Presents:-
- Sri P.Samantara,President.
- Sri G.K. Rath, Member.
Dated,Bolangir the 9th day of September 2015.
C.C.No.65 of 2014.
Kailash Sahoo, age- 36 years son of Nilakantha Sahoo
Resident of Daily Market Road Stall, Bolangir Tow,
P.O/P.S & Dist- Bolangir.
.. .. Complainant.
-Versus-
Brancha Manager, Life Insurance Corporation of India.
Bolangir Branch, At-Chandrasekhar Nagar, Bolangir
Town, P.O/P.S & Dist- Bolangir.
.. .. Opp.Party.
Adv.for the complainant- None.
Adv.for the Opp.Party. – Sri S.S.Mishra. & Associates.
Date of filing of the case- 08.09.2014
Date of order -09.09.2015
JUDGMENT.
Sri P.Samantara, President.
In the matter of an application u/s.12 of the C.P.C.Act,1986, filed by the complainant alleging deficiency in service against the O.P.
2. The complainant has taken one life insurance policy No.591987237 on dt.22.09.2004 with an assured sum of Rs 60,000/- .Premium is Rs 1063/- having the maturity date on dated 22.09.2019. The policy was “New Janarakha policy with profits + accident benefit”. It is stated complainant met an accident on dt.04.03.2011 while riding on motor cycle, consequently become senseless and shifted to Burla Medical Hospital for better treatment in post primary Health center treatment at Chudapali. Admitted at Burla, Headquarters Hospital, Neuro surgery Unit on dt. 04.03.2011 and discharged on dt.20.03.2011. Post treatment continues till the date.
3. Complainant also averred regained his sense on last part of August 2013 and submitted the claim intimation on dt.16.09.2013 and the O.P intimated vide letter No.BGR/CLAIMS/DIS.BEN. dt 18.09.2013 repudiating that the application requesting for disability benefit can not be considered as per policy condition. Praying to settle the claim in interest of justice. Relied on original policy, Repudiation letter, Discharge Certificate from Burla with related bills, vouchers in photo copies and affidavit.
4. The O.P filed the written statement contending the case is not maintainable. No purge of cause of action, the case has no merit, complainant is not entitled to any benefit so rightly claim has been rejected.
5. Further contended, the petition is contradictory to earlier averments. The fact of accident, place and date of accident is doubtful as no FIR has been lodged and ensured treatment is not categorized under “Medico legal case”. The entire fact shrouded in mystery. The policy condition has not been fulfilled by the complainant for which the claim was not considered. There is no deficiency of service by this O.P and the permanent disability is defined which precludes to entertain the settlement in violation of policy condition.
6. Heard the complainant and learned counsel of the O.P at length. Perused the case record at hand.
7. Perusal of the case record furbish that on the outset the O.P in admission states, the claim intimation on the issue of accident benefit settlement has been received on dated 17.09.2013 and repudiation letter issued on dt.18.09.2013 on ground of too belated application which amply speaks insurers’ decision is not based on sound logic and valid grounds, rather purely on technical grounds.
8. The grounds that taken into consideration by the O.P is that the claim intimation has not been communicated within the allowed 300 days of the occurrence of accident which is violative in principle of policy condition. As the accident took place on dt.04.03.2011 and claim was made on dt.16.09.2013, more than 2 and half years after the accident. Again the place of accident nature of accident, the discharged dates and thereof the disability sustained is not corroborated by any document evidence. Perusal of the record speaks the contentions raised is correct on the back drop settlement technicalities not based on any thorough investigation and reasons advanced must be handled with utmost care and caution.
9. The rider clause 10(a) para (3) reads- Immediately……And thereafter similar proof must be given as and when required by the corporation of the continuance of such disability. Any medical examiner nominated by the Corporation of the continuance of such disability…. May require.
10. Observation of the submission states above noted clause has not taken into consideration nor the complainants deny to examine before the nominated panel of doctors. So also the disability certificate procured by the complainant is issued by District Hospital, Bolangir, the nature of disability is loco motor in left of body which is caused by degeneration of the nerve fibers and the reassessment of disability is recommended after 2019,which is in realistic has not considered. Other latches as surfaced are menial and do not undermine the genuienity of the occurrence and disability sustained.
11. The insurance company could not have repudiated the claim solely on the ground of delay in submission of claim intimation. The insurance regulatory and Development authority has in its circular dated 20.09.2011 issued instructions in this behalf to the insurance companies which inter alia read as under:-
“The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents. The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning claim settlement etc. However, this condition should not prevent settlement of genuine claims particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances. The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders loosing confidence in the insurance industry, giving rise to excessive litigation. Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution, it is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time. The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurer’ stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured.”
12. In view of the above instructions of IRDA, we hold the rejection of the claim filed by the complainant on the ground of belated delay was not justified. We hold the O.P is deficient in rendering service to the complainant. Thus we direct as under:-
(1)Pay the complainant a sum of Rs 60,000/- (Rupees Sixty Thousand) only along with interest @ 6% per annum from the date of institution of this complaint till payment.
(2)Pay to the complainant a sum of Rs 3,000/- (Rupees Three Thousand) only as compensation/cost of litigation.
The above amount shall ;be paid by the O.P to the petitioner within 30 days from the date of this order, failing which the O.P shall be liable to pay interest on the entire awarded amount @ 9% per annum from the date of this order till the date of payment.
ORDER PRONOUNCED IN OPEN FORUM THIS THE 9TH DAY OF SEPTEMBER 2015.
I agree.
(G.K.Rath) (P.Samantara)
MEMBER. PRESIDENT.
