Haryana

Karnal

381/2013

Usha Aneja W/o M.L. Aneja - Complainant(s)

Versus

National Insurance Company Limited - Opp.Party(s)

Sh. S.L. Narwania

17 Sep 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.381 of 2013

                                                               Date of instt. 9.09.2013

                                                               Date of decision:  05 .10.2015

 

Usha Aneja wife of Shri M.L. Aneja resident of House No.796/13, Urban Estate, Karnal.

                                                   ……….Complainant.

                             Versus

 

National Insurance Company Ltd. IInd Floor, SCO No. 57, 26D, Madhya Marg, Chandigarh, through Branch Manager, GT Road, Karnal.

                                                           ……… Opposite party.

 

                    Complaint U/s  12  of the Consumer

                     Protection Act.

 

Before           Sh.K.C.Sharma……. President.

                   Sh.Anil Sharma ………Member.

                   Smt.Shashi Sharma…..Member.     

 

 Present:       Sh.Amit Gupta  Advocate for the complainant.

                   Sh.Sanjeev Vohra  Advocate for the OP.

ORDER:

                      

 

          This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986, on the averments that she was holder of personal accident policy No.420102/42/11/810000127 for the period of 21.2.2012 to 20.2.2013.  In the month of July, 2012 while climbing stairs, her left knee twisted, as a result of  which she developed insidious onset of pain and locking in left knee. She  had visited   a  number of local Physicians  due to acute pain and  was kept under observation by  Local physicians/Orthopaedic Surgeon.   She visited Sir Ganga Ram Hospital, New Delhi for surgical intervention and on 19.12.2012, Arthroscopic  partial meniscectomy of medical meniscus of the left knee was done in the said hospital. She remained admitted there from 18.12.2012 to 20.12.2012.After discharge, she remained on bed for  pretty long time and during that interval she visited Sir Ganga Ram Hospital, New Delhi many  times as advised. Though, she had spent a sum of more than Rs.one lacs,  yet she claimed an amount of Rs.81313/- from the Opposite Party ( in short OP),  vide letter dated 31.1.2013 being holder of the personal accident policy. However, her claim was repudiated by the OP, vide letter dated 27.2.2013 on the ground  that as per policy condition, she was required to inform the OP about the incident immediately, but the matter was not 

 

 

 

immediately reported. Repudiation of her claim was illegal, unjustified and unwarranted. Therefore, she got served upon the OP legal notice dated 8.5.2013, but to no effect.

 

2.                 Notice of the complaint was given to the OP,  who appeared  and filed written statement controverting the claim of the complainant on various grounds. Objections have  been raised that complaint is not maintainable in the present form; that the complainant has not approached this Forum with clean hands and that complaint involves  determination of complicated questions of law and facts which cannot be done without leading evidence, therefore, this Forum has no jurisdiction to  entertain and  adjudicate the present complaint.

 

                   On merits, it has been submitted that claim intimation by the complainant with regard to alleged injury, was received in the office of OP, vide letter dated 22.2.2013. After going through the contents of the letter, it was observed that accident took  place in the month of July, 2012, but the intimation as sent  after about eight months of the alleged accident. As per terms , conditions and exceptions of the policy, notice was required to be given to the OP in writing immediately upon the occurrence of any accident , loss or  damage.   Since, the complainant gave intimation after eight months of the occurrence, the OP was not having sufficient  time to investigate the  matter by deputing surveyor. Therefore, as per  terms, conditions and exceptions of the insurance  the claim  of the complainant was  made  not  maintainable  and was  conveyed  to the complainant.

 

3.                 In evidence of the complainant, she filed her affidavit Ex.CW1/A and documents Ex.C1 to Ex.C29.

 

4.                 On the other hand in evidence of the OP, affidavit of Shri R.A.Dhar, Assistant Manager Ex.O1 and documents Ex.O2 and Ex.O3 have been tendered.

 

5.                 We have heard the learned counsel for the parites and have gone through the case file very carefully.

 

6.                 The claim of the complainant was repudiated by the OP on the ground that complainant suffered knee injury in July, 2012 but the intimation thereof was given to the OP on 22.2.2013 i.e. after a period of more than eight months.

