PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN ...

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PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW

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

Smt. Lalita Singh…………..……....………………. Complainant

V/S

SBI General Insurance Co. Limited…………..………..…………Respondent

COMPLAINT NO. LCK-G-040-1920-0027 ORDER NO. IO/LCK/A/GI/0175 /2019-20

1. Name & Address of the Complainant Smt. Lalita Singh

951, Manas Nagar, Krishna Nagar

Lucknow

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

175097-0000-00

Personal Accident Policy

20.12.2017 to 19.12.2018

3. Name of the life insured

Name of the policyholder

Mr. Dharmendra Singh

Mr. Dharmendra Singh

4. Name of the insurer SBI General Insurance Co. Ltd.

5. Date of Repudiation/Rejection ---

6. Reason for repudiation/Rejection Necessary documents not submitted

7. Date of receipt of the Complaint 15.07.2019

8. Nature of complaint Delay in settlement of Claim

9. Amount of Claim ---

10. Date of Partial Settlement ---

11. Amount of relief sought ---

12. Complaint registered under Rule Rule No.13(1)(a) of Insurance Ombudsman Rule 2017

13. Date of hearing/place On 04.03.2020 at Lucknow

14. Representation at the hearing

a) For the Complainant Mrs. Lalita Singh

b) For the insurer Mr. Sanjeev Tripathi

15. Complaint how disposed Award

16. Date of Award/Order 04.03.2020

17. Smt. Lalita Singh (Complainant) has filed a complaint against SBI General Insurance Company

Limited (Respondent) alleging delay in settlement of personal accident claim of her husband.

COMPLAINT NO. LCK-G-040-1920-0027 ORDER NO. IO/LCK/A/GI/0175/2019-20

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18. Brief Facts Of the Case:- The complainant has stated that her husband had taken a PA policy from

respondent. Her husband was died on 23.06.2018 due to drowning. She had submitted the claim with the

respondent and submitted all the required documents. She had received a letter from respondent to

submit the necessary documents. All required documents were also submitted through SBI bank

Transport Nagar branch. After that the respondent had again asked to submit some documents vide their

letter dated 31.08.2018.Again she had received letters dated 28.12.2018, 05.03.2019 to submit the

documents which were already submitted to the respondent by her. She had further stated that she had

various written letters on 30.01.2019, 08.02.2019 & 05.03.2019 which were not replied by the respondent

till date. Aggrieved with the delay in settlement of claim, now the complainant had approached this

forum.

In their SCN/Reply, RIC has stated that the intimation of aforesaid claim was received on 13.07.2018

towards the accidental death of the insured. The date of accident was mentioned as 23.06.2018. The

claim was registered by the nominee. The claim was intimated after the delay of 20 days i.e. on

13.07.2018. However without prejudice to the delay intimation, the claim was investigated and assessed.

It was observed that the documents submitted by the complainant were deficient/ incomplete to access

the claim. It was further stated that various reminder vide letter dated 16.07.2018, 31.07.2018,

16.08.2018, 318.08.2018, 15.09.2018, 01.10.2018, 13.12.2018, 28.12.2018, 14.01.2019, 26.03.2019 &

17.05.2019 sent to the complainant for submitting requisite deficient documents. In the absence of the

said documents it is not possible to determine the claim. After receipt of the reminders,the papers has

been submitted by the complainant but still the post mortem of the deceased was not carried and hence

there’s no concrete evidence which could be established about the alleged cause of death i.e. due to

drowning. As per latest deficiency letter the documents are still not provided by the complainant.

Therefore there is no error on the part of the respondent.

19. The complainant has filed a complaint letter, annexure-VI-A, correspondence with respondent and

copy of policy document while respondent filed SCN with enclosures.


20. I have heard both the parties at length and perused papers filed on behalf of the complainant as well

as the insurance company.

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21. Undisputedly Sh. Dharmendra Singh was covered under the policy issued by the respondent. It is

also undisputed that Sh. Dharmendra Singh died on 23.06.2018 by drowning. Admittedly post mortem of

dead body was not conducted. His death certificate was issued by Dr. Harendra Singh of Manjushree

Hospital, Lucknow. His death was also registered IN Nagar Nigam, Lucknow on 29.06.2018. News item

was also published on 25.06.2018regarding his death by drowning.. Death was also registered in the

police record in general diary of Police station Gangaghat, Distt:Unnao. A copy of the same is also on

record.

When the death claim was preferred which is still pending. The following documents were called by the

respondent:

1. Duly filled and signed claim form with proper authentication by SBI official against insured A/c to

whom policy was given or cover letter from SBI Bank mentioning A/c and policy details of insured person

(Provided claim form is not authenticated from SBI)

2. Copy of FIR/MLC copy/spot panchanama /inquest panchanama attested by same issuing police

authorities.

3. Copy of final police investigation report attested by same issuing police authorities.

4. Copy of bank passbook of nominee.

5. Self attested copy of pan card of nominee.

6. Copy of standard application form submitted for death certificate at municipal corporation/panchayat

attested by same issuing authorities.

7. Cause of death certificate from doctor who declared death.


Complainant submits that all documents available with her have been provided but still the claim is not

decided.

In such circumstances, it would be appropriate that the respondents should decide the claim on the basis

of records already available with them. If any new document is required, they should call it from the

complainant thereafter claim shall be decided by passing a speaking order.

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Order:

Complaint is disposed off with a direction to the respondent to decide the claim of the complainant after

affording an opportunity of hearing within a period of 30 days in the light of the observations made in

the body of the order. If the complainant is not satisfied with the decision of the respondent insurance

company, she would be at liberty to proceed in accordance with the law.

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

Dated : March 04, 2020 (Justice Anil Kumar Srivastava)

Place : Lucknow Insurance Ombudsman



Mrs. Sundari Devi…………..……....………………. Complainant

V/s

SBI General Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-G-040 -1718-0159 Order No. IO/LCK/A/GI/0159/2019-20

1. Name & Address of the Complainant Mrs. Sundari Devi,

W/o late Sh. Ram Prasad,

Govindpur, Sonbhadra, UP

2. Policy No:

Type of Policy


143820-0000-01

Personal Accident Policy

23.02.2017 TO 22.02.2018



Mr. Ram Kumar

4. Name of the insurer SBI General Insurance Company Limited

5. Date of Repudiation/Rejection 30.06.2018

6. Reason for repudiation/Rejection No external factor contributing to death

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8. Nature of complaint Non settlement of claim

9. Amount of Claim Rs.400000/- plus interest

10. Date of Partial Settlement N.A.

11. Amount of relief sought Rs.400000/- plus interest

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

13. Date of hearing/place 19.02.2020 at Lucknow


c) For the Complainant Mrs. Sundari [Mother]

d) For the insurer Mr. Sanjeev Tripathi

15. Complaint how disposed Dismissed


17. Mrs. Sundari (Complainant) has filed a complaint against New India Assurance Company Limited

(Respondent) challenging repudiation of PA claim of Ram Kumar.

COMPLAINT NO:LCK-G-040-1819-0159 Order No. IO/LCK/A/GI/0159/2019-20

18. Brief Facts Of the Case:- The complaint has been made by mother of the decesased Mr. Ram

Kumar regarding non settlement of personal accident claim of her son. The reason for the death of her

son was due to drowning. The aforesaid policy was given to SBI account holder in which the LA was a

member. Aggrieved with the repudiation of the claim, she approached this forum for redressal of her

grievance.

In their SCN/reply, the respondent has stated that RIC has processed the claim and observed that as

per policy panchnama and FIR received by them clearly established that the insured fell in pond after

he sustained attack of seizure. There was no external factor contributing to death of insured, hence

definition of accident is not fulfilled. The decision of RIC to repudiate the claim was fair and in

accordance to the terms and conditions of the subject policy.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and


20. I have heard both the parities at length and perused papers filed on behalf of complainant as well

as respondent.

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21. Undoubtedly deceased life assured Mr. Ram Kumar died by drowning in the pond. In Post Mortem

Report cause of death was shown as Asphyxia due to drowning. Only point to be looked into is as to

how he fell in the pond?

In the first information report which was lodged by Mr. Man Singh, it is mentioned that deceased was

passing through the pond when on account of seizure, he fell down in the pond resulting in his death.

Also the opinion of the panchyat is to the effect that the deceased had seizure on the fateful day. He

suffered seizure and fell down in the pond. Whether it amounts to an accident? In the policy bond Part

A “ Interpretations & Deflinitions : Accident means a sudden, unforeseen and involuntary event caused

by external visible and violent means”.

If we examine the case at hand with this definition, we will find that there is no external, visible and

violent means in death of the deceased. No doubt insured died by drowning in the pond but the

drowning in the pond was not a result of an accident rather it was due to seizure. Under such

circumstances, death could not be attributed to an accident. Accordingly complainant is not entitled for

any claim for personal accident.

Order :

Complaint is dismissed.

22. Let copies of the award be given to both the parties.

Dated : February 19, 2020 (Justice Anil Kumar Srivastava)


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Mr. Anil Kumar Yadav…………..……....………………. Complainant

V/S

Iffco Tokio General Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO: LCK-G-023-1920-0046 Order No.

IO/LCK/R/GI/0150/2019-20

1. Name & Address of the Complainant Mr. Anil Kumar Yadav

S/o Sri. Raj Narayan Yadav

C-4724, Sec-12, Rajajipuram, Lucknow

2. Policy No:

Type of Policy


1-W49TYCT

Motor Package Policy

09.11.2018 TO 08.11.2019



Mr. Anil Kumar Yadav

Mr. Anil Kumar Yadav

4. Name of the insurer Iffco Tokio General Insurance Company Limited

5. Date of Repudiation/Rejection 02.08.2019

6. Reason for repudiation/Rejection Compulsory PA cover for owner-driver not given


8. Nature of complaint Repudiation of claim

9. Amount of Claim ---

10. Date of Partial Settlement ---

11. Amount of relief sought ---

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

13. Date of hearing/place On 17.02.2020 at 10.15 am at Lucknow


e) For the Complainant Mr. Anil Kumar Yadav

f) For the insurer Mr. Sumit Johar

15. Complaint how disposed Recommendation


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17. Mr. Anil Kumar Yadav (Complainant) has filed a complaint against United India Insurance Company

Limited (Respondent) challenging repudiation of personal accident cover to the owner-driver.

