6. general=group personal accident claim

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Pages(18) 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

SYNOPSES OF AWARDS 2008-09

Half Year: OCT 2008 TO MAR 2009

6. GENERAL=GROUP PERSONAL ACCIDENT CLAIM

Award dated 25-02-2009

Case No. 11-005-258-09

Mr. Basisth V. Yadav Vs. Oriental Insurance Co.Ltd.

Group Personal Accident Policy

Claim for injury in left eye while on normal duties

resulted in confinement to bed for two months period which

was repudiated by Respondent on the grounds that the

injury has resulted in partial disablement and hence TTD is

not payable (which is not supported with evidences). The

documents on record revealed that policy condition provide

for loss of one eye under table-II items 5 as TTD on the basis

of PPD (Permanent Partial Disability) is 35% of S.I =

Rs.17,500/- and as per item 6 = 1% of S.I per week = 8 week

6 days x 500/- (whatever is higher). Thus since injury is

proved as per table-III item 5 = 17,500/- becomes payable.

The Respondent was directed to settle claim of

Rs.17,500/- within 15 days.

BHOPAL

BHOPAL OMBUDSMAN CENTRE Case No.: GI/OIC/0608/45

Mr. Dushyant Kumar Sahu V/s The Oriental Insurance Co. Ltd.,

Order No.: BPL/GI/08-09/39 date of Order:- 24.2.2009

Brief Background Mr. Dushyant Kumar Sahu, was covered under Group Personal Accident

Policy No. 47/2003/251 for the period 21.08.2002 to 20.08.2007 for sum

insured Rs. 100,000/- from M/s The Oriental Insurance Co. Ltd.

Jagadalpur.

As per the complainant he was on duty as Gunman in the Govt. vehicle

No. CG-03-1651 of Commandant on 14.12.06. On the way from Bhilai to

Jagadalpur near Gotiyardeeh village one Tata Indica Car No. CG-05 B-

7496 came from Dhamtari side and dashed the vehicle where he was

injured and left hip joint was dislocated. This incident was reported to

Amanpur under Crime No. 372/06. There were 32 stitches and was

hospitalized for 45 days in Mekahara Hospital, operated in Khemka

Hospital, Raipur and 25 days in Rajnandgaon. The treatment was carried

on for 8 months and medical board certified this injury as 75% in his left

leg in the certificate of Physical Handicapped. He is performing his duties

after using a special type of shoes. He is also using Vaishakhi for

support. After the treatment, his department preferred a claim to M/s

Oriental Insurance Co. Ltd., Jagadalpur. He personally contacted

Insurance Company where he was told that he will get Rs. 50000/- but

Insurance Company repudiated the claim.

The Respondent vide its letter dated 30.06.2008 submitted that

complainant was covered under GPA Policy No. 27/2003/251 &

15360/47/208. His claim was repudiated under Policy Condition “ Total

and irrecoverable loss of sight of both eyes or loss of two hands or feet or

loss of one eye and loss of use of hand or foot” as the disability certificate

of Maharani Hospital, Jagadalpur there is 75% of Permanent Physical

Disability of Left Leg. Since it is not Total and Irrecoverable loss of one

foot as per the coverage in the policy, the claim was not payable.

Observations:

It is an admitted fact that the Complainant was covered under Group

P.A. Policy No. 47/251/2003 taken from the Respondent for the period

21.08.2002 to 20.08.2007. The accident had taken place on 14.12.2006

during returning on duty from Bhilai to Jagadalpur where his left hip

joint was dislocated. He was physically present during hearing and I

observed from the physical condition that his left foot is totally not

working. He is wearing special type of shoes for some support and it not

seems to be recoverable at all. He is even facing problem in performing

daily natural work apart from his assigned official duties. He is kept for

services in his department on humanitarian ground.

Since the complainant has no chance of recovery even after the lapse of 2

years, it should be treated as total and irrecoverable loss. The

argument of the Respondent that there is no total and irrecoverable loss

in the case has no legs to stand.

