INSURANCE OMBUDSMAN CHANDIGARH

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN,

CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Ms. Bandana Chakravarty V/S Care Health Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-G-037-2021-0181

1. Name & Address of the

Complainant

Ms. Bandana Chakravarty

Flat 506, Lvory Court 4, ESSEL Tower, M

G Road, Gurugram, Haryana- 122002

Mobile No.- 9971150420

2. Policy No:

Type of Policy

Duration of policy/Policy period

14311403

Personal accident Policy (Secure-V2)

13-06-2019 to12-06-2020

3. Name of the insured

Name of the policyholder



4. Name of the insurer Care Health Insurance Co. Ltd.

5. Date of Repudiation 17.12.2019

6. Reason for repudiation Benefit not covered

7. Date of receipt of the Complaint 10-11-2020

8. Nature of complaint Non- payment of accidental injury claim

9. Amount of Claim Rs.1,40,000/-

10. Date of Partial Settlement -

11. Amount of relief sought Rs.1,40,000/-

12. Complaint registered under

Rule no: Insurance Ombudsman

Rules, 2017

Rule 13 (1)(b) – any partial or total

repudiation of claims by an insurer

13. Date of hearing/place 12.01.2021/ online

14. Representation at the hearing

For the Complainant Ms. Bandana Chakravarty

For the insurer Dr. Nisha

15 Complaint how disposed Dismissed

16 Date of Award/Order 25.01.2021

17) Brief Facts of the Case:

On 10-11-2020, Ms. Bandana Chakravarty aged 65 years had filed a complaint

against Care Health Insurance Co. Ltd and stated that her claim of accidental injury

under personal accident policy has been rejected by the insurer on the ground of

degeneration disease as per terms and conditions of the Hospitalization Health policy,

having no direct or indirect relation to the P.A Policy no 14311403 in which

complainant has been covered. It has been a case of sudden and severe pain in

shoulders due to fall in bathroom while taking bath on 19.08.2019. The company has

been playing dual role, on the one side company has released the amount of

Rs.11,000/- and on the other hand, for remaining due amount, they have stated that

the claim doesn’t fall under terms and conditions of the policy. The complainant

further stated that that she has replied all the queries and clarified many times that his

accidental injury does not come under the condition of overuse injuries as he was fit

and performing his duties as a normal person. The complainant has sought the

intervention of this office for payment of claim as the shoulder injury very much fall

within the scope of P.A Policy.

On 18-11-2020, the complaint was forwarded to Care Health Insurance Co. Ltd.

Regional Office, Gurugram, for Para-wise comments and submission of a self-

contained note about facts of the case, which was made available to this office on

30.12.2020. As per SCN, The complainant approached the respondent company for

reimbursement claim under benefit of Temporary Total Disability. Meanwhile,

company also took a second opinion on the medical documents submitted for the

claim. Further, upon careful consideration of the documents received pertaining to the

claim, and as per second opinion obtained, following observations were made:

That as per second opinion given by Dr. Manu Bora dated 24.12.2019 on MRI report

(as submitted by the complainant with claim documents), it was clearly mentioned

that “Retraction of torn edges up to beyond humeral equation, this shows that tear is

chronic and old. Fresh tear has no retraction’. The copy of the said second opinion is

annexed with the relevant sections.MRI report is also annexed.

That as per the prescription of Dr. Gurinder Bedi, dated 19.08.2019, the insured was

advised to continue exercises which make very clear that the insured was already on

exercises before the injury. The copy of the said prescription is annexed.

It is pertinent to mention here that it is very clear with the second opinion that the

injury was chronic in nature i.e an old injury and no fresh injury and the same doesn’t

occured because of an accident. The said claim was rejected vide rejection letter dated

17.12.2019 as per policy term and conditions under “Benefit Not Covered”. The relevant

clause is reproduced for reference;

“As per clause 3- Permanent Exclusions;

(a) Exclusions applicable to all benefits and optional covers: Any claim in respect of any

Insured Person for, arising out of or directly or indirectly due to any of the following

shall not be admissible, unless expressly stated to the contrary elsewhere in the

policy:

(ii) Any pre-existing injury or disability.

“As per Clause 2.21(d) optional Cover 7; Temporary Total Disablement (TTD)

(a) If an Insured Person suffers an accident during the policy period which is the sole and

direct cause of temporary disablement……

Since the injury due to which the temporary total disablement has occurred is chronic

and old: also present accident is not sole and direct cause of the temporary total disability

in question therefore the claim Under Temporary Total disability benefit will not be

admissible as per policy terms and conditions.

It is further pertinent to mention here that due to a technical system glitch an amount of

Rs.11428/- has been processed to the complainant’s account erroneously. In the light of

the above, it is reiterated that the claim of the complainant was duly repudiated by the

respondent company as per policy terms and conditions.

The complainant was sent Annexure VI-A for compliance, which reached this office on

21-11-2020.

18) Cause of Complaint:

a) Complainant’s argument: The denial of claim is not justified as the accidental

injury to the shoulder falls within the scope of the policy

b) Insurer’s argument: Claim is not admissible as per terms and conditions of the

policy as the Injury due to which the temporary total disablement has occurred is

chronic and old.

19) Reason for Registration of Complaint: Within the scope of the Insurance

Ombudsman Rules, 2017.

20) The following documents were placed for perusal.

a) Complaint to the Company b) Copy of Policy Document

c) Annexure VI-A d) Reply of the Insurance Company

21) Result of Personal hearing with both parties (Observations & Conclusion):

On perusal of the various documents available in the file including the copy of the

complaint, SCN of the insurer and submission made by both the complainant and the

insurance company during the online hearing, it has been observed that complainant’s

reimbursement claim for accidental injury under benefit of Temporary Total

Disability of personal accident policy was denied by the insurer vide letter dated

17.12.2019 for the reason that “Benefit Not Covered” as per policy term and

conditions.

The complainant stated that despite replying to all the queries many times that her

accidental injury does not come under the condition of overuse injuries, the claim has

not been paid by the insurance company.

The representative of the insurance company stated that the injury due to which the

temporary total disablement has occurred is chronic and old, also present accident is

not sole and direct cause of the temporary total disability in question therefore the

claim under Temporary Total disability benefit is not admissible as per clause 3-

Permanent Exclusions and Clause 2.21(d) optional Cover 7; Temporary Total

Disablement (TTD) of policy terms and conditions.

The basic issue before me is to decide whether the injury causing temporary total

disablement to the complainant is accidental in nature or chronic. “As per Clause

2.21(d) optional Cover 7; Temporary Total Disablement (TTD, claim is admissible “If

an Insured Person suffers an accident during the policy period which is the sole and

direct cause of temporary disablement……”

The complainant due to fall in the bathroom and pain in the right shoulder consulted

Dr. Gurinder Bedi on 19.08.2019, who suggested for the MRI Scan and advised

patient to continue exercises. On perusal of the MRI report dated 21.08.2019 of

Mahajan Imaging, MR scan findings are suggestive of Retraction of torn edges up to

beyond humeral equator and Acromioclavicular and glenohumeral joints arthrosis.

As per opinion of Dr. Manu Bora placed on record by the insurer “Retraction of torn

edges up to beyond humeral equator, this shows that tear is chronic and old. Fresh tear

has no retraction”. Even as per the medical literature Acromioclavicular joint arthrosis

is a condition that develops when the cartilage cushioning AC joint in the shoulder

begins to wear out. The Finding of the MRI report indicates that injury of the

complainant is old and chronic and cannot be the sole and direct cause of temporary

disablement. Further, it is very unlikely that a Consultant Doctor on the very first

examination of the patient suffering from any accidental injury would use the phrase

“continue exercises” even without waiting for MRI report, unless he is aware about

the pre existing health condition of patient, as has been done by the complainant’s

Doctor. The complainant has also not placed on record any disability certificate,

issued by the treating doctor indicating type of disability suffered by her, its duration

and cause which is an essential document for claiming compensation under temporary

disablement head of the policy .Therefore, the claim denial decision of the insurer

under the circumstances is as per policy terms and conditions and does not warrant

any interference. The complainant is dismissed being devoid of merits and no relief is

granted.

ORDER

Considering the facts & circumstances of the case and the submissions made by both

the parties during online hearing, the complaint is hereby dismissed being devoid of

merits.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 25th

day of January 2021.

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY

(UNDER RULE NO: 17(1) OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI M VASANTHA KRISHNA

Case of Mr J Murugalingam Vs Universal Sompo General Insurance Co. Ltd

COMPLAINT REF: NO: CHN-G-052-2021-0100

Award No: IO/CHN/A/GI/0046/2020-2021

1. Name & Address of the Complainant

Mr J Murugalingam

1/20 East Street, Kombankulam,

Kalunguvilai 628704

2. Policy No:

Type of Policy


Sum Insured (SI)

3336/59880574/00/006

Pradhan Mantri Suraksha Bima Yojana

(PMSBY)

01/06/2019-31/05/2020

INR 2,00,000


Name of the policyholder/Proposer

Mrs T Ponrani

Indian Overseas Bank (Master

Policyholder)

4. Name of the insurer Universal Sompo General Insurance

Company Ltd.

5. Date of repudiation of the claim 29/11/2019

6. Reason for repudiation

Delayed claim intimation

7. Date of receipt of the complaint 21/10/2020

8. Nature of the complaint Non-settlement of the claim

9. Date of receipt of consent

( Annexure VIA)

16/11/2020

10. Amount of Claim Not furnished

11.

Amount of Monetary Loss

(as per Annexure VIA)

Not furnished

12. Amount paid by Insurer if any Nil

13. Amount of Relief sought


INR 2,25,000

14.a. Date of request for Self-contained

Note (SCN)

27/11/2020

14.b. Date of receipt of SCN 07/12/2020


Rule 13(1)(b) of the Insurance

Ombudsman Rules, 2017

16. Date of hearing/place By Video Conferencing (VC) on

28/12/2020

17. Representation at the hearing a) For the complainant Mr Dalwin Kumar

b) For the insurer Ms Anita Raghuwanshi

18. Disposal of the Complaint By Award 19. Date of Award/Order 12/01/2021

20. Brief Facts of the Case:

The complainant’s mother who was covered under the respondent insurer (RI)’s

Pradhan Mantri Suraksha Bima Yojana (PMSBY) through Indian Overseas Bank

(IOB), Sattankulam, was bitten by a snake on 21/07/2019 and died before being taken

to Tirunelveli Medical College for treatment.

The claim preferred on the RI under the PMSBY policy was repudiated on the ground

that there was a delay in intimation of the claim by 62 days as the complainant

submitted the claim form only on 21/09/2019.

Aggrieved by the repudiation of the claim, the complainant represented to the RI to

reconsider their decision, explaining the reasons for the delay.

Since the complainant did not get any reply from the RI for his grievance

representation, he has approached this Forum for relief.

The complainant had also represented to the Banking Ombudsman in the matter and

in response to the same, the RI sought certain details and additional documents from

him.

21. a) Complainant’s submission:

The complainant’s mother was covered under PMSBY through IOB, Sattankulam.

When a claim was preferred on the RI after his mother’s death due to snake bite, it

was rejected by them on the ground that there was a delay of 62 days in intimation of

the claim, whereas the claim should have been intimated within 30 days.

The complainant represented to the RI that the delay in issue of the death certificate

from the hospital and the post-mortem (PM) report by the Forensic Department only

caused the delay and sought reconsideration of their decision.

Since the delay in submission of the claim papers was beyond his control, Forum’s

intervention is requested for settlement of the claim.

b. Insurer’s contention:

The RI vide their SCN dated 05/12/2020 submitted to the Forum that they have

already settled the complainant’s claim for INR 2,00,000 vide UTR No.

UTIBR52020112000343282 on 20/11/2020 and requested the Forum to direct the

complainant to withdraw the complaint.

22. Reason for Registration of the Complaint:

The complaint is registered under Rule13 (1) (b) of the Insurance Ombudsman Rules, 2017,

which deals with “Any partial or total repudiation of claims by the life insurer, General

insurer or the health insurer”.

23. Documents placed before the Forum:

Written Complaint dated 19/10/2020 to the Insurance Ombudsman

Complainant’s e-mail dated 28/11/2020 to the Insurance Ombudsman

RI’s repudiation letter dated 29/11/2019

Claim settlement letter of the RI dated 21/11/2020

Consent (Annexure VI A) submitted by the Complainant

Self-contained Note (SCN) of the RI dated 05/12/2020

IOB Sattankulam’s letters dated 17/12/2019 & 29/09/2020

Death Certificate dated 07/09/2019

First Information Report (FIR) No. 145 dated 22/07/2019 of Sattankulam police

station

Post-mortem (PM) certificate No. 1182/2019 dated 22/07/2019

Department of Forensic Medicine & Toxicology’s report dated 29/08/2019

RI’s e-mail dated 05/11/2020 to the Banking Ombudsman

Banking Ombudsman’s e-mail dated 26/11/2020

24. Result of hearing (Observations & Conclusion)

1. Given the prevalent COVID 19 pandemic situation, the hearing was conducted

through VC on 28/12/2020, with the consent of and participation by both the

complainant and the RI.

2. The subject matter of the grievance is the repudiation of the complainant’s claim in

respect of the death of his mother due to snake bite, on the ground that there was a

delay in intimation of the claim by 62 days.

3. Since the claim has already been settled by the RI, the main grievance of the

complainant is already resolved.

4. The complainant vide e-mail dated 28/11/2020 confirmed that the claim has already

been settled by the RI on 22/11/2020 and sought payment of interest for the delayed

settlement since he had submitted all the claim documents as early as 21/09/2019.

5. During the hearing, the complainant was directed to submit the details of the

resolution given by the Banking Ombudsman since he had approached the said Forum

with his grievance.

6. The complainant submitted the Banking Ombudsman’s e-mail dated 26/11/2020

wherein it has been communicated to him that the bank, on receipt of the complaint

through the Banking Ombudsman, took up the matter with the insurance company and

the claim was settled on 22.11.2020.

7. It is observed that the only document the RI sought from the complainant subsequent

to the receipt of the claim documents on 21/07/2019, was the affidavit from the legal

heirs of the deceased in respect of the discrepancy in her date of birth. In the opinion

of the Forum, the age discrepancy of two years did not make a material difference

either for underwriting or for settlement of the claim. Hence, the affidavit obtained

was not of any direct relevance for the admissibility of the claim. The delay in

settlement of the claim was entirely due to the reluctance of the RI to condone the

delay in intimation and hence complainant’s demand for payment of interest due to

delayed settlement is justified.

AWARD

Taking into account the facts & circumstances of the case and the submissions made during

the hearing, the respondent insurer is directed to pay interest to the complainant on the claim

amount of INR 2,00,000 as per Rule 17 (7) of the Insurance Ombudsman Rules, 2017.

Thus, the complaint is allowed.

25. The attention of the insurer is hereby invited to the following provisions of the

Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall

comply with the award within thirty days of the receipt of the award and intimate

compliance of the same to the Ombudsman

b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the complainant

shall be entitled to such interest at a rate per annum as specified in the regulations,

framed under the Insurance Regulatory and Development Authority of India Act, 1999,

from the date the claim ought to have been settled under the regulations, till the date of

payment of the amount awarded by the Ombudsman.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of

Insurance Ombudsman shall be binding on the insurers.

Dated at Chennai on this 12th

day of January 2021

(M Vasantha Krishna)

INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY

(UNDER RULE NO: 17(1) OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI M VASANTHA KRISHNA

Case of Mr Arun Chella Samraj Mukilesh Vs SBI General Insurance Co. Ltd

COMPLAINT REF: NO: CHN-G-040-2021-0101

Award No: IO/CHN/A/GI/0055/2020-2021

1. Name & address of the Complainant

Mr Arun Chella Samraj Mukilesh

B4, Balaji Arcade, 140 Arcot Road,

Virugambakkam, Chennai 600092

2. Policy No:

Type of Policy


Sum Insured (SI)

17176306/62480314

Personal Accident (PA) Insurance Policy

14/03/2020-13/03/2021

INR 2,00,000


Name of the policyholder/proposer

Mr Arun Chella Samraj Mukilesh, C

Mr Arun Chella Samraj Mukilesh, C

4. Name of the insurer SBI General Insurance Company Ltd

5. Date of Repudiation/Short settlement

of the claim

Not applicable

6. Reason for Repudiation/Short

settlement

Not applicable

7. Date of receipt of the Complaint 27/10/2020

8. Nature of the complaint Non-receipt of the Master Policy

document and reply to query under Right

to Information (RTI) Act

9. Date of receipt of consent

(Annexure VIA)

12/11/2020

10. Amount of Claim Not applicable

11.

