Final Order / Judgement

As per Satish Sapre, President. 

1. That the Complainant has filed the present complaint under Section 35 of Consumer Protection Act 2019, the Briefly stated facts are as follows: 

2. O.P No1 is a Insurance company which insured’s farmer under the scheme run by Maharashtra Government. OP No.2 receives the claim from claimant and forward it to the Insurance Company i.e O.P No 1. In this case Complainant Parvatibai Shankar Samarth is wife of deceased Shri Shankar Samarth. On 14/09/2013 the Complainant's Husband was bitten by a poisonous snake and he died due to snake bite on the same day. Complainant mentioned in her complaint that Due to the sudden death of her husband, she was is mental shock. She didn’t know about scheme of government under which her husband was covered in insurance. 

3. The Complainant after knowing about the Insurance policy, submitted the Claim proposal on 16/07/2016 under the name and styled "SHETKARI JANATA APGHAT VIMA YOJANA Farmers Accidental Insurance Scheme" introduced by the Govt. Of Maharashtra to O.P.No.2 within the prescribed time period. 

The Respondent No.1 Insurance Company neither repudiated the claim nor it accepted it till filling this complaint. Moreever after submitting the claim O.P.No.1 failed to communicate regarding any issue.

4.   Observations of Facts and Analysis of Evidence Documents and evidences produced by both parties are perused. The Complainant has placed reliance on true copies of following Documents:

     1.   Farmer Accident Insurance Scheme 2012-2013 Tripartite Agreement.

     2.  A claim submitted by the complainant to the Taluka Agriculture Officer.

     3.  7/12 copy of complainant's husband's farm and other farm documents.

     4. Inquiry report on natural calamity regarding the accidental death of complainant's

           husband.

     5.  Certificate from Group Gram Panchayat Bhendala regarding the accident of complainant's

           husband.

     6.  Certificate issued by Police Patil regarding the accidental death of complainant's husband.

     7.  Death certificate of petitioner's husband.

     8.   Identity card of the deceased Shankar S. Samarth “husband of complainant”.

5.    After admitting the above complaint notice was issued to opposite party 1 and 2 on receipt of notice. Opposite party no. 2 appeared and filed their reply on 26/04/2022. They have mentioned in their reply about deletion of their name from the complaint as they are intermediately. Their roll is only to forward the claim of claimant after scrutiny to the concern Insurance Co. Further submitted that they have forwarded the claim of complaint husbands to the M/s Cabal Broker Insurance on 16.07.2016. and O.P. no 1 is only responsible for the claim of complainant.

             O.P.No.1 appeared and file their Written statement on 02/08/2022 on record. Defense of the O.P.No.1 is that there are 7 years delay for   filling claim. Further they have submitted complainant failed to file any documents regarding husband of the complainant was covered under insurance policy. O.P.No.1 was not at fault as the complainant failed to prove the death of her husband. That, there is no deficiency in service by the O.P.No.1 The complaint filed by the complainant should dismissed with cost on the above stated grounds.

6.    After careful analysis of evidences brought on record, and hearing both the counsel following points arise for Determination on which we record findings with the reasons given below:

      Sr.no.                                                Points                                                                   Findings

1.  Whether the Complainant is entitled To claim the reliefs sought

in the Complaint?Yes

2. Whether the Complaint is within limitation ?                                                 Yes                                                      
3. Whether there is unfair trade practice and deficiency of service

on the part of O.P.No.1 & 2 ? Yes

       4.    What Order ?                                                                                                     As per final order

-// REASONS FOR FINDINGS //-

7.      As to Point nos.1 to 3 :-   From the very tenor of the oral and documentary evidence of both the Parties, following can be said to be proved facts…

1. Complainant husband was farmer and he died on 14/09/2013 Due to the snake bite.  Complainant wife didn’t know about scheme run by Maharashtra government regarding insurance of farmer. After knowing about scheme she filed claim to Talulaka Krushi Adhikari and same was forwarded to brokerage company M/s Cabal Insurance brokerage. Brokerage company forwarded the same claim to New India Assurance Company.
2. It is admitted fact that complainant husband was farmer. After going through. Record talathi and police patil have given the cause of death due to bite of poisonous snake which is sufficient for knowing the cause of death of complainant. From this record it is clear that cause of death is due to sneak bite.
3. As far as point of limitation is concern this commission rely on judgement of Apex Court in Branch Manager, National Insurance Co.  v/s Smt. Sumitra Ramchandra Mohite +1 on 26 March, 2014 in which court mentioned that

“The aforesaid condition reflects that sufficient opportunity be given to the beneficiary to submit the claim. This can be inferred from the very fact that vide this condition of the agreement the Govt. Not only gives an additional period of 90 days to the beneficiary but in case there is further lapse of time it imposes the duty on the insurance company to condone the delay if sufficient cause for the delay is given. In our opinion the complainants claiming that they had no knowledge of the insurance scheme and had submitted the insurance claim as soon as they got the knowledge. This can be said to be a sufficient cause for condoning the delay. The condition also nowhere mentions that insurance claim submitted after delay would not be granted or would fall within the scope of breach of policy condition. The authority on which the appellant relies on the point of limitation is not applicable to the present case”.

