C.C.No.75/2008
Between:
Taragala Satyavathi, w/o.late Saibaba, age:38years, occu: House

hold, r/o.H.No.8-2-149/1, Sundaraiah nagar, Bandarugudem,

Manuguru, Khammam District.
…Complainant

and

Reliance Life Insurance Company Ltd., rep. By its Branch

Manager, Branch office, Gandhi chowk, near Andhra Bank,

Khammam.

…Opposite parties.

This C.C. came before us for final hearing on 21-10-2009; in the presence of Sri.M.Vasudev, Advocate and of Sri.V.N.Hanumantha Rao, Advocate, for complainant; Sri.G.Seetha Rama Rao, Advocate for opposite party; upon hearing the arguments and upon perusing the material papers on record, and having stood over for consideration, till this day, this Forum passed the following order:

O R D ER

(Per Sri.K.V.Kaladhar, Member)

1. This complaint is filed u/s.12-A of Consumer Protection Act, 1986. The brief facts of the complaint are that the complainant is the wife of late Taragala Saibaba (he will be hereinafter referred as the “life assured”). On 19-10-2006 the life assured had taken the insurance policy bearing No.10355497 for Rs.1,00,000/-, by introducing the complainant as nominee to receive the assured amount under the policy. On 7-4-2007 he attended his electrician duty as usually, on the same day during night time, he developed motions, shifted to hospital, while undergoing to treatment he died, the doctors opined that the life assured died due to sun stroke. Because of the death of the life assured, his family members became orphans.

2. Later on, the complainant preferred claim with the opposite party for payment of sum assured under the said policy. But to her utter surprise, the opposite party addressed a letter by stating that their investigation revealed that life assured died by committing suicide, but not due to sun stroke, as such they are not liable to pay any amount under the said policy, advising her to approach the Branch Manager, Khammam, even though the facts are not relied.

3. On enquiry the Branch Manager stated that the news item was published in Andhra Jyothi stating that the life assured committed suicide and therefore they are unable to pay insurance amount. Thereafter the complainant approached the Andhra Jyothi reporter, Manuguru, he informed that basing on wrong report, they published news item in Andhra Jyothi News paper as the life assured committed suicide, on the next day, they came to know the real fact that the death of life assured was not due to suicide and expressed apology, gave a letter dt.26-8-2007 to that effect. Accordingly the complainant approached the opposite party at Khammam, shown the letter issued by the Andhra Jyothi news paper reporter, Manuguru and the report of doctor, but they have not responded and avoiding the payment of assured amount under the said policy on one pretext or the other. Inspite of several rounds made by the complainant to the Branch office of opposite party made it clear that they are unable to settle the claim. Having no other alternative, the complainant approached the forum for redressal.

4. On receipt of notice, the opposite party appeared through their counsel and filed counter, denying the material averments made in the complaint and submitted that the policy holder died on 8-4-2007 due to sun stroke, on receipt of information, they enquired the cause of death of the policy holder, found that he committed suicide, it was published in the Andhra Jyothi news paper. The opposite party further denied the apology and the clarification letter issued by the Andhra Jyothi News paper reporter, Manuguru. It is further stated that as per the terms and conditions of the policy, if a policy holder commits suicide within one year of availing the policy then the company is not liable to pay any claim on the death of the life assured. In the present case, the policy holder committed suicide within 7 months of availing the policy, as such the complainant is not liable for claiming the assured amount under the said policy. Hence, the complaint is liable to be dismissed.

5. On behalf of the complainant, the following Xerox copies of documents are filed and the same are marked as exhibits.

Ex.A.1 - Insurance policy No.10355497 issued by opposite party,

dt.30-09-

Ex.A.2 - Letter addressed by the opposite party to the complainant,

dt.30-7-2007.

Ex.A.3 - Letter given by Andhra Jyothi Reported, Manuguru,

dt.26-8-2007.

Ex.A.4 - Death certificate of Taragala Saibaba, dt.18-4-2007.

6. On behalf of the opposite party, the following Xerox copies of documents are filed and marked as exhibits.

Ex.B.1 - Terms and conditions of the policy document.

Ex.B.2 - Repudiation letter,

Ex.B.3 - paper cutting (Andhra Jyothi news paper)

Ex.B.4 - Statement given by Sri.P.Bapi Raju, neighbour of the

complainant.

7. Both the parties have filed their written arguments. Upon hearing the arguments and upon perusing the material papers on record, now the points that arose for consideration are,

1. Whether the life assured died by committing suicide or due to

sun stroke?

2. Whether the complainant is entitled to claim the assured amount

under the insurance policy bearing No.10355497?

3. To what relief?

Point No.1:

8. It is an admitted fact that the deceased, T.Saibaba obtained insurance policy bearing No.10355497 on 19-10-2006 for Rs.1,00,000/-. It is an admitted fact that the deceased died on 8-4-2007, as per the death certificate issued by Registrar, Births and Deaths, Municipality, Manuguru. It is the contention of the opposite party that the cause of death is mentioned by the complainant was false, as the life assured had committed suicide, which is evident by the news paper article, which is published in Andhra Jyothi Daily news paper, Manuguru on 9-4-2007. It is also the contention of the opposite party that the neighbor of the deceased, life assured, Mr.Bapiraju has also given a letter stating that the deceased/life assured had committed suicide on 8-4-2007 and the same was published in 9-4-2007. Hence, the company is not liable to pay any claim of death due to suicide within 12 months from the date of issuance of the policy or the date of reinstatement of the policies.

9. As per the above contention put forth by the opposite party, we have perused the documents filed by the complainant, The Andhra Jyothi reporter wrote a letter to the complainant, dt.26-8-2007 in which it is stated that on 9-4-2007 in Andhra Jyothi News paper, it is stated that two persons committed suicide and in which one Saibaba, who is the husband of the complainant herein also committed suicide, but it is wrongly reported in this news paper and for which they apologize the complainant for the wrong published by him. Thus, the opposite party did not prove the death of husband of the complainant due to suicide. Hence, this issue is answered accordingly in favour of the complainant and the complainant is entitled to claim under the said policy.

10. In the result, the complaint is allowed, directing the opposite party to pay assured amount of Rs.1,00,000/- under the policy bearing No.10355497 with interest at 9% P.A. from the date of complaint i.e. from 17-10-2008 till the date of realization. There is no order as to costs.

Dictated to the Steno, transcribed by her, corrected and pronounced by us in the open forum on this 11th day of November, 2009.

C.C.No.75/2008
Between:
Taragala Satyavathi, w/o.late Saibaba, age:38years, occu: House

hold, r/o.H.No.8-2-149/1, Sundaraiah nagar, Bandarugudem,

Manuguru, Khammam District.

…Complainant
and
Reliance Life Insurance Company Ltd., rep. By its Branch

Manager, Branch office, Gandhi chowk, near Andhra Bank,

Khammam.

…Opposite parties.



This C.C. came before us for final hearing on 21-10-2009; in the presence of Sri.M.Vasudev, Advocate and of Sri.V.N.Hanumantha Rao, Advocate, for complainant; Sri.G.Seetha Rama Rao, Advocate for opposite party; upon hearing the arguments and upon perusing the material papers on record, and having stood over for consideration, till this day, this Forum passed the following order:


O R D ER

(Per Sri.K.V.Kaladhar, Member)



1. This complaint is filed u/s.12-A of Consumer Protection Act, 1986. The brief facts of the complaint are that the complainant is the wife of late Taragala Saibaba (he will be hereinafter referred as the “life assured”). On 19-10-2006 the life assured had taken the insurance policy bearing No.10355497 for Rs.1,00,000/-, by introducing the complainant as nominee to receive the assured amount under the policy. On 7-4-2007 he attended his electrician duty as usually, on the same day during night time, he developed motions, shifted to hospital, while undergoing to treatment he died, the doctors opined that the life assured died due to sun stroke. Because of the death of the life assured, his family members became orphans.

2. Later on, the complainant preferred claim with the opposite party for payment of sum assured under the said policy. But to her utter surprise, the opposite party addressed a letter by stating that their investigation revealed that life assured died by committing suicide, but not due to sun stroke, as such they are not liable to pay any amount under the said policy, advising her to approach the Branch Manager, Khammam, even though the facts are not relied.

3. On enquiry the Branch Manager stated that the news item was published in Andhra Jyothi stating that the life assured committed suicide and therefore they are unable to pay insurance amount. Thereafter the complainant approached the Andhra Jyothi reporter, Manuguru, he informed that basing on wrong report, they published news item in Andhra Jyothi News paper as the life assured committed suicide, on the next day, they came to know the real fact that the death of life assured was not due to suicide and expressed apology, gave a letter dt.26-8-2007 to that effect. Accordingly the complainant approached the opposite party at Khammam, shown the letter issued by the Andhra Jyothi news paper reporter, Manuguru and the report of doctor, but they have not responded and avoiding the payment of assured amount under the said policy on one pretext or the other. Inspite of several rounds made by the complainant to the Branch office of opposite party made it clear that they are unable to settle the claim. Having no other alternative, the complainant approached the forum for redressal.

