Judgment On 29.12.2006
Present. Sri B.K. Samanta, President
Sri Kumar Mukhopadhyay, Member
Smt. Jyotsna Sarkar, Member
This is a case for claim and compensation.
The complaint’s case in short is that the complaint was a professional driver of motor vehicle and as such he agreed to have the Insurance coverage under the dispute for his personal risk and made his wife as the nominee. The redpondt. No. 3 is the Branch Manager of the Respondt. No.2, who is the franchise of Respondt. No.1, received a sum of Rs.733/- on 13.08.2001 towards the premium alone with proposal form for Accidental Insurance Coverage under their scheme ‘Group Janata Accident Insurance Policy’ and in turn the Respondt. Duly issued the Policy Certificate on 08.09.2001 being Policy No. 100300/47/2K/9601062/2K/96/00551 with the period of coverage from 08.09.2001 to 07.09.2004 mid night. While the complainant was coming towards Puyada Bus Stoppage on his way to home at about 8:00 p.m. on 10.08.2003 one motor cyclist dashed him with greatly force resulting serious injuries all over the body, specially on his right leg and head. The complainant was taken to saradamoyee seva Sadan by local people and thereafter he was shifted to SSKM hospital, Kolkata on 11.08.2003 where he was treated up to 20.08.2003 and thereafter he was shifted to Calcutta Medical Research Institute on 20.08.2003 for better management. As the wounds were not cured after prolonged treatment and operations on several times, he was thereafter taken to Christian Medical College & Hospital at Vellore and on his way to Vellore he was compelled to take some treatment at Apollo Hospital, Chennai and from there he was shifted to Christian Medical College & Hospital at Vellore. After certain treatment there and to save his life, the right leg above knee was ultimately imputed there at Christian Medical College & Hospital, Vellore on 28.09.2003. He4 was released from there on 07.10.2003 but he had to stay at Vellore for about 25 days for further treatment at ODP. After returning home at Tamluk, a written complaint was lodged on 09.11.2003 with the Nandakumar Police Station as to the fact of his accident on10.08.2003 stating the cause of delay in making the complaint The complainant met Respondt. No.3 for several times and informed about his accident on 10.08.2003 stating the cause of delay in making the complaint. The complainant met Respondt. No.3 for several times and informed about his accident and requested him time to time to make arrangements so that he can get compensation money from the accidental Insurance Coverage, who also assured him in so many words but did not advise him the actual process of making claim nor supplied him any of their prescribed form. Thereafter, the complainant lodged his complaint in writing for the accidental loss to his right leg to the respondent opposite parties in respect of his Group Jzanata Personal Accident Insurance Policy through Respondt. No.3 After receiving the claim from the Complainant the Rspondt. No.2 replied to it and sought for some documents vide their letter dt. 12.05.2004. The complainant in compliance to the contest of that letter sent all those documents lying with him. After a lapse of about 5 months, the complainant received a regret letter dt. 07.12.2004 from the Respondt. No.1 with some flimsy ground that as the intimation of accident was given after 7 months from the date of accident they have closed the claim as No Claim owing to violation of the condition s the intimation of accident was essentially required to be submitted within 30 days from the date of occurrence, receiving that letter, the complainant again sent a request letter to the respond. No.1 on 04.01.2005 explaining the cause of his delay in intimating the occurrence of the accident and again requested for the early disposal of the claim. IN reply to that letter, the Respondt. No. 1, only to delay and defeat the bona fide claim of compensation of the Complainant, again vide their letter dt. 17.02.2005 called for certain documents without any cause, though those documents were submitted long ago as per their requisition from time to time. The complainant vide his letter dt. 23.02.2005 expressed his unwillingness to submit those documents afresh as he was living hand to mouth and as all those documents have already been submitted earlier. The Respondts. Willfully harassed the complainant by several means without any cogent cause only to delay and defeat the bona fide claim of injured and assured compensation money which they are under the legal obligation to pay for the permanent disablement which extended to 80% as per disablement certificate issued by the authority of Govt. of West Bengal and accordingly the Respondt. Are liable to make payment of the 80 % amount of the total insured value of Rs.3,00,000/- which amounts to Rs.2,40,000/- together with interest at the rate of 18 percent p.a. over that amount since the date of written claim as made on 02.04.2004. The complainant also claimed compensation for harassment, mental pain and agony at Rs.60,000/- as well as interest at the rate of 18 percent per annum over the amount Rs.72,580, in total Rs.3,72,580/-.
