Civil Aviation Department, Office of Director General Civil Aviation. From Ex.A7 letter it is clear that opposite party no.1 insurance company addressed a letter dt.16.08.2018 to the Government of India, DGCA for the Medical Reports of the Complainant dt.24.07.2015 conducted by Air Force Central Medical Establishments (AFCME), and for the said letter Ex.A7 is the reply by the concerned of the office of Director General of Civil Aviation. A careful perusal of Ex.A7 letter shows that class I Medical Examination was carried out on 04.07.2015. The reports of Liquid Profile, OGTT and opinion by Endocrinologist was not available with the above medical examination. Further, no medical examination was conducted in December 2015/January 2016. From this it is clear that no medical examination was conducted on complainant in December 2015/January 2016.
It is the consistent version and evidence of complainant that after receipt of Ex.A7 letter from Government of India, opposite party no.1 Insurance company requested the complainant to provide Medical Tests Reports in December 2015, for which the complainant submitted Ex.A10 and Ex.A11 pathology reports.
Now let us critical examine the said Ex.A10 and Ex.A11 reports. Ex.A10 report is dt.22.07.2015 and the same shows that on reference by Doctor Sanjoy Paul HBA1C test was conducted on the complainant by Banjara Diagnostics.
Similarly Ex.A11 is dt.26.12.2015 and the same shows on reference of Dr. Sanjay Paul HBA1C test was conducted. The results of the said two tests which were conducted with the gap of six months were furnished in Ex.A10 and Ex.A11 Reports.
30In Ex.A10 Normal, Good Diabetic Control, Fair Control, Poor Control are mentioned as follows:
Normal:<6.0% Good Diabetic Control : 6.0-7.0 % (140 mg/dl) Fair Control : 7.0-8.0% (140.0.-160.0mg/dl) Poor Control :> 8.0(> 180 mg/dl) The result of HBA1C (Glycocylated Haemoglobin) of the complainant is mentioned as 6.0%.
At page No.2 of Ex.A10 Medical Tests report of Complainant contains the details of Fasting Blood Sugar and Post Prandial Blood Sugar which are extracted below for ready reference for proper discussion.
TEST NAME RESULT REFERENCE INTERNAL UNITS Fasting Blood Sugar 92 70-110 mg/dl. Post Prandial blood 140 70-150 mg/dl. Sugar
The above details make it abundantly clear that the fasting Blood Sugar and Post Prandial Blood Sugar of the complainant are within good control and permissible limits.
Even the test results of complainant of HBA1C is normal.
Ex.A11 medical test report of the complainant is also on similar lines as that of Ex.A10 and from same it can be inevitably concluded that the Blood Sugar Levels of the complainant even after the gap of Six months from Ex.A10 report to Ex.A11 report are normal.
Admittedly opposite party no.1 insurance company neither disputed nor denied Ex.A10 and Ex.A11 are medical tests reports of complainant.
It is the grievance of the complainant that opposite party no.1 insurance company has not taken the factum of the renewal of the ALTP licence No 1485 of the complaint by DGCA basing on the Medical Tests reports conducted by Expert Specialist Doctors of Air 31 force Central Medical Establishment, basing on which opposite party no.1 insurance company renewed Ex.A2 Base Group insurance policy, every year since the year 2009 till 05.09.2017 on which date the ALTP licence of the complainant was declared permanent unfit i.e. complainant loss is licence that is cancelled on said date.
At this juncture it is also to be mentioned that Ex.A3 Additional TOP UP licence was obtained on 07.12.2015 but the ALTP licence of the complainant was cancelled on 05.09.2017 and admittedly Ex.A3 TOP UP Policy was renewed for the second year from 05.01.2017 to 04.01.2018 which very clearly shows that during the existence of Ex.A3 TOP UP Insurance Policy, the ALTP Licence No. 1485 of the complainant was cancelled.