18. Brief Facts of the Case:-. The complainant has stated that he had purchased an insurance

policy from

COMPLAINT NO:LCK-G-023-1920-0046 Order No. IO/LCK/R/GI/0150/2019-20

respondent for his vehicle. On 25.03.2019 his elder brother late Mr. Sunil Kumar Yadav was driving the

vehicle and

near Dewa road Chinhat he met with the accident and died. He had submitted the personal accident

claim with the respondent on 23.05.2019 which was repudiated by the respondent. He had further

stated that he had paid Rs. 280/- for PA to passenger and Rs. 120/- PA cover for insured person. As

the vehicle was driven by his brother and he was not the owner of the vehicle so the PA claim related

with passenger should be paid by the respondent. Aggrieved with the decision of the insurer, the

complainant has approached this forum.

In their SCN/reply, the respondent has submitted that the aforesaid death claim lodged by the insured

of his brother under the subject policy. The insured had taken a two wheeler policy for the period

09.11.2018 to 08.11.2019. The insured had paid the premium for both own damage section and the

third party liability section. A claim was reported for the accidental death of his brother Mr. Sunil Kumar

Yadav on 25.03.2019. In the aforesaid policy the insured had paid Rs. 720/- towards the premium of

basic third party liability and Rs. 280/- for additional cover for PA cover to passenger under IMT-16.

The respondent has further submitted that the IMT-16 cover is for the compensation for the bodily

injuries by any passenger other than the insured and/or the paid driver attendant or cleaner and/or a

person in the employ of the insured coming within the scope of workman compensation Act , 1923 and

subsequent amendments. The insured had claimed he had paid Rs. 120/- towards the PA cover –owner

driver is not true as per the policy documents. Therefore the aforesaid claim was repudiated by the

company on the grounds that the deceased was driving the vehicle at the time of accident but was

neither owner of the insured vehicle nor passenger.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and


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20. Sincere efforts were made for mediation to resolve the subject matter of complaint. The

complainant and the representative of the respondent company were heard. During course of the

mediation, both the parties filed joint application (Mediation Agreement) duly signed by the

complainant and the representative of the respondent mentioning therein about settlement of the

matter willingly and mutually and agreed to settle the subject matter of the complaint as follows :

COMPLAINT NO:LCK-G-023-1920-0046 Order No. IO/LCK/R/GI/0150/2019-20

The respondent Iffco Tokio General Insurance Co. Ltd. has agreed to make the payment

for Rs. 50,000/- without any interest. The amount shall be paid to the legal heir of

deceased i.e. wife Smt. Geeta Yadav. The Complainant also agreed for the same.

21. As matter within parties has resolved mutually, hence the complaint is decided in terms of

mediation/mutual agreement between both the parties.

22. Let copies of this award be given to both the parties.

Dated : February 17,2020 (Justice Anil Kumar Srivastava)


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF M.P. & C.G.


Mr.Laxmi Niwas Sarda….………………………………………...........Complainant

V/s

The Oriental Insurance Co. Ltd ……………………………..…………. Respondent

COMPLAINT NO: BHP-G- 050-1920-0093 ORDER NO: IO/BHP/A/GI/0207/2019-2020

Mr.Laxmi Niwas Sarda (Complainant) has filed a complaint against Oriental Insurance Co.

(Respondent) alleging partial settlement of personal accident claim.

Brief facts of the Case - The complainant has stated that his accident occurred on 03.03.2019

and documents were submitted to the respondent on 10.07.2019. He has submitted the claim

for Temporary Total Disablement from 03.03.19 to 05.07.19 and bills for Rs.12,379/-. The

respondent sent the mail vide dated 03.09.19 accepting claim for 6 weeks only and bills in toto

as submitted i.e Rs.12,379/-. He sent a mail dated 03.09.19 raising objection for not accepting

the period of 6 weeks with request for ground for not accepting the actual period of disability

and requested again vide mail dated 09.10.19. The respondent sent the mail dated 15.10.19

stating that disability period settled for 6 weeks. He has submitted the Doctor’s advice with

original documents for resuming normal duty. The settlement for 6 weeks is unjustified despite

1. Name & Address of the

Complainant

Mr.Laxmi Niwas Sarda,

Jain School Road,

Vardhman Nagar, Rajnandgaon CG

2. Policy No:

Type of Policy

Duration of policy/Policy period

191100/48/2019/224

Personal Accident Policy ( Individual )

16.05.18 to 15.05.19

3. Name of the insured


Mr.Laxmi Niwas Sarda

Mr.Laxmi Niwas Sarda

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

5. Date of Repudiation/ Rejection --

6. Reason for Repudiation/ Rejection --


8. Nature of complaint Partial settlement of the claim

9. Amount of Claim Rs.97,379/-

10. Date of Partial Settlement --

11. Amount of relief sought Rs.97,379/-

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

13. Date of hearing/place 04.02.2020 at Bhopal


For the Complainant Mr Laxmi Niwas Sarda

For the insurer Mr A K Kotwani, Sr Branch Manager



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doctor’s advice. He has requested to inspect the original X-rays as the calcium formation was

very slow. The complainant has approached this forum for redressal of his grievance.

The respondent in their SCN have stated that they have received the intimation from

Insured regarding the reimbursement of claim under above PA Individual Policy. The insured

had sustained injury on left metatarsal bone due to accident & he had submitted the claim form,

claim documents, Bill, diagnostic reports. The insured had submitted the claim form claiming

for TTD 5 days and his Doctor Khanduja has also mentioned that he was confined to bed for 21

days. However we have obtained opinion of Panel Doctor, who has opined that looking into the

injury and age of the patient, the TTD period should be 6 weeks. Hence respondent have settled

the claim for 6 weeks TTD and informed to insured. According to the documents submitted by

insured & opinion report of panel Doctor, insured is eligible / entitled for 6 weeks

compensation for Rs.30,000/- & Medical expenses for Rs.12,379/- & Total claim amount

Rs.42,379/-. In this case the insured has represented the case on 10.07.2019. We had called the

opinion, again, from Dr. Ashok Sahay. According to that opinion report insured is entitled /

eligible for only 6 weeks compensation Rs.30,000/- & Medical expenses for Rs.12,379/- Total

claim amount Rs.42,379/- for injury to insured. Accordingly claim is approved for Rs.42,379/-

by respondent but insured did not accept the offered amount.

The complainant has filed complaint letter, Annex. VI A and correspondence with respondent

while respondent have filed SCN with enclosures.

I have heard both the parties at length and perused papers filed on behalf of the complainant as

well as the Insurance Company.

A claim for Temporary Total Disablement from 03.03.2019 to 05.07.2019 and medical

expenses of Rs.12,379/- was filed by the complainant, out of which, medical expense of

Rs.12,379/- and eligible 6 weeks compensation for Rs.30,000/- totaling Rs.42,379/- was

approved by the respondent. Complainant did not accept the approved amount offered by the

respondent. Main dispute between the parties which remains is that whether complainant

should get Temporary Total Disablement for six weeks or for the total period claimed by the

complainant i.e. from 03.03.2019 to 05.07.2019. The representative of the respondent has

argued that as per claim form, insured remained confined for 5 days only and as per Doctor of

Khanduja Orthocare Hospital, Bilaspur insured will be able to attend his business or occupation

after recovery period of 21 days. He further argued that he had taken opinion of their panel

Doctor, Dr Ashok Sahay who opined that insured is eligible for compensation taking into

consideration TTD for 6 weeks. Complainant opposed the above argument and argued that as

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he was not able to resume his duties before 05.07.2019, hence he should get compensation upto

05.07.2019. Reports of Dr Ashok Sahay dated 02.08.2019 and 19.09.2019 are on record

wherein he has opined that the base of left metatarsal was fractured and taking into

consideration extent of fracture, injury and age of patient, maximum duration of medical

treatment and supervision in such cases including compensation should not be more than 6

weeks. As per claim form, on 03.03.2019 Doctor of complainant has given recovery period of

21 days. In prescription of Dr Vineet Jain dated 14.03.2019 insured patient has been advised

rest period for 4 weeks. Under above circumstances, action of respondent for calculation of

compensation taking into consideration TTD for 6 weeks is justified and respondent has acted

in accordance with medical records available with them and has rightly offered an amount of

Rs.42,379/- (Rs.30,000/- for compensation of 6 weeks and Rs.12,379/- towards medical

expenses) which is as per terms and conditions of the policy. In the result, complaint is liable to

be dismissed.

The complaint filed by Mr Laxmi Niwas Sarda stands dismissed herewith.

Let copies of the order be given to both the parties.

Dated : Feb 04, 2020 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman

Mrs. Kumari Bai Patel … ……………..…..………………………………Complainant

V/s

The National Insurance Co. Ltd……………..……………….………...…….Respondent

COMPLAINT NO: BHP-G-048-1920-0096 ORDER NO: IO/BHP/A/GI/0208/2019-2020


Complainant

Mrs. Kumari Bai Patel

H.No. 33/1, Vill Chapal, Post Beohari,

Teh. Ghansore, Distt.Seoni - 480997

2. Policy No:

Type of Policy


100300/47/01/9600022/03/96/30350

Group Janta Personal Accident Insurance

Policy

08.01.2004 to 07.01.2019



Smt. Kumari Bai Patel

Late Sh. Surendra Singh Patel

4. Name of the insurer The National Insurance Company Ltd.

5. Date of Repudiation/ Rejection --

6. Reason for Repudiation/ Rejection --


8. Nature of complaint Non settlement of full amount of Personal

Accident (Death)

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


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Mrs. Kumari Bai Patel (Complainant) as a Nominee has filed a complaint against the

respondent for non settlement of full amount of Personal Accident claim (Death)

Brief facts of the Case – The complainant has stated that her husband was covered under

above policy for a Sum Insured of Rs.5 lacs. He expired on 09.07.2018 due to accident (electric

current). She had deposited all the relevant papers to the respondent but respondent had

sanctioned Rs.1,30,000/- and voucher was sent to her. After receiving voucher she contacted

senior official of the respondent who responded that amount of Rs.1,30,000/- shall be paid to

her. She made a complaint to the Grievance department. At the time of taking policy

respondent had not informed about the payment that will be due / made in case of death due to

accident.

