O R D E R

(By Sri Ganesh Jadhav, President)

1. The brief facts of complaint are as follows:

2.       The complainant is the husband of the deceased insured Smt. Pallapu Laxmi. During her  life time Smt. Pallapu Laxmi was a member of Agricultural Co-Operative Society of Govindpet of Armoor mandal,  Nizamabad Distirct  and was issued Kisan Credit Card-Cum- pass book Vide No. 702. As per tie up,  KCC account holders are covered under Personal Accident Scheme issued by Opposite Party No. 3, the insurance company. The insured amount due to accidental death is Rs. 1,00,000/-and the insurance premium was paid by the KCC holder.

           The complainant’s wife Smt. Pallapu Laxmi who is KCC member of the Opposite Party No. 1 was included in the Personal Accident Master Policy issued by Opposite Party No. 3 vide Policy No. APG/10177896/51/04/C55123 valid from 01-02-2010 to 30-04-2011.

 Unfortunately the complainant’s  wife died on 06-05-2010 at about 9:00 pm accidentally as the Tractor along with Trolly in which she along with others were travelling fell in dried open agricultural well. The matter was reported to the police and the police PS Jakranpally registered a case in Cr. No.44/10 U/s 304 (A), 337 and 338 IPC and issued FIR.

 The complainant being the husband submitted claim application with all the necessary and required documents for processing the claim to Opposite Party No. 1.

 Inspite of repeated oral demands made by the complainant, the Opposite Parties did not settle the claim of the complainant which is deficiency of the service on the part of Opposite Parties 1 to 3 to the complainant.

 Therefore the complainant approached the forum with a prayer to direct Opposite Parties 1 to 3 to pay the insured amount of Rs. 1,00,000/-  under the policy, compensation of Rs. 50,000/- towards pain, suffering and mental agony and also  to pay Rs. 28,000/- towards damages with interest @ 24% per annum  on the policy amount from 03-06-2010 till the date of filling this complaint and also future interest till its realization along with Rs. 5,000/- towards costs of the complaint.

3.       The Opposite Party No.1 filed counter initially stating that, the complaint against this Op is not tenable in law and all the allegations made against them are false subject to proof of the same. In counter, Opposite Part No.1 stated that they are only facilitators and paid the insurance premium to the insurance company i.e. Opposite Party No. 3 through Opposite Party No. 2. After the scrutiny, the Opposite Party No. 3 has issued the policy. All the required documents for processing the claim were submitted to the insurance company by them, after receiving them from the complainant. As the insurance policy is issued by Opposite Party No. 3 it is the sole responsibility of the insurance company to pay the benefits under the policy/claim amount to the complainant as per terms and conditions of the policy. As there is no deficiency of service on their part prayed to dismiss the complaint against them with cost in the ends of justice and equity.

          Opposite Party No. 2 filed counter stating that the complaint against this Opposite party is not tenable either under law or on the facts of the case and all the allegations made in the complaint are false and the complainant is put to strict proof of the same. 

          In the counter, Opposite Party No. 2 submits that their role is to facilitate the member of the Opposite Party No. 1 to make them aware about the policy and to get benefits under the policy. As per norms of the NABARD they also contributed the insurance premium at the ratio of 2:1.  Unless and until they complied all the relevant formalities the insurance company would not have issued insurance policy. It is also admitted by the complainant that insurance policy was issued by the insurance company. The liability to pay the benefits under the policy is only on the insurance company.

          Finally prayed that they are not liable to pay any amount to the complainant. As there is no deficiency of service, prayed to dismiss the complaint against them in the ends of justice and equity.

          Opposite Party No. 3 filed its counter denying all the allegations made by the complainant against them and put the  complainant to strict proof of the same.

 Opposite Party No. 3 in its counter stated that they issued personal accident Insurance Policy vide No. APG/10177896/51/04/C55123 effective from  01-02-2010 to 30-04-2011 to the Kisan Credit Card holders of Opposite Party No. 2 bank  and the bank paid the premium of Rs. 76,80,218/- . The total sum insured  per Kisan Credit Card account holder is Rs. 1,00,000/- without interest and costs. The liability of the insurance company is strictly governed by the terms and conditions, exclusions laid down in the policy agreed by the parties. Any breach of terms and conditions does not make the insurance company liable for any amount under the policy.