4. On receipt of notice, the opposite party appeared through their counsel and filed counter, denying the material averments made in the complaint and submitted that the policy holder died on 8-4-2007 due to sun stroke, on receipt of information, they enquired the cause of death of the policy holder, found that he committed suicide, it was published in the Andhra Jyothi news paper. The opposite party further denied the apology and the clarification letter issued by the Andhra Jyothi News paper reporter, Manuguru. It is further stated that as per the terms and conditions of the policy, if a policy holder commits suicide within one year of availing the policy then the company is not liable to pay any claim on the death of the life assured. In the present case, the policy holder committed suicide within 7 months of availing the policy, as such the complainant is not liable for claiming the assured amount under the said policy. Hence, the complaint is liable to be dismissed.

5. On behalf of the complainant, the following Xerox copies of documents are filed and the same are marked as exhibits.

Ex.A.1 - Insurance policy No.10355497 issued by opposite party,

dt.30-09-2006.

Ex.A.2 - Letter addressed by the opposite party to the complainant,

dt.30-7-2007.

Ex.A.3 - Letter given by Andhra Jyothi Reported, Manuguru,

dt.26-8-2007.



Ex.A.4 - Death certificate of Taragala Saibaba, dt.18-4-2007.



6. On behalf of the opposite party, the following Xerox copies of documents are filed and marked as exhibits.

Ex.B.1 - Terms and conditions of the policy document.

Ex.B.2 - Repudiation letter,

Ex.B.3 - paper cutting (Andhra Jyothi news paper)

Ex.B.4 - Statement given by Sri.P.Bapi Raju, neighbour of the

complainant.

7. Both the parties have filed their written arguments. Upon hearing the arguments and upon perusing the material papers on record, now the points that arose for consideration are,

1. Whether the life assured died by committing suicide or due to

sun stroke?

2. Whether the complainant is entitled to claim the assured amount

under the insurance policy bearing No.10355497?

3. To what relief?

Point No.1:

8. It is an admitted fact that the deceased, T.Saibaba obtained insurance policy bearing No.10355497 on 19-10-2006 for Rs.1,00,000/-. It is an admitted fact that the deceased died on 8-4-2007, as per the death certificate issued by Registrar, Births and Deaths, Municipality, Manuguru. It is the contention of the opposite party that the cause of death is mentioned by the complainant was false, as the life assured had committed suicide, which is evident by the news paper article, which is published in Andhra Jyothi Daily news paper, Manuguru on 9-4-2007. It is also the contention of the opposite party that the neighbor of the deceased, life assured, Mr.Bapiraju has also given a letter stating that the deceased/life assured had committed suicide on 8-4-2007 and the same was published in 9-4-2007. Hence, the company is not liable to pay any claim of death due to suicide within 12 months from the date of issuance of the policy or the date of reinstatement of the policies.

9. As per the above contention put forth by the opposite party, we have perused the documents filed by the complainant, The Andhra Jyothi reporter wrote a letter to the complainant, dt.26-8-2007 in which it is stated that on 9-4-2007 in Andhra Jyothi News paper, it is stated that two persons committed suicide and in which one Saibaba, who is the husband of the complainant herein also committed suicide, but it is wrongly reported in this news paper and for which they apologize the complainant for the wrong published by him. Thus, the opposite party did not prove the death of husband of the complainant due to suicide. Hence, this issue is answered accordingly in favour of the complainant and the complainant is entitled to claim under the said policy.

10. In the result, the complaint is allowed, directing the opposite party to pay assured amount of Rs.1,00,000/- under the policy bearing No.10355497 with interest at 9% P.A. from the date of complaint i.e. from 17-10-2008 till the date of realization. There is no order as to costs.

Dictated to the Steno, transcribed by her, corrected and pronounced by us in the open forum on this 11th day of November, 2009.

COMPLAINT NO.1734 OF 2009

B.Praveen Singh

S/o K.Bharath Singh

Aged about 33 yrs,

R/o No.391, F-Block,

“Chandrika”

Sahakaranagar,

Bangalore – 92.

…. Complainant.

V/s



01. Reliance General Insurance

Company Ltd by its Manager,

No.C-151, Okhla Industrial Area,

Phase – I, New Delhi – 110 020.



02. Medi Assist India Private Ltd.,

By its Manager, No.49,

Shilpa Vidya, 3rd Floor, I Main,

JP Nagar, 3rd Phase, Bangalore – 78.

…. Opposite Parties

-: ORDER:-



This complaint is for a direction to the Opposite Parties to pay Rs.2,00,000/- towards reimbursement of medical expenses together with interest at 18% Per Annum from the date of claim till the date of payment, on the following grounds:-



2. The complainant was holding health insurance policy of ICICI Lombard Health Care for the period from 31/07/2006 to 30/07/2007. When the said policy was still in force, a representative of the Opposite Parties called the complainant over phone in June – 2008 and informed that the earlier policy will expire within a month and requested to take MEDICLAIM policy from Reliance General Insurance Company having tie up with ABN AMRO Bank as the complainant was holding the credit card of the said Bank. The complainant consented for the same and debited Rs.3,914/- towards premium through the credit card of ABN AMRO Bank. Thereupon the Opposite Party issued the MEDICLAIM insurance policy for the period from 30/06/2008 to 29/06/2009 for insured sum of Rs.2,00,000/-. On 19/09/2008 the complainant had some difficulty in breathing and therefore went to Columbia Asia Hospital, Hebbal. The investigation reports disclosed that there was some blockages in the heart and therefore he was kept in the Hospital for one day for observation. On 20/06/2008 he underwent By-pass surgery in Columbia Asia Hospital at Yeshwanthapur and he was discharged from the Hospital on 27/09/2008. During the period of hospitalization the Hospital had sent a requisition to the Opposite Parties for cashless facility. The Hospital raised bill for Rs.2,46,155/-, but restricted to Rs.2,00,000/- being the sum assured. The complainant submitted the claim form on 14/10/2008 and the same was acknowledged by Opposite Party No.2 on 11/10/2008. Thereafter the Opposite Parties requested the hospital to clarify some of its queries and by the letter dated 05/12/2008 the concerned Doctor has sent clarification. On 16/12/2008 opposite Party No.2 addressed another letter to the complainant requesting for information and documents which were already furnished. The wife of the complainant wrote the letter dated 05/12/2008 and 22/12/2008 to Opposite Party No.2 enclosing the additional documents and furnishing the information required. In spite of furnishing all the information and documents required, Opposite Party No.2 did not process the claim and whenever the wife of the complainant visited their office, there was no proper response. They used to pose a question whether the complainant was a chronic smoker and alcoholic. The Doctor has given clarification under certificate dated 20/12/2008 regarding the consumption of alcohol. He issued legal notice dated 04/03/2009 calling upon the Opposite Parties to settle the claim. Opposite Party No.2 sent the message through ‘e’ mail dated 12/05/2009 stating that the claim is closed. The Opposite Parties failed to settle the claim of the complainant and thus failed to provide proper service. They have declined to honor the claim of the complainant and have caused mental agony and monitory loss. Hence, the complaint.



3. In spite of service of notice, Opposite Party No.2 – Medi Assist India Private Ltd has remained absent. The contention of Opposite Party No.1 – Reliance General Insurance Company Limited is as under:-

The allegations in the complaint do not constitute any deficiency in service. The complainant has not approached the Forum with clean hands. There is no cause of action for the complaint as the claim has not been repudiated. The Opposite Party is seeking information from the complainant for processing the claim in line with the policy terms and conditions. Therefore the complaint is pre-mature. They had issued MEDICLAIM policy in favour of the complainant for the period from 30/06/2007 to 29/06/2008. Their liability if any is subjected to the terms and conditions of the policy. During validity of the policy, the complainant informed about his hospitalization and made claim for reimbursement of certain medical expenses. On receipt of the claim intimation, the complainant was called to produce certain records to process and consider the claim as per the terms and conditions of the policy. But the complainant failed to submit the required papers within a reasonable time and as such they wrote final reminder requesting the complainant to submit the documents failing which the claim will be treated as “no claim”. Since the complainant did not produce the required documents, the claim could not be considered. The claim is still in the stage of processing and as such without furnishing the records required, the complainant has approached this Forum. On these grounds, Opposite Party No.1 has prayed for dismissal of the complaint.

4. In support of the respective contentions both parties have filed affidavits. The complainant has produced copies of documents. We have heard the arguments of the learned counsel on both side.



5. The points for consideration are:-



1. Whether the complainant has proved deficiency in service on the part of Opposite Parties?



2. Whether the complainant entitled to the reliefs prayed for in the complaint?



6. Our findings are:-

Point No.(1) : In the Affirmative

to the extent stated

here under



Point No.(2) : As per final order

For the following:-



-:REASONS:-

7. It is not in dispute that the complainant had obtained MEDICLAIM insurance policy from Opposite Party No.1 in a sum of Rs.2,00,000/- for the period from 30/06/2008 to 29/06/2009 and when the policy was in force the complainant was hospitalized during the period from 19/09/2008 to 27/09/2008 and as per the medical records he underwent By-pass surgery. From the copies of the documents placed on record by the complainant, it is seen that the complainant furnished the required documents and information required by Opposite Party No.2 – the TPA of Opposite Party No.1. The claim was made on 04/10/2008, the required documents and information was furnished on 05/12/2008 and in spite of it till now the claim is not settled. Alleging deficiency in service, the complaint is filed on 23/07/2009. Therefore for over a period of nine months from the date of submission of the claim form, the Opposite Parties have not settled the claim of the complainant. This delay of nine months in settling the claim itself amounts to deficiency in service.

