The complainant Sri Sabita Devi has filed this complaint petition against Senior Divisional Manager, Golden, Multi Services Club Limited Kolkata and three others (o.ps) for realization of Rs. 5 lacs/- as sum assured with interest at the rate of bank from filing of claim in the office of o.ps ,Rs. 25,000/- as mental and economical harassment , and Rs. 25,000/- as litigation cost
The brief, facts of the case is that the husband of the complainant namely Late Shivnarayan Singh had taken a Group Personal Accident Policy bearing No.- 100300/42/04/8200012 from o.p no.- 3 & 4 through o.p no.-1 in which the complainant is nominee. The period of cover of insurance was 08-22-2004 to 07-11-2014. The further case is that on 04-04-2013 L.A Shivnarayan Singh was coming to Pokharaira from his office with his son Vikash Kr. on motor cycle Discover bearing No. BR06V4619. The Motor cycle was driven by Vikash Kr. Singh. As soon as they reached near New Road Pokhairara office to Gandhak Colony suddenly dog came in front of motor cycle so they met with an accident in course of saving dog. The further case is that Shiv Narayan Singh received fracture injury on his right shoulder and serious injury on his head and he became unconscious. The further case is that the hearing capacity of the L.A was stopped. He was treated with doctor. The further case is that a written application regarding accident was given to office incharge Jiatpur o.p who entered Sanha No.-52/2013 dated 04-06-2013. The further case is that Shivnarayan Singh informed o.ps regarding the accident in written. The further case is that he also filed claim paper regarding accident claim policy to the o.ps. The claim no of the same is – 100300/42/13/8290000080. The further case is that Shivnarayan Singh filed applicantion before o.ps on several times but no action was taken regarding claim amount. In the mean time on 03-03-2014, the complainant namely Shivnarayan Singh died. After death of the L.A. complainant filed this claim petition before the forum
The complainant has filed the following documents with the complaint petition - Photocopy of Group Personal Accident Policy certificate annexure-1, photocopy of Sanha No. 52/2013 annexure-2, photocopy of prescriptions & test reports of different Doctors annexure-3,3/1, 3/2, photocopy of Information given by DLA to ops., annexure-4, photocopy of Janta Personal Accident Policy annexure-5, photocopy of claim form annexure-5/1 , photocopy of application for obtaining information under information Act annexure-6, photocopy of Indian Postal Order annexure-6/1, photocopy of application dated 03-09-2013 filed by complainant to Senior General Manager, National Insurance Company Ltd. annexure-6/2, photocopy of petition dated 12-08-2013 to 07-07-2013 filed by complainant to Senior General Manager, Insurance Company Ltd. annexuxre-6/3 &6/4, photocopy of forwarding letter of claim documents to Senior Divisional Manager, annesxure-7, photocopy claim papers, 7/1,7/2, photocopy 2nd reminder letter dated 16-07-2013 from National Insurance Company to Shivnarayan Singh for asking papers annexure-7/3, photocopy of death certificate of Shiv Narayan Singh annexure-8.
After issuance of summon o.p no.-1 & 2 appeared and filed their w.s. 04-08-2016 with prayer to expunge/struck down their names from the complaint petition. It has been mentioned in the w.s that Mr. Shivnarayan Singh (since deceased) obtained a Personal Accident Insurance Policy of National Insurance Company Ltd. D.N. 3rd - 8 India Exchange place Kolkata under a Group Insurance Scheme through the facilitation of Golden Multi Services Club Limited. Issuance of Group Personal Accident Insurance Policy no.-100300/42/04/8200012 from national Insurance Company Ltd. In favour of Golden Multi Services Club Limited Covering the Member Mr. Shivnarayan ( since deceased ) for the period from 08-11-2004 to 07-11-2014 for sum Insured of Rs. 5 lacs/- is an admitted fact. Copy of certificate of insurance has been annexed as annexure-I. It has been further mentioned that according to memorandum of understanding existing among National Insurance Company Ltd. Division IIIrd. 8 India Exchange place, Kolkata and answering o.p Golden Multi Services Club Ltd, It empowers Golden Multi Services Club Ltd. to extend the insurance coverage to its member Mr. Shivnarayan Singh (since date of death) under the said Group Personal Incident National Policy. It has been further mentioned that the National Insurance Company Limited, division, III Kolkata have an exclusive right and authority to entertain process and settlement of such claim. It has been further mentioned that Golden Multi Services Kolkata Ltd. have no role to playin this regard or any authority being vested to them in so far as claim settlement/payment of insurance claim/ delayed settlement of claim/ rejection of claim is concerned. It has been further mentioned that no liability attaches to Golden Multi Services Club Limited for the deficiency in service. It has been further mentioned that Golden Multi Service Club Ltd. are regarded as insurance facilitator and not as authorized agent or corporate agent of the insurance company for the said insurance coverage to its member without having any liability about settlement of the claim. It has been further mentioned that as such o.p no.s 1 & 2 are never jointly and or severally liable to settle the claim of the claimant. It has been further mentioned that the authority to settle the Insurance claim is solely with the insured company o.p no.- 3 & 4. Copy of memorandum of understanding and clarification letter dated 17-07-2001 has been annexed as annexure II. It has been further mentioned that the intimation of the accident along with required documents were submitted to the insurance company but the claim has not been settled as yet.
