PRESIDENT 

1)        By this complaint the Complainants has prayed that the Opposite Party be directed to pay Rs.36,000/- TTD Claim with interest @ 18% p.a. from 18/06/08 till the case is finally decided.  It is also prayed that the Opposite Party be directed to pay Rs.50,000/- towards compensation and mental agony caused due to harassment by the SGM and the Officer In-charge responsible for settling the claim.  It is also prayed that the Opposite Party be directed to pay Rs.30,000/- towards conveyance from Prabhadevi Mumbai to Divisional Office No.3, B.S. Marg, Mumbai – 400 023 and other incidental expenses incurred towards preparation of this claim. The Complainant has also prayed to refund the premium collected from the Insured at Rs.777/- per year for renewal of policies for the period 27/06/06 to 26/06/07, 27/06/07 to 26/06/08 and 27/06/08 to 26/06/09 in total Rs.2,331/- alongwith cumulative interest @ 18% p.a. till this claim is finally decided.  It is also prayed that the Opposite Party be directed to pay Rs.235/- towards draft payment made alongwith this complaint including Rs.35/- towards bank charges.  

2)        According to the Complainant, she sustained bodily injuries as a result of an accident on 16/02/06 and was totally disabled and claim related documents were submitted on or about 20/02/07 to the Opposite Party.  According to the Complainant, vide letter dtd.11/09/07 the then S.D.M. of the Opposite Party Shri. B. Mishra acknowledged receipt of the claim and asked the Complainant to submit the exact leave position due to injuries sustained as per leave record of the employer of the Complainant to process her claim of Temporary Total Disablement (TTD). It is alleged that as per table IV of the Policy compensation at 1% of the insured amount viz; 3 Lacs being Rs.3,000/- payable per week during such disability period was payable to the Complainant.  It is alleged that as per the requirement of the Opposite Party the certificate as received from the employer of the Complainant i.e. the University of Chicago, U.S.A. was submitted on 19/06/08 vide her father’s letter (Shri. Rao) dtd.18/06/08 to which the Opposite Party did not give any response.  It is alleged that though the Complainant’s father Shri. Rao personally followed with the claim department the only response received every time ‘the claim under process’.  It is alleged that the Opposite Party vide letter dtd.21/07/09 at Exh.‘K’ informed to Mumbai Grahak Panchayat that the claim which was submitted by the Complainant to her father Mr. S.N. Rao, who is the Agent of the Opposite Party cannot be considered as the claimant has not submitted original papers and other required papers.  It was also informed under letter at Exh.‘K’ that as there is an inordinate delay for submission of papers the Opposite Party has closed the claim filed by the Complainant.  The Opposite Party thereafter also by letter at Exh.‘L’ dtd.31/12/09 had informed the Complainant that pursuant to submission of claim papers it has been observed she had not produced the original documents viz; (1) Employers Leave Certificate (2) Medical Reports (3) Fitness Certificate of Orthopedic Surgeon.  The above documents are prima facie requirement for consideration of her requirement and this fact was informed to Shri. S.N. Rao on several times, but the said requirement has not been fulfilled and she was given opportunity to produce the said documents within 15 days from the receipt of the said letter and it was also informed that otherwise her case will be treated as closed.  It is alleged that the communication made by the aforesaid letter dtd.31/12/2009 and 03/05/2010 by the Opposite Party is deficiency in service and unfair trade practice.  The complaint is filed within time as provided u/s.24A of the Consumer Protection Act. 

3)        According to the Complainant, besides the non payment of claim lodged by her on 22/02/07, the Opposite Party accepted renewal yearly premium for the policy period 2006-07, 2007-08 and 2008-09 @ 777/- per year for 3 years after the accident of the Complainant.  The Sr. Divisional Manager of the Opposite Party intervened and supersede the decision of the designated underwriting officer who had accepted the offer to renew the policy of the Complainant and refused to renew the policy in the fourth year for the period 2009-10 vide letter dtd.23/06/09 which is at Exh.‘G-2’ and returned the cheque tendered towards the said renewal ignoring his superiors letter Exh.‘G-1’.  It is alleged that thereafter the father of the Complainant Shri. Rao appeal to the Chairman of the Opposite Party and grievance cell of IRDA and other officials of the Opposite Party but did not receive any reply.  It is alleged that the Opposite Party has adopted unfair trade practice.  The Complainant has therefore, prayed for grant of reliefs as mentioned in para 1 of this order.

