Date of Filing : 15/07/2016
Order No. 13 dt. 11/12/2017
The case of the complainant in brief is that the complainant being the City Bank card member offered by Citi Bank and became a policy holder of good health policy. The complainant obtained a good health certificate being no.712500/GH/June-13/03499 starting from 01.06.2013 to 31.05.2014. The policy stood in the name of Debajyoti Bose, Susmi Basu and Ujaan Bose for some insured Rs.1,00,000/- each i.e Rs.4,00,000/- in total and premium of Rs.1433/- each totalling to Rs.5641/- which was paid in time. The eldest son of the complainant Debajyoti Bose unfortunately met with an accident in Uttar Pradesh and he died. After the demise of said son of the complainant the complainant contacted the Bank wherefrm the complainant was informed to contact New India Assurance Company Ltd. but no effective step was taken by the insurance company for payment of the amount of Rs.1,00,000/- towards the accidental benefit of the insured. The complainant thereafter sent the lawyer’s notice but no effective step was taken by the insurance company for which the complainant filed the case praying for direction upon the o.p. insurance company to pay the accidental claim of Rs.1,00,000/- and compensation of Rs.2,00,000/- as well as litigation cost of Rs.20,000/-.
Out of the o.p. nos. 1 to 4 , the o.p.nos.1 and 3 did not contest the case but other o.ps contested the case by filing w/v and denied all the material allegations of the complaint. It was stated that the policy was issued in 2010 and renewed subsequently till 2013. The policy is subject to clause GH/Oct/13 the cover granted is only mediclaim and not personal accident since inception. No cover for personal accident was granted under the policy issued by o.p. nos. 2 and 4 for the beneficiaries of the complainant and his family members. The case filed by the complainant is not maintainable since the complainant never paid any premium for personal accident. Accordingly the o.ps stated the case filed by the complainant has got no merit and the case is to be dismissed.
On the basis of the pleadings of the respective parties following points are to be decided:-
- Whether the complainant had the policy with the o.p. insurance company?
- Whether due to the accidental death of the insured the complainant will be entitled to get the compensation?
- Whether there was any deficiency in service on the part of the o.ps?
- Whether the complainant will be entitled to get any relief as prayed for?
Decision with reasons :-
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. Lawyer for the complainant argued that the complainant being the City Bank card member offered by Citi Bank and became a policy holder of good health policy. The complainant obtained a good health certificate being no.712500/GH/June-13/03499 starting from 01.06.2013 to 31.05.2014. The policy stood in the name of Debajyoti Bose, Susmi Basu and Ujjan Bose for some insured Rs.1,00,000/- each i.e Rs.4,00,000/- in total and premium of Rs.1433/- each totalling to Rs.5641/- which was paid in time. The eldest son of the complainant Debajyoti Bose unfortunately met with accident in Uttar Pradesh and he died. After the demise of said son of the complainat the complainant contacted the Bank wherefrm the complainant was informed to contact New India Assurance Company Ltd. but no effective step was taken by the insurance company for payment of the amount of Rs.1,00,000/- towards the accidental benefit of the insured. The complainant thereafter sent the lawyer’s notice but no effective step was taken by the insurance company for which the complainant filed the case praying for direction upon the o.p. insurance company to pay the accidental claim of Rs.1,00,000/- and compensation of Rs.2,00,000/- as well as litigation cost of Rs.20,000/-.
Ld. Lawyer for the o.ps. argued that the policy was issued in 2010 and renewed subsequently till 2013. The policy is subject to clause GH/Oct/13 the cover granted is only mediclaim and not personal accident since inception. No cover for personal accident was granted under the policy issued by o.p. nos. 2 and 4 for the beneficiaries of the complainant and his family members. The case filed by the complainant is not maintainable since the complainant never paid any premium for personal accident. Accordingly the o.ps stated the case filed by the complainant has got no merit and the case is to be dismissed.
Considering the submissions of the respective parties it is an admitted fact that the complainant being the card holder of o.p.1 obtained a good health policy being no.712500/GH/June-13/03499 starting from 01.06.2013 to 31.05.2014. The policy stood in the name of Debajyoti Bose, Susmi Basu and Ujaan Bose for some insured Rs.1,00,000/- each i.e Rs.4,00,000/- in total and premium of Rs.1433/- each totaling to Rs.5641/- which was paid in time. It is not disputed that unfortunately the son of the complainant died in an accident and the complainant filed the documents to that effect. It was emphasized by the Ld lawyer of the insurance company argued that the insurance covered towards mediclaim reimbursement not the personal accident for getting the benefit of the personal accident the insured ought to have paid additional premium as per premium table no.4 on the last page of good health brochure provided at the time of issuance of policy. The policy certificate attached by the complainant was covered only under mediclaim for which the complainant had paid a premium of Rs.5641/- covering 4 persons amounting to Rs.1433/- for three persons and rest for Rs.1342/-. The premium was computed as per premium chart of table-1 for mediclaim only. On perusal of the policy annexed with the complaint petition issued by New India Assurance Co Ltd. wherein personal accident section clause (PA) specifically stated that it covers accidental death, permanent disability due to accident and medical expenses for hospitalization resulting any death. Since the policy itself stated that the personal accident also covered and there is no mention of payment of any further amount to that effect thereby denial of the claim of the complainant of the benefit of personal accident caused deficiency in service on the part of the insurance company and the complainant will be entitled to get the relief.
Thus all the points are disposed of accordingly.
Hence, it is ordered,
that the case no.277/2016 is allowed on contest against the o.p. nos 2 and 4 and dismissed ex-parte against o.p.nos. 1 and 3. O.p. nos. 2 and 4 are jointly and/or severally directed to pay the accidental claim of Rs.1,00,000/- and to pay compensation of Rs.10,000/- as well as litigation cost of Rs.5,000/- within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