Opposite party No.1 Insurance company banks on vide Ex.A9 letter dt.29.01.2020 in support of his contention for repudiating the claim of the complainant under Ex.A3 TOP UP policy, wherein on second Page of Ex.A9 at Para No.2 of the said letter it is mentioned by opposite party No.1 insurance company that "Capt Gowd has stated in his above letters that authorities, in their assessment dated 24.07.2015, have certified him fit without any restrictions or limitations. However, we do not agree with this statement as the said medical assessment dt.24.07.2015 of AFCME, Government of India, Civil Aviation Department, New Delhi was issued with the followings limitations:
1. Subject to wearing of corrective glasses while exercising.
2. Advised to reduce weight to acceptable BMI.
3. Advised to use Ear Plugs in Noisy Environment.
4. Investigation/compliance for next review : Next Review at AFCME/IAM only with Lipid Profile, OGTT &HBA1C, Cured Certificate by Endocrinologist.
At this juncture at the cost of the reputation we are of the considered view that it is to be mentioned that the above tests are only recommendations to be undergone by the complainant after 32 the gap of Six months from 24.07.2015 at AFCME Government of India Civil Aviation Department, New Delhi. Admittedly to the letter addressed by Opposite party No.1Insurance company to concerned office of Director General Civil AviationGovernment of India Civil AviationDepartment New Delhi Ex.A7 reply was given wherein, at the cost of repetition, it was categorically mentioned that the reports of Liquid Profile, OGTT and opinion by endocrinologist was not available that is Class 1 Med Examination on 24.07.2015. It is made clear that in Ex.A7 reply that no medical tests were conducted in December 2015/January 2016.
It is to be noted and mentioned for proper discussion, at the cost of the repetition that only after receipt of Ex.A7 letter from the concerned of the Director Civil Aviation Government of India Civil Aviation Department New Delhi, opposite party No.1 insurance company asked the complainant to submit medical reports underwent by him from the month of July 2015 to in the month of December 2015, and in response of the same the complainant submitted Ex.A10 and A11 Medical tests reports underwent by him for knowing his fasting Blood sugar and post Post Prandial Blood Sugar and also for HBA1C, the results of the same as mentioned in Ex.A10 and A11 are extracted supra and the same authenticated show that the Blood level sugars of both of the complainant are normal. We had also made it clear that in our afforested that discussion that opposite party No.1 insurance company neither denied nor disputed Ex.A10 and Ex.11 Medical tests reports of the complainant.
But to support its speculative contention as to the repudiation of Ex.A3 TOP UP Insurance policy of the complainant, opposite party No.1 insurance company bases its defence on Ex.A9 letter wherein at page No.3 in Para No.3, it is mentioned by opposite party No.1 insurance company that Ex.A3 policy was inspected on 07.03.2015 and Cpat Jangam Gowd was examined for the first time in January 2016 for Diabetes Mellitus Grade -III which is a close proximity for the inception of the policy.
33At this juncture we want to highlight the subsequent lines of above Para 3 of opposite party No.1 insurance company that they (opposite party No.1 insurance company) vide its Email dt.11.05.2018 sent to Broker, Global Insurance Brokers Private limited requested the office of opposite party No.2 Jet Air ways (India limited ) to provide opposite party No.1 insurance company with the copies of Medical/pathology reports in support of the subjective claim however no medical/pathology reports have been submitted to opposite party No.1 insurance companywhich establishes the commencement of illness in January 2016.
At this juncture it is further to be made clear that the letter dt.16.08.2018 which was addressed by opposite party No.1 insurance company to the concerned of the office of Director General Civil Aviation Department, Government of India, a copy of which was marked to the complainant herein and as per the documentary evidence filed and got marked by the complainant which are Ex.A10 and A11 pathology reports of the complainant, on the request of opposite party No.1 insurance company for his claim under his Ex.A3 TOP UP Policy were submitted by complainant to opposite party No.1 insurance company.
But surprisingly to our astonishment opposite party No.1 insurance company, have not even mentioned about Ex.A10 and Ex.A11 pathology reports of the complainant but while its letter under Ex.A9 dt.29.01.2023, banks on the Medical opinion which was given by Doctor CH.Asrani of M/s. Inches Healthcare to the effect that as per the documents submitted and as per medical opinion obtained from CH.Asrani, CaptJangamGowd was known case of diabetes prior to 24 th July 2015 In view of the same the claim of the complainant under Ex.A3 TOP UP Policy was repudiated by opposite party No.1 insurance company.
