Pages (13) AHMEDABAD

Pages (13)

AHMEDABAD

OFFICE OF THE INSURANCE OMBUDSMAN (GUJARAT)

2nd Floor, Ambica House, Nr C.U. Shah College, Ashram Road, Ahmedabad-380014

Phone : 079-27546840, 27545441 Fax : 079-27546142

Case No. 11-005-0078-10

Mr. Gaurang R. Joshi V/s. Oriental Insurance Co. Ltd.

Award Dated 21-07-2009

Partial settlement of claim under Group Personal Accident Policy.

The Insured suffered an accidental injury causing a fracture in his right leg.

Doctor Deepak Bhatia (M.S.Ortho) treated him covering his leg by POP and

advised rest for 3 weeks. Subsequently the treating Orthopedist after removing

POP advised rest for further one week.

The respondent submitted that they obtained opinion of their two panel doctors

who opined that the complainant’s temporary total disablement (TTD) was for a

period of 3 weeks and accordingly compensated for 3 weeks.

The complainant submitted that though he started walking with crutches, he

was confined to home for 4 weeks and not for 3 weeks, he should be paid TTD

for four weeks.

Because the POP was for 3 weeks and the complainant started walking with

support, fourth week was a period of temporary partial disablement which is

not covered under the subject policy.

The decision of the respondent to settle the claim for 3 weeks TTD was upheld.

BHUBANESWAR

GROUP PERSONAL ACCIDENT POLICY

(1)

BHUBANESWAR OMBUDSMAN CENTER

Complaint No.14-011-0536

Sri Kamalakanta Das

Vrs

Bajaj Allianz General Insurance Co Ltd

Award dated 25th June 2009

Complainant had taken a Group Personal Accident Policy with Bajaj Allianz Gen Ins Co Ltd and

lost sight in one eye as a wooden chip while cutting wood hit it. A claim was lodged with the Insurance

Company along with all desired documents. But the claim has not been settled as yet.

Hon’ble Ombudsman heard the case on 17.03.2009 & 10.06.2009 where complainant was

present but Insurance Company was absent inspite of prior notice issued to them. Insurance company in

their self contained note submitted that the Medical Board certificate has been obtained by fraudulent

means. Hence delay in claim settlement.

On perusal of the documents filed by complainant in support of his claim and the document produced

by the insurer where the Medical Board of Balasore district has called complainant for re examination

by the board, Hon’ble Ombudsman directed complainant to face the board once again within 7 days of

receipt of the order and the Insurer to settle the claim on production of fresh Disability Certificate.

*************

BHOPAL

Group Personal Accident Policy

Category: Group Personal Accident Police

Sub Category: Total Repudiation of Claim

Order No.: BPL/GI/09-10/29 Case No.: GI/UII/0609/26

Order Dated 18th Sept., 2009.

Mrs. Rama Lohiya…V/s United India Insurance Co. Ltd., Bhopal …

Brief Background

Mr. A.K.Lohiya, Employee of Ujjain Sahakari Dugdh Sangh was covered under the Gruoup P.A. Policy No.191102/42/07/03/00000006 issued to M/s M.P.State Co-operative Dairy Federation Ltd. for the period from 27.04.2007 to 26.04.2008 for a Sum Insured of Rs. 5.00 lakhs by the United India Insurance Co. Ltd., Br. IV, Bhopal (hereinafter called Respondent)

As per Mrs. Rama Lohia, wife of Late Mr. Arun Kumar Lohiya (hereinafter called Complainant) lodged a complaint that his husband Late Sh. A.K.Lohiya was died on 27.11.2007 at Shamgarh Railway Station when he was going on official work and all the related claim documents were submitted for claim for Rs. 5,00,000/- to Respondent but the claim is repudiated by Respondent without giving any specific reason. The complainant approached the higher authority of the Respondent also but there is also no favorable response. Aggrieved with the decision of the Respondent, she approached this forum for necessary settlement of claim.

