Kochi Ombudsman Centre
Case No. IO / KCH / GI / 11-005-058 / 2004-05
Sri. C. L. Thomas
Vs.
Oriental Insurance Co. Ltd.
The complaint under Rule No 12(1)(b) read with Rule 13 the RPG Rules, 1998 arose out of repudiation of an accident benefit claim preferred by the complainant with the Respondent Insurer under Group Accident Policy No. GPA – 2004 / 6 Covering the employees of M / s Apollo Tyres Ltd. Perambra. The Complainant’s case is that on 01.02.2004, he had an accidental fall in his bathroom and sustaining bodily injury in this process he was unable to walk.
The complainant reportedly had restorative physiotherapy for about 10 days and could not attend to his work in the factory. The Insurer, on the other hand , resisted the claim saying that the policy excludes any injury, which is not visible, even through medical tests, like sprain and similar injuries. They also disputed that the reported disability of the Insured could not have been due to the said accident.
However, the circumstances of the case were strong enough to give credence to the version of the complainant and the medical evidence in the file further fortified his case. The complainant was drawing a monthly salary of Rs. 8305/- and the benefits calculated for 9 days of hospitalization worked out to Rs. 9966/- The Insurer was asked to pay off the claim and thus the complaint was allowed.
