PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN ...

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, AHMEDABAD

State of Gujarat and Union Territories of Dadra & Nagar Haveli, Daman and Diu

(Under Rule No: 16 / 17 of The Insurance Ombudsman Rules, 2017)

Complaint of: - Mr. Khushal M. Thaker Vs. The New India Assurance Co. Ltd.

Complaint No.: AHD-G-049-2122-0055

1 Name & Address of the Complainant Mr. Khushal Thaker

452, Nandbhoomi Appt., Opp. T. N. Rao

College, Kerala Park Main Road, Off

University Road, Rajkot-360007

Policy No:

Type of Policy:

Policy period:

Sum Insured (IDV)

13130031190300004331

Private Car Enhancement Cover Policy

30.04.2019 to 29.04.2020

Rs.6,50,000/-

3 Name of the insured

Name of the policy holder

Date of accident

Mr. Khushal Thaker

Mr. Khushal Thaker

30.07.2019

4 Name of the Insurer The New India Assurance Co. Ltd.

5 Reason for partial settlement As per policy terms and conditions

6 Date of receipt of complaint 19.03.2021

7 Nature of complaint Partial Settlement of Claim

8 Amount of claim Rs.14,52,204/-

9 Date of Consent 24.01.2022

10 Date of receipt of SCN 13.09.2021

11 Amount of relief sought Rs.2,50,000/-

12 Complaint registered under Rule No. Rule 13 (1) (b) of I. O. Rules, 2017

13 Date of hearing / mode 24.02.2022 / Online hearing

14 Representation at the

hearing:

For the Complainant:

For the Insurer:

Mr. Khushal Thaker

Ms. Varsha Mullick

15 Complaint how disposed Award

16 Date of Award 24.02.2022

17. Brief History:

The Complainant, Mr. Khushal Thaker’s Tata Nexon car, Reg. No.GJ-32-B-5376, was covered

under the Private Car Enhancement Cover Policy, No. 13130031190300004331 for the period

of 30.04.2019 to 29.04.2020 with IDV of Rs.6,50,000/- issued by The New India Assurance

Co. Ltd. His car met with an accident on 30.07.2019 for which the complainant put up a claim

for Rs.14,52,204/- which was settled by the Company for Rs.4,11,000/- on total loss / Net of

Salvage with RC basis, after deducting a value of Salvage amounting to Rs.2,38,000/- and

Rs.1,000/- as excess by construing the claim as total loss claim. However, unsatisfied with the

decision of the Company, he represented to the Company against the partial settlement, but

of no avail. Aggrieved by the same, the complainant approached this forum.

18. Cause of Complaint:

(A) Complainant’s argument:

The complainant submitted that his car met with an accident on 30.07.2019 and he

immediately intimated the intermediary agent. He stated that the claim was settled by the

respondent insurer for the amount of Rs.6,50,000/-, after a deduction of Rs.2,38,000/- for the

salvage and Rs.1000/- for an excess. He submitted that he got only Rs.65,000/- for the

salvage amount and he should be in receipt of the remaining amount from the respondent

insurer. He submitted that his claim is genuine and should be paid to him in full. He has urged

the Forum to help him in getting his balance claim.

(B) Insurer’s Argument:

The representative of the respondent submitted that, the claim was settled for Rs 4,11,000/-

on Net of Salvage with RC basis, after receiving Insured’s consent, to the financier. The

Insured has retained the salvage with RC.

It was a total loss case as the repair liability exceeds IDV. As per survey report of M/s A. S.

Rathod dated 25.09.2019, salvage of the damaged vehicle can be sold for about Rs

2,38,000/- in as & where condition with RC book subject to immediate disposal (supported by

online quotation attached) and excess was Rs 1,000/-.

Hence the settlement is proper and it is done having taken the insured’s consent.

The grievance regarding the salvage disposal was raised much after receiving the payment,

hence it is an afterthought.

In view of the same, she has prayed before the forum to dismiss the case without any relief to

the insured.

19. Result of hearing with both parties (Observation & Conclusion):

Based on the submission of both the parties and the materials made available to this Forum,

the following points have emerged which are pertinent to decide the case:-

1) The Complainant, Mr. Khushal Thaker’s Tata Nexon car, Reg. No.GJ-32-B-5376, was

covered under the Private Car Enhancement Cover Policy, No.

13130031190300004331 for the period of 30.04.2019 to 29.04.2020 with IDV of

Rs.6,50,000/- issued by The New India Assurance Co. Ltd.

2) His car met with an accident on 30.07.2019 for which the complainant put up a claim

for Rs.14,52,204/- which was settled by the Company for Rs.4,11,000/- on total loss/

Net of Salvage with RC basis, after deducting a value of Salvage amounting to

Rs.2,38,000/- and Rs.1,000/- as excess by considering the claim as total loss claim.

3) It was a total loss case as the repair liability exceeds IDV. As per survey report of M/s

A. S. Rathod dated 25.09.2019, salvage of the damaged vehicle can be sold for about

Rs 2,38,000/- in as & where condition with RC book subject to immediate disposal and

excess was Rs 1,000/-.

4) The forum also took a note of the insured’s consent dated 22.05.2020, whereby he

accepted the settlement for Rs.4,11,000/- on Net of Salvage with RC basis, after

deduction of Salvage amounting to Rs.2,38,000/-. In view of the same, without

going into the merit of the case, the forum finds no infirmity in the decision taken

by the respondent insurer to settle the claim.

5) The deduction of Rs.1,000/- towards excess is in order.

In view of the forgoing facts, the decision of the respondent insurance company to

repudiate the claim is justified, hence the complaint stands dismissed.

20. If the decision of the Forum is not acceptable to the Complainant, he/she is

at liberty to approach any other Forum/Court as per law of the land against the

respondent insurer.

Dated at Ahmedabad on 24th day of February, 2022.

(KULDIP SINGH)

INSURANCE OMBUDSMAN

AWARD

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

the complaint stands dismissed with no relief to the Insured.

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

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

OMBUDSMAN – RAVINDRA MOHAN SINGH

Mr. Ramesh Kumar Patel……..………..…………………..……………….………….…Complainant V/s

Bharti Axa General Insurance Company ..……………….…….……...…………...Respondent

COMPLAINT NO: BHP-G-007-2122-0139 ORDER NO: IO/BHP/A/GI/ 0022 /2021-2022

• Mr. Ramesh Kumar Patel (Complainant) has filed a complaint against Bharti Axa General

Insurance Company (Respondent) alleging Non Settlement of claim by the respondent.

• Brief facts of the Case –

1. Name & Address of the Complainant

Mr. Ramesh Kumar Patel B-Star 305 Royal Villas Ashima Mall Bhopal

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

P13/12900497/C3/10/004948 Private Car Policy 18.10.2018 to 17.10.2019

3. Name of the insured Name of the policyholder

Mr. Lalit Patel Mr. Lalit Patel

4. Name of the insurer Bharti Axa General Insurance Company

5. Date of Repudiation/ Rejection 10.02.2021

6. Reason for Repudiation/ Rejection

Non Settlement of claim due to change of Driver

7. Date of receipt of the Complaint 12.04.2021 & 25.01.2022

8. Nature of complaint Repudiation of death claim in Car accident

9. Amount of Claim 24.31 Lakhs

10. Date of Partial Settlement --

11. Amount of relief sought Rs. 7,76,288/- + Charges

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

13. Date of hearing/place 01.02.2022 at Bhopal

14. Representation at the hearing

a) For the Complainant Mr. Ramesh Kumar Patel over Go To Meet App

b) For the insurer Mr. Ashay Mahajan, Manager over Go To Meet App

15. Complaint how disposed Dismissed and closed

16. Date of Award/Order 01.02.2022

• Contention of the complainant –The Complainant has stated that on 06.08.2019

Policy holder / his brother late Shri Lalit Patel was driving the vehicle and another

person Manish Shukla was sitting beside him, unfortunately accident took place and

Lalit Shukla lost his life. Person with him Mr. Manish Shukla lodged the FIR. According

to FIR Late Lalit Patel was driving the car. One couple on motorcycle came suddenly

on the way and to save them his car was toppled down in valley. The damaged Car

was sent to Police Station. After taking possession through court the vehicle was taken

to repairer and claim was lodged by nominee (complainant) Mr. Ramesh Kumar Patel.

His claim was rejected due to reason that (1) as per claim intimation / claim form the

vehicle was driven by Mr. Lalit Patel and as per respondent’s investigation finding

vehicle was driven by Mr. Manish Shukla. (2) the car hit with pole. Then he

represented that his claim was rejected on the basis of faulty presumptions only. But

respondent has not resolved the grievance nor settled the claim.

• Contention of respondent-The respondent in their SCN have stated that the

complainant had obtained a motor insurance policy for his vehicle no. MP-20CH-6994

.The Insured met an accident on 6th August, 2019 and thereafter lodged a claim with

us. We deputed a surveyor for assessment of damages and an investigator to ascertain

the veracity of the claim. The surveyor submitted his assessment report and assessed

the said damage to ₹ 3,75,000. The Investigator submitted his report wherein a lot of

enumerated discrepancies were found i,e (1) Claimant & Late Insured’s friend did not

confirm the spot of accident. (2) Inward/Outward details and gate pass was denied by

the Workshop. (3) Name and age of Nominee and Claimant are found to be different.

(3) Body of the Insured was found outside the IV; not possible if the Insured would

have been using the Safety Restraint System (seat belt) making it violation of MV Act

as well as negligence under our Policy terms and condition (4) Insured Vehicle was

driven in a rash & negligent manner (also violative of Law & Policy terms and

condition) (5) Manish Shukla (co-passenger) refused to meet the fact finder and did

not coordinate in the fact finding. Given the findings of the Investigator, the claim of

the Insured stands repudiated on the grounds of concealment/misrepresentation of

facts, guilty of negligence and violation of prevailing laws among other. The claim of

the Insured doesn’t falls Policy Terms & Condition. The description of the accident

and the damages as well as the death of the Insured were not correlating.

• The Complainant has filed complaint letter, Annex. VIA and correspondence with

respondent while respondent have filed SCN with enclosures.

• I have heard both parties over Go To Meet App at length and perused paper filed on

behalf of the complainant as well as the Insurance Company.

• Observation and Conclusion :

The case was re-registered in the light of earlier Hearing / Order dated 04.10.2021 of

Ombudsman Lucknow. Wherein, the complainant was directed to file affidavit within 10

days and respondent to settle the PA claim within 30 days and for OD claim, complainant

to submit the desired documents and respondent to settle the claim within 30 days.

Further complainant would be at liberty if he is not satisfied.

In compliance of that respondent has, reported to have, settled the PA claim and

consented to settle the OD claim accordingly to repair bill as per policy terms and

conditions. The complainant approached, again, to this forum and submitted letter dated

09.12.2021, mail dated 25.01.2022. He argued during hearing that Company is liable to

get repaired his vehicle from authorized dealer using genuine auto parts and pay for

parking charges and entire transport charges.

