DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/329/2021
Date of Institution: 24.12.2021
Date of Decision: 21.11.2024
Jaswant Singh Deol aged about 46 years son of Jarnail Singh, resident of Gill Kothe, Sehna, Tehsil Tapa, District Barnala.
…Complainant
Versus
1. Kotak General Insurance Company Ltd. Branch Barnala, Tehsil and District Barnala, through its Branch Manager.
2. Kotak General Insurance Company Ltd. 8th Floor, Zone IV, Kotak Infiniti Bldg. No. 21, Infinity IT Park, Off WEH, Gen, AK Vaidya Marg, Dindoshi, Malad (E), Mumbai-400097 (India) through its Managing Director/Authorized Signatory.
3. Kotak General Insurance Company Ltd. Ground Floor, Unit No. D-2, Model Industrial Colony OPP Aarey Road, Mumbai, Maharashtra 400063 through its Manager/Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Davinderpreet Davesar Adv counsel for complainant.
Sh. B.K. Garg Adv counsel for opposite parties No. 1 to 3.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Kotak General Insurance Company Ltd. Branch Barnala, Tehsil and District Barnala, through its Branch Manager & others (in short the opposite parties).
2. The facts leading to the present complaint are that the father’s Jarnail Singh insured himself with opposite parties on 2.9.2020 vide certificate No. 6120207474, which was valid from 1.9.2020 to 31.8.2021. It is alleged that the complainant’s father was assured by opposite parties that in case any injury or disease his health will be insured by them and all the expenses will be paid by opposite parties. It is further alleged that the complainant's father received injuries on 15.12.2020 by road accident and he was seriously injured. That on 02.09.2021 complainant got his disability certificate from Medical Authority Barnala Punjab, complainant was declared 90% disability by the Medical Authority. It is further alleged that the complainant filed a claim petition before the opposite parties, which was acknowledged by the opposite parties vide Emails and the communication was addressed with Sukhjinder Singh complainant being legal heirs of the Jarnail Singh. It is alleged that Mr. Jarnail Singh died due to the injuries suffered by him in the accident on 18.10.2021. But the opposite parties did not pass the claim about the death or injuries by Jarnail Singh so for and no reason was described by the opposite parties. It is further alleged that the complainant sent all the doctors relating to accident to the opposite parties as required by them vide Emails dated 09.09.2021 and the last emails of the opposite parties were received by complainant on 30.10.2021 but after that the they stop contact with complainant. The above said facts and circumstances clearly shows deficiency and negligence on the part of the opposite party in rendering services to the complainant due to which the complainant suffering a lot of mental tension, pain, agony and physical harassment financial loss, hence the complainant is left with no other alternative but to file the present complaint. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay the insured amount of Rs. 30,00,000/-claimed amount of compensation as amount of Permanent Total Disablement to complainant with interest payable @12% per annum till realization.
- To pay an amount of Rs. 1,00,000/- as compensation for causing physical pain and harassment to the complainant and Rs. 25,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections on the grounds that the complaint of complainant is not maintainable, as such the same is liable to be dismissed. The complainant has concealed and suppressed the material facts and has not come before the Commission with clean hands. The complainant has no cause of action and locus-standi to file the present complaint against the insurance company etc.
4. On merits, it is submitted that Jarnail Singh resident of Gill Kothe, Shaina, Barnala, Punjab has obtained Kotak Group Accident Policy having Policy no. GI2020747493 from opposite party valid for the period 1/9/2020 to 30/8/2021 subject to the terms and condition of the policy and its exclusion and the sum insured under the policy in case of Accidental Death is Rs. 15,00,000/- Permanent Partial Disablement Rs. 15,00,000/- and in case of Permanent Total Disablement is Rs. 30,00,000/-. It is further alleged that as per policy the company/opposite parties will pay the Sum Insured if the Insured Person suffers Permanent Total Disablement of the nature specified in the policy wording, solely and directly due to an Accident which occurs during the Policy Period. It is alleged that Insurance is a contract between two parties and both the parties are under the obligation to obey/fulfill all terms and conditions and coverage of the policy in the strict sense of the words written therein. It is denied that complainant's father was assured by the opposite party no.1 that in case of any injury or disease his health will be insured by opposite parties or all the expenses will be paid by the opposite parties. It is further alleged that the coverage opted by the insured has been duly mentioned in the policy certificate. It is alleged that in this case there is no FIR/DDR regarding the accident and there is no Medical Legal Report (MLR) and there is no such other record like admission record which points that insured has suffered accidental injuries. It is further alleged that claim has been registered by the opposite parties vide claim No. 20250000903 and same is processed by opposite parties and have appointed JD Health Care Services, Kharar for verification of the claim and this regard he submitted his report to the opposite parties. It is alleged that as per his report, the case seems to be case of planned Policy and insured family trying to convert medical illness to accidental for claim purpose only. He has also mentioned in his report that there is no evidence of any kind of accident or injury as no MLC, FIR or no consultation papers provided by the family. He has further mentioned that Vicinity check has been made from insured neighborhood and confirmed by every villager that insured was bed ridden from past two years possible due to disease and that no history of any kind of accident or injury found during vicinity check. It is denied that insured suffered any injury in accident or died due to that injury. It is alleged that replying opposite parties has demanded various documents from insured vide letter dated 10.12.2021 and 5.1.2022 but insured or complainant failed to provide the same and hence claim of the insured has been closed. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for complainant on 20.5.2022 has suffered the statement that I do not want to file any rejoinder against the version of opposite parties.