8. The only contention of Opposite Party No.1 in the version is that the complainant did not furnish the documents and information called for. But it is not disclosed which documents and information is not furnished by the complainant. A reading of the letter dated 05/12/2008 addressed to Opposite Party No.2 by the wife of the complainant makes it clear that all the required information and documents were submitted and the same is acknowledged by Opposite Party No.2 on 05/12/2008. Nothing is placed on record to show that subsequent to 05/12/2008, the Opposite Parties addressed any letter requesting the complainant to furnish a particular document or particular information. This only indicates that in spite of furnishing all the documents and information, the insurance company has slept over the matter for over nine months. The insurance company could not have taken more than four to five months in settling the claim when once all the required documents are furnished. For this delay in settlement of the claim which amounts to deficiency in service the complainant is entitled to compensation. However, as admitted by Opposite Party No.1 the claim is not yet settled, therefore the claim is neither admitted nor repudiated. It is for the insurance company to settle the claim of the insured based on the terms and conditions of the policy. Merely because the insurance company has not settled the claim so far either way, no direction can be issued to the Opposite Party – Insurance Company to pay the insured sum itself. Therefore, it is necessary to given direction to the Opposite Parties to settle the claim of the complainant within two months from the date of the order. As stated earlier, the complainant is entitled to compensation for the deficiency in service on the part of Opposite Parties with regard to delay in settling the claim. Considering the facts and circumstances, in our opinion it is just and proper to award compensation of Rs.10,000/- including the cost of the proceedings. In the result, we pass the following:-

-:ORDER:-

1. The complaint is allowed in part.
2. The Opposite Parties are directed to pay compensation of Rs.10,000/- and settle the claim of the complainant within two months from the date of the order. In case, the decision of the insurance company goes against his interest, the complainant is at liberty to file fresh complaint.
3. Send a copy of this order to both parties free of costs, immediately.
4. Pronounced in the Open Forum on this the 30th Day of NOVEMBER 2009

C.C. NO.89/2009

DATED THIS WEDNESDAY THE 11th DAY OF NOVEMBER 2009

V.Santhi,

W/o Venkatapathi,

No.10/A, Kulandhai Street,

Salem. Complainant.

-vs-

M/s. Reliance General Insurance,

Shri Lakshmi Complex, Ist Floor,

Bharathi Street,

Omalur Main Road,

Swarnapuri, Salem 4. Opposite party.



This complaint is coming on 09.11.2009 for arguments before us in the presence of Mr.M.Vishal, Counsel for the complainant and notice served to the opposite party on 22.07.2009 but not appeared before this forum, called absent set exparte and after hearing the arguments of the complainant and having perused documents having stood for consideration till this date this forum passed the following:

ORDER

1. The case of the complainant is briefly as follows :

The complainant has purchased a 407-Maxi Cub- Tata Motors bearing Registration No.TN 54 – 5627 and insured with the opposite party bearing No.1000881528 for the period from 15.2.2008 to 14.2.2009. On 2.10.2008 the vehicle met with an accident near Satrakudi, Ramanathapuram District and a case was registered in the Satrakudi Police Station in Crime No.130/2008. The vehicle has been totally damaged. This matter has been intimated to the opposite party and they had also inspected the same and the claim form was filed. The complainant has submitted all the relevant records to the opposite party. The opposite party has to pay the insurance amount to the complainant as per the terms of insurance policy. But the opposite party has not taken any steps to settle the claim. On 1.2.2009 legal notice was issued by the complainant to the opposite party demanding to settle the claim of compensation. The opposite party has acknowledged the same on 2.2.2009 and sent a letter on 20.1.2009 stating that the claim has been repudiated. The act of



the opposite party amounts to deficiency in service and the complainant has suffered huge monetary loss and he has sustained mental agony to the tune of Rs.2,00,000/-. Hence , the complainant prayed to direct the opposite party (1) to settle the claim amount as per the claim form made to the opposite party of Rs.5,40,000/- along with interest at 18% from the date of claim till the date of realization and (2) to pay a sum of Rs.2,00,000/- towards mental agony and award costs.

2. The opposite party after receipt of notice, not appeared before this forum ; called absent and set exparte. Hence, there is no defence or rebuttal on his side.

3. Basing on the proof affidavit filed by the complainant Ex.A1 to A6 were marked. Exp.A1 is the RC book of the vehicle bearing Registration No.TN 54-5627 . Ex.A2 is the Insurance policy bearing No.l000881528 dated 15.02.2008 for the above vehicle. Ex.A3 is the Copy of the First Information Report. Ex.A4 is the letter given by the opposite party dated 19.12.2008. Ex.A5 is the Legal notice issued by the complainant to the opposite party. Exp.A6 is the acknowledgement for the receipt of the same.

4. The points for consideration is :

1. Whether there is any deficiency in service as alleged ?

2. If so, to what relief, the complainant is entitled to ?

5. POINTS. 1 & 2 : It is clear from the complaint and other documents that the complainant has purchased a 407-Maxi Cub- Tata Motors bearing Registration No.TN 54 – 5627 in Ex.A1 RC Book and insured with the opposite party bearing No.1000881528 for the period from 15.2.2008 to 14.2.2009 in Exp.A2 Insurance policy. On 2.10.2008 the vehicle met with an accident near Satrakudi, Ramanathapuram District and a case was registered in the Satrakudi Police Station in Crime No.130/2008 in Ex.A3 First Information Report. The vehicle has been totally damaged. This matter has been intimated to the opposite party and they had also inspected the same and the claim form was submitted to the opposite party. The complainanthas also submitted all the relevant records to the opposite party.


6. But, the opposite party has not taken any steps to settle the claim. Hence, on 1.2.2009 Ex.A5 legal notice wasissued by the complainant to the opposite party demanding to settle the claim and the opposite party has acknowledged the same on 2.2.2009 by Ex.A6 but not sent any reply in this regard. But on 19/12/2008 itself the opposite party sent Exp.A4 letter to the complainant stating that his claim has been repudiated as “Limitations as to use” as 21 persons traveled in the vehicle at the time of accident.

7. The Learned counsel for the complainant relied on the decision of our Hon’ble Supreme Court in the case of “B.V.Nagaraju –vs- M/s. Oriental Insurance Co.Ltd. Divisional Office, Hassan reported in 1996 (II) CTC 228 in which it was held that “ The misuse of the vehicle was somewhat irregular though, but not so fundamental in nature so as to put an end to the contract of insurance – Exclusion of terms of insurance policy must be read down so as to serve main purpose of policy to indemnify damage caused to vehicle “.

8. Likewise in the Decision of our Hon’ble National Commission in the case of “New India Assurance Co.Ltd – Appellant –vs- Narayan Prasad Appaprasad Pathak – Respondent” reported in II (2006) VPJ 144 (NC) it was held that if there is violation of terms of policy, claim to be settled on “non-standard basis”.

9. Moreover, the opposite party has not appeared before this forum even after receiving the notice, and so he was set exparte. So, it is clear that there is no rebuttal evidence or defence on the side of the opposite party. So, the opposite party has not proved that there were more number of passengers were traveling in the vehicle at the time of Accident. As the opposite party has not repudiated the claim, his act is nothing but deficiency in service.

10. The complainant has claimed Rs.5,40,000/- towards the damages of his above vehicle. The opposite party has not appeared and rebuked the claim in any manner. So, the complainant is entitled to an amount of Rs.5,40,000/- towards the damages caused to his vehicle. The complainant has claimed Rs.2,00,000/- towards mental agony due to his deficiency of service on the part of the opposite party. The amount claimed is on the higher side. Hence, a sum of Rs.20,000/- can be awarded towards mental agony.







11. In the result, the complaint is allowed. The opposite party is directed (1) to pay a sum of Rs.5,40,000/- with interest at 9%p.a. from the date of claim till the date of realization and (2) to pay a sum of Rs.20,000/- towards mental agony and to pay a sum of Rs.5000/- towards costs. These awards shall be paid within a period of two months from the date of this order, failing which the complainant shall be at liberty to proceed under Section 25 and Section 27 of the Consumer Protection Act.



Dictated by the President to steno typist transcribed by her, and corrected and pronounced this the Wednesday the 11th day of November, 2009.

100.

NO: 224/6.7.2009

Decided on:03.12.2009


Neelam Gupta, aged 41 years wd/o Sh. Ravinder Kumar r/o H. No. 58-A, Ward No. 3, Garhdiwala, Distt. Hoshiarpur.


....... Complainant

versus


1.

Chief Executive Officer, Reliance Life Insurance (Anil Dhiru Bhai Ambani Group) No. D-29, Mahotra Tower, Regd. Office H-Block, Ist Floor, Dhiru Bhai Ambani knowledge City, Navi Mumbai (Maharashtra).
2.

The Manager-Incharge, Reliance Life Insurance, Chandigarh Road, Hoshiarpur.