The respondent in his turn argued that Insurance Company does not do any repairing job

of damaged vehicle. It is insured who has to get repaired the vehicle and submit the bills

for settlement of the claim.

I am of the view that Insurance Company is not liable to repair any damaged vehicle itself

as per contract. In compliance of order dated 04.10.2021 he has already consented for

settlement to the Company, on submission of bills / Cash memo, as per policy terms and

condition. The vehicle owner is not expected to keep repairing on hold / pending for

indefinite time and wait for disputes to get resolved. Nothing on the record is available

which shows that respondent has obstructed in repairing the vehicle at any point of time,

infact during the hearing the respondent have confirmed to advance 60% of the claim

amount in order to get the vehicle repaired. During the hearing the complainant has also

claimed for transport and parking charges. In this also I don’t find any substance. The

respondent cannot be held liable if authorized dealer is not available as on date.

The order of earlier Ombudsman, issued earlier, dated 04.10.2021 is just and proper and

need no intervention. Hence the matter is being dismissed and closed with the direction

to complainant to get repaired the vehicle and submit the bills / Cash memos and to

respondent it settle the claim as per policy terms and condition with 30 days of receipt of

documents.

•

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

Place :- Bhopal M.P. ( RAVINDRA MOHAN SINGH )

Date:-21.01.2022 INSURANCE OMBUDSMAN

………………………………………………………………………………………………………………………………………………

…………..

OMBUDSMAN – RAVINDRA MOHAN SINGH

Mr. Chunnilal Atulkar …………..……………...……………..……………….…………………...…Complainant V/s SBI General Insurance Co. Ltd. ……………….. .……………….…….……...………….………...Respondent

COMPLAINT NO: BHP-G-040-2122-0024 ORDER NO: /BHP/A/GI/0008 /2021-2122

AWARD

The order dated 04.10.2021 by the earlier Ombudsman needs no intervention hence the

complainant is directed to get repaired the vehicle and submit the bills / Cash memos to

the respondent and respondent to settle the claim as per policy terms and condition

with 30 days of receipt of documents


Mr. Chunnilal Atulkar SUPER E- 1207, MPPGCL Colony, Betul - 460447

• Mr. Chunnilal Atulkar has filed a complaint against SBI General Insurance Co. Ltd.

(Respondent) alleging non settlement of the claim.

• Brief facts of the Case –

• Contention of the complainant – The Complainant states that he is the customer of

SBI General Insurance having Private Car insurance policy. The details of the same are :

Policy no. 18077925, dated 06.07.2020, Hyundai Car I20, Asta, MP04CV1126 (2018),

NCB 25% & IDV Rs. 5,21,442/-. On 13.03.2021 suddenly a cow came in front of the Car

got and it went out of the road and got damaged. On 14.03.2021 the Car was sent to

M/s. Abhishek Automobiles Pvt. Ltd., Chhindwara for repairs. They assured the

complainant that whenever survey will be undertaken he will be informed, but on

27.04.2021 he got a email from the Company stating that the claim settlement has

been done on Total loss basis and the car will be auctioned. This was done without

his knowledge and in order to give the car to the buyer he was asked to bring the

documents of the car. As there was not much damage to the car, he called up the


18077925 Private Car Insurance 03.07.2020 to 02.07.2021


Mr. Chunnilal Atulkar Mr. Chunnilal Atulkar

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

5. Date of Repudiation/ Rejection -

6. Reason for Repudiation/ Rejection

-

7. Date of receipt of the Complaint 24.06.2021

8. Nature of complaint Non Settlement of claim

9. Amount of Claim Rs. 3,61,858/-


11. Amount of relief sought Rs. 3,61,858.69

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

13. Date of hearing/place 01.02.2022 at OIO Bhopal


c) For the Complainant Mr. Devendra Kumar Atulkar, Son of complainant over Go To Meet App

d) For the insurer Ms. Chaynikca Modie, Manager over Go to Meet App

15. Complaint how disposed Dismissed


insurance Company and the workshop he demanded the estimate but both of them did

not provide the details but stated that it is now lock down time. The vehicle was jointly

insptected with the representative of M/s. Abhishek Hyundai the repairing cost with tax

came to Rs. 3,61,858/-. The complainant asks how it is then Total Loss. The earlier

estimate done by the Insurance Company and M/s. Abhisheh Hyundai was for Rs.

6,93,266.59. It was due to inclusion of the full assembly instead of individual parts. On

26.05.2021 he received the estimate of Rs.3,61,858/-. On 28.05.2021 he took up the

matter with the Insurance Co. and on 01.06.2021 he also informed the surveyor. But no

satisfactory reply was given. Hence on 03.06.2021 he informed the grievance officer of

the Insurance Company. A resurvey was done on 11.06.2021 jointly by surveyor and

Abhishek Hyundai ‘s representative. As per resurvey the estimate of the parts + labour

cost came to Rs. 2.8 lakhs only. This shows their collusion for declaring the vehicle as

total loss. Due to this reason the SBI team (Surveyor) & M/s. Abhishek Hyundai

representative did not give estimate. He also asked for the copy of joint survey dated

11.06.2021, but the same was not given to him. Again through a mal dated 12.06.2021

the copy of estimate was asked but the same was again not given. On 21.06.2021 the

GRO sent a mail stating that his claim will be settled on total loss basis. There is not

much damage to his car and can be repaired, But declaring it as total loss and being

auctioned is for avoiding paying money to repairer.