In view of the circumstances stated above, the decision of the

Respondent to repudiate the claim found unfair and unjust. Since the

complainant cannot perform his daily work from his left foot and

recovery of the same is not possible, it should be treated total and

irrecoverable loss of one foot. As per Insurance Policy condition 50% of

Total Sum insured is payable in the instant case. Total S.I. in Group P.A.

Policy is Rs. 100,000/-, the claim is payable for Rs. 50,000/- Hence, the

Respondent is directed to settle the claim for Rs. 50,000/-

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

BHUBANESHWAR

GROUP PERSONAL ACCIDENT POLICY

BHUBANESWAR OMBUDSMAN CENTER

Complaint No.14-012-0396

Smt Bidyut Prava Nayak Vrs

ICICI Lombard General Insurance Co. Ltd., Bhubaneswar Branch

Award dated 23rd

October, 2008

Complainant is the wife of Late Prakash Chandra Naik who was covered under Group PA

Policy of ICICI Lombard General Insurance Company. Insured died in a vehicular

accident on 8 May2006 but insurance company has not settled the claim for non

submission of documents.

Hon’ble Ombudsman heard the case on 15.05.2008 where both parties were

present and explained their position. After hearing the both sides and perusing the

documents Hon’ble Ombudsman held that the insurance company has not bothered to

settle the claim when adequate documents in favour of the claim have been submitted and

there fore directed the insurance company to settle the claim with all consequential

benefits within one month of receipt of the consent letter.

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



Sri Debendra Kumar Rout Vrs

National Insurance Co. Ltd., Jharsuguda Branch

Award dated 17th

March, 2009

Complainant is the wife and nominee of Late Debendra Kumar Rout who was covered

under SBI Officers Cooperative Group PA Policy with National Insurance Company Ltd

and was injured in a scooter accident and preferred a claim. He was declared Permanent

Total Disabled by the District Medical Board. Insurance company delayed payment of

Rs93568/- which complainant is entitled.

Hon’ble Ombudsman heard the case on 01.12.2008, where both sides were

present. Hon’ble Ombudsman on perusal of documents including the policy terms and

conditions for TTD and PTD, observed that complainant is entitled to get Rs 105525/-,

out of which Insurance Company has paid only Rs64294/-and directed the insurance

company to pay Rs41231/- within one month of receipt of consent letter.

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



Smt Tuni Deo

Vrs

Oriental Insurance Co. Ltd., Cuttack DO

Award dated 31st March, 2009

Complainant is the wife and nominee of Late Sachidananda Deo who was covered under

a Group P A Policy of Oriental Insurance Company Ltd. Sachidananda Deo died due to

electrical short circuit on 10.06.2003 while on duty as a helper. A claim was lodged.

Insurance Company repudiated the claim on the grounds that the group PA policy does

not cover class IV employees ,to which late Deo belonged.

Hon’ble Ombudsman heard the case on 21.01.2009, where both sides were

present. Hon’ble Ombudsman on hearing both sides and perusing documents including

the full pay roll of 7500 employees of CESCO who were insured under the Group

Personal Accident Policy, opined that Late sachidananda Deo was covered under the

scheme and directed Insurer to pay Rs 3,00,000/- to the complainant.

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

CHANDIGARH

Chandigarh Ombudsman Centre

CASE NO. GIC/425/NIA/11/09

Paramjit Kaur Vs. New India Assurance Co. Ltd.

Order dated 12.01.09 GROUP PERSONAL ACCIDENT

FACTS: Ms. Paramjit Kaur’s husband Sh. Tarsem Singh had a Bank Account No.

4120 under the Sehkari Bank Beema Yojna Scheme in the Bathinda Central Co-operative

Bank Limited. The said bank had taken Group Personal Accident Insurance Policy from

the New India Assurance Co. Ltd., D.O. Bathinda vide Policy No.

