Shri A.K. Bhattacharyya, President
The complainant’s case, in brief, is as follows:
- That the complainant’s husband, Late Samir Kumar Maiti, was a policy holder of National Insurance Co. Ltd. bearing no. 100300/47/2K/9601062/2K/96/00337 for a sum assured of Rs.400000/- only. The complainant was the nominee of the said policy.
- The complainant’s husband unfortunately fell down from bamboo ladder on 22.11.2009 causing injuries to his spine resulting in complete loss of power in lower and upper limbs. He became a permanent disabled person even after prolonged medical treatment at different Hospitals and Tamluk District Hospital issued a Disablement Certificate (86% disable) in favour of her husband.
- The complainant informed the OP no. 1 about her husband’s accident by letter dtd. 18.12.2009 for obtaining the claim form. The complainant submitted the claim form to OP no. 1 on 26.08.2010 along with necessary documents including final Police Report with regard to police case for such accident. Thereafter, the complainant’s husband died at Medical College, Kolkata on 09.08.2011. After that the complainant submitted Death Claim application along with all relevant papers on 05.09.2011 to OP no.1 for getting Death Claim Insurance Benefit, but OP no.1 paid no heed to her claim for long time. The OP no.1, with some malafide intention, sent a Regd. letter seeking to repudiate her claim on 04.11.2011 without any basis, hence the case for relief as sought for.
The OP no.1 and 2 contested the case by filing a Written Version jointly, whereby all the material allegations made by the complainant in her complaint have been denied. These OPs stated inter alia in their W/V that as per the terms and conditions of the Policy Certificate in question the occurrence of the incident requires to be informed to the Insurance Co within 1 month, but the claim was not made within the stipulated time. The Insurance Policy was availed of by suppression of actual income of the policy holder. It is stated further that there was no laches on the part of these OPs. Hence, they prayedfor dismissal of the instant case.
Initially the OP no.3, despite receipt of notice,remained absent from contesting the case. Later on, when necessary order was passed for ex-parte hearing of the case against them, the OP no. 3 appeared and sought to contest the case by filing W/V on 29.11.2012. The OP no.3 was allowed to contest the case subject to payment of Rs. 500/- as cost, but as the OP no. 3 did not pay requisite cost, the case was heard ex-parte against them.
POINTS FOR DECISION
- Whether there is any deficiency in service on the part of the OPs?
- Whether the complainant is entitled to get any relief as prayed for?
DECISIONS WITH REASONS
Point nos. 1 & 2:
Both these points are taken up together for the convenience of discussion.
Ld. lawyer for the OP nos. 1 & 2 denied any irregularity in the matter of repudiation of the claim of the complainant on the ground that the risk coverage under the Group Janata Personal Accident (GJPA) Policy depends on the income of the prospective beneficiary and submitted that no income proof document in respect of the complainant has been submitted by the Golden Multi Services Club of Golden Trust Financial Services (GTFS) and that apart, in terms of the policy the complainant was supposed to lodge the claim forthwith i.e. within one month to the company, but in this case the claim was not made within such stipulated period. Ld. Lawyer for the OP nos. 1 &2 signed-off with further contention that being the co-signatory on the policy certificate, Golden Multi Services Club cannot avoid their responsibility and liability in respect of the claim made by the complainant.
First thing first, let us see whether the alleged suppression of fact with regard to the policy renders the claim of the complainant null and void. We have noted that although the OP nos. 1 & 2 disputed deceased insured’s eligibility of getting a policy having risk coverage of Rs. 4 lakhs, they have not mentioned anywhere in the WV or WNA as to what is the cut off income for getting a policy of Rs. 4 lakhs. Anyway, it appears from the letter of the OP no. 1 dt. 08-11-2010 that they sought for ‘Employer’s Salary Certificate/Copy of Form No. 16 of I.T. Return/Income Certificate’ without specifying any particular year against which the complainant forwarded copies of I.T. returns those were readily available with her (for the period from 2005-06 to 2010-11) under cover of her letter dt. 06-12-2010. Subsequently vide their letter dt. 04-11-2011, the OP no. 1 sought to repudiate the claim of the complainant on the ground of non-submission of income proof for the year 2001-02 i.e. at the time of taking the policy. It appears from the Certificate of Registration issued by the Council of Homeopathic Medicine, West Bengal that the deceased insured was a registered Homeopathic Practitioner. It further appears from the Certificate of Enlistment issued by the Panskura Municipality that deceased insured used to run a pathological lab at Bachargram, Panskura, Purba Medinipur which invariably requires substantial investment. While all these factors points out beyond all reasonable doubt about the sound financial condition of the deceased insured, we do not find any cogent ground to believe that the deceased insured did not have sufficient income to avail of an insurance coverage of Rs. 4 lakhs.
