DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 422/2015
Date of Institution : 25.08.2015
Date of Decision : 28.04.2016
Malkit Singh son of Inder Singh resident of Randhawa Patti, Village Tallewal , Tehsil Tapa ,District Barnala
…Complainant
Versus
The Bharti AXA General Insurance Company limited ,North -Zone Office, Pearl Plaza, K-24 ,Plot No. ABDC & E, 2nd Floor , Sector -18 , Noida -201301 (U.P.) through its Zonal Manager.
The Sangrur Central Co-operative Bank Limited, Branch Tallwewal, Tehsil Tapa, District Barnala through its Branch Manager
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. Lokeshwar Sewak Counsel for complainant.
Sh. Anuj Mohan Counsel for opposite party No. 1.
Sh. Kulwant Rai Goyal Counsel for opposite party No. 2.
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(BY Ms. VANDNA SIDHU, MEMBER):
As per compliant no. 422 of 2015, the complainant is maintaining a saving bank account no. 184P 340 28100041 with opposite party no.2. The opposite party no. 2 had purchased group insurance policy for its account holders from opposite parties no. 1 and paid the premium to Opposite party no.1 opposite party no.2 debited Rs.37/- in the account of complainant by way of premium of insurance on 26.6.2014. Thus, the complainant is consumer of both the opposite parties. Complainant met with an accident on 4.9.2014 while driving his two wheeler. He admitted in Christian Medical college and hospital Ludhiana from 4-9-2014 to 26-9-2014 while driving his two wheeler. S.M.O. Civil Hospital, Barnala. A sum of Rs. 2,18,763/- was spent on the treatment of the complainant. He submitted his medical claim to opposite party no. 1 through opposite party No. 2 vide claim no. Co779667 under policy no. 1637787 but opposite party no.1 repudiated the claim on the ground of delay. It is mentioned in the repudiation letter that intimation of occurrence should have been given immediately. The terms and conditions were never supplied to the complainant. The insurance policy was never delivered to the complainant, it was delivered to bank, neither opposite party no. 2 ever delivered the insurance policy along with terms and conditions to the complainant. So, the complainant had no knowledge about the insurance policy. So, complainant did not know when he was supposed to intimate the opposite parties. When complainant came to know about the policy, he immediately lodged his claim through opposite party no.2. The opposite party no.1 had not been deficient but negligent also. In the letter dated 20-4-2015 subject is mentioned as “Death claim under Group personal accident insurance of Sh. Malkeet Singh S/o Sh. Inder Singh on dated 4-9-2014 vide claim no. C0779667 under policy no. 1637787''. Further it is mentioned by the complainant that claim is alive and claim of the complainant is regarding injuries and not death claim. Regard of limitation complainant submitted that when opposite party no.1 repudiated the claim of the complainant. In regard of jurisdiction, accident of complainant took place at near Dhilwaan Drain Bridge, Village Dhillwan. So, this court has jurisdiction to try this compliant. Hence, the present complaint is filed seeking the following reliefs:-
To pay Rs. 2,18,763/- incurred on the treatment of the complainant.
To pay Rs. 50,000/- on account of mental tension, agony and harassment.
To pay Rs. 10,000/- as costs of the proceedings.
2. Upon notice, opposite parties no. 1 and 2 submitted their version, about non maintainability of the compliant. Complainant is not admissible because the claim of the complainant is out of policy coverage as the subject policy provides coverage for accidental death as well as permanent total disablement as mentioned in the the terms and conditions of the policy. The complainant has not suffered any permanent disability as mentioned in the policy schedule. Secondly intimation regarding the alleged occurrence was received on 16-4-2015 i.e. with a delay of 224 days and as such there is violation of clause 11(a) of the policy which is reproduced as per section 11 duty of the insured person on occurrence of loss within the scope of cover under the policy, the insured person shall (a) give written notice with full particulars to the company immediately. In case of death, written notice of the death must, unless reasonable cause is shown, be so given before interment/cremation, and in any case, with in on calander 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 calender month after such loss of sight or amputation. In case the insured/person does not comply with the provisions of this clause or other obligations cast upon the insured person under this policy or any of the policy documents, all benefits under the policy shall be forfeited, at the option of the company. It is also objected by the opposite party no .1 that intimation was given after the age of 224 days which is clear cut violation of the terms and conditions of the policy. It is further submitted that the contract between the respondent and complainants is governed by its policy terms and conditions of the policy. On merits the complainant was not insured under the policy. The policy in question was issued for the period of 1-6-2014 to 31-5-2015, whereas the complainant paid the premium on 26-6-2014 i.e. after the issuance of policy. Therefore as per section 64 VB of Insurance Act, the complainant is not insured under the policy. It is also submitted that respondent no.2 took Personal Group Accident Policy bearing No. 11637787 for its saving account holder having sum assured of Rs. 1.00,000/- for unnamed 69,433 account holders. Under the policy accidental death as well as permanent total disability is covered subject to its terms and conditions. It is submitted on merits that the real state affair is that on 16-4-2015 the respondent no.2 lodged the death claim of complainant along with two other persons namely Sukhjinder Singh and Magher Singh vide letter no. 91 dated 06-4-2015. After getting the information regarding the death of Malkiat Singh i.e. complainant the answering respondent immediately wrote letter dated 20-4-2015 to opposite party no. 2 for explaining the reasons for delay in intimation of 224 days and also to provide documents. But despite the receipt of the letter, no explanation was given to the answering respondent. The answering respondent appointed M/S Probus Associates & Consultants Pvt. Ltd. New Delhi for investigating the claim of the complainant. The said investigator visited the house of complainant and recorded the statement and collected the documents. From the passbook provided by the complainant, it is found that the complainant paid the premium on 26-6 -2014, therefore the claim of the complainant is not admissible under the policy. Even without admitting the insurance of complainant, it is submitted that the claim of the complainant is also not admissible as in the disability certificate 35% disability is mentioned and re-assessment is recommended after six months which proves that the disability suffered by the complainant is temporary in nature .The complainant did not provide any permanent disability certificate to the answering respondent .Therefore the claim of the complainant is not maintainable being not covered under the policy as well as on the grounds of delay in intimation. The claim of the complainant has been rightly repudiated. There is no deficiency in service and negligence on the part of answering respondent.
3. In support of his complaint, complainant tendered in evidence Ex.C-1 his own affidavit ,Ex. C-2 is copy of Saving account of complainant, Ex. C-3 certificate dated 19-11-2014 of C.M.C. Ludhiana, Ex. C-4 bills and Ex. C-6 DISABILITY CRTIFICATE, Ex. C-7 copy of discharge summery, Ex. C-8 copy of repudiation letter and closed the evidence.
4. In rebuttal opposite party no.1 tendered into evidence Ex.o.p.1 i.e. affidavit of Budhi Raja, Ex. o.p.2 i.e. copy of letter dated 11-9-2015, Ex.O.p. 3 i.e .copy of letter dated 18-6-2014.,Ex. o.p.3. Ex. o.p.4 copy of policy information ,Ex. o.p.5 i.e. Copy of terms and conditions of insurance policy and closed the evidence.
5. In rebuttal opposite party No. 2 tendered into evidence affidavit of Jaswant Singh Ex.O.P.1.2/1, copy of application of Malkiat Singh Ex.O.P.1.2/2, copy of passbook's terms and conditions Ex.O.P.1.2/3 and closed the evidence.
6. We have heard learned counsel for appellants and have gone through the entire record in pleading of complainant, complainant did not mention the period of delay of 224 to intimate about his claim. It is further to mention here that delay of 224 days is violation of terms and conditions of Insurance As per Ex. O.P. 1. i.e. affidavit of Kamal Budhiraja, authorized signatory, Bharti Axa Insurance company Ltd., the policy in question was valid for the period of 1.6. 2014 to 31.5. 2015 and as such at the time of issuance of the policy, no premium was paid by the complainant, therefore the claim of the complainant is not admissible.
7. Further, as per Ex. OP.1 the claim of the complainant is out of policy coverage as the subject policy provides coverage for accidental death as well as permanent disablement as mentioned in the terms and condition of the policy. As per Ex. C-6 i.e. Disability certificate, which shows only disability is 35%. Further, as per Ex.C-6 re-assessment is recommended after six months by Doctor which shows that the disability is suffered by the complainant is temporary in nature.
8. So, as per Ex.C-6 its not a permanent disability certificate. The complaint of the complainant is badly hit due to grounds of delay in intimation to the insurance company and being not covered under the policy, which was issued by opposite party No. 1. As per Ex.O.P-2, it is clearly mentioned in 64VB of Insurance Act 1938, which says, “no risk to be assumed unless premium is received advance”. But in this policy which is obtained by the complainant premium was paid after the issuance of the policy. Therefore, the claim is not admissible as per policy terms and conditions. The complaint is not maintainable because the terms and conditions not fulfilled as per insurance company and complainant has no locus-standi because here is a delay of 224 days to give information to opposite party No. 1. As per the views of this Forum also complainant did not give any plausible explanation about delay and he has failed to explain unavoidable circumstances about delay.
9. It is pertinent to mention here that the claim of the complainant is out of the policy coverage as the subject policy provides coverage for accidental death as well as permanent disablement as mentioned in the terms and conditions of the policy. Moreover, intimation regarding the occurrence was received on 16.4.2015 with a delay of 224 days. As such there is violation of clause 11(a) of the policy which is re-produced as under:-
“11) Duty of the insured/insured person on occurrence of loss within the scope of cover under the policy, the insured/insured person shall:
a) give written notice with full particulars to the Company immediately. In case of death, written notice of the death must, unless reasonable cause is shown, be so given before interment/cremation, and in any case, within one calender 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 calender month after such loss of sight or amputation.
10. The Hon’ble National Commission in case titled “LIC of India and others Vs Mahendra Singh” reported as 2011(4) CLT 39, also held that “The terms of policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract-Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitute”.
11. In 2010 (1) C.P.R. 53: 2009 (4) C.P.J 72: 2010 (1) CLT 173 it was observed:-
“Consumer Protection Act, 1986 Section 2(1)(g) Insurance- Group Insurance Scheme- Delay in filing claim- Insured died in accident- Intimation about death given to insurer after one year-Claim repudiated-Complaint allowed-Appeal against- Policy condition requires intimation to be sent to Insurance Company within one month of accident-Intimation received after one year-Terms of policy violated-Claim rightly repudiated-Order set aside-Appeal allowed.
12. As a result of the above discussion, there is no merit in present complaint and the same is dismissed. Copy of the order be supplied to the parties free of costs.
The file its due completion be consigned to records.
ANNOUNCED IN THE OPEN FORUM:
28th Day of April, 2016.
(S.K. Goel)
President.
(Karnail Singh)
Member.
(Vandna Sidhu)
Member.