          Further stated that as per exclusion No. 8 ( V ) of the policy they are not liable for any payment to the complainant. After the death of insured neither the complainant nor Opposite Party No. 1 and 2 gave any written intimation with full particulars to them within one calendar month. The death intimation was reported to them beyond the prescribed period mentioned in condition-11 ( a) & ( b).  Therefore stated that the question of considering the claim does not arise and they rightly repudiated the claim of the complainant and as such they are not liable to pay any amount to the complainant.

          Finally contended as there is no deficiency of service on the part of this Opposite party to the complainant,  prayed to dismiss the complaint against them with exemplary costs in the interest of justice.

4.       During the enquiry the complainant filed his chief affidavit as PW1 in lieu of his evidence and got marked Ex. A1 to A12 documents. On behalf of Opposite party  No. 3 Sri .S. Naresh, Claim Analyst filed his chief affidavit as RW1 and got marked        Ex. B1 Insurance Policy.  On behalf of Opposite party  No.2 Sri. Ananth Rao CEO, NDCC Bank, Nizamabad Branch filed his chief affidavit as RW2 and no document was marked.

5.       Heard arguments of both side counsels  and perused the written arguments filed by Opposite party No.3 and also gone through the judgment of the Hon’ble Supreme Court cited by the Opposite Party No. 3 in support of their version  and also  the judgments of various commissions cited by the counsel for complainant in support of his version.

6.       The points for consideration are:-

i) Whether there is any deficiency of service on the part of Opposite Parties in repudiating  the claim under policy?

ii) Whether the complainant is entitled for any reliefs as prayed for?

iii) To what relief?

7.       POINT NO.1

           The facts which are not in dispute are that, the wife of the complainant namely Smt. Pallapu Laxmi was a member of Opposite  party No.1 vide account KCC No. 702. She was covered under Personal Accident Master Policy vide                                                No. APG/10177896/51/04/C55123  issued by Opposite Party No.3 valid from 01-02-2010 to 30-04-2011 . The insured amount due to accidental death is Rs. 1,00,000/-. At the time of death of the insured the policy was in force. 

The disputed facts are:-

          The complainant alleged that inspite of submission of required documents and repeated request, the Opposite Parties 1 to 3 did not settle his claim which is deficiency of service on the part of Opposite Parties 1 to 3. The complainant filed his chief affidavit as PW1 in lieu of evidence and got marked Ex. A1 to A12 documents. Opposite Parties 1 and 2 counter the said allegation of the complainant and contented that they are only facilitators and they have no role in payment of the insurance amount.  After receiving the required documents for processing the claim from the complainant they forwarded them to the insurance company i.e. Opposite Party No.3. As the policy was issued by insurance company it is for the insurance company to indemnify the loss in case of accidental death of the insured as per the terms of the policy.  Therefore prayed to dismiss the complaint against them as there is no deficiency in their service to the complainant and filed chief affidavit of Sri. Ananth Rao CEO, NDCCB  branch, Nizamabad in lieu of evidence on their behalf. No document marked.

Opposite Party No. 3 resisted the allegation of the complainant admitting issuing of personal accident master policy to the Kisan Credit Card Account holders of Opposite Party No. 2 valid from 01-02-2010 to 30-04-2011 subject to the fulfillment of terms and conditions, exclusions laid down in the policy agreed by parties. As per exclusion clause No. 8 (V) and violation of condition No. 11(a) & (b) they are not liable for payment of insurance amount to the complainant under the policy  and  contended  that they rightly repudiated the  claim as no claim and filed chief affidavit of Sri. S. Naresh Claims analyst of Bharathi Axa General Insurance Co. Hyderabad in lieu of evidence and got marked Ex. B1 document.

The document Ex. A1 support the version of the complainant, that his deceased wife was member of Co-operative Society (Op No.1) and was issued Kisan Credit Card Cum Pass Book Vide Account KCC No. 702 by Opposite Party No. 2.

