DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, ERNAKULAM

Dated this the 27^th day of April, 2024

                                                                   Filed on: 15/12/2021

PRESENT

Shri.D.B.Binu                                                                          President

Shri.V.Ramachandran                                                              Member

Smt.Sreevidhia. T.N                                                             Member

C.C. No. 497/2021

COMPLAINANT

P.N. Venurajan Nair, Devisadanam, Inchoor, Kozhippilly, Kothamangalam, Pin-686691, Ernakulam District.

Vs

OPPOSITE PARTIES

1. Divisional Manger The New India Assurance Company Ltd. 2^nd Floor Rema Plaza Near, Ayyappan Temple S.S. Coil Road, Thampanoor Thiruvananthapuram, Pin-695001
2. Sr. Manager, The New India Assurance Company Ltd. Regd & Head Office, New India Assurance Building Mahatma Gandhi Road Fort, Mumbai, Pin – 400001.

(Rep. by Adv. Joy Joseph, J&J Associates, MRRA 82, New India Lane, Kochi 682028)

F I N A L   O R D E R

D.B. Binu, President.

1. A brief statement of facts of this complaint is as stated below:

The complaint was filed under Section 35 of the Consumer Protection Act, 2019.  In March 2021, the complainant approached a nearby Veterinary Hospital to insure his milch cow. Dr. Robin J. Paul from the hospital visited the complainant's house, inspected the cow, applied ear tags (Tag Number 42000/747075), and took photographs for documentation. The complainant completed the insurance formalities by remitting Rs. 1664 to the State Bank of India, Kothamangalam Branch, under the GOSAMRUDHI-2020-21 scheme on 25-03-2021.

Three months post-insurance, in June 2021, the cow fell ill, showing significant health decline and inability to feed properly. Dr. Paul was informed and commenced treatment on 21-06-2021, which continued intermittently until 01-07-2021. Despite this, the cow’s condition deteriorated, leaving it barely able to stand.

Dr Paul notified the first opposite party, the insurance authority, of the cow’s condition and requested the deployment of their panel doctor to assess the cow. This request was declined. Following this, the insurance authority advised Dr. Paul to compile a detailed report including photographs of the cow and hinted at the disposal of the animal. Dr. Paul and the complainant submitted all necessary documents and evidence to support the insurance claim.

On 30-09-2021, the insurance authority rejected the claim, citing a discrepancy between the colour of the cow as documented in the insurance policy and the colour of the cow in the photographs submitted during the claim process. They erroneously stated that the cow was dead in the repudiation letter. Dr. Paul responded by resubmitting photographs from both the time of insurance and during the claim process, affirming that the identification marks matched. Despite this clarification, the insurance claim remained unsettled.

2) Notice

The commission sent notices to the opposite parties. The opposite parties subsequently appeared and submitted their versions.

THE VERSIONS OF THE OPPOSITE PARTIES: 1 & 2

The versions presented by the first and second opposite parties in the dispute over a Permanent Total Disablement (PTD) claim for a cow insured under the GOSAMRUDHI scheme of the Animal Husbandry Department, Kerala State, highlight the reasons for the denial of the claim. The cow was insured under policy number 76140047210400000032 with a tag number of 420007/747075. The claim was repudiated on September 30, 2021, because the identification marks of the cow, specifically its colour, did not match the insured cattle's details as per the insurance policy documents. The insured cow was documented as black in the proposal form, whereas the cow referred to in the PTD claim was of a different colour.

The policy, issued in the name of the Director of the Animal Husbandry Department, covered a black milch cow owned by the complainant for a sum of Rs. 60,000, with a coverage term from May 4, 2021, to May 3, 2024. The indemnity for a PTD claim under this policy is limited to 75% of the sum insured, which amounts to Rs. 45,000.

The insurance authority asserts that there is no deficiency of service or unfair trade practice on their part, as the claim was legally repudiated based on valid grounds. The authority contends that the complainant is not entitled to any compensation as the conditions and clauses of the policy were not met due to the discrepancy in the cow’s colour. The complainant stated that both opposite parties are jointly and severally liable for the issues and resultant damages.

4) . Evidence

The complainant filed a proof affidavit and 14 documents which are marked as Exhibits A-1 to A-14.

Exbt. A1 – Receipt of the amount remitted

Exbt. A2 -   Copy of the treatment certificate

Exbt. A3 -   Copy of the letter by the United Insuracnce Company, Thiruvananthapuram to Doctor Robn J. Paul

Exbt. A4 -   copy of the letter send by the complainant to Insurance Company

Exbt. A5 -   Copy of letter subjected with repudiation of cattle claim by the Insurance Company

Exbt. A6 -   Copy of claim document send by the Doctor

Exbt. A7 -   Copy of the letter send by the Doctor for the second time

Exbt. A8 -   Copy of the photographs send by the Doctor

Exbt. A9 -   Copy of cash bill (Medical)

Exbt. A10 - Copy of animal claim form

Exbt. A11 - Copy of description of animal form

Exbt. A12 – Copy of the insurance policy number

Exbt. A13 - Copy of the insurance tag number

Exbt. A14 - Copy of the disablement report by the doctor

The opposite parties filed 3  documents, which were marked as Exhibit B1 to B3.

