Order by:

Smt.Priti Malhotra, President

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant's husband namely Satnam Singh had purchased a health insurance policy bearing No.P/211222/02/2022/000252 and the opposite party issued  policy containing two pages only and they never provided the terms and conditions of the policy to them. In the above said insurance policy, the complainant was appointed as nominee by his husband. Unfortunately, the husband of the complainant died due to snake bite on 11.09.2021 and it is pertinent to mention here that the insured remained admitted for treatment in Harbans Nursing Home at Kot Ise Khan for the period 09.09.2021 11.09.2021 and during treatment he died in the hospital. After the death of the assured, the Complainant lodged the claim with the Opposite party for the release of benefits under the policy. It has been claimed that the complainant submitted all the original documents required by the opposite party for settlement of the claim. The factum of the said death is duly been registered with the Registrar Births & Death, Punjab. Further alleged that the complainant is an illiterate person and only know how to sign in punjabi, so at time of lodging of claim the entire forms/documents were filled up by the officials of opposite party and she disclosed entire correct facts to the officials of the opposite party and supplied the documents as asked for by the opposite party. Thereafter, the complainant kept contacting the office of the opposite party to know about the status of the claim on account of death of her husband, but to no effect. It is alleged that the opposite party is only delaying the matter on one pretext or the other. Further alleged that the complainant repeatedly approached the opposite party with a request to settle her claim and to make the payment, but to the surprise of the complainant, the opposite party has rejected the claim of the complainant. Alleged that aforesaid repudiation of the claim by opposite party is illegal, null and void, against law and facts. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite party may be directed to release the sum assured amount alongwith benefits of the policy on account of death of the husband of complainant.

b)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint being pre-mature and false is not maintainable; the complainant has not come with clean hands. She has not disclosed the entire true facts. The complainant has also suppressed the material facts from this Commission as well as from the answering opposite party; no deficiency of services have been rendered to the complainant as alleged in the complaint; the complainant is estopped to file the present complaint by her own act and conduct. The complainant herself has not been cooperating with the answering opposite party, as the complainant did not furnish the required information, record and documents etc. with the answering opposite party for the successful processing of the claim in question, inspite of repeated requests made by opposite party and thus resultantly, the alleged claim file has been closed and the claim was rejected and repudiated, in the absence of required documents, as per terms and conditions of the insurance policy, which were explained to the insured at the time of proposing policy and the same were served to the insured along with policy schedule. The insured has accepted the policy agreeing and being fully aware of such terms and conditions and had executed the proposal form. Averred further that the insured, Mr.Satnam Singh submitted the Proposal Form for “ACCIDENT CARE INDIVIDUAL INSURANCE POLICY” and in due course of business, the said policy was issued to the insured, based on the declaration in the Proposal, vide Policy No.P/211222/02/2022/000252 for the period of 23.07.2021 TO 22.07.2022 covering Mr.Satnam Singh for the sum insured of Rs.50,00,000/-. The Complainant had intimated about the claim on 01.11.2021 and submitted the claim form along with the Discharge Summary, Final Bill and Medical Investigation Report on 23.11.2021 vide Claim No.CIR/2022/211222/02/3399721. Averred that the insured expired on 11.09.2021 and the complainant had intimated the claim on 01.11.2021 with delay of 45 days which is violation of the terms and conditions of the policy. Further averred that on scrutiny of the claim records it is observed that the complainant had claimed for death benefits under the said policy where the insured alleged to have been died due to snake bite. Further, the complainant had submitted only Discharge Summary, Final Bill and other Medical Investigation report. Hence, the Opposite Party has requested the complainant to submit the following documents vide letter dated 15.12.2021:-

i.        Police First Information Report (FIR), duly signed and attested.

ii.       Police Inquest and Panchnama

iii.      Police Final Report

iv.      Post Mortem Report

v.       Medical Legal Case (MLC) from the hospital

          The opposite party has sent reminders to the complainant to submit the above said records vide letter dated 30.12.2021, 14.01.2022 & 29.01.2022. Even after repeated reminders to submit the necessary documents to review the claim, the complainant had not submitted the documents. Averred that the complainant did not submit the aforesaid document with Opposite Party, which deprived the rights of the Company in assessing the claim. Averred further that the Company reserves the right to call for additional documents wherever required and it was the duty of the insured to submit the necessary documents to process the claim. The complainant has to provide the strict proof upon the happening of the event to enable the Company to process the claim. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C6.

