| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION BATHINDA C.C.No. 40 of 11-02-2020 Decided on :14-07-2023 Sudha aged about 51 years widow of Ashok Kumar S/o Mohan Lal; Anjali aged about 27 years D/o Ashok Kumar S/o Mohan Lal; Ajay Goyal aged about 24 years S/o Ashok Kumar S/o Mohan Lal;
All residents of H.No.21905 Near Shiv Mandir, Power House Road, Bathinda. ......Complainants Versus United India Insurance Co. Limited, Registered Office: 24, Whites Road, Chennai-600014, through its Managing Director. United India Insurance Co. Limited, Branch Office: 2090-B, The Mall, Kanwar Market, Bathinda, through its Branch Manager.
.......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Lalit Mohan Dogra, President Sh. Shivdev Singh, Member Present :- For the complainants : Sh.Maninder Singh Chauhan, Advocate. For opposite parties : Sh.Tejinder Singh, Advocate. ORDER Lalit Mohan Dogra, President The complainants Sudha and Others (here-in-after referred to as complainants) have filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite parties United India Insurance Co. Limited and Other (here-in-after referred to as opposite parties). Briefly, the case of the complainants is that Ashok Kumar S/o Mohan Lal was husband of the complainant No.1 and father of complainants No. 2 and 3. He was employee of M/s Bansal Bus Service. The employer of Ashok Kumar purchased one 'Group Personal Accidental Policy bearing No.2004004216P106721564 in respect of 10 employees including Ashok Kumar. It was valid w.e.f. 22.5.2016 to 21.5.2017, having sum assured of Rs.1,00,000/-. This amount is payable to the family of the deceased employee in case of accidental death of the insured employee of M/s Bansal Bus Service. It is alleged that Ashok Kumar died in the accident on 26.7.2016 due to the fall of electric pole upon him near St.Joseph's Convent School, Bathinda within the area of P.S. Civil Lines, Bathinda. DDR No.20 dated 27.7.2016 was also got lodged with P.S., Civil Lines, Bathinda by Nirmal Gupta W/o Sh.Prem Chand i.e. sister of deceased Ashok Kumar. The postmortem of Ashok Kumar was conducted in Civil Hospital, Bathinda. It is further alleged that the complainant No.1 and her children were not aware about the Group insurance policy of deceased Ashok Kumar. As such, they could not intimate opposite parties about the same. They were under the shock of their life due to untimely death of Ashok Kumar. When they came to know about the 'Group Insurance Policy', the complainant No.1 immediately approached opposite party No.2 in its office at Bathinda and informed it about the death of Ashok Kumar in the accident and lodged the insurance claim and supplied copies of all the relevant documents viz. copies of the group insurance policy, DDR, postmortem report of the deceased, death certificate of Ashok Kumar and Aadhaar Cards of the complainants and requested opposite parties to pay amount of insurance claim of Rs.1,00,000/-, but they have failed to pay insurance claim to the complainants till date. The complainants repeatedly approached opposite parties and requested to admit their lawful claim and to pay insurance claim, but to no effect. On this backdrop of fact, the complainants have alleged that they have suffered from great mental tension, agony, botheration, harassment and financial losses. They have claimed insurance claim of Rs.1,00,000/- compensation to the tune of Rs.50,000/- and litigation expenses to the tune of Rs.5500/-. Upon notice, opposite parties appeared through their counsel and contested the complaint by filing written version. In the written version, opposite parties have raised the legal objections that the complaint is not maintainable. There are serious violations of Insurance Act and policy terms and conditions. Ashok Kumar was not employee of Bansal Bus Service on the date of alleged accident. The complainants have no locus-standi to file this complaint. The accident took-place on 26.7.2016 and opposite parties have received claim intimation on 22-7-2019 from the complainants. It has been pleaded that 'Personal Accident Group Policy was issued in the name of M/s Bansal Bus Service (insured). Conditions clearly states that : (i) upon happening of any event, which may give rise to a claim under this policy, written notice with full particulars must be given to the company immediately. In case of death, written notice also of the death must, unless reasonable cause be shown be so given before internment, cremation and in any case, within one calendar month after the death'. In this case, the accident took-place on 26.7.2016 and opposite parties received claim intimation on 22-7-2019 from the complainant i.e. after 3 years which is violation of policy condition No. 1 and the claim has been repudiated on this ground. Further legal objections are that the complainants are also guilty of their own wrongs. They did not inform about the death of Ashok Kumar to opposite parties within prescribed time limit and thus violated terms and conditions of the policy. On merits also, opposite parties have denied all the averments of