• Exhibit B1: True copy of the Memorandum of Understanding (MOU) between the Department of Animal Husbandry, Government of Kerala (GOK), and New India Assurance Company, concerning the Comprehensive Livestock Insurance Scheme - GOSAMRUDHI, based on which Policy No. 76140047210400000032 was issued.
• Exhibit B2: True copy of the photos of the cattle submitted with the proposal for insurance.
• Exhibit B3: Original photos of the cattle submitted along with the claim form.

5) The main points to be analysed in this case are as follows:

i)       Whether the complaint is maintainable or not?

ii)      Whether there is any deficiency in service or unfair trade practice from the side of the opposite party to the complainant.

iii)     If so, whether the complainant is entitled to get any relief from the side of the opposite party?

iv)     Costs of the proceedings if any

6)      The issues mentioned above are considered together and    answered as follows:

In the present case in hand, as per Section 2(7) of the Consumer Protection Act, 2019, a consumer is a person who buys any goods or hires or avails of any services for a consideration that has been paid or promised or partly paid and partly promised, or under any system of deferred payment.  The Copy of the Payment receipt issued by the opposite parties (Exhibit A-1). Hence, the complainant is a consumer as defined under the Consumer Protection Act, 2019, (Point No. i) goes against the opposite parties.

The complainant has filed a consumer complaint alleging deficiencies in service and unfair trade practices by both the first and second opposite parties.

The complainant has filed a written argument note about a Permanent Total Disablement (PTD) insurance claim dispute involving a milching cow under the GOSAMRUDHI 2020-21 scheme, managed by the Animal Husbandry Department of Kerala State. Key points and sequence of events from the complainant's note are outlined below:

• The complainant initiated the insurance process by remitting Rs. 1664 through a Demand Draft at the State Bank of India, Kothamangalam branch, for a policy under the cow's tag number 420007/747075 on March 25, 2021. Several months later, the insured cow fell ill, showing severe symptoms and inability to stand.
• The complainant immediately reported the cow's condition to the government veterinary dispensary in Varappetty, Kothamangalam, Ernakulam District. Dr. Robin J Paul from the dispensary started treating the cow on June 21, 2021, for ten days, but the treatment did not improve the cow’s condition.
• Dr. Paul informed the first opposite party about the cow's situation and requested the deployment of their panel doctor to inspect the cow. However, due to the COVID-19 lockdown, the request was denied, and the first opposite party authorized the disposal of the cow and requested photographs and a detailed report of the cow’s condition and treatment.
• On September 30, 2021, the first opposite party repudiated the claim, stating that the colour of the cow in the photographs submitted with the insurance proposal did not match the colour of the cow in the claim documents.
• In response, Dr. Paul and the complainant submitted all necessary documents, including photographs from the time of insurance and during the claim, which affirmed that the identification marks and tag number matched the insured cow.
• Despite these efforts, the first and second opposite parties repudiated the claim, citing discrepancies in the photographs of the insured and diseased cow, which the complainant asserts is false and that the original photos match.

The complainant requests the Consumer Commission to issue an order allowing the claim, including treatment costs, court costs, compensatory costs, and interest, due to alleged negligence and deficiency in service by the first and second opposite parties.

The counsel for the opposite parties submitted an argument note regarding a dispute over a Permanent Total Disablement (PTD) claim under the GOSAMRUDHI scheme, administered by the Animal Husbandry Department of Kerala State. The case centers on the repudiation of an insurance claim due to discrepancies in the identification marks of the cow in question.

Key Points Presented by the Counsel:

1. Documentation and Evidence: The opposite parties (OP 1 & 2) filed a version, proof affidavit, and documents (marked as B1 to B3), which were accepted without objection.
2. Discrepancies in Identification: The claim was denied because the colour and physical features (forehead, style and shape of horns) of the cow in the claim documents (Exhibit B3) did not match those of the insured cow as documented in the initial proposal form (Exhibit B2). These differences were deemed significant and clear, leading to the conclusion that the claim was for a different cow than the one insured.
3. Policy Terms and Legal Grounds: The liability of the opposite parties, as outlined in the policy and the Memorandum of Understanding (MOU) (Exhibit B1), is restricted to the terms, conditions, and clauses specified. The policy covered a black milch cow in the name of the complainant with a sum insured of Rs. 60,000. However, the indemnity for a PTD claim under the policy is limited to 75% of the sum insured, amounting to Rs. 45,000.
4. Claim Procedure and Indemnity Limitations: As per the MOU (Exhibit B1), the indemnity is explicitly limited to 75% of the sum insured for a PTD claim. This caps the potential liability at Rs. 45,000 for the present claim.
5. No Deficiency or Unfair Practice: The counsel asserts that there was no deficiency of service or unfair trade practice by the opposite parties. The claim was repudiated based on valid, legal grounds as the cow claimed did not match the insured cow based on the physical examination of the photographs submitted at the time of the insurance proposal and during the claim.

