Delhi

East Delhi

CC/180/2015

SANGEETA - Complainant(s)

Versus

CHOLAMANDALAM MS GEN.INS. - Opp.Party(s)

11 Apr 2019

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.        180/2015

                                                                                                   Date of Institution                30/03/2015

                                                                                                   Order reserved on                11/04/2019       

                                                                                                   Date of Order                        15/04/2019                                                                                    

 

In matter of

Mrs. Sangeeta jain w/o Ajay jain

H.No. 220, Paras Vihar Apartment,

IP. Exnt., Delhi-92……………………………..……………...…………….Complainant

                             

                                      Vs

 

M/s Manager, United India Insurance Co. Ltd. 

D-8, CS, Azad Marg, Laxmi Nagar

Vikas Marg, Delhi 110092 ……………………..……………..….…………..Opponent

 

Complainant  advocate                                   Mr. Mridul Jain & Piyush Jain  

Opponent  advocate                                       Mr. N K Chauhan & Asso.               

 

Quorum                     Sh Sukhdev  Singh        President

                                    Dr P N Tiwari                 Member

                                    Mrs Harpreet Kaur       Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief Facts of the case                                                                                                

Complainant/ Mrs Sangeeta Jain, aged 37 years, purchased CHOLA Accident Protection Plan Schedule from OP from Noida branch, UP vide policy no 2826/00106293/000/00 effective from 08/02/2013 to 07/02/2014 after opting “Self option with Hospital Daily Cash” plan 2 for a sum insured Rs 10 lacs. OP issued policy with terms and conditions after accepting policy proposal form (Ex CW1/1).  

It was stated that complainant suffered both bone fracture in her leg on 24/08/2013 and intimated OP about fracture and filed claim as per policy weekly benefit schedule Rs 85,000/- with Broken Bone benefit Rs 50,000/-and Family transport benefit Rs 5000/-. She also claimed Hospital daily cash Rs 2,500/-, thus total amount claimed Rs 1,42,500/-, but OP paid Rs 25,000/- under Bone break head which were accepted.

OP did not pay balance amount despite of visiting OP office and reminding repeatedly for balance claim amount Rs 1,17,500/-with 24% interest. When no reply received, felt mentally harassed due to deficiency in services of OP, so also claimed compensation of Rs 50,000/-for harassment and mental agony.

In written statement OP denied all allegations of deficiency and also stated that present Forum had no territorial jurisdiction to proceed with this complaint. It was admitted that complainant was issued “Chola Accident Protection Policy” with policy terms and conditions and policy wordings from 08/02/2013 to 07/02/2014 after declaring in policy proposal form annexed here as (Ex OPW1/Anne.A & B). The policy was issued from Noida, Branch, at UP for herself having sum insured Rs 10 lacs. Complainant had declared herself as self employed person having gross income Rs 1,99,192/-per year as per her annexed ITR of 2011-2012.

It was stated that complainant violated policy terms and conditions in intimating OP after four months gap on 02/01/2014, whereas accident happed on 24/08/2013. The claim intimation was received at Noida having delay of over four months. Under policy conditions intimation had to be given immediately, but here intimation was given very late. Timely intimating OP could had appointed an Investigator for finding nature of alleged accident. Investigator was appointed as soon as intimation was received, who submitted report that (as per complainant’s statement and presence of witness as her husband) she fell down in her house and was a House wife (Ex OPW1/Anne.C). She did not submit any details of hospital treatment records pertaining to nature of treatment taken, hospital admission with medicine bills for verification. It was also stated that she had deposited all treatment records to National Insurance Co. and got the claim as per statement given to investigator (Ex OPW1/Ann.D) page 25.

As she declared herself a House wife, the present policy benefits were not applicable under policy schedule under clause 3 which states as –

“Accidental Weekly Policy Indemnity”-this part of the policy to which it is attached and is valid only if form number, benefit and appropriate premium as indicate done the Schedule for said policy or is endorsed thereon; Benefits in consideration of payment or additional premium, it is hereby understood and agreed that in the event of Accidental Injury, the company will pay Weekly Benefit amount during a period of continuous Temporary Total Disability of as Insured person as certified by a Medical Practitioner provided –‘SUCH INJURY SHALL BE THE SOLE AND DIRECT CAUSE OF TEMPORARRY TOTAL DISABLEMENT,’ and so long as the Insured Person shall be totally disabled from engaging any employment or occupation of any description whatsoever, 1% of Sum Insured subject to maximum Rs 10,000/-per week for a period not exceeding 100 weeks from the date of Accident/Bodily Injury. If the Insured is totally disabled for a portion of a week, one seventh (1/7^th) of Weekly Benefits shall be payable for each day he/she is Totally Disabled.”

It was stated that the benefit of above clause was to compensate for any loss of income for livelihood and other family members, but in this case complainant had continuous source of income through rental income as disclosed by complainant in her own hand writing during investigation and also shown in her ITR of 2011-12 was also not disclosed correctly. Based on the facts and circumstances, declaring herself as “Self Employed” person and absence of all treatment documents, Weekly Benefit was not payable.

It was also submitted that under clause Benefit 8 – Accidental hospital Daily Cash-which states-

“In the event of accidental injury, an insured is hospitalized in the hospital; the Company will pay daily hospital cash allowance per day as per the amount mentioned in the Schedule as under-.

1. The company will pay to the accidental hospital daily cash benefit for each continuous and complete period of 24 hours hospitalization in India for a limited period person/family and as per policy tenure. The limits under this section are as mentioned and the schedule of benefits.
2. The benefit is subject to the hospitalization related to accidental injury for which there is a valid claim admitted under the policy for that or permanent partial disablement or a weekly indemnity or broken bones.
3. If opted for family, the benefit amount for the proposer floats for himself and the dependents mentioned in the policy schedule.”

