Complaint filed on: 23-07-2010
Disposed on: 11-03-2011
BEFORE THE BANGALORE IV ADDITIONAL DISTRICT
CONSUMER DISPUTES REDRESSAL FORUM,
BANGALORE URBAN DISTRICT, NO.8, SAHAKARA BHAVAN, CUNNINGHAM ROAD, BANGALORE – 560 052
C.C.No.1696/2010
DATED THIS THE 11th MARCH 2011
PRESENT
SRI.D.KRISHNAPPA., PRESIDENT
SRI.GANGANARASAIAH, MEMBER
SMT. ANITA SHIVAKUMAR. K, MEMBER
Complainant: -
Hanumanthappa
Venkatappa
Aged about 47 years,
Agricultural Cooli,
R/o Kaneve Belachi Village,
Channagere Taluk,
Davanagere district
V/s
Opposite parties: -
1. The Manger/Authorised officer,
Claims department,
TATA AIG General Insurance Co.
Ltd, A-501, 5th Floor, Building No.4, Lt finity park, Dindoshi,
Mated (E) Mumbai-97
2. The branch officer, TATA AIG
General Insurance Co, Ltd,
1st floor, office no.612, 80 feet road, 6th block, Koramangala, Bangalore - 34
O R D E R
SRI. D.KRISHNAPPA., PRESIDENT.,
Brief facts of the complaint field by the complainant against the opposite parties [herein after called as OPs] are, that he was inspired by the Ops to take an Accident Guard Policy and he accordingly took such policy on 7-4-2005 by paying one time premium of Rs.3,056=00 through an authorized agent of the Ops and policy was valid from 7-4-2005 to 6-4-2006. That he on 11-8-2005, met with an accident and sustained fracture to his right hand and other parts of his body and has taken treatment from Basaveswara Health Centre, Davanagere. During the course of treatment, he was operated and his right hand was amputated leading to 100% disablement. That he informed this to the Ops and made a claim with them for paying insurance amount on 8-1-2006 alongwith all the relevant documents. But the Ops did not honour his claim and therefore after keeping in touch with the OPs through telephone and sent a letter to the Ops who through their reply dated 16-4-2010 stated that they are unable to re-open the claim after lapse of 4 years and had even lodged a criminal complaint to the Davanagere police complaining illegal claim of insurance money by some people, but Davanagere policy filed B-report. Then he lastly issued a letter on 25-3-2010 and complaining that the Ops have caused deficiency in their service in not honouring his claim has prayed for a direction to the Ops to pay insurance money of Rs.20,00,000=00.
2. OPs have appeared through their advocate and filed version, contending that the complaint is not maintainable. The Ops though admitted to have issued a policy in the name of the complainant as claimed by the complainant and the validity period have contended that the complainant has suppressed the fact of his falling from the coconut tree while plucking coconuts and suffered facture to his right hand which turned to resulted in gangrene leading to amputation. The complainant has also suppressed the other policies, he had taken from other companies. The Ops have referred to investigation taken up by their private investigating agency, who have collected some evidence and recorded statements of some persons who disclosed about this complainant suffering facture to his right hand by fall from a coconut tree. That M/s Bajaj Allianz General Insurance Co. Ltd had appointed their investigator, who after finding false claim made by the complainant and others filed a complaint to the concerned police, but they have filed B-report for want of evidence. It is stated that they learnt that the complainant had suffered injury to his right hand 6 or 7 years back by fall from coconut three and did not due to road accident on 11-8-2006 as contended by him. The accident according to the complainant, though took place on 11-8-2005, the complainant made claim on 8-1-2006 and after making such claim, he never approached them till he wrote a letter on 15-3-2010 and therefore further contending that the complainant has not followed the conditions of the policy and have stated that they have after considering the claim of the complainant with all earnestness have rejected the claim, which do not amounts to deficiency and therefore have submitted for dismissal of the complaint.
3. In the course of enquiry into the complaint, the complainant and the Senior Manger of the OPs have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. The complainant alongwith the complaint has produced the insurance policy, copy of letters of the Ops dated 20-12-2005, copy of the claim form, he submitted to the Ops, copy of statement of doctor who attended the complainant, copy of letter that he had addressed to OP, copy of discharge summary of Basaveswara Health Centre and copies of correspondences, with copies of other police investigation papers. Ops have produced copies of the statements and some documents recorded by the police officer in the course of investigation on a complaint filed on behalf of the insurance company in respect of illegal claim against the insurance company, copy of condition of the policy and other police investigation papers. The counsel for both parties have filed written arguments. We have heard them in brief and perused the records.
