Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 195/2014
Jasmail Kaur w/o Lt. Sh. Gulzar Singh
S/o Ganga Singh R/o Preet Nagar,
Hareri Road, Sangrur, Punjab ...Complainant
Versus
OP-1 Oriental Insurance Company Ltd.
through General Manager,
A-25/27, Asaf Ali Road,
New Delhi-110002
OP-2 Oriental Insurance Company Ltd.
through its Manager
10184 Main Arya Samaj Road,
Hotel Land Mark Inn,
3rd Floor, Karol Bagh, Near Bikanerwala,
New Delhi-110005 ...Opposite Parties
Date of filing: 26.05.2014
Date of Order: 17.06.2023
Coram: Sh. Inder Jeet Singh, President
Ms. Shahina, Member -Female
Sh. Vyas Muni Rai, Member
Vyas Muni Rai
ORDER
1.1. The present complaint case has been filed u/s 12 of Consumer Protection Act, 1986 against the Oriental Insurance Company Limited through its General Manager, Asaf Ali Road, New Delhi (in short ‘OP1’) and Oriental Insurance Company Limited through its Manager, Arya Samaj Road, Karol Bagh, Delhi (in short ‘OP2’).
1.2. The representative of the OP2 approached the complainant’s husband, Lt. Gulzar Singh and persuaded him to take Nagrik Suraksha Policy; as well as GPA Policy of OPs representing that policies are very helpful in case of any accident, death of any person; and further assured that any claim against the policy to be settled within a period of one month from the date of filing the claim.
1.3 On the aforesaid representation of the OP2, husband of the complainant invested in two policies of OP2; the first one being part of the Nagrik Suraksha Policy bearing no. 271201/48/2010/426 for the period of 20.07.2009 to 19.07.2010 and policy no. 271201/48/2010/429 having validity period of 20.07.2009 to 19.07.2010; in both the policies name of assignee/beneficiary is Jasmail Kaur-(complainant) wife of policy holder; Lt. Sh. Gulzar Singh for 100% share; in the first policy the insured amount for accident was 2,00,000/- and Rs. 50,000/-for hospitalization; and in the second policy sum insured was 3,00,000/- (photocopy of the policies are at page-12-13 of the paper book).
1.4. Complainant’s husband Lt. Sh. Gulzar Singh was employed as E.A. (Environment Assistant) in Punjab Pollution Control Board at its Regional Office at Sangrur; on 07.07.2010; Sh. Gulzar Singh, during the course of his employment and while on official duty; visited M/s Guru Kripa Rice Mills at village Jhaner, Tehsil Malerkotla, District Sungrur, Punjab along with Assistant Environment Engineer and Junior Scientific Engineer to collect the stack emission sample.
1.5. During sampling, Lt. Sh. Gulzar Singh fell down on paddy bags due to breakage of roof sheets provided on the rice storage shed, and as a result; suffered from serious injuries in the said accident; he was first admitted at Gulzar Bone and Joint Hospital, Malerkotla; after taking some first aid from the said hospital, he was referred to Dr. Bhandari’s Brain and Spins Centre at Patiala on the same day; he was given treatment from 07.07.2010 to 13.07.2010; thereafter he was referred to Government Medical College and Hospital, Sector-32, Chandigarh on 13.07.2010 (prescriptions/letters of the hospitals are at page no. 14-16 of the paper book).
1.6. Further, without wasting any time, the complainant sent a letter dated 08.07.2010 to the Branch Manager of OP at its New Delhi Office; bringing to their notice that the accident had occurred and they should take steps whatever were necessary (copy of the letter dated 08.07.2010 is at page-17 of the paper book).
1.7. Unfortunately, during the treatment, Sh. Gulzar Singh passed away on 17.07.2010 due to said accident and injury at Government Medical College and Hospital, Chandigarh (death certificate of Lt. Sh. Gulzar Singh is at page 18 of the paper book).
1.8. The complainant intimated OPs in time about the death of Sh. Gulzar Singh; and also submitted the requisite documents; personal accident claim form bearing claim no. 2722203/48/2011/000027 as well as the claim form for claim under the GPA No. 2722203/48/2011/000028 (copy of both the claim forms are at page 19 to 23 of the paper book).