 The affidavit of complainant coupled with Ex.A3 ( FIR), Ex.A5 inquest panchanama, Ex.A6 Post Mortem Report, Ex.A7 Death Certificate  led to prove that the insured died on 06-05-2010 accidentally due to severe head injury, As per Ex. A8 Family member certificate  the complainant is the husband of the insured. Ex. B1 equal to Ex.A12 is the attested true copy of the Group Personal Accident Insurance Policy issued by Opposite party No. 3 covering Kisan Credit Card Account holders of Opposite Party No.2.  The sum assured under the policy is Rs. 1,00,000/-.

The insurance company contended that the death of the insured deceased was not accidental but a concocted storey, as no satisfactory proof is produced which attracts the exclusion clause 8 (v) of Ex. B1 policy.

 The Opposite party though alleged that there is fraud or misrepresentation and the death of insured due to accident is false and based on concocted stories did not produce any evidence to the contrary to rebut the evidence of the complainant in Ex.A3 to A8.

The National Commission in case of New India Insurance Co. Ltd., V/s. State of Haryana & others reported in II (2008) CPJ 371 (NC) held that insurer can’t discount and reject reports and statement of Government Hospital authorities and also the Gram Panchayat and other Government authorities without evidence to contrary and stated that repudiation of claim by insurance company is deficiency in service.

Therefore there is no stuff in the plea of opposite party No. 3 that the death of deceased was not accidental and attracts the exclusion clause 8 (V) of Ex. B1 policy.

Further the case of Opposite party No. 3 is that the claim of the complainant is beyond prescribed period of one month which is violation of condition in 11 (a) & (b) of the policy.

The counsel for Opposite Party No. 3 vehemently argued that breach of terms and conditions of the policy does not make the insurance company liable for payment of insurance amount and relied upon the Hon’ble Supreme Court judgments in Civil Appeal No. 1557/04 in case of Export Credit Guarantee Corporation of India V/s M/s. Garg Sons International.

 Learned counsel for the complainant retaliated the said contention of the Insurance Company and contended that there was no delay on their part in claiming GPA policy amount under Ex. B1. However if it is presumed but not admitted that prescribed period of one month mentioned in condition 11(a) & (b) of Ex.B1 policy is not a mandatory, to repudiate genuine claim as no claim. Further contended that the Hon’ble Apex Court judgment (stated supra) is not applicable to the facts of the present case. Counsel for complainant relied upon Hon’ble Tamilnadu State Commission judgment between New India Assurance Company Ltd., V/s N. Ekabaram reported in CPJ (IV)  2005 October part  at Pg. 41.

          On perusal of material on record we observe that there is no proof of intimation of death of insured given in writing to the insurance company of opposite party No.3 either by the complainant or the Opposite Parties 1 & 2 within prescribed period from the date of accidental death of the deceased. Therefore we are not inclined to accept the version of the complainant that there is no delay in claiming GPA Policy amount under Ex.B1

The point for discussion is:-

Whether the delay in claim beyond prescribed period of one calendar month mentioned as condition No.11 under clauses (a) & (b) of Ex.B1 policy is a mandatory for repudiation of claim as no claim? or only a directory to speed-up the process of claim?

          The counsel for opposite party No.3 has cited the Hon’ble Apex Court common judgment as stated supra supporting his contention.  In said case, the facts are that the Export Credit Guarantee Corporation of India Ltd., is a Government Company, dealing the business of insuring exporters.  M/s Garg Sons International purchased a policy on 23-3-1995 for insuring a shipment to foreign buyers i.e. M/s Natural Selection Co Ltd., of U.K. and the said buyer committed default in making payments towards such policy from 28-12-1995 onwards with respect to the said consignment.  Hence failed to comply with the clause 8 (b) of insurance agreement.  Therefore the claims were rejected.  The Hon’ble Apex court held that while upholding the rejection of claims that it is not permissible for the court to substitute the terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance.

          As per clause 8 (b) of agreement, the insured shall declare and deliver the shipments and its over dues on or before 15^th day of every month to the insurer which remained wholly or partly unpaid for more than 30 days.

