The complainant Harbhajan Singh (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against United India Insurance Co. Ltd., and others (here-in-after referred to as opposite parties).
Briefly stated, the case of the complainant is that he is having a saving account No.021034028000489 with opposite parties No.2 & 3 in their Dhapali Branch. The complainant is duly insured with opposite parties under which all the account holders insured i.e. Group P.A. Policy. The opposite parties did not issue any Insurance Policy to the complainant, rather the same is still in the possession of the opposite parties.
It is alleged that complainant met with a roadside accident on 16.10.2016 and received serious injuries. He was admitted in Adesh Institute of Medical Sciences & Research, Bathinda. The left leg of the complainant was got crushed and it was amputated by the doctors of Adesh Institute of Medical Sciences & Research, Bathinda. The complainant had no knowledge on that date that he was insured with the opposite parties under any Bank Scheme for the sum of Rs.1.00 Lakh and Medical Treatment bills. The complainant was on bed upto Jan., 2017. When he visited opposite party No.3 in Feb., 2017, he came to know that he was insured with the opposite parties under P.A. Scheme. The complainant immediately lodged the claim with the opposite parties along with necessary papers i.e. photocopy of Police Report, photocopy of Discharge Slip of Hospital, photocopy of Passbook, photocopy of Bills & photocopy of Disability Certificate etc.
The complainant alleged that he requested all the opposite parties many times and requested them to to pay his claim as per P.A. Insurance Scheme but there is no response from them. The opposite parties appointed Mr. Satish Bansal as investigator who verified facts and took signatures of the complainant on blank papers with the assurance that the total claim of Rs.1.00 Lakh and medical expenses will be paid as per Insurance Policy.
It is alleged that opposite party No.1 issued one Letter Ref. No.BO BTI/PO/RBJ/2017/254 dated 24.10.2017 after one year, to the complainant with the illegal objection and against the facts and rejected the legal claim of the complainant with remarks that the claim is not intimated in time as the Intimation was given to Insurance Company after 3 month 24 days. The complainant got served legal notice upon the opposite parties on 31-12-2017, in this regard, but the opposite parties neither replied nor paid single penny to the complainant till date.
It is further alleged that opposite parties illegally and on flimsy ground rejected the Legal claim of Rs.1,60,000/- (Rs.1,00,000/- as per P.A. Insurance & Rs.60,000/- as Medical Expenses) of the complainant by using such type of illegal and vague clause of Late Intimation. Due to non-payment of the claim i.e. Rs.1,60,000/- by the opposite parties, the complainant has suffered mental agony and pains for which he claims compensation to the tune of Rs.15,000/-.
On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay total claim amount of Rs. 1,60,000/- with interest in addition to damages to the extent of Rs. 15,000/- besides Rs. 22,000/- as litigation expenses.
Upon notice opposite parties appeared through counsel and contested the complaint by filing written reply. Opposite party No.1 filed separate written reply raising legal objections that the complainant has concealed material facts and documents from this Commission as well as from the relying opposite party.
It is pleaded that the accident has taken place on 16-10-2016 but the complainant intimated the opposite parties No.2 & 3 in February, 2017 and the opposite parties No.2 & 3 intimated the relying opposite party vide letter dated 06-02-2017 but did not submit the DL,which is required for verification as this is an road accident case as per condition No.2. There is delay of 3 months 20 days in giving intimation to opposite party No. 1, as such the claim of the complainant rightly repudiated as no claim on account of violation of condition No.1 and 2 of the policy vide letter No. BO BTI/PO/RBJ/2017/254 dated 24-10-2017.
Further legal objections are that the complainant is not consumer of opposite party No. 1 and that the complainant has no locus standi or cause of action to file the present complaint against opposite party No. 1.
On merits, the opposite party No.1 denied that the opposite party No. 1 never issued the insurance policy rather the replying opposite party issued the insurance policy to opposite parties No. 2 and 3. It is also denied that the complainant has no knowledge on the day alleged accident that he was insured with the opposite parties under any bank scheme for Rs,1,00,000/- or medical treatment bills.
It is pleaded that the opposite parties No.2 and 3 submitted the claim of the complainant with opposite party No. 1 vide letter dated 06-02-2017 and there is delay of 3 months 20 days in lodging the claim which is violation of clause No.1 of the insurance policy. The opposite party No. 1 repudiated the claim of the complainant vide letter dated 24-10-2017. The opposite party No. 1 admitted that it deputed Mr. Satish Bansal as Investigator for verifying the facts but denied that the said investigator took any signatures of complainant on any blank papers with any insurance that the total claim or medical expenses is payable.