............ Opposite Parties


Complaint u/S 12 of the Consumer Protection Act, 1986.


Quorum: Sh. P.D. Goel, President,

Sh. A.S. Jauhar, Member.


Present: Sh. B.B. Handa, Counsel for the complainant.

Sh. V.K. Menon, Counsel for the opposite parties.


PER P.D. GOEL, PRESIDENT:


1.

The complainant namely Neelam Gupta has filed the present complaint, under Section 12 of the Consumer Protection Act, 1986 (as amended upto date) “hereinafter referred as the Act”. In short, the facts of the case are that the husband of the complainant, Sh. Ravinder Kumar was insured under Reliance Money Guarantee Plan for Rs. 2,40,000/- with the opposite parties, who died in Civil Hospital, Hoshiarpur on 21.8.2008 i.e., after 9 days of taking the policy, due to Cardiac Arrest, Respiratory Failure. The complainant is the nominee of the insured.
2.

It is the case of the complainant that she handed over all the relevant papers regarding the death claim of her husband to the agent of the opposite parties on 10.11.2008. That despite of completion of all the formalities, the claim was not settled. Thus, the complainant served a legal notice on 13.1.2009.
3.

It is the allegation of the complainant that the period of five months has elapsed, but the opposite parties have not settled the death claim of her husband, hence this complaint.
4.

The opposite parties filed the joint reply. The preliminary objection with regard to suppression of material facts was raised. On merits, the claim put forth by the complainant has been denied. It is replied that the contract of insurance is void ab initio as the policy holder had suppressed the material facts regarding his health condition at the time of getting the insurance policy. The deceased-policy holder was a known case of ALD with HTN with Esophageal Varices with Cardiac diseases. That the deceased-policyholder was hospitalized in the month of August, 2008 for Liver Cirrhosis in Dayanand Medical College and Hospital, Ludhiana i.e., just 3 days prior to proposing for insurance with the opposite parties. The said fact was not disclosed at the time of filling up the proposal form , hence the opposite parties have rightly repudiated the claim on the ground of non-disclosure of material facts.
5.

However, it is admitted that the husband of the complainant, Mr. Ravinder Kumar had applied for Reliance Money Guarantee Plan Policy bearing No. 12390506 on August 11, 2008 with Risk Commencement Date (RCD) as August 12, 2008 for Rs. 2,40,000/-. The policyholder expired on August 21, 2008. That an investigation was carried out by the replying opposite parties. That as per the terms and conditions of the policy contract, since the deceased-policyholder had suppressed the material facts, so all claim benefits were not payable and the opposite parties had the legal right to forfeit the same. However, as a gesture of goodwill, the fund balance amount of Rs. 25,896.58 vide cheque bearing No. 141302 dated 26.2.2009, drawn on ICICI Bank was sent to the complainant, but she refused to accept the same.
6.

It is further replied that vide letter dated 26.2.2009, the complainant was informed about the repudiation of the death claim. The complainant is not entitled for the sum assured and the repudiation of the claim is legal as there is no contract of insurance between the policyholder and the insurance company.
7.

In order to prove the case, the complainant tendered in evidence his affidavit – Ex. C-1, copy of premium receipt dated 12.10.2008 – Mark C-2, insurance policy – Mark C-3, payment schedule – Mark C-4 (receipts-4 sheets), admission record – Mark C-5 (7 pages), legal notice – Mark C-6, letter dated 4.2.2009 – Mark C-7, letter dated 29.1.2009 – Mark C-8, benefit illustration chart – Mark C-9, another affidavit of the complainant – Ex. C-10 and closed the evidence.
8.

In rebuttal, the opposite parties tendered in evidence affidavit of Shaily Kaushal – Ex. OP-2, insurance policy – Ex. A1 (4 sheets), medical record of DMC – Mark A-2 (8 sheets), payment advice – Ex. A-3, letter dated 26.2.2009 – Ex. A-4, legal notice dated 13.1.2009 – Ex. A-5, reply to the notice dated 4.2.2009 – Ex. A-6, proforma policy – Ex. A-7 and closed the evidence on behalf of the opposite parties.

9.

The learned counsel for the parties have filed written arguments. We have gone through the written submissions and record of the file minutely.
10.

The learned counsel for the opposite parties submitted that the husband of the complainant, Mr. Ravinder Kumar (now deceased) had applied for Reliance Money Guarantee Plan Policy on August 11, 2008 with a sum of Rs. 2,40,000/-. It was argued that the complainant has alleged that the policyholder expired on August 21,2008 in Civil Hospital, Hoshiarpur due to Cardiac Arrest, Respiratory Failure. That despite of completing all the requirements, the opposite parties have not settled the claim. It was further argued that on receipt of the information with regard to the death of the insured, an investigation was carried out, wherein it came to light that deceased policyholder was a known case of ALD (Alcoholic liver disease ), Cirrhosis (liver failure – a late stage of liver disease) with Portal Hypertension (HTN) . He was also suffering from left Middle Cerebral Artery (MCA) with Complex Partial Seizures with Respiratory Failure with Esophageal Varices with Cardiac diseases. It was further argued that deceased-policyholder was hospitalized in the month of August 2008 i.e., just 3 days before proposing for insurance for Liver Cirrhosis and other complications of ALD etc in Dayanand Medical College and Hospital, Ludhiana. The said diseases were not disclosed by the policyholder holder at the time of filling up the Proposal Form. The proposal forms filled by the deceased-policyholder are Ex. A-1 and Mark C-1. It was further argued that Ravinder Kumar-deceased was a patient of Cirrhosis for 2 ½ years, a chronic smoker, a chronic alcoholic, thus deceased- Ravinder Kumar is guilty of concealment of material facts with regard to his ailment at the time of filling up the Proposal Form. The policyholder was suffering from pre-existing disease at the time of

obtaining the policy, therefore, the claim has been rightly repudiated by the opposite parties vide repudiation letter – Ex. A-4. The witnesses produced by the opposite parties – OW1 and OW-2, the treating doctors from DMC Ludhiana and Civil Hospital, Hoshiarpur have proved that the policyholder was a known case of ALD (Alcoholic liver disease), Cirrhosis with Portal Hypertension. He was also suffering from Hpersplenism with left Middle Cerebral Artery with Complex Partial Seizures with Respiratory failure with Esophageal Varices and also with Cardiac diseases.
11.

The learned counsel for the opposite parties argued that in Ex. A1 – proposal form, it has been specifically recoded that “every fact of materiality must be disclosed, otherwise there is a good ground for recession of the contract. The duty to disclose material facts continues right up to the conclusion of the contract and also implies any material alteration in the character of the risk which may take place between proposal and acceptance. If there is any misstatement or suppression of material facts, the policy can be called in question”.
12.

The claim has been repudiated vide repudiation letter – Ex. A-4, wherein it has been stated that late Mr. Lalit Ravinder Kumar submitted proposal for insurance on 11.8.2008. Questions No. 28 and 29 have been reproduced. The non disclosure of cirrhosis of liver was material to the issuance of the policy and ought to have been disclosed in the proposal form. By not doing so, the insured had misled to grant him insurance cover on the terms as stated in the policy schedule. In the light of the above facts, the insured had provided false and inaccurate answers, as such, the claim was repudiated in terms of section 45 of the Insurance Act, 1938.
13.

Now, the only point which calls decision from this Court is that whether the opposite parties were justified to repudiate the claim in terms of section 45 of the Insurance Act, as stated in the repudiation letter – Ex. A-4? The answer to this in the negative.
14.

Mark A-2 is the history of patient – Ravinder Kumar dated 20.8.2008. OW-1- Dr. Kanish Bansal had stated on oath that the patient Ravinder Kumar was admitted on 7.8.2008 in DMC, Ludhiana. The policyholder-insured was discharged on 20.8.2008 from DMC, Ludhiana. The Proposal Form – Mark A-1 was filled on 11.8.2008. This proves that the Proposal Form – Ex. A1 was filled by the insured namely Ravinder Kumar on 11.8.2008, when he was admitted in DMC, Ludhiana, as he was discharged from the said Hospital on 20.8.2008, as is clear from the discharge summary – Ex. A-2. Thus, it can be concluded without any hesitation that the Proposal Form – Mark A-1 was filled in the hospital by the insured – Ravinder Kumar on 11.8.2008, as he was admitted in the DMC, Ludhiana on 7.8.2008 and was discharged on 20.8.2008.
15.

Now, it is established on record that the Proposal Form – Mark A-1 was filled by the policyholder – deceased in the hospital, therefore, the duty was casted upon the insurance company – opposite parties to ensure that the policyholder was not suffering from any disease and in case, they failed to do so, the opposite parties are estopped from raising the plea that the insured had concealed the material fact regarding the ailment from which he was suffering at the time of obtaining the policy. It was open for the opposite parties – insurance company either to provide or not to provide the policy to deceased, Ravinder Kumar and it was for the insurance company to ensure that the policyholder at the time of filling up the Proposal Form – Ex. A-1 on 11.8.2008 was not suffering from any ailment.
16.

Admittedly, the insured was admitted in DMC Hospital, Ludhiana on 7.8.2008 and was discharged on 20.8.2008 qua Mark A-2. The said fact that the policyholder was admitted in the DMC Hospital on 7.8.2008 has also been admitted by OW-1 – Dr. Kanish Bansal, who was produced by the opposite parties.
17.

