O R D E R

(By Sri D.Shankar Rao, Member)

1. The brief facts of complaint are that the husband of complainant namely B.Yadagiri was member in the Society of opposite party No.1 and holder of Kisan Credit Card (KCC) by covering personal accident Group Insurance Master Policy No.APG/10177896/51/04/C55123 from 01-02-2010 to 30-04-2011 through the insurance company of opposite party No.3 in view of tie-up with the opposite party No.2 Bank.  

          That the husband of complainant B.Yadagiri was died accidentally due to hit by a bull from his behind with its horns and hit him repeatedly mercilessly on 12-05-2010 while he providing water to his bulls.  The Yellareddy police have issued FIR No.42 of 2010 and finally reported that the deceased B.Yadagiri was died accidentally.   The complainant has made claim but opposite parties 1 to 3 have not settled.  Hence filed this complaint for payment of Rs.1,00,000/- under personal accident Group insurance policy with interest and compensation along with costs.

1. The opposite parties 1 and 2 have filed their counters separately but their replies are one and the same.  They mainly contended that they are only facilitators for covering personal accident Group Insurance Policy to the KCC holders of Co-operative Society members from the insurance company of opposite party No.3 as per the norms of NABARD.  It is bounden duty of opposite party No.3 company to settle the claim under Group policy.  There is no negligence on their part and the complaint is liable to be dismissed against opposite parties 1 and 2.

3.       The opposite party No.3 filed counter and stated that the complainant suppressed real facts and concocted story for wrong fall gain and got issued FIR No.42 of 2010 of PS Yellareddy, that the husband of complainant B.Yadagiri was died accidently.  As per exclusion No.(8) (v), the opposite party No.3 shall not liable under the policy.  After death, any written notice either by complainant or by opposite parties 1 and 2 have not given nor furnished with full particulars to the opposite party No.3 for claim but reported beyond the prescribed period.  Therefore violated condition (11) (a & b) of the policy.  The question of considering the claim does not arise at all and rightly repudiated the claim.  This is a fraudulent claim on all false grounds created by complainant for wrongfull gains, as such the complaint is not maintainable either in-law or on facts.   Further stated that the opposite party No.2 obtained Bharati Axa Group Personal Accident insurance policy No.APG/10177896/51/04/C55123 effective from 01-02-2010 to midnight 30-04-2011, covering KCC account holder of the bank for the risk of one lakh Rupees only without interest and costs under the policy.  The liability of opposite party No.3 is strictly governed by terms and conditions, exclusions laid down in the policy.  Any breach of terms and conditions does not make liable the opposite party No.3 for payment of any amount under the policy.  All other allegations are denied.  There is no deficiency or negligence on the part of opposite party No.3 and the complaint is fit to be dismissed with exemplary costs. 

1. During enquiry, the complainant filed affidavit as PW1 and got marked Ex.A1 to A12 documents and closed the evidence.  The opposite parties 1 and 2 have filed the affidavit of Ananth Rao CEO NDCC Bank, Nizamabad as RW2 and closed their evidence.  The opposite party No.3 filed the affidavit of S.Naresh claims Analyst of Bharati Axa General Insurance Company Ltd., Hyderabad as RW1 and got marked Ex.B1 document and closed its evidence.

5.       Heard Arguments.

6.       The points for consideration are:-

          1)  Whether there is any deficiency Service on the part of opposite parties                 in repudiating the claim under policy ?

          2)  To what relief?

7.       Point No. 1 &2: There is no dispute that the insurance company of opposite party No.3 has issued personal accident group insurance master policy No.APG/10177896/51/04/C55123 valid from 01-02-2010 to 30-04-2011 in Ex.B1 for sum insured Rs.1,00,000/- each to the KCC (Kisan Credit Card) holders of Co-operative Societies in Nizamabad district as per tie-up with the NDCC (Nizamabad District Co-operative Central) Bank of opposite party No.2. 

          The insurance company of opposite party No.3 has resisted and repudiated the claim of complainant mainly on the premise that the death of deceased was not an accidental one and there was a delay in claim which are excluded under clause 8 (V) and violated the condition under clause 11 (a) & (b) of the respective policy terms conditions and exclusions.

          The case of the complainant is that her husband B.Yadagiri was a KCC holder through opposite party No.1 society and died accidentally.  She submitted her claim through opposite parties 1 and 2, but the opposite party No.3 has repudiated the same.  She relied upon Ex.A1 to A12 documents to prove her case. 

          Ex.A1 is Attested copy of FIR in Cr.No.42/2010 of PS Yellareddy, Ex.A2 is Attested copy of Inquest Panchanama of B.Yadagiri, Ex.A3, A4 is Attested copy of PME Report of B.Yadagir – due to Cervical Spinal injury, Ex.A5 is Attested copy of Final Report, Ex.A6 is Letter Dt:25.07.2011 sent by OP.No.3 to the complainant – repudiation, Ex.A7 is Copy of List of Members of Society, Ex.A8, A9, A10 & A11 is Medical Bills of Shravana Hospital, Hyderabad, and Ex.A12 is Family Member Certificate issued by Tahsildhar Yellareddy.

          It is mentioned in Ex.B1 policy that the GPA policy was issued on UN-NAMED basis for KCC account holders of Nizamabad District Co-operative Central Bank (NDCCB) under its identification.  The opposite parties 1 and 2 have admitted that the deceased was a KCC holder through the society of opposite party No.1 and enlisted his name into Personal Accident Group Insurance Master policy for the year 2010-2011 in Ex.B1.  Ex.A7 is showing the name of deceased in the list of members issued by opposite party No.1.  Hence it is held that the deceased was KCC holder and his name was enlisted in Ex.B1 GPA policy.

