Complainant a widow of insured Lt. Ashutosh Das who by filing this complaint submitted that her husband was a broker of Kotak Securities Ltd. that is op no.1 and her husband is one of the partner of ABB Financial Services firm registered by Security and Exchange Board of India (SEBI) Registered No.-IN B010808153 and that firm is a sub-broker of Kotak Securities (Stock Broker) affiliated to Bombay Stock Exchange and said Kotak Securities made a Kotak Group Term Life Insurance Policy vide No.G105 in favour of ABB Financial Services under Kotak Mahindra Old Mutual Life Insurance Ltd. 5^th Floor, Indian House, 69, Ganesh Chandra Avenue, Kolkata – 700013 on 18.07.2008 and said Kotak Securities under whom ABB Financial Services the firm of which her husband was a partner, a Sub-broker paid an amount of Rs.2,57,603/- as premium through a cheque No.1009885 dated 20.08.2009 of HDFC Bank and the policy renewal issued by Kotak Mahindra Old Mutual Life Insurance Ltd. proved that policy contract No. G105 issued on 24.05.2006 was in the Form upto 24.05.2008 and renewal upto 14.05.2009.

          Fact remains her husband Late Ashutosh Das died in a street accident on 03.01.2009 and after accidental death of her husband complainant as nominee repeatedly contacted the Authority of Kotak Securities Ltd. and Kotak Mahindra Old Mutual Life Insurance Ltd. for settlement of the claim of death benefit scheme under the policy and op sent a blank claim form and the same was submitted to the op duly filled up along with all necessary documentary papers and as per requirement of the op all the papers including Death Certificate, Police Report, Post Mortem were also sent to them in original in December, 2010.

          In the ‘Master Details’ of the policy (last page) the Member name is written as Ashutosh Das and the details pertain to his matter only and so the claim should be paid in full in favour of his legal heir.  Then further submitted that in respect of the death claim of Ashutosh Das final claim was submitted so the full amount of Rs.10,00,000/- as sum assured should be paid as insurance claim of the complainant.  But allegation of the complainant is that her claim was not settled for long period even after repeated persuasions and requests and for which ultimately complainant submitted the complaint before the Insurance Ombudsmen against Kotak Mahindra Old Mutual Life Insurance Ltd. and accordingly the Ombudsmen on 11.04.2011 passed such order observing that the claim of the complainant is genuine and admissible and so directed the op for payment of the same within 15 days from the date of order on 11.04.2011.  But even after passing that order, op did nothing and practically is creating trouble upon the complainant for getting a little amount of Rs.1,00,000/- against the claim of Rs.10,00,000/-.  But complainant refused it and for which subsequently op over phone informed the complainant to settle the matter only by accepting Rs.3,33,000/-.  But complainant refused it and confirming that op having no desire to comply the order of Insurance Ombudsmen also and they are not in a mood to pay and for which the complainant has prayed for relief along with compensation and interest etc.

          On the other hand op by filing written statement submitted that complainant is not a consumer under the op as per C.P. Act 1986 and there is no previty of contract in between the complainant and the op no.1 but admitted fact is that Kotak Securities Ltd purchased Group Insurance Policy from the op bearing Policy No. G105 for the benefit of the employees/partners of their franchisee and the husband of the complainant was one of the partners of ABB Financial Services which is one of their franchisees and it is further submitted that the policy contract issued by the op nos. 2 & 3 in favour of the op no.1 on 24.05.2006 and it was in force upto 14.05.2008 and op no.1 requested the husband of the complainant for renewal of the contract on 25.09.2008.

          In response to the said renewal application, the insurer vide its addendum letter dated 25.09.2008 had communicated to the policy holder that the said policy stands renewed subject to changes/amendments in the terms and conditions mentioned therein and in the said addendum it is categorically mentioned at Clause 3 that the ‘ver’ for each member will be subject to evidence of good health and such further terms and conditions as may be stipulated by the company and the age of the deceased was 42 years.  Hence, as per Underwriting Requirement in respect of the deceased member, the ‘cover’ was not effective as per c;aise 3 of the Policy Renewal Contract.

          It is further submitted that Policy Renewal Contract was sent to the policy holder under cover of op no.1’s letter dated 25.09.2008 but even free cover limit period the said member did not report it and for which the said claim cannot be entertained by the op and for non compliance of the provision and for non compliance of the declaration by the insured the present claim cannot be entertained and for which the op did not disburse the same.  But lastly op in para-15 of the written statement submitted that op for their genuine desire to settle the matter out of Court and for which op offered Rs. 1 lac towards full and final settlement but complainant did not response and fact remains basic claim itself is not payable in this case due to non compliance of Underwriting Requirement on the part of the policy holder, therefore, all contentions about payment of accidental death benefit are denied.

          Further it is admitted in para-19 of the written version that order was passed by Insurance Ombudsmen on 11.04.2011 then on 16.02.2012 a tripartite mediation meeting held at complainant’s office when all the parties were present.  But the matter could not be settled.  So the relief claimed by the complainant is not tenable and the complaint should be dismissed.