Amount of Monetary Loss


Not applicable

12. Amount paid by the Insurer, if any Nil

13. Amount of Relief sought


Compensation for mental agony due to

the scandalous act of State Bank of India

(SBI)

14.a. Date of request for Self-contained

Note (SCN)

29/10/2020

14.b. Date of receipt of SCN 02/12/2020


Rule 13(1)(f) of the Insurance

Ombudsman Rules, 2017

16. Date of hearing/place By Video Conferencing (VC) on

28/12/2020


c) For the Complainant Mr Arun Chella Samraj Mukilesh

d) For the insurer Ms Chynikca Modie

18. Disposal of Complaint By Award

19. Date of Award/Order 29/01/2021

20. Brief Facts of the Case:

The complainant received a certificate of insurance dated 17/03/2020 under Personal

Accident (PA) Master Policy from SBI General Insurance Co. Ltd., the respondent

insurer (RI) on 11/05/2020 wherein the complainant is shown as the insured and one

Ms Anita Subramanian (spouse), as the nominee.

According to the complainant, he had not applied for any PA coverage nor did he

nominate Ms Anita Subramanian as the nominee.

A Right to Information (RTI) application was submitted to the RI, seeking details as

to who authorized the deduction of premium from his savings account for the PA

policy, besides the date on which the policy was requested, the person who had

applied for the same, and the person who had nominated Anita Subramanian as the

nominee. The complainant also sought the original certificate and the master policy

from the RI.

The complainant also requested for the change of nominee in the certificate of

insurance by a separate letter dated 20/05/2020 and the same was accepted and

effected by the RI. The RI sent a policy download link to the complainant and the

downloaded certificate showed the change in nomination to his mother’s name.

The complainant insisted on the hard copy of the certificate and the RI informed him

that the soft copy is equivalent to the hard copy and requested him to take a printout

of the same. When the complainant insisted again for the hard copies of the old and

changed certificates besides the master policy, the RI provided a hard copy of the

current certificate with changed nominee but not the old certificate. They also did not

provide the master policy.

Though the complainant is not interested in mediation by this Forum, he has accepted

the same in view of the policy provisions and given his consent in order to resolve the

mental agony meted out to him by RI and for the release of the master policy and the

old policy.

21. a) Complainant’s submission:

On 11/05/2020, the complainant received a certificate of insurance dated 17/03/2020

under Personal Accident (PA) policy from the RI showing him as the insured and one

Anita Subramanian (spouse), as the nominee.

The complainant sought the below-mentioned details from the RI through an RTI

application dated 20/05/2020.

a) The person by whom and the date on which the application was made for PA

policy in the name of the complainant.

b) Who authorized Ms Anita Subramanian as the nominee?

c) Who authorized the debit of premium from the complainant’s bank account?

d) The reason for not providing the original certificate of insurance bearing no.

62480314

e) The person by whom and the date on which application was made for the Master

Policy no. 17176306?.

f) The reason for not providing the original Master Policy to the complainant.

Since no reply was received to the RTI application, the complainant escalated the

matter to the Insurance Regulatory & Development Authority of India (IRDAI).

Thereafter, the RI sent the link to enable the complainant to download the soft copy of

the certificate but hard copies of the certificate and Master Policy were not provided.

After making repeated requests, the hard copy of the certificate of insurance with the

changed nomination was received. But the complainant still did not receive the

certificate with the previous nominee’s name and the master policy.

The complainant was therefore forced to approach the Forum of Insurance

Ombudsman as per the policy terms, even though he is not interested in such

mediation.

The complainant hopes that the mental agony meted out to him by the RI would be

resolved by the Forum immediately without any further delay and within the

stipulated time and the complainant would get the copies of the master policy and the

old policy.

The complainant would be forced to seek legal help in future if the RI did not provide

the documents requested.

b) Insurer’s contention:

The RI received an advance premium of INR 100 from the insured’s banker SBI, Ram

Nagar Branch Coimbatore, on 13/03/2020 through Bank Account no. 20391166073

for the PA coverage in the name of the Complainant “Mr Arun Chella Samraj

Mukilesh” and they, in turn, issued the certificate of insurance under Master policy

bearing no. 0000000017176306 which is effective from 14/03/2020 to 13/03/2021.

After its issue, the certificate was promptly dispatched to the complainant on

17/03/2020 and the same was received by him on 11/05/2020, after the relaxation of

the first phase of nationwide lockdown due to COVID 19 pandemic.

On receipt of the document, the complainant sent an e-mail on 20/05/2020 to the RI

seeking change in the nomination from Mrs Anita Subramanian (spouse) to his

mother, Mrs Anuradha Bhavani. The RI immediately acknowledged the aforesaid

request of the complainant and corrected the name of the nominee. Given the situation

arising out of the COVID 19 pandemic, the soft copy of the revised certificate could

be e-mailed to the complainant only on 21/09/2020.

The RI is not a public authority as defined under Section 2(h) of the Right to

Information Act, 2005 and hence is not liable to provide information under the said

Act.

The GRC (Grievance Redressal Committee) of the RI has not received any

representation from the Complainant. It is pertinent to mention that policyholders who

have grievances against insurers are required to first approach the

Complaints/Grievance Redressal Cell of the insurer concerned. If they do not receive

a response from the insurer within a reasonable period or are dissatisfied with the

response received, they may approach the Forum of Insurance Ombudsman.

However, in the present case, the complainant has approached the Ombudsman

without exhausting the remedy of approaching the GRC of the RI and thus his right to

file a complaint with the Ombudsman has not accrued.

Nevertheless, on receipt of the present complaint to the Ombudsman, the complainant

was again approached by the RI to inform him that his grievances have already been

favourably addressed by the RI. Further, vide e-mail dated 27/11/2020, the soft copy

of the revised Certificate of Insurance was again sent to the complainant. Hence, the

present complaint is as such rendered infructuous and is liable to be closed/ dismissed

on the grounds mentioned.

22. Reason for Registration of Complaint:

The complaint is registered under Rule13 (1) (f) of the Insurance Ombudsman Rules, 2017,

which deals with “policy servicing related grievances against insurers and their agents and

intermediaries”.

23. Documents placed before the Forum:

Written Complaint dated 23/10/2020 and 11/11/2020 to the Insurance Ombudsman

Complainant’s representations dated 23/09/2020, 26/09/2020, 02/11/2020 &

10/11/2020 to the RI

RI’s response dated 25/09/2020, 28/09/2020 & 04/11/2020 to the Complainant

Consent (Annexure VI A) submitted by the Complainant.

Self-contained Note (SCN) of the RI dated

Certificate of Insurance dated 17/03/2020 under the PA Master Policy

Complainant’s letter dated 20/05/2020 for change of nomination

Complainant’s RTI application dated 20/05/2020.

Complainant’s letter dated 11/11/2020.

RI’s letter dated 24/11/2020 to the complainant

24. Result of hearing (Observations & Conclusion):

8. Because of the prevalent COVID 19 pandemic situation, the hearing was conducted

through VC on 28/12/2020, with the consent of and participation by both the

complainant and the RI.

9. The Forum records its displeasure over the delay in submission of SCN by the RI and

also their failure to provide a copy of the relevant enrolment form as per the directions

given during the hearing.

10. Complainant’s grievance is as follows.

a) Issuance of the certificate of insurance for PA cover by the RI when no such

request was made by him.

b) Ms Anita Subramanian was mentioned as the nominee in the certificate when no

such request was made by him.

c) The master policy was not provided to him despite several requests to the RI.

11. The complainant’s apprehension is that he was covered under a PA Policy against

accidental death when no such request was made by him to the RI. The fact that a

nominee not authorized by him was chosen in the policy, confirms his fear that his life

may be in danger.

12. The RI’s contention that the complainant’s right to approach the Forum has not

accrued is incorrect as per Rule no. 14 (3) of the Insurance Ombudsman Rules, 2017

which reads as below.