The respondent in their SCN have stated that complainant took a Janta Personal Accident

Policy for Rs.5 lacs effective from 08.01.2004 to 07.01.2019 on the basis of his income

declaration. On 09.07.2018 the husband of complainant was electrocuted and died. From

available papers respondent admitted the claim and the claim was settled for Rs.1,30,000/- (60

times of Monthly Income norms followed in case of Personal Accident Policy). Complainant

was requested to submit proof of income at the time of policy taking period. Two documents

were submitted (a) Parivar Patra issued by Office of the District Collector, Seoni MP where

insured’s yearly income was registered as Rs.12,000/- per year (b) Income certificate from

Tehsildar, Ghansur dated 31.01.2019 where his income was registered as Rs.26,000/- per year

in the year 2004-05 & 2005-06. Considering the most authentic income proof we have settled

the claim for Rs.1,30,000/- i.e. 26000/12*60. Accordingly, pre- receipt voucher was dispatched

to the claimant on 28.03.2019 for her signature but the same was sent back to respondent with

remark NOT ACCEPTABLE.

The complainant has filed complaint letter, Annex. VI A and correspondence with respondent,

while respondent have filed SCN with enclosures

I have heard both parties at length and perused paper filed on behalf of the complainant as well

as the Insurance Company.

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

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

13. Date of hearing/place On 05.02.2020 at Bhopal


For the Complainant Mr Krishna Kumar Patel, Son

For the insurer Mr Shibu John, Assistant Manager

15. Complaint how disposed Allowed


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An accidental death claim under above policy was lodged by the complainant on account of

death of her husband / insured due to electrocution on 09.07.2018. Respondent had settled the

claim for Rs.1,30,000/- and sent the pre-receipt voucher to complainant for her signature, but it

was sent back to respondent as not acceptable. The complainant has raised objection that she is

not being offered the full sum insured payable on death due to accident, mentioned in the

policy bond and nowhere it is mentioned in the policy bond that the accidental death claim will

be evaluated on the basis of income of the insured. In support of her complaint, the

complainant has filed certificate of insurance under policy No.100300/47/01/9600022/

03/96/30350 with period of insurance from 08.01.2004 to 07.01.2019 issued by the respondent.

The certificate of insurance bears Sl.No.01924071/103040721374 and is dated 08.01.2004. In

the schedule of the certificate, the sum insured is mentioned as Rs.5 lacs with nominee as Mrs

Kumari Bai, wife of the life assured. On the back of the certificate, terms and conditions,

exclusions and definitions of the policy plan have been mentioned wherein it is mentioned

under the Benefits payable that on death of the life assured solely and directly due to accident,

100% of the sum insured will be payable. As per respondent’s letter dated 30.10.2019 sent to

the complainant, an amount of Rs.1,30,000/- is payable to the complainant which is 60 times of

the monthly income of the life assured. Main dispute between the parties is that whether the

claim should be decided on the basis of income of the life insured or in accordance with the

sum insured mentioned in the policy certificate. Respondent has not submitted any evidence to

support that the basis of calculation of death claim shall be the income of the life assured. They

have also not shown any clause in the policy conditions which states that the amount payable

on death due to accident will be dependant on the income of the life assured and sum insured

shall be flexible. In policy bond / certificate of insurance also nothing has been mentioned with

respect to above. On the basis of documents submitted by the respondent the monthly income

of the life assured is relevant for determining the capital sum insured at the time of inception of

the policy and once the capital sum insured is finalized and policy is issued accordingly, the

respondent is bound by the sum insured declared under the policy. Under the circumstances,

the respondent is liable to pay the sum insured of Rs.5 lacs as mentioned in policy, on death of

the life assured due to accident. The respondent has therefore erred in not allowing the full sum

insured to the complainant. In the result, complaint is liable to be allowed.

The complaint filed by Mrs Kumari Bai Patel is allowed and respondent is directed to pay an

amount of Rs.5 lacs (Rupees Five Lacs only) as per terms and conditions of the policy within

30 days from the date of receipt of this award.

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Mr. Hansdev Gupta..……………….………………………….. Complainant

V/s

SBI General Insurance Co. Ltd ………………………..………..Respondent

COMPLAINT NO: BHP-G-040-1920-0016 ORDER NO: IO/BHP/A/GI/ 0209 /2019-2020

Mr. Hansdev Gupta (Complainant) has filed a complaint against SBI General Insurance Co.

Ltd.(Respondent) alleging repudiation of Personal Accident claim of his brother.

Brief facts of the Case -The complainant has stated that his brother Mr. Rajeev Gupta was

covered under a policy issued by the respondent company while opening the account with

SBI Tikamgarh Branch in which complainant was nominee. Insured expired in a road

accident on 19.01.2018. Thereafter he lodged claim before the respondent along with claim

documents but his claim was not settled by the respondent and demanding succession


Complainant

Mr. Hansdev Gupta,

Karnika Bihar Colony Near R.K.Hospital,

Pali Road, Umaria.

2. Policy No:

Type of Policy


175104-0000-00

Personal Accident Insurance policy (group)

01.07.2017 to 30.06.2018



Mr. Rajeev Gupta

SBI Bank

4. Name of the insurer SBI General Insurance Co. Ltd

5. Date of Repudiation/ Rejection 27.08.2018

6. Reason for Repudiation/ Rejection Discrepancies observed and investigation

pending


8. Nature of complaint Repudiation of PA Claim




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

13. Date of hearing/place 06.02.2020 at Bhopal


For the Complainant Mr Hansdev Gupta

For the insurer Mr Sanjiv Tripathi, Head – Legal



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certificate issued by the court though he is nominee in the policy. The complainant also spoke

to the customer care number of the Company on different dates i.e. on 19.09.2018,

08.10.2018, 09.11.2018, 18.12.2018, 02.01.2019, 02.02.2019, 06.02.2019, 12.02.2019,

01.03.2019. The complainant has approached this forum for payment of his claim.

The respondent in their SCN dated 10.05.2019 have stated that on 05.03.2018 a claim

was registered on the behalf of complainant towards death of the insured Mr. Rajeev Gupta

allegedly having taken place on 19.01.2018 due to an accident. The insured met with an

accident and succumbed to death on 19.01.2018 however the aforesaid claim was lodged with

respondent on 05.03.2018 with a delay of nearly 2 months. After going through the claim

documents received from the complainant, it was observed that the documents submitted by

the complainant were deficient / incomplete to assess the claim, hence complainant was

approached several times through letter and reminders dated 21.03.2018, 05.04.2018,

25.05.2018 etc. thereby requesting him to submit all requisite deficient documents but

complainant had submitted few documents and some were still not submitted. Claim is

delayed because of the lack of complainant’s support in providing the requisite documents to

allow to conclusively assess the said claim. Amended SCN dated 03.02.2020 has been filed

by the respondent in which it is stated that the complainant still did not submit certain

necessary documents and claim is pending and unresolved for lack of succession certificate

confirming legal heirs of the insured from competent Court ascertaining beneficiary to

receive the claim amount. It came to their knowledge that multiple policies on the life of Mr

Rajiv Gupta have been taken across industry within a period one month and thereafter shown

that the insured passed away in a few days in road traffic accident. Investigation report of

Vision Inv, Services pointed out that possible misrepresentation and fraud have been

committed by the complainant with the insurance Companies and with the respondent. In this

back ground a joint meeting of insurance Companies consisting of SBIG, ICICI Prudential

life Company and Reliance General Insurance Company was held on 06.07.2018 wherein it

was observed that the case is that of a planned industry wide fraud to unlawfully extract huge

monetary gains from multiple insurance companies. It was decided in the meeting to file a

complaint against the complainant herein. Hence the respondent filed a complaint dated

28.06.2019 with the SP, Tikamgarh, MP to bring forward the facts and circumstances on

record and in notice of the concerned authorities. The said police complaint is being

investigated. It is submitted that the present matter involves complex questions of facts which

cannot be decided by the present forum the reason being that the insured availed accidental

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insurance from several insurers without disclosing the fact of existence of other similar

polices to any of the insurers. Similar claims in other insurance Companies clearly indicates

the intent to defraud and unjustly enrich himself. The insured did not disclose the fact that the

former was suffering from mental illness since birth and the fact the policy was obtained by

misrepresentation to the respondent and the present claim is being pursued by

misrepresentation on before the Hon’ble Ombudsman. The fact that the insured was married

and had two children was also not disclosed at the time of availing the policy and also at the

time of pursuing the present claim. On enquiry during the claim process the complainant

again misrepresented that the insured was unmarried and did not have any children. The

respondent has placed on record the VIS report which illustrates the fraud played by the

insured in collusion with the Complainant. The insured was mentally unfit since birth as was

corroborated by several witnesses, the Nagar Panchayat Adikari and copy of Smagra

Pariwar card and voter list attested by the authority which mentions that the insured was

mentally unwell. The investigators met with one Ms.Asha Jain an Aagnawadi worker in

Badagoan and obtained her certificate in which she has certified that the insured was married

and has two children. The insured’s wife name is Rekha Gupta and children’s names are

Harsh and Varsha Gupta. The insured’s wife was missing since October 2017 and her

children live with maternal grandparents in Sagar. Barring the land lord of the rented house

where the insured lived none of the neighbours were aware of the where about or death of the

insured. The investigator also found that the death of the insured occurred within 10 kms

from Jai Singh Nagar and yet the Complainant informed the location of the accident at

Beohari which is 40 kms away, when he contacted police on 100 number. It was also

discovered that once the insured was declared to be dead on arrival, the complainant and Mr

Salman Khan conducted his funeral near the accident spot without informing or involving any

other family members/neighbours. It is submitted that despite several reminders, the

Complainant failed to submit the succession certificate from a competent Court to establish

the status of legal heir of the insured and ascertain if the beneficiary was entitled to receive

the claim amount.