• Contention of respondent- The respondent in their SCN have stated that Complaint has

been lodged by Complainant with foremost prayer to allow repair mode of

indemnification. Claim of the complainant has already been assessed through an IRDA

Licensed independent Surveyor having prescribed skillset and knowledge. Further, as

per the findings of the Surveyor vis-a-vis policy terms and conditions, it was observed

that the Loss assessed is 104.69% higher than the IDV of the vehicle and thus the

Company as per terms and conditions of the policy has offered to settle the claim

through a Constructive Total Loss mode of settlement. Alternatively, the Complainant

was also offered the option to retain the vehicle in the same wreck value as received in

Online Auction and receive the rest of the offered settlement amount. However despite

receiving the Offer of settlement and its repeated reminders, the complainant did not

agree with either of the option given or shared any of the required documents till date.

Hence, the said claim is pending for lack of cooperation from Insured. The same is

substantiated and explained herewith. the relevant and material facts of the case are as

under: A Private Car Insurance Policy- Package (Annual) Policy Bearing No.

0000000018077925 was issued by SBI General in the name of Complainant/ Insured i.e.

“Mr. Chunni Lal Atulkar”, which was effective from 03.07.2020 to Midnight 02.07.2021,

for insuring the vehicle “Hyundai I20 Asta”, bearing registration no. MP 04 CV 1126

subject to its terms and conditions and any claim is admissible in adherence to the same.

Immediately after registration of the claim, an IRDA licensed Independent Surveyor,

namely “Mr. Sandeep Singh Chandel” was appointed by SBI General for evaluation and

assessment of the reported accident and submission of a Survey report based on the

terms and conditions of the subject policy. Based on the observations and findings

regarding the loss, the Surveyor issued the Final Survey Report to the Company post

completion of Survey keeping in view the terms and conditions of the said Policy. The

Company evaluated complainant’s claim and observed that the IDV of the insured

vehicle as per the policy is Rs. 5,21,442/-, whereas the Repair estimated provided by the

Workshop, Abhishek Automotive Private Limited Nagpur, was Rs 6,93,266/-. Further,

the loss assessed by the Surveyor was Rs. 5,45,883/-, which was 104.69% of the IDV,

that is, more than 75% of the IDV which is the maximum limit to which the Company is

liable for repairs. Hence, claim was forwarded for Constructive Total Loss Mode of

Settlement to be settled for Rs. 1, 48,942/- (excluding wreck value) in the favour of

Insured/ Financier as applicable. Further, the vehicle wreck was offered to be disposed

through identified salvage buyer M/S Samil, against DD payment of Rs 3,71,500/-. The

payment bifurcation is reproduced below for the reference. Insured Declared Value : Rs.

521442/-Less : Wreck Value of damaged vehicle payable by highest bidder through

Salvage Vendor: Rs. 371500/ Less policy excess: Rs. 1000/- Net full and final settlement

by Company Rs. 148942/- Alternately, the Insured/ Complainant was also given the

option to retain the vehicle with him in the same amount of wreck value as identified

by the Company through online auction, under the subject policy. That accordingly the

offer was duly communicated to the Insured vide Company’s offer letter/mail dated

27.04.2021 thereby requesting for acceptance of either of the offers of settlement by

submitting the requisite documents/information to allow us to process the settlement.

An Insurance contract is effected for indemnity of loss i.e. an agreement requiring the

just indemnification of insured for the loss caused. Thus the indemnification should be

appropriately done to bar any unjust enrichment or gratuitous profit beyond the pale of

indemnity. It is further submitted that it is the prerogative of the Company to decide

whether to repair, replace or settle the claim on total loss basis under Condition 3 of the

subject Policy and the offer of settlement made to the Complainant was done in

conformity with all the aforesaid principles and policy condition 3 in order to accurately

indemnify him of his loss. In view of the above, the relevant extracts of the policy are

reproduced hereunder for ready reference: SUM INSURED- INSURED’S DECLARED

VALUE (IDV): The insured vehicle shall be treated as a CTL if the aggregate cost of

retrieval and / or repair of the vehicle, subject to terms and conditions of the Policy,

exceeds 75% of the IDV of the vehicle. CONDITION: 3. The Company may at its own

option repair reinstate or replace the vehicle or part thereof and/or its accessories or

may pay in cash the amount of the loss or damage and the liability of the Company shall

not exceed: (a) For total loss / constructive total loss of the vehicle - the Insured's

Declared Value (IDV) of the vehicle (including accessories thereon) as specified in the

Schedule less the value of the wreck. (b) For partial losses, i.e. losses other than Total

Loss/Constructive Total Loss of the vehicle - actual and reasonable costs of repair and/or

replacement of parts lost/damaged subject to depreciation as per limits specified.

However the insured did not give his consent to either of the modes for settlement, and

maintained that the damage to his car is less than the loss assessed by the Surveyor.

That in line with the Company’s policy of fair, just and transparent assessment of claims,

the Company scheduled another Survey with the workshop manager and Surveyor, in

the presence of the Insured/ Complainant. Further, in the said joint inspection, the

Surveyor and Workshop manager had explained the loss on damaged parts to the

insured. It is also relevant to mention here that the Survey Report was not shared with

the Insured/Complainant as the Company did not receive any requirement from the

Insured for the same. Often when a claim is filed, there could be differences between

what an insurer and the insured believe the actual loss in a particular situation to be.