 

7.                 The learned counsel for the OP put great thrust upon the contention that informing the OP by the complainant regarding knee injury suffered by her in July, 2012 after a period of more than eight months amounted to breach of condition of the insurance policy. The OP was not in a position to investigate the factum of knee injury suffered by the complainant after such a long period and thus prejudice was caused to the OP. Therefore, the repudiation of the claim of the complainant by the OP was legally justified.  In support of his contention he  placed reliance upon   Satpal Versus United India Insurance co. Ltd. and others 2013(3) CPC 518 and  Ramesh Chandra Vs. ICICI Lombard General Insurance Co. Ltd. 2014(1) CPC 335.

 

8.                 On the other hand learned counsel for the complainant  has vehemently argued that after suffering knee injury  while climbing stairs, the complainant got treatment from local physicians and also resorted to home  remedies, therefore,  there was no question of informing the OP about knee injury.  The complainant was advised surgical intervention  in the month of December, 2012 and Arthrolscopic  partial meniscectomy of medical meniscus of the left knee was done on 19.12.2012 and she remained admitted  in Sir Ganga Ram Hospital , New Delhi from 18.12.2012 to 20.12.2012. The complainant was required to inform the OP after the operation in order to claim reimbursement  of the expenses incurred on medical treatment.  She informed the OP vide letter dated 31.1.2013 and thus there was no unreasonable delay. The learned counsel for the complainant  further argued that  no time limit  was fixed as per conditions of the insurance policy for informing the OP. Even otherwise,  as per guide lines of Insurance Regulatory Development Authority, the claim of the complainant could not be repudiated merely on such technical ground of delay.  In this regard he made reference to Circular dated 20.9.2011 issued by Insurance Regulatory Development Authority, Reliance General Insurance Co.Ltd. Vs.Sri Avvn Ganesh  2012 (1) CPJ (NC)176 .

 

                         There is no dispute regarding the proposition of law laid down in the authorities cited on behalf of the OP but the same were based upon the facts peculiar to those  cases and do not cut any ice in   favour of the OP under the facts and circumstances of the present case. In Satpal’s case (Supra), insured vehicle was stolen but the intimation to the insurance company was delayed for more than 30 days. Under those circumstances it was held by the Hon’ble National Commission that breach of condition of policy was well proved. Moreover, there was delay of 133 days  in filing the complaint, which was not condoned as there was no reasonable explanation for condonation of such inordinate delay.  In  Ramesh Chandra’s case (Supra) insured truck was stolen.  As per version of the complainant, he had gone to the fields to attend the call of nature, when the truck was stolen.  Police and Insurance company were informed about the theft after 10-11 days. The claim of the complainant was repudiated by the Insurance company. State Commission upheld the repudiation of the claim for simple reason that truck was  lying unattended and secondly police and company were informed with delay of 10-11 days.  Under those circumstances, it was held by the Hon’ble National Commission that violation committed by the complainant was grave because by failing to intimate the theft to the police and insurance company, the  petitioner had prevented those authorities from taking prompt action to locate and recover the truck.

 