360600/42/07/03/00000024 for the period 01.06.07 to 31.05.08. of all the account holders

under the S.B.B.Y Scheme for sum insured of Rs. 1,00,000/-. Sh. Tarsem Singh got

injured in a road accident on 22.12.07 and expired on the same day in the hospital. The

post-mortem was conducted and accident was reported to Police Station, Bhatinda and

DDR was registered vide no. 7 dt. 23.12.07. The claim was reported to insurance

company with all the documents but her claim was rejected without any reasonable

grounds. Parties were called for hearing on 12.01.2009.

FINDINGS: During the course of hearing the insurer clarified that this was an SBBY

Scheme policy in respect of account holders of Bhatinda Central Co-operative Bank Ltd.

It is a fact that the DLA boarded a wrong bus and requested the driver to stop the Bus.

Since the Bus did not stop, he jumped from the Bus and was crushed under the wheels of

the bus. While death due to accident is payable under the terms and conditions of the

GPA policy, there are some exclusion clauses relating to intentional self injury, suicide or

attempted suicide’. This was treated as an intentional self-injury and hence the claim was

repudiated.

DECISION: Held that the DLA did not have an intention / motive of getting killed at

the time of jumping from the Bus. The death should be treated as being caused due to

accident. As per terms and conditions of the GPA policy, the accidental death benefit is

therefore payable. It is hereby ordered that an amount of Rs. 1.00 lakh should be paid by

the insurer to the complainant by 31.01.2009 under intimation to this office. Penal

interest @8% per annum from 01.02.08 till the date of payment should also be paid along

with Rs. 1.00 lakh by 31.01.2009.

Chandigarh Ombudsman Centre

CASE NO. GIC/540/NIC/11/09

Sarup Kaur Vs. National Insurance Co. Ltd.

Order dated 10.02.09 GROUP PERSONAL ACCIDENT

FACTS: Smt. Sarup Kaur’s husband, Sh. Paramjit Singh had taken a Personal

Accident policy no. 401308/9600001/98, Certificate No. 0006306, Membership No. 293

for the period 19.04.1999 to 18.04.2014 for sum insured of Rs. 5,00,000/- through M/s

Stargold Mine Chita (P) Ltd. Ahmedgarh. The insured died in a road accident on

19.10.2008 and claim was lodged by his wife on 03.11.2008. However, the company vide

its letter dt. 03.11.2008, rejected the claim informing that policy has been cancelled on

29.07.2005 and public notice in this regard had been published in Punjab Kesri news

paper on 15.11.2005. Parties were called for hearing on 10.02.2009 at Ludhiana.

FINDIGNS: During the course of hearing the insurer clarified that the policy was Janta

Personal Accidental Policy and was a group policy with Star Gold Mine. Due to heavy

claims, the policy was cancelled and due notice was given in the newspaper. Hence on

the day of death of the insured, the policy was not in existence. On a query, whether the

complainant was informed in writing about cancellation of policy and premium refunded,

the insurer replied in the negative.

DECISION: Held that simply giving a newspaper advertisement cannot be the basis of

cancellation of policy. Due notice should be given to the party and pro-rata premium

refunded. Hence, the policy cannot be declared to be cancelled. It was operative on the

day of death of the life assured. The repudiation of the claim is, therefore, not in order.

The claim is payable. It is hereby ordered that the admissible amount of claim should be

paid by the insurer to the complainant.

CHENNAI

Chennai Ombudsman Centre

Case No.IO(CHN) 11.12.1503/2008 – 09

Mrs. S. Bhanumathy

Vs

ICICI Lombard General Insurance Co. Ltd

Award No. 056 dated 31/10/2008

The complainant, Mrs S Bhanumathy is the wife of Late Shri. S Shivakumar, who

had been holding an ICICI Bank Credit card. By virtue of being a credit card

holder, he informed that he was covered under Personal Accident insurance and

Credit Shield insurance cover of the insurer offered to the holders of ICICI Bank

credit cards. The insured died due to a road accident on 23/02/2007. The spouse of

the deceased claimed under the PA and Credit Shield Insurance. The insurer

repudiated the claim on the grounds that the coverage was not available to the

insured on the date of death.