(3) No complaint to the Insurance Ombudsman shall lie unless

(a) the complainant makes a written representation to the insurer named in the

complaint and

(i) either the insurer had rejected the complaint; or

(ii) the complainant had not received any reply within a period of one month after the

insurer received his representation; or

(iii) the complainant is not satisfied with the reply given to him by the insurer;

As per Rule14(3)(a), the complainant should make a representation to the insurer and

not necessarily to their GRC. By his mail dated 23/09/2020 addressed to the Head,

Customer Care of the RI, the complainant sought hard copies of the Master Policy and

the previous certificate of insurance which was not responded to by the RI. In case,

the Master Policy cannot be provided to the complainant since it represents the

contract between SBI, the master policyholder and the RI, they should have informed

the complainant accordingly, instead of keeping silent. Similarly, the RI should have

responded to his RTI application and informed him that they are not coming within

the purview of the Act. Therefore, the complainant was justified in approaching this

Forum vide his letter dated 23/10/2020, due to lack of response from the RI and as

provided in the Rules.

13. During the hearing, it was explained by the Forum to the complainant that the Master

Policy being the document issued to SBI as the Master Policyholder, the complainant

is not entitled to receive a copy of the same from the RI. He is however entitled to

receive the certificate of insurance.

14. The demand of the complainant that the RI should send him a hard copy of the

certificate of insurance showing Ms Anita Subramanian as the nominee is

meaningless since it was already received by him on 11/05/2020. The present

complaint itself has been initiated by him based on the said document.

15. The Forum agrees with the RI’s submission that they are not a public authority under

Section 2(h) of the Right to Information Act, 2005 and hence they are not liable to

provide any information under the same. In any case, the information sought by the

complainant such as, who applied for the PA insurance, who authorized the debit of

premium to his account and who approved the nomination of Ms Anita Subramanian

can only be answered by SBI since the RI has submitted that they issued the

certificate of insurance based on a request received from the Bank along with the

premium. Hence, the complainant may approach SBI for the information required.

16. In conclusion, the Forum is of the opinion that there is no merit in the complaint

against the RI since it is established that they had issued the certificate of insurance

under the Master Policy as per the mandate given by SBI, the master policyholder and

have effected change in the nomination as requested by the complainant.

17. The complainant’s request for remedy/compensation for his mental agony does not

fall within the purview of the Forum.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both

the parties, the Forum holds that there is no merit in the complaint made against the

respondent insurer.

Thus, the complaint is not allowed.

25. If the decision of the Forum is not acceptable to the Complainant, he is at liberty to

approach any other Forum/Court as per laws of the land against the respondent

insurer.

Dated at Chennai on this 29th

day of January 2021.

(M Vasantha Krishna)

INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND

UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD

CASE OF MR. GOPAL FUTELA V/S THE ORIENTAL INSURANCE CO. LTD.

COMPLAINT REF: NO: NOI-G-050-2021-0107

AWARD NO:


Complainant

Mr. Gopal Futela

Saifpur Firojpur, Meerut, UP-250404

2. Policy No:

Type of Policy


221100/48/2019/200

Group Personal Accident Tailor made

Policy

Mukhya mantri Kissan and Sarvhit Bima

Yojna

14.09.2018 to 13.09.2019



Late Shri Dariyayi Lal

The Governor of Uttar Pradesh through

Commissioner and Secretary, Board of

Revenue, UP.

4. Name of the insurer The Oriental Insurance Co. Ltd.


6. Reason for repudiation Not covered under the policy

7. Date of receipt of the Complaint 07.02.11.2020

8. Nature of complaint Repudiation of claim

9. Amount of Claim As per sum insured of the policy-upto 5

lakhs

10. Date of Partial Settlement nil

11. Amount of relief sought As per the sum insured of the policy-upto

5 lakhs

12. Complaint registered under IOB

rules

13 (1) (b)

13. Date of hearing/place 20.01. 2021 at Noida – online hearing


a) For the Complainant Mr. Gopal Futela, Self

b) For the insurer Mr. S.K. Tiwari, Dy. Manager

15 Complaint how disposed Dismiss


17) Brief Facts of the Case: This complaint is filed by Mr. Gopal Futela against M/s

Oriental Insurance Insurance Co. Ltd. for repudiation of accidental death claim of his

father.


Complainant’s argument: The complainant’s father, Late Shri Dariyayi Lal, was covered

under Mukhyamantri Kissan and Sarvhit Bima Yojna, covering the residents of UP as per the

eligibility. On 14.02.2019, his father accidently died due to lighting when he was working in

his field. The complainant filed accidental death claim with the insurance company but they

rejected the claim 22.07.2019.

Insurers’ argument: The insurance company submitted their SCN dated 04.12.2020

wherein they stated that a MOU was signed between the insurance company and the

Governor of Uttar Pradesh through special Secretary, Institutional Finance and Externally

Aided Project, Govt. of Uttar Pradesh. As per the MOU, after the death of eligible person,

his/her dependent had right to get the compensation. In the present case, the complainant was

a married person and he had his own family and was not dependent on his father. Hence, they

rejected the claim as per the terms and conditions. Further, the insurance company stated that

as per the MOU, the claim file had been referred to the District Magistrate Claim Committee

for review and they were awaiting the decision.

19) Reason for Registration of Complaint: Repudiation of claim.


a) Complaint letter

b) MOU

c) Policy document

d) SCN

e) Investigator Report

21) Observations and Conclusion: - The complainant and the representative of the insurance

company were present for online hearing on 20.01.2021. The complainant stated that the

insurance company did not pay the death claim of his father. The insurance company reiterated

that the deceased was covered under the welfare scheme of UP Govt. where a MOU between the

insurance company and the Governor of Uttar Pradesh through special Secretary, Institutional

Finance and Externally Aided Project, Govt. of Uttar Pradesh had been signed narrating the

terms, conditions and exclusions of this policy. This policy provided compensation of Rs.5 lakhs

in the case of accidental death of the insurance person to the dependent nominee or legal heirs. It

is argued that the complainant was not dependent upon the insured person as he himself gave a

statement to the investigator that he was a 43 years old person, having three children and he was

the bread winner of his family. Hence, he was not a dependent on his father as per the policy

condition. The insurance company further stated that the claim file had been referred by them to

the District Magistrate Claim Committee for their review and were awaiting the decision.

Ongoing through the documents exhibited and the oral submissions made by both the parties

during the hearing, it has been noted from the MOU signed between the Govt of UP and the

insurance company under point no. 19 which says “To resolve any dispute in deciding the claim

of beneficiary, there shall be a committee headed by the District Magistrate of the concerned

District. A representative of the Oriental Insurance Co. Ltd, Chief Medical Officer (CMO) and

concerned S.D.M. will be the members. The decision of the Committee will be final and binding

on the Oriental Insurance Company ltd”. Accordingly, the insurance company has already

referred the claim file to the District Magistrate Claim Committee for review and is awaiting

their decision. I have no jurisdiction to interfere in the dispute.

The complaint is dismissed.

Place – Noida C. S. PRASAD

Date- 21.01.2021 INSURANCE

OMBUDSMAN

(Western U.P. &

Uttarakhand)

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND

UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD

CASE OF MRS. KUSMA DEVI V/S THE ORIENTAL INSURANCE CO. LTD.

COMPLAINT REF: NO: NOI-G-050-2021-0104

AWARD NO:


Complainant

Mrs. Kusma Devi

Vill & PO Banthra, Bidhuna, Auriya, UP-

206243.

2. Policy No:

Type of Policy


221100/48/2018/206

Mukhya Mantri Kisan & Sarvhit Bima

Yojna

14.09.2017 to 13.09.2018



Late Shri Rajendra Kumar

The Governor of UP through special

Secretary Institutional Finance, Insurance

& Externally Aided Project, Govt of UP.

4. Name of the insurer The Oriental Insurance Co. Ltd.


6. Reason for repudiation Delay in submission of claim papers

7. Date of receipt of the Complaint 02.11.2020

8. Nature of complaint Repudiation of claim

9. Amount of Claim Rs. 5,00,000/-

10. Date of Partial Settlement n.a.

11. Amount of relief sought Rs. 5,00,000/-

12. Complaint registered under IOB

rules

13 (1) (b)

Recommendation

Taking into account the facts and circumstances of the case and the submissions made by

both the parties, the insurance company had already referred the claim file the District

Magistrate Claim Committee for review and are awaiting their decision. I see no reason

to interfere with the grievance Redressal machinery as per the MOU.