The OP No.1, National Insurance Company, contested the case by filing a written statement wherein he denied the material allegation of the case and also stated that the case is not maintainable. He denied the accident as alleged by the complainant. He further stated the at the OP 2 and 3 were the agent of OP No.1 to procure insurance business against commission and they were so engaged to do certain deeds and things on behalf of Op No.1 as per terms of understanding/agreement and as such, they also cannot avoid their liability to render necessary services to their clients regarding the initial co-operation as liaso for the reason that the benefit of insurance business is also shared with them by the OP No.1, As per terms and conditions of the policy certificate under this dispute, it was mandatory to intimate the occurrence of any accident forthwith i.e. within one month to the company. But in this case the claim was made after a lapse of about 7 months without showing any reasonable cause for such delay. As such, the OP has closed the claim was made after a lapse of about 7 months without showing any reasonable cause for such delay. As such, the OP has closed the claim as ‘No Claim as per terms of policy certificate. It is further submitted that the OP has not received any copy of the stated Annexure in the complaint to assess the alleged claim to the tune of Rs.60,000/- for the stated loss or damages for mental pain or agony. The OP vide letter dt.17.02.2005 asked the complainant to submit some documents for proceeding further as to his case on humanitarian and sympathetic cause to reopen the closed file but he complainant without doing so has come before this Forum with a Claim of exorbitant amount for getting illegal benefit from the Forum. As such, the complainant being premature is liable to be rejected at this stage. The OP also stated that on receiving the notice of this case, the National Insurance Co. has further appointed agency for verification and confirmation of the disputed driving license of the Complainant and as such prays for submission of additional statement after receiving the same very shortly. Under the circumstances, the OP No.1 prays for dismissal of the case.
The OP No.2 & 3 contested the case by filing a written statement wherein they stated that this is a matter resting with the competent jurisdiction of the Ld. Forum. There is no deficiency in service incurred by Respondt. No.2 & 3 towards the settlement of the claim lodged by the petitioner under the policy. In the MOU as entered into between the Respondt. 1 and 2 , the authority for settlement to claim has been vested with the Respondt. No.1 and Respondt. No.2 and 3 have no jurisdiction or even any control over the subject. The r3esponsibility and liability towards settlement of claim is exclusively falling within the authority of Respondt. No.1 and in such cases the question of main Respondt No.2 and 3 jointly and severally liable is redundant. Respondt. No.2 & 3 have been imputed worngluffly as a party to the petition and requested the Forum to expunge the name of Respondt. No.2 & 3 from the petition. Under the circumstances, they pray for dismissal of the case.
Points for decision
Based on the above pleadings by all parties, the following points are taken up for consideration.
- Is the case maintainable?
- Is there any deficiency in service on the part of the OP?
- Is the complainant entitled to get any relief as prayed for?
Decision
Point No.1. It is admitted by all the parties that the complainant procured an insurance policy under OP No.1 through their agent OP No.2 and also paid premium. The Policy in question is marked Ext. 1. So, it is admitted fact that the complainant is a consumer under OP No.1, Thus the case is maintainable in its present form under Consumer protection Act.
Point No.2: In the instant case the complainant prays for insurance claim as per terms of the policy against the OP No.1 In this regard he filed the policy (Ext.1) which clearly shows that the policy was for a sum of Rs.3 lakhs. The medical certificate submitted by the complainant shows that he met with an accident(Ext. 2 series) and amputation has been done right over the knee. From the certificate it can be clearly seen that the complainant lost is entire right foot. The OP repudiated the claim of the complaint by saying that it has not been filed within 30 days (Ext.4) The terms of policy prov. 4 condition 1 clearly shows that if reasonable cause is shown the matter can be considered after expiry of the period (Ext.1/1) Subsequently the letter dt. 17.02.2005 (Ext.5) clearly shows that he insurance company sought some papers for consideration. Therefore, we can assume that the insurance company was ready to condone the delay. In fact in such cases when a person is under treatment for a prolonged period, it takes some time to lodge a claim. As such, the delay in filing a claim is normally condoned. The entire right foot of the complainant has been imputed. As per terms of policy (Ext.1/2), he is entitled to get 50% of the insured sum. In the instant case, insured sum is Rs.3 lakhs. So the complainant is entitled to get Rs.1,50,000/- as the accident took place on 10.08.2003 while the policy was in vogue. Therefore, it can be said that the complainant is entitled to get 50 % of the sum insured from the OP. Now the question raised by OP No.1 that OP No.2 and 3 are also liable to share the liability. But it is also admitted by the OP No.1 that Op No.2 and 3 are nothing but his agent. The document9Ext. A) filed by OP No.2 and 3 clearly shows that duties of the insured person is to submit all the required document/papers through Golden Multi Services Club to national Insurance Co. and for non settlement of any valid claim whatsoever, the responsibility and liability is with National Insurance Co. itself and none else. So the responsibility of setting complainant’s claim is solely lies with Op No.1 Under the circumstances we can say that nonpayment of insured sum even after receiving claim through OP No.2 and 3, is no doubt deficiency in service on the part of OP No.1, If there is any contractual dispute in between OP No.1 and OP no.2 & 3, the same being an internal matter among the OPs, a prospective consumer cannot suffer therefore.
Point No.3. ON the basis of foregoing discussions and materials on record, we are of opinion that the complainant is entitled to have 50 % of the sum insured as well as compensation.
Hence,
Ordered
That the case be and the same is allowed on contest against OP No.1, 2 and 3. The complainant is entitled to have 50% of the insured sum i.e. Rs.1,50,000/- from OP No.1 compensation Rs.5,000/-. The OP No.1 is directed to pay the same by one month from this date failing which the complainant is entitled to have the same by way of execution through this Forum after expiry of the period mentioned above along with interest at the rate of 8 percent p.a. on and from the date of filing this case i.e. 16.08.2005 till realization.
