Pages (16) AHMEDABAD

Pages (16)

AHMEDABAD

Case No. 11-002-0077-10

Mr.Chetanbhai H. Makwana V/s. The New India Assurance Co. Ltd.

Awarded Dated 29-07-2009

Special Contingency Ins. Policy

Complainant lodged a claim for theft of his Laptop from his Motorcycle.

Claim repudiated by the Respondent Insurer on the ground of breach of

policy condition No.5 “negligence”, the applicant had kept Laptop on

Motorcycle unattended. The theft occurred due to gross negligence on the

part of the Complainant, hence claim is not admissible. Police FIR,

Investigation Report and Panchnama indicates negligence is on the part of

the Complainant. So rejection of the claim by the Respondent is justified.

Case No. 11-002-0155-10

Mr.U. H. Parikh Vs. The New India Assurance Co. Ltd.

Award Dated 31-08-2009

Partial settlement of claim under House holds Insurance Policy:

The insured had lodged his claim for damage to the electric motor and

External body of his washing machine. The Insurer had partially settled the

claim and rejected the partial claim in respect of damage to the body of the

washing machine invoking the provisions of the subject policy on breakdown

of Domestic Appliances.

The complainant submitted that due to sudden vibration, the machine fell

down causing damage to the body.

In support to his claim, he produced two different quotations

1) For Rs.3000/- dated 28-12-08 for damage to electric Motor and

2) For Rs.4750/- dated 11-12-08 for damage to the body.

The surveyor of the insurer assessed the loss for Rs.2850/- disallowing body

assembly on the ground that damage was not covered under the subject

policy.

Because it was not convincing why the insured obtained quotation of

different dates and secondly simply because of vibration in electric motor

the machine fell down in-spite of its perfect design, the forum passed an

order justifying the decision of Repudiation of the Insurer.

In the result the complaint fails to succeed.

BHUBANESHWAR

MISCELLANEOUS POLICY (GENERAL)

BHUBANESWAR OMBUDSMAN CENTER

Complaint No.11-003-0558

Sri Gyan Prakash Das

Vrs

National Insurance Co. Ltd., Bhubaneswar DO-II

Award dated 03rd July, 2009

Complainant is the sole proprietor of M/S Simtel and had insured his business premises

under Shopkeeper’s Insurance Policy of National Insurance Company. The premises was raided by

burglars in absence of Insured. A claim was lodged with Insurance Company. After receiving

intimation from complainant that the police have recovered the stolen articles from the burglars,

which were handed over on Zimma to him, the Insurance Company closed the claim. But all articles

were not recovered.

Hon’ble Ombudsman heard the case on 12.05.2009, in presence of both the parties. After

hearing both parties and perusing the documents like survey report and Police Investigation Report,

held that the all the stolen articles have not been recovered. Accordingly directed Insurance

Company to compare the list of stolen articles with that of the retrieved articles mentioned on the

seizure list and find out the articles lost but not found and accordingly settle the claim within 30 days

of receipt of consent letter.

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



Smt Padmini Brahma

Vrs

Oriental Insurance Co. Ltd., Berhampur DO

Award dated 07th Aug, 2009

Complainant had taken a Plantation Insurance Policy with Oriental Insurance Company Ltd,

for a crop of “Safed Mulsi”for the duration 11.11.05 to 10.11.06.The crop was affected by wild

elephant intrusion. A claim was lodged with the Insurance Company but was not settled on the

grounds of late intimation and inadequate precautions taken to safeguard the loss.

Hon’ble Ombudsman heard the case on 12.05.2009 & 20th July 2009, where both sides were

present. After hearing both sides and on perusing the documents produced by both sides including

the survey report, he has observed that the grounds for non payment of the claim are not tenable

and rather held that the assessment of surveyor is just and proper and directed insurer to pay Rs

2,98,000/-as per assessment.

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



Sri Bhajahari Parida

Vrs

National Insurance Co. Ltd., Balasore Branch

Award dated 25 th Aug 2009

Complainant had insured his poultry business premises under Shopkeeper’s Insurance Policy

of National Insurance Company Ltd. The premises was affected in a tornado causing loss of poultry

birds, poultry feed and the shed. A claim was lodged with Insurance Company. Even after submission

of the documents the claim has not been settled.

