Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that father of the complainant namely Balwinder Singh had purchased one ‘Accident Care Individual Policy’, bearing no.P/211222/2023/000973 for the period 23.11.2022 to 22.11.2024 from the Opposite Parties. The complainant was nominee under the said policy. During the policy period, the father of the complainant died in road accident on 10.04.2023. In this regard FIR No.33 dated 10.04.2023 u/s 304A/279/427 IPC was registered with Police Station, Sadar Moga on the statement of complainant. After the Bhog Ceremny of his father, the complainant being nominee under the policy, filed the claim with Opposite Parties and fulfilled all the formalities required by Opposite Parties and produced the documents with regard to death of his father, but despite that Opposite Parties failed to make payment regarding the death claim of his deceased father. The complainant also issued a legal notice dated 30.01.2024 to the Opposite Parties, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Party may be directed to pay an amount of Rs.10,00,000/- to the complainant alongwith interest @ 24% per annum till its realization.
b) To pay an amount of Rs.50,000/- as compensation on account of mental tension and harassment.
c) To pay an amount of Rs.33,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant has got no locus-standi or cause of action to file the present complaint against Opposite Parties; the complaint is not maintainable in the present form; the complaint being pre-mature is not maintainable; the complainant is stopped to file the present complaint by his own act and conduct. Averred that the insured Balwinder Singh (now deceased) obtained an ‘Accident Care Individual Insurance Policy’ bearing no.P/211222/02/2023/000973 for the period 23.11.2022 to 22.11.2024. Averred further that the complainant himself has not been cooperating with answering Opposite Parties, as the complainant did not furnish the required information, record and documents etc. with the answering Opposite Parties for the successful processing of the claim in question, despite repeated requests made by Opposite Parties and resultantly, the alleged claim file has been closed and the claim was ‘closed’ in the absence of required documents as per terms and conditions of the insurance policy, which were explained to the insured at the time of proposing policy. The insured has accepted the policy agreeing and fully aware of such terms and conditions and had executed the proposal form. Averred that the complainant has not furnished the required essential documents for final processing of the claim i.e. Police Final Report/Charge sheet, Police Inquest Panchnama, Driving License copy of insured/its particular/number etc., past medical history of the insured and treatment records, if any, legal heir certificate. The complainant was requested to furnish these documents/information vide three letters dated 30.08.2023, 14.09.2023 and 29.09.2023, but to no effect. Even after several reminders, the complainant has not sent these required documents to Opposite Party insurance company. Hence no deficient services have been rendered to the complainant as alleged.
Averred further that on scrutiny of claim documents, following major points were observed:-
It is noted that claim was preferred in the 6th month of the policy coverage.
During the incident, the hit vehicle pillion riders-2 women were also fell down and sustained injury but there is no details (Name of Person, contact numbers & address) mentioned in the FIR. Genuineness of the accident cannot be confirmed.
During checks conducted with neighbor, AVR obtained- as per the lady confirmed that life insured is chronic drug abuser since 1987 and he was addicted to alcoholic, drinks daily and take drugs like opium. Life insured was taken to Rajeev Hospital first and then taken to Civil Hospital.
As per Post Mortem report dated 11.04.2024, the cause of death is due to respiratory failure.
As per ante mortem report the cause of death is due to hemothoraxay complication collapse of lung leading to respiratory failure.
Insured’s son told that life insured had undergone knee surgery since 2 years back at Rajeev Hospital, however no medical reports shared by him.
Life insured had lost his Driving License at the time of accident as confirmed by insured’s son.
Checked in California Public School, as per account staff of the school they do not maintain the data who paid the fee.
Final Police report, charge sheet is not yet prepared. The claim may be decided after the final report of police.
Case look suspicious on insured death since in the absence of MLC/first consultation of medical reports from Rajeev Hospital/accident register/ previous medical reports which he had undergone surgery in Rajeev Hospital/Final Police report/Chronic Alcoholic/Driving License/details of accused and other 2 pillion riders, MLC, medical report of pillion riders. Evidence/supporting documents FIR, Post Mortem Report, Spot photos, Deceased photo, vehicle photo and AVR- call recording of neighbor.
Hence the alleged claim was termed as ‘no claim’, vide letter dated 14.10.2023 and conveyed to the complainant.
