NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
(From the order dated 21.03.2006 in
Appeal No.2000/2005 of
the State Commission,
Versus
The Chief Executive Officer,
GE-Plaza,
Yerwada,
Pune0411 006 .. Respondent
AND
(From the order dated 21.03.2006 in Appeal
No.103/2006 of the State Commission,
C-31/32,
Versus
BEFORE
:
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.
Admittedly,
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/-.
Against
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:
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.
Sd/-
J.
(M.B.
SHAH)
PRESIDENT
Sd/-
(P. D.
SHENOY)
MEMBER