State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India vs Mukesh Kumar Son Of Sh. Raja Ram on 23 October, 2013
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 295 of 2009
Date of institution: 9.3.2009
Date of Decision:23.10.2013
1. Life Insurance Corporation of India (LIC) through its Divisional
Manager, Divisional Office, Jallandhar.
2. Life Insurance Corporation (LIC) of India through its Branch
Manager, Branch Office Tinkoni Chowk Malout, Tehsil Malout,
District Muktsar.
3. Om Parkash Agent of Life Insurance Corporation, resident of
Guru Ravidas Nagar, St. Kundan Lal Wali Malout, Distt. Muktsar.
.....Appellants/Opposite Parties
Versus
Mukesh Kumar son of Sh. Raja Ram r/o Guru Ravidas Nagar Ward No.
14, Street Khaily Ram Wali Malout Tehsil Malout, District Muktsar.
.....Respondent/Complainant
Argued By:-
For the appellants : Sh. P.K. Longia, Advocate
For the respondent : None.
2nd Appeal
First Appeal No. 306 of 2009
Date of institution: 12.3.2009
Mukesh Kumar son of Sh. Raja Ram r/o Guru Ravidas Nagar Ward No.
14, Street Khaily Ram Wali Malout Tehsil Malout, District Muktsar.
.....Appellant/Complainant
Versus
1. Life Insurance Corporation of India (LIC) through its Divisional
Manager, Divisional Office, Jallandhar.
FIRST APPEAL NO. 295 OF 2009 2
2. Life Insurance Corporation (LIC) of India through its Branch
Manager, Branch Office Tinkoni Chowk Malout, Tehsil Malout,
District Muktsar.
3. Om Parkash Agent of Life Insurance Corporation, resident of Guru
Ravidas Nagar, St. Kundan Lal Wali Malout, Distt. Muktsar.
.....Respondents/Opposite Parties
Argued By:-
For the appellant : None.
For the respondents : Sh. P.K. Longia, Advocate
First Appeal against the order dated 2.1.2009
passed by the District Consumer Disputes
Redressal Forum, Muktsar.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Piare Lal Garg, Member Shri Jasbir Singh Gill, Member Gurcharan Singh Saran, Presiding Judicial Member This order will dispose of two appeals i.e. (1) First Appeal No. 295 of 2009(LIC and others versus Mukesh Kumar) and (2) First Appeal No. 306 of 2009(Mukesh Kumar versus LIC and others). Both the appeals are arising out of the same order dated 2.1.2009 passed by the District Consumer Disputes Redressal Forum, Muktsar(in short the "District Forum") vide which the complaint No. 124 dated 24.6.2008 filed by complainant was allowed to the tune of Rs. 50,000/- as compensation against OP Nos. 1 & 2.
2. The complainant Mukesh Kumar filed the complaint under Section 12 of the Consumer Protection Act, 1986 (in short 'the Act') against the Ops on the allegations that he obtained one LIC policy named as "New Janraksha Plan with profits - with Accident Benefits"
for a sum of Rs. 1,05,000/- on 24.12.2007 with policy No. 132680941 after paying the required premium and after that he was paying the premiums from time to time, therefore, he is consumer of the Ops. FIRST APPEAL NO. 295 OF 2009 3 However, he was met with an accident on 18.3.2008 and his left hand met with a machine injury and it had to be totally amputated below the wrist. He had been attending his work with left hand. He got himself admitted with Amandeep Hospital, Model Town, G.T. Road, Amritsar and despite best efforts of the Doctors, only one finger was saved and his left hand had become totally disabled and during the treatment he spent a sum of Rs. 50,000/-, therefore, he is entitled to reimbursement of this amount from the opposite party as per the insurance policy but it was not paid by the Ops, which amounts to deficiency in service on their part, hence, the complaint with the direction to the Ops to pay a sum of Rs. 50,000/- i.e. medical expenses incurred by him on his treatment during that period when he was under the Policy of the Ops obtained by him on dated 24.12.2007 bearing Policy No. 132680941 for an amount of Rs. 1,05,000/- named as (New Janraksha Plan with profits - with Accident benefits) alongwith interest @ 12% per annum from the date of accrual of the claim till its realization as the said obtained by the complainant from the Ops after paying all its premium etc. with the Ops time to time, further to pay compensation for mental tension, harassment, agony, litigation expenses, any other relief to which this Hon'ble Forum deems fit.
3. The complaint was contested by the Ops by filing written reply taking preliminary objections that under the policy there is no provision of reimbursement of expenses incurred during hospitalization under Table 91; as per the terms and conditions of the policy, the Ops are required to make the payment to policy holder on FIRST APPEAL NO. 295 OF 2009 4 permanent total disablement and that the following are considered to be permanent total disability:-
1. Irrecoverable loss of entire sight of both of the eyes.
2. Amputation of both hands at or above the wrist.
3. Amputation of both feet at or above the ankle.
4. Amputation of one hand at or above the wrist and one foot at on above the ankle.
The complainant has not come to the Forum/Court with clean hands; that complicated questions of law and facts are involved, therefore, the matter be relegated to the Civil Court; the complainant has no cause of action to file the present complaint; the complainant is not a consumer of the Ops; the complaint is vague imaginary hypothetical , as such, the complaint is false, vexatious and frivolous to the knowledge of the complainant, therefore, liable to be dismissed under Section 26 of the Act. On merits, it has been admitted that the complainant had taken the insurance policy of the Ops under "New Jan Raksha Plan". It has also been admitted that the complainant informed OP No. 2 vide letter dated 23.4.2008 that on 18.3.2008 his left hand was cut by Khophra machine and his four fingers of his hand were cut and he was hospitalized in Amandeep Hospital from 18.3.2008 to 24.3.2008. However, there is no provision of reimbursement under Table 91. The Ops are governed by the rules and regulations, as such, there is no question of lingering of the claim of the complainant. At the end, it has been stated that there is no deficiency in service on the part of the Ops, therefore, the same be dismissed.
4. The parties were allowed by the learned District Forum to lead their evidence.
FIRST APPEAL NO. 295 OF 2009 5
5. In support of his allegations, the complainant had tendered into evidence his affidavit Ex. CW-1, copy of policy Ex. CW- 2, copy of premium receipt Ex. CW-3, medical bills and details Ex. CW-4 to CW-7, discharge summary Ex. CW-8. On the other hand, opposite party No. 3 had tendered into evidence his affidavit Ex. OP-
1. OP Nos. 1 & 2 had tendered into evidence affidavit of V.K. Arora, A.O. Claims Ex. OP-2, copy of application dated 23.4.2008 Ex. OP-3, copy of discharge summary Ex. OP-4, insurance policy copy Ex. OP-5.
6. After going through the allegations in the complaint, written statement, evidence and documents brought on the record, the learned District Forum vide impugned order held that Mukesh Kumar had lost three fingers permanently and one finger although has not been amputated but has also been effected badly by the injury. The complainant is working as a labourer in which working of both the hands has a major role, therefore, the injury on one of his hand rendered him incapacitated to work as a Labourer, therefore, to that extent the complainant has suffered total/permanent disablement of one hand and after relying upon the judgment of the Hon'ble Apex Court "Partap Narain Singh Deo vs. Sriniwas Sabata", (1976) 1 SCC 289 holding that the injury to the left hand resulting in amputation above elbow as total disablement. Since the complainant was working as a Carpenter and on account of amputation he could no longer carry the work as a Carpenter. Though under the Workman's Compensation Act, this injury is covered under the partial FIRST APPEAL NO. 295 OF 2009 6 permanent disablement, therefore, he is entitled to compensation. Accordingly, the complaint was allowed as stated above.
7. Aggrieved with the order passed by the learned District Forum, the appellants/opposite parties as well as the complainant has filed the appeals with the State Commission.
8. In the appeal filed by the Ops, it has been contended that the learned District Forum had travelled beyond the terms and conditions of the policy as in the policy, there is no provision of reimbursement of expenses incurred as under Table 91 (New Janraksha Plan), the policy conditions of the policy has been annexed as Annexure A-1 and the appellant is under obligation to make the payment if the policy holder is under permanent total disablement. The respondent has placed on the record the discharge card and from the perusal the injury to the complainant was diagnosed by the Doctor as "Machine injury Lt. Hand with amputation lt. Middle, ring and little finger with multiple level injury lt. index finger with multiple cuts over the palm." The operation notes on the same document clarifies further "Wound Debridement + K-wire fixation of index finger + repair of FDS Tendon of index finger + stump closure of middle, ring, little finger + suturing of wounds", therefore, the claim of the respondent is not covered under the terms and conditions of the policy. The policy conditions are binding on both the parties and the learned District Forum has held the definition of "permanent disability", therefore, the claim awarded by the learned District Forum is liable to be set-aside.
FIRST APPEAL NO. 295 OF 2009 7
9. The terms and conditions of the policy are binding upon both the parties. The counsel for the appellant has referred to Table 91 {New Janraksha Plan) under which the policy holder is entitled on the event of permanent total disablement. The policy has been tendered on the record as Ex. CW-2. The total detail of the hospital has been brought on the record as Ex. CW-5. Ex. CW-8 is discharge summary. The terms and conditions have been attached with the policy as Ex. OP-5. Accidental benefit has been defined under Clause 10 and Clause 10(a), which reads as under:-
"(a) Disability to the Life Assured : (i) to pay in monthly installments spread over 10 years an additional sum equal to the Sum Assured under the Policy. If the policy becomes a claim before the expiry of the said period of 10 years, the disability benefit installments which have not fallen due will be paid along with the claim, (ii) to waive the payment of future premiums.