O.p no.- 3 & 4 appeared and filed their w.s. on 25-07-2018 with prayer to dismiss the claim case. It has been mentioned in the w.s. that the case is not maintainable . It has been further mentioned that the case is barred by limitation as this case is filed 3 years after accident and 2 years after death of claimant. It has been further mentioned that o.ps demanded twice through letter dated 12-06-2013 and 16-07-2013 from insured for filing the following papers- (I) Attested copy of ration card, , voter I.D., Pan Card,(II) final police report /charge sheet through court, (III) employees salary certificate, copy of fora -18 (I.T return) (iv), local Panchayat Municipal certificate regarding the incidence and status of nominee in original. (v) Origional J.P.A/Gr.P.A certificate. (vi) Attested copy of FIR and Fard Bayan-(vii) Attested photocopy of disablement certificate from Government medical board along with claim forum is sent to him. It has been further mentioned that the risks which come under purview of the Gr.P.A in insurance are death, permanent total disablements , actual loss by physical separation/amputation of hand/ legs loss of eye sight arising out of any accident caused by external visible and violent means. It has been further mentioned that in the present case there is no amputation of hand/foot and or loss of eye sight arising out of accident which is clearly scheduled under benefit of scope of cover in back side of certificate. It has been further mentioned that the insured has failed to file disablement certificate during his life time and failed to file the papers demanded by this o.p which was necessary for settlement of claim under the Gr.P.A, the claim was repudiated on September 2016 was informed to insured, so no amount is payable by this o.p.
On behalf of complainant AW-1 Vikash Kr. has been examined.
The claim of the claimant has been repudiated by the o.ps no.3 & 4 on the ground which has been mentioned in repudiation letter dated 17-10-2013 filed on behalf of complainant as part of annexure 7/3 and the same is as follows-
“It is clear that the risks which come under the purview of G.P.A Insurance are death, permanent/ total disablement/actual loss by final separation/amputation of hand loss of eye sight arising out of any accident caused by external visible and violent means. In the present case there is no amputation of hand, foot and/ or loss of eye sight arising out of accident which is clearly scheduled under ‘Benefit’ of the scope of cover in the backside of the certificate. There is no permanent total disablement caused to the insured. There is no document evidently confirming any accident leading to disability of the insured, no FIR, No police report has been submitted, no Disability certificate from any board or government hospital to ascertain the PTD caused to insured.”
In the complaint petition, it has been mentioned that on 04-04-2013 husband of complainant late Shivnarayan Singh was going to Pokhairara Gandhak Colony from his office with his son Vikash Kr with motor cycle Discover no- BR06V-4619. The further case of the complainant is that motor cycle was driven by Vikash Kr and as soon as they reached near Road Pokharaira Gandak Colony, suddenly a dog came in front of the motor cycle in running condition and in course of escaping of dog the motor cycle met with an accident and Shivnarayan Singh fell on the road so he received injuries on his left shoulder and head, resulting fracture of bone of right shoulder. The further case is that he was under treatment with many doctors and ultimately on 03-03-2014 he died. The complainant has supported the aforesaid facts in his deposition filed on affidavit. On behalf of complainant the photocopy of Sanha- 52/13 (annexure-2) certificate of Rajendra Pd. S.H.O Jaitpur o.p annexure 2/1 and certificate of Mukhiya Gram Panchayat Pokharaira has been filed to prove the fact of accident and receiving of injuries to the insured. On perusal of prescription /reports of many doctors and investigation report (annexure-3) the same, proves the injuries sustained to insured i.e fracture of bone of right shoulder. The complainant has also filed, photocopy of death certificate as annexure-8.