As per the self contained note together with other documents it is submitted by Respondent that the Claim is Repudiated because the cause of loss falls under Exception No. 5 (i & v). The Respondent further added that as per Police investigation report, it reveals that it is a case of suicide as there is no Ticket recovered from the body of the deceased, moreover, the Insured instead of using the Foot over bridge, chooses to cross the Railway track to go on the other side on the Station which is an offence and punishable under the provisions of the Railways Act which suggests that crossing of a Railway track and being heard tantamount to self inflicted injury. The Insured/deceased has certainly committed breach of Law by crossing the Railway track which is punishable under the Railways Act. Respondent further added in self contained note that Mr. Manoj .Gupta was deputed to investigate the above case who has also categorically stated in his report that the Insured’s death occurred on prohibited area.

Observations:

There is no dispute that Mr. A.K.Lohiya was covered under the above-mentioned policy for Rs. 5.00 Lakhs Sum Insured who died at Shamgarh Railway Station on 27.11.2007 due to Train Accident. The only dispute is for whether the claim is payable or not under the Policy conditions. During the course of hearing the complainant reiterated almost all the things as mentioned in her main Complaint and stated that the Claim is wrongly Repudiated by Respondent without going through the Merits of case as there are sufficient documents which proved that the above death is due to Rail Accident when her husband was at the Railway Station for going to Indore for his official Work. On the other side the Respondent explained that the Claim is Repudiated on the ground of Breach of the Policy terms and conditions No. 5(i), (v) of the Policy as already explained in their self contained note. The forum asked the Respondent to produce the document in support of their opinion that the deceased was crossing the railway line at the time of Accident, but even after their all out efforts to search in the File, none document could be shown &/or produced. Similarly, it was also asked to Respondent to explained under what Policy condition/clause the claim is repudiated, it was explained by Respondent by reading the condition No. 5(v) “The Company shall not be liable under this policy for death arising or resulting from the insured committing any breach of the law with criminal intent”. Then the Respondent was asked what criminal intent of deceased was there at the material time of incident in the above claim, but the Respondent neither replied in positive nor submitted any document to substantiate their decision of Repudiation. However, it is described by respondent that since, the body found on Railway Track, No Ticket is recovered from the body, hence, it is assumed that the deceased has committed breach of Law &/or it is a self intentional injury, suicide or attempted suicide.

In view of the circumstances stated above, the decision to repudiate the claim by Respondent is unfair and unjust as the same found taken merely on the basis of assumption without any concrete evidential support, without

thoroughly going through the Police investigation, P.M.report etc. On going through the produced and available documents i.e. Police Report, P.M.report

and Investigation report carried out by G.R.P. Shamgarh, it is found that there is no mention in any of the document that the deceased was crossing the Railway Lane with criminal intent and also there is no mention about any

suicide &/or attempted suicide. On the other hand, as per the details available in the Letter/certificate issued by G.R.P Shamgarh dated 16.9.2008

wherein it is certified that “On 27.11.2007 deceased Arun Lohiya was at Shamgarh Railway Station to go to Indore by Jodhpur-Indore Train and was waiting for Ranthambhore Express and at that time one Goods train

was haulted at Platform and the time was to cross the Rajdhani Express and the time was also to come Jodhpur-Indore Express. During this course the deceased moved little with here and there due to perplexion

and dashed by the Rajdhani Express causing death of deceased due to Rail accident”. Since, there is no evidence neither found nor produced by

Respondent to establish that there is violation of Policy condition No. 5(i) & (v), hence, the claim is found well payable. Therefore, the Respondent is directed

to pay the claim for Rs. 5, 00,000/- to the Legal heir of deceased within 15 days from the receipt of consent letter from the Complainant.

--------------------------------------END-----------------------------------------

CHANDIGARH

Chandigarh Ombudsman Centre

CASE NO. GIC/593/NIC/11/09

Meena Devi Vs. National Insurance Co. Ltd.

Order dated: 23rd April, 2009 GPA claim

FACTS: Smt. Meena Devi’s husband, Sh. Amar Nath was covered for GPA taken by M/s Asia Resorts under Hotel Package Policy vide cover note NO. 519328 dt. 24.02.2000 for period 24.02.2000 to 23.02.2001. Sh. Amar Nath had met with a road accident on 28.09.2000 and died on the spot. The complainant has submitted all the claim documents through the insured to insurer. However, her claim has not been settled.

FINDINGS: During the course of hearing, the insurer clarified the position by stating that death certificate from registrar of births and deaths was required. Since it was not submitted by complainant the case was made as no claim on 05.10.01. On a query, whether death certificate was available, the complainant stated that death certificate from ESIC and from Gram Panchyat, Solan were available. These documents were handed over to the insurer during the hearing.

DECISION: Held that the case was dealt with in a very lackadaisical and indifferent manner. No sensitivity has been shown to the members of the bereaved family. The absence of one certificate alone does not mean that the DLA had not expired. Taking the above into consideration, the payment should be made without any further delay along with simple interest @8% per annum from 05.10.01 till the date of payment to Smt. Meena Devi widow of the deceased Sh. Amar Nath. The payment should be made by 10.05.09.

CHENNAI

GPA-30.4.09

Chennai Ombudsman Centre

Case No.IO(CHN) 11.13.1379/2008 – 09

Mr. V.S. Sankaran

vs

HDFC ERGO Gen. Insurance Co. Ltd

Award 01 dated 30.04.09

The son of the Complainant, was covered under a Group Personal Accident Policy taken by

his employer from the insurer. During the policy period, the complainant’s son met with an

accident and passed away. The claim of the complainant was rejected by the insurer on the

grounds that at the time of accident, his son had been driving a two wheeler with engine

capacity exceeding 150cc.

The point to be considered is whether the rejection of the claim by the insurer on the

grounds of exclusion relating to driving of two wheeler having engine capacity exceeding

150 cc at the time of accident is in order.

The restrictive condition of 150cc seems to have been imposed without any compelling

reason and a casual addition to the Policy. It did not also prohibit the insured in driving four

wheeler vehicles having higher cubic capacities. There are differences between the entries

in the RC book and insurance policy copy regarding details of the vehicle. The employer’s

intention to exclude their young engineers who ride bikes with cubic capacity over 150 cc is

not established.

There is no record submitted to the effect that the coverage of the policy was explained to

the employees in a meeting or get together, news letter etc. Hence an Ex-Gratia of Rs.50,000/-

is awarded.

GUWAHATI

GUWAHATI OMBUDSMAN CENTRE

Complaint No. 11-011-0065/09-10

Mrs. Alomoni Munda …….. Complainant

- Vs -

Bajaj Allianz Gen. Insurance Co. Ltd. ….. Opposite Party/Insurer

Award Dated : 10.09.2009

Mr. Sulaman Munda, husband of the Complainant, was covered under a Group Personal Accident

Insurance Policy covering the period from 08.06.2008 to 07.06.2009 for a Sum Assured of

Rs.50,000/-. The Insured died on 23.06.2008 due to a motor vehicle accident. A claim was

lodged before the Insurer which was repudiated on the ground of non submission of required

documents.

The Insurer has contended in their “Self Contained Note” that in spite of their repeated

reminders, the Complainant has failed to submit the required documents and due to non

submission of the documents, the Insurer, they have closed the claim.

