DATE OF FILING: 22.09.2012
DATE OF DISPOSAL: 22.02.2016
Dr. N.Tuna Sahu, Member:
The complainant has alleged deficiency in insurance service against the Opposite Parties (for short O.Ps) in this consumer dispute.
2. Briefly stated the case of the complainant is that the complainant is the mother of one Santunu Kumar Padhy who is a policy holder with I.C.I.C.I. Lambard General Insurance Company Ltd vide policy bearing No. 4005/M/0000009/290064 dated 21.4.2011 relating to a Hero Honda passion plus bearing Regd. No.OR-07-T-8255 having its Engine No.HA-10 EBA 9B 00358 Chassis No.MBL HA 10EL A9 B 00 458. The complainant’s son while purchasing the vehicle from Laxmi Motors, Berhampur, entered into a contract of insurance policy with respondents and paid premium of Rs.50/- towards owner’s liabilities. This policy was executed by I.C.I.C.I. Lambard General Insurance Company Ltd with effect from 21.4.2011. Due to misfortune the complainant’s son who is the policy holder met with an accident at Sekhar Patnaik Medical Store near Khadasingi village being negligently driven by the driver of Truck bearing Regd. No.OR-06-B-6939. The complainant’s son died in the said accident on 30.7.2011 where a case was registered by B.N.Pur Police Station vide its P.S.Case No. 131/2011 under sections 279/304 (A) of IPC and sent the injured to the MKCG Medical College and Hospital where the authorities declared him as dead. The same case is sub-judies before the J.M.F.C. vide G.R. Case No. 847/2011. After receiving the vehicle from the police on 1.8.2011 the deceased’s father took the same to Laxmi Motors for repairing and also claimed damage of the vehicle from the O.Ps, who in turn settled the claim for damaged vehicle for an amount of Rs. 17,243/- and paid the same on 18.11.2011 through cheque bearing No.21341. Therefore, she also contended that OPs cannot take a plea that this is not within their knowledge as the damage of the vehicle has already been settled. But the O.Ps intentionally did not settle the death claim of the deceased. As a result, the complainant again approached the O.Ps for settlement of the claim as the said policy covered owners liability (first party) as per the terms and condition of the policy. The complaint intimate the matter to the O.P. No.1 on 16.2.2012 who received the same by acknowledge in the copy of the said letter but again no response was made from the side of the O.Ps finally on 8.6.2012 the complainant issued a registered legal notice to the O.Ps through her counsel which the Ops though received but did not choose to reply or settle the claim of the nominee complainant. As per the policy issued by the O.Ps the policy holder paid a premium towards owners liability but even in spite of specific condition mentioned in the policy the O.Ps intentionally avoiding to settle the policy claim in favour of the complainant as she being the legal heir and nominee of the policy holder and OPs caused deficiency of service by violating the condition of the policy which they entered with the policy holder. Alleging deficiency in service on the part of the O.Ps the nominee complainant prayed to direct the O.Ps to pay the insured amount of Rs.1,00,000/- as per the agreed clause, compensation and cost of Rs.25,000/- in the best interest of justice.
3. Upon notice the O.Ps entered its appearance through learned counsel Sri R.K. Panigrahi and filed written version resisting the claim of the complainant. It is that the complainant has not given any intimation of the alleged death of her son (alleged to have occurred on 30.7.2011) as per the terms and conditions of the alleged insurance policy and has also not lodged any claim before this O.P. till 8.6.2011. After long lapse of more than one year of the incident the complainant issued a legal notice on 8.6.2012 for the first time does not create any cause of action, only with a view to file a complaint against the O.Ps under the Provisions of Consumer Protection Act and as such the complaint against the O.Ps is not maintainable and the present O.P. can’t be dragged to take part in the present case. A cause of action against Insurance Company would arise when a claim is lodged as per the conditions of the insurance policy. The complainant slept over till 8.6.2012 and for the first time issued a legal notice on 8.6.2012 which is not maintainable as per the conditions of the insurance policy. In the present case no such claim was ever raised with the insurance company for which no occasion arose before it to render any service. Hence the complainant is not backed by any legitimate cause of action. For the purpose of the present litigation a cause of action was attempted to invent by serving a claim on 8.6.2012 which did not possess any merit and for that the present claim against these O.Ps. Such a vexatious creation of cause in bringing the present litigation may be viewed with heavy hand and the complainant be asked to submit authentic evidence of lodging of claim before the Insurance Company. The complainant has not approached with clean hands and she has played fraud, has misled, has adhere to all such frivolous activities, has deliberately suppressed the material evidence has concealed the truth for the purpose of the claim. Hence, the complainant is not entitled for any such relief. Keeping in view of the above facts and circumstances, non-lodging of the claim soon after the accident as per the term and condition of the insurance policy, no deficiency in service, barred by limitation, the case is not maintainable and the same is liable to dismissed.
