ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
Complainant is the syndicate Arogya group Mediclaim policy holder of OP company vide its policy no. 040500/48/11/14/00001650 for the period from 13.8.2012 to 12.8.2013 for a sum of Rs.3,50,000/-.
It is alleged by the complainant that during the subsistence of the insurance policy, her husband met with an accident on 18.8.2012 and sustained fatal injuries. The intimation of the accident was given to the OP and its TPA.
It is further alleged by the complainant that OP refused cashless facilities on the plea that the deceased received injuries within first 20 days of the inception of the policy, however, because of her continuous persuasion, the OP company and its TPA finally settled her mediclaim and paid her an amount of Rs.2,34,532/- but did not pay her a sum of Rs.3,50,000/- on account of accident death claim.
It is alleged by the complainant that non-payment of the personal accident death claim of Rs.3,50,000/- by the OP amounts to deficiency in services on its part. Hence this complaint.
Complaint has been contested by the OP insurance company Para NO. 4 and 5 of the preliminary objection of the W.S. filed by the OP is relevant and same is reproduced as under:-
4. It is submitted that as per policy UPON HAPPENDING OF ANY EVENT WHICH MAY GIVE RISE TO ANY CLAIM UNDER THE POLICY WRITTEN NOTICE WITH FULL PARTICULARS MUST BE GIVEN TO THE COMPANY IN CASE OF DEATH WRITTEN NOTICE ALSOOF DEATH UNLESS REASONABLE CAUSE IS SHOWN BE GIVEN BEFORE INTEWRMMENT CREAMATION AND IN ANY CASE WITHIN ONE MONTH AFTER DEATH. In the present matter the condition was not complied with although medical claim was paid by the company which was also delayed. It is admitted fact that the accident took place on 18.8.2012, The medical claim was lodged on 11.9.2012 and the same was paid by the company on 22.11.2012.
5. That the present claim is not payable as per terms and conditions of the insurance policy as there was much delay in lodgement of the claim.
Both the parties have filed their evidence by way of affidavit.
We have heard the arguments advanced at bar and have perused the record.
The counsel for the OP has contended that the present claim is not payable as per the terms and condition of the Insurance policy as there was much delay in lodging of the claim.. It is further contended by the counsel for the OP that, the complainant lodged two separate claims under the same policy; the mediclaim which was slightly delayed was paid by the OP company, but the other claim was too much delayed and as such was not paid.
It has prayed for the dismissal of the complaint.
We however are not in agreement with the contention of the counsel for the OP. Besides, a bald statement nothing was placed on record by the OP to show as to how much delay was there is filing the present claim?
Moreover, as per the guidelines issued by IRDA claims cannot be repudiated merely on the ground of delay.
The relevant part of the circular dated 2.9.2011 of IRDA is reproduced as under:
The current contractual obligation imposing the condition that the claim 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 f 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 policyholders losing confidence in the Insurance Industry giving rise to excessive litigation.
Therefore, it is advised that all insurer need to develop a sound mechanism of their own to handle such claim with utmost care and caution. It is also advised that the insurers must not repudiate such claim unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claim would have otherwise been rejected even if reported in time.
It is, therefore, clear that OP ought not to have rejected the claim of the complaint on the sole ground of delay in lodging the claim.
Merely, saying that there is an abnormal delay in filing the claim does not help the cause of the OP .
In view of the above discussion and in the lights of the guidelines issued by IRDA, we are of the considered opinion that OP was not justified in repudiating the claim of the complainant.
We therefore hold OP guilty of deficiency in service and direct it as under:-
- Pay to the complainant a sum of Rs.3,50,000/-(Three Lac Fifty Thousand only) alongwith 10% interest from the date of filing of complaint i.e. 20.10.2015 till payment.
- Pay to the complainant a sum of Rs.10,000/- (Rupees Ten Thousand only ) for mental pain and agony suffered by her.
- Pay to the complainant a sum of Rs.5000/-(Rupees Five Thousand only ) as a cost of litigation.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule.
File be consigned to record room.
Announced in open sitting of the Forum on ___________