Hon’ble Ombudsman heard the case on 12.05.2009 & 20.07.2009, in presence of both the

parties. After hearing both parties and perusing the documents like survey report and bank stock

statements, he directed complainant to produce the purchase receipts etc, which were not

produced even after reminders from the forum. More over the complainant failed to explain the

disposal of the debris which worked out to several truck loads. Hon’ble ombudsman in his order

held that the complainant has not approached the forum in clean hands and hence dismissed the

complaint.

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



Sri Rabi Narayan Das

Vrs

New India Assurance Co. Ltd., Jajpur Road DO

Award dated 14th July, 2009

Complainant had insured his grocery shop under Shopkeeper’s Insurance Policy of New India

Assurance Company Ltd. A theft was committed in the grocery shop on 07.09.2006.Both police and

Insurer were informed. A claim was lodged, but has not been settled yet.

Hon’ble Ombudsman heard the case on 12.05.2009, in presence of both the parties. The

Insurance Company in their self contained note explained that the claim would be settled within 60

days of receipt of the Survey Report. Likely delay was for verification of stock statement. After

hearing both parties and perusing the documents like survey report and bank statement, held that

the assessment of loss could be arrived at by taking the Bank Statement as the basis with addition

and subtraction of stocks purchased and sold prior to the occurrence and directed insurer to settle

the claim within one month of receipt of the consent letter.

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



Sri Rabi Narayan Das

Vrs

New India Assurance Co. Ltd., Jajpur Road DO

Award dated 14th July, 2009

Complainant had insured his grocery shop under Shopkeeper’s Insurance Policy of New India

Assurance Company Ltd. A theft was committed in the grocery shop on 07.09.2006.Both police and

Insurer were informed. A claim was lodged, but has not been settled yet.

Hon’ble Ombudsman heard the case on 12.05.2009, in presence of both the parties. The

Insurance Company in their self contained note explained that the claim would be settled within 60

days of receipt of the Survey Report. Likely delay was for verification of stock statement. After

hearing both parties and perusing the documents like survey report and bank statement, held that

the assessment of loss could be arrived at by taking the Bank Statement as the basis with addition

and subtraction of stocks purchased and sold prior to the occurrence and directed insurer to settle

the claim within one month of receipt of the consent letter.

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



Smt Archana Somani

Vrs

ICICI Lombard Gen Insurance Co Ltd.

Bhubaneswar

Award dated 24th August 2009

Complainant had taken a Travel Insurance Policy with ICICI Lombard Gen Insurance Co Ltd.

While returning from Australia via Thai Airways, the flight to kolkata was cancelled due to sudden

strike. A claim was preferred on the insurer under “Trip cancellation and interruption clause” of the

policy. Insurer rejected the claim on technical grounds of interpretation of the clause.

Hon’ble Ombudsman heard the case on 21.07.2009 & 24 Aug 2009.On perusal of the policy

with the terms and conditions along with the document submitted by both sides, held that the

grounds of rejection of the claim by insurer is justified as per policy conditions and hence dismissed

the complaint.

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



Sri Radha Govind Jena

Vrs

National Insurance Co. Ltd., Balasore Branch

Award dated 22nd Sept 2009

Complainant had insured his book shop under Shopkeeper’s Insurance Policy of National

Insurance Company poultry birds, poultry feed Ltd. The premises were affected in storm and heavy

rain causing loss of stocks. A claim was lodged with Insurance Company. But the loss assessed was

less than policy excess so no claim was paid.

Hon’ble Ombudsman heard the case on 20.07.2009 &14.09.2009, in presence of both the

parties. After hearing both parties and perusing the documents like survey report and bank stock

statements, he observed that a number of items which are reflected in stock statement submitted to

the bank prior to incident has not been included in the surveyors assessment. So directed insurance

company to verify the list of items included in claim intimation with that of the bank statement and

compare with the survey report. Items left out be taken on their cost value and added to the already

assessed items for arriving at the final loss amount for settlement.

ENGINEERING



Sri Pradeep Kumar Beuria

Vrs

Oriental Insurance Co. Ltd., Bhadrak Branch

Award dated 21st April ,2009

Complainant had taken Contractor’s all Risk policy for construction of two roads as per work

order issued by an Executive Engineer of Orissa State Government. Due to flood in the area he

suffered huge loss on material stored at site on both the roads. He lodged a claim of Rs 7,16,035/-for

both work sites. But insurance company has delayed in settling the claims as yet.

