Chandigarh

DF-II

CC/718/2018

Sanjay Kumar Mishra - Complainant(s)

Versus

Bajaj Allianz General Insurance Company Ltd. - Opp.Party(s)

In Person

28 Feb 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	718 of 2018
Date  of  Institution	:	17.12.2018
Date   of   Decision	:	28.02.2020

 

 

 

 

Sanjay Kumar Mishra, H.No.1224, G/F, New HBC, Sector 19, Panchkula 134113

             …..Complainant

Versus

Bajaj Allianz General Insurance Company Limited, Claim Department, SCO No.156-159, 2^nd floor, Sector 9-C, UT, Chandigarh 160009

   ….. Opposite Party 

 

BEFORE:  SH.RAJAN DEWAN        PRESIDENT

SMT.PRITI MALHOTRA    MEMBER

                                        

 

For Complainant :    Complainant exempted from appearance.

For OPs         :    Sh.Devinder Kumar, Advocate proxy          for Sh.Rajesh Verma, Advocate

 

 

PER PRITI MALHOTRA, MEMBER

 

         Succinctly put, the complainant availed Motor Insurance Policy from OP for his TVS Max 100 Motorcycle bearing Regd.No.CH-03-Q-5394, which was effective from 13.2.2016 to 12.2.2017.  It is averred that the said insurance policy also covered Personal Accident Cover for owner-driver for (1) Death (2) Permanent Total Disability and (3) Permanent Partial Disability.

         It is averred that unfortunately, the complainant met with a road accident on 27.4.2016. The accident was reported to Police, who registered FIR No.137, dated 16.5.2016, Police Station  Indl.Area, Phase-1, Chandigarh.  However, the police could not trace out the offending vehicle, which hit the complainant and ran away.  It is submitted that in the said accident, the right leg of the complainant was badly fractured and it has been operated twice and finally the complainant was declared 30% permanent disable by Medical Board.  Accordingly, the complainant lodged claim with OP for Permanent Partial Disability of 30% as assessed by Medical Board. The surveyor appointed by the OP has been supplied with all requisite documents as demanded, but to shock of the complainant, the OP vide letter dated 24.11.2018 has refused the claim. Hence, this complaint has been filed alleging the said refusal of claim as illegal and a deficient act on the part of OP.

 

2]       The OP has filed reply and while admitting the factual matrix of the case, stated that after scrutinizing the claim documents submitted by complainant, it was observed that the date of occurrence is 27.4.2016 and the claim has been lodged on 27.9.2018 i.e. there is a delay of 883 days in submission of documents, which is contrary to condition No.1 of the policy, and it prevented the OP of spot survey and had no opportunity to ascertain the facts, which is not under the purview of the policy.  It is stated that claim is payable only if death or permanent disability occur and not for temporary disablement.  It is also stated that as per terms & conditions of policy, medical treatment coverage is not given and the claim is payable only for death and permanent disablement.  It is submitted that the claim has rightly been rejected being not payable under the terms & conditions of the policy.  Pleading no deficiency in service and denying rest of the allegations, the OP has have prayed for dismissal of the complaint.

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that made in reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the OP and and have also perused the entire record.

6]       Admittedly, the complainant availed Insurance Policy from OP for his Motorcycle bearing Regd.No.CH-03-Q-5394, effective from 13.2.2016 to 12.2.2017 and said policy also covered Personal Accident Cover for owner-driver for (1) Death (2) Permanent Total Disability and (3) Permanent Partial Disability. It is not disputed that the complainant met with road accident on 27.4.2016 for which FIR No.137, dated 16.5.2016, Police Station Indl.Area, Phase-1, Chandigarh was registered and that in the said accident, the right leg of the complainant got badly fractured, which was operated twice and finally complainant was declared 30% permanent disable by the Medical Board. 

 

7]       The grouse of the complainant is that his claim lodged with OP for grant of permanent partial disability benefit under the policy in question has been refused by OP vide letter dated 24.11.2018.  To this the stand of the OP is that the claim has been lodged after a delay 883 days and that the claim is not payable as it is payable only if death or permanent disability occurred not for temporary disablement.

 

8]       We do not find any merit in the submission of OP.  As per Clause No.3 of the Personal Accident Insurance Policy in question (Page No.22 (Ann.C-6), Permanent Partial Disability for ‘A leg up to beneath the knee’ is payable for 50% of the sum assured.  As such the genuine claim of the complainant has wrongly been rejected by the OP claiming being not covered or payable, which amounts to deficiency in service on its part.    

 

9]      The repudiation of the claim on account of delay of intimation is also not sustainable for the reason that the complainant has duly explained in his rejoinder dated 27.5.2019 filed in the case, about the reasons of delay, which we find to be justifiable and satisfactory.

 

10]      We put reliance on the judgment dated 04.10.2017 of the Hon’ble Supreme Court in Civil Appeal No.15611 of 2017 – Om Prakash Vs. Reliance General Insurance and Anr. Which also goes in favour of the complainant because in the said judgment it has been categorically held that:-

“a person who lost his vehicle may not straightaway go to the Insurance Company to claim compensation. At first, he will make efforts to trace the vehicle. It is true that the owner has to intimate the insurer immediately after the theft of the vehicle. However, this condition should not bar settlement of genuine claims particularly when the delay in intimation or submission of documents is due to unavoidable circumstances. The decision of the insurer to reject the claim has to be based on valid grounds. Rejection of the claims on purely technical grounds in a mechanical manner will result in loss of confidence of policy-holders in the insurance industry. If the reason for delay in making a claim is satisfactorily explained, such a claim cannot be rejected on the ground of delay. It is also necessary to state here that it would not be fair and reasonable to reject genuine claims which had already been verified and found to be correct by the Investigator.”

 

 

11]      In view of above discussion & findings as well as settled position of law, as made in the preceding paragraphs, we are of the opinion that the genuine claim of the complainant has wrongly & illegally been repudiated by the OP, which amounts to gross deficiency in service on its part. Therefore, the present complaint is allowed against the OP with direction to pay an amount of Rs.50,000/- (50% of sum insured of Rs.One lakh) to the complainant along with compository amount of Rs.15,000/- towards compensation for causing mental & physical harassment as well as litigation expenses.

         This order shall be complied with by the OP within a period of 30 days from the date of receipt of copy of this order, failing which it shall be liable to pay additional cost of Rs.10,000/- to the complainant, apart from the above relief.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

28^th February, 2020                         

                                                                                      Sd/-

 (RAJAN DEWAN)

PRESIDENT

                                                                                               

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER