Individual Personal Accident Policy

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1 Individual Personal Accident Policy Case No. OIC / 1 / 146 Mr. Trilok R. Gupta Oriental Insurance Co. Ltd. Award Dated Repudiation of claim under Individual P.A. Policy. Complainant s left leg and foot was injured by the wheel of a Bus in public place. He was taken to a Orthopaedic Hospital where his leg and foot was plastered and advised bed rest of three weeks by the Treating Doctor. Respondent submitted that according to their MR s opinion the Complainant was treated in the Hospital conservatively with plaster slab. There was no Bone injury or Soft Tissue injury. As swelling was not covered under the Policy they closed the file as No claim. Documents and submissions perused. The cover extended and the injury suffered by vehicle accident are not disputed. Referring to the Respondent s argument that since there are only swelling and no bone injury or soft tissue injury, the claim is not payable, it is surprised to note that under which Rule of Individual Personal Accident Policy the claim could be repudiated simply because there was only swelling. Further when one of the leg and foot is plastered nothing other than confinement is advisable. Respondent to pay claimed amount towards TTD and medical expenses. Case No Mr. Jayesh A. Shah The New India Assurance Co. Ltd. Award Dated Mr. Ambalal Shah was a holder of P.A. Policy. He sustained head injury and fracture on right leg due to which he was operated on He was again admitted in the hospital for removal of Implants and re-fixation on , but he died in the Hospital. Claim for accidental death benefit repudiated on the ground that bodily injury sustained by accident was not the sole and direct cause of death, but offered to pay TTD for 25 weeks amounting to Rs. 12,500/-. Complainant submitted that strain of the second operation alongwith bleeding and other complications arose from the operation led to the death of his father on Respondent submitted that in the case papers of Treating Surgeon, it was noted that the insured was a patient of Parkinsons Disease with senile tremors as well as of low haemoglobin. They further pointedout that their MR opined that the death cannot be attributed to accidental injury. The point taken for determination of the subject case is whether it has been proved that the accident was not the proximate cause of the Insured s death. Documents and submissions perused. It is observed that the Treating Surgeon has commented that exact cause of death is difficult to be given and has not mentioned surgeries as cause of death. The MR s Report also contained the same statement that exact cause of death is difficult to be given with further contention that death connot be

2 attributed because of injury. Held that the death was not caused by accidental injury. Respondent to pay TTD of 25 weeks amouting to Rs /- as FFS as has been offered by them. Case No. GIC / NIA / 1 / 277 Smt. Madhuben Patel The New India Assurances Co. Itd. Award Dated Husband of the Complainant who held a P.A Policy fell down and expired in the Hospital. Claim repudiated. Documents and submissions perused. Since the occasion of accident stated in Police complaint, in the letter to this office and stated during Hearing was conflicting each other, no weightage has been paid on such inconsistent statements. Therefore, the complaint is examined with regard to P.A Policy Conditions. No weightage is given to the Certificates submitted by the Complainant from a Children Specialist and Jain Merchant Society. Opinion of the Cardiologist of V. S. Hospital and the noting in the History Sheet of said Hospital are considered appropriate to assess the cause of death. Held that the death was not solely and directly caused by accidental injury. Repudiation upheld. Case No Mr. R. M. Vakharia United India Insurance Co. Ltd. Award Dated Wife of the Complainant was covered under P.A. Policy. Complainants lodged claim under this Policy stating that while walking on road, his wife s foot tumbled leading to an injury in her Right Foot. Respondent repudiated the Claim. Documents perused. It is observed from the Medical Attendant s Form that the Treating Physician described the nature and accident of injury as Diabetic Foot-wound over Right Foot. Held that the reported injury on the Corn of the Right Foot is due to Diabetic and cannot be attributed solely and directly from any accident. Repudiation sustained. Case No Mr. Valji J. Shingala National Insurance Co. Ltd. Award Dated Complainant held a P.A. Policy. He sustained injury when he accidentally fell down. Towards settlement of Claim, Respondent offered compensation of 12 Rs. 2500/- per week which was not acceptable to the Complainant. Documents and submissions perused. It is observed that Medical Referee of the Respondent initially recommended 6 weeks TTD which he subsequently changed and suggested for 12 weeks. The increase of benefits by 100% within a span of 2 months by the medical Referee is found to be some what incredible. Hence, based on such recommendation, the settlement offered by the Respondent is not acceptable. In the meantime, that TTD recommended by the Treating Surgeons has been taken as reasonable, and accordingly Respondent to pay 18 weeks Rs. 2500/- per week. Chandigarh Ombudsman Centre Case No. GIC / 79 / UII / 11 / 05