4. On the above contentions following points for determination arise.
1) Whether the complainant proves that he had met with road traffic accident on 11-8-2005 and suffered fracture to his right hand leading to amputation of his right hand?
2) Whether the complainant proves that the Ops have caused deficiency in their service by not paying the insurance amount?
3) To what reliefs, the complainant is entitled to?
5. Our findings are as under:
Point no.1: In the Negative
Point no.2: In the Negative
Point no.3: See the final Order
REASONS
6. Answer on Points No.1 and 2: The claim of the complainant that, he had taken an “Accident Guard Policy” from Ops with effect from 7-4-2006 with a insured value of Rs.20,00,000=00 with one time premium of Rs.3,056=00, which was valid from 7-4-2005 to 6-4-2006 is not denied by the Ops. But the claim of the complainant that, he on 11-8-2005 met with road traffic accident and suffered fracture to his right hand and that lead to amputation of his right hand has been very vehemently disputed by the Ops by contending that the complainant had lost his right hand by fall from coconut tree while plucking coconuts about 6 or 7 years back and referred to some fictitious claim made by some people including this complainant have in this regard referred to a case registered by Davanagere police in Crime No.72/2006 under section 420, 465, 468, 471 read with section 34 IPC. The Ops have further contended that the complainant though alleged to had met with an accident on 11-8-2005, he never informed them about the accident until he made a claim for insurance amount on 8-1-2006 and further contended that the complainant even thereafter did not approach them for anything until he gave a representation to them on 15-3-2010 and therefore have contended that the claim of the complainant is not bonafide and he has also violated certain mandatory conditions of the policy and have submitted for dismissal of the complaint.
7. The complainant has not denied that, after he had allegedly met with an accident on 11-8-2005, he informed the Ops for the first time on 8-1-2006 after morethan 4 months, he has also not referred to any complaint, he had given in this regard to the concerned police against the driver of the vehicle who caused the accident. Though, the complainant has produced a copy of FIR in crime no.94/2005 of Ranibennur Rural Police Station in connection with the alleged accident. It is not made clear by the complainant, whether he was travelling in that vehicle as a passenger, which met with an accident or how that accident had taken place and he suffered injuries. However, in the charge sheet, this complainant’s name is shown as one of the witness, who alleged to had sustained injuries. The copy of the charge sheet discloses that several passengers including this complainant were travelling in that bus. In that case concerned police must have gone to the spot soon after the accident and shifted the injured persons to the hospital, but we do not find any such document evidencing shifting of this complainant as one of the injured to the hospital by the police. However, the complainant has produced a Xerox copy of discharge card said to have been issued by Basaveswara Health Centre, Davanagere which shows as if the complainant was admitted on 12-8-2005 and was discharged on 19-9-2005 with history of RTA. The complainant has not produced the case sheet of the hospital for he having undergone treatment from 12-8-2005 to 19-9-2005, even from this Xerox copy, we do not find whether the hospital authority referred to the concerned police as it is a MLC. Thus this document produced by the complainant besides, they are all Xerox copies do not give full details of what happened after alleged accident. When the complainant had suffered a grievous injury like fracture what was he doing from 11-9-2005 till 12-9-2005 is not made clear.
8. As stated above, the complainant, who alleged had suffered grievous injury got the right hand amputated and got discharged on 19-9-2005 itself, he never bothered to inform the Ops about the accident until 8-1-2006. It is only on 8-1-2006, the complainant made a claim for the first time claiming insurance amount, why there is so much delay in informing the insurance company and make a claim of the insurance amount is not forthcoming. Condition No.8 of the conditions of the policy which refers to the notice of claim/loss which says, that it is a condition precedent that a written notice of claim must be given to OP within 7 days after an actual incident take place and it further reads that in any event not later then 30 days after an actual loss begins. The complainant has admittedly did not inform the Ops in writing about the accident and loss of his right hand till expiry of 4 months. Further, condition no.10 of conditions of the policy says time for filing claim form and evidence and it says that completed claim form and written evidence of loss must be furnished to the Ops within 30 days after the date of such loss, however failure to furnish such evidence within the time required shall not invalidate nor reduce any claim that says that complainant can satisfy reason for any delay and he can make a claim upto the period of one year. But the complainant nowhere assigned reason for not informing the Ops about accident nor made claim by assigning reason for delay.
