Punjab

Ludhiana

CC/15/296

Satvinder Singh - Complainant(s)

Versus

SBI Cardit Ins.Co.Ltd - Opp.Party(s)

Damandeep Singh Adv.

01 Jun 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 296 of 04.05.2015

Date of Decision            :   01.06.2016 

 

Satwinder Singh son of Shri Gurdev Singh, VPO Virk, PS Sidhwa Wait, Tehsil Jagraon, District Ludhiana.

 

….. Complainant

                                                         Versus

 

SBI General Insurance Company Limited, AVP Claims Health, 101, 201, 301, Natraj, Junction of Western Express Highway & Andheri Kulra Road, Andheri East, Mumbai-400069 through its General Manager.

…Opposite party

             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

 

SH.G.K.DHIR, PRESIDENT                                     

MRS.          BABITA, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :          Sh.Damandeep Singh, Advocate

For OP                           :          Sh.Vyom Bansal, Advocate.

 

PER G.K.DHIR, PRESIDENT

 

1.                Complaint under Section 12 of Consumer Protection Act, 1986(hereinafter in short referred to as ‘Act’) filed by complainant Sh.Satwinder Singh against Op  by claiming that he lodged claim No.CL-006965 under the insurance policy No.137715-0000-00,Certificate General No.860259.Nominee namely Satwinder Singh, on account of death of his son Gurdeep Singh lodged claim with OP by submitting the requisite documents. After receipt of letter dated 16.5.2014, complainant sent the copies of the documents required by the OP, but thereafter, he has not heard anything from the OP. By pleading deficiency in service on the part of OP, it is claimed that despite service of legal notice dated 19.1.2013 through counsel and sending of all the documents, OP failed to pay compensation and as such, complainant seeks directions to Op to pay compensation under the policy with interest @18% p.a. from the date of intimation till payment. Rs.50,000/- on account of mental pain and sufferings, but Rs.22,000/- as legal expenses claimed.

2.                 In the written statement filed by OP, it is admitted that Gurdeep Singh was insured for the period from 23.1.2013 to 22.1.2014 vide policy No.13771500000 under Group Personal Accident Insurance Claim Policy for sum of Rs.4 lac by the Op. Terms and conditions of the policy are binding on the parties. Claim receipt was intimated to      OP via call centre on 27.2.2014 and after receipt of the same, the said claim was registered vide No.CL-006965. Claim deficiency letter dated 28.2.2014 was sent to  the complainant for calling him to supply the documents detailed in that letter. However, complainant failed to respond and that is why letters dated 15.3.2015, 1.4.2014 and 3.4.2014 were sent to the complainant for calling upon him to provide the documents. Claim form dated 7.4.2014 was received from the complainant along with some other documents, but despite that some documents remained pending and that is why letter dated 16.4.2014 was sent to the complainant, but despite that the remaining documents never supplied to the insurance company. So, due to non submission of the documents and not hearing from anything from the complainant, officials of OP after scrutinizing the documents, repudiated the claim by issuing closure letter dated 27.4.2015. It is pleaded interalia as if complaint is not maintainable in the present form; complainant has no cause of action; complaint is false and frivolous; complainant by suppressing and twisting the material facts with dishonest intention wants to extract money          in illegal way. Besides, it is claimed that intricate question of law and facts are involved, due to which, complaint in summary proceedings cannot be decided. Other averments of the complaint denied.

3.                Complainant to prove his case tendered in evidence his affidavit Ex.CA, Ex.CB of Sh.Lachhman Singh, Sarpanch along with documents Ex.C1 to Ex.C16 and thereafter, his counsel closed the evidence.

4.                On the other hand, counsel for the OP tendered in evidence affidavit Ex.RA of Sh.Manish Laxman Kerkar, Assistant Manager-cum-Authorized Signatory of OP along with documents Ex.R1 to Ex.R15 and thereafter, closed the evidence.

5.                          Written arguments not submitted by any of the parties. Oral arguments alone addressed by the counsel for the parties and those were heard. Records gone through minutely. 

6.                The bone of contention remains as to whether the rejection of claim by issue of letter Ex.R15 is proper or not?

7.                It is vehemently contended by Sh.Vyom Bansal, Advocate representing OP that despite issue of number of letters, requisite documents have not been submitted and as such fault lay with the complainant in not getting the claim processed. Reference to letters Ex.R2 to Ex.R5 and Ex.R7 to Ex.R14 in this respect can be specifically made. Initially through letters Ex.R2 to Ex.R5, 10 documents were sought from the complainant, but later on through letter Ex.R7, seven documents were demanded, which shows as if some of the sought documents submitted by the complainant with OP. After scrutinizing the submitted documents, still three documents mentioned in letters Ex.R8 to Ex.R14 were not submitted by the complainant and as such, claim was rejected vide letter ex.R15.

8.                That rejection of the claim through letter Ex.R15 ordered due to non supply of the documents i.e.1) copy of indoor case papers of hospitalization attested by issuing authority, 2)copy of cause of death certificate attested by issuing authorities 3)copy of FIR/MLC copy/Spot Panchnama/Inquest Panchnama attested by issuing authorities.

9.                Postmortem on dead body of Gurdeep Singh was not conducted and as such, certainly complainant cannot supply the copy of cause of death certificate attested by the issuing authorities. Copy of Indoor Case papers of hospitalization as available with the complainant has been produced on record of this file as Ex.C2; Ex.C5 and Ex.C7. Medico legally examination was refused by the attendants of the patient is a fact borne from certificate Ex.C2 issued by the Superintendent of Dayanand Medical College & Hospital, Ludhiana and as such, in view of non conduct of medico legally examination, the cause of death certainly cannot be disclosed by the hospital authorities. If that be the position, then production of attested copy of cause of death by the complainant is not possible at all. So demand in that respect is not proper.

10.              Copy of death certificate of Gurdeep Singh produced on record as Ex.C3 for disclosing as if his death took place in DMC & Hospital, Ludhiana. Certificate Ex.C4 also thereto shows that dead body was handed over by DMC & Hospital, Ludhiana authorities to the complainant Satwinder Singh. Dead body of Gurdeep Singh kept in mortuary of the hospital is a fact borne from the contents of Ex.C5. Application Ex.C7 was submitted by Manjit Kaur for keeping the dead body in the hospital mortuary and Ex.C7 is the record of admission, in which, also cause of death not mentioned, but symptoms alone are recorded. In Ex.C10, the newspaper clipping item, cause of death mentioned as if the same took place because of coming of body in contact with the running engine belt. So whatever documents qua cause of death available with the complainant, the same have been produced on record. If postmortem on the dead body not conducted, but proceedings under section 174 Cr.P.C. conducted after supply of information to police as disclosed by Ex.C12 to Ex.C15, then how attested copy of certificate qua cause of death can be produced by the complainant. So, demand in this respect is not genuine and as such, repudiation of claim for this cause is improper.

11.              Copy of Indoor Case Papers of hospitalization qua patient attested by issuing hospital authority can be procured by the insurance company itself from the concerned hospital because whatever record available with the complainant in that respect, he has already produced as discussed above.

12.              In case titled as Avneet G.Singh vs. ICICI Lombard General Insurance Company Limited and others-2014(2)CLT-374(CHD), it has been held that when a cashless health insurance policy purchased by complainant and he lodged claim by providing the available medical record with him, then claim of insurance cannot be repudiated merely because of non supply of some more record because the insurance company itself can collect medical record from hospital concerned. As after lodging of claim for insurance, the medical record can be collected by the insurance company itself from the concerned hospital named by the complainant and as such, repudiation of claim due to non supply of  some more record  is improper. Besides,    it is contended by the counsel for the complainant that FIR in this case has not been registered because proceedings under section 174 Cr.P.C. initiated and that fact is borne from contents of documents Ex.C12 to Ex.C14. Through Ex.C13 and Ex.C14, Sh.Ajmer Singh, Member Panchayat and Sh.Darshan Singh claimed before the police that death of Gurdeep Singh took place due to natural circumstances and they do not want to take any action against anyone. If action for commission of an offence would have been contemplated, only then FIR would have been registered. However, action for commission of cognizable offence not contemplated or has been taken by the police. So, question of registration of FIR or of preparation of Spot Panchnama or Inquest Panchnama does not arise. From the facts and circumstances referred above, it is made out that whatever documents available with the complainant, copies of the same had already been placed by him on the record and as such, rejection of the claim is improper, particularly when OP by appointing investigator itself can verify about non registration of the FIR or non issue of certificate qua cause of death etc.

13.              Sh.Vyom Bansal, Advocate representing Op has placed reliance on law laid down in case of Puriben Ramjibhai Patel vs. New India Assurance Co.Ltd.-1994(2)CPJ-453(Gujarat State Consumer Disputes Redressal Commission, Ahmedabad) for arguing that in case, claim for accidental death put forth, then it is obligatory on the part of the complainant to establish that death of the insured took place in the accident. Benefit from the ratio of this case is not available to the Op because the copies of documents produced by the complainant on record of this file enough to find out as to whether the death in question is accidental or not? Rejection of claim through letter Ex.R15 has not taken place because of non proof of cause of death, but the same has taken place due to non submission of documents sought through letters Ex.R8 to Ex.R14. As repudiation of claim has not taken place due to non proof of accidental death of the insured and as such, benefit from ratio of this case not available to the counsel for the OP. As repudiation of claim is not legally justified and as such, deficiency in service on the part of OP certainly is there, due to which, the complainant entitled for compensation for mental harassment and even for litigation expenses. However, insurance company must be given chance to verify as to whether the claim on merit is sustainable or not?

14.              Therefore, as a sequel of the above discussion, complaint allowed in terms that OP will reconsider the claim on merits by keeping in view the documents produced by the complainant in the file of this case within 60 days from the date of receipt of copy of this order. If on such reconsideration,   complainant is found entitled to any amount of compensation, then it must be paid within 30 days from the date of finalization of claim matter, failing which, complainant will be entitled the adjudged amount from insurance company with interest @8% p.a. from today onwards till payment. Compensation for mental agony and harassment of Rs.7000/- and litigation expenses of Rs.3000/- more allowed in favour of complainant and against OP. These amounts of compensation and litigation expenses be paid by OP within 30 days from the date of receipt of copy of order. Copies of order be supplied to the parties free of costs as per rules.

15.                        File be indexed and consigned to record room.

 

                   (Babita)                                        (G.K. Dhir)

          Member                                          President

Announced in Open Forum

Dated:01.06.2016

Gurpreet Sharma.