13. Date of hearing/place 20.01. 2021 at Noida – online hearing


a) For the Complainant Mrs. Kusma Devi, Self

b) For the insurer Mr. Anil Yadav, Div. Manager, Agra DO

15 Complaint how disposed Dismiss


17) Brief Facts of the Case: This complaint is filed by Mrs. Kusma Devi against M/s

Oriental Insurance Co. Ltd. for repudiation of the death claim of his husband.


Complainant’s argument: The complainant’s husband, Late Shri Rajendra Kumar, was

covered under Group Personal Accident Policy named Mukhya Mantri Kisan & Sarvhit Bima

Yojna. The policy was issued by the Oriental Insurance Company Ltd by signing a MOU

between UP Govt and the insurance company. The policy was issued for the period from

14.9.2017 to 13.9.2018. The policy covered the farmers whose age were between 18 to 70

years and their names must be entered in Khatouni as account holder or co-account holder.

This policy would pay Rs. 5 lakhs to the legal heir of the insured person if he died accidently.

The complainant’s husband, Late Shri Rajender Kumar, died in a road accident on

26.06.2018. He was a registered farmer and was covered under the above policy. The

complainant sent claim papers to the District Magistrate, Distt Auraiya, via speed post on

24.10.2018 who forwarded the claim to the insurance company at Agra. As per the MOU, the

documents were submitted before the expiry of policy period but the insurance company

repudiated the claim on the ground that the date of death was 26.08.2018 and the papers were

submitted to the DM office on 27.10.2018, as per the condition of MOU, the claim

documents were to be submitted within a period of 90 days from the date of death. The

complainant further stated that as per page no. 10 of MOU if there was a delay of more than

three months in submission of documents, the DM could condone the delay upto one month.

The complaint submitted the documents on 27.10.2018 even though the insurance company

repudiated the claim.

Insurers’ argument: The insurance company submitted their SCN dated 01.01.2021

wherein they stated that the claim belonged to MUKHYA MANTRI KISAN & SARVHIT

BIMA YOJNA submitted for claim amount of Rs. 500000/ -.This policy gave Personal

Accident cover to farmers of Uttar Pradesh (without any income limit), landless farmers,

those related to agriculture related activities, (Fishery, milk producing, pig farming, goat

farming, beekeeping etc.) nomadic/roaming families, businessmen (who are not covered

under any others Government Scheme), forest workers, retailers, Rickshaw pullers, porters

and those engaged in other activities who are residents of rural or urban areas whose annual

income is less than INR 75000/- per year and age limit in between 18 to 70 years shall be

eligible for this Scheme. As per claim papers submitted by the complainant, they found that

the date of death was 26.06.2018 and papers received by their office on 27.10.2018 i.e. after 4

months i.e. 122 days. As per term and condition of the policy all claim papers should reach

their office along-with all enclosures of scan copy within 3 months (maximum limit). As per

terms and condition of MOU the insurance company repudiated the claim and intimated the

insured vide their letter dated 19.04.2019. The insurance company further stated that the

power to condone the delay of one month was lying with the District Magistrate. In this case,

the claim was received after 4 months and the claim had been reconsidered as per terms &

condition of MOU, hence, the claim was not payable. Further, the insurance company put-up

the above case in a D.M. Committee meeting held on 14 June, 2019. In that meeting the

committee had instructed to reconsider / review the case as per MOU terms & conditions.

Accordingly the said claim was reviewed and it was decided that as per MOU terms &

conditions the claim was not found payable.

17) Reason for Registration of Complaint: Repudiation of claim.


a) Complaint letter

b) Discharge Summary

c) Policy document

d) SCN

21)Observations and Conclusion: - The complainant and the representative of the insurance

company were present for online hearing on 20.01.2021. The complainant stated that the

insurance company did not pay the death claim of his husband. The insurance company

reiterated that the deceased was covered under the welfare scheme of UP Govt. where a

MOU between the insurance company and the Governor of Uttar Pradesh through special

Secretary, Institutional Finance and Externally Aided Project, Govt. of Uttar Pradesh had

been signed narrating the terms, conditions and exclusions of this policy. The insured person

died on 26.06.2018 and they received claims intimation on 26.06.2018 after a period of 4

months whereas, as per the MOU all claim papers should reach their office within a period of

3 months. The power to condone the delay of one month was rested with the District

Magistrate. As per the MOU, they put-up the above case in a D.M. Committee meeting held

on 14 June, 2019, the said claim was reviewed and it was decided that the claim was not

payable.

Ongoing through the documents exhibited and the oral submissions made by both the parties

during the hearing, it has been noted that as per the MOU signed between the Govt. of UP

and the insurance company under point no. 19 says “To resolve any dispute in deciding the

claim of beneficiary, there shall be a committee headed by the District Magistrate of the

concerned District. A representative of the Oriental Insurance Co. Ltd, Chief Medical Officer

(CMO) and concerned S.D.M. will be the members. The decision of the Committee will be

final and binding on the Oriental Insurance Company ltd”. The insurance company has

submitted a copy of a letter dated 3rd

July, 2019 issued by the Office of the DM where the

case of deceased was reviewed (Sr. No. 9) but was not considered to be paid for the reason of

delay. The insurance company had referred the claim file to the District Magistrate Claim

Committee for review after deciding that the claim was not payable. I have no jurisdiction to

interfere in the matter. The final authority to resolve the dispute is the District Magistrate

Claim Committee, Govt. of U.P.


Place – Noida C. S.

PRASAD

Date- 21.01.2021 INSURANCE

OMBUDSMAN

(Western U.P. &

Uttarakhand)

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Mrs. Sofia Abrar…………..……....………………. Complainant

V/S

New India Assurance Co. Limited…………..………..…………Respondent

COMPLAINT NO. LCK-G-049-2021-0097 ORDER NO.

IO/LCK/A/GI/0045/2020-21

1. Name & Address of the Complainant Mrs. Sofia Abrar,

S-8/4-15-1-K, Raza Colony,

Maqbool Alam Road, Varanasi-221001.

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

42240031180200009931

Two wheeler Liability Policy

26.10.2018 to 25.10.2019

Recommendation

Taking into account the facts and circumstances of the case and the submissions made

by both the parties, the insurance company had referred the claim file the District

Magistrate Claim Committee for review who reconsidered the claim and found the

claim is not payable. I see no reason to interfere with the Grievance Redressal

Machinery set up by the insurance company and the Govt. of U.P.


3. Name of the life insured


Mr. Javed Ahmad Siddiqui

4. Name of the insurer New India Assurance Company Limited

5. Date of Repudiation/Rejection 02.07.2020

6. Reason for repudiation/Rejection No FIR, No PMR and Late intimation

7. Date of receipt of the Complaint 07.12.2020

8. Nature of complaint Unjustified repudiation of claim

9. Amount of Claim Rs.15,00,000/-

10. Date of Partial Settlement ---

11. Amount of relief sought Rs.15,00,000/-

12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule 2017

13. Date of hearing/place On 27.01.2021 at Lucknow


e) For the Complainant Present [Mr. Jahid Abrar ]

f) For the insurer Present [Mr.Ashwini Kumar ]

15. Complaint how disposed Award

16. Date of Award/Order 27.01.2021

17. Mrs. Sofia Abrar (Complainant) has filed a complaint against New India Assurance Company

Limited (Respondent) alleging for non settlement of PA claim[death of her husband] under motor

policy of the respondent.

18. Brief Facts Of the Case:- The complainant’s husband late Javed Ahmad Siddiqui purchased two

wheeler liability policy for his motorcycle Hero Honda CD no: UP-65-Z-5647 for period 26.10.2018 to

25.10.2019. He met with an accident on 06.09.2019 and sustained grievous injuries. He was taken to

Trauma Centre, BHU where he expired on 18.09.2019. Intimation of death was given to the

respondent after 76 days of death. The complainant lodged a PA death claim with the respondent

which was repudiated on 02.07.2020 on the ground that post mortem was not conducted, FIR was not

registered and intimation of death was given after inordinate delay of 76 days.