The complainant has filed complaint letter, Annex. VI A and correspondence with

respondent, while respondent have filed SCN with enclosures.

I have heard both the parties at length and perused papers filed on behalf of the complainant

as well as the Insurance Company.

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A claim on account of death of insured, Late Mr Rajiv Gupta (DLA) caused in a road traffic

accident, was filed by the complainant, as a nominee, which was rejected by the respondent.

As per complainant, respondent is asking to submit succession certificate of the deceased

while he has been named as the nominee in the policy. The representative of the respondent,

during hearing, has informed that they asked the complainant to submit succession certificate

of the deceased which was not yet submitted by him. He further stated that DLA was suffering

from mental illness since birth and was married to Mrs Rekha Gupta and had two children,

Harsh Gupta and Varsha Gupta. These facts were not disclosed by the complainant and

suppressed at the time of inception of the policy. He further stated that complainant in his

statement had stated that DLA was unmarried and was having no issue while voter list,

Samagra Parivar Card shows that the husband of Rekha Gupta and father of Harsh and Varsha

Gupta was DLA. The representative of the respondent has further argued that under aforesaid

circumstances there was suppression of material facts with respect to the legal heirs so as to

ascertain the beneficiary. Hence filing of succession certificate was necessary for just decision

of the claim which was asked to be submitted by the complainant and not submitted till date.

It is evident from records that the claim has not been decided on merits but withheld for non-

submisison of succession certificate. Respondent has filed photocopy of affidavit of father

and brother of wife of DLA in which it is mentioned that Rekha was married to Rajiv Gupta

S/o Jagdish Gupta who was mentally retarded which was not disclosed to them at the time of

marriage. Electoral list 2018 of Tikamgarh legislative Assembly shows the name of DLA as

husband of Rekha Gupta. Record of Aanganwadi also shows the same. Statement of

complainant / claimant has been filed by respondent wherein it has been stated by the

complainant that Rajeev Gupta, DLA was his unmarried brother and was having no issues.

During hearing complainant admitted that DLA was married and having two children. Under

these facts and circumstances order of respondent for submission of succession certificate is

fair and rational for the just decision of the claim. Hence respondent has not erred in any way.

In the result complaint is liable to be dismissed.

The complaint filed by Mr Hansdev Gupta stands dismissed herewith.




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PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM (Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. Suresh Babu

Case between: Mr. PIYUSH BAJAJ……………The Complainant Vs M/s ICICI Lombard General Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).G -020-1920-0307

Award No.: I.O.(HYD)/A/GI/ 0383 /2019-20

1. Name & address of the complainant Mr. Piyush Bajaj,

G-17, 6-3-1096, Metro Palmgrove Apartments, PH-1, Rajbhavan Road, Somajiguda, Hyderabad,Telengana State-500 082.

2. Policy No./Collection No. Type of Policy Duration of Policy/Policy period

Various policies Personal Protect Policy 3-5 years; 23 nos. policies

3. Name of the insured Name of the Policyholder

Mr. Piyush Bajaj Mr. Piyush Bajaj

4. Name of the insurer M/s ICICI Lombard General insurance Co. Ltd.

5. Date of Repudiation -----

6. Reason for repudiation ------


8. Nature of complaint Mis-sale of insurance product

9. Amount of Claim Premium amount paid in all the 23 policies

10. Date of Partial Settlement -----

11. Amount of Relief sought Rs. 6,50,000/-

12. Complaint registered under Rule No.13.1 (b) of Ins. Ombudsman Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of claims by the Life insurer, General Insurer or the Health insurer

13. Date of hearing/place 06.02.2020 / Hyderabad


a) For the complainant Self

b) For the insurer Mr.Amit Tirani, Legal Manager Mr.Mohammed Babu, Manager Legal


16. Date of Order/Award 06.02.2020

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17) Brief Facts of the Case: Mr. Piyush Bajaj was sold the same product by respondent with different effective dates of commencement

and was thus issued 23 nos. of policy documents with different sum insured and with different nominees

against each policy document. Premium amount against each policy was debited from his account stating it

was towards renewal premium and only after he had received the policy documents, he learnt that all of

them pertained to the same insurance product. He had therefore approached this Forum with a complaint

against the respondent for selling him the same product multiple no. of times for which he had to pay

premium amounts unnecessarily and seeking refund for the same.

18) Cause of Complaint: Multiple time sale of same insurance product.

a) Complainant’s argument:

The complainant had stated that he had been misled and misinformed into taking a number of new insurance policies by dubious means by telling marketing executives. When he contacted them, he was told that he was renewing his existing policies when instead they were actually selling him new policies with wrong details such as different e-mails, different mobile numbers, and wrong addresses. In this way 23 policies were sold to him. They had fraudulently sold these policies to him without his consent and despite his representation to the respondent asking them to refund the entire premium amounts paid against these policies that were fraudulently sold to him; they had not resolved his matter till date. b) Insurer’s argument: The respondent had submitted his SCN on 06.02.2020 i.e date of hearing. They have issued 23 policies such as secure Mind policies as well as Personal Protect policies coving personal accident of the insured as listed hereunder:

Sl.No Policy no Period of insurance Policy period

1 4111/EPP/114147629/00/000 9.3.16 - 8.3.2021 5 years

2 4111/EPP/114373750/00/000 15.3.16 – 14.3.2021 5 years

3 4065/SM/115419278/00/000 5.4.16 – 4.4.2021 5 years

4 4065/SM/117352220/00/000 27.5.16 – 26.5.2021 5 years

5 4065/SM/118359009/00/000 2.7.16 – 1.7.2021 5 years

6 4111/EPP/120215901/00/000 19.08.16- 18.8.2021 5 years

7 4111/EPP/120215847/00/000 19.08.16- 18.8.2021 5 years

8 4111/EPP/128205462/00/000 8.3.17- 3.7.2020 3 years

9 4111/EPP/131767736/00/000 7.6.17- 6.6.2020 3 years

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10 4111/EPP/131767930/00/000 7.6.17- 6.6.2020 3 years

11 4065/SM/133885757/00/000 24.7.17 -23.7.2020 3 years

12 4065/SM/135142809/00/000 18.8.17- 17.8.2020 3 years

13 4065/SM/135142799/00/000 18.8.17- 17.8.2020 3 years

14 4065/SM/136382036/00/000 22.9.17 – 21.9.2020 3 years

15 4065/SM/136382105/00/000 22.9.17 – 21.9.2020 3 years

16 4013/W-63559225/00/000 29.9.17 – 28.9.2022 5 years

17 4111/EPP/144750868/00/000 26.2.18- 25.2.2021 3 years

18 4111/EPP/144750826/00/000 26.2.18- 25.2.2021 3 years

19 4065/SM/152369565/00/000 30.7.18- 29.7.2021 3 years

20 4065/SM/152369582/00/000 30.7.18- 29.7.2021 3 years

21 4111/EPP/154393703/00/000 24.8.18- 23.8.2021 3 years

22 4065/SM/158591415/00/000 3.11.18 -2.11.2021 3 years

23 4065/SM/1758591643/00/000 3.11.18 -2.11.2021 3 years

Also all the policies were not mis sold as contended by the insured. All the policies were sold and delivered with his consent only. Policies were issued in 2016, 2017, 2018 and the complainant did not bring it to their notice immediately. He was covered under the policy and enjoying the benefits provided under the said policies. He approached the company on 19.6.2019 seeking cancellation of the policies and not prior to that. They had agreed to cancel the policies and make a pro-rata refund of premium for which the insured did not agree. Two policies 4065/SM/117352220/00/000 & 4065/SM/152369565/00/000 were cancelled and premium refunded Rs.35050/- & 5779/-. 19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copies b. Correspondence with insurer c. Self contained Note 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the personal hearing at Hyderabad on 06.02.2020. Both the parties reiterated their stand for and against the complaint.