the complainants and reiterated their version as pleaded in legal objections and detailed above. In the end, the opposite parties have prayed for dismissal of complaint. In support of their claim, the complainants have tendered into evidence affidavit of Sudha dated 28-1-2020 (Ex. C-1) and documents (Ex. C-2 to Ex. C-18). To rebut the claim of the complainants, opposite parties have tendered into evidence affidavit of Baldev Singh dated 25.3.2018, (Ex.OP-1/4) and documents (Ex. OP-1/1 to Ex. OP-1/3. The learned counsel for the complainants has argued that Ashok Kumar was employee of M/s. Bansal Bus Service and the employer had purchased Personal Accident Group Insurance Policy in respect of 10 employees including Ashok Kumar. It is further argued that Ashok Kumar died on 26-7-2016 due to accidental fall of electric poll upon him and DDR was lodged with the police and as well as post mortem of dead body of the deceased was got conducted. It is further argued that complainants remained under shock and were not aware about Personal Accident Group Insurance Policy obtained by the employer and as such, when the complainants approached the opposite parties for payment of compensation of Rs. 1,00,000/-, the opposite parties refused to pay the same on account of which complainants had filed Consumer Complaint bearing CC/18/128 on 2-5-2018 before this Commission which was disposed of by this Commission vide order dated 7-5-2019 with the directions to the complainants to lodge claim with the opposite parties. Accordingly, complainants had lodged claim with the opposite parties on 3-6-2019 vide intimation letter Ex. C-18 but the opposite parties have refused to pay the claim vide letter Ex. C-2, which amounts to deficiency in service on the part of the opposite parties. On the other hand, learned counsel for the opposite parties has argued that accident took place on 26-7-2016 and intimation of claim was received on 22-7-2019 from the complainants. As per Clause 9 of policy terms and conditions Ex. OP-1/1, intimation was required to be given within one month, as such, claims is not payable and was rightly repudiated by the opposite parties. We have heard learned counsel for parties and gone through the file. It is admitted fact that Ashok Kumar was insured for a sum of Rs. 1,00,000/- through his employer vide Insurance Policy Ex. C-3. It is further admitted fact that Ashok Kumar expired in accidental death which fact is proved through DDR Ex. C-4, Death Certificate Ex. C-5, Postmortem Report Ex. C-6. The only ground for denial of claim is clause of policy of insurance. However, this Commission is of the view that complainants have fully explained the cause of delay in para No. 3 of complaint and affidavit of complainant No. 1 and have clearly mentioned that they were not aware of the Personal Accident Group Insurance Policy of Ashok Kumar. Moreover, it is not the case of the opposite parties that employer had intimated the complainants about the said policy. Therefore, this Commission is of the view that since the policy in question was obtained by the employer of the deceased and as such, the existence of the insurance cover was in the knowledge of Insurer, Insured and employer and complainants are legal heirs of deceased, are not supposed to be aware about the same, as such, opposite parties could not take shelter of exclusion clause and delay in intimation. Moreover, counsel for the opposite parties has not been able to explain that when the complainants were not aware of the insurance policy how the complainants can be bound by said clause. Moreover, the I.R.D.A has issued circular regarding delay in claim intimation/documents submissions. For the sake of convenience, the circular is being reproduced as under :- “ Ref No. IRDA/HLTH/MISC/CIR/216/09/2011 Dated 20-09-2011 C I R C U L A R To : All life insurers and non-life insurers. Re : Delay in claim intimation/documents submission with respect to i) All life insurance contracts and ii) All Non-life individual and group insurance contracts. The Authority has been receiving several complaints 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 need 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. The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurers' stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured." This Commission is of the view that in the present case complainants have fully explained the delay in intimation, a such, there is deficiency in service on the part of the opposite parties in repudiating the genuine claim of the complainants. Accordingly, this complaint is partly allowed and the opposite parties are directed to pay Rs. 1,00,000/- alongwith interest @9% p.a. from the date of filing of complaint till realization. The complainants are also held entitled to Rs. 10,000/- as compensation on account of mental tension and harassment and Rs. 3,000/- as cost of litigation. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced:- 14-07-2023 - (Lalit Mohan Dogra)
President (Shivdev Singh) Member
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