Order-18.

Date-13/10/2015.

This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that complainant husband is a bona fide mediclaim insurance policy holder of OP1 having policy no.4751220001799/E. No.47 – 30888 and Certificate No.200000139853 and the policy is under the name and heading of Janata Personal Accident Insurance Policy and mentioned its risk cover accidental death/loss of limbs/permanent total disablement policy.  The said policy issued in the year 2000 on 25-07-2000 bearing certificate serial No.0172501/200000139853, policy period from 15-07-2000 to 14-07-2015 and the said insurance coverage was for husband of the complainant and complainant is the nominee of the same and sum insured was for Rs.4 lakhs as policy coverage.  During the subsistence of the policy complainant’s husband namely Tarak Kumar Roy, s/o. Late Sudhir Chandra Roy was seriously injured due to burning for leakage of gas cylinder in his house on 14-09-2012 at 3:00 hrs. and therefore he was immediately admitted at Arambagh Hospital, then Tarak Kumar Roy was admitted at Shree Vishudhanand Hospital and Research Institution for better treatment on 14-09-2012 but after admission in the hospital of the complainant’s husband he died on that hospital due to said burn injuries and the death was reported to Chandrakana P.S. on 18-09-2012.  After the release of dead body complainant’s brother-in-law intimated the insurance company about such hospitalization and death and complainant submitted claim in respect of reimbursement of said amount as per official procedure for necessary action but even after receiving the same OP insurance company did not take any measure to solve the claim.  Thereafter, complainant herself requested the OP for settlement of the claim but they turned a deaf ear and harassed the complainant and that s the common practice of OP for which for proper redressal complainant has filed this complaint. 

          On the other hand, OP, the New India Assurance Company Ltd. by filing written statement submitted practically original policy copy issued by the GTFS because printed form was in their custody and they issued it and in fact, same policy was issued by the GTFS but actually it was issued on 15-07-2000 but long before that GTFS was injected by High Court in WP. No.1144 of 1999 vide order dated 06-07-1999 and that GTFS are injected from collecting any premium from category of friends from the date of such order.  But violating that order illegally this policy was issued by GTFS.  Fact remains deceased was not an employee or agent or development officer or field officer of GTFS and, in fact, GTFS initially was the insured and as per yearly statement of the employee, agent and field workers shall be covered by the insurance policy and same shall be submitted that had never been submitted by GTFS and at the same time at the opening of the said policy there was no information submitted by the insured GTFS.  Complainant was asked to establish the status of the diseased by documentary evidence but that was not fulfilled and it is the duty of GTFS to prove by way of evidence that the deceased was a certificate holder of the GTFS and he was employed being appointed and other documents and also GTFS failed to produce any remuneration list year to year of the deceased as field worker and no identity card was also submitted but no document has been filed by the complainant for which that was repudiated.  Fact remains complainant was directed to submit the identity card of the field worker, appointment letter as field worker, cash receipt of actual amount deposited in GTFS and etc. but she failed to do that but fact remains everything was done by the GTFS and the claim was submitted by the GTFS and that is the provision in case of group insurance policy and it is a group insurance policy, original insurance policy was given by GTFS  as per said order by GTFS only for their such sort of worker, agent, field workers who shall come under the purview of such insurance coverage but directly no insurance was issued in favour of the deceased or any workers of the GTFS so, the present complaint is not maintainable and there was no deficiency or negligent and on the part of the OP.