          The complainant has stated that her husband was died accidentally due to hit by a bull from his behind on 12-5-2010.  Ex.A1 is the FIR, Ex.A2 is the inquest panchanama over the dead body, Ex.A3 and Ex.A4 are the post-mortem report and Ex.A5 is the final report filed by police basing on post-mortem report in Ex.A3 & Ex.A4.  It is mentioned in post-mortem report in Ex.A3 & Ex.A4 that opinion as to the cause of death is due to cervical spinal injury.  The version of the opposite party No.3 is that the death of the deceased was not accidental, but it is a concocted story which attracts the exclusion clause 8 (V) of Ex.B1 policy.

The exclusion clause 8 (V) of Ex.B1 policy is re-produced here under:-

          General Exclusions:-

          8        Any claim in respect of accidental death or permanent disablement of the              insured person:

          V)      Arising or resulting from the insured person committing any breach of                             law or participating in an actual or attempted felony, riot, crime,                            misdemeanour or civil commotion.

          No investigator is appointed nor adduced any pies of evidence by opposite party No.3 to rebutting the evidence in Ex.A1, Ex.A2, Ex.A3, Ex.A4 and Ex.A5 adduced by complainant.  We do not see any reason not to give credence to the evidence of post mortem report in Ex.A3 and Ex.A4 that the deceased was died accidentally due to hit by a bull from his behind.  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 complainant claim is beyond prescribed period of one calendar month which is violated the condition in 11 (a) & (b) of the policy in Ex.B1 and repudiated the same as no claim. 

          As far as the intimation of accidental death is concerned, the complainant has stated that she submitted her claim within time.

          The learned counsel for the opposite party No.3 has vehemently argued and filed written arguments that the liability of insurance company of opposite party No.3 is strictly governed by terms and conditions, exclusions laid down in Ex.B1 policy and he relied mainly on a common judgement of Hon’ble Apex court in a Civil Appeal No.1557 of 2004 between Export Credit Guarantee Corpn. of India Versus M/s Garg Sons International with Civil Appeal Nos.1553, 1548, 1555, 1556, 1549, 1552, 1551, 1558, 1550, 1559, 1543, 1542, 1546, 1544, 1545 and 1547 of 2004. 

          The learned counsel for the complainant also vehemently argued that there is no delay on the part of complainant in claiming GPA policy amount under Ex.B1.  However, if it is presumed but not admitted, the prescribed period of one calendar month mentioned as condition in 11 (a) & (b) of Ex.B1 policy is not a mandatory to repudiated genuine claim as no claim.  The said condition is only a directory to speed-up the process of claim.  The learned counsel for complainant further stated that the Hon’ble Apex court’s common judgement (stated supra) is not applicable to the facts of present case.  He mainly relied upon Hon’ble Tamil Nadu State Commission judgement between New India Assurance Company Ltd., Versus N.Ekambaram reported in CPJ 2005 October part in page No.41.

          In view of aforesaid submissions it is just and necessary to reproduce the condition mentioned in 11 (a) & (B) of Ex.B1 policy herein under:-

CONDITIONS:-

          11)    Duty of the insured / insured person on occurrence of loss: On the                       occurrence of loss within the scope of cover under the policy, the insured             / insured person shall:-

1.      Give written notice with full particulars to the company immediately.  In      case of death, written notice of death must; unless reasonable cause is    shown be so given before interment / cremation, and in any case within one calendar month after the death, and in the event of loss of sight or         amputation of limb (s), written notice thereof must be given within one calendar month after such loss of sight or amputation.

1.      Proof satisfactory to the company shall be furnished on all matters upon      which a claim is based.

          There is no proof of intimation given in writing to the insurance company of opposite party No.3 either by complainant or by opposite parties 1 and 2 within prescribed period from the date of accidental death of deceased.  Therefore we have not inclined to accept the version of complainant that there is no delay in claiming GPA policy amount under Ex.B1

          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 judgement as stated supra supporting to 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 overdues 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 ‘only on declaration of shipments’ and ‘its overdue payments’.  In the instant case the said 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.  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 in cited common judgement case and the Hon’ble Apex court judgement 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 as stated supra supporting to 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 does not amount to fundamental breach – company liable under policy. 

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

1. Bimla Devi & Others versus life insurance corporation of India.  H.P. State Commission – Reported in CPJ II 2007 page No.300.

1. New India Assurance Co Ltd., Versus Mr. Nanasaheb Hanumant Jadhav & others – Maharashtra State Commission – Reported in CPR (2) 2005 May / June part page No.24.

1. Reliance General Insurance Co Ltd., Versus Sri AVN Ganesh – RP No.3572/2011 dated 29-11-2011 N.C. New Delhi.

          In all the above cases holds that the condition with regard to the time limit is not mandatory.  It is directory.  The time limit clause is meant for the interest of the insured in order to facilitate prompt scrutiny of the claim.  Therefore the time limit clause cannot be used in detriment to the interest of the insured.

          In view of aforesaid discussion and findings we are of the view that the action of repudiation on the part of insurance company of opposite party No.3 is not at all justified.  Therefore the opposite party is liable to pay the insurance claim to the complainant under Ex.B1 policy.

          The role of opposite parties 1 and 2 is only facilitators for providing GPA insurance policy in Ex.B1 as per the norms of NABARD.  They are not find fault in any part of action for repudiation of the claim.  Hence the complaint is liable to be dismissed against opposite parties 1 and 2.

          The complainant has not adduced any evidence for awarding compensation and damages.

8.       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. 07-01-202 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 the Member in Open Forum on this the 28^th day of January 2014.