Delhi

North

CC/101/2022

SUNIL KUMAR MATHURIA - Complainant(s)

Versus

FUTURE GENERAL INDIA INSURANCE COMPANY LIMITED - Opp.Party(s)

22 May 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No.: 101/2022

 

IN THE MATTER OF:

 

Sunil Kumar Mathuria

Proprietor,

 Kashi Vishwanath Travels, & Cargo

Shop No.: 47A, Shankar Market,

Tis Hazari Court Gate No.5,

Delhi-110054.                                                        …                 Complainant

 

Vs

 

Future General India Insurance Co. Ltd.

Through its Director,

Office No.3, 3^rd Floor,

Building AG-O-Squire, Sr. N.249+350,

Near Makar Chowk, Anundh Hinjewadi,

Link Road, Wakad, Pune-411057,

Maharashtra.

 

Regd. & Corporate office:-

Embassy 24X7, Park, 801 & 802,

8^th Floor, L.B.S. Marg, Vikhroli West,

Mumbari-400083, Maharashtra.                             …                 Opposite Party

ORDER

22/05/2024

 

Ashwani Kumar Mehta, Member:

 

1.       The present complaint has been filed under Section 35 of the Consumer Protection Act, 2019. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that:-

1. The Complainant purchased Accidental Suraksha Policy bearing Policy No.2019-A1662517-PAL, for a period of one year w.e.f. 21.04.2019 up till 20.04.2020 and paid the premium of Rs.2,734/-. The Policy covers accident Suraksha during the above mentioned period.
2. Unfortunately the Complainant met with a road accident , on 17.02.2020 at about 05:30 and was sustained multiple injuries in his body. The Complainant was firstly admitted in a Government Hospital i.e. Aruna Asaf Ali Hospital and after one week, he got admitted and medically treated in Sant Parmanand Hospital 18, Sham Nath Marg, Civil Lines Delhi-110054. Due to above accident, the Complainant was bed ridden for a period of one month (17.02.2020 to 16.03.2020) and had spent huge amount towards his treatment etc.
3. The Complainant informed the Opposite Party about the above said accident within time. After being physically fit, the Complainant made call to the Opposite Party for accidental claim but the Opposite Party did not give any response. Thereafter, the Complainant further made many calls on Customer Care number of the Opposite Party and somehow managed to get reply from the Opposite Party as the Opposite Party asked him to download a claim application form from the site of the Opposite Party and to send the duly filled form with treatment documents etc. to the Opposite Party for processing the claim covered under the above said policy. Therefore, as per demand of the Opposite Party, the Complainant sent the entire original treatment and medical document, original X-Ray with duly filled up claim Application Form by post on 22.06.2020 at claims department at Pune of the Opposite Party.
4. Thereafter, the Complainant made several calls on customer care number of the Opposite Party, but the Opposite party delayed the matter on one pretext and the other. Thereafter, official of the Opposite Party contacted the Complainant, somewhere in the month of the November 2021, on his mobile and asked him to get the above said policy renewed. The Complainant raised the issue of accidental claim, but the above said official/ agent advised the Complainant that if the complainant will get renewed Policy No.2019-A1662517-PAL, his claim will be settled as the official of the Opposite Party will talk from the head office of the Opposite Party to release the claim of the Complainant. The official of the Opposite Party further asked the Complainant to send fresh claim application with documents to the claim department. The Complainant told him that that the Complainant had already sent all the original treatment and medical document, original X-Ray on 22.06.2020 and he is having photocopy of the same. The official of the Opposite Party asked him to send the photocopies of the same at Pune office of the Opposite Party. Thereafter, the Complainant paid a sum of Rs.2,734/- to the Opposite Party on account of renewal of the above said policy.
5. On advised of above official of the opposite Party, the Complainant again sent the entire treatment/ medical document with duly filled claim form and Medical Certificate dated 01.12.2021 by post on 04.12.2021 to the Opposite Party at claims department at Pune.
6. However, the Complainant received a fresh Accident Suraksha Policy bearing No.A-3261997 dated 04.12.2021 for period w.e.f. 03.12.2021 up till 02.12.2022 in place of renewed policy No.2019-A1662517-PAL from the Opposite party for which the Complainant had already paid a sum of Rs.2,734/-. The Complainant immediately tried to contact the official Mr. Chandan at his mobile No.7827844787 but he did not pick up pone of the Complainant. Thereafter, the Complainant made call on the customer care number of the Opposite Party but despite many efforts did not get any reply from Opposite Party about his accident claim till the date which is clear cut violation of law.
7. The Complainant is running a very small shop in name and style of kasha Vishwanath Travels and Cargo and proprietor of the Kashi Vishwanath Travels and Cargo and income from the said shop is only source for the livelihood of the Complainant and is sole bread earner of the family. Due to above accident the Complainant was confined with bed for a period of one months and have suffered with great pain, shock, mental torture and agony besides the financial and emotional and dependency loss.
8. The Complainant is insured person under the policy No. No.2019-A1662517-PAL and is entitled for reimbursement of accident claim amount from the Opposite Party:-

1. Sum insured towards temporary Total disablement :Rs.2,00,000/-
2. Medical Treatment Expenses: Rs.7,083/-
3. Son and daughter Education Expenses: Rs.12.000/-
4. Transport Allowance towards visiting Hospital for treatment from Loni (U.P.) residence of the complainant to the Hospital: Rs.4,000/-.
5. Bed Rest Allowance Rs.6,000/-
6. Loss of monthly income Rs.35,000/-/

total Rs.2,64,083/-

 

2.       It has been alleged that the Opposite Party is acting in very arbitrary and illegal manner without fear of the law of land. Due to illegal act of the Opposite Party, the Complainant has become mentally disturbed and upset. In fact, the Opposite Party has mentally and economically tortured to the Complainant and has deprived the Complainant from his legitimate claim, for which the Opposite Party is liable and responsible. The intention of the Opposite Party was malafide right from very beginning towards the Complainant and in order to achieve nefarious goal the Opposite Party created a rosy picture and misrepresent about his policy with intentions to cheat the Complainant, in fact the Opposite Party has provided deficiency in services to the Complainant, thus, the Opposite Party cannot avoid and escape from his legal liability.

3.       The Complainant sent a legal notice to the Opposite Party on 09.03.2022 where by the Opposite Party was called upon to pay Rs.2,64,083/- (Rupees Two Lakh sixty Four Thousand Eighty Three Only) alongwith an interest @ 18% p.a. from 17.03.2020 on the said amount in cash to the Complainant within 15 days after receipt of this legal notice but despite the service of the legal notice the Opposite Party neither complied the legal notice nor sent any reply to the legal notice to the Complainant till date. The conduct, act and activity of the respondent/ Opposite Party is highly illegal, unwarranted, unfair unjustified and against the natural justice. Therefore, the Complainant has filed this complaint alongwith copies of the following documents:-

1. Policy No.2019-A1662517-PAL
2. Original postal receipt dated 20.06.2020
3. The entire medical treatment documents
4. Original postal receipt dated 04.12.2021
5. Medical certificate dated 01.12.2021
6. New policy bearing No. A 3261997
7. Legal notice dated 09.03.2020
8. Postal receipts and article tracking reports
9. Copy of Claim form alongwith the documents sent to the OP.

4.       The complainant has prayed to :-

1. Award a sum of Rs.2,64,,083/- (Rupees Two Lakh Sixty Four Thousand Eighty Three Only) with an interest @ 18% p.a. from 17.03.2020 in favour of the Complainant and against the Opposite Party up till actual realization of the same;
2.  Direct the Opposite Party to pay compensation of Rs.3,00,000/- (Rupees Three Lakh Only) to the complainant for causing mental agony, paid and suffering to him;
3. Direct the Opposite Party to pay litigation expenses of Rs.50,000/- (Rupees Fifty Thousand Only) to the Complainant;
4. Pass any further orders in favour of the Complainant and against the Opposite Party may kindly be also passed which this Hon’ble District Commission may deem fit and proper in the facts and circumstances of the case.

5.       Accordingly, notice was issued to the OP to defend the complaint before the Commission but the OP was proceeded Ex-parte on 04.08.2022 as OP was not appearing in this matter despite service and the reply filed by OP was not taken on record also in view of the fact that the OP filed reply on 23.09.2022 in the Registry of the Commission  vide diary no. 923 and statutory period for filing of reply by OP was already over on the date of filing of reply in the registry, in view of the judgment of Hon’ble Supreme Court in the matter of New India Assurance company Limited Vs. Hilli Multipurpose Cold Storage Private Limited, [(2020) 5 SCC 757] wherein it has been held that the Consumer Commission can neither extend the period for filing reply beyond statutory period of 45 days nor can accept the reply filed by the OP after the expiry of the said statutory period under the provisions of Consumer Protection Act. However, the OP was allowed to participate in the proceedings. The possibilities of settlement were also explored but failed.

6.       The complainant has filed evidence by way of affidavit and led the oral arguments. The OP has also led the oral arguments and stated that the OP has not repudiated the  claim in dispute  and it lying pending for want of following clarification/ information/ documents sought from the Complainant vide letter dated 17.08.2020 :-

1. Medical Fitness certificate mentioning the disability period with seal, signature and registration no. of treating doctor.
2. details of treatment taken during rest period (16-03-2020 to 17-04-20).
3. Duly Completed Personal Accident claim Form signed by Insured / Nominee along with completely filled Attending physician statement.

 

7.       The complaint has been examined on merits on the basis of the documents/evidences and material available on records and it has been observed that:-

i.       On the perusal of the Insurance Policy, it has been noticed that the complainant has taken Accident Suraksha Policy which is different than the Health Insurance or Life insurance policies and the benefits falling due in case of accident of the policy holder shall be admissible only on the basis of documents/medical records to be filed with the claim form upto the satisfaction of the insurer.

ii.      On perusal of the copy of the claim form and documents filed by the complainant, it has been found that the claim form is not duly filled and documents sought by the insurer vide letter dated 17-08-2020 has not been furnished by the complainant due to ignorance or misunderstanding of the requirements. 

8.       Therefore, we feel appropriate to direct the OP (Future Generali India Insurance Co. Ltd.) to depute a responsible officer immediately to contact the complainant personally to educate & assist him in filling up the claim form properly and submitting all the required documents as per the terms & conditions. Upon completing the formalities by the complainant, the OP shall process and decide the claim within 30 days from the date of receipt of all documents failing which the OP shall be liable to pay Rs.500/- per day till the decision of claim to the complainant. In case, the complainant is not satisfied with the decision of the OP, he may file fresh complaint in this commission as per the provisions of the CP Act, 2019.

9.       Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

           ASHWANI KUMAR MEHTA                                              HARPREET KAUR CHARYA

                           Member                                                                                 Member      

                  DCDRC-1 (North)                                                                       DCDRC-1 (North)

 

                                   DIVYA JYOTI JAIPURIAR

                                       President 

                                DCDRC-1 (North)