4)        The Opposite Party filed written statement and contested the claim. It is contended that the Complainant has consciously suppressed material facts and has not come to the Forum which clean hands.  It is contended that a personal accidental insurance policy which was taken by the father of the Complainant Mr. Shridhar Rao was the agent of the Insurance Company he had obtained the policy on behalf of his family – which covered himself, his wife and his daughter who was unmarried and resided with him.  It is submitted that in the year 2005 the daughter of Shridhar Rao i.e. Complainant got married and started residing U.S.A. as N.I.R. and was working in the USA for gains as Senior Research Tech in the University of Chicago.  The policy was being renewed as the Insurance Company was not made aware that the Complainant had got married and settled in USA till the date of accident in the year 2006  and  it  came to  know  to  the  Opposite  Party only when it was intimated to the Opposite Party after a gap of one year i.e. on 20/02/07 that she met with an accident in USA while tracking in the year 2006.  It is contended that the main issue regarding the rejection of claim is two fold, firstly there was delay of more than one year, secondly the person insured had changed her status from being Indian citizen as she has settled in USA and working for gain and married.  It is also contended that the third and most important point for rejection of claim is that at no point of time the Complainant had given the original hospital papers of the treatment given to her as well as the balance disability leave from her employer and the injury certificate from treatment doctor and not furnishing fitness certificate from treating doctor to process the temporary total disablement claim.  It is submitted that as the original papers which were prerequisite of processing any claim were not given to the Opposite Party therefore, the claim was rightly rejected.

5)        It is contended that the Complainant’s father who is an agent of the Opposite Party cannot be given a go by just because he was working as agent of the Opposite Party for production of original papers to process the claim.  According to the Opposite Party the father of the Complainant had approached the Grievance Cell, the Mumbai Grahak Panchayat and IRDA and also obtained papers under RTI Act, however, he was not able to give original of the xerox copies as that the Complainant had already claimed the benefits from her employer (the University of Chicago) as she had requested benefits for of taking medical insurance, dental insurance, life insurance, long term disability as well as personal accident insurance from dated 03/02/06 and signed by her.  It is contended that therefore, she cannot be allowed to benefit twice one in U.S.A. and the other in India.  It is alleged that the Complainant is filed by the father of the Complainant.  She personally did not come to India either to file the complaint or to pursue the matter with the Opposite Party which shows her disinterest.  It is the case of the Opposite Party that the Complainant might have already received the benefits and as she is not interested in pursuing before this Forum or with the Opposite Party or she would have already submitted the originals to the other authority on that count the complaint deserves to be dismissed with heavy cost.

6)        It is denied that the cause of action for this complaint arose on 03/05/2010.  It is contended that the cause  of  action arose for this complaint in the year 2006 when the Complainant met with an accident while tracking in USA as her vehicle in which she was traveling hit to a tree and she received bodily injuries.  According to the Opposite Party, however, the claim form with xerox copies was submitted on 20/02/07 to the Opposite Party by the Complainant’s father i.e. after a gap of more than one year whereas the time limit for submission with the required medical papers in original is thirty days.  The copy of the claim form is submitted at Exh.‘A’.  It is contended that the complaint is required to be rejected as the same has been filed more than two years since the cause of action arose as it is barred by limitation u/s.24A of the Consumer Protection Act.  It is alleged that no application for condonation of delay is filed by the Complainant.  It is contended that the Opposite Party has rightly rejected the claim by its last letter dtd.31/12/09 for non compliance of the documents and for the required information as well the non submission of original documents of medical treatment.  The Opposite Party did not renew the policy in the year 2010 when the father of the Complainant failed to take note of the request of the Opposite Party.  It is contended that the complaint be dismissed with heavy cost.

7)        The Complainant herself has not filed her own affidavit of evidence in support of the claim made in the complaint.  However, her father S.M. Rao has filed his affidavit to whom the Complainant had given her power of attorney (copy of which is filed on record).  The Asst. Divisional Manager – Mr. V.M. Nikam has filed affidavit in support of the defence raised by the Opposite Party.  The power of attorney of the Complainant Mr. S.M. Rao filed written argument on behalf of the Complainant.  The Opposite Party has also filed its written argument.  We heard the oral argument of the power of Attorney Shri.S.M. Rao and Smt. Parvin Contractor, the Ld.Advocate for the Opposite Party and also perused the documents placed on record by both the parties.

