Karnataka

Belgaum

CC/427/2015

The Managing Dircetor. The Krishna Sahakari Sakkare Karkhane Nyt. - Complainant(s)

Versus

The Branch Manager. The Oriental Insurance C, Ltd - Opp.Party(s)

S G Jamkhandi

15 Jul 2017

ORDER

JUDGEMENT

 

By  Sri.A.G. Maldar, President.

 

 

1.      This is a Complaint filed by the complainant under Section 12 of the Consumer Protection Act, 1986 (herein after referred to as Act) against the Opposite Parties (in short the “Ops”) directed them to settle the death claim of Rs.1,00,000/- of Sri.Gundu B. Charate with interest @ 18% p.a. from the date of repudiation till its realization and Rs.50,000/- towards compensation for mental agony and Rs.5,000/- towards cost of the proceedings etc.,

 

2.      The facts of the case in brief are that;

 

          The case of the complainant is that, the complainant had taken Janata Personal Accident (Group) insurance Policy from OP/Company, covering period from 17.06.2013 to 09.06.2014 under policy No.472502/47/2014/458 and the said policy covered the risk of the employee and their members in event of accidental death during the policy period and further one of the complainant’s member i.e. Sri. Gundu Bharamu Charate died on dtd: 15.01.2014 due to injuries sustained in a road traffic accident and the case is registered by Kagwad Police Station Under its Cr.No.57/2014 and further regarding the said accident the complainant had informed to the OP/Company vide claim form dtd: 20.08.2014 alongwith necessary documents required for settling the claim.

  

          It is further case of the complainant that, the OP/Insurance company did not respond nor settled the death claim of Sri.Gundu. B. Charate and ultimately the complainant had issued a legal notice dtd: 19.01.2015 calling upon the Ops to settle the death claim. But, the OP/Insurance company replied the said notice and stating that, there is inordinate delay in raising the claim and the OP/company is not in a position to satisfy the claim of the complainant and further the family members of the deceased who are agriculturist are mostly illiterate and were unaware of all the facilities extended under the membership of the deceased and further the legal heirs of the deceased had approach the complainant and informed the accidental death of Sri.Gundu B. Charate and requested to submit the necessary documents like FIR, PM Report, Death Certificate, Survival Members Certificate necessary to lodge the claim and this process consumed lot of time and hence there was delay in intimating the death to the OP/company there are not intentional and same is due to bonafide reasons and there is no any latches from the complainant side.

 

It is further contended that, the OP/Insurance company while promoting the policy to the complainant had not briefed about the condition that, the death of the member or employee had to be informed to the OP/company within one month from the date of its occurrence and further the OP only issued the Certificate of Policy without terms and conditions. Hence, this term was not within the knowledge of the complainant and the same is not binding on the complainant and further the OP/company also did not give an opportunity to explain the delay and hence the rejection of the death claims of Sri.Gundu B. Charate is arbitrary and against the principals of natural justice, this act of the OPs its clearly shows that, there is a deficiency in service on the part of the OPs. Hence, the complainant is constrained to file this complaint.

 

3.      After issue of notice to the Opponents, the Ops have appeared through their counsel and resisted the claim of the complainant that, the complainant has filed this false complaint only to harass the OPs and the Ops have denied all the averments made by the complainant.

 

          It is case of the OPs that, not possessing the knowledge about a facility extended by complainant to its members/ employees cannot be a valid excuse to accommodate the delayed claim and  further submitted that, since the policy is obtained by complainant which is a registered Co-operative Sugar Factory to enforce the contractual obligations under such a policy within the time permitted in the policy and it may be true that, family members of member of the complainant were not aware of Insurance Policy. But, the complainant who had knowledge of both currency of the insurance policy as well as the death of its member could have raised the claim within a period of one month from the date of death of the beneficiary, but there is an inordinate delay in raising the claim and further submits that, there is a specific condition in the policy that, the death of any beneficiary under the policy should be intimated to the OP/company within a period of one calendar month after the event of death of complainant’s member/employee. Hence, there is no deficiency of service on the part of the OPs. Therefore, the repudiation of the claim of the complainant is in line with the terms and conditions of the policy and prayed for dismissal of the complaint.