The matter does not rest here. The insurance company is further bound to seek the opinion from the doctors on panel with regard to the health of the person to whom insurance policy is to be issued and in this case, no evidence has come on the record to prove that the opinion of the doctor on panel by the insurance company – opposite parties was sought, therefore, the opposite parties cannot be allowed to take advantage from their own wrong. Thus, it does not lie in the mouth of the opposite parties that policyholder – Ravinder Kumar was guilty of concealment of material facts at the time of obtaining the insurance policy and also at the time of filling up the proposal form – Mark A-1.
18.

Dr. Kanish Bansal appearing as OW-1 has admitted in the cross-examination that the patient remained under the treatment of Dr. Narinder Pal Jain. Admittedly, said Narinder Pal Jain has not been examined to prove the diagnosis and the treatment administered to the policyholder.
19.

OW-2 – Dr. Tek Raj , Medical Officer, Civil Hospital, Hoshiarpur has admitted with regard to the systems of cardiac arrest on 21.8.2008. Dr. Tek Raj – OW-2 has also admitted that there can be many reasons for the cardiac arrest and the liver cirrhosis is not the only cause. This part of the statement of Dr. Tek Raj – OW-2, who has been examined by the opposite parties, proves on record that the liver cirrhosis is not the only cause of cardiac arrest and there can be other reasons also.
20.

It has been held by the Hon'ble National Commission that in case the insured suffers from diabetes and Coronary Artery Disease and the insurance company repudiates the claim for non disclosure of these diseases and the patient died due to cirrhosis of liver, which has no connection with Coronary Artery Disease, the insurance company is not justified to repudiate the claim. Reliance placed on 2009(3) CLT 228, New India Assurance Co. Ltd. Versus Arunaben Jayantibhai Shah.
21.

It has been held by the Hon'ble Punjab State Consumer Disputes Redressal Commission, Chandigarh in re-case Life Insurance Corporation of India versus Smt. Sukhwinder Kaur that in case the insured-deceased is a chronic alcoholic for the last 20 years and the said fact is concealed by the insured, and in that eventuality, the repudiation of the claim is unjust and unrealistic and taking of liquor is not a disease.
22.

It has also been held by the Hon'ble Punjab State Consumer Disputes Redressal Commission, Chandigarh in re-case 2009 CTJ 1308, Life Insurance Corporation of India and another versus Smt. Usha Rani, that Hypertension is not a material disease, which can be fatal itself and the claim cannot be repudiated on this ground.
23.

As a result of the above discussion, it is held that the opposite parties were not justified in repudiating the claim, which amounts to deficiency in service. Consequently, the complaint of the complainant is accepted and the opposite parties are direction to pay Rs. 2,40,000/- (the insured amount) to the complainant with interest @ 9% per annum from the date of filing of complaint i.e. 6.7.2009 till realization. Litigation expenses are assessed at Rs. 1,000/- to be paid by the opposite parties to the complainant. Compliance of the order be made within one month from the date of receipt of copy of the order. Copy of the order be sent to the parties free of cost. File be consigned to the record room.

Complaint No. 643/11.9.2008.

Date of order 4.12.2009.



1. Pran Nath Arora son of Sh. Harnam Dass Arora, aged 71 years, resident of 1108/1, Mukand Lal Road, Tegore Nagar, Civil Lines, Ludhiana.

(Complainant)

Vs.



1. M/s Paramount Health Services Pvt. Ltd. F-90/12, Near ESI Hospital, Okhla Industrial Area, Phase 1, Delhi-110020.



2. The Claims Manager, Reliance General Insurance Company Limited, 7th Floor, Surya Tower, 108, The Mall, Ludhiana.

(Opposite parties)



COMPLAINT UNDER SECTION 12 OF THE CONSUMER PROTECTION ACT, 1986.

------------------------------------------------------------

Quorum:

Sh. T.N. Vaidya, President.

Smt. Priti Malhotra, Member.



Present:

Sh. Stevon Soni Advocate for the complainant.

Sh. Rajiv Abhi Advocate for opposite parties.



O R D E R

T.N. VAIDYA, PRESIDENT:

1. Complainant obtained medi-claim insurance policy bearing no.1000479908 effective from 3.4.3007 to 2.7.2008 for a sum of Rs.5,00,000/- and paid premium of Rs. 28,397/- to the opposite party. During currency of the policy, complainant remained admitted in Indraprastha Apollo Hospital, New Delhi from 1.2.2008 to 8.2.2008 and again from 1.3.2008 to 8.3.2008. Spent Rs.2,72,566/- and Rs.2,53,473/- respectively towards medical expenses on treatment and lodged claim under the policy with the opposite party. But opposite party only remitted a sum of Rs.2,00,000/- and refused to pay the balance amount vide their letter dated 25.6.2008. Validity of not allowing the entire claim has been assailed in the present complaint under section 12 of the Consumer Protection Act, 1986 and claimed that he is entitled for Rs. 72,566/- and Rs.2,53,473/- along with Rs.50,000/- damages and cost Rs.10,000/-.

2. Opposite party admitted obtaining of insurance for Rs.5,00,000/- by the complainant and lodging claim thereunder, which was paid to the extent of Rs.2,00,000/- only. It is averred that claim of the complainant was referred to Paramount Health Services Pvt. Ltd., New Delhi a TPA licensed by the Insurance Regulatory and Development Authority. TPA after investigation repudiated the claim vide letter dated 27.5.2008 and 25.6.2008 on the ground that the sum insured is exhausted as there is sum insured capping of Rs.2,00,000/- only during the period of entire insurance from 3.4.2007 to 2.4.3008. The sum insured for this complication was capped within that sum insured. Capped amount of Rs.2,00,000/- stand paid to the complainant. He is not entitled for any further amount.

3. Parties led their evidence by way of affidavits and documents in support of their respective contentions.

4. We have heard the arguments addressed by the ld. counsel for the parties, gone through file, scanned the documents and other material on record.

5. The sole question surviving for determination is whether there was an agreement or contract between the parties restricting insurance claim to the tune of Rs. 2,00,000/- by way of putting caption on claim of the ailment.

6. Sh. Stevon Soni Advocate, Ld. counsel for the complainant, contended that there was no capping in the claim and insurance was obtained for Rs.5,00,000/- without any stipulation in the insurance contract for any capping upto Rs.2,00,000/- for any disease. Whereas Sh. Rajiv Abhi, ld. counsel for the opposite party contended that the present policy under which the claim was lodged was in continuation of previous policies provided in caption. Hence, under that caption, entitlement of the complainant was for Rs.2,00,000/- only, which stand paid and accepted by him. Therefore, the complaint deserves dismissal.

7. After considering rival contentions of the parties, we find ourselves in agreement with averments and contentions of the complainant. Because, in the insurance policy, copy of which is Ex.P1 (Ex.R.9) there was no condition of capping. This insurance policy was effective from 3.4.2007 to 2.4.2008. Under this policy, claim was lodged by the complainant and stand repudiated by its TPA, Paramount Health Services Pvt. Ltd. vide letter Ex.P5 dated 4.8.2008. Perusal of terms and conditions of the policy Ex.P1 (Ex.R.9) goes to show that the Insurance was subject to terms and conditions of the policy attached. Specific conditions were mentioned to be ‘NIL’. It means except terms and conditions of the policy attached therewith, there was no other specific condition attached to the same. Ex.P2 is copy of the terms and conditions attached with the policy. Condition no.1 of the policy is relevant, which reads as under:

1. Any one Illness:

“Any one illness will mean continuous period of illness and includes relapse within 45 days from the date of last consultation at the Hospital/Nursing Home where treatment was taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.”



8. So, after going through this condition no.1 of the policy Ex.P2, it is evident that illness will be taken to be one, if had again occured within 45 days from the date of last consultation/hospitalization where treatment was taken. If such disease reoccurs after a lapse of 45 days, then it shall be considered to be fresh illness.

9. In the present case, there is a proof and not in dispute that claim lodged by the complainant qua his ailment was of one illness as after first hospitalization in Indraprastha Apollo Hospital, New Delhi, he for the same ailment got treatment within 45 days of the first treatment. Hence, it has to be taken as one illness. Because, firstly he was admitted on 1.2.2008 to 8.2.2008 and thereafter again admitted on 1.3.2008 to 8.3.2008.

10. Whereas, opposite parties have relied on condition contained in previous policies obtained by the complainant effective from 3.4.2006 to 2.4.2007 (Ex.R11) and 3.4.2005 to 2.4.2006 (Ex.R12). Both these policies for the previous years Ex.R.11 and R.12 contain a stipulation restricting claim to Rs.2,00,000/- by way of caption. In both these policies Ex.R.11 and R.12 such conditions are similarly worded. So, we are only referring specific condition of the policy Ex.R.11 of the previous year policy valid from 3.4.2006 to 2.4.2007. It is mentioned as under in Ex.R.11:-

“This Insurance is subject to the terms and conditions of the policy attached.