Hence, Insurance Regulatory and Development Authority (IRDA) under Section 64UM of

The Insurance Act, 1938, authorizes independent entities/individuals (called Surveyor &

Loss Assessors) to act as a professional link between the insured and the insurer. A

surveyor and loss assessor for motor insurance possess mandatory qualifications in

mechanical or automobile engineering. Further, the surveyor and loss assessors

evaluate the damage and submit their report which is independent of the insurer and

the insured’s view. Accordingly, the aforesaid claim was approved as per the surveyor’s

independent and professional view vide the Surveyor’s report submitted to the

Company. Thereafter, the complainant was again reminded about the aforesaid offer of

claim settlement and required documents vide the Company’s letters/Mails dated

17.06.2021 and 25.06.2021.By denying each and every allegation as mentioned in the

said complaint under the present reply (SCN), SBI General states that the contents of

the complaint, wherever admitted, are a matter of record. Further, the said settlement

offer was just, lawful as per the policy terms and conditions, It is thus submitted that

Complainant’s Ombudsman Complaint is misconceived and is liable to be dismissed.

• The Complainant has filed complaint letter, Annex. VIA 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.

• Observation and Conclusion : The case was re-registered in the light of earlier Hearing

/ Order dated 06.10.2021 of Hon’ble Ombudsman. Wherein, the respondent were

directed to appoint a surveyor under the guidelines and get the Survey report within 15

days and respondent shall decide the claim within a period of 30 days. If complainant is

aggrieved with the decision, he would be at liberty to approach this forum again.

In compliance of that complainant has approached this forum and submitted a letter

dated 24.12.2021 stating that Co has arranged the survey again and provided a copy of

report to him on dated 10.12.2021. The insurance Co has offered Total Loss settlement

again. He submitted and argued during the hearing again that the surveyor has assessed

for some of affected parts which need not to be replaced for his accidented vehicle.

Whereas he wants to get it repaired and the vehicle is very much repairable. The

respondent argued further that the cost of repair shall be well within the 75 % of the

IDV and he is ready to bear the difference over that cost.

The respondent in his turn argued that insurance Co has complied with the Ombudsman

Order dated 06.10.2021. In compliance of that Co has arranged for the 2nd Surveyor,

provided the copy of report and offered the settlement as per assessment of surveyor.

The complainant cannot put his condition to get the claim settled. Claim settlement shall

be as per policy terms / condition only. Respondent argued further that insured cannot

challenge the assessment of professionally qualified and duly licensed Surveyor. The

respondent further submitted that from their side they have done everything to resolve

the complainant’s grievance.

I have heard both the parties and have carefully examined the documents on record.

I am of the considered opinion that respondent has already complied with the

Ombudsman’s Order and offered for claim settlement of claim as per Second Surveyor

assessment. As per policy condition no 3 ‘Co may its own option repair, reinstate or

replace the vehicle..’ So insured cannot insist to go for settlement as per his choice. The

policy states that Vehicle shall be treated as Constructive Total Loss if the aggregate

cost of retrieval and / repair of the vehicle exceeds 75% of the IDV of the vehicle. So

respondent’s action / offer of settlement is in accordance with the terms and condition

of the policy. There cannot be any other option of settlement of the claim beyond

method specified in the policy.

The order of earlier Hon’ble Ombudsman, issued earlier, dated 06.10.2021 is just and

proper and need no intervention. The complaint filed for review, is dismissed with the

direction to insured / complainant to proceed as per settlement initiated by respondent

Co in compliance of Ombudsman’s order passed on dated 06.10.2021.

AWARD

The revised complaint of Mr. Chunnilal Atulkar is herewith dismissed and earlier

award of Hon’ble Ombudsman is upheld.

• Let copies of the order be given to both the parties. Compliance shall be intimated to this

forum.

Place : Bhopal (RAVINDRA MOHAN

SINGH)

Date : 01.02.2022 INSURANCE

OMBUDSMAN

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 MR. SRIKANTA KUMAR BRAHMA Vrs. THE NEW INDIA ASSURANCE COMPANY

LIMITED COMPLAINT REF: NO: BHU-G-049-2122-0181

AWARD NO: IO/BHU/A/GI/ /2021-22


Mr.Srikanta Kumar Brahma, Biju Pattnaik Chhak, Tulsipur, Cuttck, Odisha.Pin-753008 Cell no.9437011500


55010531150100003610 Two wheeler package policy-Honda Aviator OD-05-AD-7847- 2008 Model-IDV-Rs.19,500/- 12 months-20/12/2015 to 19/12/2016, D.O.L.-11/06/2016


Mr.Srikanta Kumar Brahma Mr.Srikanta Kumar Brahma

4. Name of the insurer The New India Assurance Company Limited

5. Date of Repudiation Neither repudiated nor settled Not applicable 6. Reason for repudiation

7. Dt of receipt of the Complaint

26/11/2021

8. Nature of complaint Non settlement of claim

9. Amount of Claim Rs.19,500/-

10. Date of Partial Settlement Neither repudiated nor settled

11. Amount of relief sought Rs.22,230/-

12. Complaint registered under Rule no: of IO rules

13(1)b

13. Date of hearing/place 04/02/2022, Bhubaneswar


a) For the Complainant Self through VC

b) For the insurer Mr. MAQ Baig, Asst. Manager through VC

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

16 Date of Award/Order 04/02/2022

17. a. Brief Facts of the Case/ Cause of Complaint: -The complainant had insured his 2008 Model Honda Aviator bearing Registration no.OD-05-AD-7847 for an IDV-Rs.19,500/- for the period 20/12/2015 to 19/12/2016 with The New India Assurance Company Limited. On 11/06/2016, Mr Nirakar Swain had parked the said vehicle in front of their office at Plot no.841, Keshab Complex, Cuttack Puri Road and around 3.30 pm did not found the vehicle

