Punjab

Ludhiana

CC/21/53

Dr.Rajan Satiya - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

Gurdeep Singh

01 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  53 dated 03.02.2021.                               Date of decision: 01.10.2024. 

 

Dr. Rajan Satija aged 69 years son of Sh. Mohinder Satija, resident of 603-L, Model Town, Ludhiana.                                                                                                                                                                        ..…Complainant

                                                Versus

1. United India Insurance Company Limited, Branch Office: SCF No.2, Above Bank of India, Shaheed Udham Singh Market, Ludhiana, through its Manager.
2. United India Insurance Company limited, Head Office: 24, Whites Road, Chennai-600014, through its Manager.                                                                                                                         …..Opposite parties 

Complaint Under Section 35 of The Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Gurdeep Singh Sherdil, Advocate

For OPs                          :         Sh. Rajeev Abhi, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant is a doctor and he purchased  an insurance policy namely “Individual Personal Accident Policy” from the OP on 01.06.2018 for a sum insured of Rs.5,00,000/-. On 19.11.2018, the complainant met with an accident resultantly, he received injuries on leg for which he took medicines himself being a doctor. Due to non-serious nature of injuries, he informed the policy and got medical treatment and he was given symptomatic treatment. On 27.11.2018, due to worst condition of wound he was referred to Deep Hospital where he was treated and was discharged after treatment. The complainant kept the treatment on but due to worst condition of the would he got admitted in Preet Hospital, Ludhiana where he was treated by Dr. Darshan Singh and was further referred to Medanta Hospital, Gurgaon where he was treated by Dr. Rajeev Pareakh. During his treatment, the complainant informed the OPs  through Ms. Ritu Khanna, agent. The complainant lodged the claim with the OPs along with documents but the OPs refused to admit his claim on the ground that he approached the OPs late. The complainant claimed to have suffered mental pain, agony, harassment at the hands of the OPs due to refusal to admit his claim. The complainant served a legal notice dated 30.10.2020 upon the OPs but the no effect. Hence this complaint, whereby the complainant has requested to direct the OPs to pay claim amount of Rs.96,428/- along with compensation of Rs.2,00,000/- and litigation expenses of Rs.50,000/-.

2.                Upon notice, the OPs appeared and filed written statement assailed by complaint by taking preliminary objections on the grounds of maintainability; lack of cause of action; the complainant being estopped by his own act and conduct; the complainant has not come with clean hands; suppression of material facts etc. The OPs stated that immediately on the receipt of the claim vide letter dated 25.01.2019 received by hand through the representative of the complainant on 28.01.2019, it was entertained but not registered due to over delay claim intimation. The OPs further stated that the complainant obtained Individual Personal Accident Policy bearing No.200800421P103487887 valid from 11.07.2018 to 10.07.2019, covering the following risks:-

Name	Covers	CSI (Rs.)	Premium	Risk loading/discount	Premium
Rajan Satija	Table IV Death PPD PTD TTD	500,0000.00	750.00	Family Discount	0.00
	Table 1 Death	4,500,000.00	2,025.00
	Medical Expenses	0.00	555.00
Mrs. Jeewan Rani	Table IV Death PPD PTD TTD	200,0000.00	300.00	Family Discount	0.00
	Table 1 Death	300,000.00	135.00
	Medical Expenses	0.00	87.00

 

According to the OPs, the insurance policy is a contract in itself and the parties are bound by the terms and conditions of the insurance policy. It is one of the conditions No.1 in the policy obtained by the complainant that "Upon the happening of any event which may give rise to claim under the policy, written notice with full particulars must be given to the company immediately. In case of death written notice of the death must unless reasonable cause is shown to be given before internment, cementation and in any case within one calendar 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 calendar month after such loss of a sight or amputation." It is also one of the conditions No.2 of the policy that "Satisfactory proof to the company shall be furnished of all matters upon which a claim is based….”.  The OPs claimed to have received the first claim intimation letter by hand through insured's representative on 28.01.2019 without mentioning of date, time and place of accident. The opposite parties immediately sent registered letter No.554 dated 29.01.2019 to give full information of the accident, date, time and place of accident and submit required documents. Since without date, time and place of accident it was not possible for the opposite party to entertain the claim which was not informed to the OPs till 27.05.2019.

                   The OPs further stated that the documents and the information sought for was material documents required for processing of the claim. The complainant received the letter dated 29.01.2019 but informed them vide letter dated 21.05.2019 that date/time of the accident was 19.11.2018 at about 8:00 PM at Model Town, Ludhiana which was received by the OPs on 27.05.2019 but the said fact was never intimated to the OPs within the reasonable time of accident/injury. Further as per the express condition No.1 of the policy, the complainant was bound to give written notice with full particulars to the company immediately on the happening of the event which may give rise to claim under the policy. The complainant deprived the legitimate right of the OPs to get the injury examined by their empanelled doctor and as such the complainant has violated the above condition No. 1 of the policy as the insured failed to give claim intimation to the company immediately as the complainant first claim letter was received by the opposite party after 70 days of the alleged injury that too without mentioning the date and time of accident and again the complainant took another almost four months to inform the actual date, time and place of accident and provided incomplete documents.

