ORDER (Passed on 26/03/2019) PER SHRI.ATUL D.ALSI, PRESIDENT. The complainant has filed this complaint U/s 12 of the Consumer Protection Act,1986 against the repudiation of his insurance claim arising out of two policies amounting to Rs.8 lac and thereby claiming claim amount alongwith interest thereon, compensation and cost of litigation. 2. The facts in short giving rise to this petition are that the complainant No.1 is the son of complainant No.2 who was in employment of OP No.3 M.S.E.D.C.L. as a Jr.Technician. Complainant No.1 had insured himself with the OP No.1 under two insurance plicies one namely Dhanvapasi Jeevan Surabhi policy bearing No.973919469 for assured amount of Rs.1 lac against monthly premium of Rs.462/- w.e.f. 15/10/2012 and the other policy namely Jeevan Anand policy bearing No.973837645 for assured amount of Rs.7 lac against monthly premium of Rs.3051/- w.e.f.28/12/2012. 3. On 10/6/2013, the complainant No.1, while working, was electrocuted and sustained burn injuries to his arms, legs and chest. Thereafter, the complainant No. 1 was admitted to Multispeciality Hospital at Chandrapur, but there was no improvement in his health condition. Therefore he was shifted to Swastic Critical Care Centre at Nagpur. The complainants incurred medical expenses of Rs.2,97,000/- . On 28/3/2016 Indira Gandhi Medical College, Nagpur issued permanent disability certificate to the complinant No.1. Thereafter the complainant moved an application alongwith requisite documents to get medical benefits under the policies. However, on 4/5/2017, the OP Nos.1 & 2 repudiated the insurance claim on technical ground. Therefore the counsel for the complainants issued legal notice on 30/8/2017 for reconsideration of repudiation of claim, but the OP Nos. 1 & 2 did not consider his request and hence the present petition is filed. 4. The complaint is admitted and notices were served on the OPs. The OP No.1 and 2 filed their joint reply. They admitted to have issued abovesaid two policies to the complainant No.1. However, they denied all adverse allegations against them and submitted that the policies in questions are in lapsed condition as the complainant No.1 has paid premiums till November,2014 only. The accident occurred on 10/6/2013 and the disability certificate came to be issued on 28/3/2016. Hence the permanent disability did not occure within 180 days from the accrual of accident. From the disability certificate there appears no connection between the accident and the disability sustained by complainant No.1. Hence there is breach of term and condition No.10 of the policies which reads as under. “ Immediately after the happening of the disability, full particulars thereof be given in writing to the offices of Corporation where this policy is served together with the then address and whereabouts of the life assured and within 180 days after the happening of the disability there must be given to the servicing Divisional Office of the Corporation in the manner required by if, proof of disability satisfactory to the Corporation…” 5. The complainants gave information about the accrual of disability to the OPs on 31/3/2017 though the accident occurred on 10/6/2013 and the disability certificate was issued by the competent authority to the complainant on 28/3/2016. Hence there is no permanent disability occurred within 180 days from the date of accident and as per the disability certificate, there is no nexus between the accrual of accident and sustaining of disability by the complainant No.1. Further, the intimation of the disability was given to the OP Nos.1 & 2 after a period of 180 days from obtaining disability certificate by the complainant No.1. Hence there is a breach of terms and conditions of the policy and as such the complainants were not entitled to the medical benefits under the policies. Hence the OPs have rightly repudiated insurance claim of the complainant’s on these grounds and there is no deficiency in service on their part in doing so. 6. The OP No.3 filed its reply to the complaint. They admitted that the complainant No.1 was in their employment as Jr.Technician and the accident occurred on 10/6/2013 due to electrocution wherein the complainant No.1 sustained injuries to his arms, legs and chest. However, they denied all adverse allegations against them and submitted that the dispute about repudiation of the insurance claim is between the complainants and OP Nos.1 & 2 only and OP No.3 has no concern with it. All the benefits of employment have been already paid to the complainant No.1. Hence the complaint may be dismissed as against OP No.3. 7. Counsel for the complainant argued that the complainant, after accrual of accident had immediately intimated the OP Nos.1 & 2 about the accident and after obtaining disability certificate, he moved application dated 31/3/2017 and another application dated 23/12/2018 for grant of disability benefits with the OP Nos.1 & 2 which is filed at Exh.14 & 34 respectively. The complainant No.1, after discharge from the hospital, was bedridden and was under the follow up treatment and the time was required for collection of documents and requisite papers. Therefore there is no delay in submission of claim. The delay is not intentional and hence the repudiation of claim does amount to deficiency in service. 8. The counsel for OP Nos.1 & 2 argued that the complainant No.1 has paid premiums upto November,2014 only and as such the policy is in lapsed condition. The disability certificate was issued on 24/3/2016 however, the insurance claim was submitted on 28/3/2017. Hence there is a delay in giving intimation about the accident and also in submitting the claim beyond 180 days from the date of accident hence it is a breach of condition No.10 of the terms and conditions of the policy. Therefore repudiation of claim as per letter dated 4/5/2017 does not amount to deficiency in service. The OP Nos.1 & 2 further submitted that if the complainant again submit the insurance claim with requisite documents, it would be decided on merit. Therefore at this juncture the petition has no merit and hence it may be dismissed with costs. 