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The respondents have issued 23 policies Secure Mind policies as well as Personal Protect policies coving personal accident of the insured. All the policies were not mis sold as contended by the insured. All the policies were sold and delivered with his consent only. Policies were issued in 2016, 2017, 2018 and the complainant did not bring it to their notice immediately. He was covered under the policy and enjoying the benefits provided under the said policies. He approached the company on 19.6.2019 seeking cancellation of the policies and not prior to that. They had agreed to cancel the policies and make a pro-rata refund of premium for which the insured did not agree. Two policies 4065/SM/117352220/00/000 & 4065/SM/152369565/00/000 were cancelled and premium refunded for Rs.35050/- & 5779/-. The recorded Teleservice marketing sales talk was presented to show that the insured was duly informed and policies were issued with his consent only. That premium under a credit card cannot be auto debited without the insured’s consent. The insured stated that he was associated with ICICI Lombard Insurance since 2008. He had 7 policies covering his home, health, PA etc,. He was approached over phone by Mr.Manoj of Teleservices informing his premium due for his renewal policies. He received several phone calls and each time he paid the premium assuming he was paying premium towards renewal of his old policies. He would agree to the information given and pay the premium through his credit card issued by ICICI Lombard banking services and would give his consent. He never verified his credit card statement nor the policy sent to him. It was his banker friend who brought to his notice that along with renewing his old policies, funds were diverted in issuing new Personal Accident Policies some in his name, some in the name of his aged parents, with different nominees, with different insured name, different genders, different email IDs and different postal addresses. He informed that he had a blind trust for the brand name of ICICI and therefore never doubted even once why he was made to pay several times. The postal addresses on the cover were correct whereas the policy copy inside the cover bore different addresses to his surprise. He questioned the insurer in case of a claim, how would they settle it, because his identity in the form of name, address, gender, address, mail ID etc would never tally. He got SMS alerts for some premium payments where his correct phone number was mentioned and not for others where different numbers were entered. Policies pertaining to his aged parents were cancelled and premium refunded because they belong to high risk band. It is very obvious that unscrupulous and greedy agents took undue advantage of the blind faith of insured in ICICI Lombard Insurance and his busy business schedule. They issued different policies with different names, telephone numbers, e-mails so that their nefarious activities would not be noticed by the appropriate authorities. It is nothing but breach of trust of policy holder. Unfortunately, instead of mending or improving the strained relationship with the customer, the insurer aggravated it further, with his high handed and adamant stand. It is nothing but a missale, a fraudulent sale of policies by avaricious agents for monetary gains. The Forum observed that the insured was given 23 Personal accident policies with different names, gender, addresses, email IDs, phone numbers, and different nominees. The payment towards the policies was however made by the insured with his consent. The insured was under the assumption that he was paying premium towards his renewal policies as his credit card statement also did not clarify whether the premium pertained to renewal or new policy. The voice recording heard explained in lightning speed. It is very difficult to comprehend and felt as if it was a recorded voice rather than being spoken to a person by another person. The PIVC i.e pre issuance voice recording call only contained the policy terms and never explained the payment details, policy term, nature of policy, nor ascertained or confirmed the insured name, telephone number, email ID, residential address etc., strictly these are not PIVC call at all. When the insurer was questioned how they could give policies with so many mistakes, it was answered as Technical typographical mistake. All the guidelines and Elements of Insurance Contract say that Contract of Insurance cannot be complete without consent of both the parties. Both the parties should agree to the same thing in the same sense. In other words there should be “Consensus ad - idem” between both the parties. The basic principle of Contract Act i.e., Consent has been violated in letter and spirit by the insurer. Hence The Forum therefore directs the insurers to refund premium under all the Policies in full without pro-rata calculation to foster confidence in the mechanism of Insurance at large.

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A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to refund the total premium collected in full. The complaint is allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance Ombudsman

Rules, 2017:

a) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

b) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act 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), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 6th day of February , 2020

( I. SURESH BABU )

OMBUDSMAN FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE


Ombudsman - Shri I. Suresh Babu Case between: SMT PARAGATI SYAMALA………………The Complainant Vs M/s The United India Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).G .051.0373/2019-20 Award No.: I.O.(HYD)/A/GI/ 0384/2019-20

1. Name & address of the complainant Mrs. Paragati Syamala W/o Late Nagaraju D.No. 1-176/1, Nudurupadu Post, Phirangipuram Mandal, Guntur, Andhra Pradesh : 522 529 (Cell No. 99634-04971)


1508004218P104721305 Pradhan Mantri Suraksha BIma Yojana Policy

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01.06.2018 to 31.05.2019


Mr Paragati Nagaraju; beneficiary: Mrs. Paragati Syamala M/s Chaitanya Godavari Grameena Bank PMSBY

4. Name of the insurer M/s The United India Insurance Co. Ltd.

5. Date of Repudiation 05.07.2019

6. Reason for repudiation Claim falls under exclusion clause 4(b) of policy


8. Nature of complaint Claim pertaining to Accident insurance

9. Amount of Claim Rs. 200,000/-


11. Amount of Relief sought Rs. 200,000/-






b) For the insurer Ms. Nafeesa Zeenath Pathan & Dr. Sudeep. A.M.,



17) Brief Facts of the Case: Mr. Paragati Nagaraju was covered under the Pradhan Mantri Suraksha BIma Yojana Policy

which was issued in the name of M/s Chaitanya Godavari Grameena Bank where their account

holders were the insured members of this scheme. On 19.10.2018, he was travelling as pillion rider

on a motor cycle that was being ridden by a person named Mr Kuraganti Poorna Chandra Rao. As

per the charge sheet framed by the SI of Police, Nandigama PS in the court of AJFCM, Nandigama,

when the rider of the motor cycle was proceeding in the wrong direction at about 00.00 Hours on

20.10.2018, a car that was approaching them from the opposite direction and was stated to be

driven in a rash and negligent manner without blowing horn had dashed against this vehicle which

led to the death of pillion on 20.10.2018 and the rider of motor cycle on 26.10.2018.

The deceased’s wife had applied for an accident claim with the respondent company but it

was denied by them on grounds that the deceased was under the influence of alcohol at the time of

accident. Aggrieved by the decision of respondent, she had filed a complaint in this Forum.

18) Cause of Complaint: Rejection of claim pertaining to PMSBY insurance policy.

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a) Complainant’s argument:

The complainant who is the wife of deceased had submitted that the inquest was conducted on the dead body of her husband and thereafter the body was sent for postmortem examination by a doctor. As per the PME report, there was no trace of alcohol or its contents found by the doctor. Once after she had filed a claim under the policy, the investigating official of the respondent had visited her village to record the statements of her neighbor as well as hers. Subsequently, she had received a letter from the company’s official that her claim was rejected because her husband was under the influence of alcohol and hence her claim had attracted the exclusion clause of the said policy. Her contention was that the investigating official did not conduct a fair enquiry and the repudiation of her claim without proper documentary evidence was arbitrary. She had therefore prayed to this Forum to peruse all her documents and pass orders in her favor. b) Insurer’s argument: In the self contained note submitted by respondent to this Forum, it was mentioned that the deceased had declared his wife Mrs. Paragati Syamala as his nominee in the consent certificate submitted by him to his banker at the time of enrolling himself in the PMSBY scheme. The fact that the deceased died in a road accident was not disputed; it was also confirmed that all the relevant claim documents were received by them. Upon receipt of such documents, an investigator was appointed who in his report dated 18.12.2018 had mentioned that the cause of accident might be due to a long gradual meandering of road followed by the motor cycle being ridden in the wrong direction of road by its rider who as well as his pillion were in an intoxicated state. Further, their investigator had submitted an additional report dated 21.12.2018 along with the record of statements made by the nominee of deceased and the deceased’s younger brother wherein they had declared that the deceased and the rider of the motorcycle had consumed alcohol before their commencement of journey on 19.10.2018 at about 11.00 PM. Since both the relatives of deceased had declared that the deceased was under the influence of alcohol, the claim was repudiated as per the exclusion clause 4.1 of the policy which states that “the company shall not be liable under the policy for payment of compensation in respect of death, injury or disablement of insured when he was under the influence of intoxicating liquor or drugs”. Hence, it was prayed that the complaint filed by her be dismissed with costs. 19) Reason for registration of complaint: The claim preferred by the complainant was rejected by the insurer on the ground of ‘intoxication of deceased’ as per policy exclusion. As the complaint falls under rule 13.1(b) of Ombudsman Rules 2017, it was registered. 20) The following copies of documents were placed for perusal:

a) Policy copy with conditions. b) Bank account details of deceased. c) FIR, Panchanama, Charge sheet; and PM Report. d) Claim repudiation Letter. e) Review letter for reconsideration of claim.

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f) Self contained note submitted by insurer. 21) Result of personal hearing with both the parties: Pursuant to the notices given, both the parties attended the personal hearing on 06.02.2020 at Hyderabad, and the following arguments were noted. The complainant herself attended the personal hearing and informed that her husband was an account holder of Chaitanya Grameena Bank, of Nudurupadu branch, and he had been covered personal accident insurance as per PMSBY scheme through bank for the period 01.06.2018 to 31.05.2019. She again informed that on 19.10.2018 at 11 PM, while her husband was returning from a family function at Sanagapadu as pillion rider on a motor cycle driven by his relative Mr Purna Chandra Rao, near Hanumanthupalem x roads, their m/cycle was hit by an opposite coming car with bright lights resulting her husband died on the spot and the rider also died after few days. As the matter was reported to PS Nandigama on the same day, they issued FIR No: 307/18 dated 20.10.2018. After completion of Panchanama, they arranged to conduct PM at PHC Nudurupadu on the same day. She further stated that when she lodged the claim with insurers with all the supporting documents, the claim had been rejected by the insurers stating that ‘as per the investigation report which they arranged, it was revealed that her deceased husband was under the influence of intoxication of Liquor at the time of accident which is falling under exclusion No: 4(b) of policy’. Even after she sent review application for reconsideration of her claim to their grievance dept, no favourable decision has come, and hence she approached this forum for redressal. On the other side, insurers contended as per the SCN submitted and briefly stated that they have appointed one investigator, and as per his report it was found that the rider of the m/cycle and the pillion rider (deceased) both have consumed liquor before starting their journey, and it was concluded that the deceased was under the influence of intoxication of liquor at the time of accident falling under policy exclusion No: 4(b). More over they argued during hearing that the motor cycle been driven in wrong side of the road which was the prima-facie for causing accident. In support of the investigator’s findings, they submitted the statement duly signed by the complainant, and other one from their close relative. Hence they confirmed their repudiation decision. On close scrutiny of all the documents, and arguments during hearing, the Forum observed the following: The insurers did not dispute the occurrence of accident and the death of the insured person. They relied on the investigators findings alone, basing on the statements given by his wife. As far as the proximate cause for occurrence of accident is concerned, the insured happened to be a pillion rider on the motor cycle, and he was nothing to do with the driving of the vehicle as well as being driven wrong side of the road. During the hearing the Forum observed that the claimant is a remote villager, and not much literate. When we put the cross question during hearing about her statement given to investigator, it was noted that the investigator obtained her sign on plain white paper promising her that he would help to admit the claim by insurers, and later written on his own without her knowledge. It is also observed that the statement of the complainant about signing on

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white paper without any content on it, not been rebutted by the insurer during hearing. Even otherwise, nowhere it was written about intoxication in crime documents such as FIR, Panchanama, Charge sheet and also in PM report which was conducted after few hours of death., and the deceased’s intoxication condition is not in any way the proximate cause for the occurrence of accident., since he is a pillion rider.