It has been pleaded that opposite party No. 1 legally repudiated the claim of the complainant as the complainant as well as opposite parties No.2 and 3 lodged claim after the delay of 3 months 20 days which is violation of clause No.1 of the insurance policy. The complainant is not entitled to any amount against the insurance. The allegations levelled by the complainant are totally false and baseless. It is denied that the opposite party No. 1 illegally or on any flimsy grounds rejected the legal claim of the complainant rather the repudiation letter is fully legal and valid and as per terms of the conditions of the policy. After denying all other averments of the complainant, the opposite party No. 1 prayed for the dismissal of the complaint.
Opposite party No.2 & 3 have filed joint written reply raising legal objections that the complainant has got no locus standi and cause of action to file the present complaint. The opposite parties No. 2 & 3 had paid the premium to the opposite party No.1, therefore, the opposite parties No. 2 & 3 are not liable for any claim as alleged by complainant.
It is pleaded that somehow if this Commission comes to the conclusion that the complainant is entitled to the claim, then the same is payable by the opposite party No.1.
Further legal objections are that the complaint is not maintainable; that the complainant does not fall under the definition of Consumer as defined under the 'Act'; that the complaint against opposite parties No. 2 & 3 is false, frivolous to the knowledge of the complainant and that the opposite parties No. 2 & 3 are not rendering any service to the complainant.
It is pleaded that the opposite parties No. 2 & 3 have made all required formalities regarding the claim of the complainant and had sent the claim along with all required documents to opposite party No.1 immediately after the intimation received from complainant and this fact has been admitted by opposite party No.1 vide his letter/reference No. BO BTI/PO/RBJ/2017/254 dated 24-10-2017, hence, opposite parties No. 2 & 3 have performed their duties as required and there is no deficiency on their part.
On merits, opposite party No.2 & 3 have pleaded that the opposite party No. 2 had deposited the premium of policy to opposite party No.1 and policy was to be issued by the opposite party No.1 but the complainant never complained regarding non supply of insurance policy by opposite party No.1. The claim of the complainant was sent to the opposite party No.1 and the claim has been repudiated by opposite party No.1. After denying all other averments of the complainant, the opposite parties No. 2 & 3 prayed for the dismissal of the complaint.
In support of his complaint, the complainant has tendered into evidence affidavit of Harbhajan Singh dated 17-05-2018 (Ex.C-1) photo copy of pass book (Ex.C-2),photo copy of disability certificate (Ex.C-3), photo copy of discharge slip (Ex.C-4) photo copy of DDR (Ex.C-5) photo copy of no claim letter (Ex.C-6) photo copy of legal notice along with postal receipt ( Ex.C-7) photo copy of circular ( Ex.C-8) and closed evidence.
To rebut the evidence of the complainant, opposite party No.1 tendered into evidence affidavit of Baldev Singh dated 30-07-2018 (Ex.OP-1/1), photocopy of DDR (Ex.OP-1/2) photocopy of letter (Ex.OP-1/3 and Ex.OP-1/4) photocopy of policy (Ex.OP-1/5) affidavit of Satish Kumar Bansal dated 12-09-2018 (Ex.OP-1/6) photocopy of investigation report (Ex.OP-1/7) photocopy of DL (Ex.OP-1/8) and closed evidence.
Opposite party No.2 and 3 have tendered into evidence affidavit dated 13-7-2018 of Yadwinder Singh (Ex. OP-2/1) and closed the evidence.
We have heard learned counsel for the parties and gone through the record.
These are admitted facts of the parties that complainant was having saving bank A/c with opposite parties No. 2 & 3 and he was insured under Group Personal Accident Insurance Policy of opposite party No. 1 vide No. 2004014716P104038010 from 1-6-2016 to 31-5-2017 (Ex. OP-1/5) under which all the account holders are insured. The complainant met with an accident on 16-10-2016. DDR No. 23 dated 21-11-2016 (Ex. C-5) was lodged in PS Phul, District Bathinda, in this regard. After accident, complainant was taken to Civil Hospital, Remapiura thereafter he was referred to Adesh Institute of Medical Sciences and Research, Bathinda, where he remained admitted till 21-11-2016 and his left leg was amputated due to serious injury. The complainant submitted claim with the opposite parties and opposite party No. 1 repudiated his claim vide letter 24-10-2017 (Ex. C-6).