The Forum had taken up the matter directly with ICICI Bank. The ICICI Bank has

confirmed that the deceased, Late Mr S Sivakumar who had availed of Loans had

not availed of insurance cover for all the three loan accounts at the time of availing

the loan. The insurer have confirmed that, the ICICI BANK, which is a separate

entity, had not taken any policy with them in respect of such loans. The

complainant has also not produced any documents like loan offer letter, loan

sanction letter, insurance cover note or certificate in proof of existence of another

insurance policy. No documents are available to set aside the contentions of the

insurer. The pamphlet submitted by the complainant refers only to the credit card

and makes no mention about the savings accounts. Hence, the decision of the

insurer to reject the claim is in order and the complaint is dismissed.


Case No.IO(CHN) 11.02.1126/2008 – 09

Mrs. D. Rajeswari

Vs

United India Insurance Co. Ltd

Award No.058 dated 10/11/2008

The complainant‟s husband; Mr. K. Diwakar had taken a “Servo

Suraksha” master policy with United India Insurance Co. Ltd..

He died in a road accident and his spouse claimed an amount

of Rs 2.00 lacs under this policy. In proof of his identity, she

had submitted copies of the trip sheets, goods vehicle records

and also the Transfer certificate of her daughter, bearing his

signature. The claim was not settled since the complainant had

not submitted any valid proof of signature of the deceased

husband to the insurer.

The point to be considered is whether the rejection of the claim

by the insurer on the grounds that the certificates of insurance

were not issued as per the terms and conditions of the policy

and because the nominee has not produced any valid document

bearing the signature of the insured for verification is in order.

To find out whether the certificates were issued in the name of Mr Diwakar after

his demise, a comparison of the signature of the deceased on the insurance related

documents against some authentic original document was made. The attempts of the

insurer to obtain his original signature from some document held by either his

original employer; his last employer or his own family has not yielded any result.

But the insurer’s contention is that the signature on the insurance certificate/Petrol

cash bills are not that of Mr Diwakar but done subsequent to his death. These

signatures are at variance with his signature on the Transfer Certificate of his

daughter. The representatives of the insured could not submit even one document

like Driving License, Passport, Bank documents containing insured’s signature

made before his death. In the absence of any such acceptable, authentic proof, the

complaint is dismissed.


Case No.IO(CHN) 11.02.1174/2008 – 09

Mr.S.R. Chandrasekaran

Vs

The New India Assurance Co. Ltd


The Complainant and his family were covered under Good Health

Policy issued by New India Assurance Co. Ltd to Citibank Card

holders, which provided for both Mediclaim as well as Personal

Accident Cover. The insured and his wife met with an accident

at Bangalore resulting in the hospitalization and subsequent

demise of his wife. The insurer rejected the PA claim for the

death of his wife on the grounds that the insured had requested

for cancellation of the policy before happening of the event. The

complainant contended that he had never written any letter to

the insurer for canceling the policy.

The insurer has confirmed that they have cancelled the policy on the

specific instructions received from their Master policyholder, who is

the bank. The bank has contended that the cancellation had been

done only as per the request of the complainant. The contention of the

complainant is that the insurer has refused to pay the PA claim on

the death of his wife saying there was no policy in force. The point to

be decided is whether the cancellation of the policy was done by the

insurer as per terms and conditions of the policy.

It is unfortunate, that the wife of the complainant died under tragic circumstances on

08/03/2006 due to injuries suffered in a road accident on 13/02/2006. As instructed by

the complainant on 19/01/2006, which is confirmed by the voice recording of the

conversation, the policy had been cancelled and the refund premium credited to

insured’s account on 23/01/2006. The policy having been cancelled before the death

of the wife of the complainant, the complaint is dismissed.