The complainant has not come with clean hands. He has not disclosed the entire true facts. The complainant has also suppressed the material facts from this Commission as well as from the answering Opposite Parties. The complainant instead of submitting the documents referred to file the present consumer complaint. The complaint is bad for mis joinder of necessary parties. The other legal heirs of deceased i.e. his widow and other unknown children have not joined in the complaint. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. Complainant has also filed replication to the written reply Opposite Parties denying the objections raised by them in their written reply.
4. In order to prove the case, the complainant has placed on record her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.
5. On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar Sharma as Ex.OP1, 2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/15.
6. We have heard the ld. counsel for both the parties and also gone through the record.
7. It is admitted and proved on record that father of the complainant availed ‘Accident Care Individual Insurance Policy’ bearing no.P/211222/02/2023/000973 for the period 23.11.2022 to 22.11.2024 for self for a sum insured of Rs.10,00,000/- and the complainant was nominee under the said policy. It is also proved on record that during the policy coverage, father of the complainant died in road accident and FIR in this regard was also registered with Police Station Sadar, Moga. It is also proved on record that the complainant being nominee under the said policy lodged the death claim of his father with Opposite Parties, but the Opposite Parties rejected the claim of the complainant, vide letter dated 14.10.2023.
8. The Opposite Parties rejected the claim of the complainant, vide letter dated 14.10.2023 (Ex.OP1,2/14). The contents of which are reproduced as under:-
“Please refer to our earlier letter dated 30-Aug-2023, 14-Sep-2023 and 29-Sep-2023, advising you to send us the following documents to process your claim.
S.No. | Description of documents required |
1. | Regret to hear your unfortunate happening. But our Procedures does not allow to deviate from the requested document. Please provide us the requested documents to expedite our process. |
2. | Police Final Report/Charge Sheet |
3. | Police Inquest Panchanama |
4. | Driving licence copy of the insured. (DL Number Mandatory. |
5. | Past Medical history of the insured and if any treatment records. |
Even after reminders, you have not sent us the above documents. We further presume that you are not interested in your claim and hence your claim is rejected.
8. The perusal of rejection letter reveals that the Opposite Parties demanded Police Final report/Charge sheet and Police Inquest Panchanama from the complainant, we are of the concerted view that if the FIR regarding the said accident got registered timely with police station concerned and post mortem of the father of the complainant duly conducted, then the demand of police final report and police inquest panchanama is not genuine, as not within the reach of complainant. Further the Opposite Parties demanded the driving license of the insured, but perusal of the FIR Ex.C4 clearly reveals that the vehicle of the father of the complainant was hit by another vehicle and there is no negligent driving on the part of the father of the complainant, so demand of driving licencse of the insured is also not genuine. It has been observed that the father of the complainant obtained ‘Accident Care Individual Insurance Policy’ and perusal of the policy conditions put on record nowhere necessitates that the insured under the policy must have a valid driving license. Perusal of the repudiation letter further reveals that the Opposite Parties demanded the Past Medical history of the insured and treatment records of the insured, if any, but this demand of the Opposite Parties is also not genuine, as the insured suffered severe bodily injuries due to the said accident which is clearly mentioned in the post mortem report (Ex.OP1,2/7). Moreover, the policy in question is an accidental policy and the insured under the policy was covered qua accidental death, which is not in dispute, so rejection of the death claim of the insured by the Opposite Parties is not justified. Perusal of the record reveals that the Opposite Parties issued number of letters whereby demanded numerous documents, which have already been discussed in preceding paragraphs. Perusal of the policy (Ex.C2) reveals that complainant has filed the present complaint being nominee under the policy in question, so in our concerted opinion all the legal heirs of the deceased policy holder are equally entitled for the amount of sum assured, but the complainant has failed to implead other legal heirs of deceased life assured as party in the present complaint. In this eventuality as well as in the interest of justice, Opposite Parties are directed to pay the sum assured amount to the legal heirs of deceased life assured/policy holder.
9. In view of the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to pay a sum of Rs.10,00,000/- (Rupees Ten Lakh only) to the legal heirs of the deceased life assured/policy holder in equal shares on production of legal heirs certificate by the complainant. Opposite Parties are also directed to pay compository cost of Rs.10,000/-(Rupees Ten Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of the order be made by Opposite Parties next within 30 days from the receipt of the copy of the legal heir certificate from the complainant, failing which, the Opposite Parties are further burdened with additional costs of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