Decision with Reasons

On proper consideration of the complaint and the written version and also considering the judgment passed in WP No.1740 (W) of 2012 dated 09-02-2012 it is clear that in the writ petition Hon’ble High Court by passing judgment submitted that if deceased belongs to any friends category in question and it should be adjudicated and determined by proving all documents by the GTFS because GTFS is the insured and their field workers and employees are covered by the policy so, it is the liability of the GTFS to prove and in this regard a decision reported (2001) 2 SCC 160 (LIC) and others vs. Asha Goel and another is relief so we find that it must be proved that complainant’s deceased husband was a field worker in view of the order of High Court dated 06-07-1999 as passed because by that order GTFS is specifically restricted to collect premium in the category of friends so, in the present case main question is whether deceased was an employee or field worker of GTFS on the date of death and on the date of covering the insurance.  When that order was passed on 06-07-1999 but present policy was issued by the GTFS on 15-07-2000 in that case it is the duty of the complainant with the help of the GTFS and also the GTFS is to prove that prior to 15-07-2000 that deceased was an employee or field worker of the GTFS.  If it is not proved in that case there is no scope to grant any relief in favour of the complainant.  Most interesting factor is that GTFS was served with notice and GTFS filed a written statement and submitted that they forwarded the claim form, original copy of death certificate, income certificate, pan card, ration card of the insured and field worker certificate, residential certificate etc.  Practically it is the duty of GTFS to produce appointment letter as employee or field worker and remuneration receipt by the complainant etc. but that has not been done.  So, in the eye of Law when it is a group insurance policy then it is the duty of the insured that is the GTFS to produce all documents that is payment of remuneration as field worker or employee’s monthly remuneration receipt of the deceased etc. and if it is not proved then in that case the person who comes under the coverage of the group insurance policy shall not get such amount.

          No doubt principle of group insurance policy must be properly applied, in fact, if any group insurance policy is issued to any company then it is the duty of that company to yearly submit the status of the employees etc. whether their employees or workers are already discharged or resigned and it is generally submitted per year to the insurer that means in the present case GTFS is liable to submit all these but that has not been done.  Truth is that after the order of the Hon’ble High Court on 06-07-1999 and as per Central Policy no group insurance policy shall be more than Rs.1 lakh.  Practically, it is a Janata Personal Accident Policy, then how it was become Rs.4 lakhs that is a question.  Considering all the above facts and circumstances and the material and also judgment we find that on the death of Tarak Kumar Roy the complainant is entitled to get the policy amount if GTFS can produce such document that he was an employee or field worker on 15-07-2000 and till death he was a employee till death or field worker if it is not proved in that case in respect of present policy insurance company cannot be compelled to decide the matter.  No doubt GTFS has taken a very bad business and not only that they have also issued policies to professor, teacher, government employees and they are facing same problem and under any circumstances in that case there was no scope to grant any relief because professors, teachers or Government employees cannot be treated as employees of GTFS by any means.  In the light of the above observations we are disposing the complaint by directing the complainant and GTFS to produce all the documents regarding appointment of the deceased, his remuneration, per month payment of remuneration or commission as field worker etc. to the deceased till his death should be produced to the OP1 Insurance Company for settlement of the claim.  In this regard complainant and GTFS shall have to produce all those documents as required by the insurance companies and it must be submitted within 60 days from the date f this order to the insurance company for settlement of the claim of the complainant.

In the result, the case succeeds.

Hence,

Ordered

That the case be and the same is allowed on contest but without any cost against the OPs.

OP3 is directed to produce entire document regarding appointment of deceased Tarak Kumar Roy, s/o. Late Sudhir Chandra Roy as field worker or employee of the OP3 prior to 15-07-2000 and its continuous service and month by month remuneration payment till his death on 18-09-2012 and it must be deposited by the OP3 to the insurance companies along with all original file within 60 days from the date of this order and as because complainant’s application was forwarded by the OP3 so, it is the liability of the OP3 to produce all the documents related to said deceased which are required by the insurance company and if OP3 fails to produce all documents in support of proving the status of deceased as employee or field workers in that case there is no necessary to settle the matter but the claim shall be treated as repudiated as already made.

After completion of 60 days from the date of this order if GTFS fails to prove the status of the deceased husband of the complainant in that case the claim shall be treated as repudiated, as final.

Even if it is found that OPs are reluctant to comply the order in that case penal action u/s.25 read with Section 27 of the C.P. Act shall be started against them for which further penalty and fine shall be imposed.