Case No.IO(CHN) 11.03.1234/2008 – 09

Mrs G. Priya

Vs

National Insurance Co. Ltd


The Complainant was covered under Workers Welfare

policy taken by her employer from the insurer for a sum insured

of Rs.2.00 lacs. The policy covered both PA and hospitalization

expenses. On 22/08/2007, she met with an accident and had to

undergo surgical correction. She filed a claim for Rs.54,000/- .

The insurer offered to settle the claim for Rs.36,600/- as

reasonable and disallowed Rs.17,400/-.

The insured was pregnant at the time of happening of the

accident and the passers by have admitted her into this hospital

so that proper and immediate treatment would be provided to

her. The insured did not have any option in the choice of the

hospital since the passersby admitted her. The insured had to be

kept in the ICU for observation because of her state of health,

being in an advance state of pregnancy.

The only point of dispute is the quantum of claim. Whether Rs

54,000/-charged by the hospital for the minor surgery of setting

right the fracture to the elbow is reasonable. But, the policy

clause also does not give any definition to the word „reasonable

expenses’. Care and expenses taken under such emergency

conditions and its reasonableness or otherwise will have to be

studied in the context of when it is incurred. In the absence of

any classification / grading of hospitals, the expenses actually

incurred by the claimant is deemed to have been reasonably and

necessarily incurred. The insurer was not able to convincingly

state the rationale behind the rejection of certain amounts. The

insurer is directed to process and settle the claim as per other

terms and conditions of the policy and the complaint was

allowed.


Case No.IO(CHN) 11.09.1418 / 2008-09

Mrs. N. Soundararajan

Vs

Reliance General Insurance Co. Ltd

AWARD No.110/2008-09

The Complainant has been covered under a Group Personal Accident Policy through M/s

Road Safety Club Pvt. Ltd. He had a fall and started suffering from headache. The

insured was hospitalized for Anterior Communicating Artery Aneurysm and submitted

the bills for reimbursement of medical expenses. The insurer rejected the claim on the

grounds that the hospitalization was not as a result of accident but due to an underlying

ailment and falls under the exclusion of the policy

From the medical records submitted by the insured, it is found that

the insured was hospitalized for Anterior Communicating Artery

Aneurysm. There is no dispute regarding the hospitalization

required but the insurer has rejected the claim in the absence of any

tangible proof substantiating the accident. The main coverage is

towards accidental benefits and the hospitalization is an add-on

benefit only wherein the pre condition is proof of accident.

The insurer has obtained opinion from their panel doctor who had

confirmed that ailment of “Anterior Communicating Artery

Aneurysm” is not due to any accidental fall and is a disease only.

The insurer had concluded that the expenses are incurred for

medical management of an ailment in the absence of any evidence

to the occurrence of an accident. No evidence has been produced by

the complainant to establish that he had suffered an accidental fall.

The insured has not been able to produce any clinching evidence to

support his contention that he had suffered a fall and that the

condition requiring hospitalization had occurred due to accident

only. Hence the complaint is dismissed.

KOCHI

OFFICE OF THE INSURANCE OMBUDSMAN, KOCHI

Complaint No.IO/KCH/GI/11-004-267/2008-09

Smt.Maggie Thomas

Vs

United India Insurance Co.Ltd.

AWARD DATED 18.12.2008

The son of complainant was holding a credit card of SBI issued for the account

opened in 2006. While issuing credit card, he was given a certificate of insurance under a master policy on condition of payment of card fee which provides insurance

coverage on death by accident. On 25.01.2007, he expired in an accident, but the claim was repudiated on the ground that at the time of death, the policy was not in

existence. The master policy was taken by SBI. The complainant’s son was only the beneficiary. He did not pay the premium. Premium was paid by SBI. Hence it is the look out of SBI to renew the policy. The policy was valid up to December 2006

only. There is no coverage after 31.12.2006. There is nothing to show that the policy was renewed after 31.12.2006. Date of death is on 25.01.2007. As there is no

valid policy as on the date of death, complaint stands DISMISSED.