Hon’ble Ombudsman heard the case on 21.01.2009 where both parties were present. After

hearing both parties and perusing the documents ,Hon’ble Ombudsman observed that the insurer as

per their self contained note is ready to settle the claim on production of the copy of Measurement

Book by the complain. As per direction of the forum he has already submitted the same collecting it

from office of the Executive Engineer and hence directed the insurer to settle the claim within 30

days of receipt of consent letter from complainant with instructions to provide copy of

Measurement Book to the Insurance Company along with the order copy by the forum.

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



Smt. Suryamani Sahoo

Vrs

Oriental Insurance Co. Ltd., Bhubaneswar D.O-I

Award dated 05th May2009

The Complainant had insured his excavator with Oriental Insurance Co. Ltd. The excavator met with

an accident on 18.11.2007.Complainant claimed on Insurance Company but the same was

repudiated on the ground that the damage was due to mechanical break down, which is an exclusion

under the policy.

Hon’ble Ombudsman heard the case on 16.03.2009 and 03.04.2009 where both parties were

present. After hearing both parties and perusing the documents Hon’ble Ombudsman observed that

the complainant is unable to produce any documentary evidence challenging the decision of

Insurers, and hence up held decision of repudiation

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

MARINE



Sri Himansu sekhar Das

Vrs

National Insurance Co. Ltd., Link Road Branch

Award dated 09 April ,2009

Complainant had insured his Fishing Trawler bearing No- ORM-JS(T)7933 with National

Insurance Co. Ltd. The Trawler was agrounded at EKAKULANASI off Paradeep coast on 04.06.2006.A

claim was lodged, which was repudiated by the insurance company on the grounds that negligence

on part of complainant was the major cause for loss.

Hon’ble Ombudsman heard the case on 19.01.2009 where both parties were present. After

hearing both parties and perusing the documents, Hon’ble Ombudsman held that the complainant

left the fishing vessel totally un attended resulting in reported theft of engine parts. The theft was

not reported to police either. Hence up held the decision of Insurance Company to repudiate the

claim & accordingly dismissed the complaint.

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

CHANDIGARH

CHANDIGARH OMBUDSMAN CENTRE

CASE NO. GIC/336/NIA/11/10

Karnail Singh Vs. New India Assurance Co. Ltd.

ORDER DATED: 18th September, 2009 Cattle Claim

FACTS: The complainant Shri Karnail Singh had purchased one buffalo after taking loan from the

bank under Govt. of Haryana Scheme. After some time the said buffalo died. The claim was lodged

with the insurance company. The company settled the claim and paid 50% of the claimed amount.

On query it was informed that the said buffalo was insured under Non-scheme animal and in such

cases only 50% of the sum insured is payable.

FINDINGS: The insurer clarified the position by stating that as per the indemnity clause a buffalo less

than 4 months pregnant can be considered only for payment of 50% of the sum insured. The

relevant indemnity clause states as follows:

“(1) If death occurs during any period and if the animal is pregnant for less than four

months, the indemnity will be restricted to 50% of Sum Insured or Market Value

whichever is less.

(2) In case of scheme animals, the policy is agreed value policy, hence claim will be

settled for 100% of Sum Insured.”

DECISION: As per the above clauses the claim is payable on 100% basis because firstly the buffalo

was more than 4 months pregnant and even if it was less than 4 months pregnant, since it is

purchased under a government scheme, 100% insured amount is payable. The insurer was hereby

order to make the balance payment of 50% of the sum insured to the complainant.


CASE NO. GIC/667/NIC/11/09

Subodh Abhi Vs National Insurance Co. Ltd.

Order Dated: 15th June, 2009 OTHERS

FACTS : The complainant Sh. Subodh Abhi had insured his residential building under Sumpurna

Insurance policy for the period 30.06.08 to 29.06.09. His building was damaged due to rains that

lashed several hours. The survey was completed on 23.08.2009. Several letters were written to

insurer. Another letter was written on 08.01.09 detailing the discussion with the surveyor and

explaining how rain storm was covered under time and allied perils in terms of the policy. However

the claim was repudiated.

FINDINGS : The insurer clarified the position by stating that the damage was due to a storage area

which was adjacent to the garage. As per cover note only residential building was insured. This

portion appears to be an adjunct of the residential building as per surveyor report. Moreover

damage due to heavy rain is not covered under the perils in the policy.

The branch manager along with the surveyor had visited the insured’s premises and he was

of the opinion that the damage of the cow shed does not form part of the residential building

DECISION: On going through the policy conditions carefully, it was found that Section II in respect

of residential building states as under:

“The residential building covered shall be the same contents of which are covered under

section (1) above.”