During hearing, the representative of the Insurer has stated that the Insurer has insisted

production of certain documents since 10.10.2008 but the Complainant has failed to submit

those documents. According to him, excepting the Death certificate, Postmortem report and

Police report, no other documents have been submitted and those submitted documents are not

sufficient to settle a claim. According to the Complainant, she had submitted all those

documents before the TPA – Golden Multi Services Club Ltd. and on receipt of the same, the

above TPA had forwarded all those documents to the Insurer. She has produced a copy of the

letter dated 14.03.2009 which goes to show that the TPA - Golden Multi Services Club Ltd., on

receipt of the documents, forwarded the same to the Insurer under Ref:

GMSCL/Claims/BPA/JC/01993 dated 14.03.2009. It appears from the above letter that though all

the documents required by the Insurer were not submitted, but the documents submitted by

the Complainant appears to be enough to prove the death of the Insured in connection with an

accident and also about his identity. The Complainant appears to have complied with the

requirements of the Insurer by producing relevant documents and it is for the Insurance

Company to reconsider the matter on the basis of the documents submitted. In case, the

Insurer has not yet received the documents forwarded by their TPA vide letter dated 14.03.2009

they may collect duplicate copies of such documents from their TPA and take appropriate action

in the matter. The Insurer was directed to dispose of the claim within 15 days from the date of

the Order.


Complaint No. 11-011-0195/08-09

Mrs. Benu Suklabaidya …….. Complainant

- Vs -

Bajaj Allianz gen. Insurance Co. Ltd. ….. Opposite Party/Insurer


Mr. Sajal Suklabaidya, son of the Complainant, was covered under a “Personal Accident Insurance

Policy” covering the period from 30.05.2005 to 29.05.2010. The Insured Sajal Suklabaidya

sustained burn injuries accidentally due to electrocution and died on 27.02.2008. A claim was

lodged with the Insurer who rejected the claim on the ground of non submission of certain

documents as called for by the Insurer regarding proof of death of the Insured.

The Insurer has contended that the Insured had no valid license or work permit to work with

electricity, but he had endangered his life by climbing on electric pole, which itself constitutes a

self inflicted injury and therefore a violation of the terms and conditions of the Personal

Accident Insurance Policy in terms of proviso 4 of the terms, conditions, exclusions, definitions.

During hearing, the representative of the Insurer has mentioned that the policy was issued on

the basis of the proposal wherein the column regarding “Occupation” was kept blank. The

proposal was accepted presumably waiving such particulars. But the “occupation column” in the

proposal form was kept blank and there is nothing on record to show that the Insured was

performing electrical jobs. The FIR, Police Investigation Report and other connected documents

also failed to disclose that the injuries were sustained by the Insured while climbing on the

electricity pole. It is also note that there is no document to establish the fact of climbing the

electricity pole by the Insured. When the representative of the Insurer was asked to state

whether the Insurer has got any proof to show that the Insured sustained injuries while working

with the electricity, his clear answer was in the negative. The copy of the FIR, Police report,

Final investigation report, Death certificate, Postmortem report are sufficient enough to prove

the death of the deceased / Insured due to burn injuries sustained because of electrocution. This

appears to be an accidental death as none can be expected to play with electricity intentionally

or work with electricity carelessly. So, the decision of repudiation of the claim appears to be not

on a justified ground which is set aside. The Insurer was directed to settle the claim within

fifteen days.


Complaint No. 11-011-0166/08-09

Mrs. Labanya Kumar …….. Complainant/Insured

- Vs -

Bajaj Allianz Gen. Insurance Co. Ltd. ….. Opposite Party/Insurer


Complainant’s son Binay Kumar was covered under Group Personal Accident Insurance Policy

under Bajaj Allianz Gen. Insurance Co. Ltd. covering a period of one year commencing from

23.08.2007 to 22.08.2008. The Insured died in a road traffic accident on 12.12.2007. The

Complainant had lodged a claim before the Insurer which was however repudiated by the

Insurance Company on the ground of non submission of some documents by the Complainant.

Being aggrieved, the Complainant had approached this forum for redressal of his grievances.

On receipt of the claim intimation, the Insurer considered production of some documents in order to

substantiate the claim. The letter produced by the Complainant proves that all the required

documents were submitted by the Complainant before the Insurer. Again the Insurer insisted

production of the following documents from the complainant, as it appears from the copy of their

letter dated 25-7-2008 :

1. Attested copy of charge sheet/Final investigation report of police bearing final report number.

2. Copy of Driving license bearing the signature of the insured/any authentic document

bearing the signature of the insured.