                   The OPs further stated that after the receipt of the letter of the complainant dated 21.05.2019 on 27.05.2019 and after scrutinizing the documents placed in the claim file by their officials in terms of the insurance policy obtained by the complainant and after due application of the mind by their officials, the claim of the complainant was repudiated as no claim vide letter dated 31.05.2019 on the grounds of violation of condition No. 1 of the insurance policy due to over delay claim intimation as condition No.1 of the insurance policy obtained by the complainant clearly states that "written notice with full particulars must be given to the company immediately on happening of an event which may give rise to claim under policy" since the complainant failed to give claim intimation to the company immediately as the first claim letter was received by the opposite parties after 70 days of the alleged injury that too without mentioning the date and time of accident and again the complainant took another almost four months to inform the actual date, time and place of accident and provided incomplete documents without that the claim cannot be registered and the complainant by doing this had debarred their legitimate right to examine the alleged injured person by their authorized representative. The claim of the complainant has rightly been not registered and rejected on account of over delay in intimation and violation of condition No.1 of the insurance policy vide letter dated 31.o5.2019. Even the complainant field complaint with Insurance Ombudsman, Chandigarh which was dismissed vide award/order dated 20.03.2020 on the ground that the complainant violated terms and conditions of the policy without any justification and denial of the claim by the insurance company is in order and does not want any interference and the complaint is dismissed being devoid of merits.

                   On merits, the OPs reiterated the crux of averments made in the preliminary objections and factual submission of the case. The OPs have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 to Ex. C9 and closed the evidence.

4.                On the other hand, the counsel for the Ops tendered affidavit Ex. RA of Sh. Sanjeev Kumar, Senior Divisinal Manager of the OPs as well as affidavit Ex. RB of Ms. Ritu Khanna, Agent of the OPs along with documents Ex. R1 to Ex. R23 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents as well as written statement, affidavit and documents produced on record by the parties.

6.                The complainant a senior citizen and Doctor by profession, obtained an Individual Personal Accident Policy Ex. C1 = Ex. R1 having a coverage for himself and for his wife for death and permanent disability etc. having a maximum coverage of Rs.5,00,000/-. However, he did not avail the cover for medical expenses. The complainant stated to have met with an accident on 19.11.2018 and sustained injury on his leg. Being a doctor, he initially indulged in self medication and subsequently due to deterioration of his condition, the complainant was treated at Deep Hospital and Preet Hospital, Ludhiana from where he was referred to Medanta Hospital, Gurgaon. The complainant had incurred a total expenses of Rs.96,428/- on his treatment.

7.                Although, the complainant claimed himself to have intimated the OPs through one agent namely Ms. Ritu Khanna having an agent code No.AGN1016368 but as per available record vide letter dated 25.01.2019, he requested the OPs to supply the claim form for completion of the documents. On receipt of the claim form Ex. R8, the OPs on 29.01.2019 vide letter ex. R3 requisitioned the documents and information from the complainant on nine counts. The complainant on 21.05.2019 vide letter Ex. R6 provided some of the requisite documents and information. However, after considering the response of the complainant, on 31.05.2019, the OPs invoked the condition No.1 of the policy and declined to entertain the claim of the complainant on delayed claim intimation vide letter Ex. R11. During the proceedings before this Commission, it also became evident from the record that the complainant also approached the Insurance Ombudsman whereby vide award Ex. R23, the action of the OPs was upheld. Further it also came to the notice that the complainant had also preferred a claim with New India Insurance Limited against health insurance policy. However, the fate of his reimbursement claim with that insurance company remained a mystery till date.

8.                Perusal of the repudiation letter reveals that the claim was repudiated on the basis of delay in intimation to the OPs and the claim was never settled on merits. Recently, the Hon’ble Supreme Court of India in Civil Appeal No.4758 of 2023 title as Ashok Kumar Vs New India Assurance Co. Ltd. whereby it has been held as under:-

“Insurance - Theft of Vehicle – Mere delay in intimating the insurance company about the occurrence of the theft cannot be a ground to deny the claim of the insured.”

9.                As such, keeping in view the above said facts and circumstances, it will be just and appropriate if the complainant is directed to lodge a fresh claim with the OPs along with all requisitioned documents within 30 days from the date of receipt of copy of order and thereafter, the OPs will consider and settle the claim of the complainant within 30 days from the date of receipt of claim from the complainant.

10.              As a result of above discussion, the complaint is partly allowed with direction to the complainant to lodge a fresh claim with the OPs along with all requisitioned documents within 30 days from the date of receipt of copy of order and thereafter, the OPs will consider and settle the claim of the complainant within 30 days from the date of receipt of claim from the complainant. Keeping in view the peculiar circumstances of the case, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.   

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:01.10.2024.

Gobind Ram.