9. The Ops after receipt of claim form of the complainant on 8-1-2006 stated to had called for certain documents in response to which, the complainant through his letter dated 20-12-2005 stated to had sent duly completed claim, Discharge summary of hospital and his photograph and stated as if the investigator of the Ops had collected few documents. The complainant after allegedly had sent claim form in the year 2006 proved to had kept quiet without taking up the matter with the Ops and for the first time on 15-3-2010 shown to had addressed a letter to the Ops requesting them to settle his claim. In this letter itself, the complainant has admitted to have made claim on 8-1-2006 after he met with an accident on 11-8-2005. Even at that stage, it is found, the complainant did not forward the details of hospital records to show whether he really met with an accident on that date and he was under treatment in the hospital referred to above or any other hospital. OP has replied to the notice of the complainant dated 15-3-2010, on 16-4-2010 in which they have referred to a case registered in crime no.72/2006 in Davanagere police station against this complainant and others in connection with the fictitious claim made by him and others against the insurance amount allegedly through fraudulent method. The Ops have also produced police records in this regard wherein some of the persons including this complainant stated to had indulged in making false claim against the Ops. The complainant has not thereafter sent any reply about the allegation made by the Ops through their letter dated 16-4-2010. The Ops have also referred to the report of their investigating agency about the involvement of certain persons making illegal claim against the insurance company.
10. The Ops have produced a CD containing enquiries made by the Davanagere police officers, on the complaint given by an insurance company with regard to rampant involvement of persons in making illegal claims against them, the CD was played in the open court of this forum in the presence of the complainant and his counsel and in the presence of the counsel for the Ops, we have viewed the CD and heard the conversation and a note in that regard is recorded in the order sheet dated 2-3-2011 the same is reproduced as here under:
“CD is played in the presence of the complainant and his counsel and counsel for the OP by the men of OP. Of course, CD contain a picture of the complainant and his sister and a team of investigation officials wherein some conversation is heard about fictitious claim made against the insurance company and it is heard that the complainant’s is one of such cases. We have also viewed the sister of the complainant’s identified by the complainant was telling that he met with an accident at Ranebennur and he suffered fracture of his hand. Another person in the CD was also heard telling he fell from a coconut tree and lost his right hand.”
11. On going through all these materials and conversation, we have heard and viewed through CD, there is some element found in the contention of the Ops about genuineness of the claim of the complainant. The complainant either should have produced entire case sheet of the hospital or could have filed affidavit of hospital authority to prove that he suffered injuries due to road traffic accident, but has failed to prove the same to the satisfaction of this forum.
12. The complainant as referred to above, after filing a claim with the Ops on 8-1-2006 has not proved too had been in touch with the Ops or was following the claim application for its processing until its finality. His allegations that he spoken several times through telephone is not substantiated, thereafter after morethan four years, he sent a letter on 25-3-2010 on which the Ops rightly stated, that they cannot re-open the file after lapse of 4 years. The complainant has filed an application under section 24A of the Consumer Protection Act, 1986 and affidavit in which except alleging that after 8-1-2006 he was contacting the Ops through telephone and issued a letter on 25-3-2010 has not made out any grounds for condonation of delay. Therefore application filed for condonation of delay do not disclose any reasonable grounds to condone the long delay, as such, the complaint is devoid of merits and therefore is liable to be dismissed. The learned counsel appearing for the Ops referred to certain decisions reported in II (1996) CPJ 511 of Orissa State Consumer Disputes Redressal Commission, Cuttack and the Hon’ble Supreme Court rendered in C.A.No.4913/1997 and few other decisions and submitted that contract of insurance policy between the parties is contract between them, wherein the insurer under takes to compensate the loss suffered by the insured and that policy will have to be viewed in strict terms and conditions of the policy and conditions have to be strictly adhered. For the aforesaid reasons, we hold that the complainant’s claim is doubtful in nature and he has not proved point no.1 and 2, therefore is not entitled for any relief. As the result, we answer point No.1 and 2 in the Negative and pass the following order:
ORDER
Complaint is dismissed. Parties to bear their own cost.
Dictated to the Stenographer, Got it transcribed and corrected, Pronounced on the Open Forum on this 11th March 2011.
Member Member President
