SHRI A.P.MUND, PRESIDENT: - Complainant Mst. Sukumari Sethi has filed this case against the O.Ps alleging deficiency in service. Brief fact of the case is that complainant is the wife and nominee of deceased Dinabandhu Sethi, who was working as a helper under WESCO, East Electrical Division, Jail Road, Sambalpur. WESCO(O.P.Nos.1 & 3) as a social welfare measure tied up with the Oriental Insurance Company Ltd., (O.P.No.2) a Group Personal Accident (GPA) insurance policy covering all employees of WESCO for a period of one year with renewal clause every year. The objective of such a measure is to provide financial assistance to the family of the employee, who dies in an accident. The sum payable is Rs.3 lakhs to non-executive employees. Towards this, Circular No.,CS-LIC/03/16/966(25) dt.28.03.2000 was issued by WESCO. Under this scheme, deceased Dinabandhu Sethi was covered vide Policy No.345600/44/2008/128 which was valid till dt.27.02.2009.
2. The insured Dinbandhu Sethi died in a motor vehicular accident on dt.02.10.2008 near Rani Bhoi under Handapa Police Station. F.I.R. was lodged by the son of the deceased at Handapa P.S. and a case was booked under Section 304(A) IPC by the police.
3. This accidental death was duly intimated to the S.D.O., WESCO, Rairakhol, who paid Rs.1,500/- towards the funeral ceremony of the deceased. The family of the deceased submitted legal heir certificate, death certificate, photograph and an affidavit made by the major sons authorizing the mother, the present complainant to receive the statutory dues of the deceased. The complainant received the statutory dues from the WESCO.
4. Complainant alleges that though statutory dues were paid by WESCO, the WESCO authorities did not take any active steps to pursue the Group Personal Accident claim case. In the circular of WESCO as mentioned above, the employer has a designated officer for the purpose of giving information about the accidental death of the employee to the Insurance Company. But they did not carry out this obligation. The complainant being illiterate did not know about the GPA policy at the first instance and later on came to know about the policy vide a written acknowledgement from the office of the O.P.No.1 on dt.25.9.2012.
5. After knowing about the benefits under the GPA policy, claim paper was submitted to the O.P.No.3 on dt.17.10.2012 and the same was forwarded to the O.P.No.2 vide official Letter No.1358 (2) dt.19.10.2012. The O.P.No.2 repudiated the claim vide their dated.31.10.2012 on the ground of delay as the death took place on dt.02.10.2008 and the claim document was filed on dt.19.10.2012, which is a delay of around 4 years.
6. When the complainant knew about this repudiation, she sent a registered letter on dt.21.01.2013 to the O.P.no.1 requesting to settle the death claim. O.P.No.1 remained silent and gave no reply to the letter.
7. It is further averred by the complainant that the employer has not duly discharged his statutory duties as provided in their office Circular issued by WESCO, which is a gross deficiency of service. Besides the Insurance company on mere technical ground denied the legal legitimacy of the death claim. The O.P.No.2 cannot absolve from its liability of paying the insured amount, when measure conditions are fulfilled. The O.P.No.2 has not applied its judicious mind while dealing with this claim case and repudiated the claim on a technical ground of delay of four (4) years.
8. Complainant further states that she has been penalized for the inaction of the O.P.Nos.1 & 3. The O.P.Nos.1 & 3 did not supply the claim papers earlier, which caused the delay and these O.Ps have shown utter negligence in discharging their statutory duties and deliberately debarred the complainant from receiving her genuine and legitimate dues covered under the GPA policy.
9. Basing on the above allegations, complainant filed this case claiming for the following relief
(i) to make payment of the insured amount of Rs.3,00,000/-
(ii) to pay interest 18% p.a. from the date of death till the actual date of payment.
(iii) to pay compensation of Rs.1,00,000/- towards mental agony, undue harassment and financial loss.
(iv) to pay the cost of the proceeding and any other reliefs to which the Forum may feel it proper.
In support of her case, complainant has filed Xerox copies of following documents
- Office Circular of WESCO Ref: CS-/LIC/03/16/966(25) dt.28.3.2000(2) Relevant documents submitted to the E.E., SEED by the complainant on dt.25.9.2012 regarding settlement of death claim of her husband under the policy (3) Refusal for settlement of the claim by D.M., Oriental Insurance Co.Ltd., Sambalpur (4) Complaint sent by regd. Letter on 21.10.2013 to the employer for settlement of the death claim (5) Death certificate of late Dinabandhu Sethi (6) Legal heir certificate of Late Dinabamdhu Sethi.
10. After receipt of notice, O.Ps appeared through their Advocates and filed written versions. O.P.Nos. 1 & 3 filed their joint written version. They have concurred with the complainant regarding the accidental death of the deceased and the GPA policy which is a beneficial policy of the employer in favour of the employees working under WESCO. These O.Ps states that GPA policy is subject to conditions stipulated therein. They claim that the complainant is bound to file the claim petition with all necessary records within the specified time of seven days. Only on receiving the same these answering O.Ps would be able to forward the same in time to the O.P.No.2 Insurance Company for consideration.
11. O.P.Nos.1 & 3 further avers that they have released all statutory dues and pensionary benefits. Hence they claim that there are no latches on their part and they are not responsible for the repudiation of the personal accident benefit as claimant filed application after long delay.
12. They further averred that they have intimated the complainant to get all necessary records in favour of the claim regarding the personal accident benefit earlier but the complainant did nothing for depositing relevant documents and as the complainant herself has neglected, this complaint petition is not maintainable before this Forum
13. Further submission of O.P.Nos.1 & 3 is that the complainant after a delay of three and half years on dt.25.7.2012 deposited the relevant documents claiming GPA insurance amount which should have been supplied within seven days of occurrence of accidental death on dt.02.10.2008. After receipt of the claim documents, they forwarded the same to the O.P.No.2 Insurance Company, who in turn repudiated the same on the ground of delay. This was intimated to the complainant and according to them they are not negligent in doing their official duty and the complainant is solely responsible for the delay in submitting the required documents and for the delay caused by the complainant no benefits can be provided to the complainant even if the deceased is lawfully covered under the beneficiary scheme. These O.Ps claims that they are not liable to pay any compensation to the complainant and the complaint petition is liable to be dismissed against them.
14. O.P.Nos.1 & 3 files Xerox copies of (1) Letter to the Executive Engineer WESCO dt.6.9.2012 (2) Letter to WESCO dt.31.10.2012 (3) Senior Divisional Manager Oriental Insurance Co., Sambalpur dt.19.10.2012 ( 4 ) To Company Secretary dt.02.10.2012 (5) Claim Form dt.25.9.2012 (6) Letter to the Executive Engineer, East Electrical Division, Sambalpur dt.25.,9.2012 , Death certificate, legal heir certificate, police paper etc.
15. O.P.No.2 appeared and filed their written version through their Advocate. It also concurred with the submission of the complainant regarding the Group Personal Accident (GPA) policy under which Rs.3 lakhs is to be paid to the non-executive employees, who are covered under this policy under the terms and conditions of the policy. WESCO is the insured and they should intimate the O.P.No.2 Insurance Company about the personal accident of the employee and thereafter the procedure of claim settlement is to be followed with issuance of claim form and submission of claim form along with documents related to the personal accident of the employee with proof of his employment under certificate of WESCO. There is a further condition that the claim of the insured is not maintainable if there is a delay in intimation of the claim to the Insurance Company.
16. This O.P.on dt.19.10.2012 received from O.P.No.3 intimation regarding death of one Dinabandhu Sethi ex-line helper S.E.E.D. ,Sambalpur. With this intimation O.P.No.3 submitted claim form of the complainant along with other papers. This O.P. carefully considered the matter and as per the policy condition, rejected the claim on the ground of delay of four years. This rejection was duly intimated on dt.31.10.2012 to WESCO.
17. O.P.No.2 further averred that no intimation whatsoever was received about the death of the deceased earlier and only on dt.19.10.2012 they received the intimation with documents. O.P.No.2 further submits that the complainant is not entitled to any claim under the policy of insurance and they rightfully repudiated the claim as the Insurance Company was intimated regarding the death after lapse of four years. Hence this O.P. is not negligent in dealing with the claim of the complainant and they have not rendered any deficient service. It is the O.P.Nos.1 & 3, who is negligent in intimating the claim in time to this O.P. Hence O.P.No.2 avers that this is a frivolous claim against the Insurance Company and complainant is liable to be punished. No documents were filed from the side of the O.P.No.2 Insurance Company.
18. The learned counsel for the complainant filed copies of following decisions in order to support his case
(i) 2013(1) CPR-91(H.P.) Himachal Pradesh state CDR Commission.
(Principal Government Polytechnic for Women Kandaghat, Dist: Solan(HP) Vrs.
Reliance General Insurance Co.Ltd.)
(ii) 2014(2) CPR-19(Chhat.) Chhatishgarh State CDR Commission
(Oriental Insurance Co.Ltd., Vrs. Sevati Sahu and Others)
(iii) 2010(1) CPR-2109 (Maharashtra State CDR Commission)
( Kamalabai Prakashs Chavan Vrss. The Authorised Signatory ICICI Lombard Insurance Co.Ltd.,
and Another)
(iv) Order dated.15.3.2007 passed by this Forum in C.D.Case No.118 of 2006
(v) 109(2010) CLT-258
( Satyaranjkan Kar Vrs. Chairman-cum-Managing Director , Grid Corporation of Orissa Ltd.,BBSR
and Others)
19. Heard the learned counsels for the parties and perused the documents and citations filed by them and placed on record. After carefully going through the pleadings of the parties, following three issues are framed to decide the case
(1) Whether the O.P.Nos. 1 & 3 are negligent in intimating the complainant regarding the claim
form to be submitted by the complainant to O.P.No.2?
- Whether the repudiation of the claim by O.P.No.2 Insurance Company on the ground of delay in submission of claim is legally valid?
- Whether complainant is entitled to any relief as claimed for or not?
20. It is clear from the arguments advanced by the parties that deceased Dinabandhu Sethi was an employee of WSESCO,O.P.Nos.1 & 3 and he was covered under the Group Personal Accident(GPA) insurance policy which was issued by the O.P.No.2. This is a beneficial measure. Under this scheme, for non-executive employees the sum assured in case of accidental death is Rs.3 lakhs. This is a welfare scheme and the legal heir/nominee of the deceased employees is entitled to receive the amount from the Insurance Company with the assistance of the employer.
21. In this connection a circular was issued by WESCO vide Reference No. CS-/LIC/03/16/966(25) dt.28.03.2000. In this circular para-7 describes the claim procedure. In para-7(1) it is clearly mentioned that if there is intimation regarding the accidental. Death of an employee, the designated officer of WESCO shall make telephonic intimation to the O.P.No.2 followed by written notice containing further details. In para-7(2) it is mentioned that the designated officer shall sent the claim form to the nominee of the deceased employee asking him/her to submit claim form with other documents.
22. According to us, this circular has been violated by the designated officer of WESCO, O.P.Nos.1 & 3 in this case. There is no averment by these O.Ps regarding any telephonic intimation to O.P.No.2 or supply of any claim form to the nominee of the deceased employee. Hence it is a pure case of negligence and indifferent attitude of the designated officer of WESCO, which has prevented the complainant-nominee of the deceased to receive her legitimate dues.
23. Hence applying the yard stick of negligence, we hold that O.P.Nos.1 & 3 WESCO , being the agent of O.P.No.2 are squarely liable for the delay as they have failed to comply with their official circular which clearly speaks about the procedure which is to be followed by the designated officer in case of accidental death of an employee of WESCO. Accordingly issue No.1 is decided against the O.P.Nos.1 & 3 WESCO.
24. It is true that the submission of claim form was made after a gap of around 4 years . Admittedly the death of the insured occurred on dt.02.10.2008 and intimation was received by O.P.No.2 on dt.19.10.2012 only. The claim was repudiated vide registered letter dated.31.10.2012 of O.P.No.2 on the ground of delay. Admittedly this is a social welfare measure wherein the family of the bereaved are entitled to a fixed sum of Rs.3 lakhs in case of accidental death. There is no other ground for rejection of the claim besides the delay.O.P.No.2 being a national Insurance Company should not have rejected the claim as this is a welfare measure and it is for the protection and welfare of the family of the deceased.