The police investigation report in final form referred to in section 173 Cr.P.C. is submitted by the police

on completion of usual investigation of a case and naturally it takes sufficient time and that is required

only to proceed with the criminal trial against the erring person(s). In the instant claim, the Insured

became the victim of the accident and his mother preferred the claim under the policy. When police

report, Copy of FIR and the post-mortem report has been filed in proof of death of the insured due to

injuries sustained in the accident, such documents appears to be sufficient to prove his death and

the insurer can easily act upon it. The copy of Driving License has already been submitted.

Under the above circumstances, the decision of repudiation of the claim is not proper and

justified. The Insurer was directed to settle the claim within fifteen days from the date of

receipt of the letter of acceptance of the Award from the Complainant.

KOCHI

OFFICE OF THE INSURANCE OMBUDSMAN, KOCHI

Complaint No.IO/KCH/GI/14-004-025/2009-10

Laly Suresh

Vs

United India Insurance Co.Ltd.

AWARD DATED 13.07.2009

The complaint under Rule 12[1][e] read with Rule 13 of RPG Rules 1998 is against repudiation of claim

under a personal accident policy. The complainant’s husband, being a toddy tapper, was covered under a

group personal accident policy. On 08.04.2007, he fell from a coconut tree and sustained injuries. He

was taken to General Hospital, Ernakulam. From there, he was referred to Medical College Hospital.

While under treatment there, he was found missing on 12.04.2007. Later his body was found on a

railway track as hit down by a train. The claim was repudiated on the ground that the insured

committed suicide by jumping in front of a running train. However, it was submitted that it was only an

accident and there is no reason to believe that he had committed suicide.

The policy is a personal accident policy, which covers death by accident only. The complainant herself

had admitted that while her husband was undergoing treatment at Medical College Hospital, Kottayam,

he was found missing and later, his body was found on the railway track. FIR was registered as a suicide

case. The police officer has given a report to Sub-Divisional Magistrate, Kottayam, that it was a case of

death by suicide. The place of death is kilometers away from Medical College. It is nowhere near his

house. He had no reason to go near the railway track. Hence it is a clear case of suicide and the complaint

is liable to be DISMISSED.



Smt.Merlin James

Vs

United India Insurance Co.Ltd.


The complaint under Rule 12[1][e] read with Rule 13 of RPG Rules 1998 is against repudiation of a claim under an accident package policy. The complainant’s husband, being a card holder of Margin Free Market, was covered under a group accident policy covering death due to accident for Rs.1,00,000/- during the period 18.10.2006 to 17.10.2007. He expired on 15.05.2007 due to injury sustained in the accident

occurred on 24.03.2007. The claim raised on 22.04.2008 was repudiated on account of delay in submission of claim application and delay in intimating the claim. It was submitted by the insurer that as per policy condition, immediately on the happening of the insured event, it must be intimated to the insurer, in any case not later than 30 days. Here the intimation was received after a period of 11 months. As this is an express condition under the policy, they are not liable to honour the claim. The contention of the complainant is that she was not aware of the existence of the policy. The policy was issued to Consumer Protection & Guidance Society. Also on death of her husband, she was in a depressed mood and was under treatment for the same for about one year. For about one year, she did not attend her job also. She came to know of the policy from one of her friends and immediately thereafter, claim was lodged with the insurer.