KOLKATA

GROUP PERSONAL ACCIDENT POLICY

Kolkata Ombudsman Centre

Case No.297/11/003/NL/07/2008-09

Smt. Yasmeen Begum

Vs.

National Insurance Company Ltd

Order Dated : 29.01.2009

Facts & Submissions :

This petition was against repudiation of accidental death claim under Group Personal Accident

(PA) policy issued to Golden Multi Services Club Ltd. (GMSCL) by the National Insurance

Company Ltd. (NICL).

The petitioner Smt. Yasmeen Begum stated that her husband Late Md. Suleman Khan took a

Group Personal Accident Policy for the period 08.10.2004 to 07.10.2014 of NICL through

GMSCL. She further stated that her husband while riding a motorcycle met with an accident due

to collision with a jeep and died on 04.02.2006. She being the nominee under the said policy gave

the death intimation to the branch office of GMSCL on 01.03.2006 GMSCL issued her claim

form which she duly submitted in the said office on 03.03.2006 along with the required

documents.

However, the insurance company repudiated the claim vide their letter dated 04.12.2006 on

flimsy non-technical and non-existent ground of delay and/ or not filing of documents i.e. (i)

Death Certificate (ii) First Information Report to Police (iii) Final Investigation Report of Police

(iv) Post Mortem Report (v) Doctor’s Certificate (vi) All the treatment papers of hospital/ nursing

home (vii) Disablement Certificate issued by Medical Board.

She submitted claim form along with all required documents within 27 days. The delay occurred

in the transit of papers from the GMSCL, Agra Office to their head Office at Kolkata. This fact of

transitory delay was also properly explained by GMSCL to the insurance company in their

forwarding letter dated 10.03.2006. Regarding non-submission mentioned in the insurance

company’s letter dated 04.12.2006 she stated that she had submitted all the documents mentioned

in Sl. No. 1 to 4 through GMSCL and the remaining 3 documents i..e., Sl. No. 5 to 7 was not at

all applicable since it was case of instant death after accident. After receiving the said repudiation

letter from the insurance company she made representation to the insurance company vide her

letter dated 15.01.2007, 13.04.2007 and GMSCL on their part also requested the insurer for

reconsideration of her claim vide their letter dated 25.01.2007 wherein they explained the reason

of delay due to transit of papers from their Agra office to their Head Office at Kolkata and also

sought to explain the facts that by arrangement and/or mutual agreement between the insurance

company and the GMSCL, any paper submitted to them shall be deemed to the papers submitted

to the insurance company. Moreover, the said company was carrying on their business under the

logo of the insurance company. In spite of all explanation the insurance company neglected and

failed to consider the bonafide claim of the nominee which she had valid and legal claim against

the insurance company which was liable to pay her the sum assured of Rs.5 lakhs along with

commercial rate of interest until the date of payment.

The insurance company did not provide self-contained note.

DECISION:

Since this was a case of death, the delay though claimed to have been intimated in time to the

GMSCL, Hon’ble Ombudsman found that GMSCL in turn did not intimate the same to the

insurance company in time. However, keeping in view the death of the insured, it was felt that

delay of one month five days could be condoned. Therefore, he condoned the delay in filing the

intimation. Since the claim had not yet been investigated, he directed the insurance company to

investigate the claim and settle the same after that.

-----O------


Case No. 339/11/003/NL/08/2008-09

Shri Sanjay Kumar Gupta

Vs.

National Insurance Company Ltd



This petition was against repudiation of a claim under exclusion clause no. 2.7 of Group Personal

Accident (PA) policy issued to Golden Multi Services Club Ltd. (GMSCL) by the National

Insurance Company Ltd.