 

 

4.      Both the parties have filed their affidavits in support of their case, the complainant has produced 10 documents which are marked as Ex.P-1 to Ex.P-10, and on behalf of the OP.No.2 has also filed 05 documents and same are marked as Ex.R-1 to Ex.R-5, for sake of our convenience, we have marked as P & R series. The Adv. for Op.No.2 has filed his written synopsis. Heard the arguments on both sides.

 

 

Now, on the basis of these facts, the following points that would arise for our consideration:

 

1. Whether the complainant has proved that, there is deficiency of service on the part of the OPs for not settling  the claim  towards death of Sri.Gundu?

 

 

2. What order?

5.      Our findings to the above points are as under:

 

                              

1. In Affirmative.
2. As per the final order for the following:

 

R E A S O N S

 

 

 

6.      POINT NO:1:-  We have perused the pleadings of the parties and the affidavit evidence and documents placed on record and the arguments advanced.  It is an admitted fact that, the complainant had taken Janata Personal Accident (Group) insurance Policy from OP/Company, covering period from 17.06.2013 to 09.06.2014 under policy No.472502/47/2014/458 and the said policy covered the risk of the employee and their members during the policy period, the deceased Sri.Gundu B. Charate died, who was a member of Krishna Sahakari Sakkare Kharkhane Niyamit, Athani, and the same has evident from document which is produced by the complainant is already marked as Ex.P-9 for assured sum of Rs.1,00,000/- for each employee and their member of the said Kharkhane, the complainant is Managing Director of said Kharkhane and the policy is in force on the date of death of Sri.Gundu B. Charate.           After the death of Sri.Gundu B. Charate, the Lrs of the deceased submitted the all required and necessary documents for claiming the sum assured amount before the complainant and put forward the claim under the said policy as legal heir of the deceased Sri.Gundu B. Charate. The same has been submitted by the complainant before the OP/Insurance Company for settle the claim. But, the Ops did not settle the claim and issued letter vide dtd; 08.09.2014 stated that, “we regret out inability to entertain the claim as the claim intimation received very late and also the policy period expired on 09.06.2014 hence the claim registration is not possible.

 

          In order to prove the contention contended in complaint, the complainant has produced material documents i.e. Insurance Policy, Death Certificate, FIR, Copy of Complaint, Wound Certificate, MVI Report, P.M. Report, Copy of Legal notice, I.D. Card and List of Membership, which are already marked as Ex.P-1 to Ex.P-10 and supporting affidavit evidence of complainant wherein it is clearly stated that, the deceased Sri.Gundu B. Charate was the member of Krishna Sahakari Sakkare Kharkhane Niyamit, Athani and deceased Sri.Gundu died in a road traffic accident on dtd: 15.01.2014 and the case is registered by Kagwad Police Station under its Cr.No.57/2014 the said document is already marked and the same is informed to the OP/Company vide claim form dtd: 20.08.2014 alongwith necessary documents for settling the claim. The MD of Krishna Sahakari Sakkare Kharkhane Niyamit, Athani had obtained Insurance Policy in favour of their employees and their members and the said contention has not disputed by the Ops. It is admitted that, the complainant has paid huge premium amount of Rs.6,38,724/- for the benefit of their employee and members of Krishna Sahakari Sakkare Kharkhane Niyamit, when the complainant has paid the huge premium, the Ops must have indemnified by giving  accidental death claim which is genuine and covered under the policy for a Sum of Rs.1,00,000/- each member.

 