where it was parked. The matter was intimated to Sahid Nagar Police by Mr Nirakar Swain who had registered the case vide vide FIR no.403 dated 18/07/2016. The intimation regarding theft was informed to Insurer on 13/06/2016 by complainant. Mr Manoj Kumar Sahoo was deputed by Insurer for investigation who submitted his report to Insurer on 03/07/2017. Investigator opined that theft claim should be settled subject to submission of Final Police report and other documents from Insured. Complainant has submitted zerox copy of FIR, final form which was submitted by investigation officer vide FF no.398 dated 30/09/2016, Form no.35 (1) and (5) to this forum. Final form does not contain any documentary evidence as to whether the same has been accepted by court or not. Insured has submitted a copy of representation dated 01/10/2021 without his signature addressed to Sr D.M. Bhubaneswar D.O.1 with a copy to Claim hub at Alok Bharati Tower, Saheed Nagar. The letter does not speak on any acknowledgment from Insurer’s office. Insurer has not submitted any letter issued by them to Insured for compliance of documents required for processing and settlement of claim. Being not satisfied on settlement of the claim complainant has approached this forum for redressal of his grievance. b. The insurer, in its self-contained note, has admitted insurance of the vehicle and receipt of claim intimation letter, FIR, Claim form from complainant. They have also submitted investigator’s report submitted by Mr Manoj Kumar Sahoo. They have further stated that insured is yet to submit required documents like Original Policy, FIR and Final Report accepted by court, Original RC, certified copy of RC with theft endorsement, keys in duplicate, letter of subrogation/Indemnity, Form 29, 30, 35 from RTO, proof of intimation to NCRB by registered post, Pan, Aadhar/Voter ID copy, Bank details with pre-printed cancelled cheque for processing and settlement of claim. 18. a. Complainant’s Argument: - He had lodged the FIR on 11/06/2016 and submitted police final investigation report to Insurer zerox copy of which has been sent to us. In spite of several request and last letter sent on 01/10/2021 to Insurer, the claim has not been settled for which he is entitled for getting claim proceeds. b.Insurer’s Argument: - Insured is yet to submit required documents like Original Policy, FIR and Final Report accepted by court, Original RC, certified copy of RC with theft endorsement, keys in duplicate, letter of subrogation/Indemnity, Form 29, 30, 35 from RTO, proof of intimation to NCRB by registered post, Pan, Aadhar/Voter ID copy, Bank details with pre-printed cancelled cheque for which claim is pending for processing and settlement.

19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017. 20. The following documents are placed in the file:- Photocopies of Policy, Investigation report, claim intimation, claim form, FIR submitted by Insurer, Photocopies of form 35(1) and (5), intimation letter, representation dated 01/10/2021 sent to Insurer, RC book, Final form submitted by complainant 21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents relating the complaint and heard both the parties. The complainant stated that he submitted all required documents except policy copy in original and the Final Report copy from Court. He stated that he did not collect the final report

from court as he did not challenge the police final report, but he has already submitted the Police Final Report. He further stated that the insurer has not yet settled the claim in spite of their receiving all other documents. The insurer claimed that the complainant has not submitted any document and therefore, they are not in a position to settle the claim. 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 Rule 17(8) of the said rules and award of the Insurance Ombudsman shall be binding on the Insurers.

Dated at Bhubaneswar on the 4th day of February, 2022 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 MR DEBASHIS OJHA Vrs. BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

COMPLAINT REF: NO: BHU-G-005-2122-0164

AWARD

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

the parties during the course of hearing, the Forum finds that the insurer has submitted

xerox copies of all necessary documents to this office and believes that he has submitted

the documents to the insurer except the Policy copy and final report from the court. The

Forum observes that since Police Final report is already submitted and the complainant is

not against the Police findings, the Final Report from Court may not be a necessary

document. Therefore, the complainant is advised to submit the original policy copy to the

insurer within a week from the date of receipt of the order and the insurer is directed to

pay the complainant the full IDV subject to deduction of policy excess, on receipt of the

original policy document as full and final disposal of the complaint. Accordingly, the

complaint is allowed.

AWARD NO: IO/BHU/A/GI/ /2021-22


Mr. Debashis Ojha, C/o Sri Ramesh Chandra Ojha, At-Balianta Patna, PO/PS-Balianta, Dist-Khordha, Odisha. Pin-752101. Cell no.7735146472


OG-2024031802-00000970, Two-wheeler package policy 12 months-23/08/2019 to 22/08/2020 Pulser-180 Regd no. OD-33Q-7691 IDV-Rs.59,336/- DOL-30/08/2019