The policy was issued not to the complainant’s husband, but to the Consumer Society. Her husband was only the beneficiary. Hence it is likely that the existence of the policy was not known to the complainant. Apart from that, she was under treatment for depression for about one year. If she was under treatment for depression for one year, it will not be possible for her to raise the claim. But it looks that neither under the policy condition nor under the RPG Rules, there is a provision to condone delay. Here strictly speaking, the claim is not sustainable. But it is to be noted that the one month condition is stipulated for the purpose of conducting investigation. Here death was due to accident and there is no dispute regarding cause of death. Hence no prejudice was caused against the insurer by this delay. Hence there is no meaning in insisting compliance with procedure. All these procedures are only to advance the interest of justice and not to deny the same. Hence it is found proper to award an ex-gratia payment. An award is, therefore, passed directing the insurer to pay an amount of Rs.1,00,000/- as ex-gratia.



Smt.T.A.Ayisha

Vs

The New India Assurance Co.Ltd.


The complainant and her husband had together availed a housing loan of from SBI. On availing loan, they

were admitted to a group insurance policy taken by SBI from New India Assurance Co.Ltd., under which

the sum assured will be outstanding loan and interest as on the date of death of the insured. The

complainant’s husband died on 24.12.2005 as involved in an accident. The outstanding loan as on the

date of death was Rs.10,21,660/-. On death of one of the borrowers, the eligible amount as per policy

condition must be 50% of outstanding loan + interest i.e., Rs.5,10,830/-. The insurer allowed only

Rs.3,49,280/-. Aggrieved by this, she approached this forum. It was submitted by the insurer that the

outstanding loan of Rs.10,21,660/- is inclusive of Rs.90,248/- paid towards insurance premium. As it is

not a part of loan, they have reduced that amount from the claim amount. Apart from that, as per policy

condition, immediately on death, in any case within 30 days of death, intimation must be given to the

insurer. But the intimation was given only after 1 ½ years. Hence they are not bound to honour the

claim. However, on humanitarian ground, the claim was settled as sub-standard and 75% of eligible

amount was only paid.

There is no dispute to the fact that the insured died due to accident on 24.12.2005 and outstanding loan

and interest as on the date of death is Rs.10,21,660/-. Hence the eligible sum assured must be

Rs.5,10,830/-. Out of it, the insurer deducted Rs.90,248/- as the amount was paid towards insurance

premium and not as loan. However, on verification of the bank account held by the insured, it can be

seen that they have paid the amount directly to the Bank before deducting towards insurance premium.

Hence this recovery of Rs.90,248/- from the claim amount is faulty. Hence she is eligible for Rs.5,10,830/-

. As per policy condition, intimation of death must be given within one month of death. But death

intimation was given only after 1 ½ years. Hence the insurer has treated it as a sub-standard claim and

paid only 75% of the eligible amount. Hence the insured is eligible to get Rs.3,83, 122/-, but the insurer

has paid only Rs.3,49,280/-. An award is, therefore, passed directing the insurer to pay the balance

amount of Rs.33,842/- with 8% interest and a cost of Rs.1,000/-.



T.Vijayan

Vs

The Oriental Insurance Co.Ltd.


The complainant, as an employee of M/s Apollo Tyres Ltd., was admitted to Group Personal

Accident policy. On 20.01.2008, while on duty, he suffered crush amputation with loss of TP region

of left index finger. He claimed weekly compensation and medical expenses. Not satisfied with the

amount granted, he approached this forum for justice. It was submitted by the insurer that the

treating doctor has advised only 70 days of rest and they have paid compensation for that period.

The complainant is eligible for Rs.50,000/- as weekly compensation and also 25% of the sum assured

towards medical expenses. They have paid these amounts already and nothing more is payable as

per the policy condition. As per policy condition, only one benefit, which is favourable to the insured,

is payable i.e., either temporary disability benefit or permanent disability benefit. The disability was

assessed as 5% by the Board appointed for that purpose.

The insured is eligible for weekly compensation of Rs.50,000/- and medical expenses of rs.12,500/-

and hence the total eligibility is only Rs.62,500/-. He is not eligible for both, temporary and

permanent disability benefit. He himself had admitted that he had received a total amount of

Rs.62,500/-. Hence nothing more is payable as per policy condition and complaint is, therefore,

DISMISSED.

Documents

Pages (13) AHMEDABAD