1.9. The complainant received a letter dated 03.03.2011 from the Surveyor/Investigator, namely, Sh. S.K. Khari vide which list of documents mentioned in the letter dated 03.03.2011 were required from the complainant; in the concluding para of the said letter Investigator had also stated that some incomplete documents are being returned which are to be submitted after filling complete information (letter of the Investigator dated 03.03.2011 is at page- 24-25 of the paper book).
1.10. Thereafter, complainant received a letter dated 08.08.2012 from OP2 with regard to the death claim of Lt. Gulzar Singh (‘NSP and GPA Policy’) in the said letter dated 08.08.2012; OP2 had requested to submit authority letter (specimen attached) to enable OP to collect the requisite documents/information from Dr. Bhandari’s Brain, Spin and Trauma Centre; in respect of treatment of the deceased Sh. Gulzar Singh; to enable OPs to proceed further in the matter (copy of letter dated 08.08.2012 is at page-26 of the paper book).
1.11. The said authority letter as well as ‘No Objection Certificate’ were deposited with OP2 without wasting of time.
1.12. Further, to the utter shock of the complainant, despite having followed up with the OPs as to the status of claims, no information has been given till date; nor OPs have made the payments of money; which they are legally bound to do. The Complainant vide her authority letter; (unsigned) addressed to the M.S., Dr. Bhandari’s Brain, Spine & Trauma Centre, Patiala had authorized M/s Oriental Insurance Company Limited, CBO-21, 10184, Arya Samaj Road, Karol Bagh, New Delhi; (with whom the claim of her deceased husband Lt. Gulzar Singh is pending for settlement for want of requisite information/documents); to get the requisite documents and whatever information the company requires from the hospital for the settlement of the claim, for which she had no objection (copy of authority letter is at page-27 of the paper book).
1.13. Thereafter, a legal notice dated 29.07.2013 was sent to the OPs; but neither the reply was received nor the compensation; and complainant was constrained to file present complaint for directions to OP1 and OP2 to make the payment to the tune of Rs. 5,50,000/- along with interest @ 24% p.a. from the date the amounts became payable till the date of actual payment; including pendent-lite and future interest; apart from Rs. 20,000/- as litigation cost; and Rs. 4,00,000/- as compensation for mental harassment and agony.
2.1 OPs have filed composite reply under the signature of Sh. Sunil Gupta, Divisional Manager, of OP1. OP1 has taken the stand that no cause of action arose in favour of complainant and against the OP; nor there is deficiency of service on the part of OP; the present claim is not maintainable and is liable to be rejected.
2.2. Complainant has not come before the Hon’ble Commission with clean hands; and has suppressed the material facts from the Commission; the complaint does not lie under the provisions of CP Act, 1986; Forum has no jurisdiction to try and entertained the present complaint.
2.3. The complaint is pre-mature; and complainant did not file the copy of FIR, copy of MLC and discharge summary; copy of Postmortem Report of the deceased; and also delay in intimating to OP about the happening of the accident, Sh. S.K. Khari, Investigator; appointed by OP sent letters dated 24.02.2011, 03.03.2011 and 22.06.2011 to the complainant to submit the necessary documents; but till today complainant has not filed the required documents of the deceased, instead complainant filed complaint before the Hon’ble Commission; and the same is liable to the dismissed (copies of letters dated 24.02.2011, 03.03.2011 and 22.06.2011 are at page-5 to 10 of paper book of OPs)
2.4. The complainant did not intimate OPs about the happening of incident in time; which is in violation of terms and conditions of the policy; but complainant submitted affidavit in the office of OP; regarding late intimation of the incident (copy of the affidavit dated 17.06.2011 from the complainant is at page-11 with the reply).
2.5. OPs have admitted about selling of two policies as mentioned in para no. 1.3, having validity period from 20.07.2009 to 19.07.2010; in favour of Gulzar Singh and the said policy was issued from CBO, Karol Bagh, Delhi of the OP; the said policy covered the risks; subject to strict compliance of the terms & conditions, clauses, warranties and endorsement of the policy, proposal or declaration. (Copy of the insurance policy having terms & conditions has been filed with the reply).