6. The complainant tendered into evidence affidavit of complainant Ex.C-1, copy of certificate of insurance Ex.C-2 (containing 5 pages), copy of disability certificate Ex.C-3, copies of Emails Ex.C-4 to Ex.C-9, copy of death certificate Ex.C-10 and closed the evidence.
7. The opposite parties tendered into evidence copy of Letter dated 10.12.2021 as Ex.OPs-1, copy of letter dated 05.01.2022 as Ex.OPs-2, copy of claim form dated 26.08.2021 as Ex.OPs-3 (containing 4 pages), copy of certificate of insurance alongwith terms and conditions as Ex.OPs-4 (containing 9 pages), copy of questionnaire for claimant/insured as Ex.OPs-5 (containing 2 pages), copy of JD Health care service report as Ex.OPs-6 (containing 2 pages), affidavit of Dr. Gurpreet Singh as Ex.OPs-7, affidavit of Milind Myakal as Ex.OPs-8 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the opposite parties.
9. Ld. Counsel for the complainant argued that the father of the complainant deceased Jarnail Singh insured himself with opposite parties on 2.9.2020 vide certificate No. 6120207474, which was valid from 1.9.2020 to 31.8.2021. It is further argued that the complainant’s father was assured by opposite parties that in case any injury or disease his health will be insured by them and all the expenses will be paid by opposite parties. It is further argued that the complainant's father received injuries on 15.12.2020 by road accident and he was seriously injured and on 02.09.2021 complainant got his disability certificate from Medical Authority Barnala Punjab, vide which the father of the complainant was declared 90% disability by the Medical Authority. It is further argued that the complainant filed a claim petition before the opposite parties, which was acknowledged by the opposite parties vide Emails and the communication was addressed with Sukhjinder Singh complainant being legal heirs of the Jarnail Singh. It is further argued that Mr. Jarnail Singh died due to the injuries suffered by him in the accident on 18.10.2021, but the opposite parties did not pass the claim about the death or injuries suffered by Jarnail Singh and no reason was described by the opposite parties.
10. On the other hand, Ld. Counsel for the opposite parties argued that as per policy the company/opposite parties will pay the Sum Insured if the Insured Person suffers Permanent Total Disablement of the nature specified in the policy wording, solely and directly due to an Accident which occurs during the Policy Period. It is further argued that Insurance is a contract between two parties and both the parties are under the obligation to obey/fulfill all terms and conditions and coverage of the policy in the strict sense of the words written therein. It is further argued that in this case there is no FIR/DDR regarding the accident and there is no Medical Legal Report (MLR) and there is no such other record like admission record which points that insured has suffered accidental injuries. It is further argued that the said disability certificate nowhere says that the said disability of the insured is due to any injuries sustained to him and as per disability certificate the case of insured is of Cerebral Palsy and diagnosis in the case is Paraparesis of Lower Limbs. It is further argued that claim has been registered by the opposite parties vide claim No. 20250000903 and same is processed by opposite parties and have appointed JD Health Care Services, Kharar for verification of the claim and this regard he submitted his report to the opposite parties and as per his report, the case seems to be case of planned Policy and insured family trying to convert medical illness to accidental for claim purpose only and there is no evidence of any kind of accident or injury as no MLC, FIR or no consultation papers provided by the family. He has further mentioned that Vicinity check has been made from insured neighborhood and confirmed by every villager that insured was bed ridden from past two years possible due to disease and that no history of any kind of accident or injury found during vicinity check and it is denied that insured suffered any injury in accident or died due to that injury. It is further argued that the opposite parties have demanded various documents from insured vide letter dated 10.12.2021 and 5.1.2022 but insured or complainant failed to provide the same and hence claim of the insured has been ‘closed’.
