Haryana

Karnal

CC/159/2022

Rajesh Kumar - Complainant(s)

Versus

Tata AIG General Insurance Company Limited - Opp.Party(s)

Rahul Bali

20 Jun 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 159 of 2022

                                                        Date of instt 24.03.2022

                                                        Date of Decision: 20.06.2024

 

Rajesh Kumar aged about 38 years son of late Shri Dharam Singh, resident of village Shahpur, Post Office Sirsi, District Karnal. Aadhar no.3592 4074 2146.

 

                                                                        …….Complainant.

                                              Versus

 

1. TATA AIG General Insurance Co. Ltd. Divisional Office SCF-16, Mahila Ashram Complex, Railway Road, behind Bus Stand, Karnal, Haryana, through its Manager.

 

2. TATA AIG General Insurance Co. Ltd.Regd. Office: Tower A, Peninsula Business Park, 15^th floor, G.K. Marg, Lower Parel, Mumbai-400013, through its MD/CEO/Authorized signatory.

 

                                                                …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Rahul Bali, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OPs.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that the father of the complainant namely Shri Dharam Singh (now deceased) during his life time had purchased a Master Insurance Policy bearing no.0237793684 from the OPs. The detail of the policy is as under:-

Master Policy no.	0237793684
Certificate no.	900021
Certificate Effective from	18.07.2020 to 17.07.2025
Sum Assured	Rs.3,00,050/-
Accidental Death	Rs.3,00,050/-
Permanent Disability	Rs.3,00,050/-
Child Education Benefits	10% of base Sum Insured or Rs. 5 lakhs whoever is lower.
Nominee	Rajesh (son) complainant.

 

On 01.10.2021, all of sudden father of complainant had fallen from the staircase of his house and received serious and grievous hidden injuries. After the said accident, father of complainant was brought to hospital for his treatment but on the way to hospital, he expired. After the death of his father, complainant being nominee had approached to the OPs and requested for disbursement of the claim amount of Rs.3,00,050/-in his favour as per section 2, Clause-1 of aforesaid insurance policy, which state that “We will pay the base sum assured as stated in the policy schedule if an accident results in loss of your life during the policy period.” OP no.1 had taken signature of the complainant on some printed unfilled papers and also received copies of relevant documents of policy as well as KYC documents, death certificate, bank account details and had assured to the complainant that the insurance claim in respect of aforesaid insurance policy would be disbursed in favour of the complainant being nominee of the insurance policy holder, and the insurance claim of Rs.3,00,050/- will be credited directly in the bank account of the complainant, within a short span of time but till date complainant neither received the insurance claim amount nor received any communication from the side of the OPs. The complainant requested the OPs so many times for releasing of the claim but OPs did not pay any heed to the request of complainant. Then complainant sent a legal notice dated 24.02.2022 but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that after getting the intimation regarding claim, OPs enquired the cause of death from claimant and as per telephonic intimation, insured expired on 01.10.2021 due to heart attack. As the insured expired due to sickness no claim was admissible, as per terms and conditions of the policy, claim of the complainant was repudiated. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of intimation cum preliminary claim Ex.C2, copy of death certificate of Dharam Singh Ex.C3, legal notice dated 24.02.2022 Ex.C4, postal receipt Ex.C5 and Ex.C6, affidavits of Rajesh Kumar, Nisha, Jarso Devi, Krishan Kumar and Rajbir Lamberdar Ex.C7 to Ex.C11 and closed the evidence on 14.12.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Rohit Udiwal Ex.RW1/A, copy of certificate of insurance Ex.R1 and closed the evidence on 12.10.2023 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the father of the complainant had purchased a Master Insurance Policy from the OPs. The sum insured under the policy is Rs.3,00,050/-. On 01.10.2021, all of sudden father of complainant had fallen from the staircase of his house and received serious and grievous hidden injuries and due to injuries, he expired. Complainant being nominee lodged the claim with the OPs and submitted all the required documents for settlement of the claim but the claim of the complainant has been rejected by the OPs on the false ground i.e. LA expired due to heart attack, whereas LA has expired due to falling from the stairs and lastly prayed for allowing the complaint. Learned counsel for complainant has placed reliance on the judgment titled as The Divisional Manager, LIC of India Versus Y. Ratnamma FA No.460 of 1999, DOD 21.02.2000 of Hon’ble State Consumer Commission, Andhra Pradesh.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that after getting the intimation regarding claim, OPs enquired the cause of death and found that insured expired on 01.10.2021 due to heart attack thus, the claim of complainant was not admissible and the same was rightly repudiated by the OPs. He further argued that no post mortem was conducted on the dead body of life assured to ascertain the cause of death of the LA and no FIR has been placed on file by the complainant and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, the father of complainant (since deceased) purchased a Master Insurance Policy from the OPs and the sum insured under the policy was Rs.3,00,050/-. It is also admitted that complainant is the nominee in the said policy.

11.           The claim of the complainant has been denied by the OPs on the ground that life assured died due to heart attack, thus as per terms and conditions of the policy, claim was not admissible.

13.           The complainant has alleged that his father was expired due to serious injuries suffered by falling from stairs. To prove his version, the complainant has tendered his affidavit Ex.CW1/A, affidavit of Rajesh Kumar Nambardar Ex.C7, affidavit of Nisha wife of Rajesh Kumar Ex.C8, affidavit of Jarasho Devi wife of Life Assured Ex.C9, affidavit of Krishan Kumar Ex.C10 and affidavit of Rajbir Nambardar Ex.C11. In all the aforesaid affidavits, the deponents have specifically stated that the Life Assured has died due to injuries received by falling from stairs. To rebut the aforesaid affidavits, the OPs have not examined any witness or tender any documentary evidence. The OPs have alleged that they have confirmed the cause of death telephonically from the complainant but the said fact has been specifically denied by the complainant. The OPs have not investigated the matter properly by appointing any investigator.  Hence, the plea taken by the OPs are not tenable in the eyes of law.

 14.          Admittedly, the postmortem upon the dead body of the deceased was not conducted, thus, there is violation of terms and conditions of the policy but on this ground the claim cannot be denied in toto. In this regard, we placed reliance upon the case laws cited in Revision Petition no.1870 of 2015(NC) decided on 14.08.2018 titled as New India Assurance Co. Ltd. Versus Thirath Singh Brar and authority of our own Hon’ble State Commission in First Appeal no.717 of 2016 decided on 6.4.2017 titled as United India Insurance Company Limited and others Versus Anshul Bansal.  In both judgments it was held that in case of any breach of warranty/condition of the policy the insurer is liable to pay 75% of admissible claim on non-standard basis.

15.  

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.   

 

16.           Keeping in view the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of the complainant in toto amounts to deficiency in service and unfair trade practice, which is otherwise proved as genuine one.  Hence, complainant is entitled to get 75% only of the admissible claim on non-standard basis.

 17.          As per insurance policy Ex.C1/R1, the sum insured under policy is Rs.3,00,050/-. Hence the complainant being nominee is entitled for 2,25,037/- i.e. 75% of the sum insured alongwith interest, compensation for harassment, mental pain and agony and litigation expenses etc.

18.           In view of the above discussion, we partly allow the present complaint and direct the OPs to pay Rs.2,25,037/- to the complainant alongwith interest @ 9% per annum from the date of denial of the claim till its realization. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment suffered by her and Rs.11,000/-for the litigation expense. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced
Dated:20.06.2024 

  President,       

District Consumer Disputes

Redressal Commission, Karnal.

 

                  (Vineet Kaushik)              (Dr. Suman Singh)

                        Member                             Member