NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
(From the order dated 21.03.2006 in
Appeal No.2000/2005 of
the State Commission,
The Chief Executive Officer,
Yerwada, Pune0411 006 .. Respondent
(From the order dated 21.03.2006 in Appeal
No.103/2006 of the State Commission,
HONBLE MR.JUSTICE M.B. SHAH, PRESIDENT
DR. P.D. SHENOY, MEMBER
For the Petitioner in RP 267/2006 and : In Person
Respondent in RP1016/2006
For the Respondent in RP 267/2006 : Mr. P.K. Seth,
And Petitioner in RP 1016/2006 Advocate.
the Complainant has taken a policy under Personal Accident Scheme for a period
from 12.2.2003 to 11.2.2004. On
15.8.2003 a quarrel/fight took place between him and others and the
Complainant was injured. It is his contention that he has lost his
palm. He filed a claim with the Insurance
Company on 29.9.2003. He also furnished a medical certificate dated
5.11.2003 issued by the Civil Surgeon, Ahmednagar, wherein
it was mentioned that disability of the insured is to the
extent of 60%. After some harassment and
visiting the office of the Insurance
Company again and again, the Complainant was paid an amount of Rs.3,30,750/- towards the
settlement of his claim which according
to the Complainant was grossly inadequate but the same was accepted by him due to delay in settling the
claim. Thereafter, Consumer Complainant No.PDF-282/2004 was filed before the
District Forum, Pune,
The District Forum considered the facts that the sum assured was Rs.7,35,000/- and the Insurance Company paid Rs.3,30,750/- on the basis that the disability was to the extent to 45% in terms of the break up that was given in the written version to the effect that 10% for the loss of index finger, 20% for the loss of thumb and 15% for the loss of other three fingers. This was on the basis of partial permanent disability clause provided in the policy. The District Forum, however, considered that there was total amputation of hand from the level of wrist and it should be held that loss of hand at the wrist as a whole. Thereafter, the District Forum relying on a disability table held that the Insurance Company is required to pay 55% of the sum assured, thereby arriving at the conclusion that the Complainant was entitled to Rs.4,04,250/- instead of Rs.3,30,750/-. Hence, the District Forum directed the Insurance Company to pay the remaining amount of Rs.73,500/- with interest thereon @ 9% per annum from the date of filing of the complaint i.e. 7th August, 2004 till realization of the amount and costs of Rs.500/-.
that order, the Complainant preferred Appeal No. 2000/2005 and the Insurance Co. also preferred First Appeal
No.103/2006. Both the appeals were
dismissed by the State
Commission by order dated
Against that order the Complainant has filed Revision Petition No.267/2006 and the Insurance Company-Opposite Party has filed Revision Petition No.1016/2006.
For deciding the question in dispute, we would refer to the terms of the policy issued by the Insurance Company. The relevant clause 2.3.1 is reproduced hereunder:
In the event of Accidental Bodily Injury causing the Insureds Permanent Partial Disability as mentioned in the PPD Table below within 12 months of the Accidental Bodily Injury being sustained, the Company will pay the percentage of the Sum Assured specified for each and every form of impairment mentioned in the PPD Table:
An arm at the shoulder joint 70%
An arm above the elbow joint 65%
An arm beneath the elbow joint 60%
A hand at the wrist 55%
A thumb 20%
An index finger 10%
Any other finger 5%
A leg above mid thigh 70%
A leg up to might thigh 60%
A leg up to beneath the knee 50%
A leg up to mid-calf 45%
A foot at the ankle 40%
A large toe 5%
Any other toe 2%
An eye 50%
Hearing of one ear 30%
Hearing of both ears 75%
Sense of smell 10%
Sense of taste 5%.
It is true that if we consider it on the basis of loss of thumb, index finger and other fingers, the calculation made by the Insurance Company is justified. However, in the present case, it is apparent that the Complainant has lost his entire palm including fingers and thumb. It is just above the wrist. Taking this aspect into consideration, the District Forum and the State Commission arrived at the conclusion that the Complainant is entitled to 55% as per the Table quoted above.
In our view, the said findings cannot be said to be in any way erroneous as Complainant has lost A hand at the wrist. Injury is slightly above the wrist, but at the same time it is upto wrist and therefore, it cannot be said that simpliciter fingers and thumb are cut. Beyond fingers entire palm upto wrist was cut. It is not necessary that his entire wrist have been removed for getting the benefit as per the PPD table given by the Insurance Company.
However, the Complainant relied upon the certificate given by the Hospital to the effect that the disability was 60%. In view of the specific provision made in the insurance policy with regard to loss of bodily injury by giving specific table, Medical Certificate cannot be the basis for reimbursement. Hence, the State Commission has rightly not relied upon the said certificate.
Mr. Seth, learned counsel appearing on behalf of the Insurance Company submitted that in the present case the complainant has taken various policies from different Insurance Companies and that this was not a fit case for making any observations by the State Commission against the Insurance Company. We agree with the said submission that the insured/complainant is neither illiterate, ignorant nor innocent.
In the result, both the revision petitions are dismissed. There shall be no order as to costs.
(P. D. SHENOY)