Special Conditions: Liability of the Company in respect of the Insured person shall be restricted to Rs.2,00,000/- and domiciliary hospitalization Lim Rs.35,000/- each in respect of any expenses whatsoever incurred in connection with or in respect of any disease. Which was pre-existing at the time increase in sum insured to Rs.5,00,000/- each under medicalim policy with an insurer in India.”

11. It is apparent that in previous policies for the year 2006-07 and 2005-06, a specific condition was appended restricting claim and putting caption of Rs.2,00,000/- in connection with any disease. Whereas in the present policy Ex.P.1(Ex.R.9) no such specific condition was incorporated. Rather this specific condition column was referred as ‘NIL’. When there is no specific condition attached to the policy under which claim was lodged, condition which was binding between the parties during previous policies which stood lapsed, would not have atomically applied in the next policy, without any special agreement thereto. Complainant and opposite party never agreed for such condition of capping by putting such condition. In absence of contract, such condition of capping of the previous policies, consequently would not be attracted and applicable to the policy in question.

12. Hon’ble Union Territory Consumer Disputes Redressal Commission, Chandigarh in case titled as V.K. Gupta Vs. Raksha TPA Pvt. Ltd. & Anr. reported in 1 (2009) CPJ 130, in similar situated circumstances has held that if claim taken in previous year, then claimed in subsequent year with respect to the same disease, can not be restricted to same amount paid in previous year, as it was not disclosed. Hence, it was held that claim can not be restricted to Rs,1,00,000/- only. Same are the facts of the case in hand, as there was no agreement to restrict the claim under the policy in question.

13. Hon’ble West Bengal State Consumer Disputes redressal Commission, Kolkata in case titled as Sukanta Das Vs. National Insurance Co. Ltd. reported in II (2009) CPJ 294, held that where exclusion clause not incorporated in policy and not main part of the policy on its renewal, insurance company can not impose exclusion clause in later date.

14. This proposition with condition of the policy without any mention in the policy, do not bind the parties. We again refer to the case reported as National Insurance Co. Ltd. Vs. Kanta Kansal & Ors reported as 1 (2009) CPJ 260 (Rajasthan State Consumer Disputes redressal Commission, Jaipur)

15. Whereas, it is argued on behalf of the opposite party that complainant received Rs.2,00,000/- as full and final settlement of his claim, so, not entitled for any further amount and in support referred us to case reported as II (2009) CPJ 223 titled as Savitri Salt Suppliers Vs. Oriental Insurance Co. Ltd. decided by Hon’ble Tripura State Consumer Disputes Redressal Commission, Agartala and 1 (2001) CPJ 158 titled as Oriental Insurance Co. ltd. & Anr. Vs. Shashi Mohan Singh of Hon’ble Bihar State Consumer Disputes Redressal Commission, Patna. But there is no proof that complainant received Rs.2,00,000/- as full and final settlement of his claim. Therefore, the authorities would have no bearing to the case in hand.

16. It is as such apparent that opposite party and its TPA wrongly relied the clause of caption in the policy Ex.P1 (Ex.R9). Though there was no agreement of putting caption on the claim and no specific condition qua it was attached to the policy. Therefore, they wrongly and illegally rejected the claim of the complainant by restricting it to Rs.2,00,000/- only. Consequently, opposite party would be guilty of not rendering fare services to their own consumers.

17. As a result we allow this complaint and consequently direct opposite party not to apply clause of capping in the policy Ex.P1 (R.9) of the complainant and make payment after settlement of the entire amount of the complainant, so spent by him on his treatment and pay the entire amount minus Rs.2,00,000/- paid earlier, within 30 days of the receipt of copy of the order. For deficiency in service, opposite party also ordered to pay compensation of Rs.20,000/- to the complaint. Copy of order be made available to the parties free of costs. File be completed and consigned to record.

Consumer Complaint No: 61/2008

Date of presentation: 15.05.2008

Date of decision: 22/01/2010.


Chaman Lal S/O Shri Amar Singh,

Resident of Village Meerpur Kotla,

Post Office Trilokpur, Tehsil Nahan,

District Sirmour, H.P.

… Complainant.
Versus

Reliance General Insurance Company Limited

SCO 147-146, First Floor Madhya Marg,

Sector 9-C, Chandigarh-16009.

…Opposite Party.

For the complainant: Mr. Sandeep Aggarwal, Advocate.

For the Opposite Party: Mr. V.R. Chauhan, Advocate.

O R D E R:
Sureshwar Thakur (District Judge) President:- This instant complaint, has been filed by Shri Chaman Lal, by invoking the provisions of Section 12 of the Consumer Protection Act, 1986. The complainant avers that, he, is registered owner of Motorcycle bearing registration No. HP-18A-3848, which was insured by him, with the OP-Company. It is averred that, on, 26.04.2007, the aforesaid motorcycle was being driven by the brother-in-law of the complainant, who is working with him, in his shop for last three years, having valid driving licence, who was coming from Moginand to Kala-Amb, and when he reached near Salini bridge, a maruti car coming from the opposite side, hit the back portion of the motorcycle, as a result of which, it collided with parapet and fell down from the bridge, causing total loss. The factum of accident, was brought to the notice of the OP-Company, and thereafter the motorcycle was got repaired by spending a sum of Rs.27,719/-. Thereafter, the insurance claim was lodged with the OP-Company, for indemnification, who instead of settling it, dilly-dallied the same on one pretext or the other. Hence, feeling aggrieved and dissatisfied by the act of the OP-Company, the complainant appears that, there is apparent deficiency in service on the part of the OP-Company and accordingly relief to the extent as detailed in the relief clause be awarded in favour of the complainant.

2. The OP-Company, in its written version, to the complaint, contended that, the complainant, is, guilty of suppressio very suggestio, as he has detailed the name of the driver as Raj Kumar, in the claim form, whereas, in the complaint, one Karan Kumar, has been introduced, as driver. Though the loss was assessed by the surveyor at Rs.12,156/-, yet, it was payable subject to the terms and conditions of the insurance policy. Since, the complainant, has tried to mislead the insurance company, in order to get undue claim, hence, it is denied, that, there was any deficiency in service on their part or that they have indulged in an unfair trade practice.

3. Thereafter, the parties adduced evidence, by way of affidavits, and, documents in support of their respective, contentions.

4. We have heard the learned counsel for the parties at length and, have, also thoroughly scanned the entire record of the case.

5. The complainant, is, aggrieved by the act of the OP-Company, in not settling his claim, qua the damage caused to his insured motorcycle, in an accident, on, 24.06.2007, during the currency of the insurance policy. The OP-Company, in its reply has contended that, since the complainant, while lodging the insurance claim with it, has disclosed the name of the driver as Raj Kumar, whereas, in the instant complaint, he has averred, that, the motorcycle was being driven by one Karan Kumar, hence, it being infraction of the terms and conditions of the insurance policy, the OP-Company, is, exculpating its liability.

6. The only point, which requires adjudication, by this Forum, is, whether the OP-Company, has been able to prove the fact, that the motorcycle when, it, met with an accident, was being driven by Raj Kumar, and not by Karan Kumar, as averred by the complainant in the complaint. The OP-Company, is, placing reliance on Annexure OP-1, which is, a, copy of claim form, so submitted by the complainant to the OP-Company, wherein, the name of the driver, is, detailed, as Raj Kumar. However, the complainant, in the replication to the reply under paragraph 2 has categorically contended that the claim form was filled in, by the clerk of the OP-Company, wherein the name of the driver has been wrongly mentioned as Raj Kumar instead of Karan Kumar. The complainant, has also placed on record, Annexure-6, which is the copy of the report, prepared by SHO, Nahan, in which the name of the driver, is, also mentioned as Karan Kumar, who is also facing trial in the court of the learned Chief Judicial Magistrate, Nahan. Besides this, the complainant, has also placed on record, the copy of the driving licence possessed by Karan Kumar, Annexure-3, which is valid upto 21.09.2024, authorizing him to drive the motorcycle. Hence, from the above discussed, it is, candidly clear and established on record, that, at the time when the motorcycle met with an accident, on, 24.06.2007, it was being driven by Shri Karan Kumar, who was, also, having a valid and effective driving licence to drive, the motorcycle. Hence, in our considered view, the non-settlement of the claim of the complainant, by the OP-Company, on the purported ground that it was being drive by Raj Kumar, was, not legal and justified, and its non-settlement, tantamounts both to deficiency in service and an unfair trade practice.

7. Now comes the point of indemnification to which amount, the complainant, is, entitled from the OP-Company. Though, the complainant, is, claiming an amount of Rs.27,719/-, so spent on repairs of the motorcycle, yet, no material exist on record to substantiate the said fact. However, the OP-Company, has placed on record the affidavit of Shri A.K. Chatwal, Surveyor and Loss Assessor, who in his affidavit has made a deposition that the loss was assessed at Rs.12,156/-. This affidavit having remained un-repulsed and un-benumbed on record, on behalf of the complainant, has to be accorded sanctity, for lack of its rebuttal.

8. As a sequitor to the above, we allow this complaint and direct the OP-Company to indemnify the complainant to the extent of Rs.12,156/-, along with interest at the rate of 9% per annum, from the date of filing of the complaint, i.e. 15.05.2008, till actual payment is made. In addition to this, the OP-Company shall also pay litigation cost of Rs.1500/- to the complainant. This order shall be complied with, by the OP-Company within a period of forty five days, after the date of receipt of copy of this order, failing which it shall also be liable to pay punitive damages of Rs.5,000/-, to the complainant. Hence, in the above terms, the complaint stands disposed of.