34The said opinion of Doctor CH.Asrani is dt.28.02.2019. The same shows that there is the gap of almost 4 years from the date of medical assessment which was 27.07.2015 by Air Force Central Medical Establishment (AFCME) Government of India, civil Aviation Department New Delhi.
We have seen the report of Dr.Asrani which was appended to Ex.A9 letter of opposite party No.1 insurance company addressed to opposite party No.2 Jet Airways, of course for the reasons known to opposite party No.1 insurance company, the said report of Dr. CH Asrani was not sent to complainant.
A perusal of the said report of Dr. CH Asrani shows that his qualification are " DNB Family Medicine; MBBS; Advance diploma in Forensic Medicine & Toxicology; Post Graduate Diploma in Medico Legal systems.
From the very first paragraph of the report of Dr.CH Asrani, he in first person stated that he is Practicing as a Consultant Family Physician and Insurance Claims Consultant in Mumbai.
He also stated that he was Defacto CMO- Sun life Insurance Co ltd from Jan 2009 to till 30 April 2013. Pre viously worked as Consultant Claims at ICICI Prudential Life Insurance from 2005 till 2010.
In the next paragraph Dr.CH Asrani, stated that opposite party No.1 insurance company approached him seeking his opinion in the claim of the complainant herein.
At this juncture it is to be mentioned that it is the contention/evidence of the complainant that the Medical Tests for the renewal of his licence as like the licence of other pilots, are conducted by Air Force Central Medical Establishment (AFCME) Government of India Civil Avi ation Department. The complainant appeared to the said Medical Tests on 24.01.2015 and after the Medical check-ups done and after being satisfied by the same, the DGCA renewed his ALTP Pilot Licence No.1485 without any restrictions or limitations.
35It is also to be mentioned here that the counsel for the complainant in his oral arguments vehemently submitted that the complainant had flown the International Air Craft From Brussels to Mumbai on 21.01.2016. If the contention of opposite party No.1 insurance company that the complainant suffering from the alleged Diabetes Miletus Type II 24.07.2015, the DGCA could not have allowed him to fly the said International Aircraft from Brussels to Mumbai on 21.01.2016 and e ven opposite party No.2 Jet Airways could not have taken risks of lives of 300 passengers who travelled in the said International Air Craft and also could not have taken the risk of the said Air craft worth Crores of Rupees.
There is no answer from opposite party No.1 insurance company to the above consistent version/evidence of the complainant. If the facts and circumstances of the present Consumer Complaint are critically ascertained, examined, with the scale of preponderance of probabilities, credence is to be given to the above version/evidence of the complainant.
At this juncture it is to be mentioned that the required Medical Tests for the renewal of licence of the pilot to fly the air craft are conducted by the expert/specialist certified Doctors at Air Force Central Medical Establishment of Director General, Civil Aviation New Delhi.
It is an admitted fact that opposite party No. 1 Insurance company renewed the licences of the pilots of Opposite party No.2 Jet Airways (India Limited) including the complainant herein , right from inception of Ex.A2 prime/Base Group Insurance Policy since the year 2009 till the complainant declared permanent unfit to fly the Air crafts on 05.09.2017.
Having scrutinised the so called report/Medical Opinion of Doctor CH. Asrani, it is our considered view that he is not that much of Expert/specialist Doctor as he is not a qualified endocrinologist, and his opinion cannot be equated with the Expert/specialist Doctors of Air Force Central Medical 36 Establishment (AFCME) Government of India Civil Aviation Department, New Delhi and further opposite party No.1 Insurance Company, ignoring the reports of AFCME of the complainant, giving credence to the opinion of Dr. CH Asrani who is like a panel Doctor of Insurance company, gives the impression that only to repudiate the legal claim of the complainant under both Ex.A2 and A3 polices, the said opinion was got obtained by opposite party No.1 insurance company, which is not sustainable under law.
Complainant is admittedly an Air Force Pilot being employed in Opposite party No.2 Jet Airways, Designated as Senior Commander, which fact is also evident from, Ex.A1 ALTP Pilot Licence No.1485 of him, right from the year 2009. He was declared Permanent Unfit to fly the Aircraft on 05.09.2017 which shows that he had successfully worked as a pilot of International Air crafts for a span of 9 continuous years which according to him after 20,000 hrs of flying time of experience without any remarks as he had flown the International Air craft from Brussels to Mumbai on 21.01.2016, which fact is not denied by opposite party No.1 Insurance company.