In their SCN/Reply dated 23.12.2020, the respondents have submitted that the personal accident claim

of late Javed Ahmad Siddiqui stands repudiated on the following grounds :

1. Post mortem of deceased was not conduced which was necessary to prove accidental death.

2. Intimation of death was given to insurance company after 76 days. This is breach of policy

condition.

3. As per death certificate issued by BHU, Varanasi treatment was given to the deceased as a non-

medico legal case whereas in personal accident cases, patient is treated as a medico legal case and

information of injury is given to local police

4. In a written intimation given by Mr. Zahid Abrar to Sarnath Police Station, registration number of

motorcycle is not mentioned. In PA Claim form provided to the investigator, there is no mention of

registration number of motorcycle and name of eye witness.

5. In her second claim form submitted in office on 25.12.2019, the complainant mentioned date of

death as 06.09.2019. The shown eye witness Mr. Ehteshaam Ahmad did not lodge any FIR

immediately after the accident. As such his presence on the spot is doubtful.

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly

filled/signed submitted by the complainant while respondent filed SCN along with enclosures.

20. I have heard the complainant’s representative in person. I have also heard the respondent’s

representative.

21. This is a peculiar type of case wherein husband of the complainant namely Javed Ahmad Siddiqui

(insured with the respondent) met with an accident on 06.09.2019 at about 12 noon when he was

coming back from Ghazipur to Varanasi by motorcycle No: UP-65-Z-5647. When he reached near

St.John’s turn near Gram :Ledhipur, all of sudden a bull came in front of the vehicle. Motorcycle s got

uncontrolled and dashed with a cable drum. Deceased life assured sustained injuries who was admitted

at Trauma Centre, BHU, Varanasi on 06.09.2019. He was transferred in the ward on 07.09.2019

wherein he succumbed to the injuries on 18.09.2019 at 12:16 hours.

Admittedly information was given to the respondent with a delay of 76 days. Post mortem of the dead

body was also not conducted by the hospital authorities. Information regarding accident was given by

the brother in law of the deceased namely Mr. Arif Abrar on 22.09.2019 which was entered at GD No

:44 at PS : Sarnath, District Varanasi. But vehicle number was not mentioned. Subsequently another

information was given in PS :Sarnath on 16.01.2020 which was entered in GD No: 66 wherein

registration number of motorcycle was mentioned as UP-65-Z-5647. The claim was repudiated by the

respondent on 02.07.2020 on the following grounds :

Post mortem of deceased was not conduced which was necessary to prove accidental death.

Intimation of death was given to insurance company after 76 days. This is breach of policy

condition.

As per death certificate issued by BHU, Varanasi treatment was given to the deceased as a

non-medico legal case whereas in personal accident cases, patient is treated as a medico legal

case and information of injury is given to local police

In a written intimation given by Mr. Zahid Abrar to Sarnath Police Station, registration

number of motorcycle is not mentioned. In PA Claim form provided to the investigator, there is

no mention of registration number of motorcycle and name of eye witness.

In her second claim form submitted in office on 25.12.2019, the complainant mentioned date of

death as 06.09.2019. The shown eye witness Mr. Ehteshaam Ahmad did not lodge any FIR

immediately after the accident. As such his presence on the spot is doubtful.

During the hearing, I gave an opportunity of hearing to Mr. Rajesh Kumar Mishra, Sr. Divisional

Manager, DO Varanasi of the respondent who could not give satisfactory reply of the queries put to

him. Even the SCN submitted by the respondent is very sketchy which did not contain the full details

of the respondent’s defence. It is apparent that claim was repudiated without giving an opportunity of

hearing to the widow of the deceased. It is settled legal principle that an opportunity of hearing should

be given to the complainant.

As far as question of submission of post mortem report and non mention of vehicle number in the

initial GD and treatment of the deceased life assured as non medico legal case is concerned,

complainant has no role to play in it. Deceased was admitted in the hospital after sustaining the

injuries. He died in the hospital. When he was admitted in the hospital, it was responsibility of the

hospital authority to intimate the police. Even if it is not done, complainant was not at fault in it.

Further after the death, it was responsibility of the hospital authority to advise for post mortem and

conduct the post mortem of the deceased. It is not a case of the respondent that the complainant was

not agreeable for the post mortem hence complainant had no role if the post mortem is not done. There

is no dispute regarding insured vehicle number.

As far as delay is concerned, complainant has duly explained it. It is more important when the

respondent’s have not given an opportunity of hearing to the complainant. However, it would be in the

interest of justice that respondent should be given an option to reconsider and reassess the claim on

the basis of facts recorded in the judgment within a period of 30 days.

Order :

Complaint is allowed. Respondents are directed to reassess and reconsider the claim within 30 days

from today after giving an opportunity of hearing to the complainant. If the complainant is not satisfied

with the processing of the claim, she would have an opportunity to approach this forum again.

Let a copy of this order be sent to Sh. Rajiv Kohli, DGM, New India Assurance Company, Regional

Office, Kanpur for information and necessary action

22. Let a copy of award be given to both the parties.

Dated : January 27, 2021 Justice (Retd.) Anil Kumar Srivastava

Place : Lucknow Insurance Ombudsman

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017)

OMBUDSMAN – K.B. SAHA

CASE OF: : Complainant MRS.BOBY BEGUM VS NATIONAL INSURANCE

CO.LTD

COMPLAINT REF. NO: GUW- 051-2021-0094 : Award No


Complainant

MRS.BABI BEGUM

2. Policy No:

Type of Policy


10030047019600022039630200

JANATA PERSONAL ACCIDENT

08/09/2003 TO 07/09/2018



MD.TAZNUR ALI

4. Name of the insurer NATIONAL INSURANCE COMPANY

LIMITED

5. Date OF OCCURANCE OF

LOSS/CLAIM

04/01/2018

6. DETAILS OF LOSS Rs.300000/-

7. REASON FOR GRIEVANCES Rules 17(6) of the Insurance

ombudsman Rule 2017

8.a

8.b

Nature of complaint

Date of receipt of the complain

NO RESPONSE FROM INSURANCE

CO.

16/11/2020

9. Amount of Claim Rs.300000/-

10. Date & Amount of Partial

Settlement

NIL

11 Amount of relief sought Rs.300000/-


Rules of Insurance Ombudsman

2017

13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati

19/01/2021


For the Complainant MRS.BABI BEGUM

For the insurer MR. SAMRAT MONDAL

15 Complaint how disposed Through personal Hearing

16 Date of Award/Order 19/01/2021

17) Brief Facts of the Case: As stated by Mrs. Babi Begum, the complainant, that her

husband Md. Taznur Ali had a Janata Personal Accident Policy with National

Insurance Co. Ltd. Unfortunately , on 03/01/2018 Md. Ali died due to spinal shock

following injuries in the body as stated in the police report. After death of her husband

she visited many branches & written to National Insurance Co. but not responded by

the insurance co. So she has approached to us for her claim.

18 a) Complainant’s Argument: - Same as point no 17.

18b) Insurers’ argument: Insurance Co. stated in their SCN that,It is found that the

nominee name is mentioned as Bobey Begum in the policy schedule and in other ID

proof documents (i.e. PAN card, Bank Passbook) it is mentioned as Babi Begum. A

correction/affidavit was sought from the concerned person through letter dated

08/06/2018 along with legible copy of final police report, aadhar card copy. The above

mentioned documents are yet to be received; on receipt of the same they shall be in a

position to process the claim.

19) Reason for Registration of Complaint: -: Scope of the Insurance Ombudsman Rules

2017 (Rule after proper approval from honorable ombudsman13 (1) (b).


a) Complaint letter

b) Annexure – VI A

c) Copy o the policy

d) Annexure VII A

e) S C N

Result of hearing with both parties (Observations & Conclusion):- Both the parties

were called for hearing on 19/01/2021. The complainant was represented by herself and

the insurer was represented by Mr. Samrat Mondal (online)

DECISION

We have taken into consideration the facts & circumstances of the case from the

documentary as well as verbal submission made by the claimant and representative of

Insurance co. We have also gone through the records. During the course of hearing, we

observed that the nominee name is mentioned as Bobey begum in the policy schedule &

in other ID proof documents i.e.,(PAN CARD,AADHAR,BANK PASSBOOK) it is

mentioned as Babi Begum. Insurance co. sought a correction/affidavit from the nominee

of the deceased person letter dated 08/06/2018.They also called for a legible copy of final

police report, aadhar card copy. But they did not receive the same till date. So they

could not process the claim. The Forum also observed that, in the Final police report it

is clearly mentioned that Death was due to spinal shock following injuries in the body,

that proves that it is an accidental death. In the post mortem report also it is clearly

written that Death due to spinal shock following injuries. So, these are the corroborative

evidence of accidental death. During the course of hearing insurer pointed out that may

be it is a suicide case. But no where in police Final Report or in Death Certificate the

possibility of suicide was mentioned. So no question of suicide appears in this case. It is

a clear case of accidental death.