9. We have gone through the complaint, written versions filed by OP No.1 and OP Nos.2 & 3, affidavit, documents and WNA filed by the parties. We have also heard the oral arguments advanced by parties. Points Finding 1. Whether the complainant is a Consumer ? Yes 2. Whether the OP Nos.1 & 2 have rendered deficient Service to the complainants ? Yes 3. Whether the OP Nos.3 has rendered deficient Service to the complainants ? No 4. What order ? As per final order.. As to issue No.1 10. It is not disputed that the complainant No.1 is in the employment of OP No.3 M.S.E.D.C.L. as a Jr.Technician and he had insured himself with the OP No.1 under two insurance plicies one namely Dhanvapasi Jeevan Surabhi policy bearing No.973919469 for assured amount of Rs.1 lac and the other policy namely Jeevan Anand policy bearing No.973837645 for assured amount of Rs.7 lac. The premium used to be deducted by his employer MSEDCL i.e.OP No.3 from the salary of complainant No.1 and remitted to the OP No.1 insurance company. In view of these undisputed facts, the complainant is a “consumer” within the meaning of Section 2(1) D and the services as promised are the services within the meaning of section 2(1)(d)(ii) of CP act. and hence the issue is decided accordingly. As to issue No.2 11. The complainant No.1, Sandeep Kumare, who was in the employment of OP No.3, MSEDCL was electrocuted on 10/6/2013 while working and in that mishap, he sustained seviour injuries to his arms, legs and chest. Thereafter, the complainant No. 1 was firstly admitted to Multispeciality Hospital at Chandrapur, but as there was no improvement in his health condition, he was shifted to Swastic Critical Care Centre at Nagpur. After discharge from the hospital, he was under regular follow up treatment and was fighting for his fitness. On 28/3/2016 Indira Gandhi Medical College, Nagpur issued permanent disability certificate to the complinant No.1 which is filed at Exh.36 which clearly proves that the complainant sustained disability of permanent nature. Thereafter the complainant moved insurance claim alongwith requisite documents to get medical benefits under the policies. However, on 4/5/2017, the OP Nos.1 & 2 repudiated the insurance claim alleging breach of term and condition No.10 of the policy in not filing the insurance claim within 180 days from the accrual of accident. 12. After the accident, the complainant No.1 was continuously under follow up treatment of doctors and, the disability certificate came to be issued by the government authority on 28/3/2016. The certificate of permanent disability was an essential document to file the claim under the policy. Further, after recovery from the ailment, time was required for collection of necessary documents from government departments. It is usual that it takes considerable time to obtain/collect documents from government departments. Therefore, the complainants were precluded by the circumstances from filing the claim within 180 days from the date of accrual of accident, as has been envisaged under Term and Condition No.10 of the policy. Therefore the delay caused in filing the claim under such peculiar circumstances has to be considered as caused for bonafide reasons. Furthermore, the condition No.10 invisaging filing of claim within 180 days is not a condition precedent or a basic term of the policy. There is nothing on record to show that from the date of accrual of accident till the period of claim, the complainant No.1 suffered injuries due to some other reasons, which led to his permanent disablement. It is neither the say of the OP Nos.1 & 2 that the complainant No.1 sustained injuries resulting into his disability due to some other reasons nor they have produced any cogent and reliable evidence to prove otherwise. So, the contention of the complainant No.1 that he sustained permanent injury as a result of accident has to be accepted. 13. It is the contention of the OP Nos.1 & 2 that the premium under both the policies were paid till November,2014 only and the claim therein came to be filed in the year 2017 and hence the policy was in lapsed condition at the time of filing of the claim. It is undisputed that the accident in question occurred on 10/6/2013 and hence on the date of accident the policy was in force and fully paid up. It is admitted that the premiums under both the policies were deducted by OP No.3 from the salary of complainant No.1. This fact also gets affirmed from the written communication dated 28/12/2015 between OP Nos.1-2 and the OP No.3 which is filed on record at Exh.34. Perusal of that document shows that the said letter is acknowledged by OP No.1. It is also pertinent to note that as per the terms and conditions of the policy, in the event of death or sustaining permanent disability of the insured, future premiums are waived. Hence under the circumstances the policies were in force on the date of accrual of accident and the delay caused on the part of complainants in filing the claim was bonafide. In the circumstances of the case, repudiation of insurance claim by the OP Nos.1 & 2 amounts to Unfair Trade Practice and also a deficiency in service. Therefore the complainants are entitled to the benefits under both the policies. hence the issue is decided accordingly. As to issue No.3 14. It is admitted that the premiums under both the policies were deducted by OP No.3 MSEDCL from the salary of complainant No.1. As per Condition No.10 A of the terms and conditions of the policy, in the event of death or sustaining permanent disability of the insured, future premiums are waived. The OP No.3 has deducted amount of insurance premium from salary of insured complainant No.1 & remitted the same to OP No.1 & 2 till November,2014. Furthermore, OP No.3 has acted as an implied agent of OP Nos.1 & 2 in the matter of deducting premium from the salary of complainant and remitting the same to OP No.1. So there is no deficiency in service on the part of OP No.3 and no liability can be fastened against it. hence the issue is decided accordingly. As to issue No.3 15. In view of our observations as above, we pass the following order.. Final order
1. The Complaint is partly allowed.
2. The OP Nos.1 & 2 shall jointly and severally pay the claim of Rs.8 lac under both the policies alongwith accurued benefits, if any, thereunder, to the complainants. 3. The OP Nos.1 & 2 shall jointly and severally pay to the complainants Rs.25,000/- as compensation for mental agony and further Rs.10,000/- towards cost of proceeding. 4. The complaint as against OP No.3 is dismissed. 5. Copy of the order be furnished to both the parties free of cost. (Smt.Kalpana Jangade (Kute) (Smt.Kirti Vaidya (Gadgil) (Shri.Atul D.Alsi) Member Member President | 