11. We have gone through the facts and evidence produced by both the parties. The complainant has produced insurance policy Ex.C-2 vide which it established that benefits coverage is only in case of Accident. It is the specific case of the opposite parties that in this case there is no FIR/DDR regarding the accident and there is no Medical Legal Report (MLR) and there is no such other record like admission record which points that insured has suffered accidental injuries and the said disability certificate Ex.C-3 nowhere says that the said disability of the insured is due to any injuries sustained to him and as per disability certificate the case of insured is of Cerebral Palsy and diagnosis in the case is Paraparesis of Lower Limbs. We have perused the Disability Certificate of Jarnail Singh i.e. Ex.C-3 vide which it is mentioned that he is a case of Cerebral Palsy and the diagnosis in his case is Paraparesis of the lower limbs. On the other hand, to prove their case/version the opposite parties have placed on record copy of JD Health Care Services report dated 7.10.2021 Ex.O.Ps-6 vide which in the coloumn of observations it is mentioned that;
“As per investigation findings and available evidence it has been found that insured is Disabled due to Cerebral Palsy, there is no evidence of any kind of accident or injury as no MLC, FIR or No consultation papers provided by the family and even in the vicinity it has been confirmed that Insured was bed ridden for past two years, seems to be case of Planned Policy and PED family trying to convert medical illness to accidental for Claim Purpose only”. The opposite parties in order to prove their case have also placed on record affidavit of Dr. Gurpeet Singh of JD Health Care Services as Ex.O.Ps-7 vide which he deposed as under;-
1. “I say that I work as an independent investigator. I was entrusted the claim file of insured Jarnail Singh for the verification of facts of the case.
2. I say that I have thoroughly gone through the records and after considering each and every aspect of the claim, I have submitted my report dated 07.10.2021 to the insurance company.
I say that below are the observations and findings given by me in my report:
i. No OPD Record and investigation reports of Phull Neuro Hospital Patiala and DMC Ludhiana has been provided by the family as per them all documents submitted to Civil Hospital Barnala for disability certificate.
ii. No Details of Scooter RC and Pictures provided by the family as per them even they are not aware on whose scooter he was travelling.
iii. Visit to Civil Hospital Barnala has been made to meet with Civil Surgeon to get copy of record on which basis Disability certificate was issued but they are delaying in providing the record for one and other reason,
iv. Visit to DMC Hospital Ludhiana has been made no OPD/IPD Record of the insured found with available contact details.
v. Visit to Phull Neuro Hospital Patiala has been made but they are non- cooperative refused to provide or show any record in the absence of any OPD Record or Doctor Prescription Slip.
vi. Visit to Fortis Hospital Ludhiana, CMC Hospital Ludhiana has been made but no OPD/IPD Record of the insured found.
vii. Disability certificate of the insured has been verified online from Govt. Site, certificate found to be genuine but cause of Disability is specified as "Cerebral Palsy" no document submitted by the insured on Govt. Site as well seems as Disability of insured is due to Medical illness.
viii. As per investigation findings and available evidences it has been found that insured is Disabled due to Cerebral Palsy, there is no evidence of any kind of accident or injury as no MLC, FIR or No consultation papers provided by the family and even in the vicinity it has been confirmed that Insured was bed ridden for past two years, seems to be case of Planned Policy and PED family trying to convert medical illness to accidental for Claim Purpose only”.
12. Moreover, in support of their case the opposite parties have placed on record letter dated 10.12.2021 Ex.O.Ps-1 which was sent to deceased Jarnail Singh vide which the opposite parties have demanded the required documents to settle the claim of the insured/complainant i.e. Provide all consultation, testing including CT & MRI report since the beginning of the ailment till date, Provide copy of MLC, FIR & police verification report, Photographs of the Insured Person reflecting the injury & disablement, Required each & every hospitalization, discharge summary, indoor case records from the hospital since last one year. But the complainant has failed to provide the above said documents to the opposite parties. Thereafter, the opposite parties sent letter dated 5.1.2022 Ex.O.Ps-2 to the deceased Jarnail Singh to inform that “we have waited for long time but we have not received any response from your end so far, in view of the no response we are treating this claim as ‘Closed’. On the other hand, the complainant has failed to place on record any medical record of the deceased Jarnail Singh to prove the fact that deceased Jarnail Singh received serious injuries on 15.12.2020 in road accident. Moreover, the complainant has also failed to place on record any copy of FIR/DDR and MLR to prove the fact that the deceased met with an accident and suffered injuries. We are of the view that the above said documents were mandatorily required to support the claim and in the absence of above said documents the exact cause of disability and death of the Jarnail Singh insured is not established. Therefore, in view of the above said facts and circumstances we are of the considered view that there is no deficiency in service or unfair trade practice on the part of the opposite parties and the complainant has failed to prove his case by producing cogent, reliable and trustworthy evidence.
13. In view of the above discussion, there is no merit in the present complaint and the same is dismissed without costs. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
21st Day of November, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