O.P. Nos.- 1 & 2 has mentioned in their w.s. regarding obtaining of Personal Accident Insurance Policy by insured Mr. Shivnarayan Singh from National Insurance Company Ltd. The complainant has annexed copy of certificate of insurance as annexure-1. They have also mentioned in their w.s. that according to memorandum of understanding existing amongst national insurance company Ltd. division III, 8 India Exchange Place Kolkata -700001 and answering o.p Golden Multi Services Club limited, it empowers Golden Multi Services Club Limited to extend insurance coverage to its members Mr. Shivnarayan Singh (since deceased) under the said Group Personal Accident Insurance Policy. They have further mentioned in the w.s. that national Insurance Company Ltd. Kolkata have an exclusive right and authority to entertain the process and settlement of such claim. They have further mentioned that Golden Multi Services Club Ltd. have no role to play in this regard or any authority being vested to them in so far as claim settlement/payment of insurance claim/ delayed settlement of claim/ rejection of claim is concerned and as such o.ps no.-1 & 2 are never jointly and or severally liable to settle the claim of the claimant. They have further mentioned that the authority to said the insurance claim is solely with the insurance under o.p no.-3 & 4. The copy of memorandum of understanding and clarification letter dated 17-07-2001 have been annexed by them as annexure-II. They have further mentioned in their w.s. that intimation of the accident along with required documents were submitted to insurance company but the claim has not been settled as yet. They have also accepted the death of Shiv Narayan Singh on 03-03-2014. They have further mentioned that they have forwarded the claim form along with policy certificate copy , ration card, Pan Card, voter I.D. Card, residential certificate, Gram Panchayat certificate treatment papers bank pass book etc. to National Insurance Company Ltd. Division-III Kolkata in support of the accidental death claim. Photocopy of memorandum of understanding has been filed by the o.ps no. 1 & 2 as annexure-II. In para -26 of the above memorandum these guidelines have been mentioned for claim settlement.
GMSC Ltd. Shall interalia endeavour to extend following services in connection with claims, if any, arising under the policy issued to it by NIC Ltd (a). Coordinate with the insured members/beneficiaries regarding submission of intimation of claim in the prescribed form of NIC Ltd. (b) coordinate with NIC Ltd. regarding settlement of claims on behalf of its members. (c) other services which may be either required by NIC Ltd. or the insured NIC Ltd. shall similarly make the sincere endeavours to settle claims lodged either by the insured the G.M.SC ltd. preferably within 30 days after receipt of all requisite papers/ and/ or information. (d) claims will be paid to beneficiaries only and claim cheque to be sent directly to the claimant.
Accordingly, as per above agreement, the duty of o.ps no. 1 & 2 to refer the claim for settlement to NIC and they discharged the same as per his w.s. The complainant also admits this fact, so the o.p no.- 1 & 2 performed his duty in settlement of claim. Accordingly, they are not liable for payment of claim.
As regards responsibilities of o.p nos.-3 & 4, in payment of claim amount, the o.ps no. 3 & 4 has repudiated the claim of the complainant on the ground that there is no amputation hand/foot and or loss of eye sight assigned on accident which is clearly schedule under benefit of the scope of cover in the back side in the certificate of the claim. The same has also been repudiated on the ground that no document evidently confirming any accident leading disability of insured, so the o.p no. 3 & 4 are not liable to pay the insured amount in case of death. Another reason which has been assigned by o.p nos.- 3 & 4 in repudiation letter for not providing insured amount is that the insured which is beneficiaries, has not submitted FIR nor police report. The case of the complainant is that accident occurred in escaping the dog who suddenly came in front of the motor cycle and a Sanha bearing No. 52/2013 dated 04-06-2003. Was registered. This fact has been corroborate by the AW-1 Vikash Kr in his deposition on affidavit. This fact has also been supported by photocopy of written petition filed by Shivnaryan Singh to Office of incharge Saraiya P.S.-(Annexure-2) and certificate granted by Rajendra Pd. S.H.O Jaitpur o.p (annexure – 2/1) and certificate granted by Mukhiya Gram Panchayat Raj Pokhairara annexure-2 /2). In S.D. case no investigation is being held, so there is no question of filing police report. The same matter was informed by complainant to o.ps no. 3 & 4 by sending petition dated 03-09-2013 annexure- 6/2. Copy of the same is on the record as annexure-6/2.
From the above discussion we are of the opinion that there is deficiency on the part of the o.p 3 & 4 and they are liable to pay the claim amount.
Accordingly, the complaint petition is allowed with direction to o.p. no.s 3 & 4 r to pay sum assured Rs. 5 lacs. with 7 % interest p.a. from the date of filing of complaint petition that is on 23-02-2016, Rs. 20,000/- as physical and mental harassment and Rs. 10,000/- as litigation cost within two months from the date of order, /, on failure they shall be responsible to pay the above amount with 8 % p.a. interest till realization. Let a copy of this order be furnished to both the parties as per rule.