2.6. It is also the stand of OP; that the claim of the complainant was processed as assessed by its Investigator; who sent three letters to complainant (as mentioned in para no. 2.3) to furnish/submit the documents mentioned in those letters; but complainant did not file the documents till date; hence the present complaint is pre-mature, false and frivolous. OP denies that the complainant sent a letter dated 08.07.2010 to the Branch Manager of OP2; regarding happening of the accident of Sh. Gulzar Singh; as the complainant has not filed any postal receipt or acknowledgement for service of the said letter. The complainant herself; submitted affidavit of late intimation of the accident; it has been denied that complainant intimated to OP in time, regarding death of Sh. Gulzar Singh; submissions of requisite documents by the complainant has also been denied; as per requirement of OP; complainant wrote a letter to the Medical Superintendent; Dr. Bhandari’s Spine and Trauma Centre; Patiala, authorizing M/s Oriental Insurance Company Limited, CBO’21, 10184, Arya Samaj Road, Karol Bagh, New Delhi, (with whom the claim of her deceased husband Gulzar Singh is pending for want of requisite information/documents) to get the requisite documents and whatever information the company requires from the hospital for settlement of the claim as subjected in the authority letter, for which complainant had no objection (photocopy of the authority letter submitted on record is unsigned).
2.7. OP also deny para no. 14 of the complaint; that despite follow up for the status of claim; no information was given; nor the claim settled by the OP; for this OP has submitted that the claim form; is not rejected/repudiated; as the complainant did not submit the requisite documents to the office of OP to proceed the claim form; rest of the pleadings have also been denied by the OP.
3. Rejoinder, purported to have been filed by the complainant is on the line of pleadings in the complaint (rejoinder has neither been signed by the complainant nor her counsel); however, information about the death of , Gulzar Singh was given in time.
4. The complainant has filed affidavit of evidence under her signature; which is on the line of complaint; OP has filed the affidavit under the signature of Sh. Sunil Gupta, Divisional Manager; of OP2; at Jhhandewalan Extension, New Delhi; and contents of the affidavit are on the line of reply.
5. Written arguments have also been filed on behalf of both the parties based on record; OP in its written arguments has submitted terms & conditions of the Nagrik Suraksha Policy under the head “Claim Procedure and Requirements”;
6. We have carefully considered and analyzed the contentions of complaint, reply, affidavits of evidence; written arguments and documents submitted by the parties; in addition to documents filed on record from both side.
7. Admitted facts between the parties are, that Sh. Gulzar Singh, husband of the complainant took two policies, namely, Nagrik Suraksha Policy and GPA Policy; both the policies were given validity period w.e.f. 20.07.2009 to 19.07.2010; in both the policies; Ms. Jasmail Kaur (complainant and wife of policy holder) is assignee/beneficiary for 100% share; claim form duly filled up for both the policies were submitted with OP for processing her claim.
8. During the validity period of the policy; policy holder/husband of the complainant; met with an accident, while on official duty and died during treatment in the hospitalization; the accident happened due to breakage of roof sheets provided on the rice storage shed; during inspection of paddy bags; for the purpose of collecting the stack emission sample.
9. Perusal of the records, evidence and submissions of both the parties; depicts that bone of contention between both the parties are related to the submission of required documents; for the purpose of processing the claim of the complainant; stand of the OP throughout has been that the Investigator appointed by OP sent letters/reminders dated 24.02.2011, 03.03.2011 and 22.06.2011 to the complainant; for submission of documents mentioned in these letters to process the claim; but complainant did not submit the necessary documents; while; it is the submission of the complainant that all necessary documents required by OP; were submitted but her claim was not processed and paid by the OP; but OP has submitted that due to non-submission of the necessary documents by the complainant; claim was not processed and the filing of complaint before this Commission is pre-mature; and no deficiency can be attributed on the part of OP.