Ex. C-6 is the letter dated 24-10-2017, vide which opposite party No. 1 repudiated the claim of the complainant on account of violation of condition No. 1 of the policy and for Non-submission of DL particulars of insured which was required for verification as this was an road accident case and original medical treatment papers/bill of hospital as per condition No. 2.
Condition No. 1 of Insurance Policy (Ex.-1/5) reads as under :-
“ Upon the happening of any event which may give rise to a claim under this policy the insured shall forthwith give notice thereof to the Company unless reasonable cause is shown the insured should, within one calendar month after the even which may give rise to a claim under the policy, give written notice to the Company with full particulars of the claim.”
In the case in hand, insurance of all the account holders was purchased by opposite parties No. 2 & 3 from opposite party No.1. It was a group policy wherein all the account holders were insured. Therefore, the policy was in possession of opposite parties No. 2 & 3. The opposite parties have not placed on file any document to show that terms and conditions of the policy were ever sent to complainant. Therefore, in such circumstances, the complainant/insured is not bound by such terms and conditions which were never furnished to him.
The complainant has pleaded that he was not aware about the insurance policy in question and remained on bed upto January, 2017 and when in February, 2017, he visited opposite party No. 3, he came to know about the insurance in question. Admittedly accident took place on 16-10-2016 and thereafter left leg of complainant was amputated and in such circumstances, keeping in view the serious injuries suffered by complainant, version of the complainant can be believed that he must have remained in shock and on bed upto January, 2017.
Ex. OP-1/2 is the copy of DDR No. 23 which was lodged on 22-11-2016, which proves the accident of complainant on 16-10-2016. After intimation by complainant, the opposite parties deputed Satish Kumar Bansal, Investigator, to investigate the claim in question of complainant. He has confirmed the accident, injuries to complainant and amputation of his left leg. The said Investigator has given observations that various records pertaining to the captioned GPA Injury claim case which includes bank, police and other records are verified and found in order.
Therefore, it is proved on file that claim of the complainant is genuine one although it has been filed/intimated late.
The I.R.D.A has issued circular regarding delay in claim intimation/documents submissions. For the sake of convenience, the circular is being reproduced as under :-
“ Ref No. IRDA/HLTH/MISC/CIR/216/09/2011 Dated 20-09-2011
C I R C U L A R
To : All life insurers and non-life insurers.
Re : Delay in claim intimation/documents submission with respect to
i) All life insurance contracts and
ii) All Non-life individual and group insurance contracts.
The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.
The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances.
The Insurers' decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.
Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.
The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurers' stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured."
From the perusal of aforesaid circular, it is clear that delay in intimation should not prevent settlement of genuine claim.
The opposite parties have also pleaded that complainant did not submit driving licence which is required for verification. The investigator checked the driving licence of the complainant and mentioned in his Investigation Report (Ex. OP-1/7) that in the DL name of Harbhajan Singh is mentioned as Mohar Singh meaning thereby that other particulars of driving licence are of Harbhajan Singh only, and has not disputed identity of Harbhajan Singh. Moreover, the said investigator has opined that Harbhajan Singh got injured in the accident with faulty Thrasher parked on the road due to darkness. Further more, it is proved on file that case of the complainant is genuine one. The opposite parties failed to show any law or condition in policy by which complainant is not entitled for claim. Thus, complainant is entitled for the claim under Personal Accident Insurance Policy and opposite parties cannot be permitted to frustrate the claim on technicalities. Hence, there is deficiency in service on the part of opposite party No. 1 in repudiating the genuine claim of complainant and complainant is entitled to claim amount.
The insurance policy in question is Group Personal Accident Insurance policy (Ex. OP-1/5). The complainant has placed on file Disability Certificate (Ex. C-3) issued by Civil Hospital, Rampura Phul which proves that complainant has suffered 75% disability due to accident in question.
In view of what has been discussed above, this complaint is partly accepted with Rs. 10,000/- as cost and compensation against opposite party No. 1 and dismissed qua opposite parties No. 2 & 3. The opposite party No. 1 is directed to pay sum assured amount of insurance policy in question to complainant with interest @9% p.a. w.e.f. 5-2-2018 (date of filing of complaint) till payment.
The compliance of this order by made by opposite party No. 1 within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record.
Announced :
17-12-2021
(Kanwar Sandeep Singh)
President
(Shivdev Singh)
Member