9. The learned counsel for the parties undertook to collect the certified copy of this order from the office, free of cost, as per rules. The file after due completion, be consigned to record room.

Consumer Complaint No: 66/2008

Date of presentation: 12.06.2008

Date of decision: 21/01/2010.

Sh. Sardar Singh, S/o Jainda Ram,

R/o Village Kolar, Tehsil Paonta Sahib,

District Sirmour, H.P.

… Complainant.

Versus



Reliance Life Insurance Company Limited,

Through its General Manager,

Registered Office at H Block, Ist Floor,

Dhirubhai Ambani Knowledge City, Navi Mumbai,

Maharashtra-400710, India.

…Opposite Party.

For the complainant: Mr. Pradeep K. Saini, Advocate.

For the Opposite Party: Mr. V.R. Chauhan, Advocate.


O R D E R:

Sureshwar Thakur (District Judge) President:- This instant complaint, has been filed by Shri Sardar Singh, by invoking the provisions of Section 12 of the Consumer Protection Act, 1986. The complainant avers that, one Mr. Abhishek Leekha, approached him at, his home for advising him to invest money in the market return plan and accordingly, he, filled an application No.11756503 for the policy and deposited Rs.20,000/-. It is averred that thereafter, he also underwent medical examination and after completion of all the codal formalities, submitted the same to the OP-Company, who promised the complainant that the policy will be issued to him as early as possible, but despite repeated requests, the policy was not issued to him. However, the OP-Company, issued him cheque bearing No.034617 dated 12.11.2007, for an amount of Rs.20,000/-. Hence, feeling aggrieved and dissatisfied by the act of the OP-Company, the complainant avers that, there is apparent deficiency in service on the part of the OP-Company and accordingly relief to the extent as detailed in the relief clause be awarded in favour of the complainant.

2. The OP-Company, in its written version, to the complaint, raised preliminary objections regarding maintainability of the complaint, inasmuch, as, complaint being false, and suppression of material facts. On merits, it is admitted, that, the complainant did apply for Reliance Market Return Plan Policy, on 08.08.2007, for a sum of Rs.1,60,000/-, with an annual premium of Rs.20,000/- for a term of 16 years. It is contended that since the complainant failed to submit the consent letter for the CFR, that, was raised on October, 01, 2007, subsequently the policy was cancelled on, 01.11.2007, and a refund of Rs.20,000/- was issued. Hence, it is denied, that, there was any deficiency in service on their part or that they have indulged in an unfair trade practice.

3. Thereafter, the parties adduced evidence, by way of affidavits, and, documents in support of their respective, contentions.

4. We have heard the learned counsel for the parties at length and, have, also thoroughly scanned the entire record of the case.

5. The complainant, is, aggrieved by the act of the OP-Company, in not issuing the Reliance Market Return Plan Policy, in his favour, despite, the admitted fact of its having received the insurance premium. The OP-Company, in, its, reply has contended that, since the complainant, failed to submit, his, consent for the CFR, that was raised, on, 01.10.2007, as such, the policy was not issued to the complainant, hence, OP-Company, is, exculpating its liability.

6. The only point, which requires adjudication, by this Forum, is, whether the OP-Company, has been able to prove the fact, that, the complainant did not submit the documents to them, so as to enable them, to, issue the policy. However, this fact has been categorically denied by the complainant in his affidavit, wherein, he has made a deposition, that, all the required documents were submitted to the OP-Company, who, promised him, that, the policy will be issued to him later on. This affidavit having remained un-repulsed and un-benumbed on record, hence, it is to be construed, that, the act of the OP-Company, in, not issuing the policy in favour of the complainant, notwithstanding, the, fact that all the required formalities were completed by him, is, untenable. Besides, the, admitted fact of its having received premium, raises a tenable inference, that, it was so received them, only on the complainant, completing, all the ordained formalities, hence, estops them to raise an objection of non- completion of such formalities by him, which, subsequently raised objection, is, also, hence, merely an after thought, which clearly tantamounts to both a deficiency in service and an unfair trade practice.

7. Undisputedly, the draft bearing No.268725 for an amount of Rs.20,000/- was deposited with the OP-Company, on, 03.08.2007. However, the refund was received by him, on, 12.11.2007, that, too, without any interest. Since, the amount remained with the OP-Company, for the aforesaid period, and it has been utilized by them for their own benefit, hence, they, cannot, exculpate their liability to pay interest, on this sum, for the period, it, remained with the OP-Company, besides reasonable compensation. However since the complainant has not prayed for granting him relief of the OP-Company being directed to issue a policy in his favour, the, same being not sought for , is, refused.

8. As a sequitor to the above, we allow this complaint and direct the OP-Company to pay interest on the sum of Rs.20,000/-, at the rate of 9% per annum, with effect from 03.08.2007 upto 12.11.2007. In addition to this, the OP-Company, shall also pay damages of Rs.5,000/- to, the, complainant, for, causing him, pain and sufferings, besides litigation cost of Rs.1000/-. This order shall be complied with, by the OP-Company within a period of forty five days, after the date of receipt of copy of this order, failing which it shall also be liable to pay punitive damages of Rs.2,000/-, to the complainant. Hence, in the above terms, the complaint stands disposed of.

9. The learned counsel for the parties undertook to collect the certified copy of this order from the office, free of cost, as per rules. The file after due completion, be consigned to record room.

Consumer Complaint No: 265/2008

Date of presentation: 06.08.2008

Date of decision: 06.01.2010

Shri Ashok Kochhar S/O late Shri B.D. Kochhar,

Resident of Flat No.2, Block-C,

Regent House Apartment, The Mall, Shimla, H.P.
… Complainant.
Versus
Reliance General Insurance Company Limited,

Rain Basera Building Khalini, Shimla,

Through its Branch Manager.

…Opposite Party

For the complainant: Mr. S.S. Roach, Advocate.

For the Opposite Party: Exparte.

O R D E R:
Per, Charanjit Singh, Member:- The complainant, Shri Ashok Kochhar, has filed this complaint, by invoking the provisions of Section 12 of the Consumer Protection Act, 1986. The complainant avers that he alongwith his wife Smt. Karuna Kochhar, had obtained a policy known as ‘Hospitalization & Domiciliary Benefit Policy’ from New India Assurance Company, which was valid from 30.03.2007 to 29.03.2008. It is averred that, on, 27.03.2008, he was approached by Mr. Rohit, who was working as a Customer Service Officer in the OP-Company, and he advised and prevailed upon the complainant to obtain a similar policy of the OP-Company known as ‘Reliance Health wise Policy’ and thereafter he purchased the said policy and handed over the cheque of Rs.3,810/- drawn on Indian Bank, Shimla as premium. Thereafter, after completion of all the codal formalities, the necessary documents were submitted to the OP-Company through its aforesaid representative, but failed to issue the policy to him, instead a letter dated 12.05.2008, was received by him enclosing therewith documents and cheque of Rs.3,870/-. Hence, feeling dissatisfied and aggrieved by the act of the OP-Company, the complainant avers that there is apparent deficiency in service on the part of the OP-Company, and, accordingly, the relief to the extent, as detailed in the relief clause, be awarded in favour of the complainant.

2. Notice of this complaint was issued to the OP-Company, who failed to put in appearance before this Forum, despite the fact that notice was duly served upon it, for,13.10.2008, hence, was ordered to be proceeded against exparte, vide zimni order dated 13.10.2008

3. Thereafter, the complainant led evidence in the shape of affidavit/document, in support of his claim.

4. We have heard the learned counsel for the complainant and have thoroughly scanned the entire record of the case.

5. The grievance of the complainant, is, that the action of the OP-Company, in not issuing to him the Policy known as “Reliance Health wise Policy”, for which the OP-Company, had accepted the documents and cheque, amounts to a clear cut deficiency in service, hence, has sought for issuance of a direction to the OP-Company to issue medi-claim policy.

6. In so far as the prayer of the complainant with regard to issuance of direction to the OP-Company to issue medi-claim policy, is, concerned, we find that, such directions cannot be issued by this Forum, for lack of jurisdiction vested with this Forum. Rather, certainly, the complainant, is, entitled for compensation from the OP-company, for indulging in an unfair trade practice, adopted by the OP-Company, for the reasons to be observed hereinafter.

7. It is, the allegation of the complainant that the OP-company despite receipt of all the documents and insurance premium, from him, failed to issue medi-claim policy in his favour. In this behalf, the complainant has also placed on record documents and affidavit in support of the averments made in the complaint. The said averment, so averred in the complaint, having remained un-repulsed and un-benumbed on record, has to be accorded sanctity, for lack of rebut to it. Therefore, we have no hesitation in construing that the act of the OP-Company, in accepting the documents and premium for issuance of policy and then its failure not to issue the purported policy in favour of the complainant thereby causing him financial loss, not only amounts to a deficiency in service, rather, it shows their indulgence in an unfair trade practice.