It appears, the OP insurer sought to blame each and everyone save and except itself for the impasse over settlement of complainant’s claim without appreciating the fact that as an insurer they are equally responsible to verify the antecedents/eligibility of new entrants before acceptance of premium/issuance of policy. They cannot abdicate their liability simply by accusing their authorized agent of withholding vital information about the insured. In case of any dispute over non-cooperation/wrongdoing on the part of its authorized agent, the insurer has every right to seek redressal of their grievance before the appropriate forum, but under any circumstances, citing such bilateral dispute, an insurer cannot leave the beneficiary in the lurch. In our considered opinion, therefore, calling in question the instant policy after nearly 10 years since its commencement, is highly unethical/illogical/illegal, hence not tenable.
Another ground cited by the OP nos. 1 & 2 behind their inability to entertain the claim of the complainant is that the same was not submitted within the stipulated timeframe of one month from the date of occurrence of accident. We, however, find from the materials on record that the accident took place on 22-11-2009 and the complainant intimated the OP no. 1 about the same vide her letter dt. 18-12-2009. It clearly goes to show that the OP insurer was kept in the loop about the occurrence of accident of the insured by the complainant within the stipulated time frame. It is a fact that the complainant lodged her first claim with the OP insurer on 26-08-2010 i.e. after a lapse of more than 9 months. However, taking into consideration the fact that insured Samir Kumar Maiti, since deceased, was under treatment at different hospitals from 22-11-2009 till his death and above all the Disability Certificate in respect of the insured, since deceased, was issued by the appropriate authority i.e. Superintendent, District Hospital, Tamluk, Purba Medinipur on 13-07-2010 which was essential to ascertain the quantum of claim based on the percentage of disability, we find there was indeed cogent ground behind such delay in lodging the claim with the OP insurer and to our mind, such unintentional delay cannot and should not be a hindrance for settlement of a bona fide claim.
Admittedly, the OP no. 3 was the franchise-agent of OP no. 1 & 2 who were engaged to procure insurance business against commission. There is nothing on record to show that the OP no. 3 is supposed to share any liability in the event of lodging of an insurance claim by the beneficiary/nominee. Thus, we do not find any merit in the contention of OP no. 1 & 2 that the OP no. 3 is also responsible/liable to bear the burden of settlement of claim.
In terms of the GJPA policy in question the OP insurer is liable to settle insurance claim in the event of accidental death/loss of limbs/permanent total disablement for an overall capital sum limit of Rs. 4 lakhs. Admittedly, the insured died of an accident on 09-08-2011 giving rise to the insurance claim, but the OP no. 1 & 2 instead of settling such claim, preferred sitting tight over the claim of the complainant, which is clearly an act of deficiency in service. Therefore, the OP nos. 1 & 2 are liable to extend the insurance benefit to the complainant for a sum of Rs. 4 lakhs together with compensation Rs. 20,000/- for causing mental agony and harassment to her and litigation cost Rs. 3,000/-.
All these points are, thus, decided in favour of the complainant.
Hence, it is
O R D E R E D
that the instant c.c. no. 34/2012 be and the same is allowed on contest against the OP nos. 1& 2 and dismissed ex-parte against OP no. 3. The OP nos. 1 & 2 are directed to pay death benefit Rs. 4 lakhs to the complainant along with Rs. 20,000/- as compensation and litigation cost for a sum of Rs. 3,000/- within 45 days from the date of communication of this order i.d. the complainant is at liberty to execute this order in accordance with law in which case the OP nos. 1 & 2 shall be liable to pay interest over the total aforesaid awarded amount @ 8% p.a. from the date of this order till full and final settlement.
S.S. Ali A.K. Bhattacharyya
Member President