Section (1) relates to personal effects of the proposer and family members staying with the

proposer.

It was not sure whether the cattle shed and its contents can be classified under personal

effect of the proposer and family member staying with the proposer, even if the shed forms a part of

the residential building as claimed by the complainant. In the interest of justice and fair play, held

that the cattle shed and its contents are outside the scope of the insured premises as per the above

clarifications. Hence, the repudiation of the claim is, therefore, in order. No further action is called

for. The complaint is dismissed.

CHENNAI

MISC-29.5.09

Chennai Ombudsman Centre

Case No.IO(CHN) 11.05.1630/2008 – 09

Mrs. R. Pandiammal

vs

The Oriental Insurance Co. Ltd

Award 005 dated 29.05.09

The Complainant had covered her cow with the insurer and State Bank of India had

financed the animal. The insured animal died due to Acute Tympany disease. The insurer

rejected her claim for death of the cow on the grounds that the insured was not the owner

of the cow at the time of its death.

The Bank has informed in writing that the cow was temporarily left at the premises of the

insured’s brother when the insured was away. The investigator also could not prove with

evidence that the sale of the insured animal had actually taken place. Also the

investigator has based his finding on the letter that has been written by a person who

does not know to write and the letter has been written by some one else and read out to

him, and he has affixed his signature. Further, it is seen that the bankers are a

nationalized bank and the description of the animal insured tallies with the deceased

animal, which had undergone postmortem. The insured also has got a duty to clearly

satisfy the insurer regarding their requirements during settlement of claim as per the

claim procedure of the insurer. Since, insurer and insured are unable to submit clinching

evidence to prove their version of the ownership issue, the rejection of the claim only on

the basis of an investigation report which was not supported by any concrete legally

tenable evidence, an amount of Rs.10,000/- is awarded as Ex Gratia

DELHI

MISC

Case No.GI/26/OIC/09 In the matter of Shri Bipin Chandra Vs

Oriental Insurance Company Limited.

AWARD dated 22.06.2009

1. The only grievance in this case is with regard to load on the premium as well as

provision of excess on claims on renewal of the insurance policy no. 271702/48/2009/1415.

The normal rate of premium as per the policy holder, the normal premium rate as per the

Insurance Company, actual premium paid and load calculated by the policy holder and load

calculated by the Insurance Company are detailed hereunder:

Year Sun

Assured

Premium

paid

Normal

premium

as per the

policy

holder

Normal

premium

as per the

Insurance

Company

Load as

calculated

by the

Policy

holder

Load as

calculated

by the

Insurance

Company

2006-07 1 lakh

(including

Rs.30,000/-

as No

Claim

Bonus)

Rs.6250/- Rs.2658/- Rs.5554/- Rs.3592/- Rs.696/-

2007-08 1 Lakh Rs.8602/- Rs.2658/- Rs.7906/- Rs.5944/- Rs.696/-

It is submitted that there should not have been any load on the premium and the excess

amount paid should be refunded. Similarly it is submitted that there should not be any

excess calculation of claim amounting to Rs.10,000/- as done by the Insurance Company.

2. Before me it is submitted that load was added to the premium with the approval of

the Zonal Office considering the policy holder’s age which had crossed 80 years and for

similar reason excess was calculated on the claim to the tune of 10%. It is submitted that

the load or excess which is 10% of the premium/ sum assured should be considered

reasonable in the circumstances.

3. It was informed at the time of hearing that for the year 2008-09, the Insurance

Company has jettisoned the load considering that there was no claim in the intervening

years.

4. No one appeared on behalf of the policy holder.

5. Age of course is a relevant factor in adding the load to the premium or calculating

the excess amount to be deducted from the claim, but that should not be only factor.

Someone at the age of 82 can be fit and enjoying a normal healthy life or someone else at

the age of 57 may be ailing or not fit. Health therefore is a consideration, though age may

affect the health because of biological deterioration, but it is not so all the time. In the

instant case no claims have been made with reference to this policy in the preceding two

years. This is primary evidence for good health. In fact the Insurance Company itself has

jettisoned the load as well as the excess in the year 2008-09 considering that no claim were

made.

6. Considering these facts, I am of the opinion that for the preceding two years also the

load as well as the excess should be jettisoned and the excess amount paid should be

refunded to the policy holder.