4. On the date of hearing we heard the argument from both the learned counsel for the complainant as well as for the O.Ps and have also gone through the complaint of the complainant and written argument filed both parties. We have also perused the case in detail and have also gone through documents filed by parties to this dispute. After going through the case record we found that it is not in dispute that deceased policy holder procured the policy bearing No.4005/M/0000009/290064 on 21.04.2011 which was valid from 21.04.2011 to 20.4.2012 on payment of Rs.1015/- towards premiums for registered owners of Hero Honda bearing Regd. No.OR-07-T-8255 along with insurance for accidental death of the owner under Nsure Plus Policy of ICICI Lombard General Insurance. It is also beyond dispute or doubt that the present complainant was nominated as nominee of the said policy since she was the mother of the deceased policy holder. It is also a fact not in dispute that the deceased policy holder died on 30.7.2011 on account of a road accident occurred in front of Sekhar Pattnaik Medical Store under P.S. B.N.Pur, Berhampur, District: Ganjam as is evident from the copy of FIR where a P.S Case bearing No.131 of 2011 U/s 279/337/338/ 304(A) of IPC was registered placed on the case record as Annexure-5. The inquest report and Post-Mortem Report placed on the case record also proves beyond doubt the accidental death of the deceased policy holder.
During the course of oral arguments, the learned counsel for the complainant argued that the O.Ps did not settle the accidental death claim of the complainant for Rs.1,00,000/- in spite of the matter intimated to them. He also contended that the O.Ps on 18.11.2011 settled the claim of the damaged vehicle (OR-07-T-8255) of the deceased policy holder by sending a cheque bearing No.213421 dated 18.11.2011 for Rs.17243/- in the address of the deceased policy holder. But did not settle the death claim of the complainant even after intimation on 16.02.2012 and subsequent legal notice on 08.06.2012 hence liable to pay Rs.25,000/- towards compensation along with death claim of Rs.1,00,000/- in the interest of justice.
Per contra, the learned counsel for the O.Ps Shri R.K. Panigrahi vehemently argued that the complainant has not given any intimation of the alleged death of her son on 30.07.2011 as per the terms and conditions of the insurance policy and has also not lodged any claim before this O.P. till 08.06.2012. After long lapse of more than one year of the incident the complainant issued a legal notice on 08.06.2012 for the first time does not create any cause of action. The complainant slept over till 08.06.2012 and for the first time issued a legal notice on the said date is not maintainable as per the conditions of insurance policy. In the present case, no such claim was ever raised with the insurance company for which no occasion arose before it to render any service and the complainant is not backed by legitimate cause of action. For the purpose of the present litigation a cause of action was attempted to invent by service a claim on 08.06.2012 which did not possess any merit and for that this complaint is not maintainable and same is liable to be dismissed. This complaint is barred by limitation and suffered from inherent vice so deserve to be dismissed. He also argued that a cause of action against the O.P. would arise when a claim is lodged after which either no decision is given or delayed decision is given or a claim is wholly or partially repudiated. The complainant has not approached with clean hands and she has prayed fraud, has misled, has adhered to frivolous activities, has deliberately suppressed the material evidence and has concealed the truth for the purpose of the claim hence the complaint is not entitled for any such relief. Keeping in view the above facts and circumstances of the complaint the case is not maintainable and the same is liable to be dismissed.
We perused the above pleadings of learned counsels for both the parties and also verified the vital documents placed on the case record. From the above pleadings it appears that the learned counsel for the O.Ps contended that the claim of the complainant is not maintainable since there was delay in giving intimation to the Insurance Company after long lapse of one year i.e. on 08.06.2012. The points to be decided in this consumer dispute, whether the complainant was delay in intimating the claim to the O.Ps? And whether the complainant is entitled to get the accidental death claim of her deceased policy holder son? The aforesaid points are taken up together for a discussion with reasons through following observation and decision.