          It is an accident death of one member of Sahakari Sakkare Kharkhane Niyamit, Athani which is covered under the policy obtained as alleged by the complainant and though the complainant has produced material and cogent documents and supporting affidavit evidence to show that, the delay has been caused due to bonafide reasons as alleged by the Lrs of deceased for getting all material documents which are necessary to submit before the insurance company for claiming the insurance amount and for getting above said document it requires more time to get from the Govt. authority, due to this reason, the delay has been caused which has not intentional and merely the Ops contended that, the claim intimation received very late and also the policy period expired on 09.06.2014, the same is not established by the Ops by producing cogent and material documents and reliable evidence and a ordinary person or layman did not have a knowledge regarding the same to get immediate intimate the same and submit before the Insurance Company within one month and the same cannot be except from such a rural poor people or a villager as contended in terms and conditions of the policy which is away from their knowledge and same cannot be taken as weapon by the insurer and rejected the claim of a poor village people. No doubt, it is a terms and conditions of the policy which has incorporated the bond, is it not a duty of the insurer to explain how to give complaint and within how many days? But straightway taking a blunder step and contended un-sustainable ground in written version which is not proper. It is also transpired during the course of hearing that, vide its Circular No.IRDA/HLTH/Mis./ Cir/216/09/2011 dtd: 20.09.2011, Insurance Regulatory and Development Authority has advised the insurers not to repudiate the claims on account of the delay in intimating the loss to the insurer, without first ascertaining the reason for the said delay and as per IRDA circular, no genuine claim should be rejected on technical ground of delay. So in our consider view that, the contention stated in the written version and in affidavit evidence of Ops have no merit and it is not acceptable. Therefore, the complainant has explained in the complaint as well affidavit evidence and it is reliable and acceptable evidence and the Ops not settling the claim of the complainant is not proper and not justified.

 

          So, in the light above observation and undisputed facts, the only question which would arise for our consideration is “whether the Ops are justified in not settling the claim of the complainant under the said insurance policy, when there is covered under the insurance? Looking to the above observations and in our considered opinion that, the Ops are not settling the claim of the complainant is not proper which amounts to deficiency in service on the part of the Ops, for the reasons discussed above. 

 

            It is an important to note that, when the Ops alleged about only delay, the burden of proving the said contention as stated in the written version is lies on the Ops, when the complainant has detailed explained regarding delay why it has been caused, and further it is bonafide one, so under such circumstances, the complainant has detailed explained in the complaint which has been not challenged by the Ops nor disprove the same. When such is the situation and without affording opportunity to the complainant to explain delay caused for submitting the claim before the Ops. How the Ops could have taken untenable questions regarding delay and it is not fetal for the case at the time of settling the claim, which is not sustainable in the eye of law. Therefore, in our considered opinion that, not settling the claim of the complainant by the Ops is not justified and not proper.

 

          In the light of above observation, we are of the consider opinion that, there is a deficiency of service on the part of OPs for not settling the claim of the complainant. So, it would be proper to award a sum of Rs.1,00,000/- to meet ends of justice which is cover under the policy of Janata Personal Accident (Group) Insurance Policy, it is evident from record produced by the complainant which is already marked as Ex.P-1 and the same has been produced by the complainant. Therefore, in our consider view, as per Janata Personal Accident (Group) Insurance Policy Schedule and the said policy is inforce at the time of death of deceased Sri.Gundu B. Charate.

 

Now our considered opinion, we have no hesitation to hold that, the OP/Insurance Company are to be held liable to pay Rs.1,00,000/- as per policy and further the complainant is entitled for mental agony and costs of the proceedings for Rs.2,000/-.  Accordingly, we answer Point No:1 in the Affirmative and proceed to pass the following:

 

O R D E R

 

For the reasons discussed above, the complaint filed by the complainant U/s.12 of the Consumer Protection Act, 1986 is hereby partly allowed with costs.

 

           The Ops are ordered to pay a sum of Rs.1,00,000/- towards accidental death to the legal heirs of deceased Gundu B. Charate who was member of Krishna Sahakari Sakkare Kharkhane Niyamit, Athani, under the policy bearing No.472502/47/ 2014/458 period from 17.06.2013 to 09.06.2014.

 

          The Ops are ordered to pay a sum of Rs.2,000/- towards mental agony and cost of the proceedings.

 

          The OPs are granted 10 weeks time for compliance of this order, failing which liable to pay interest @ 8% p.a. from the date of complaint i.e. 01.09.2015 till its realization. 

 

             (This order is dictated to the Stenographer, transcript edited, corrected and then pronounced in the open forum on this 15^th day of July, 2017).

 

 

 

Sri. A.G.Maldar,   President.

Smt.J.S. Kajagar,    Lady Member.