4.       To rebut the evidence of complainant, ld. counsel for the Opposite Party has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1/A alongwith copies of documents Ex.OP1/1 to Ex.OP1/12.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is an admitted fact that husband of the complainant was covered under “Accident Care Individual Insurance Policy” bearing policy no.P/211222/02/2022/000252 for the period 23.07.2021 to 22.07.2022 with a sum assured of Rs.50,00,000/-. Also it is on record that the insured expired during the policy currency on 11.09.2021. The present complaint has been filed by wife of the deceased policy holder being nominee under the policy in question claiming that claim filed by her has wrongly been rejected by the Opposite Party. On the contrary, the stand of the Opposite Party for rejecting the claim pertains to the non submission of documents required for processing of the claim. Also the objections raised by the Opposite Party in the written reply as well at the time of arguments is that death of the insured occurred on 11.09.2021 and claim was intimated on 01.11.2021 with much delay of 45 days from the date of occurrence.

7.       In the scenario above, we have to decide the present complaint. The thorough perusal of the record reveals that evidently insured (now deceased) was covered under the policy in question, who expired on 11.09.2021 and also there is no denial to the fact that the insurance company in question was intimated on 01.11.2021 i.e. after delay of 45 days and former claim was lodged on 23.11.2021. In the body of the complaint as well in the arguments no plausible explanation was given by the ld. counsel for the complainant qua late intimation of claim in question.

8.       The complainant has alleged that the insured under the policy in question died due to snake bite and was rushed to Harbans Nursing Home and Maternity Hospital, Kot Ise Khan. To the utter surprise, the occupation of the insured in the policy in question is mentioned as ‘Business’ and there is no explanation to the fact that where, when and how the insured got snake bite and why the insured who is resident of Sant Nagar, Amritsar Road, Moga was taken to Harbans Nursing Home, Kot Ise Khan, which is at far off place i.e. about 16 km away from the city where the complainant resides, whereas in the city itself there is a Civil Hospital besides other hospitals available within the city itself; also within Sant Nagar, where the complainant resides. It has further been observed that alleged medical record made available on file is not been signed by the treating doctor and also no authentic version of the treating doctor has been placed on record to substantiate that death caused due to snake bite. No Viscera report of the insured has been made part of the record which in our opinion is the most authentic document to prove that the death of the insured occurred due to the Snake bite. Even also there is no Post Mortem report has been placed on record for the reasons best know to complainant.

9.       It is the stand of the Opposite Party that vide letter dated 15.12.2021 (Ex.OP1/8), it has asked the complainant to submit certain documents i.e. Police FIR, duly signed and attested, Police Inquest and Panchnama, Police Final Report, Post Mortem Report, Medical Legal Case (MLC) from the hospital,  but the complainant failed to supply the same. Vide reminders dated 30.12.2021, and 14.01.2022 (Ex.OP1/9 & Ex.OP1/10 respectively), the complainant was again asked to submit certain documents, which were never supplied and resultantly for non submission of documents, the claim in question was repudiated vide letter dated 29.01.2022 (Ex.OP1/11).

10.     We have also gone through the terms and conditions of the policy in question and placed on record by the Opposite Party, in which under the column “For Death Claims” certain documents i.e. Death Certificate, Post-mortem certificate, if conducted, FIR (wherever required), Viscera Sample Report (wherever required), Forensic Science Laboratory report (wherever required), Legal Heir Certificate, Succession Certificate (wherever required) are required in order to process the death claim to pay claim under the policy in question. Thus, in our concerted view the complainant not only as per the terms and conditions but also otherwise is duty bound to supply the requisite documents necessary for processing of the claim in question. Further the Opposite Party is well within its right to ask for the documents in order to process the claim and also to inquire the genuineness of the claim. In our concerted opinion, the Opposite Party is not only duty bound to process the claim, but also has the prerogative to go through the requisite documents for processing the claim. The raising of the claim is not sufficient enough for establishing the authenticity of the claim.

11.     For the reasons discussed above, we are of the concerned view that the Opposite Party has the right to verify the genuineness of the death claim and rightfully they have rejected the claim for want of documents which are required for processing the claim. During the course of arguments, ld. counsel for the complainant categorically denied the factum that the complainant ever received any document or received any letter/reminders issued by the Opposite Party for supply of the documents. In the given eventuality, we hereby disposed of the present complaint by giving liberty to the complainant to submit the requisite documents in order to enable the Opposite Party to process the claim in question. Further Opposite Party is at liberty to investigate/process the claim on the basis of requisite documents. For this observation, we are also well guided by the judgement of Hon’ble Punjab and Haryana High Court in case titled as National Insurance Company Ltd. & ors.  Vs.  Suraj Bhan & ors., Civil Writ Petition No.8685 of 2014, decided on 19.11.2014. Keeping in view of the peculiar circumstances parties are left to bear their own costs. The pending application (s), if any also stands disposed of. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission