DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: BHADRAK
Dated the 26th day of July, 2019
C.D Case No. 89 of 2017
Present 1. Shri Raghunath Kar, President
2. Shri Basanta Kumar Mallick, Member
3. Afsara Begum, Member
Smt. Anusaya Rout
W/o: Late Balaram Rout
Vill: Talanga,
Po: Bandhagaon,
Ps: Bhadrak (R),
Dist: Bhadrak
……………………. Complainant
(Versus)
1. The Secretary,
Ambaroli, Service Co-operative Society Ltd.,
At/Po: Ambaroli,
Ps: Bhadrak (R),
Dist: Bhadrak
2. The Branch Manager,
Balasore Bhadark Central Co-operative Ltd.,
At: Naripur (Astal),
Po/Ps/Dist: Bhadrak
3. The Manager, Balasore Bhadark Central Co-operative Ltd.
O.T Road, F.M Circle, Near Head Post Office, Balasore
4. The Branch Manager, IFCO-TOKIO General Insurance Company Ltd.
At: Bonth Chhak,
Po: Bhadark (T),
Dist: Bhadark
5. The Branch Manager, IFCO-TOKIO General Insurance Company Ltd.
At: Baral Building, Kalidaspur Balasore,
At/Po/Ps/Dist: Balasore
6. The Managing Director, IFCO-TOKIO General Insurance Company Ltd.
Regd. Officer At: IFFCO Sadan, C- 1, District Center,
Saket, New Delhi- 110017
7. The Regional Manager, IFCO-TOKIO General Insurance Company Ltd.
1st & 2nd Floor, HIG 22, opposite PAL HIGHTS,
SBD Colony, Jayadev Vihar, Bhubaneswar, Odisha
…………………………..Opp. Parties
Counsel For Complainant: Sri G. Bal, Adv & Associates
Counsel For the O.Ps No. 1, 2 & 3: M.A Khan, Adv
Counsel For the O.Ps No. 4: Set Ex-parte
Counsel For the O.Ps No. 5, 6 & 7: Arun Kumar Chand, Adv
Date of hearing: 15.04.2017
Date of order: 26.07.2019
RAGHUNATH KAR, PRESIDENT
This dispute arises out of the complaint filed by the complainant alleging deficiency of service.
The complainant is the widow of Late Balaram Rout who had availed crop loan of Rs 60,600/- from Ambaroli Service Co-operative Society Ltd. (OP No. 1) 09.06.2015 and his life was insured under Group Personal Accident Insurance Scheme on payment of required premium to the Bank (OP No. 3). But unfortunately Late Rout faced a road accident on dt. 09.12.2015 and succumbed to death on the same day. The complainant, being the wife of the deceased borrower, intimated OP No. 1 about the sad demise of her husband requesting the OP No. 1 to initiate necessary step for submission of claim to the insurer (OP No. 5) through OP No. 3 so as to enable her to get the claim settled. After submission of preliminary intimation to OP No. 1, complainant also signed and submitted the claim form duly filled in along with all required documents as required within the stipulated time but the claim which was to be settled within a month but could not be settled. The complainant, being desperated with the callous and negative attitude of the O.Ps, in course of her visit to different offices and finding no other way to get her claim settled, raised this dispute with a hope to get justice praying for a direction to the O.Ps to settle the claim of the complainant.
O.Ps resisted the claim of the complainant and contested the case. OP No. 1, 2 & 3 represented through advocate MA Khan to conduct the case on their behalf and submitted the written version in admitting that the deceased husband of the complainant was covered under GPA Insurance scheme and entitled to get the death claim according to the terms and conditions of the policy but it is presumed that the insurer (OP No. 5) repudiated the claim because of delay in staking the claim for settlement. It is further added by the answering OP that the complainant has failed to submit the claim within the stipulated time as mentioned in the policy condition which caused delay in forwarding the proposal to the insured within the stipulated time. It is an admitted fact that although the death claim was complete in all respects, was submitted off late but repudiation of claim in respect of a death claim somehow contravening the settled provisions of IRDA Rules. In order to substantiate their objection, the answering O.Ps have cited the decision of Hon’ble National Commission in revision petition No. 305/2011 decided on 15.02.2017 wherein it is held “condition of giving intimation to insurance company within a specified number of days should not prevent the settlement of claim”. In addition to above decision the answering O.Ps also cited another decision of Hon’ble National Commission in first appeal No. 1641/2016 decided on 11.01.2018, “”rejection of claim on purely technical ground in a mechanical manner will result in loss of confidence of policy holders in the insurance industry”. That apart the said answering O.Ps have also cited another decision of Hon’ble National Commission pronounced on 19.07.2017 in revision petition No. 3228/2015, it is held that “since the complainant failed to prefer claim under group insurance policy on the death of her husband within two years, the claim is barred by limitation and delay of four years in intimation of death claim to insurance company may lead to dismissal ”. It is understood from the above decision that the claim preferred within two years from the date of death would certainly be considered for settlement. Submitting as above the answering O.Ps have also demanded the settlement of claim as the action of insurer with regards to repudiation of claim is not just and proper.
OP No. 5, 6 & 7 appeared through their advocate and submitted written version where in it is stated that the complainant is not a consumer in eye of law and the dispute itself is not maintainable in the present form. It is also added that since the answering O.Ps have not caused any deficiency of service, the present dispute is not maintainable in the present Forum and liable to be dismissed. It is also stated by the said O.Ps that the matter of inclusion of the deceased husband of complainant in the GPA Insurance Scheme was beyond their knowledge and also denied to all the allegations exaggeratedly described in the complaint. That the answering O.Ps have drawn the attention of the Forum to point No. 7 of general conditions of the policy certificate wherein it is mentioned as “An event, which might become a claim under the policy, must be reported to the company as soon as possible. In case of death, written notice also of death must, unless reasonable cause is shown, be given before internment/cremation and in any case, within one calander month after the death, and in the event of loss of sight or amputation of limbs, written notice thereof must also be given within one calander month after such loss of sight or amputation”. Accordingly the complainant had to submit the preliminary intimation within 08.01.2016 as the husband of the complainant died due to road accident on 09.12.2015 but the complainant has intimated the O.Ps on 07.11.2017 which proves that inordinate delay has been caused which compelled the O.Ps to close the claim as “no claim”. In the above premises the complaint filed by the complainant is devoid of merit and therefore need to be dismissed.
Evidently the husband of the complainant was a borrower of OP No. 1 and covered under GPA Insurance Scheme on payment of required premium covering the period of one year. As the husband of the complainant died due to road accident, the survivor/nomine of the deceased is entitled to get the claim as the sum insured for KCC borrower was of Rs 5,00,000/-. Apart from above all other points of allegation are disputed by the parties to this case.
Gone through the complaint petition, written versions submitted by the O.Ps, heard the parties in course of hearing, perused materials on record and observed as detailed here under.
1. At the outset, OP No. 4, 5 & 6 (hear in after said as insurer) raised the question of maintainability on the ground of cause of action, barred by limitation and above all the complainant is not a consumer within the meaning of CP Act. On the contrary the complainant submitted in stating that the cause of action arose when the complainant came to know about the fact of repudiation of her claim from the O.Ps and served notice upon the insurer through her advocate on 13.11.2017 requesting settlement of claim. As such this dispute does not fall under barred by limitation. It is also evident that whatever premium was paid by the deceased husband of the complainant was finally went to insurer before issue of policy. As the premium includes service charges etc. the complainant’s claim for the status of a consumer cannot be forfeited.
2. The insurer raised the question of submission of preliminary intimation was inordinate delayed as the complainant has submitted the intimation on 06.11.2017 where as the complainant claims to have submitted the preliminary intimation to the secretary Ambroli SCS (OP No. 1) on dt. 18.12.2015 and the same was forwarded to the insured (OP No. 3) on the same day and the insured claims to have transmitted the intimation on the next day. Therefore the objection raised by insurer O.Ps is not sustainable.
