ORAL

      STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

                             UTTAR PRADESH, LUCKNOW

                          COMPLAINT NO. 312 OF 2019

Smt. Zaida Begum

W/o Marhoom Ansar Ahmad Mewat (Muslim)

R/o House No. 159 Village Chidavak

Police Station Gulawathi

Tehsil and District Bulandshahr 

                                                                                    ....Complainant

                                                          Versus

1. HDFC ERGO General Insurance Company Limited

Branch Ratan Square

21A Vidhan Sabha Marg

Lucknow

Through Branch Manager 

2. HDFC ERGO General Insurance Co. Ltd.

Regd. & Corporate Office

1st Floor, HDFC House

165-166 Backbey Reclamation

H.T. Parekh Marg, Churchgate

                                                                                     ....Opposite Parties

BEFORE:

HON’BLE MR. JUSTICE ASHOK KUMAR, PRESIDENT

For the Complainant        :  Sri Sanjay Kumar Verma, Advocate.

For the Opposite Party     :  Sri Manoj Kumar Dubey, Advocate.

Dated :  16-04-2024

                                         JUDGMENT

MR. JUSTICE ASHOK KUMAR, PRESIDENT

This is a complaint filed by the complainant Smt. Zaida Begum against the opposite parties HDFC ERGO General Insurance Company Limited and another under Section 17 of the Consumer Protection Act 1986 by which the complainant has prayed for the following reliefs:-

(1) To direct the opposite parties to give payment of Rs.50,00,000/- to complainant alongwith interest @ 18% from the date of accident. 

(2) To direct the opposite party to pay Rs.10,00,000/- compensation for physical and mental harassment.

(3) To direct the opposite party to pay Rs.55,000/- towards cost of the case to complainant.

(4) To pass any other order which this Hon’ble Court deems fit and proper in the interest of justice. 

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I have heard Sri Sanjay Kumar Verma, learned Counsel for the complainant and Sri Manoj Kumar Dubey, learned Counsel for the opposite parties and perused the record.

I have also perused the written statement and evidence filed by the both parties alongwith the other documents available on record.

Facts of the case stated in brief are that the complainant’s husband was a businessman and he has a big workshop for repairing trucks. The complainant’s husband Late Ansar Ahmad had taken a personal accident insurance policy from opposite parties. The policy No. is 33171001 6622 9501 000. The aforesaid policy was valid from 02-01-2018 to 01-01-2019. The complainant is the nominee in the aforesaid policy. It is clear from the aforesaid policy that the sum assured under the aforesaid policy is Rs.50,00,000/-. The complainant’s husband had deposited premium of Rs.6,830/-.

It has been stated by the complainant in her complaint that her husband met with an accident when he was coming from Rampura Ghati by motor cycle on 12-05-2018. He died on the spot in the said accident. Thereafter the brother of deceased lodged F.I.R. in the Police Station Patan, District Sikar (Rajasthan) on 12-05-2018. The F.I.R. was lodged against the unknown driver under Section 279, 304A of IPC. The postmortem of the deceased was also done at Samudaik Swasth Kendra Patan, District Sikar on 12-05-2018.  

It has been further stated by the complainant in her complaint that information of the accident was given to the Insurance Company and submitted the claim for payment of sum assured as per policy Rs.50,00,000/- because in case of accidental death Rs.50,00,000/- has to be given by the Insurance Company to the nominee and the complainant is the nominee in the policy. The complainant has submitted all the relevant documents which she has with as per their requirement. The opposite parties have instead of making payment to complainant sent letter dated 14-08-2018 and demanded income proof of deceased, income tax return of last three years, salary slip and bank statement of last six months.

It has been alleged in complaint that thereafter the complainant has provided all the relevant documents to the opposite parties but whatever opposite parties are demanding through their letter dated 14-08-2019 it is

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not possible to give because complainant is a lady and she has no knowledge about ITR etc. The complainant’s husband has PAN Card. The number of PAN Card is BLYPA0043B.

It has been further stated by the complainant in her complaint that in the aforesaid policy the risk of accidental death was covered and the deceased had duly insured with the Insurance Company and had deposited premium. Had the Insurance Company any doubt about the income of the deceased then the opposite party/Insurance Company should have made the enquiry before issuing the policy but after the death raising of such questions are meaningless and are not sustainable in the eyes of law. The opposite party/Insurance Company has committed gross deficiency in service by not paying the sum assured under the policy to the complainant. The complainant has been harassed too much mentally and monetarily.

The cause of action arose on 12-05-2018 when the complainant died in accident and the sum assured Rs.50,00,000/- is not being given by the Insurance Company for this reason or that. The complaint case is well within limitation as the accident took place on 12-05-2018. There is no delay in filing the complaint case before this Commission as it is being filed within the limitation period as provided under Section 24A of the Consumer Protection Act 1986.

In support of the complaint the complainant has filed the affidavit alongwith the following documents.

01.Copy of Policy Schedule Personal Accident Insurance (Plan 3).