Mr Sunil Kumar Moharana Mr Sunil Kumar Moharana

4. Name of the insurer Bajaj Allianz General Insurance Company Limited

5. Date of Repudiation 21/10/2019 & 28/10/2019 No insurable interest 6. Reason for repudiation


11/10/2021


9. Amount of Claim Full insured value

10. Date of Partial Settlement Not applicable

11. Amount of relief sought Full insured value


13(1)b



a) For the Complainant Self through VC and phone

b) For the insurer Mr. Prateek Harichandan, Executive through VC



17. a. Brief Facts of the Case/ Cause of Complaint: - Mr Sunil Kumar Moharana had insured his Pulser-180 Motorcycle bearing Regd no. OD-33Q-7691with Bajaj Allianz General Insurance Company Limited against Package cover for an IDV-Rs.59,336/- vide policy no. OG-2024031802-00000970 for the period 23/08/2019 to 22/08/2020. Mr Debashis Ojha as usual used to keep the said Motorcycle with chain lock, disk lock, handle lock outside of his house. On 30/08/2019 Mr Debashis Ojha kept the motorcycle in the said place and on 31/08/2019 could not find the vehicle. He intimated the matter to Dhauli PS which was registered vide FIR no. 0120 on 31/08/2019. Theft matter was intimated to the insurer by Debashis Ojha online which was registered vide claim no. OC-20-2403-1802-00000114 wherein he was asked to submit policy copy and Panchanam/FIR in nearby claim location of Insurer’s office. Complainant had submitted transfer fees receipt of Rs.200/- deposited at office of RTA II vide receipt no. OR-33R19100000898/OR19101018638775 wherein transfer date has been mentioned as 27/08/2019 and accordingly RC was issued in favour of Mr Debashis Ojha. On 20/07/2019 complainant had intimated Insurer that after receipt of policy bond Mr Sunil Kumar Moharana and complaint had been to Finance company for obtaining No due certificate and submitted papers at RTO for change of ownership on 28/08/2019. No proof

has been submitted by complainant as to when he had intimated for the first time for transfer of policy in his name though after theft i.e. on 31/08/2019 he has intimated Insurer on theft of the vehicle. Police had final report as “Final Report true but No Clue u/s 379 of IPC vide vide no.53 dated 10/03/2021 which was accepted by Hon’ble SDJM Bhubaneswar. On 19/07/2021 Insured Mr Sunil Kumar Moharana informed Insurer that he had sold the motorcycle to Mr Debashis Ojha which was stolen on 30/08/2019. Though documents were submitted for transfer of ownership the same was affected in October 2019. However, he has no objection if the insurance amount is paid to Mr Debashis Ojha. b. The insurer, in its self-contained note, has admitted insurance of the vehicle No. OG-20-2403-1802-00000970 in favour of Mr Sunil Kumar Moharana for the period 23/08/2019 to 22/08/2020. On receipt of theft intimation investigator was deputed for investigation of loss and based on the same claim was closed as insurance was not transferred to Mr Debashis Ojha. Neither the complainant nor Sunil Ku mar Moharana intimated them for change of ownership nor provided any written intimation to change name of insured which is a gross violation of GR 17 of Indian Motor Tariff. As per GR 17 on transfer of ownership, the Liability only cover either under liability only policy or under a package policy is deemed to have been transferred in favour of the person to whom the motor vehicle is transferred with effect from the date of transfer. The transferee shall apply within fourteen days from the date of transfer in writing under recorded delivery to the insurer who has insured the vehicle with the details of registration number of vehicle and the insurance policy for making necessary changes in record the issue fresh certificate of insurance. For effecting transfer, a fresh proposal form duly completed must be obtained in respect of both liability only and package policies on payment of Rs.50/- along with refund of NCB if any. The old certificate is required to be surrendered and if not submitted a proper declaration to that effect is to be taken from the transferee before a new certificate of Insurance is issued. As the insurance was not transferred in the name of complainant there is no insurable interest for which the claim was rightfully repudiated on which they have no deficiency. 18. a. Complainant’s Argument: - Though he had purchased the motorcycle prior to theft and submitted papers to RTO office II Bhubaneswar for transfer of vehicle in his name same could not be done due to rush due to implementation of new MVI policy and insurance was made prior to theft for the period 23/08/2019 to 22/08/2020 he is entitled to get the claim towards theft loss of captioned Motorcycle which occurred on 30/08/2019. b.Insurer’s Argument: - As neither the complainant nor insured had intimated them for change of ownership it was a gross violation of GR 17 of Indian Motor Tariff. The transferee shall have to apply within 14 days from the date of transfer and submit a fresh proposal form and Rs.50/- for issuance of fresh certificate. As the same was not complied and vehicle was not transferred to Debashis Ojha he has no insurance interest for which the claim was repudiated an communicated to the complainant. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017. 20. The following documents are placed in the file:- Photocopies of Policy, & policy wordings, note sheet for repudiation, repudiation letter submitted by Insurer, Photocopies of FIR, Final

report, money receipt towards deposit of transfer fees in RTO Bhubaneswar, representation by Insured and complaint for settlement of claim submitted by complainant. 21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents relating the complaint and heard both the parties. The complainant stated that he had purchased the vehicle and had already changed the registration with RTO to his name but he had not received the transferred registration certificate before theft of the vehicle and therefore, he could not change the insurance to his name. He further stated that since it is a process and he is the registered owner, he should be paid the compensation. The insurer stated that as per the Motor Tariff, there is a process of transfer of insurance and it is necessary to get the insurance transferred to his name but any loss to the vehicle in between is not covered. The insurer stated that the complainant is not a policy-holder and is not entitled for the claim. Dated at Bhubaneswar on the 4th day of February 2022 INSURANCE OMBUDSMAN


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 MR PRASANTA KUMAR JENA Vrs. HDFC ERGO GENERAL INSURANCE COMPANY

LIMITED COMPLAINT REF: NO: BHU-G-018-2122-0170

AWARD NO: IO/BHU/A/GI/0060 /2021-22


Mr. Prasanta Kumar Jena, At-Bhatapada, Po-Debidola, Dist Jagatsoinghpur Mobile-9438182447

2. Policy No: 2311203135743201000, Private Car Package Policy

AWARD


the parties during the course of hearing, the Forum finds that the insurance is not

transferred to the complainant’s name before the loss and therefore there is no insurance

contract exists between the insurer and the complainant, hence the complainant is not

entitled to get compensation for the theft of the vehicle in question. Accordingly, the

complaint stands dismissed.