10. Further; of the contents of copies of letters dated 24.02.2011, 03.03.2011 and 22.06.2011; sent by the Investigator appointed by OP; required different documents from the complainant to proceed the claim; reveals that letter dated 24.02.2011 stated to have been sent by the Investigator to the complainant; is not supported by acknowledgment receipt; letter dated 03.03.2011 of the Investigator ‘First Reminder’; and letter dated 22.06.2011 (Final Reminder) bears photocopy of postal receipt pasted on the body of letter; minute perusal of these letters sent by OPs Investigator to the complainant; requiring submission of necessary documents; reflects that the nature and type of the documents mentioned in his letters is not monotonous; not only this; nature and type of documents dated 12.07.2019; filed by OP; during pendency of complaint case; is not matching with documents required and mentioned in the letters of the Investigator; in nutshell OP’s letters sent to the complainant requiring documents to process the claim are mismatching in itself.
11. Complainant vide letter dated 08.07.2010; addressed to Branch Manager of OP2; informed about accident/injury and hospitalization of her husband (policy holder); in the said letter details of the policies were also given and request was made to take necessary action; but this letter is not supported by proof of receipt by OP.
12. OP has also submitted a letter dated 08.08.2012; having reference of the death claim of Lt. Gulzar Singh; with regard to both the policies; wherein; OP requested for authority letter (specimen attached) from the complainant; to enable OP to collect the requisite documents/information from Dr. Bhandari’s Spine and Trauma Centre in Patiala; in respect of treatment of the deceased Sh. Gulzar Singh to proceed further in the matter; (letter dated 08.08.2012 from OP has also been not supported by acknowledgment); however, undated, unsigned ‘Authority Letter’; from the Jasmail Kaur-complainant; addressed to the Medical Superintendent, Dr. Bhandari’s Brain and Spine Centre; having reference of claim/policy authorized M/s Oriental Insurance Company Limited, CBO-21, 10184, Arya Samaj Road, Karol Bagh, New Delhi; with request to provide the requisite information/documents and whatever information to the company (OP); from hospital for processing of the claim, for which she had no objection; but OP has submitted that; after getting confirmed from the hospital; it was revealed that; no such authority letter from the complainant was received by the hospital; if that is so, OP should have taken the prudent step to inform the complainant; about non-receipt of authority letter by the hospital; but it was not done so by the OP.
13. OP has also filed an affidavit signed by the complainant/deponent; having details of the policies and information about death of her husband/policy holder; wherein; in para no. 3 of said affidavit; it has been declared ‘being illiterate and with grieved shock of my husband; I could not inform the concerned authority; to provide information regarding death of my husband, which may be excused; this is also one of the stand taken by OP; that information about accident/death of the policy holder was not given timely by the complainant.
14. Complainant also served legal notice dated 29.07.2013; at both addresses of OP; wherein; it has been submitted that the information regarding the death of Sh. Gulzar Singh was given to OP; and all relevant documents as demanded by OP; were also submitted; but neither the claim was processed; nor the compensation amount of the policies was given to the complainant, on account of death of her husband; on the last page of the legal notice photocopy of the postal receipts have also been pasted.
15. OP, in its written arguments has also taken the stand about violation of terms & conditions of policy by the complainant.
From the aforesaid discussions, considerations and rival contentions of the parties, it has come to notice that some documents exchanged between the parties are not supported by postal receipt/proof/acknowledgment for service; however, OP has also submitted in its reply that claim of the complainant has not been rejected/repudiated, but it was not processed for want of requisite documents.
16. From the facts and circumstances of the case; it is also established that cause of action exist in favour of the complainant; but claim has not been settled by the OP for want of necessary documents; as submitted in para-9 of its reply.
17. The above circumstances and scenario; we deem fit and appropriate to pass the following orders:-
(a) OP shall give letter in writing to the complainant within fifteen days from the receipt of this order; for submission of requisite documents; for considering and processing the claim of the complainant; on receipt of such letter from OP; complainant will comply the requirement within one month from the date of receipt of letter.
(b) If; on written request of the OP; as in para (a) above; the complainant submits the requisite documents; OP will process the claim of the complainant within four months; from the date of receipt of the documents; and inform the complainant about out-come of her claim subsequently.
18. Our directions at (a) and (b) in para-18 above, is without pre-judice to the rights of parties available in law.
19. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
20. Announced on this 17th June, 2023.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