The counsel for the opposite parties requests that the Commission consider the version, deposition in the proof affidavit, and documents submitted by them and dismiss the complaint against them, potentially with costs. They maintain that the complainant is not entitled to any amount as claimed due to the discrepancies in the identification details of the cow.

We have carefully heard the submission made at length by the learned Counsel representing both parties and considered the entire evidence on record.

The complainant approached the Veterinary Hospital to insure his milch cow under the GOSAMRUDHI-2020-21 scheme. After the cow fell ill and despite notifying the insurance authority and submitting all required documents, the insurance claim was rejected based on discrepancies concerning the cow's colour and alleged misidentification.

1. Maintainability: The complainant has duly completed the transaction for the insurance of the cow and thus is recognized as a consumer under Section 2(7) of the Consumer Protection Act, 2019. The complaint is thus maintainable.
2. Deficiency in Service and Negligence: The failure of the insurance authority to dispatch a panel doctor upon request and the rejection of the claim based on a colour discrepancy that was later clarified constitutes a deficiency in service. The photographic evidence and the verification by Dr. Paul affirm that the insured cow and the cow in the claim are the same, challenging the grounds for claim denial.
3.  Liability of the Opposite Parties:

     Dr. Paul acted within his professional capacity, leaving the liability primarily with the insurance authority, which failed to adequately verify the claim despite clear evidence.

The Supreme Court in National Insurance Co. Ltd vs Swaran Singh & Ors, 5 January 2004 (AIR 2004 S C 1531), has held that insurance claims should not be denied on trivial technical grounds and that the consumer's interests should be protected unless there is a material breach affecting the risk covered.

The opposite parties failed to act in the best interest of the consumer by adhering to the procedural formalities rather than addressing the substantive issue at hand—the health and subsequent claim concerning the insured cow.

We determine that issue numbers (i) to (iv) are resolved in the complainant's favour due to the significant service deficiency and the unfair trade practices on the part of the opposite parties. Consequently, the complainant has endured considerable inconvenience, mental distress, hardships, and financial losses as a result of the negligence of the opposite parties.

In view of the above facts and circumstances of the case, we are of the opinion that the opposite parties are liable to compensate the complainant.

Hence the prayer is partly allowed as follows:

1. The opposite parties shall pay the insurance claim for the sum of ₹45,000 (Rupees Forty-Five Thousand Only) to the complainant as per the policy's indemnity limit for Permanent Total Disablement.
2. The opposite parties shall pay ₹15,000 (Rupees Fifteen Thousand Only) as compensation for unfair trade practices and the mental agony and hardship suffered by the complainant.
3. The opposite parties shall also pay ₹10,000 (Rupees Ten Thousand Only) towards the cost of the proceedings.

The Opposite Parties are jointly and severally liable to fulfil the aforementioned directives within 45 days of receiving this order. Should they fail to comply, the amounts specified in points (I) and (II) will accrue interest at 9% per annum, calculated from the date of filing the complaint (15-12-2021), until the date of payment.

Pronounced in the Open Commission on this the 27^th day of April, 2024Sd/-                                            

Sd/-

                                                                             D.B.Binu, President

Sd/-

V. Ramachandran, Member

Sd/-

Sreevidhia T.N., Member        

Forwarded/By Order

 Assistant Registrar  

Appendix

Complainant’s Evidence

Exbt. 1 –    Receipt of the amount remitted

Exbt. A2 -   Copy of the treatment certificate

Exbt. A3 -   Copy of the letter by the United Insuracnce Company, Thiruvananthapuram to Doctor Robn J. Paul

Exbt. A4 -   copy of the letter send by the complainant to Insurance Company

Exbt. A5 -   Copy of letter subjected with repudiation of cattle claim by the Insurance Company

Exbt. A6 -   Copy of claim document send by the Doctor

Exbt. A7 -   Copy of the letter send by the Doctor for the second time

Exbt. A8 -   Copy of the photographs send by the Doctor

Exbt. A9 -   Copy of cash bill (Medical)

Exbt. A10 - Copy of animal claim form

Exbt. A11 - Copy of description of animal form

Exbt. A12 – Copy of the insurance policy number

Exbt. A13 - Copy of the insurance tag number

Exbt. A14 - Copy of the disablement report by the doctor

Opposite party’s Exhibits

Exhibit B1: True copy of the Memorandum of Understanding (MOU) between the Department of Animal Husbandry, Government of Kerala (GOK), and New India Assurance Company, concerning the Comprehensive Livestock Insurance Scheme - GOSAMRUDHI, based on which Policy No. 76140047210400000032 was issued.

Exhibit B2: True copy of the photos of the cattle submitted with the proposal for insurance.

Exhibit B3: Original photos of the cattle submitted along with the claim form.

Despatch date:

By hand:     By post                                                  

kp/

CC No. 497/2021

Order Date: 27/04/2024