25. Complainant has filed copies of decisions referred to above in support of her case. In the decision reported in 2013(1) CPR-91(HP) , in para-11 the Honble Himachal Pradesh State Commission has held Now, when it is established beyond doubt and is also not disputed by opposite parties No.1 and 2 that deceased Kamalesh Kumar had died on 1.11.2007, in a vehicular accident, merely for the reason that the appellant did not inform opposite parties No.1 and 2 about the death of Kamalesh Kumar within one month cannot be a ground for repudiation of claim, especially when the scheme or the policy nowhere provides that in case intimation was not given within one month, the insurer will not be liable to pay the insurance money. Delay in informing the insurer about the date of death, may be a good ground for repudiation of claim in a case where there is serious dispute creating reasonable doubt about the death or the cause of death of the insured person, but not in a case like the present one, where there is no dispute that the insured employee had died and her death was accidental.
26. In the decision of Honble Chhatishgarh State Commission reported in 2014(2) CPR-19; they have quoted at para-9 a decision of the Honble Supreme Court in the case of Madras Port Trust Vrs. Hymanshu International by its Proprietor Venkat giri(Dead) by LRs(1979) 4 Supreme Court Cases 176, where it has been held We do not think that this is a fit case where we should proceed to determine whether the claim of the respondent was barred by Section 110 of the Madras Port Trust Act(I) of 1905. The plea of limitation based on this section is one which the court always looks upon with disfavor and it is unfortunate that a public authority like the Port Trust should, in all mortality and justice, take up such a plea to defeat a just claim of the citizen. It is high time that government and public authorities adopt the practice of not relying upon technical pleas for the purpose of defeating legitimate claims of citizens and do what is fair and just to the citizen………
In para-10 of the decision it has been held by the Honble State Commission that From the law laid down by the Honble Supreme Court in Madras Port Trust(supra), it is clear that a nationalized insurance company was not required to resort to plea of limitation to defeat just claim of the citizen which is a claim of an employee who has lost his life accidentally and regarding which accidental cover was provided by the Insurance Company.
27. In the order passed by this Forum in C.D. Case No.118 of 2006 dated.15.3.2007 at para-10 it has been held that
In the above circumstances, the pela taken by the Insurance company that the death of the insured was reported after a long gap of two years is not a ground to repudiate the claim .Even if it is a fact, for the mistake of O.P.No.4, the insured cannot be deprived from the benefits under the policy. So, we are unable to accept the submission of the learned counsel for the Insurance Company that the repudiation is justified due to delay in submission of the papers. In our considered opinion, the stand taken by the Insurance Company(O.P.Nos.1 & 3) is not reasonable and justified, so we negated it………….
28. In view of the above decisions, we hold that the repudiation of the claim made by O.P.No.2 on the ground of delay is not a valid ground besides they have not disputed the accidental death of the deceased employee; and accordingly, issue No.2 is decided against O.P.No.2.
29. Taking into consideration the facts and circumstances discussed above, we hold that complainant is entitled to get the death claim benefits under the policy and accordingly issue No.3 is decided in favour of the complainant.
30. In the result, we allow the case of the complainant against the O.Ps on contest and pass the following order
O.P.No.2 Insurance Company is directed to pay to the complainant the assured amount of Rs.3 lakhs (Rupees Three lakhs). The O.P.Nos.1 & 3, WESCO, has failed to perform their duty as per the circular issued by them regarding the matter for which complainant has suffered a lot and she is entitled to get interest on the insured amount from the date of death of the insured, which they are liable to pay as O.P.No.2 is not liable for the delay caused in submission of the claim papers. Hence O.P.Nos. 1 & 3, WESCO are directed to pay to the complainant interest 9(Nine) percent per annum on the assured amount of Rs.3 lakhs(Rupees Lakhs) from the date of death of the insured till the actual date of payment along with Rs.10,000/- (Rupees Ten thousand) towards cost of the proceeding. The O.Ps are to comply their part of the order within two months from the date of order.