The petitioner, Shri Sanjay Kumar Gupta stated that his father Late Dukh Bhanjan Prasad Gupta

was covered under Group PA Policy of NICL issued in the name of Golden Multi Services Club

Ltd. for the period 15.09.2004 to 14.09.2014 with a sum insured of Rs.2,00,000/- and the

complainant was the nominee of the deceased. His father died on 27.06.2006 due to snake bite

which was proved by reports and certificates. He duly intimated about the accident on 12.07.2006

through M/s GMSCL. The claim forms duly filled in and signed by him as well as by the

attending doctor on 12.07.2006 and the same was submitted to the insurer through GMSCL,

Sitamarhi on 11.08.2006 along with attested copies of documents.

After that he received a letter dated 27.04.2007 from NICL wherein the insurance company

intimated him that his claim had been treated as No claim for non submission of Final

investigation report of police/ charge sheet in original or certified true copy, Post Mortem Report

in original or certified true copy, Employer Salary certificate/ I.T. Return/ income certificate,

Attested photocopy of Ration Card of the deceased and the nominee and Local Panchayat

certificate regarding status of the nominee.

On receipt of the letter of the insurer dated 27.04.2007 complainant had written a letter to the

insurer wherein he gave following information.

Final investigation report of police/ charge sheet – Intimation of police was given and entered

vide SAD No. 709/06 dated 28.06.2006 but no investigation report of charge sheet was prepared

as it was case of snake bite; Post Mortem Report – No Post Mortem was conducted and the dead

body was released by the hospital for cremation as it was case of snake bite. He enclosed a

Panchnama which was prepared before cremation of the body; Employer Salary Certificate –

The life insured was not employed any where; Attested copy of Ration Card; Local Panchayat

Certificate regarding status of the nominee.

He further cited the example of LICI that in case of snake bite LICI did not insist for police report

and post mortem report. They give regard to the social customs and privileges. He referred a

judgement between United India Insurance Company Ltd. – Petitioner – Vs – Pallamreddy Aruna

– Respondent, Revision Petition No. 3329 of 2007 Decided on 22.10.2007 where the Hon’ble

Justice had decided the case and the judgement was as follows:

“Consumer Protection Act, 1986 – Section 21 (b) – Insurance – Death due to snake bite – Proved by

Certificate of Police Officer, Village Administrative Officer and doctor – Contention, without conducting

post-mortem, doctor cannot say that person died because of snake bite – Contention not acceptable –

Doctor can on considering symptoms/ cause of snake bite easily certify that person died because of poison

– Villagers in small village would not wait for post-mortem in snake bite case – Revision dismissed.”

His representation to the insurance company did not yield any positive result.

The insurance company did not provide the send the self-contained note.

DECISION:

Hon’ble Ombudsman was agreed with the arguments of the complainant and directed the

insurance authorities not to insist on the documents like final investigation report by the police,

post-mortem report and employer’s salary certificate. It has been stated that the complainant

submitted other documents that have been requisitioned by the insurance authorities. The

complainant had also quoted a case decided by the National Consumer Disputes Redressal

Commission, New Delhi, in favour of the complainant with regard to death that took place due to

snake bite. This should also be taken into consideration by the insurance authorities. Keeping in

view of the above, he directed the insurance authorities to settle the claim after initiation

procedure of the settlement of the claim

-----O------


Case No. 451/14/002/NL/09/2008-09

Smt. Champa Rana

Vs.

The New India Assurance Company Ltd.



This petition was filed by the petitioner against delay in settlement of death claim under

Group JPA policy issued to GTFS by the New India Assurance Company Ltd.

The petitioner Smt. Champa Rana stated that her husband Shri Binode Behari Rana was covered

under a Group JPA policy for sum insured of Rs.1 lakh for the period 23.01.2001 to 22.01.2016.