3 Smt. Surabhi Khullar United India Insurance Co. Ltd. Award Dated Facts : Smt. Surabhi Khullar subscribed to silver credit card of HDFC Bank, which inter alia, provided a restricted insurance cover for personal accident. She slipped on the road and suffered multiple fractures at elbow, forearm and upper arm on the right side. She was rushed to Dr. Pradeep Aggarwal s Bone and Joint Surgical Centre, Manimajra where she was operated upon and treated for two months. Subsequently, she was treated at Saket Hospital, Panchkula. She lodged the claim with United India Insurance Company, which was rejected on the plea that slipping on the road was not a road accident as per M.V. Act. Findings : As per the terms and conditions of the policy, claim for hospitalization is entertainable only as an extension of rail, road or air accident. This is also explicitly stated in the Card-Member agreement that only hospitalization claims arising out of rail / road / air accident are payable. Decision : Held that the claim is not payable as per terms and conditions of policy, as injury in the instant case was not caused during travel by any of the specified modes. Kochi Ombudsman Centre Case No. IO(KCH) / GI / / Shri C. A. Francis New India Assurance Co. Ltd. Award Dated The complaint under Rule 12 (I) (b) read with Rule 13 of the RPG Rules 1998 is as a consequence of repudiation of a Personal Accident claim by the insurer in relation to a Master policy covering the subscribers of M/s. Asianet Satellite Communications. The complainant was one of the subscribers and as per terms of the master policy, the complainant, his wife and the first-two children (in all 4 persons) were covered under the Policy. There was no provision to include a fifth member. The complainant s son Shri. Lijo Joseph the third child - met with a Motor-bike accident on The insurer repudiated the claim on the plea that the third child was not covered under the scheme. Besides, the insurer had also alleged some gap in the instalment remittances which, however, was found very feeble to stand the test of law. However, the main plea that the deceased was the third child of the complainant and hence not covered under the scheme was found to be correct, Iegally tenable and acceptable when read with the terms and conditions of the policy. The complainant was also aware of these terms and conditions. In the aforesaid circumstances, it was proved beyond doubt that the deceased child was not covered under the scheme and hence the repudiation of the claim by the insurer was upheld. Mumbai Ombudsman Centre Case No. IO / MUM / GI / Shri M. C. Shah United India Insurance Company Limited Award Dated Shri M. C. Shah was covered under a Personal Accident Policy for the period from to vide Policy No / 42 / 01 / with the United India for a sum insured of Rs.3,00,000/-. The Complainant accidentally fell down in his house on and he was hospitalised at Dr. Desai s Sushrut Clinic from to On discharge he was advised to bed rest. He preferred an Accident claim of