As far as the wrong side driving of the vehicle, it may so happen some times by anybody while approaching a high way, the riders of the m/cycles may drive little distance upto the divider and take U turn thereafter, to go in shortest distance for taking right way on the road., and that too it might be happened in the present case since it was being night, and observed less traffic at the time of accident. More over the sole negligence been attributed to the opposite car as crime vehicle, and not to the rider of the subject motor cycle as per charge sheet issued by the police.

In view of the above the Forum opined that no credence to be given for the points raised by

the respondent insurer in repudiating the claim, and feels that the rejection of complainant’s claim is unjust as per policy exclusion 4(b), and the insurer is directed to settle claim as per policy condtions.

Hence the complaint is ALLOWED.

AWARD Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to settle the claim as per Policy provisions along with interest as per Insurance Ombudsman Rules 2017 under rule 17(7) and advised to submit the compliance. Hence the complaint is Allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017:

d) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

e) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act 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.

f) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 7th day of February,2020. ( I. SURESH BABU ) OMBUDSMAN

FOR THE STATES OF A.P., TELANGANA AND YANAM CITY

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PROCEEDINGS BEFORE


Ombudsman - Shri I. Suresh Babu

Case between: Smt. BHAGYASREE SATYANARAYAN MORE………………The Complainant Vs M/s HDFC ERGO General Insurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).G-018-1920-0382

Award No.: I.O.(HYD)/A/GI/ 0385 /2019-20

1. Name & address of the complainant Mrs. Bhagyasree Satyanarayan More

7-1-276/A/1, Balkampet, Near Holy Cross High School (Renuka Nagar), Hyderabad,Telengana State- 500 016 (Cell No. 86868-44858)


3317 2025 2089 0400 000 Personal Accident Insurance Plan 5 23.11.2018 to 22.11.2021


Mr. Satyanarayan More Mr. Satyanarayan More

4. Name of the insurer M/s HDFC ERGO General insurance Co. Ltd.

5. Date of Repudiation 27.08.2019

6. Reason for repudiation Accident due to intoxication not covered


8. Nature of complaint Claim pertaining to Personal Accident insurance

9. Amount of Claim Rs. 25,00,000/-


11. Amount of Relief sought Rs. 25,00,000/-






b) For the insurer Mr.R.Lakshminarayan, Manager



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17) Brief Facts of the Case: Mr. Satyanarayan More had purchased a 3 year personal accident policy in his name from the respondent

company which covered accidental death for an amount of Rs. 25 Lakhs. As per the police records, on

09.06.2019, while he was in a drunken state between 21.45 hours and 22.00 hrs, an argument took place

between him and his family and he used abusive words and left his house thereafter. His family made frantic

search of him when he did not return home. He was finally found dead around 22.15 hrs in between Nature

cure and Fatehnagar station. The incident occurred when he tried to cross the railway track without noticing

a moving MMTS train. He died on the spot after he had sustained severe head injury. When his wife who was

made a nominee in the insurance policy had approached the respondent company and filed an accidental

death claim, the respondent had rejected the same citing reason that her claim fell outside the purview of

policy. Aggrieved by the decision going against her favor, she had approached this Forum for Justice.

18) Cause of Complaint: Rejection of claim pertaining to Personal Accident insurance policy. a) Complainant’s argument:

The complainant had submitted that after the argument between her spouse and the members in her family, they were under the impression that he was in an intoxicated state and hence had reported the same in the FIR lodged with police. However, from the post mortem examination/ autopsy examination done on her husband, it came to light that the reports did not specify any contents related to his intoxication. The cause of death of her husband was due to an accident and was not due to intoxication as per reports. The final report given by Railway police station vide No.128/2019 dated 27.07.2019 was that no foul play was suspected as to the cause of death of her husband and it was concluded that his death was due to accident. Hence she had contended that the medical reports did not support the FIR statement and despite pursuing with the respondent for more than 2 months to settle her claim, she did not receive any response from them. b) Insurer’s argument: The insurer had submitted their self contained on 27.01.2020. They had issued a Personal Accident Policy for three years. The nominee, spouse of the deceased claimed for death of her husband who died due to head injury on 09.06.2019 at Km No.147/7 upline hit by a train. On Scrutiny of the documents submitted, it was seen that Late Satyanarayana More aged 50 years was a private employee working as salesman and the PA policy was issued against a loan he had taken from HDFC bank. As per FIR lodged at Sanjeevreddy nagar police station FIR no 449/2019 on 09/06/2019 at 21.45 to 22.00 hours, the deceased was in a drunken state, had an argument with relatives, left home and died whilst being hit by a train while crossing the track. The Final Report read as “ A male trespasser was hit by MMTS no 47220 at 22.15 hrs on 09/06/2019. That he went to his elder brothers house to attend to marriage proposal of his nephew and returned home in the evening at 22.00 hrs and left house under intoxication and did not return home”. PM report confirms death due to head injury. PA policy excludes death due to intoxication the claim was rejected. 19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

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20) The following copies of documents were placed for perusal: a. Policy copy b. Rejection letter c. Correspondence with insurer d. Self contained note e. FIR, Final report from railway, PM report etc, 21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the personal hearing at Hyderabad on 11.02.2020. The complainant’s son spoke on behalf of his mother. He said his father was missing in June 2019, they gave a complaint at the police station within 24 hours and they were informed after one week of his death through satyaharishchandra foundation. The complainant said lost her husband who died due to head injury whilst crossing the railway track on 09.06.2019. He was covered under Personal Accident Policy issued by the respondent and her claim was rejected as cause of death was due to intoxication and trespassing. She contended that he died due to head injury and not due to intoxication as per Post Mortem report submitted. Also there was a door/ space left for people to move about towards the track; hence it cannot be called as trespassing. The insured informed that as per FIR lodged at Sanjeevreddy nagar police station FIR no 449/2019 on 09/06/2019 at 21.45 to 22.00 hours, the deceased was in a drunken state, had an argument with relatives, left home and died whilst being hit by a train while crossing the track. The Final Report read as “A male trespasser was hit by MMTS no 47220 at 22.15 hrs on 09/06/2019. That he went to his elder brother’s house to attend to marriage proposal of his nephew and returned home in the evening at 22.00 hrs and left house under intoxication and did not return home”. PM report confirms death due to head injury. PA policy excludes death due to intoxication the claim was rejected. The train was moving at a speed of 21 kms hence at night, lights were clearly visible for a person under normal sense to avoid the accident. To the question raised by the complainant that if her husband was drunk, why was the same not reflected in the Post Mortem report, it was answered that PM was done on 11.06.2019 i.e after two days hence traces of ethanol was undetectable.

The Railway Police in their Final Report bearing No. Cr. No. 128/2019 U/sec. 174 Cr.PC of RPS

Secunderabad stated that the deceased who trespassed the railway tracks without observing train movements at km no 177/10 near nature cure hospital railway station accidently hit by MMTS train no 47220 sustained head injury and died on the spot. Trespassing railway track is an illegal act and violation of provisions of Section 147 of the Railways Act, 1989. The danger of being run over by a passing trains, when crossing the railway lines/tracks imposes a necessity for utmost caution on all the persons and whoever crossing it do so at their own risk. Hence, it was concluded that the insured involved in misdemeanor and an illegal act. Since, trespassing under intoxication mainly contributed to the accident this Forum concurs with the decision of repudiation of claim.

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A W A R D

Taking into account the facts & circumstances of the case, the documents on record and the submissions made by both the parties during the course of personal hearing, the complaint being devoid of any merit is dismissed.

Dated at Hyderabad on the 11th day of February , 2020.

( I. SURESH BABU ) OMBUDSMAN

FOR THE STATES OF A.P., TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Ms. Minati Das Vrs. M/S SBI General Insurance Co Ltd

COMPLAINT REF: NO: BHU-H-040-1920-0094

AWARD NO: IO/BHU/A/GI/ /2019-20

1. Name & Address of the Complainant

Ms. Minati Das, At- Paschimakalika PO- Genguti. Dist- Balasore 756001 (9439060561)

2. Policy No: Type of Policy Duration of policy/Policy period

143820-0000-01 (Certificate No- 19980559) Personal Accident Insurance Policy (Sum Assured Rs.2.00 lac) 30.03.2015 to 29.03.2016 Date of Accident- 21.10.2015 (Date of Death 20.01.2017)

3. Name of the insured Name of the policyholder

Mr. Raghunath Das Mr. Raghunath Das

4. Name of the insurer M/S SBI General Insurance Co Ltd

5. Date of Repudiation 19.02.2018 Death occurred after 365 days of alleged accident to the insured 6. Reason for repudiation

7. Date of receipt of the Complaint

27.08.2019

8. Nature of complaint Repudiation of accidental death claim


10. Date of Partial Settlement Not applicable as the claim is fully repudiated


12. Complaint registered under Rule no: of IO rules

13(1)b

13. Date of hearing/place 06.02.2020, Bhubaneswar


For the Complainant Mr. Khageswar Dash (Husband of the complainant)

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For the insurer Ms. Chynikca Modie, Sr. Legal Executive

