Ld Advocates are present. Judgement is ready and pronounced in open Commission. 

BY - SRI.SAURAV CHANDRA, MEMBER

1. Brief facts of the Complainant’s case are that the Opposite Party No.1 is a Bank through which the claimantinsured his life under the Accident Shield Policy# 0285130774during the period 18.02.2017 to 17.02.2020 with Sum Assured of Rs.5,00,000.00 through the Opposite Party No.1by way of deduction of premiumamounting to Rs.1,355.00 on 04.02.2017 from his Saving Bank A/c # 915010039663452towards necessary remittance to the Opposite Party No.2.

2. The claimantseverely injured in a Road Accident on 04.05.2018 with lost his both eyes for which the Purba Medinipur District Hospital issued him 100% Disability Handicapped Certificateon 12.10.2018.

3. The claimantlodged a claim for Rs.5,00,000.00 before the Op No.1 & 2 on 01.08.2018as per the terms and conditions of the said policy but, not received the claim. Then he sent a Legal Notice to the Ops on 25.02.2020 through his authorized Advocate by claiming Rs.8,00,000.00 in total including compensation for mental harassment but, got no response.

4. Therefore, the claimantprefers to move before this Commission for necessary redressal. Subsequently he died on 30.01.2023 for which his name substituted with his four legal heirs as Complainants.

5. So, from the bundle of facts arising out of the materials on record, the Complainant intimated the claim to the Op No.2on 18.07.2019 and circumstances of the case, the cause of action of this case arose on and from 18.07.2019.

• The Complainants, therefore, prays for:-

1. To pay the ClaimAmountof Rs.5,00,000.00 with Interest from the date of due payment of the claim.

2. To payCompensation to the Complainants formental harassment.

3. To pay Litigation Costto the Complainants for conducting the case.

4. Any other reliefs.
   6. Notices were duly served upon the Opsagainst which they havecontested the case by submitting Written Version against the complaint.

7. While resisting the claim of the Complainants, the Op No.1in its’ Written Version stated inter alia that this complaint is liable to reject because in-spite of several follow up by email, the Complainant did not submitted any documents before the Op No.1 in order to assess the loss happened to the Complainant as per the requirement of Op No.2 and therefore not liable to pay the loss of the Complainant as claimed in this case.The insurance policy was issued by the Op No.2 and not by Op No.1. The role of Op No.1 is only of the facilitator and they have not rendered any sort of insurance related service to the Complainant.  Therefore, there is no Deficiency of Service on the part of the Op No.1.

8. Under the above Op No.1 prays for dismissal of the present case.

9. the Op No.2in its’ Written Version stated inter alia that the Complainant submitted few documents along with Advocate Notice but, failed to submit the following documents as required for processing of the claim as per policy terms.

• Completely Filled Claim Form.
• Copy of Disability Certificate.
• Certificate from Ophthalmologist confirming the case detail, acuity and % of vision loss in both eyes; prognosis & current condition.
• Complete Photograph of the Insured along with the injury.
• Copy of FIR/MLC towards alleged accident.
• Copy of complete medical records along with indoor case papers, Investigation Reports & follow up Consultation Papers.
• CKYC Form along with Photo Id & Address Proof of Insured.
• Cancelled Cheque copy/copy of Bank Account Pass Book of Insured.
• New Paper Cutting (if any)
• Completely filled CKYC (attached herewith)

10. It is further submitted by the Op No.2 that the claim was intimated on 18.07.2019 against which the Op No.2 via email conveyed the claim number, a claim form and claim documents check list on 26.07.2019. These documents are vital and mandatory for processing the claim as per the policy terms. Therefore, reminder emails sent to the Complainant on 29.08.2019 requesting to submit the relevant documents and medical records but despite all these reminders the Op No.2 have not received the documents and medical reports to decide about the assumption of liability under the policy.Moreover, the Op No.2 has duly responded the Legal Notice of the Complainant dated: 08.05.2020,although due to COVID-19 Pandemic situation and Lock Down, the Op No.2 could not send the hard copy of the reply via Post but, replied the Legal Notice to the Insured email id due to non-availability of Advocates email id. Even the Op No.2 again conveyed the Insured that the submission of documents is pending at his end which are vital for processing of the claim. Therefore, the petition is liable to be dismissed/claim to be rejected.

11. Points for determination are:

1. Is the case maintainable in its present form and in law?
2. Is the Complainant entitled to the relief(s) as sought for?

12. Decision with reasons

1. Both the points I and II, being inter related to each other, are taken up together for discussion for sake of brevity and convenience.

2. We have carefully perused the material on record includingComplaint on Affidavit, Evidence in Chief on Affidavit, Questionnaire, Reply, List of submitted documents, Written Version of the Ops, Brief Notes on Argumentsalongwith all related papers and documents.

3. Having regards had to the facts and circumstances of the case in the light of evidence, it is evident that there is no dispute that Complainant is a consumer having grievances against the Ops, as such the case is maintainable in its present form and in law.

4. In the instant case, this Complainant failed to producethe copy of submitted Claim Form along with supportingAcknowledged documents as required by the Op No.2 above.This Commission also did not find any claim denial/repudiation letter issued by theOp No.2.

5. It is evident from the Bank Statementas well as Premium Receipt, the Op No.1 duly received the premium of Rs.1,355.00on 04.02.2017in respect of the said claim by way of deduction from Savings Bank A/c # 915010039663452 of the deceased.Hence, the Complainants have fails to establish the Element of Negligence and Gross Deficiency in Service on the part of the Opsin respect of their claim.

6. However, considering the genuineness of the accident case vide submitted documents likethe copy of Policy Certificate, Policy Premium Receipt, Bank Statement, Medical Records, Disability Certificate, Claim Letter in form of Legal Noticeetc.,liberty is given to theComplainantsto file the Claim Form along with supporting documents afresh as per the requirements of the Op No.2mentioned above for necessary settlement within 60 days in total from the date of submission of claim form.

7. Accordingly,both the points are decided accordingly.

Hence, it is

        O R D E R E D

That the CC-187 of 2020 be and the same is allowed in part against the Op No.2 and dismissed on contest against Op No.1.

The Complainant would be at liberty to file the Claim Form along with supporting documents afresh within 30 days from the date of this order as per the requirements of the Op No.2 as mentioned in Paragraph No.8 of Written Version,for necessary settlement within 60 days in total from the date of submission of claim form.

Let a copy of this judgment be provided to all the parties free of cost expeditiously upon compliance of all legal formalities. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.

File be consigned to record section along with a copy of this   judgment.