The life of a pilot such as complainant herein who flies the International Aircraft, is sophisticated and gives sufficient security to him and his family members for their lives, that is the reason why opposite party No.2 Jet Airways being the employer of the complainant and several other pilots/employees of it, with a view to provide security to the further life of the pilots and family members, when once their pilot licence is cancelled, obtained Ex.A2 Prime Group Insurance Policy and Ex.A3 TOP UP Additional Policy, by paying the required premium amounts from the salaries of the pilots, including complainant herein. Having collected the premiums in huge amounts and having issued Ex.A2 and A3 insurance polices, opposite party No.1 Insurance company has got legal obligation to honour the said policies and to pay the assured sum of amounts under the said two polices to the complainant as his pilot licence was cancelled. Hence opposite party No.1 insurance company is not justified in repudiating the legal claims of complainant under Ex.A2 and A3 polices.
37Thus having scrutinised the whole material borne by the record, we are of the considered view, that the complaint of the complainant deserves to be allowed in part, but not as prayed for in toto.
In the result, the complaint is allowed in part directing opposite party No.1 Insurance company to pay the insurance amount of Rs.1,15,00,000( Rupees one crore fifteen lakhs only ) under Ex.A3 Top UP Policy and also directed to pay the balance amount of Rs.57,50,000/- (Fifty Seven lakhs fifty thousand only) Under Ex.A2 the prime/the Base Group Insurance policy, with interest at 9% p.a. from the date of cancellation of the licence i.e. 05.09.2017 till the date of realization of the said amounts, to the complainant;
Opposite party No.1 Insurance company is further directed to pay costs of Rs.25,000/- towards the legal expenses to the complainant.
Time for compliance of this order is 30 days from the date of receipt of this order, failing which the rate of interest will be enhanced from 9% to 12% on the insurance amounts under Ex.A2 and A3 polices.
Typed to the dictation to the Steno on system, corrected and pronounced by us in the open bench on 19.11.2024.
MEMBER(J) M EMBER(N-J)
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Dated: 1911.2024
38
APPENDIX OF EVIDENCE
WITNESS EXAM INED
Evidence affidavit of Evidence affidavit of
The Complainant: Opposite Party No.1:
PW1:Smt.Captain Jangam Raghunath Gowd DW1:T.Balagopal
EXHIBITS MARKED
For Complainant:
Ex.A1 is the copy of Pilots License ALTP 1485
Ex.A2 is the copy of Primary Policy document and terms and conditions.
Ex.A3 is the copy of Additional Top Up Policy with terms and conditions.
Ex.A4 is the copy of Claim made to the Insurance Company. Ex.A5 is the copy of Letter, dated 20.08.2018.
Ex.A6 is the copy of Letter, dated 03.10.2017.
Ex.A7 is the copy of Letter, dated 17.09.2018.
Ex.A8 is the copy of Repudiation Letter, dated 05.11.2018. Ex.A9 is the Letter, dated 29.01.2020.
Ex.A10 is the copy of Pathology Reports, dated 22.07.2015. Ex.A11 is the copy of Pathology Reports, dated 26.12.2015. Ex.A12 is the copy of Email dated 23.12.2019.
Ex.A13 is the copy of Letter.
Ex.A14 is the copy of Medical Policy.
For opposite parties:
Ex.B1 is the copy of Aviation Loss of Licence Insurance Policy (Group).
Ex.B2 is the copy of Loss of Licence, dated 30.11.2017. Ex.B3 is the copy of Letter Ex.B4 is the copy of Medical Assessment, dated 03.10.2017. Ex.B5 is the copy of Letter, dated 11.09.2018.
Ex.B6 is the copy of Letter, dated 20.08.2018.
Ex.B7 is the copy of Letter.
Ex.B8 is the copy of Letter, dated 05.11.2019.
SD/- SD/-
MEMBER(J) MEMBER(NJ)
------------------------------------------- Dated :19.11.2024