15 Complaint how disposed U/R 17 of the Insurance Ombudsman Rules, 2017

16 Date of Award/Order 06.02.2020

17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant’s husband Mr. Raghunath Das was covered under a Personal Accident Policy for a Sum assured of Rs.2.00 lac for the period from 30.03.2015 to 29.03.2016. The complainant says that her husband met with an accident on 21.10.2015. And her husband died on 20.01.2017. She filed the insurance claim with the insurer, but the insurer repudiated the claim under the ground that the insured person died after 365 days of the accident, and therefore, the claim is not payable under policy terms and conditions. The medical documents available with this complaint pertain to the period from 19.01.2017 to 20.01.2017, where the disease of treatment is mentioned as Loose Motion. The complainant, being aggrieved on repudiation of the claim, preferred an appeal before this forum for redressal. b. The insurer states that the claim is not payable as per the policy, which reads as- “We will pay the sum insured as mentioned in the certificate of insurance, for any injury that is caused due to an accident that immediately or eventually results in insured’s loss of life, provided that such loss occurs under the circumstances described in the policy within 365 days from the date of accident which caused the injury”. 18. a) Complainant’s Argument: - The complainant, says that her husband met with an accident and

suffered spinal cord injury and virtually died on 20.01.2017. She says that the policy is valid from 22.03.2016

to 21.03.2017 for which the premium was debited from her husband’s bank account. As the date of death is

21.01.2017, the death is covered under the policy. Therefore, the claim should be settled.

b) Insurer’s Argument: - The insurer states that the claim is not payable as per the policy, which reads as- “We will pay the sum insured as mentioned in the certificate of insurance, for any injury that is caused due to an accident that immediately or eventually results in insured’s loss of life, provided that such loss occurs under the circumstances described in the policy within 365 days from the date of accident which caused the injury”.

19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017

20. The following documents are placed in the file.

a. Photocopy of the Certificate of Insurance,

b. Photocopy of Death Certificate,

c. Photocopies of Medical documents for treatment from 19.01.2017 to 20.01.2017

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone

through all the documents submitted relating the complaint and heard both the parties. It is

observed from the policy coverage that the death claim is payable if the death occurs within 365

days from the date of accident.

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Dated at Bhubaneswar on the 6th day of February, 2019 INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF Ms. B Rama Das Vrs. M/S Universal Sompo General Insurance Co Ltd COMPLAINT REF: NO: BHU-G-052-1920-0087

AWARD NO: IO/BHU/A/GI/ /2019-20

1. Name & Address of the Complainant

Ms. B Rama Das At- Badakanjia, Choudamana. GP- Pentha Pada 752014 PS- satyabadi, Dist: PURI, Odisha (Mob- 8984313316)


3336/55120802/00/182 PMSBY (OGB SB account no- 16022) OGB Sakhigopal Code no- 0090 dated 28.05.2015 Date of accident: 10.03.2016


Late Shri B Gopal das Late Shri B Gopal das

4. Name of the insurer Universal Sompo General Insurance Co Ltd

5. Date of Repudiation 22.03.2018 Delay in submission of information 6. Reason for repudiation

7. Date of receipt of the Complaint

16.08.2019 (1st intimation to this office on 03.07.2019)

8. Nature of complaint Repudiation of claim

9. Amount of Claim Rs.5.00 lac

10. Date of Partial Settlement NIL

11. Amount of relief sought Rs.2.00 lac

12. Complaint registered under Rule no: of IO rules

13(1)b

13. Date of hearing/place 18.02.2020, Bhubaneswar


For the Complainant Self

For the insurer Mr. S Baral, ZCM

AWARD

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

by both the parties during the course of hearing, the Forum finds that the claim is not

payable under the policy terms and conditions as the accidental death has occurred

after 365 days of the date of accident.

Therefore, the complaint stands dismissed.

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15 Complaint how disposed U/R 17 of the Insurance Ombudsman Rules, 2017


17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant states that the Odisha Gramya Bank had covered her husband under PMSBY with Universal Sompo General Insurance Co Ltd. Her husband died out of a Rail accident on 11.03.2016. She lodged the claim with the insurer through the Bank. The Bank received the intimation on 12.03.2018. The Insurer, after registering the claim, through the Bank repudiated the claim stating huge delay in intimation of the case. The applicant being aggrieved on repudiation of the claim by the insurer, has preferred an appeal before this forum for redressal.

b. The insurer in its mail dated 22.03.2018 repudiated the claim on the ground of delayed submission of the information of loss. But in its SCN received on 02.11.2020, the insurer states that they have not issued any cover to the deceased person. They say that the policy number given by the complainant is not issued by them. More so they have a specified pattern of policy number which always begin with 3366/ and the policy number provided by the claimant does not match with the pattern. Therefore, they have no liability in this case.

18. a) Complainant’s Argument: - The complainant states that it took time to collect the documents from

Govt offices and therefore it caused delay in submission to the Bank/Insurer.

b) Insurer’s Argument: - The Insurer denies issuance of any such policy to the alleged insured. However, if the claimant/Bank provides any correct information they would verify and respond.

19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017

20. The following documents are placed in the file.

a. Photocopies Death Certificate,

b. Photocopies FIR, Inquest Report, PM Report

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone

through all the documents submitted relating the complaint and heard both the parties. It is observed that

the insurer first declined the claim due to huge delay of 2 years in intimating the claim to the insurer.

Subsequently, the insurer in SCN said that they do not have any liability as they have not issued any policy in

this regard. Thereafter, on 11.02.2020, the insurer submitted the copy of the policy confirming the deceased

under PMSBY for Rs.2.00 lac. During hearing, the applicant informed the Forum that it was very difficult to

get the documents from various Departments of the Government. Being a poor lady and not aware of the

procedures to claim against the death of her husband, during such crucial time of misery, it was delayed to

collect the documents from the govt authorities. The documents like FIR, Inquest Report, PM Report etc

mention about the death due to rail accident.

AWARD

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

parties during the course of hearing, the Forum finds that the deceased is duly covered by the

insurer under PMSBY for Rs.2.00 lac against accident-death. As far as delay is concerned, the

Forum is convinced with the reasons given by the innocent poor lady. The IRDAI circular dated

20.09.2011 states not to reject a claim for late intimation purely on technical grounds but to see

on merit and good spirit. The circular also states to consider a claim if the same would have not

been rejected had it been reported on time. Considering the above facts, the insurer is directed to

settle and pay Rs. two lac only to the complainant towards full and final settlement of the claim.

Hence, the complaint stands admitted.

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

Insurance Ombudsman Rules, 2017:

a. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply with the

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

to the Ombudsman.

b. As per the Rule 17(7) 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 of the claim ought to have been settled under the regulations,

till the date of payment of amount awarded by the Ombudsman.

c. As per Rule 17(8) of the said rules and award of the Insurance Ombudsman shall be binding on

the Insurers.

Dated at Bhubaneswar on the 18th day of February, 2020 INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Fateh Singh V/S The New India Assurance Co. Ltd.

COMPLAINT REF. NO: CHD-G-049-1920-0083

1. On 25-06-2019, Mr. Fateh Singh had filed a complaint in this office against The New India

Assurance Co. Ltd for not settling the PA claim. The required documents were

submitted to the insurance company but the insurance company did not settle the

PA claim under policy no. 6522350002815293.

2. This office pursued the case with the insurance company to re-examine the complaint and they

agreed to reconsider the claim.

3. Mr. Fateh Singh confirmed telephonically that his complaint has been resolved by insurance

company and he has received payment of his claim and wants to withdraw his complaint from

this forum.

4. In view of the above, no further action is required to be taken by this office and the complaint is

disposed off accordingly.

Dated : 24.02.2020 (Dr. D.K. VERMA)

PLACE: CHANDIGARH INSURANCE OMBUDSMAN

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PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017) INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Narinder Kumar V/S HDFC ERGO General Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-018-1920-0206

1. Name & Address of the Complainant Mr. Narinder Kumar # 858- A, Street No.- 8, Tripuri, Patiala, Punjab- 147001 Mobile No.- 9216882003


52042083 Individual Personal Accident Plan 03-06-2015 to 02-06-2017


Mr. Narinder Kumar Mr. Narinder Kumar

4. Name of the insurer HDFC ERGO General Insurance Co. Ltd.

5. Date of Repudiation 24/09/2019

6. Reason for repudiation Loss date does not fall under policy period

7. Date of receipt of the Complaint 10-10-2019

8. Nature of complaint Non Payment of Disability Claim

9. Amount of Claim Not mentioned

10. Date of Partial Settlement N.A

11. Amount of relief sought N.A

12. Complaint registered under Rule no: Insurance Ombudsman Rules, 2017

Rule 13 (1)(b) – any partial or total repudiation of claim by an insurer

13. Date of hearing/place 10-02-2020/ Chandigarh


For the Complainant Mr. Narinder Kumar

For the insurer Ms. Shweta Pokhriyal Asstt. Manager

15 Complaint how disposed Dismissed


17) Brief Facts of the Case: On 10-10-2019, Mr. Narinder Kumar had filed a complaint of Non Payment of accidental Disability claim by the HDFC ERGO General Insurance Co. Ltd and submitted that he is having a credit card of HDFC bank and the customer care executive of the bank called and apprised him to buy the policy on monthly EMI basis. The complainant disclosed to the executive about his accident of 10.12.2014 while filling application form and after completing all the formalities the policy was issued on 04.06.2015 and renewed the policy from that date to till date. The complainant read the policy on its renewal on 6/2019 and found that there was a permanent disablement clause and immediately checked the permanent disablement certificate issued by the civil surgeon Patiala vide No. Med/457 dated 29/06/2015, copy attached according to which he is having 80 percent of permanent disability equivalent to 100% in left hand. No doubt the policy was purchased on 04.06.2015and the accident occurred on 10.12.2014, whereas the permanent disability certificate was issued to him 29/06/2015 after getting the policy. All the relevant documents including the policy copy, hospital bills admission/discharge from hospital, permanent disability certificate, cancelled cheque, disabled left hand snaps, claim form. NEFT and KYC forms etc. were sent to the Noida office of the insurance company and on 24/09/2019 they informed that the claim cannot be registered under policy No. 52042083 as the loss date 10.12.2014 does not fall under the policy period.