4 Rs.39,000/- for his Temporary Total Disablement (weekly benefit) against the Insurance Company. The Company settled his claim for Rs.21,775/- for which the Complainant represented to them which was considered. Dissatisfied by the decision of the Company, Shri M.C.Shah, approached the Insurance Ombudsman for intervention in the matter of settlement of his claim. After perusing the documents a hearing was fixed on when the Complainant and the representative of the Insurance Company were heard. Shri M.C.Shah, the Insured, appeared and deposed before the Ombudsman that he was completely bedridden for 13 weeks but the Company had settled the claim for 7 weeks and the Personal Accident Policy is a valued policy his claim should be settled for 13 weeks and not for 7 weeks. He further stated that his claim was for Rs.39,000/- calculated at Rs.3,000/- per week while the Company has settled only Rs.21,775/-. There was a short fall of Rs.18,000/- and the Company did not settle the same. The Company was represented by Shri S.V.Deshkulkarni and he submitted that the claim was settled for 13 weeks and not for 7 weeks and the amount was calculated based on the average income. The average income was calculated on the basis of 3 years income by taking income from pension, business sources, bank interest and consultancy. After taking the average figure of Rs.1,67,501/- weekly compensation of Rs.1,675/- was arrived at and for 13 weeks, the total amount was settled for Rs.21,775/-. All submissions, contentions and evidence on recorded have been duly considered by this Forum. The Policy is designed to cover loss of earnings as a result of the Insured being incapacitated as a result of the accident. It appears from the statement submitted to this Forum by the Company as per their letter dated that they have based their calculations on the basis of Income Tax statements as per SARAL Form submitted by the Insured. In fact while there is no impact on pension and interest income which would remain unaffected irrespective of the accident, they have calculated the same to arrive at the average income which is quite reasonable. Accordingly 1% of Rs /- comes to Rs.1675/- per week, hence Rs.21775/- for 13 weeks paid by the Company is justifiable. Accordingly the complaint of Shri M.C.Shah claiming a settlement of Rs.39,000/- i.e. Rs.17,225/- more as balance amount is not sustainable. Mumbai Ombudsman Centre Case No. IO / MUM / GI of Smt. Hansa Gandhi The Oriental Insurance Company Limited Award Dated Smt. Hansa Gandhi was covered under Personal Accident policy of the Oriental Insurance Company Ltd. Smt. Gandhi had an accidental fall on sustaining injury to her left eye. She was taken to Adarsh General & Maternity Nursing Home for treatment and Ophthalmic examination revealed traumatic expulsion of IOL with Iris prolapsed. After controlling her diabetes Mellitus wound was repaired with anterior virectomy which was done on at Mehta Eye Clinic (P) Ltd. She was taken to Aditya Jyot Eye Hospital for the complaints of pain in the left eye. Dr. Natarajan in his case notings stated that the Insured was diabetic since last 15 years and was on insulin, hypertensive since 8.10 years cataract extraction with IOL in both eyes done in He also stated that she had diabetic maculopathy in right eye and no vision in left eye. After hospitalization, the insured preferred a claim for loss of vision in left eye. The Company referred the matter to Dr. M.S.Kamath for his medical opinion and he opined that the Insured had undergone a cataract surgery with lens implantation prior to talking the policy and was suffering from diabetes from 15 years and hypertension form 8.10 years and this fact had not been disclosed in the proposal form. The Company informed the insured about its decision to repudiate the claim. The hospital records clearly reveal the past history of Smt. Hansa Gandhi that she had diabetes since last 15 years and on insulin, had hypertension since 8.10 years, had cataract operation with IOL implanted on both eyes in All these vital

5 information was not passed on to the Insurance Company as per proposal form submitted by the Insured. Opthalmic examination revealed (left eye) cataract wound gape with expulsion of IOL, iris alliary body prolapse with vitreous in anterior chamber and hyphaema. Wound repair with anterior vitrectomy was done after adequate control of diabetes. As regards the fall and direct impact of the trauma we may rely upon the notings again. She had a fall on 26th May afternoon as per report and she was taken to Adarsh General & Maternity Nursing Home only next day 27th at 1.30 p.m. The reason stated by Shri Bhupendra Gandhi was that she was kept at house as she was opposed to go to hospital at all particularly at night. However, he admitted the lens came out and blood was oozing whole night with distinct chance of retinal detachment. From all these it would be clear that the entire episode of fall would be just the tip of the iceberg. Essentially it was a prolonged diabetes, hypertension and cataract extraction and a series of eye treatment she had that intrinsically and vitally affected the eyesight not only in left eye but equally so in right eye. Both eyes are actually vulnerable to loss of sight and doctor has admitted that right eye has Diabetic Retinopathy. It cannot ever be direct impact of fall and the bulging out of the IOL would not be in normal eye as there is no cataract removal and IOL implantation. All these were there as predisposing factors with severe diabetes for 15 long years which always causes most dangerous effect on eyes which is a known medical fact. Consequently the loss of sight is a gradual phenomena which can occur in right eye also even with sufficient care and action because of invasive progress of the disease. In the facts and circumstances of the case, I have no valid ground to interfere with the decision taken by the company to repudiate the claim.

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