7. Before parting with the order, I must also mention that in Insurance Company’s

calculation, the load is lower than the policy holder’s calculation. Apparently the policy

holder has calculated the normal premium with reference to the original sum assured i.e.

Rs.70,000/- which is subsequently increased because of addition of No Claim Bonus and

apparently the normal premium amount also has gone up. The Insurance Company will re-

check its calculation and return the excess amount calculated.

Case No. GI/33/NIC/09

In the matter of Smt. Maya Devi Vs

National Insurance Company Limited

AWARD dated 30.06.2009

1. The policy holder’s mediclaim of Rs.19449/- was settled for a sum of Rs.16161/-.

There was hospitalization only for one day, that is, on 30.04.2007. The policy

holder’s grievance is two fold. Firstly, there should not be any disallowance and

whole amount should have been allowed. Secondly, there is long delay in settling

the policy. The cheque of settled amount has been issued on 23.03.2009 whereas

hospitalization was on 30.04.2007.

2. At the time of hearing, with regard to disallowance, the representative of the

Insurance Company pointed out that this was as per the policy stipulations where

consumables were not allowable. As regards delay, he submitted that it was a

failure of the TPA.

3. Since disallowance is as per the policy stipulations no interference is called for. With

regard to the delay, the Insurance Company cannot shirk its responsibility by merely

putting the blame on TPA. TPA only acts on behalf of the Insurance Company. TPA’s

failure is, therefore, Insurance Company’s failure.

4. Accordingly, it is directed that interest should be paid at the rate of 8% on the settled

amount for the period of delay from the due date till the date of payment. The

compliance of the Award shall be intimated to my office for information and record.

by 31.07.2009.

5. Copies of the Award to both the parties.

KOCHI

OFFICE OF THE INSURANCE OMBUDSMAN, KOCHI

Complaint No.IO/KCH/GI/12-012-210/2009-10

Smt.Bindu Radhakrishnan

Vs

ICICI Lombard General Insurance Co.Ltd.

AWARD DATED 08.09.2009

The complainant is the account holder of ICICI Bank, Edapally. In September 2008, one Ms.Krishna

of Chennai Branch contacted her over phone and represented that she was selected as winner of a

lucky draw and that, herself and her family will be covered under a health insurance policy up to the

age of 70 years, on payment of a single premium of Rs.13,536/-. Later the insurance company

deducted the amount from her bank account and she got a soft copy of the policy by email. On going

through the policy, she understood that the coverage under the policy is only for one year and to

continue the policy after one year, it is to be renewed by paying premium. Immediately she sent a

request to cancel the policy and refund the entire premium deducted from her bank account.

However, she was informed by the insurer that, on surrendering, 75% of the amount will be deducted

and only the balance will be paid. Aggrieved by this, she approached this forum for justice. In the

complaint, she has alleged that the policy was mis-sold by giving false promise and violating all IRDA

norms. It was submitted by the insurer that the amount was deducted from her account only after

explaining to her everything in detail. All the conversation is recorded and nowhere in the

conversation it was stated that the policy will cover up to the age of 70 and also it is a single premium

policy.

The insurance company submitted the self contained note after going through the complaint of the

insured. Nowhere in the self contained note has the insurer denied the charge of the insured that she

was informed of winning a lucky draw. They have also produced CD of a recorded conversation to

substantiate their stand that everything was explained to the insured before deducting the premium

from her account. Nowhere in the conversation, it was stated that it a single premium policy and it

had coverage up to 70 years of age. It was also submitted on behalf of the insurer that no written

proposal form was received and everything was done as per recorded voice communication.

The insurance company is substantiating their stand only on the basis of recorded conversation. It is

likely that the recorded conversation may not contain all the details. It might be an edited one

particularly when it is in the control and custody of the insurer. It was informed by the insurer that

no confirmation was obtained from the insured as to the correctness of the recorded message. It can

be seen that the insurer had violated all the IRDA stipulations. As per IRDA guidelines, a written

proposal must be obtained and a copy of the same is to be given to the proposer along with the policy.

In this case, it has not been done so. No written proposal was obtained. Evidently the policy is sold

by giving false information that she was the winner of a lucky draw. Hence the policy was mis-sold

violating all the IRDA norms and hence the contract is to be treated as null and void. Further the

policy document was also not issued till date. An award is, therefore, passed directing the insurer to

pay the amount which was deducted from her SB Account with interest @ 8% p.a. and a cost of

Rs.1,000/-.