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On 29-10-2019, the complaint was forwarded to HDFC ERGO General Insurance Co. Ltd. Regional Office,

Noida, for Para-wise comments and submission of a self-contained note about facts of the case, which was

made available to this office on 27.01.2020.As per SCN,

The present complaint pertains to grievance under individual personal accident plan 1 policy having policy

no. 52042083 valid from 03/06/2015 to 02/06/2017.As per the submission made in complaint, the

complainant met with an accident on 10/12/2014 and was subsequently issued a disability certificate on

29/06/2015.Now the complainant wants to claim the benefit under permanent disablement which was a

result of an accident that happened on 10/02/2014.It is submitted that the insurance policy issued to the

complainant is strictly subject to terms and conditions .That as per terms and conditions of the policy, for

any claim to be admissible under the category of permanent disablement the bodily injury leading to

disability should have occurred during the period of insurance. The relevant conditions of the policy i.e

Section 2 Permanent Disablement states “If during the period of insurance an insured person sustains bodily

injury which is directly and independently of all the causes results in disablement within 12 months of the

date of loss, then the company agrees to pay to the insured person the compensation stated in the specific

table of benefits below, which is shown as The Table of Benefits in the Schedule. The deductible or franchise,

if applicable, shall be deducted from the compensation payable.” The terms period of insurance is defined in

the policy as : “Period of Insurance means the Operative Time stated in the Schedule, commencing on or

after the policy effective date and terminating on or before the policy expiration date’

As per the terms of the present insurance contract, the insurer’s were liable to indemnify the insured against

any loss happening during the period of insurance i.e 03/06/2015 to 02/06/2017, however the loss

happened outside the period of insurance and hence the company is not liable to pay any sort of

compensation to the complainant.

The complainant was sent Annexure VI-A for compliance, which reached this office on 07-11-2019.

18) Cause of Complaint:

a) Complainants argument: Since the disability certificate was issued after taking the insurance policy,

his claim for the disability should be paid

b) Insurers’ argument: The loss happened outside the period of insurance so company is not liable to

pay the claim.

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): I have gone through the

documents placed on record including the copy of complaint, SCN of insurer, policy terms and conditions

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and disability certificate. It has been observed that the complainant’s claim under the personal accident

policy effective from 03/06/2015 to 02/06/2017,for the permanent disability suffered by him due to an

accident on 10/02/2014 was denied by the insurance company. The basic issue before me is to decide

whether the denial of disability claim by insurer is in order or not as per terms and conditions of the

policy.

The relevant condition ,Section 2of the policy states that if during the period of insurance an insured

person sustains bodily injury which is directly and independently of all the causes results in disablement

within 12 months from the date of loss then the company agrees to pay the insured person the

compensation stated in the specific table of benefits. The term period of insurance is defined in the

policy as “Period of insurance means the operative time stated in the schedule, commencing on or after

the policy effective date and terminating on or before the policy expiry date” As per terms of policy, the

insurer’s were liable to indemnify the insured against any loss happening during the period of insurance

i.e 03/06/2015 to 02/06/2017, however the loss happened outside the period of insurance ,the

insurance company is not liable to pay any compensation . As the disability for which the claim is made

related with the accident which took place on 10/02/2014 i.e prior to the commencement of the policy,

it is beyond the scope of cover of policy. Therefore the denial of claim by the insurer is in order and does

not call for any interference .The complaint is dismissed being devoid merits.

AWARD

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

parties during the course of personal hearing, no relief is granted to the complainant.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 25th day of February 2020.

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATES OF WEST BENGAL, SIKKIM AND UT OF ANDAMAN & NICOBER ISLANDS

(Under Rule No.16 (1)/17 of the Insurance Ombudsman Rules -2017)

OMBUDSMAN–SHRI P. K. RATH

Case of Sri Debjit Singha vs Universal Sompo General Insurance Company Ltd.

COMPLAINT REF NO: KOL-G-052-1819-0324 AWARD NO: IO/KOL/A /GI /0251 / 2019-2020

1. Name & Address of the Complainant Sri Debjit Singha S/o Late Dipak Singha

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Vill- Arjunpur, P.O- Purandarpur, Dist- Bankura.--- 722155 West Bengal.


3336/56182853/00/096 Pradhan Mantri Suraksha Bima Yojana ( PMSBY ) 01/06/2016 to 31/05/2017


(Late Dipak Singha Insured ID- 101192359309 ) Allahabad Bank, Kolkata branch office .

4. Name & address of the insurer Universal Sompo General Insurance Company Ltd.( Mumbai ) Plot no- EL-94, KLS Tower, TTC Industrial Area, MIDC, Mahape, Navi Mumbai- 400710.

5. Date of Repudiation 11/01/2017.

6. Reason for repudiation For late submission of claim intimation & documents by 219 days.

7. Date of receipt of the Complaint 26/10/2018

8. Nature of complaint Claim rejection for late submission.

9. Amount of Claim Rs 200000/-

10. Date of Partial Settlement NA

11. Amount of relief sought Rs.200000/-

12. Complaint registered under IOR-2017 13(1)(b)

13. Date of hearing/place 22/02/2020 at Durgapur.

14. Representation at the hearing --------

For the Complainant Sri Debjit Singha

For the insurer Sri Sandipan Banerjee

15 Complaint how disposed By Conducting Hearing

16 Date of Award/Order 25/02/2020.

17) Brief Facts of the Case:- Policy Name :: Pradhan Mantri Suraksha Bima Yojana Policy Holder :: (Late Dipak Singha Insured ID- 101192359309 ) Policy Type :: Personal Accident Insurance Policy, Policy period :: 01/06/2016 to 31/05/2017 Date of Death :: 25/10/2016 Amount of claim- :: Rs 200000/- Nature of complaint :: Accidental Insurance Claim by road Accident. The Complainant Sri Debjit Singha, son of late Dipak Singha, the Insured, stated that his father Late Dipak Singha of village arjunpur, Dist- Bankura, while walking, met with a road accident on 22/10/2016 by a motorcycle, resulting severe injury. Then he was shifted to B.S.M.CH, Bankura. But since the situation of the Injured was worsened; he was advised to rush to Kolkata. Meanwhile, in consideration of his health status while shifting to Kolkata, he was again admitted at Mission Hospital, Durgapur, mid way. Then further shifted to S.S.K.M, Kolkata & on dated 25/10/2016 at about 9.50 in the morning he expired. Being mentally & physically unstable, wife of the victim, lodged FIR after a substantial period on 23/04/2017, specifically specifying the reason of delay reporting to Bankura P.S. But initially it was referred to Bhawanipore Police Station.

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Subsequently, after completion of all formalities & on getting all required documents including death certificate & post mortem report she submitted the documents to the respective Insurance Company with whom the victim had a personal accident policy under PMSBY scheme where the premium was only Rs 12/- against Sun Insured of Rs 200000/- as confirmed by the Policy holder bank M/S Allahabad Bank under the policy no of above description. In subsequent period, the claim was declined by the Insurance Company for late submission of claim papers by 219 days, thus violating the claim procedural norms under condition 3 of the stipulated policy. (Claim to be submitted within 30 days). . Complainant’s Argument: The Complainant said that because of mental & physical breakdown after the accidental death of the Insured (His Father), he could not fulfil all the formalities in time. Further, in order to obtain Post mortem report & other documents it took further time from their end. But they did not have any bad intention of it other than the reasons as cited above. The complainant, son of the victim, therefore requested the honourable Ombudsman to consider his claim sympathetically. Insurer’s Argument: As per SCN submitted by the Insurance Company, M/S UNIVERSAL SOMPO GENERAL

INSURANCE CO. LTD. on dated 27/11/2018 that the claim cannot be considered for settlement

because of late submission of claim intimation by 219 days, violating condition 3 of the stipulated

claim procedure under the policy.

19) Reason for Registration of Complaint:- Scope of The Insurance Ombudsman Rules-2017

under section 13 (1) (b).

20) The following documents were placed for perusal. (a) Claim form (Annex. VIA) (b) Policy Copy c) Complainants Claim to Insurance

Ombudsman d) SCN of the Insurance Company dated 27/11/2018.(e) death certificate f) FIR & Post mortem Report

21) Result of hearing with both parties (Observations & Conclusion) The complainant stated at the time of hearing that initially after the sad demise of his father, the total family was under the grip of deep shock. Then for obtaining documents like post mortem report & others, it took sufficient time to submit claim papers to Insurance Company. The sudden Death of his father also made them perplexed as to what to do. Therefore he requested to Insurance Company to consider his claim. Finally, finding no way & after rejection of his claim he appealed to Insurance Ombudsman for getting justice. The Insurance Company , on the other hand , showed the same reason for denial of claim as that in SCN that delay submission of claim, is the reason for rejection of the claim.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both the parties, it is established from the submitted documents that the Insured as stated, had an Accidental Insurance Policy under the Pradhan Mantri Suraksha Bima Yojana scheme with Allahabad Bank, Kolkata Branch. This is also confirmed by the said bank with all detal particulars. Unfortunately the Insured, Late Dipak singha, died because of road accident. Death Certificate, Post mortem report & Police Final report confirmed the same. In consideration of unfortunate accidental death & as it is under the purview of the Policy cover, the decision of the Insurance Company is set aside & the

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Insurer M/S Universal Sompo General Insurance Co. Ltd (Mumbai) is directed to make payment of Rs 200000/- as being the Sum Insured under the purview of terms & conditions of the policy. Hence, the complaint is treated as disposed of.

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

of the 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 shall intimate the compliance to the Ombudsman.

Dated at Kolkata on the.25th day of..February 2020.

Sd/-

INSURANCE OMBUDSMAN STATES OF WEST BENGAL, SIKIM, A & N ISLAND

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN ...

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