Brief fact of this case is that, Complainant is having an Insurance Policy bearing No.2311203943392601000 (HDFC ERGO)met with an accident at Pentha beach and suffered some minor injuries. No FIR was lodged as no third party was damaged. The complainant informed the Insurance Company about the accident which was recorded as Malicious damage instead of accident. The Insurance Company rejected the complainant’s insurance claim as reasons mentioned are not correct vide claim No. C230022352112 and also the complainant was not provided with the survey report. Being deprived of the proper facilitated procurement the complainant again and again intimated the respondent by way of telephonic conversation and by way of electronic mail in-order to solve the issue but the respondent failed to give proper service even a constructive reply till date. Hence the complainant states that the above mentioned dispute that there was negligence and unfair trade practice which has caused mental agony and stress. The cause of action of the instant complaint arose on upon non performance of the respondents of their obligations despite Notice of the learned Advocate on dt. 25.01.2023. The complainant prays the Hon’ble Commission to direct the respondent to render proper service with a settlement amount of Rs.3,50,000/-.                                              

The complainant relies upon the following documents:

1. Payment details-Photocopy of HDFC ERGO Standalone Motor Own damage cover private car(Policy documents)Annexure-B.
2. Legal Notice.
3. Photocopy of rejection letter.
4. Photocopy of Service Quotation from Utkal Automobiles Pvt.Ltd.
5. Photo copy of Tax Invoice for repair estimate from Utkal Automobiles Pvt.Ltd.
6. Photocopy of E-mail correspondence..10pages.
7. Photo copy of Mobile screenshot of SMS.
8. Photographs and documents.(Annexure A to E)

Under the above complain the case was admitted and notice issued to Ops. The Op appeared and filed their written version in detail. In their written version the Ops stated that the contents are notmaintainable neither in Law nor in facts hence liable to be dismissed and also the complaint does not come under the purview of Consumer Protection Act. However, a standalone Motor Own damage cover private Car policy bearing No.2311203934492601000 was issued to the complainant from 30^th Dec2021 to 29^thDec2022 for a Mahindra Bolero-B6 bearing number JH-06P-3766,copy of the policy schedule along with Policy conditions is annexed hereto and marked as Annexure A,B. After receipt of claim intimation this OP had engaged an Investigator as per standard practice for verification of the claim. Upon receipt of the Investigator’s report so many discrepancies were noted. Considering the facts from investigation findings and Surveyors inspection, the discrepancies clearly indicated foul play hence this OP was constrained to close the claim due to misrepresentation of fact perpetrated by the complainant.It is an established principle of insurance law that a policy of insurance is based on the principle of utmost good faith as per declaration by the insured. Further it is categorically submitted that misrepresentation of facts, material to the claim goes against the complainant himself whereby the declaration, on the reverse side of the claim form is quoted for reference.” I/We the above named do hereby to the best of my/our knowledge and belief warrant the truth of the forgoing statement in every respect and I/We agree if I/We have made or in any further declaration the Company may require in respect of the said accident shall make any false or fraudulent statement or suppression or any suppression concealment, the policy shall be void and all rights to recover there-under in respect of past or future accidents shall be forfeited.” It is necessary that the insured acts in good faith and discloses all material and relevant information to the insurer and in default of doing the same or insured indulging in fraudulent activities to seek coverage or false and fabricated claim under Insurance policies, then under such circumstances, this OP will not be liable to indemnify the insured.The complaint petition is a gross abuse of the process of law and has been filed with a sole purpose of harassing and pressurizing this OP to submit to the unreasonable and mischievous demands of the complainant. Despite numerous correspondences, the complainant did not cooperate to provide clear clarification with corroborative documentary evidence to the OP disproving the investigation report findings, knowing very well the importance of the same in deciding the claim on merit and to this day queries with respect to the claim remain unsolved. Hence deficiency of service does not arise. The OP opts the best trade practices and always acts in the interest of the policy holders but at the same time it reserves the right to protect itself from the mischief of wrong doers.                                                     

In connection to the aforesaid submission, the OP would like to draw the attention of Commission towards the following decisions/precedents.(1) M/sSeemax Constructions Pvt.Ltd. -vs- SBI,AIR 1992(Delhi)197 wherein the suit was liable to be dismissed without going in to the merits as the Plaintiff therein had suppressed the materials facts from the Hon’ble Forum.(2)S.P.Chengalvarya Naidu -vs- Jagannath, AIR 1994 SC 853 wherein the litigant had withheld vital documents and suppressed material fact from the OP and the Hon’ble Court relating to litigation. It was held that it was fraud being committed on court and the guilty party be thrown out at any stage.(3)It has been held by Hon’ble Supreme Court in General Assurance Society Ltd. -vs-Chandmull Jain 1966 AIR SC 1644 as under “Interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves. It is submitted that the Complainant is not entitled for the compensation claimed in the complaint petition. It is therefore most respectfully prayed that this Hon’ble Commission may kindly be pleased to dismiss the Complaint of the complainant with exemplary cost in favour of the answering OP and against the complainant in the interest of justice.

The OP relies upon the following documents:-

1. Policy schedule - Annexure-A.
2. Policy wording..Annexure-B
3. Insurance claim form-Annexure-C.
4. Intimation to Claim Manager-Annexure-D&G..2sheets.
5. OD Investigation report..Annexure-I
6. Rejection of Motor Insurance Claim..Annexure-J.
7. Copy of Survey report with assessment.

On the above pleadings the following issues are framed to decide the case.

1. Whether the case is maintainable?
2. Whether any cause of action arises on this case?
3. Whether Ops have made any deficiency of service?
4. Whether the complainant is entitled to get any relief sought for?

  FINDINGS

All the issues are discussed jointly to decide the case. The complainant admitted that the accident took place on dt.17.11.2022 at Pentha beach, Kendrapada. The complainant suffered from some minor injuries and no FIR was lodged at nearest Police station.There was no dispute about the Policy details as the Insurance was valid from 30.12.2021 to 29.12.2022. After getting information from the complainant the OP Insurance Company appointed a surveyor who conducted the survey and submitted his report.

In survey report, the surveyor made assessment that the damages of the vehicle are not matched with the manner of accident for which he repudiated the claim in his survey report. The Insurance Company at last repudiated the claim. The accident spot as verified was a new road where construction work was going on and there was no such high heap of sand as described. Copy of Accident spot photos are annexed hereto and marked as Annexure F series as per written version but the OP has not submitted the Annexure F series. The OP Insurance Company submitted that the complainant has misrepresented the facts and the materials, so the claim goes against the complainant.From the evidence affidavit and counter written version submitted by the complainant it is clear that after 16 (sixteen) days of accident the spot was changed due to construction of a new road. At Pentha beach it was full of sand everywhere. The complainant to prove his case has filed some photographs with documents (Annexure A to E).

From the above analysis this commission comes to the conclusion that the natural justice to be granted in favour of complainant as he has lost and suffered by the negligent work of OP Insurance company. In this situation the claim applied by the complainant is a genuine one.So this case is maintainable. The OP Insurance Company has failed to establish the reasons of repudiation. It is deficiency of service to complainant, so the complainant is entitled to get the reliefs as prayed for. Hence it is ordered. 

ORDER

            The complaint petition is allowed on contest. The OP Insurance Company is directed to pay the claim amount of Rs. 3,50,000.00 and Rs.1,00,000 for mental harassment and cost of litigation. The OP is further directed that if he fails to comply the order within 45 days of receipt of this order it shall carry 9% interest per annum on total amount Rs.4,50,000.00 from the date of application.