Complaint No.IO/KCH/LI/21-009-080/2009-10

Shri C.T.Madhusoodanan

Vs

Bajaj Allianz Life Insurance Co.Ltd.


The complainant had taken an insurance policy for an assured sum of Rs.50,000/-. He also

opted for hospital cash benefit as rider benefit. He met with an accident in July 2008 and

claimed the hospital cash benefit. However, it was repudiated on the ground that the policy was

issued without rider benefit and as such, the claim was not payable. However, it was submitted

by the insured that while proposing for insurance, he had opted for hospital cash benefit also and

he had produced a copy of the proposal form. It was submitted by the insurer that though he had

proposed for an insurance policy with rider benefit, later by letter dated 12.09.2006, withdrew the

option and hence the policy was issued without hospital cash benefit. The policy was issued in

September 2006 and accident occurred in July 2008. Though almost 2 years have lapsed, he

never complained that the policy was issued without rider benefit. Only after 2 years at the time

of arising a claim, he is disputing that he opted for a policy with rider benefit. During the time of

hearing, it was observed that the insured proposed for a policy with rider benefit. The letter

dated 12.09.2006 produced by the insurer requesting to withdraw rider benefit was not signed by

the insured. Finally the insurer agreed to cancel the policy and refund the entire premium paid

for which, the complainant also agreed. An award is, therefore, passed directing the insurer to

refund the entire premium paid.



E.A.Shaji

Vs

The New India Assurance Co.Ltd.


The complainant had insured his elephant, Yedukrishnan a/s Kiran, for a sum of Rs.2,00,000/-

covering the period 30.09.2007 to 29.09.2008. On 01.05.2008, it died due to liver dysfunction, anemia

and pneumonia. The claim was repudiated on the ground that the elephant is being ill-treated by the

owner which led to the death of the animal. It was submitted by the insurer that the Forest Range

Officer has filed a charge sheet against the owner of the elephant before the First Class Magistrate,

Kothamangalam, alleging the ill-treatment of the animal by the owner. The case is still pending.

Hence they can consider the claim only after disposal of the case. Also the owner of the elephant has

lodged a police complaint against the mahout for ill treating the animal. Hence there is every reason

to believe that the elephant was being ill treated before its death, which is against policy condition.

It was submitted by the complainant that there is no truth in the complaint of ill treatments. The

elephant was well taken care of and he had spent more than Rs.2,00,000/- for its treatment. Once he

had a quarrel with the mahout and the mahout threatened to kill the elephant by poisoning. On the

day the elephant fell, the mahout disappeared and suspecting foul play by the mahout, complaint has

been filed against him. The complaint before the Forest Range officer was filed before taking the

policy and the complaint was filed by some of his enemies; there is no truth in the complaint.

The main reason for repudiation of claim is the case filed before the Chief Judicial Magistrate. It is to

be noted that the FIR was registered on 24.04.2007 i.e., 5 months before taking the policy. The policy

was taken on 30.09.2007, after medical examination by the veterinary doctor. The representative of

the insurer also admitted that insurance policy was issued only after medical examination of the

elephant to the satisfaction of the insurer. Hence there is no justification of denying the claim on this

ground. Another ground is the complaint given by the owner against the mahout for ill treating the

elephant. The complainant has submitted that as the mahout, on an earlier occasion, threatened to

poison the animal, he felt suspicious against the mahout when the elephant fell and also, the mahout

was missing at that time. But it is to be noted that the animal died due to liver disease and

pneumonia and not due to poisoning. Hence the complaint is of no avail to establish ill treatment of

the elephant. As the material relied by the insurer is not sufficient to repudiate the claim, an award is

passed directing the insurer to pay the claim amount of Rs.2,00,000/- with 8% interest p.a. and a cost

of Rs.2,000/-.



Indus Motors Co.Pvt.Ltd.

Vs

United India Insurance Co.Ltd.


The complainant is a dealer of Maruti vehicles. The manufacturing company was providing

maintenance warranty for the 1st year of sale. By way of sales promotion tacts, the complainant dealer

resolved to give extended warranty for a further period of 2 years. For such an extended warranty, a

MOU was entered between the insurance company and the dealer, by which insurance cover was

provided for the extended period of 2 years with an annual premium of Rs.400/-. On such payment,

certificate of insurance was issued in respect of each vehicle. Later the manufacturer extended the

original warranty for one more year. So the extended warranty was required for the 3rd year only and

premium was fixed as Rs.200/-. On 29.12.2001, the complainant terminated the policy for the

remaining period and request for refund of premium for outstanding policy terms. The complaint

which was received in the office in 2001 was not entertained by this office as the policy was issued

not on personal lines. The complainant approached the Hon. High Court of Kerala. Hon. High Court

of Kerala directed us to hear the case and dispose of as expeditiously as possible.