The forum allowed one day to the complainant to submit an affidavit which proves

that Babi Begum and Bobey Begum is the same and one person. The complainant

submitted us the the same document in the next day i.e., on 20/01/2021. It may be noted

that a clear copy of Police Final Report as submitted by the claimant has already been

forwarded to the Insurer on 06/01/2021 vide e.mail. Moreover, as required by the

representative of the Insurer a scanned copy of above affidavit along with a copy of

cancelled cheque and Bank Pass Book of the claimant are being forwarded to the

Insurer for necessary action.

Under the circumstances in order to ensure fairness to the complainant the Forum

directs the insurance co. to pay full sum assured to the nominee of the deceased, Mrs.

Babi Begum.

Hence the complaint is treated as closed.

The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017.

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30

days of the receipt of the award and intimate compliance of the same to the

Ombudsman.

Dated at Guwahati, the 19 th

Day of January 2021

K.B.Saha

Insurance Ombudsman

AWARD NO. IO/KOC/A/HI/0359/2020-2021

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI

(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF

THE INSURANCE OMBUDSMAN RULES, 2017)

Complaint No. KOC-H-048-2021-0500

PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI.

AWARD PASSED ON 20.01.2021

1. Name and Address of the

complainant

: Mrs. Priyanka Nair

Jyotsna, MRA-30, Ottukal Street, Kaithamukku, Thiruvanathapuram 695024

2. Policy Number : 240600421999999901

3. Name of the Insured

: Lt. Col. S Anand

4. Name of the Insurer

: The National Insurance Co. Ltd.

5. Date of receipt of Complaint

: 10.11.2020

6. Nature of complaint

: Rejection of death claim

7. Amount of relief sought

: --

8. Date of hearing

: 14.12.2020

9. Parties present at the hearing a) For the Complainant

: Col. M N Gopakumar (online)

b) For the Insurer : Ms. Thankamani

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance

Ombudsman Rules, 2017. The complaint is regarding non payment of death claim. The

complainant, Mrs. Priyanka Nair is the wife of the policy holder.

1. Averments in the complaint are as follows:

The Complainant stated that she is a widow of martyred Lt Col S Anand, SHAURYA CHAKRA,

whose death, though was classified as “Battle Casualty” by Army Authorities (while on

operational duty at the China Border), the claim under the scheme was repudiated by The

National Insurance Co Ltd. Policy Certificate is submitted as Exhibit 1. The claim was

rejected by the National Insurance Company without assigning any specific reason and

merely stating “Claim is NOT Admissible as per ‘terms and conditions’ of the

policy(Repudiation Email is attached as Exhibit 3). The ‘Terms and Conditions’ , which were

non existing was quoted, as the impugned “Terms and Conditions” was not available,

neither on the web sites of State Bank Of India(SBI) nor NICL, utmost efforts were made by

the claimant to procure it. When asked through the bank, NICL made available a document

(as email) purporting it to be the PMSBY-POLICY CONDITIOS. On perusal it came to notice

that the impugned document was seemingly a sham due to discrepancies as listed below:-

Page 4, Para 1 revealed that the impugned document is of “Future Generali India

Insurance company Ltd ad NOT of NICL.

The impugned document did not have the UIN allotted by the IRDA.

“Service on duty with any armed force” was listed among major exclusions in the

document; this is an absolute contravention to Govt Policy – see the last sentence of

‘Origin of PMSBY Scheme’ (Source:Govt website URL:

https://www.jamasuraksha.gov.in/Files/PMSBY/English/About -PMSBY.pdf)

As a move towards creating a universal social security system and family’s financial security,

which gets pulled to the ground due to accidental death of the “breadwinner”, the Prime

Minister launched the GOVERNMENT SPONSORED PMSBY nationally on 9th May 205. The

scheme was made available to all with a savings bank account who give their consent to join

and was to be offered by Public Sector General Insurance Companies or others, the One and

only Exclusion Clause was to be that age should not be below 18 and not above 70 years.

NICL could not provide answers to the anomalies as above and replied with an apology to

the bank. In view of the Omissions and commissions by the NICL, it is evident that (a) NICL

did not have any “T & C”, for PMSBY of its own (also confirmed by their own admission in

reply to the RTI query (Submitted as Exhibit 2) (b) Even if NICL had any “T & C”, it was

neither put out in their website nor was made available to the “subscriber(s)” through the

Master Policy Holder(SBI) as was mandatorily required under “Protection of Policyholders’

Interest) Regulations, 2017.”

https://www.jamasuraksha.gov.in/Files/PMSBY/English/About%20-PMSBY.pdf

Initially, to meet the deadline of initiating the ‘Death Claim’, only the then available

‘Autopsy Report’ was sent. The medical terms in the Autopsy Report merely

conveyed/depicted the state of the vital organs in the body at the time of death and did

not contain any information on the circumstances that led to the sudden death of a

perfectly healthy Officer (medically declared FIT for all severely strenuous military duties

anywhere) or how he came to be in that state. Hence, a REPORT prepared after

comprehensive inquiries by the ARMY authorities, was sent to NICL as additional

documentary evidence (the said Report titled TO WHOMSOEVER IT MAY CONCERN & is of

two pages – submitted as Exhibit 8)

However, NICL totally disregarding the contents of the above ‘Additional ARMY Report’ in

the correct perspective, again repudiated the claim. Hence the claimant through RTI sought

facts from both SBI and NICL on the “T & C” and replies were received from both. The RTI

replies have established that neither the SBI nor the NICL had neither posted nor displayed

any “T & C” for the PMSBY Scheme. After the second repudiation, the claimant took up the

case with the Centralised Public Grievance and Monitoring System, but again the Kochi

Regional Office of the NICL obstinately stuck to their repudiation.

In spite of the Joint Secretary to the Govt of India, Ministry of Finance, Department of

Financial Services finding merit in the arguments of the claimant, bringing in a totally new,

skewed and erroneous justification the claim has been repudiated by the Head Office of

NICL stating: “…the death of Shri Lt.Col. S Anand was due to illness (Sick)… The claim

therefore fall under the ambit of the PMSBY Scheme.

Death consequent to being subjected to “Convulsions of Nature” is a qualifying condition for

The PMSBY Scheme. This point is elaborated: Replies to clarifications from SBI and NICL on

the “T & C” through RTI. It is therefore prayed before the Honourable Ombudsman that the

claim is admissible and to kindly consider the detailed submissions and favourable orders

may kindly be passed in favour of the claimant/complainant, the grieving your window,

which will in addition to facilitating “financial security”, will also be a matter of recognition

and honour for her Martyred your ARMY Officer husband, thrice recipient of Gallantry

Awards.

2. The Respondent Insurer entered appearance and filed a self contained note. It is

submitted that the nominee of the policy no: 37020442158200000256, Mrs.Priyanka Nair,

lodged a death claim under the PMSBY Scheme on 23/8/2019 based on which the claim was

processed by the PMSBY Cell, KRO and the claim was repudiated via letter dated 23/9/2019

mentioning that the claim is not admissible as PMSBY Scheme covers only death solely due

to accident. As per the terms and conditions of the PMSBY policy, the Company will pay

Specified Sum Insured, to the insured person or nominee “in case of accidental

death/permanent total disability, resulting solely and directly from accident caused by

external, violent and visible means”. From the Autopsy Report submitted by the nominee

of the deceased it is evident that the deceased was admitted as a case of fever with severe

sepsis and multi organ dysfunction syndrome, which led to cardiopulmonary arrest and

death. The record issued by the ROM. Rayang, Arunachal Pradesh, confirms that the death

was due to infection and the resultant bodily affliction of severe sepsis which lead to multi

organ dysfunction and acute respiratory distress syndrome.