8.     Commission also  rests upon the Circular No. IRDA/HLTH/MISC./CIR/216/09/2011 dated 20.9.2011, issued by Insurance Regulatory and Development Authority (IRDA).  The said circular, to the extent it is relevant, reads as under:

          “The Authority has been receiving several complaint that claims are being rejected on the ground of delayed submission of intimation and documents.

          The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc.  However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.

          The insurers’ decision to reject a claim shall be based on sound logic and valid grounds.  It may be noted that such limitation clause does not work in isolation and is not absolute.  One needs to see the merits and good spirit of the clause, without compromising on bad claims.  Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.

          Therefore, it is advised that all insurers needs to develop a sound mechanism of their own to handle such claims with utmost care and caution.  It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.”

9.      It is thus evident that a genuine claim is not to be rejected by the insurer only on account of delay in its submission.  The insurer is required to enquire from the claimant as to what was the reason or the delay in submission of the claim.  The claim should be rejected only where the insurer finds that it was liable to be rejected even if it had been submitted in time.  In the present case, admittedly, no attempt was made by the insurer to ascertain the reasons for the delay in submission of the claim from the complainant.  Therefore, she did not get an opportunity to explain the said delay.  This is not the case of the petitioner that the husband of the complainant had not died in an accident or that he was not a depositor of O.P company.

10.       Opposite party No.1 neither informed the rejection of claim nor they required claimant about compliance of any documents. On the contrary they have admitted filling of the claim by petitioner to them. Hence defense of limitation taken by them are not justified.

It is noted from the documents annexed at Complaint especially Death certificate is issued by secretary GramPanchayat Bhendala. Taluka Mouda, Dist.Nagpur. and report given by Talathi shows that death is due to snake bite. It is noted and admitted fact that, Krishi Adhikari and Borkarage company scrutinised the claim papers and submitted to the opposite party. Specific allegation of the opposite party is that, PM was not done and it is not submitted with claim.

11.        In this regard  commission rely upon judgment of National Commission AjmeriKhatun Vs. General Manager, National Insurance Company Ltd. &Ors.; 2015 1 CPR (NC) 162 wherein the Hon'ble National Commission has held that in snake bite cases, post- mortem examination is not conducted, then it is not justifiable ground to repudiate the claim.

There is no dispute in regard complainant is farmer and all Heirs are totally depends on the earnings of the deceased and object of the policy is that if head of family member is injured or died. Due to the accident then earning of that family stops and critical Condition can be arose. This insurance policy framed by the State Govt. Of Maharashtra Viz. Farmers Personal Accident Insurance claims. So repudiation of the claim below policy by the opposite party insurance company is Arbitrary and not considering the principle and object of the policy. It is observed that opposite party insurance company kept claim Pending and failed to follow terms and condition of policy, and further they failed to Inform defects in documents scrutinized by Krishi Adhikari and Brokerage Company and failed to inform to O.P.No.2 and inform directly to the complainant regarding repudiation of the claim. Opposite Party failed to substantiate deceased died due to his own fault. Considering these findings derived we answer issue No.3 as Yes and Held that, there is deficiency in service and unfair trade practices on Part of opposite party insurance company. O.P.No.2 is intermediately they have complied their role by forwarding  claim of claimant to O.P.No.1. therefore this commission not held liable for deficiency in service and unfair trade practice to O.P.No.2.

12.       As to issue No.4 :- As complainant proved that, there is Deficiency in services and unfair trade practices on part of opposite Party No.1 and it will justifiable to held complainant partly entitle for relief Sought in prayers as per mentioned in final order. The Complainant has claimed Rs.  1,00,000/- with 18% interest. But no documentary evidence brought on record to support 18% interest. It is justified to grant 9% interest on the claim amount. From the date of filing the complaint till its realization.

Thus Commission is going to pass following order :-

                                                      -// FINAL ORDER //-

1. CC/22/32 is hereby party allowed against opposite party No.1 Insurance company.
2. It is hereby declared that, opposite party No.1 insurance company Committed deficiency in services and unfair trade practices towards complainant while providing the insurance claim Services to the complainant below Insurance policy framed by State govt. of the Maharashtra.
3. It is hereby directed to the opposite party No.1 to pay Rs.1,00,000/- alongwith 9% interest from the filing of complaint till its realisation. Which is receivable under the policy of Farmers Personal Accident Insurance Scheme. Within 45 days from the date of this order.
4. It is directed to opposite party No.1 to pay Rs.20,000/- as Compensation to the complainant towards mental agony suffered by her and litigation cost of Rs.5,000/-.
5. If O.P.No.1 is failed to comply the order within 45 days, then interest on claim amount will be 12% per annum.
6. The copy of order be sent to both the parties free of costs.