The complainant is demanding the refund of premium for the unexpired term of policy, on

cancellation of policy document. It was submitted by the insurer that the policy was issued subject

to a MOU arrived at between the insurer and the dealer. As per the MOU, there is no provision to

cancel the policy. This is a tailor-made policy and the terms and conditions are different from

conventional policies, where there is provision for cancellation. The insurer also produced copy of

MOU, which does not contain any provision for cancellation. It was argued by the complainant that

there is provision in the policy document for cancellation. But they have expressed their inability to

produce any of the policy document, as the same is not available with them. In this circumstance, the

contention of the insurer that there is no provision for cancellation of policy only is to be believed.

There is no provision as per MOU also for cancellation of policy. The complaint is, therefore, devoid

of any merit and hence DISMISSED.



Smt.Rathy Sudhakaran

Vs

ICICI Lombard General Insurance Co.Ltd.


The complainant was issued with a Home Insurance Policy for 3 years from 15.05.2007 to

14.05.2010. That policy was cancelled w.e.f. 14.08.2008 by the insured, but the refund of the

premium for the unexpired period of the policy was not paid by the insurer. During the time

of hearing, the representative of the insurance company has submitted that they have

cancelled the policy and showed a cheque No.090564 towards refund of premium for

Rs.4,988/-. But they have not so far despatched the cheque to the insured. There is no

dispute regarding cancellation of policy and refund of proportionate premium for unexpired

term of the policy. But the insurer is still holding the cheque without despatching it. An

award is, therefore, passed directing the insurer to pay the amount of Rs.4,988/- with 8%

interest p.a. and a cost of Rs.250/-.


Complaint No.IO/KCH/LI/21-004-589/2008-09

Shinu Ramakrishna Pillai

Vs

ICICI Prudential Life Insurance Co.ltd.


The complainant was issued a policy under Hospital Care Plan w.e.f. 22.04.2008. On 20.06.2008, he

was admitted at AIMS, Kochi, and on 26.08.2008, kidney transplantation was done. The claim was

repudiated on the ground that the illness was diagnosed within 3 months of taking the policy, during

the waiting period.

As per Cl.6 of policy condition, there is a waiting period of 3 months. Any disease, for which

symptoms were present during the first 3 months of policy, is not covered during the entire term of

the policy. Here there is no dispute to the fact that the illness was diagnosed in May 2008 and the

policy was taken on 21.04.2008. But the contention of insured is that he was not aware of such

condition. But it is to be noted that as the policy was issued in April 2008 itself, and the insured

being a post graduate, has got sufficient time to go through the policy condition. As the policy

condition is very specific about 3 months waiting period, the claim is liable to be repudiated and the

complaint is DISMISSED.

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CHANDIGARH Chandigarh Ombudsman Centre

CASE NO. GIC/645/UII/11/08

Vipan Jain Vs. United India Insurance Co. Ltd.

Order dated: 05th May,2009 Household Claim

FACTS: Sh. Vipan Jain had taken a policy covering jewellery vide policy No.

200700/48/07/32/0000835 for the period 22.10.07 to 21.10.08. His wife Mrs. Vandana Jain suffered

loss of some jewellery and cash on 31.01.2008. The FIR for same was lodged with Police and claim

also lodged with insurer. The said company deputed the investigator and all relevant papers/

documents were handed over to investigator who assessed that claim will be settled after

submitting untraceable report from police. The said untraceable report dt. 24.08.08 was submitted

to insurer in Sept. 2008. However, the insurer rejected his claim vide letter dt. 09.09.08 on flimsy

ground.

FINDINGS: During the course of hearing, the insurer clarified the position by stating that the

vehicle was not locked at the time of theft. Hence the claim was repudiated as per terms and

conditions of the policy. On a query as to whether vehicle was left unattended, and unlocked. Smt.

Vandana Jain said that it was 9.30 p.m. There was dense fog. She had got out of the vehicle to clean

the wind screen when 2-3 miscreants made away with her purse.