02. Copy of F.I.R.

03. Copy of Post-Mortem Report.

04. Claim Form.

05. Copy of PAN Card of deceased.

06. Copy of letter dated 14-08-2018 issued by Insurance Company.

07. Copy of Legal Notice issued by Sri Harikishan Singh, Advocate.

The opposite party HDFC ERGO General Insurance Company Limited has filed the written statement in which the allegation made by the complainant in her complaint has been denied.

It has been stated by the opposite party in its written statement that the cause of action as alleged can only be ascertained after the

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complainant cooperates the Insurance Company in conducting the investigation with regard to the alleged accident. In the instant case the complainant has failed to cooperate the Insurance Company by not providing the relevant documents. The complainant has failed to provide any documents which proves the business of the deceased. The income certificate was demanded from the complainant but the same was not provided.

It has been stated by the opposite party in its written statement that several letters have been written to the complainant for providing necessary documents for processing the claim but the complainant did not pay any heed to the letters of the opposite party. Thus, there is no deficiency in service on the part of the Insurance Company and the instant complaint is liable to be dismissed.

It has been further stated by the opposite party in its written statement that there is no deficiency on the part of Insurance Company rather the complainant has prematurely approached this Commission without waiting for the final order of the competent authority of the Insurance Company. No cause of action has accrued in favour of the complainant.

Evidence by way of affidavit has been filed by the complainant alongwith various documents which is available on record.

An affidavit on behalf of opposite party has been filed by Sri Shiv Prakash Singh, Assistant Manager, HDFC Ergo General Insurance Company Limited. The following documents have also been filed by the opposite party alongwith the evidence.

01.Annexure No.01 - The copy of Policy Schedule Personal Accident Insurance (Plan 3).

02.Annexure No.02 - The copy of letter dated 09-06-2018 (Reminder 1) issued by opposite party.

03.Annexure No.03 - The copy of letter dated 21-06-2018 (Reminder 2) issued by the opposite party.

04. Annexure No.04 – The copy of letter dated 14-08-2018 issued by opposite party.

05. Annexure No.05 – The copy of letter dated 12-10-2018 issued by opposite party.

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I have perused both the evidence filed by both the parties as well as the annexures filed alongwith the evidence.

I have heard learned Counsel for the parties and perused the whole record very carefully.

It has been argued by the learned Counsel for the complainant that the cause of action arose on 12-05-2018 when the complainant died in an accident and the sum assured Rs.50,00,000/- has not been paid to the complainant. The complainant had duly informed the Insurance Company and submitted the claim for payment of sum assured as per policy Rs.50,00,000/- because in case of accidental death Rs.50,00,000/- has to be given by the Insurance Company to the nominee and the complainant is the nominee in the policy.

It has been argued by the learned Counsel for the complainant that the complainant has submitted all the relevant documents which she has with as per their requirement. Instead of making the payment of sum assured the opposite parties sent letter dated 14-08-2018 to the complainant and demanded various documents. Thereafter complainant has provided all the relevant documents demanded by the opposite parties but whatever opposite parties are demanding through their letter dated 14-08-2018 it is not possible to give because complainant is a lady and she has no knowledge about ITR etc. In the aforesaid policy the risk of accidental death was covered and deceased had duly insured with the Insurance Company and has deposited premium.

It has been further argued by the learned Counsel for the complainant that had the Insurance Company any doubt about the income of the deceased then the opposite party Insurance Company should have been made the enquiry before issuing policy but after the death raising of such questions are meaningless and are not sustainable in the eyes of law.  

It has been argued by the learned Counsel for the complainant that the opposite party has committed gross deficiency in service by not paying the sum assured under the policy to the complainant. Thus, the complainant has been harassed too much mentally and monetarily. Since the complainant is consumer of the opposite party, therefore the complaint case is maintainable before this Commission and is fully entitled to get Rs.50,00,000/- sum assured under the policy and also compensation of

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Rs.10,00,000/- for physical and mental harassment.

Learned Counsel for the complainant has further contended that the dispute involved in complaint case is purely consumer dispute and falls within the purview of definition of consumer as per Consumer Protection Act, 1986.  

It has been argued by the learned Counsel for the opposite party that the present complaint is false, frivolous, vexatious and abuse of the process of this Commission and, therefore, the same is liable to be dismissed.

It has been contended by the learned Counsel for the opposite party that the husband of the complainant executed a Personal Accident Insurance Policy from the opposite parties. The said policy was effective from 02-01-2018 to 01-01-2019.  It was alleged by the complainant that her husband died on 12-05-2018 in a road accident when his motor cycle was hit by a trailer. Due to the rash and negligence of the driver of the Trailer, the accident took place and the husband of the complainant died on the spot.

It has been contended by the learned Counsel for the opposite party that the claim of the complainant was bereft of certain documents which are necessary to be looked into before processing the claim. Vide letter dated 09-06-2018 the Insurance Company demanded claim form, copy of the FIR and Panchnama, copy of the post-mortem report, death certificate, treating doctors certificate bearing details of injuries etc. the complainant did not pay any heed to the letter dated 09-06-2018, the opposite party again requested the complainant to send the same documents as required vide letter dated 09-06-2018. Vide letter dated 21-06-2018 the Insurance Company demanded the same documents from the complainant.