          Therefore the matrix of case is that the coverage of insurance with respect to consignment is only on declaration of shipments and its overdue payments.  In the instant case the mandatory requirement of declaration for the insurance coverage of certain claims periodically is not necessary.  The present claim of case is based on Group Personal Accident insurance policy to bear the risk of KCC ( Kisan Credit Card) holders and agriculture loan account holders under the control of opposite parties 1 and 2.  The master policy in Ex.B1 was issued for a period of one year.  The risk will be covered during the policy period.  Therefore we are of the view that the facts in present case are quite different with the facts cited in the case and the Hon’ble Apex court judgment in Civil Appeal No.1557 of 2004 and its batch is not applicable to the present case.

          The learned counsel for complainant has cited the Hon’ble Tamilnadu State Commission judgment supporting his version.  The fact of the case is that the claim is repudiated on the ground that the complainant has not chosen to inform about the accident immediately and thus there is breach of condition.  The Hon’ble State Commission held that the condition even if not complied not fatal to claim as it does not amount to fundamental breach – company liable under policy. 

          There are also similar  judgments on delay in insurance claim as follows:-

1. Bimla Devi & Others versus life insurance corporation of India.  H.P. State Commission – Reported in CPJ volume II, part V, May  2007 page No.300.
2. New India Assurance Co Ltd., Versus Mr. Nanasaheb Hanumant Jadhav & others – Maharashtra State Commission – Reported in CPR part V and VI 2005 May / June page No.24.
3. Reliance General Insurance Co Ltd., Versus Sri AVN Ganesh – RP No.3572/2011 dated 29-11-2011 N.C. New Delhi.

In all above cases the condition of intimation for the death of the insured within one month is only directory and not mandatory. Merely because the claim is not made within the stipulated time the claim is not void. The time limit clause is meant for the interest of the insured in order to facilitator prompt scrutiny of the claim.

After careful consideration of the submissions made by both parties and on perusal of record we are of the opinion that the Opposite Parties 1 and 2 are only facilitators for providing GPA Insurance policy (Ex.B1) as per norms of NABARD and they have no role in payments of the insurance amount as the insurance policy was issued by Opposite Party No. 3. The Opposite Parties 1 and 2 forwarded the claim of the complainant to the insurance company i.e. Opposite Party No. 3 after receiving the required claim documents from the complainant. Therefore we are of the considered opinion that there is no deficiency in service on the part of Opposite Parties 1 and 2 in discharging their duties towards complainant.

          In view of discussion held supra and the judgments referred above we are of the considered opinion that there is deficiency of service on the part of Opposite Parties No.3 only, in repudiating the claim of the complainant. Hence point No.1 is answered against Opposite party No. 3 only and in favour of the complainant. 

8. POINT No.2 & 3:

          In view of our findings on the foregoing point No.1 and the reasons mentioned there in, we are of the considered opinion that the complainant is entitled for the following reliefs.

          The Opposite party No.3 is directed to pay Rs. 1,00,000/- ( Rupees one lakh only) under Personal Accident Master Policy vide No. APG/10177896/51/04/C55123 to the complainant  along with interest @ 9% per annum from the date of complaint i.e 28-07-2011 till the date of realization towards accidental death claim under Ex.B1 GPA Insurance Policy.       The Opposite party No.3 is also directed to pay Rs. 1,000/- to the complaint towards cost. The complaint is liable to be Dismissed against Opposite party No. 1 & 2.

9.       IN THE RESULT, the complaint is allowed in part as under:-

1. The opposite party No.3 is directed to pay Rs.1,00,000/- (Rupees One Lakh only) to the complainant with 9% interest per annum from the date of complaint i.e. 28-07-2011 till realisation towards accidental death claim under Ex.B1 GPA insurance policy.
2. The opposite party No.3 also directed to pay Rs.1,000/- (Rupees One thousand only) to the complainant towards costs.
3. The complaint is “DISMISSED” against opposite party 1 and 2 without costs.
4. The opposite party No.3 also further directed to comply the above 1 and 2 directions within a month from the date of receipt of this order.

          Typed to dictation, corrected and pronounced by me in Open Forum on this the 28^th day of January 2014.