Under the policy conditions, complainant demanded Family Transport Benefit as Rs 5000/-,but             complainant was not entitled under fraud because complainant/insured had not submitted any evidence pertaining to treatment documents and stated all benefits as per policy conditions, but OP had to establish genuineness of claim, but here genuineness could not be proved in absence of documents so benefits were not payable under the policy heads.

Benefit no. 6-  states –Family Transportation Benefit-“This form is a part of policy to which it is attached and is valid if the form no., benefits and appropriate premium is indicated on the schedule for said policy or is endorsed thereon. 

The OP was not liable to pay any benefit under the policy conditions as there was no evidence from complainant to support their claim. Despite of policy conditions, OP paid Rs 25,000/- based on investigation reports as “Broken Bone”. The amount (Rs 25,000-) was accepted by complainant without any protest, so complainant was not entitled for further benefits.

Under Benefit no. 8- Accidental Hospital Daily Cash- In absence of treatment documents and certificate from treating doctor, which was not available in this case, company was not liable to pay. OP also cited references of certain judgments where terms and conditions were the main contents for OP to decide any loss/damages. These were –

 

1 UIIC  vs Harchand Rai Chandan Lal, JT 2004 (8) SC,

2- Suraj Mal Ram Niwas Oil Mills (Pvt) Ltd vs UIIC  & others, (2010) 10 SCC 567,

3-OIC vs Sony Cheriyan (1999) 6 SCC 451

4-Sikka Papers Ltd vs National Insurance Co. Ltd % others (2009) 7 SCC 777.

 

So OP had to consider terms and conditions in indemnify the loss suffered by the insured on account of risks covered by the parties. Hence under this claim, neither complainant intimated OP immediately as soon as injury /accident occurred, but received intimation after delay of over four months. Also no treatment documents, in original, were produced with claim or during investigation. Complainant was a house wife and earning her livelihood through good rental income, so was not entitled for any benefit under the policy conditions, still OP paid Rs 25,000/- based of broken bones (fracture) case based on the spot investigation. Thus further claim amount was not payable by OP and this complaint deserves dismissal.  

Complainant submitted rejoinder to written statement of OP and denied all replies of OP. She stated that her facts of complaints were correct and true. She stated that she was having mediclaim policy since 2013 to 2014 under Chola Accident Protection Plan and OP intentionally withheld her claim amount after partially paying Rs 25,000/-. She had also annexed one hand written statement dated 17/12/2013. She also submitted evidences through her own affidavit where she affirmed on oath that all the facts were correct and true. She relied on policy copies (Ex CW1/1) and hand written statement dated 17/12/2013. Despite of submitting all the required documents, OP did not consider her claim and not paid balance claim amount, so OP be directed to process the claim as per policy terms and conditions. 

OP also submitted their evidence on affidavit through Mr Anirudh Devraj, Manager Legal at OP office and affirmed on oath that all the procedures adopted by them were as per the IRDA guidelines and policy terms conditions. OP relied on policy and its terms and conditions and investigation report submitted by investigator where complainant had given self written note (Ex OPW1/Anne. A,B C &D). So, there was no deficiency in services of OP. Rather OP was always bound by the policy terms and conditions under privity of contract between insured and insurer as in various citations of Apex Court where law had been laid down regarding policy terms and conditions.  Hence, all facts and allegations were false and complaint may be dismissed. 

Complainant submitted written arguments and stressed on IRDA notification dated 16/10/2002 as “Protection of policyholders Interest” Regulations 2002 so taken on record. 

 

Arguments were heard. After perusal of materials on record, order was reserved.

Before coming to the conclusion of this case, we scrutinized all the evidences on record submitted by the complainant and OP. It was seen that there was no treatment documents on record from where policy benefits could be availed by the complainant. On the basis of statement given by complainant to investigator, fracture / Broken Bone was evident but no documents were supplied to OP. Still under the above head, Rs 25,000/- was paid and the same was accepted without any protest or objection. It was also noted that complainant stated that she fell down in house and got slipped over key chain and fell down on floor and sustained injury in her leg. By falling on floor one could not get leg bones fractured, but could had sustained head injury or elbow fracture, but could not get leg bones fractured. When complainant had received amount Rs 25,000/-under Breakage of Bone head without protest, was not a consumer thereafter. Also during arguments, complainant’s AR stressed that the complainant was a working woman and it hardly matters whether she was doing consultation from home or her own work.

We have also seen ITR cover note on record which showed that there was a gross income which was less than 2 lacs. No salary head was shown. A working woman will get salary or a fixed amount per month which is subjected to TDS and other deductions and rebates. The present ITR is a simple cover note and had zero Tax or deduction meaning thereby she was not a serving woman; hence submission during arguments had no weight because a working person always work under his/her employer and gets fixed perks/salary per month. No such heads were seen in ITR. Also complainant had not justified herself by submitting her passbook which can be an evidence of getting fixed salary/perks. Complainant has failed to prove her own case by any concrete evidence against OP. So, there was no deficiency in services of OP in not giving policy benefits under policy terms and conditions to the complainant. So, this complaint has no merit and deserves to be dismissed so dismissed without any order to cost.

First free copy of this order be sent to the parties under Regulation 18(6) of the Consumer Protection Regulations, 2005 (in short CPR) and file be consigned to Record Room under Regulation 20(1) of the CPR.  

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President