8. Consequently, we allow this complaint and direct the OP-Company to pay compensation of Rs.25,000/- to the complainant, for causing him, financial loss, inconvenience and humiliation, within a period of forty five days, after the date of issue of this order, failing which it shall also be liable to pay interest on the aforesaid sum, at the rate of 9% per annum, with effect from the date of filing of the complaint, i.e. 06.08.2008, till actual payment is made. The litigation cost, is, quantified at Rs.1500/- payable by the OP-Company, to the complainant. The learned counsel for the complainant has undertaken to collect the certified copy of this order from the office, whereas, a certified copy of this order shall be sent to the OP through UPC, for compliance. The file after due completion, be consigned to record room.

CONSUMER COMPLAINT No. 22 / 2009

Langar Khan Mahabunnisa, W/o Late Silar Minuddin,

aged 35 years, Residing of 6/227, Ammavarisala,

Duvvur Village and Mandal, Kadapa District. ….. Complainant.

Vs.

1. Kapil Health Club Pvt. Ltd., Rep. by its

Chairman, 84, P & T Colony, Secunderabad.

2. Kapil Health Club Pvt. Ltd., Rep. by its

Executive Director, 84, P & T colony, Secunderabad.

3. Kapil Health Club Pvt. Ltd., Rep. by its

Branch Manager, Upstairs of Andhra Bank,

Badvel Branch, Badvel, Kadapa Dist.

4. Reliance General insurance Co. Ltd., Deccan Chambers,

4th floor, 6-3-666/B, Somajiguda, Hyderabad. ….. Respondents.
This complaint coming on this day for final hearing on 12-1-2010 in the presence of Sri P. Raghunatha Reddy, Advocate for complainant and Sri D. Rajasekhar Reddy, Advocate for R4 and R1 to R3 were called absent and set exparte and upon perusing the material papers on record, the Forum made the following:-


O R D E R



(Per Sri P.V. Nageswara Rao, President),



1. Complaint filed under section 12 of the Consumer Protection Act 1986.



2. The brief facts of the complaint is as follows:- The complainant was the wife of late Silar Minuddin. During the life time Silar Minuddin joined Kapil Health Club Pvt. Ltd., represented by opposite parties 1 to 3 as a Member in Kapil Health Club plan on 18-7-2007 at Badvel branch i.e. O.P. No. 3. As per the terms of the plan a Member should pay Rs. 6,000/- towards insurance i.e. accident death and permanent disablement for Rs. 2,00,000/- and Rs. 1,00,000/- respectively. Silar Minuddin paid Rs. 6,000/- on 18-7-2007 to O.P. No. 3, who issued a receipt to that effect. The O.P. No. 4 had business tie up with O.P. Nos. 1 to 3 and issued a policy bearing No. 1804-37-29-14-100008 with I.D. No. 096-00113-28262. Silar Minuddin died subsequently in a road accident near Duvvur. Therefore, O.P Nos. 1 to 4 had to pay Rs. 2,00,000/- to the complainant, who was the wife and nominee of the deceased Silar Minuddin. As the O.P’s failed to pay the amount inspite of oral demands made by the complainant, she got issued a legal notice, dt. 2-2-2008 to the O.P.Nos. 1 to 4. O.P. Nos. 1 & 2 did not receive a notice but O.P. No. 3 & 4 received notice but failed to give reply. Thus the complaint was filed against opposite parties jointly and severally to pay Rs. 2,00,000/- together with interest @ 24% p.a. from 18-7-2007 till the date of realization and Rs. 10,000/- towards damages for mental agony and Rs. 1,000/- towards costs.



3. Notices were served to R2 and R3 and Sri M. Nagi Reddy, Advicate filed Vakalath for R2 & R3 on 17-3-2009 and took time on different adjournments for filing counter and failed to file the counter even imposing costs on three occasions and atlast the R2 and R3 were set exparte on 12-8-2009. Notice was served to R1 and was set exparte on 18-8-2009.



4. The R4 alone represented through an Advocate and filed Vakalath and counter. The brief facts of the counter is as follows. The complaint was not maintainable because the entire transaction in between R1 and R4 was happened at Hyderabad and Secunderabad. R1 to R3 were one and same and it was a company. The R1 provided services under Kapil Health Club Pvt. Ltd., to its members. The R1 remitted premium to R4 at Hyderabad. The R4 issued Group Personal Accident policy bearing No. 1804-37-29-14-100008 for a period from 4-8-2007 to 3-8-2008 at Secunderabad only. Therefore, the District Consumer Forum, Kadapa had no territorial jurisdiction to entertain the complaint. The application for membership disclosed the jurisdiction was at Hyderabad and Secunderabad. Thus the petition was not maintainable. The coverage of the policy was from 4-8-2007 to 3-8-2008 and it was issued in favour of Kapil Health Club Pvt. Ltd., to its members by R4. The death of Silar Minuddin, who was a member of R1 was occurred on 21-7-2007 and same was registered in the death register issued by Tahsildar, Duvvur. Thus the death of deceased was out of purview of insurance coverage. Hence, the R4 company was not liable to pay any compensation. The complaint may be dismissed with costs as there was no deficiency of service on the part of this respondent.



5. On the basis of the above pleadings the following points are settled for determination.

i. Whether there is any negligence and deficiency of service on the part of the respondents?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?



6. On behalf of the complainant Ex. A1 to A4 were marked and on behalf of the respondent No. 4 Ex. B1 and B2 were marked. R4 filed written arguments.



7. Point No. 1 & 2 There was no dispute that the R4 insurance company issued a group personal accident policy bearing No. 1804-37-29-14-100008, I.D. No. 096-00113-28262 in favour of Kapil Health Club Pvt. Ltd., Secunderabad in which the deceased Silar Minuddin was a member and the cove rage of the policy was one year period with effect from 4-8-2007 to 3-8-2008. It was no doubt true that in case of accidental death the nominee of the Member should get Rs. 2,00,000/- from the Insurance Company. It was an admitted fact that late Silar Minuddin died on 21-7-2007 and to that effect a Xerox copy of the death certificate issued by Tahsildar, Duvvur was filed by the complainant under Ex. A2. Thus the death was prior to the effect of insurance policy i.e. to say the death of the deceased was out of the purview of the insurance coverage. The complainant filed a Xerox copy of receipt for Rs. 6,000/-, dt. 18-7-2007 issued by R3 to Silar Minuddin towards member ship fee in Kapil Health Club Pvt. Ltd., Secunderabad. Ex. A3 was Xerox copy of refundable membership certificate issued by Kapil Health Club Pvt. Ltd., Secunderabad under Kapil Health Club Plan. The R4 filed a Xerox copy of application for membership submitted by the deceased Silar Minuddin under Ex. B1 in which the complainant was shown as the wife and nominee of the member Silar Minuddin. Ex. B2 was Xerox copy of the personal accident insurance (Group) policy issued in favour of the insured M/s Kapil health Club Pvt. Ltd., Secunderabad. Therefore, the death of Silar Minuddin was prior to the commencement of policy under Ex. A4 issued by R4. The death of the Silar Minuddin was not covered under the said policy. Therefore, there was no deficiency of service or negligence on the part of the respondents. So the complainant is not entitled to any relief from the respondents. Hence, the points are answered accordingly.

8. Point No. 3 In the result, the complaint is dismissed without costs.

Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open forum, this the 19th January 2010

am rajdeep Singh belongs to distt. Ludhiana
i make an isurance of my car that is ford fiesta
my policy number :3001/55726241
dated : 26-12-2009

last week my car met an accident and get hit from back
and i sent that car to bhagat ford workshop at ludhiana
but they people said that i have to pay for the claim..
and also reliance people rejected to pay it as cashless

but i get this policy only on cashless bassis and that is also written on the cover note

on the time now,my car get ready from the workshop and they asked me to deposit the payment of bills and get the car
in the meantime i send many e-mails to reliannce general insurance company ,but no answer from there side
also i talked on phone with there representatives, they said that in this they can do nothin ,,,i have to pay first then they will give me cheque after 7 or 10 days


this is hirassment now...

i didnt get what was committed

and i get this insurance from :
Himanshu Jain
ph. 09988110736

he also said that he can do nothin

now what i have to do ,pls suggest me ...

Dear Sir dt 24.06.2010

your agent promised our service is promt and good

i have given my car renuval insurance on 17.6.2010 the agents taken photographs of my car and immediatly they are issued a cover note No : 110000247134, dt. 17.06.2010 agent code- 325757 , secundrabad. till date your agent not deposited chequee. i am waiting for policy. in case any accident of my car what is my rights to clime, the cover note is suffcianet with out payment of primum, becouse your not deposited till today

at the same time my two weelars also insured i am paid Rs. 610/-for Hero Honda Splendar
the another one is Suzike Access 125 paid through cheque

agent said on 18/6/2010 the splendar policy will handover the next day till today i am received policy or cash receipt of Rs.610/-, now how can i belive your agents. in case any thing (accident) what is my position tell me

kindly check your agents service, responce my complient immediatly

thanking you

M.SREEDHAR
MEGHAN AND MEDHA ASSOCIATES
#604, D-BLOCK, KANCHANJUNGA APT'S
ADITYA ENCLAVE
AMEERPET
HYDERABAD