DECISION: Held that the contention of the insurer that the vehicle was left open and

unattended is not borne out by the statement of Smt. Vandana Jain. A strong inclination in

agreement with her statement was felt. The repudiation of the claim therefore, was not found in

order. The claim was payable. It was ordered that the admissible amount of claim should be paid by

the insurer to the complainant.


CASE NO. GIC/752/IFFCO TOKIO/11/09

Hem Nalini Vs IFFCO Tokio General Ins Co.

ORDER DATED: 3rd July, 2009 HOUSEHOLD

FACTS : The complainant Smt. Hem Nalini had a Home & Family Protector Policy issued

by Iffco Tokio General Insurance Co. Ltd. for the period 09.11.07 to 08.11.08. In the

insurance cover besides other items, a Panasonic MP 3 CD player had also been included

in the cover. The CD player which is very small in size had fallen at the Heathrow Airport

from the hands of one of the security personnel while she was leaving for Chicago. After

coming to India she made a request to the insurance company for deputing the surveyor

to assess the loss. They deputed M/S A.K. Enterprises. However, the insurance company

repudiated her claim.

FINDINGS : The insurer stated that the complainant was covered under section 7 of the

terms and conditions of the Home and Family Protection Policy which is limited to

breakdown of domestic appliance within the residential premises. On perusal of the

policy it was found that there was an insurance cover for Rs. 77000/- under section 6

and Rs. 75000/- under section 7 of the terms and conditions of the policy. A clarification

was required whether the CD player was covered in the list of items under section 6 or

section 7. In the deferred hearing the insurer stated that CD player was a speciation

addition to the policy under section V – Electronic Equipment Insurance. The section V

covers damage only within the home.

DECISION: Held that the electronic equipment was covered under section V and

damage was payable only at the home. Hence the repudiation of the claim was in order.

The complaint was dismissed.

ORDER DATED: 11th September, 2009 HOUSEHOLD

FACTS: The complainant Shri Amarjit Singh Anand was having a Householders’ Policy. for the period

19.09.08 to 19.09.09. In this policy his TV Philips 29” (Imported Model No. 29 PT 5783/69R Year

1998) was also covered for Rs. 35,000/- with other items. The TV got faulty and claim was reported

to insurance company. They deputed a surveyor and on his suggestion TV was sent to Philips

Authorized Workshop for repair. The workshop gave the estimate of Rs. 27,444/-. The surveyor

conveyed him that it is not feasible to go for repair and the claim will be settled on Total Loss Basis.

After few days, he was surprised to receive a cheque of Rs. 4,650/- as full and final settlement of

claim. A TV costing and insured for Rs. 35,000/- has strangely been valued as Rs. 12,000/-. The

calculation of claim given was cost of product- 12000/- , depreciation- 6000/-, salvage- 1000/-,

excess- 350/-, Net Claim Amount – 4650/-.

FINDINGS: The insurer clarified the position by stating that due to change in technology, the TV

which was damaged can be replaced by a new TV whose market value is Rs. 12000/-. Giving 50%

depreciation and other charges, the net amount payable works out to Rs. 4650/-. Accordingly an

amount of Rs. 4650/- was paid to the complainant through cheque. On a query, as to why the

declared value has been changed from 35000/- to 12000/-, the insurer stated that the insured

amount is the value of the New TV of similar model.

DECISION: Clause 10 relating to general condition of indemnity, clearly states that the company has

an option to reinstate, replace or repair the property damaged instead of paying the amount of loss

of damage. The total expenditure should not exceed the sum insured which is this case is Rs. 35000/-

. There should not be any depreciation on the new TV (Indian Model in the market). If at all the

depreciation takes place, it should be at the market value of imported TV of similar brand. While it is

a fact that the repair is costing more than the new TV (Indian make), the insurer is duty bound to

either repair the TV or to replace it with a suitable model. It would be unfair to the insured if an

insured item of Rs. 35000/- is being considered for payment at Rs. 12000/- with depreciation. Taking

the above points into consideration the insurer should take recourse to one of the three options

given below:

a. Get the TV repaired. b. Get 11 years old imported TV of similar model and replace the existing TV with this

model. c. To buy a new TV at Rs. 12000/- and install at the premises of the insured.

They also have the option to pay Rs. 12000/- for purchase of new TV to the complainant as

per the market value. The case should be settled either for replacement or repair or by cash

payment.

Documents

Pages (16) AHMEDABAD