On perusal of documents and as per the merits, it is found that the complainant has actually intimated the matter to the O.Ps soon after death of her deceased son in an unfortunate road accident on 30.07.2011 as discussed above. Accordingly the O.P. No.1 has also settled the claim of the damaged vehicle (OR-07-T-8255) of the deceased policy holder by sending a cheque bearing No.213421 dated 18.11.2011 for Rs.17,243/- in the name and address of the deceased policy holder. It is further revealed that after receipt of the claim of damaged vehicle the complainant on 16.02.2012 intimated to O.P.No.3 for settlement of death claim of her son (deceased policy holder) which was also duly acknowledged by the O.P.No.3 placed on the case record as a vital document. It is also a matter of fact that despite receipt of the aforesaid intimation letter, the O.Ps did not take any initiative to settle the death claim of the deceased policy holder. Therefore, the complainant once again issued registered letter on 08.06.2012 through her counsel which was received but did not choose to reply by the O.Ps. In view of the facts stated above, in our view the arguments presented by the learned counsel for the O.Ps are vague and no force at all. We found absolutely no merit in this plea. As far as the point of limitation is concerned, we find that there is no merit in the submissions made by the learned counsel for the O.Ps. As per materials on record, the O.P. No.1 settled the claim of the damaged vehicle of deceased policy holder on 18.11.2011 which is beyond dispute or doubt. Subsequently, the intimation letter dated 16.02.2012 which was duly acknowledged by the O.P. No.3 and registered legal notice dated 08.06.2012 of the complainant to the O.Ps for settlement of death claim proved that the matter is within the knowledge of the O.Ps since the O.Ps has settled the vehicle damage claim of the deceased policy holder prior to the intimation for settlement of his death claim and after that death claim intimation of complainant was received with acknowledgment. However, even after receipt of the intimation letter for settlement of death claim, the O.Ps remained silent and slept over the matter. The notice from this Forum also did not serve any purpose. We would also like state that the O.P. even did not follow the I.R.D.A. (Protection of Policy Holders’ Interest) Regulations, 2002. The I.R.D.A. Regulations, 2002 which prescribes the claim procedure in detail in respect of a life insurance policy to be followed by the insurance companies is referred hereunder. The relevant portion of the said regulations is extracted below for useful reference in the present case.
8. Claims procedure in respect of a life insurance policy.
(1) A life insurance policy shall state the primary documents which are normally required to be submitted by a claimant in support of a claim.
(2) A life insurance company, upon receiving a claim, shall process the claim without delay. Any queries or requirement of additional documents, to the extent possible, shall be raised all at once and not in a piece-meal manner, within a period of 15 days of the receipt of the claim.
(3) A claim under a policy shall be paid or be disputed giving all the relevant reasons, within 30 days from the date of receipt of all relevant papers and clarifications required. However, where the circumstances of a claim warrant an investigation in the opinion of insurance company, it shall initiate and complete such investigation at the earliest, in any case not later than 6 months from the time of lodging the claim.
As per the above clauses of I.R.D.A. (Protection of Policy Holders’ Interest) Regulations 2002, the insurance company required to process the claim without delay in terms of clause 8(2) (3) of the Regulations. In our view, the O.Ps even could have settled the genuine claim of the complainant soon after receipt of the notice from this Forum but they did not do so. This shows the negligent attitude of O.Ps towards the complaint which proves deficiency in service on part of the O.Ps. This is a welfare society and in a welfare state, the Insurance Company is to help the legal representative of the deceased policy holder in their crisis period and not to make delay the settlement of the death claim on flimsy grounds of delay in intimation, limitation or deliberate suppression of material evidence. In the present case, we observed that there is no delay in intimation, no limitation and there is no deliberate suppression of material facts by the complainant. Hence, the insurance company can’t sit silently over a genuine claim on specious grounds. Therefore, we are not inclined to accept the contentions of the learned counsel for the O.Ps which has got no merit in the facts and circumstance of the case.
In the light of aforesaid discussion, in our considered view, the O.Ps are deficient in service for non-settlement of the genuine death claim of the nominee complainant. Hence, the O.Ps are liable to settle the death claim of the deceased policy holder without further delay. As far as the death claim is concerned, as per the policy conditions under policy certificate No.4005/M/0000009/290064 the maximum liability of insurer is Rs.1,00,000/- for accidental death under Section I of the policy. In the instant case, as per the police report and postmortem report of M.K.C.G. Medical College & Hospital, the deceased policy holder was died due to accident on 30.7.2011. Accordingly and as per the policy conditions, the nominee complainant is entitled to receive assured sum of Rs.1,00,000/- for the said accidental death of the deceased policy holder. Besides, under the present fact and circumstances of the case, the O.Ps are also liable to pay interest for delay in settlement of the genuine claim of the nominee complainant and for deficiency in service along with cost of litigation since the O.Ps unnecessarily dragged the complainant to the litigation and for that she has also hired the services of a legal professional to file her case.
As a result, the complaint of the complainant is allowed against the O.Ps and the O.Ps who are jointly and severally liable to pay assured sum of Rs.1,00,000/- to the complainant towards accidental death claim along with interest @6% from the date of filing of this case in this Forum. The O.Ps are also simultaneously directed to pay a modest amount of Rs.4,000/- towards cost of litigation to the complainant. The aforesaid amount to be paid to the nominee complainant within two months from the date of receipt of this order failing which entire amount shall be recovered from the O.Ps with interest @8% per annum under Section 27 of the Consumer Protection Act, 1986. Accordingly, consumer dispute of the complainant is disposed of.
The order is pronounced on this day of 22th February 2016 under signature and seal of this Forum. The office is directed to supply copies of the order to parties free of cost.