Her husband Shri Binode Behari Rana was wounded by falling roof wall on the head – traumatic

injury on 05.02.2007 and he was treated by local doctors and then transferred to Kolkata S.S.K.M

Hospital for better treatment. Ultimately he died in the said hospital on 15.02.2007. Being the

nominee under the policy an intimation of the claim along with a claim form was submitted to the

insurance company through G.T.F.S on 02.04.2007. The petitioner also gave a reminder to the

insurance company on 14.12.2007 for settlement of her claim which had not been replied to.

The insurance company stated that from the year 1995 JPA coverage was given to

Sanchayani/GTFS without any MOU and the operation of the policy was only based on

administrative order and the coverage was granted to the investors and their family members and

field workers etc. Thereafter MOU was made with Sanchayani/ GTFS mentioning that the said

two companies would give JPA coverage to their clients such as Investors and their family

members i.e., who would invest lump sum money as fixed deposit to their company and also who

would work as field worker/ agent of the company and also to the friends, associates who are

closely associated with the company.

The Insurer thereafter due to various violations in the operation of the policy and also with

regard to the coverage to the insured person cancelled the MOU and did not accept

premium from Sanchayani/ G.T.F.S dated 21.04.1999 whereupon the GTFS/Sanchayani

filed a Writ Petition before the Hon’ble Calcutta High Court and the Hon’ble High Court

passed 2 orders dated 06.07.1999 for GTFS and 08.07.1999 to the Sanchayani directing the

Petitioners not to collect any premium from the categories of friends and associates. The

Hon’ble Justice Mr. Pinaki Chandra Ghosh also restrained the respondent insurance

company to give effect in respect to their letter dated 07.05.1999 and also told the petitioner

to deposit the premium amount. Keeping in view the said Order the Insurer asked the

claimant for furnishing some documents to prove the identity of the Insured as per the High

Court Order and also the proof of profession, age and income particulars of the Insured

where from they found that various claims pending with them do not fulfill the guidelines of

the Calcutta High Court order and the insurance company thereafter cancelled the JPA

policy given to the GTFS. The GTFS filed another Writ Petition to the Calcutta High Court

against cancellation of the policy. The Hon’ble justice Pinaki Chandra Ghosh had passed

another order dated 16.03.2006 directing the insurance company to settle the claims on

merit with relation to the previous order. Going by the said Court order the insurance

company asked the claimants for Investment Certificate / Agency License/ Identity Card/

appointment letter of Field worker, age of income proof, profession and actual amount

deposited to GTFS etc. and many claims are pending in absence of the above documents

from the GTFS/ claimants. Since the GTFS/ the claimant could not furnish the documents

required by the insurance company they have treated the claim as ‘no claim’.

DECISION:

Based on the earlier cases in which the Hon’ble Insurance Ombudsman had taken a decision that

the complainant should file all the documents including proper identification given by the GTFS

with regard to the Insured being Investor or Field Worker or their family member. This decision

was given keeping in view the two decisions given by Hon’ble Calcutta High Court, one on

06/08.07.1999 and the other on 16.03.2006. According to these decisions the category of friends

had been removed from the various categories and the Hon’ble Court directed that no person

should be insured from the category of friends. Later Hon’ble Court passed an order dated

16.03.2006 directing the insurance company to settle the claims on merit with relation to the

previous order. The insurance company consequent to this order had requested the claimant to file

all the documents including the identification given by the GTFS with regard to the person being

Investor or Field worker or their family member. This office held that this request had been

reasonable keeping in view the decisions of the Hon’ble Calcutta High Court and directed the

complainant to file the required documentation with regard to identity and others so that the

insurance authorities could process the claim.

Keeping in view the above circumstances, in conformity with the previous orders that had already

been passed, Hon’ble Ombudsman directed the complainant to file all the documentation required

with regard to identity and others and simultaneously directed the insurance authorities to process

the claim after receipt of such documentation.

6. general=group personal accident claim

Documents