The nominee had further sent a letter to the Grievance Cell, KRO by email dated 12/12/2019

upon which the file had been reviewed by the Grievance Cell in charge and it was observed

that the repudiation by the PMSBY cell was in order. Based on this, a reply was sent to the

nominee on 12/12/2019, mentioning our inability to consider the claim.

Subsequently one Mr.Col.(Rtd) M.N.Gopakumar, claiming to be the father of the nominee,

had approached the CPGRAMS PORTAL on 17/3/2020, which was responded by the same

message.

Later Mr.Col.(Rtd) M.N.Gopakumar approached the Department of Financial Services,

Ministry of Finance with the same grievance. The Under Secretary, DFS, replied to the same

stating that the repudiation of the claim by the Insurance Company is in order and hence

the grievance is treated as closed. Aggrieved by the decision of the Under Secretary,

Mr.Col.(Rtd) M.N.Gopakumar approached DFS with the request to reconsider its stand

which in turn had forwarded the request for reconsideration by National Insurance

Company Ltd.

We received a mail from our HO dated 11/6/2020 with the instruction to review the claim

by the Regional Customer Relations Committee which also opined that the decision taken by

the claim servicing office is in order.

Insurance company Observations:

The PMSBY Cell, KRO and Grievance Cell KRO had repudiated the claim strictly on the basis

of the terms and conditions of the policy as the death of the insured had not been caused

solely and directly by an accident arising out of external, violent and visible means. The

repudiation by National Insurance Company had subsequently been found to be in order by

the Under Secretary, Department Of Financial Services, Government Of India, when the

matter had been escalated by Mr.Col.(Rtd) M.N.Gopakumar to the department.

As per the Pradhan Mantri Suraksha Bima Yojana, specified Sum Insured shall be payable

only if “any bodily injury to the insured person resulting solely and directly from accident

caused by external, violent and visible means, lead to his/her death or permanent

irrecoverable total disability within one calendar year” . Since the death of the insured

person is not due an accident as defined above, we do not have any liability under the

policy.Hence the repudiation of the claim is in order and the complainant was categorically

informed of our decision immediately.

3. I heard the Complainant and the Respondent Insurer. On behalf of the Complainant, her

father Col.MN Gopakumar – Retd, entered appearance through online and submitted that

his daughter Priyanka Nair is the complainant who is the widow of Late Col S.Anand,

SHAURYA CHAKRA and the nominee of the insured in the policy no.37020442158200000256

issued under the PMSBY Scheme of GOI. The claimant was 10 weeks pregnant and was

staying alone at Jalandhar (Punjab) with her aged and ailing Mother in Law and her 9 year

old son when her husband was Martyred which was unbearable, traumatic and extremely

agonizing. He (Father of the claimant) handed the claim related matters with National

Insurance Company limited, the respondent insurer. The Head Office of National Insurance

Company, Kolkata repudiating the claim stating “illness” as the cause of death is out right

erroneous and is plainly misconceived. World Health Organisation’s (WHO) “Global Report

on the Epidemiology and Burden of Sepsis” states that “Sepsis is not a specific illness but

rather a syndrome encompassing a still-uncertain pathobiology.” He further submitted that

the insured contracted an infection when he was out on an Operational Assignment at the

China border in extremely difficult terrain in Arunachal Pradesh when he was suddenly

exposed to “convulsions of nature”, this in turn triggered a Sepsis. The proximate cause

(causa proxima), in this case was undoubtedly, an infection due to an external cause, which

was unexpected and unforeseen which triggered a Sepsis leading to life threatening organ

dysfunctions leading to Multi Organ dysfunction, respiratory distress syndrome and death. It

is submitted that death consequent to being subjected to “Convulsions of Nature” is a

qualifying condition for the PMSBY scheme. That the death of the insured was certified by

ARMY HQ as “The officer died on 28th June 2019 due to ‘Fever with Severe Sepsis and Multi

Organ Dysfunction Syndrome’ due to climatic conditions during Operational Recce at Tuting

on the Line of Actual Control and was classified as “Battle Casualty” and hence was accorded

the highest status of a “Martyr.” And in the additional ARMY REPORT it is stated that “due

to the accidental infection contracted by the Officer and the resultant bodily affliction of

“Severe Sepsis” which the former triggered, lead to multi organ dysfunction and acute

respiratory distress syndrome culminating in the most unanticipated, unexpected and

unfortunate death of the officer on 28 June 2019.” It is submitted that the repudiation of

this claim is unjust & arbitrary and exemplifies skewed and erroneous understanding of the

case by the respondent insurance company officials who have examined it.

The Respondent Insurer submitted that the claim submitted by the widow of Late Col

S.Anand, SHAURYA CHAKRA and the nominee of the insured in the policy

no.37020442158200000256 issued under the PMSBY Scheme was repudiated by the Kochi

Regional Office of the company stating the reason that the claim is not admissible as PMSBY

Scheme covers death solely due to accident only. As per the terms and conditions of the

PMSBY policy, the company will pay Specified Sum Insured, to the insured person or

nominee “in case of accidental death/permanent total disability, resulting solely and directly

from accident caused by external, violent and visible means.” The repudiation by National

Insurance Company had subsequently been found to be in order by the Under Secretary,

Department of Financial Services, Govt of India, when the matter had been escalated by

Col.(Retd) MN Gopakumar (Father of the claimant) to the DFS. As per the PMSBY scheme,

specified sum insured shall be payable, only if “any bodily injury to the insured person

resulting solely and directly from accident caused by external, violent and visible means,

lead to his/her death or permanent irrecoverable total disability within one calendar year.”

Since the death of the insured person is not due to an accident as defined above, they do

not have any liability under the policy. Hence the repudiation of the claim is in order and

the complainant was categorically informed of the company’s decision immediately.

4. Pradhan Mantri Suraksha Bima Yojana (PMSBY) is a group accidental insurance policy. It

provides life coverage of Rs. 2 lakh for the accidental demise and permanent total disability

and Rs. 1 lakh for permanent partial disability. Pradhan Mantri Suraksha Bima Yojana

(PMSBY) was launched especially for people for whom insurance was out of reach due to a

financial constraint. The scheme was officially launched by our current Prime Minister of

India, Shri Narendra Modi on 9th May, 2015, as a move towards creating a universal social

security system and family’s financial security, which gets pulled to the ground due to

unexpected accidental death of the breadwinner. This case is of a Martyred Army Officer,

whose death was classified by the Army Authorities as a “Battle Casualty” while on

operational duty at the China Border was repudiated by the respondent insurance company.

The death of the insured was certified by ARMY HQ “due to climatic conditions during

Operational Recce” and was classified as “Battle Casualty” and hence was accorded the

highest status of a “Martyr” and his name appeared as Sl.No. 1 in the List submitted as

evidence(Exbt.2) titled “INDIAN ARMY SALUTES THE BRAVEHEARTS WHO MADE THE

SUPREME SACRIFICE IN 2019.” In the additional ARMY REPORT it is stated that “due to the

accidental infection contracted by the Officer and the resultant bodily affliction of “Severe

Sepsis” which the former triggered, lead to multi organ dysfunction and acute respiratory

distress syndrome culminating in the most unanticipated, unexpected and unfortunate

death of the officer on 28th June 2019.” The circumstances that led to the sudden death of a

perfectly healthy Army Officer who was medically declared fit for all severely strenuous

military duties is definitely consequent to the “Convulsions of Nature”, which is a qualifying

condition for the PMSBY Scheme. The causa proxima of the unanticipated, unexpected and

unfortunate death of a healthy Army Officer during his operational assignment is

undoubtedly “convulsions of nature”, this in turn triggered a Sepsis causing death of the

officer. The unanticipated and unexpected sudden death of any healthy Army Officer /

Jawan, during their army operations is to be treated as accidental unless otherwise certified

and reported medico legally. As a state owned insurance company like National Insurance

company, it seemed proper to pay tribute to the great martyred by paying this claim to the

legal nominee.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of

Rs.2,00,000/-, within the period mentioned hereunder. No cost.

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply

with the award within 30 days of receipt of the award and intimate compliance of the same

to the Ombudsman.

Dated this the 20th day of January 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

INSURANCE OMBUDSMAN CHANDIGARH

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