The maximum aggregate limit of assurance under all policies issued under Jeevan Sanchay Plan on the same life to which benefits (i) and (ii) above apply shall not in any event exceed Rs. 50,00,000. If there be more policies than one and if the total assurance exceeds Rs. 50,00,000 the benefits shall apply to the first Rs. 50,00,000 sum assured in order of date of the Policies issued.
The waiver of all premium shall extinguish all option under this policy except as to such assurance, if any, as exceeds the maximum aggregate limit of Rs. 50,00,000 and which may have been kept in force by continued payment of premiums and the benefits covered by (b) of this clause."
10. It will reveal the maximum amount, which can be paid under disability clause. Table 91 has not been referred in the terms and conditions of the policy. Otherwise also it has not been brought on the record of the Forum to show its applicability. Therefore, in case the complainant received some injury of permanent nature and FIRST APPEAL NO. 295 OF 2009 8 keeping in view the fact that he was working as Carpenter and now has been rendered incapacitated to work as a Carpenter then he will be entitled to some amount of compensation. In case of partial permanent disability then proportionate disability can be allowed. It has been held by the Hon'ble National Commission in "Mahendra Aggarwal vs. OIC Ins. Co." III 2010 CPJ 291(NC), Om Parkash Lokery Vs. CMC Hospital, II (2009) CPJ 178(NC) and "L.I.C. Vs. Ram Singh Tanwar", 1 (2007) CPJ 48 (NC).
11. In this case, three fingers of the left hand have been amputated and 4th index finger is also not properly working and keeping in view the nature of the job as a Carpenter without the help of left hand now he has been rendered incapacitated to work as a Carpenter, therefore, his case can be taken as a proportionate permanent disablement and in view of the above referred judgments, he is entitled to compensation and the amount of compensation has been allowed as Rs. 50,000/- lumpsum only and this amount was paid by him with the Amandeep Hospital as per bill Ex. C-5, which comes to Rs. 60,644/-. The counsel for the appellant has referred to some judgments i.e. M/s Suraj Mal Ram Niwas Oil Mills (P) Ltd. versus United India Insurance Co. Ltd.", 2010 (4) R.C.R. (Civil) 845 of the Hon'ble Supreme Court that in the Contract of Insurance, rights and obligations are strictly governed by the terms of the policy and no exception of relaxation can be given on the ground of equity.
"Dinakar Babasahed Tandale versus New India Assurance Co. Ltd. & Ors.", 2012(3) CPC 488 of Hon'ble National Commission. In that case, the complainant when driving his motor cycle met with an FIRST APPEAL NO. 295 OF 2009 9 accident - He suffered fracture in his left leg - District Forum directed the respondent company to pay a claim of Rs. 5 lacs. State Commission set aside the order as the insured had suffered only 25% disability, therefore, he is not entitled to any claim and its revision petition was also dismissed by the Hon'ble National Commission. He has also referred "Ajay Kumar versus Life Insurance Corporation of India", 2007 (1) CPC 456 of the Hon'ble National Commission that disability amount on the basis of partial disability cannot be made. But in view of the latest judgment of the Hon'ble National Commission referred to above, the amount on account of partial disablement can also be awarded. Therefore, we are of the opinion that the amount so awarded by the learned District Forum is quite reasonable. We do not find any infirmity in the same, therefore, we do not find any merit in appeal No. 295 of 2009 and the same is hereby dismissed.
12. None was present on behalf of the complainant but in the grounds of appeal it has been contended that in the complaint he has claimed Rs. 50,000/- as medical expenses, Rs. 30,000/- as mental tension and Rs. 5500/- as litigation expenses but he has allowed just Rs. 50,000/-.
13. Since this is a case of partial permanent disablement, therefore, the amount of compensation awarded by the learned District Forum is quite reasonable. We do not find any merit to enhance the same, therefore, appeal No. 306 of 2009 is hereby dismissed.FIRST APPEAL NO. 295 OF 2009 10
14. The arguments in these appeals were heard on 10.10.2013 and the orders were reserved. Now the orders be communicated to the parties as per rules.
15. The appellants in F.A. No. 295 of 2009 had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal. This amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to the respondent by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellants. Remaining amount shall be paid by the appellants to the respondent within 30 days from the receipt of the copy of the order.
16. The appeals could not be decided within the statutory period due to heavy pendency of Court cases.
17. Copy of this order be placed on First Appeal No. 306 of 2009(Mukesh Kumar versus LIC and others).
(Gurcharan Singh Saran) Presiding Judicial Member (Piare Lal Garg) Member October 23, 2013. (Jasbir Singh Gill) as Member