8)        While considering the point of limitation of filing of complaint it is necessary to be seen that the Complainant met with an accident on 16/02/06.  The Complainant submitted the claim to the Opposite Party on 22/02/07.  The Opposite Party vide letter dtd.31/12/09 at Exh.‘L’ had informed the Complainant to produce the original documents viz; 1) Employer’s Leave Certificate, 2) Medical Reports & 3) Fitness Certificate of the Orthopedic Surgeon.  The Opposite Party vide above letter had also informed to  the  Complainant that the said documents is a prima facie requirement for consideration of her claim.  It was also informed under the said letter that the Opposite Party had several times informed about it to her agent and/or representative Mr. S.N. Rao but the same requirement is not fulfilled till 31/12/09.  In the said letter it was also informed that the Complainant should submit the original document within 15 days from the receipt of the said letter otherwise the claim filed by her will be treated closed for her without giving any further notice to the mater.  Thus, the repudiation communicated by the Opposite Party to the Complainant will have to be considered lastly on 31/12/09.  The present complaint is filed on 11/01/2012 which is beyond two years from the last communication of repudiation of claim of the Complainant by the Opposite Party.  In our view therefore, the objection raised by the Opposite Party that the complaint is barred by limitation u/s.24A of the Consumer Protection Act, is legal and proper.  We therefore, hold that the claim made by the Complainant for grant of Rs.36,000/- towards TTD Claim against the Opposite Party is barred by limitation and the same cannot be entertained.  The claim made by the Complainant for refund of the premium collected from the Insured at Rs.777/- per year for renewal of policies for the period 2006-07, 2007-08 and 2008-09 and non renewal of the accident policy in respect of the Complainant for the period 2009-10 also cannot be said within limitation as the Opposite Party by letter dtd.28/08/09 informed the Complainant’s father that the Complainant should submit proposal form duly completed and signed by her as there are some changes in status as regards to matriarchal aspects, income and residential and corresponding address which is registered with her employer an abroad. The said letter is filed at Exh.‘G’ to the Complainant under which the Opposite Party had informed to Shri. S.N. Rao that as there is no response from his client the Opposite Parties returning herewith his cheque which is submitted by him in the matter.  In our view as the complaint is filed for the reliefs mentioned regarding policy premiums is also filed beyond two years, the present complaint can be said barred by limitation.  The case made out by the complainant that the letter at Exh.‘D’ dtd.03/05/2010 was received on 05/05/2010 from the Regional Manager of the Opposite Party and therefore, the limitation for this complaint required to be taken into consideration from the said date cannot be accepted as in the aforesaid letters.  It was communicated to the Complainant that “In this connection the matter was taken up with the concerned D.O. No.3 who have informed us that in the absence of original claim papers, the claim could not be considered and they have closed the file for inordinate delay in submission of the papers.”  Considering this facts we hold that the complaint filed by the Complainant is barred by limitation and the same cannot be entertained. 

9)        Even assuming that the claim made in the complaint as it is whether can be considered in favour of the Complainant on merits, we are of the view that the Complainant did not comply the requirements directed to be complied by the Opposite Party.  The Complainant did not supply the original documents of medical treatment obtained by her in USA in spite of repeated demand vide letter at Exh.‘K’ ‘L’ dtd.21/07/09, 31/12/09, thus, in our view the Opposite Party has rightly closed the claim submitted to it. The Complainant at the time of oral argument submitted the Medico legal opinion of Dr. M.S. Kamath i.e. Medico-legal Consultant of the Opposite Party dtd.24/04/09 and submitted that in view of the said opinion the Opposite Party ought to have allowed the claim for the benefit of TTD Claim. In our view the sad submission also cannot be accepted as the Opposite Party has placed on record the opinion of Dr. Kamath dtd.04/05/09 in which he had advised the Opposite Party to ask for the originals. In the said opinion it was also opined that as the Complainant is permanent resident abroad at the time of taking the policy, she may be denied a policy and hence, the claim.  It is also opined that at the time of renewal, the Company may insist for a proposal form in view of change of name, address, etc.  From the document filed by the Opposite Party alongwith Exh.‘E’ it appears that the Complainant had concealed many facts while submitting the claim of TTD as well as Renewal of Policy such as, the address was not changed either by the Insured i.e. Complainant or the Agent i.e., the father of the Insured Mr. S.N. Rao though the circumstances and status of the Complainant were changed.  It also appears that the Complainant got married on 16/02/05 and it was registered with the Registrar of Marriage, Mumbai.  On 25/02/05 her name has been change to Mrs. Anjali S. Desai, but the Complainant or her father did not submit the said information to the Opposite Party.  The Complainant has also not submitted the claim form within 30 days of completion of treatment to the Opposite Party.  By taking into consideration all these facts we hold that the Complainant has not come out with clean hands and the Opposite Party has rightly  rejected/closed  the  reliefs  claimed in this complaint.  The submission made by  Shri. S. N. Rao, the Representative/Power of Attorney Holder of the Complainant in our view for grant of reliefs claimed in the complaint in favour of the Complainant are devoid of merits.  In the result we pass the following order –

O R D E R

i.                    Complaint No.05/2012 is dismissed with no order as to cost.

 ii.                 Certified copies of this order be furnished to the parties.