                                                  Decision with reasons

On in depth study of the complaint and the written version we have gathered that it is undisputed fact rather admitted fact that complainant’s husband was insured under the op through Kotak Securities Ltd and it is admitted by the op that his policy was renewed but their only contention is that complainant’s husband did not submit the Underwriting Requirement on the part of the policy holder but submitting the declaration about his good health.  But fact remains the policy was renewed by the op and invariably the said requirement was submitted by the Kotak Securities.  So, the policy was renewed, so at this stage op cannot deny or cannot raise any such objection about his good health and question of good health is arisen when anyone dies due to any pre-existing disease and in this case it is proved that death of the insured i.e. Lt Ashutosh Das was completely accidental death due to road accident he was one of the partners of ABB Financial Services and Kotak Securities Ltd being a Group Policy of the above on 18.07.2008 paid premium of Rs.2,51,603/- and it is fact rather admitted fact that he died in a road accident on 03.01.2009 at Dharma (Jamkunda) of Midnapore Town in the district of Paschim Mednipur and after his demise his wife being nominee repeatedly contacted with the op Kotak Securities Ltd and Kotak Mahindra Old Mutual Life Insurance Ltd. for settlement of the claim of death benefit scheme on the basis of the said policy.  When she submitted the claim papers to the insurer on 24.12.2010 even after lapse of 3 years it has not been decided as yet even after passing of the order by the Insurance Ombudsmen on 11.04.2011 against the op after contested hearing of the same and as per decision of the Insurance Ombudsmen, the claim is continuing and admissible and insurer was directed to admit the claim and to make payment within 15 days from the date of receipt of the order along with consent letter from the complainant.

          Most interesting factor is that op company a party to the said Ombudsmen proceeding did not challenge the order of the Ombudsmen anywhere rather they tried to follow that order by sending Rs.3,33,000/-.  Then it is clear that op did not try to show respect to the order of the Insurance Ombudsmen because their order went against the op and admitted position is that the complainant submitted all the required documents.  But it was not settled and ultimately op in the written statement submitted for non disclosure of Underwriting Required documents that matter was rejected by the op even after decision of the Insurance Ombudsmen passed in Complaint No. 1167/24/008/L/02/2010-11 passed on 11.04.2011.  So considering the above fact we are convinced to hold that present op insurance company and the op are reluctant to comply the order of the Insurance Ombudsmen and they have no desire to release the said sum of Rs.10 lakhs in favour of the nominee the present complainant for which such a fault and no doubt such an act on the part of the op insurance company is unfair trade practice and practically for such orders the op insurance company has been harassing the complainant in so many manners even after existence of the order of the Insurance Ombudsmen by which op is directed to release the said claim amount in favour of the complainant within 15 days from the date of that order of Insurance Ombudsmen on 11.04.2011.

          Then it is clear that op acted illegally, arbitrarily and also violating the order of the Insurance Ombudsmen  and their act is no doubt unfair trade practice and at the same time for their illegal immoral and unsocial act the present valid policy holder’s wife nominee has been suffering for last 3 years but op has been sitting idle and enjoying the fruits of the said claim amount and in the above circumstances we are convinced to hold that op is legally bound to release the sum assured Rs.10,00,000/- on the basis of the claim submitted by the complainant within one month from the date of this order along with interest @ 10% over the sum since 24.12.2010 and till its full and final payment to the complainant.

          In the result, the complaint succeeds.

          Hence, it is

                                                   ORDERED

          That the complaint be and the same is allowed on contest against the ops with cost of Rs.10,000/- but op nos. 2 & 3 shall have to pay litigation cost of Rs.10,000/- jointly and severally to the complainant.

          Op nos. 2 & 3 are hereby directed to pay and release a sum of Rs.10,00,000/- as insured amount in respect of the claim of the complainant on 24.12.2010 and also @ 10 % interest over the said amount w.e.f. 24.12.2010 and till its full payment by the op nos. 2 & 3.

          For causing mental pain and agony and harassment and also financial loss to the complainant by the op nos. 2 & 3 they jointly and severally shall have to pay damages to the extent of Rs.30,000/- to the complainant within one month from the date of this order.

          For adopting unfair trade practice and for not complying the order of the Insurance Ombudsmen passed on 11.04.2011 op nos. 2 & 3 jointly and severally shall have to pay punitive damages to the extent of Rs.50,000/- for adopting unfair trade practice and for checking the such practice of the op nos. 2 & 3 for releasing the claim amount/sum of the insured and said amount shall be deposited to the State Consumer Welfare Fund within one month from the date of this order.

          Op nos. 2 & 3 are directed to comply the order very strictly within one month from the date of this order (within stipulated period) by satisfying the decree in toto failing which for each day’s delay penal interest @ Rs.500/- shall be assessed till full satisfaction of the decree and if it is collected same shall be deposited to State Consumer Welfare Fund and even if it is found that op nos. 2 & 3 are reluctant to comply this order in that case the penal proceeding shall be started and even to arrest warrant shall be issued against them for implementation of this order.

          Op no.1 is directed to take such step to comply the order by the op nos. 2 & 3 and in this regard op no.1 shall have to act very promptly otherwise op no.1 shall be imposed penalty of Rs.10,000/- if the entire decree is not satisfied by the op nos. 2 & 3 within one month from the date of this order and if it is collected it shall be deposited to State Consumer Welfare Fund.