In pursuant to the letter dated 21-06-2018 some of the documents were sent by the complainant but still some necessary documents were requested by the Insurance Company for processing the claim. Vide letter dated 14-08-2018, the complainant was requested to provide the income proof/salary slip and bank statement of the insured for the last six month. All these documents are significant for verifying the authenticity of the person as well as the claim lodged on his behalf as such the Insurance Company sought these documents from the complainant.

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It has been further contended by the learned Counsel for the opposite party that the maximum compensation in respect of the insured person shall not exceed seven times the annual income. Further it is provided that the income proof for availing the compensation at the time of the claim is mandatory. Income proof shall mean the income tax return filed with the Income Tax Department. The complainant has not responded to the letters sent by the Insurance Company and neither supplied the Income Proof as stipulated in the policy. The complainant did not respond to the letter dated 14-08-2018 sent by the opposite parties as such again vide letter dated 12-10-2018 the complainant was requested to provide the documents. The opposite party on the basis of the available documents as well as the limited information available with him continued with his investigation for the preparation of the fact finding report but due to the nonavailability of the documents as well as the desired information, the fact finder could not finalize his fact finding report.

Learned Counsel for the opposite party has further contended that the claim of the complainant is pending for disposal at the end of the opposite parties. The necessary documents required for processing of the claim were not provided by the complainant. The present complaint has been filed by the complainant only for harassing and tarnishing the image of the Insurance Company. The present complaint petition filed by the complainant is completely premature as the final investigation report of the fact finder is yet to be submitted. The complainant with an ulterior motive has filed the complaint petition to prevent the Insurance Company from extracting the truth and the genuineness of the claim.

I have heard the learned Counsel for the parties and perused the material available on record.

Learned Counsel for the complainant has drawn my attention to the coverage part of the Policy Schedule Personal Accident Insurance (Plan 3) which is extracted below.

The insured person is admittedly not an educated person as such he is carrying on the business of running a motor vehicle workshop. The agent deputed by the opposite party Insurance Company has placed the documents which were running in dozens of pages and were prepared in English language. Since the insurer was not informed nor any kind of intimation with regard to the details allegedly mentioned in English language therefore the documents which were given and are signed by the insured, he was not aware about any conditions whatsoever mentioned in those documents. 

Having heard the arguments of learned Counsel for both the parties and after considering the facts and circumstances of the case I am of the positive opinion that the submission of learned Counsel for the complainant appears to be justified and the ground alleged by the

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opposite party in not accepting the claim is not justified and the complainant was entitled to recover the claim under the insurance policy.

In view of the aforesaid, I am of the positive opinion that the argument of the learned Counsel for the complainant has got force and the complaint of the complainant is liable to be allowed. The opposite party HDFC Ergo General Insurance Company Limited is liable to pay the amount of Rs.50,00,000/- (Rupees Fifty Lacs Only) to the complainant under the policy of insurance issued by the opposite party. The opposite party Insurance Company is also liable to pay interest at the rate of 10% per annum from the date of accident till the actual payment is made to the complainant.

So far as the claim with regard to the compensation for physical  harassment and mental agony is concerned, I find it appropriate to direct the opposite party Insurance Company to pay sum of Rs.2,00,000/- (Rupees Two Lacs Only) to the complainant and I also award towards the cost of the proceedings to the complainant to the tune of Rs.25,000/- (Rupees Twenty Five Thousand Only). The opposite party Insurance Company is directed to comply the aforesaid directions within 60 days from the date of receiving the certified copy of this judgment and order.   

                                                           ORDER

The complaint is allowed. The opposite party HDFC Ergo General Insurance Company Limited is directed to pay the amount of Rs.50,00,000/- ( Rupees Fifty Lacs Only ) to the complainant under the policy of insurance issued by the opposite party. The opposite party Insurance Company shall pay interest at the rate of 10% per annum from the date of accident till the actual payment is made to the complainant.

The opposite party Insurance Company is further directed to pay to the complainant towards the compensation for physical harassment and mental agony Rs.2,00,000/- (Rupees Two Lacs Only) and also the cost of the proceedings to the complainant to the tune of Rs.25,000/- (Rupees Twenty Five Thousand Only).

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The opposite party Insurance Company is directed to comply the aforesaid directions within 60 days from the date of receiving the certified copy of this judgment and order failing which the rate of interest will be paid @ 12% on the decretal amount.

The opposite party Insurance Company is hereby directed to prepare the documents including the insurance policy in Hindi language as well as in all other Indian languages accordingly.

Let copy of this order be made available to the parties as per rules.

The Stenographer is requested to upload this order on the website of this Commission today itself.  

                                                      ( JUSTICE ASHOK KUMAR )

                                                                     PRESIDENT

Pnt.