9.                 In the instant case, complainant had obtained  personal accident claim policy from OP. Had she gone for surgical intervention immediately after  suffering knee injury, then it was incumbent upon her to inform the insurance company immediately thereafter, but she did not  get any surgical intervention before 19.12.2012.  In  such a situation, the right to claim reimbursement of  the medical expenses  arose to the complainant only after surgical intervention and not before that.  As per conditions of the insurance policy no specific time limit was fixed for giving written  notice  Of the claim to the insurance company. As per condition no.1 written notice was required to be given to the company immediately upon happening of the event, which may give rise to claim under the policy. The complainant claimed reimbursement  in respect of the expenses incurred by her on the diagnosis/tests and surgical intervention in Sir Ganga Ram Hospital, New Delhi, therefore, she was required to give written intimation to the company after the said surgical intervention. As per, the case of the complainant, claim was sent to the complainant on 31.1.2013 whereas according to the case of the OP, the claim was received vide letter dated 22.2.2013.  The claim regarding reimbursement of medical expenses incurred on the injury does not stand on the same footings as the claim regarding theft of a truck. The genuineness of the claim of the complainant regarding surgical intervention on account of knee injury suffered by her could very well be verified by the OP from medical   record. Therefore, no prejudice was caused to the OP just for the reason that complainant informed the OP about the injury and medical expenses, after about two months of the surgical intervention. The OP should not have repudiated such claim of the complainant merely on the ground of delay which was otherwise proved to be genuine and the reasonable.  Such  view stands fortified from the circular dated 20.9.2011 issued by the Insurance Regulatory Development Authority and the law  laid down in   Sri Avvn  Ganesh’s case (Supra)    wherein the claim was repudiated by the insurance company  that death of insured was intimated after four months as against the stipulated period of one month.  All the conditions for acceptance of insurance claim except point of reporting loss within one month of its occurrence had been substantially fulfilled.  The delay in imitation of death of insured was due to injuries he suffered on account of accident. It was held by the Hon’ble National Commission that   delay  could not be  distructive  to insurance claim because the facts and circumstances of death were clearly established on the basis of medical on records as well as deposition of doctor who attended the insured.   Like in case of theft of moveable insured property, delay in intimation is not prejudicial to the insurer,  because in such cases, insurance company was not prevented, because of delay, from carrying out any investigation into the facts and circumstances as to whether the accident and consequent loss fell within the substantive condition of insurance policy and it cannot be imagined that  complainant  could have cooked up the story  that his father died in the manner stated and that too in active collaboration and collusion with doctor of the hospital.

 

10.               In view of the aforesaid discussion, we have no hesitation in observing that repudiation of the claim of the complainant by the OP was not justified under the facts and circumstances of the case as the complainant neither breached any condition of the insurance policy nor any prejudice was caused to the interest of OP merely on account of delay in getting information because the matter could very well be investigated from the medical record. Thus, there was  deficiency in services on the part of OP. The total amount of the bills provided lby the complainant comes to Rs.76593/-.therefore, the complainant is entitled to get reimbursement of the said amount from the OP No.1.

 

11.               As a sequel to the foregoing discussion, we accept the present complaint and direct the OP to make the payment of Rs.76593/-/-  to the complainant alongwith interest at the rate of 9%per annum from the date of  filing of the present complaint i.e. 9.09.2013 till its actual realization. The complainant shall also be entitled for a sum of Rs.10,000/- as compensation for the mental agony and harassment caused to her and for the litigation expenses. The OP shall make the compliance of this order within a period of thirty days from the date of receipt of the copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

 

Announced
dated:05.10.2015                                                                            

                                                               (K.C.Sharma)

                                                                   President,

                                                         District Consumer Disputes

                                                          Redressal Forum, Karnal.

 (Anil Sharma)       (Smt.Shashi Sharma)    

   Member.                              Member.

 

 

 

 

 

Present:        Sh.Amit Gupta  Advocate for the complainant.

                   Sh.Sanjeev Vohra  Advocate for the OP.

 

                   Arguments in part heard. For remaining arguments, the case is adjourned to 5.10.2015.

 

Announced
dated:30.09.2015                                                                            

                                                               (K.C.Sharma)

                                                                   President,

                                                         District Consumer Disputes

                                                          Redressal Forum, Karnal.

 (Anil Sharma)       (Smt.Shashi Sharma)    

   Member.                              Member.

 

 

 

Present:        Sh.Amit Gupta  Advocate for the complainant.

                   Sh.Sanjeev Vohra Advocate for the OP.

 

                   Remaining arguments heard. Vide our separate order of the even date, the present complaint has been accepted. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

 

Announced
dated:5.10.2015                                                                             

                                                               (K.C.Sharma)

                                                                   President,

                                                         District Consumer Disputes

                                                          Redressal Forum, Karnal.

 (Anil Sharma)       (Smt.Shashi Sharma)    

   Member.                              Member.