3. The O.Ps stated as to the claim staked by the complainant is treated as no claim because of inordinate delay in submission of intimation depriving the insurer to conduct inspection to ascertain the cause of death and the authenticity of the date of death for which the claim was repudiated. On the contrary the complainant vehemently opposed in stating that the preliminary intimation was issued on 18.12.2015, after nine days of death, which comes under one calander month or within 30 days from the date of death. That apart when a lot of documents have been submitted by the complainant to prove the death of the husband of complainant the plea taken by the insurer O.Ps regarding availment of opportunity for conducting inspection is absolutely false with an intention to avoid settlement of claim. Further the decision for repudiation of claim by the insurer O.Ps contravenes the very settled position of IRDA Rules and the decisions of Hon’ble National Commission. The complainant has cited the decisions of Hon’ble National Commission in revision petition No. 2575 of 2011 decided on 04.04.2012 wherein it is held by the Hon’ble Commission as “delay in lodging claim not itself sufficient ground to repudiate the claim”. In addition to above, the insured O.Ps have cited three decisions of Hon’ble National Commission wherein it is held that “condition of giving intimation to insurance company within a specified a number days should not prevent settlement of claim”, “rejection of claims on clearly technical ground in a mechanical manner will lose confidence of policy holders in the insurance industry” and since the complainant failed to prefer to claim under Group Insurance Policy on the death of her husband within two years, the claim is barred by limitation and delay of four years in giving intimation of death to insurance company may lead to be dismissal, with regards to revision petition No. 305/2011 decided on 15.02.2017, first appeal No. 1641/2016 decided on 11.01.2018 and revision petition No. 3228/2015 decided on 19.07.2017 respectively.
4. It is very much important to discuss here on the point of delay in staking claim, the question arises as to where the delay was caused and whether the delay is intentional or not. On analysis of material evidence available on record furnished by the parties to this case it is found that the preliminary intimation was submitted by the complainant on 18.12.2015 where as the insured O.Ps claimed to have received the death claim proposal on 06.11.2017 which is considered by the insured O.Ps as preliminary intimation. But on examination of documents and taking the submission of the parties in course of hearing into consideration, this Forum reached at the conclusion that the preliminary intimation was given on dt. 18.12.2015, just nine days after the date of death and therefore we are not inclined to accept the objection of insured O.Ps on this score. Secondly the date of intimation and the date of claim may have a wide gap but it is confirmed that the intimation was given in due time under the seal and signature of the OP No. 1. Under such circumstances the complainant should not be deprived of getting her claim for the sad demise of her husband by the whimsical decision and deliberate avoidance of the insured O.Ps.
If we analyze the decision of Hon’ble National Commission in respect of revision petition No. 3228/2015 decided on 19.07.2017 wherein it is held that if the claim is staked within a period of two years from the date of death, the insurance company cannot take the plea of delayed intimation/submission of claim for repudiation of the claim or treating the claim as “no claim”.
In the above premises and taking the facts analyzed in the fore going paragraphs into consideration it is made crystal that the insured O.Ps have defaulted in providing proper service to the complainant and have resorted to unfair trade practice in avoiding the claim without any just and proper reason and as such the insured O.Ps are liable to pay the entire claim together with cost and compensation. Since other O.Ps have not neglected in performing their legitimate duties with due diligence, they are not responsible and liable for any financial burden.
- ORDER
In the result, the complaint be and the same is allowed on contest against OP No. 5, 6 & 7 with a direction to pay a sum of Rs 5,00,000/- (the sum insured per unnamed KCC borrower) together with compensation Rs 5,000/- towards mental agony and harassment and Rs 3,000/- towards cost of litigation within a period of 30 days from the date of order, failing which interest @ Rs 9% per annum at quarterly rest shall be charged on the sum insured amount along with compensation with effect from the date of order.
This order is pronounced in the open Forum on this day of 26th July, 2019 under my hand and seal of the Forum.