Type of Policy Duration of policy/Policy period

21/11/2020 to 20/11/2021 Vehicle no. OD-02-AG-5356 Mahindra Scorpio -2016 Model IDV-9,00,000/- DOL-21/03/2021


Mr Prasanta Kumar Nanda Mr Prasanta Kumar Nanda

4. Name of the insurer HDFC ERGO General Insurance Company Limited

5. Date of Repudiation 22/07/2021 Misrepresentation 6. Reason for repudiation


03/09/2021


9. Amount of Claim Rs.8,45,805/-

10. Date of Partial Settlement Claim repudiated

11. Amount of relief sought Rs.9,00,000/-


13(1)b



c) For the Complainant Self through phone

d) For the insurer Ms. Saswata Banerjee, Executive through VC



17. a. Brief Facts of the Case/ Cause of Complaint: -The complaint had insured his 2016 Model Mahindra Scorpio Vehicle no. OD-02-AG-5356 for the period 21/11/2020 to 20/11/2021 for an IDV of Rs.9,00,000/-. The vehicle was hypothecated to Syndicate Bank, Salajangha branch, Jagatsinghpur. As per the claim form on 21/03/2021 some unknown persons set fire to front portion of the car as a result of which vehicle was burnt totally. The matter was intimated by complainant to Baripada Sadar PS which was registered vide SD entry no.07 dated 04/05/2021. As per SD entry while the vehicle was standing on left side of his house, it caught fire due to short circuit of internal system. After getting the loss intimation by complainant on 22/03/2021 Er Suvendu Kumar Jena was engaged to assess the loss. Er Jena had assessed the loss for Rs.6,14,956/- after deduction of depreciation, policy excess and salvage. As there were two different reasons mentioned in two different documents i.e. claim form and FIR the insurer repudiated the claim on the ground of misrepresentation. After repudiation, the policy was cancelled and premium amounting to Rs.7539/- was refunded on 29/07/2021. The Fire Incident Report and FIR record the same reason of short-circuit. Being aggrieved by repudiation, the complainant has approached this forum for redressal of his grievance. b. The insurer, in its self-contained note, has admitted insurance of vehicle and loss within policy period. They have admitted that surveyor had assessed the loss for Rs.6,14.956/-. They have stated that as per claim form submitted by complaint vehicle was set fire by unknown persons whereas in the SD entry filed by complainant cause of loss was mentioned as short circuit. As there was discrepancy in the manner of loss and since such discrepancy was material fact, the claim was denied on the ground of suppression of material fact and

misrepresentation to them for getting insurance claim somehow. As per principle of General insurance “If there is non-disclosure or misrepresentation with fraudulent intention, the insurance contract becomes void. Avoid contract has no legal effect or validity. In fact, it is not contract at all. If the duty is broken in any other way, the contract voidable, which means, the Insurer will have the option to avoid the contract and reject it”. Moreover, as the vehicle was a case of CTL/total loss and hence required RC cancellation has not been undertaken by complainant. They have also cancelled the policy wef 20/03/2021 and premium amount for Rs.7539/- was refunded to complainant. In view of misrepresentation, they have repudiated the claim on valid and legal grounds and there is no deficiency of service or unfair trade practice. 18. a. Complainant’s Argument: - As during the effective period of insurance vehicle was burnt, he is entitled to get the claim proceeds from Insurer. The complainant states that the surveyor himself did not attend the case but his office staff named Basanta (9853164119) verified the vehicle at spot, who guided complainant’s person to fill in the claim form which he found later on to be incorrect. b.Insurer’s Argument: - As there was suppression of material fact, and two different reasons was mentioned on cause of in claim form and station diary they had repudiated the claim on valid and legal ground and cancelled the insurance after which premium amounting to Rs.7539/- was refunded to complainant. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017. 20. The following documents are placed in the file:- Photocopies of Policy, & policy wordings, survey report, claim form, station diary, cancellation endorsement submitted by insurer, Photocopies of vehicular documents, confirmation of receipt of refund amount of premium to the tune of Rs.7539/- submitted by complainant 21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents relating the complaint and heard both the parties. The complainant stated that he found the vehicle was lost due to fire, which is covered under the policy but the insurer has denied the claim. The Forum examined the claim form details and found the complainant has mentioned that the loss has taken place due to some unknown persons put fire on the vehicle. The complainant has further stated that he was not exactly sure as to how the fire took place but he guessed some unknown persons might have caused the loss. The insurer informed that the vehicle got burnt due to electrical short-circuit as per the Police Record and the Fire-Brigade report. Since the complainant has given mis-information about the cause of loss, the insurer declined the claim under Mis-representation clause and also cancelled the policy by refunding the premium.

AWARD


the parties during the course of hearing, the Forum has examined the Fire incident

certificate of the Fire Station and the SD entry of the Police and found that the loss has

taken place due to short circuit of internal electric system. The Forum also examined the

claim form, where the complainant alleged the loss to have happened due to fire being put

by some unknown persons. The insured, during hearing, stated that he was not sure about

the exact cause of loss, but out of guess he mentioned the loss to be caused by unknown

persons. Under the above circumstances, the insurer could have taken into confidence the

Police record and the Fire station record which are authentic in nature and accordingly

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 Rule 17(8) of the said rules and award of the Insurance Ombudsman shall be binding on the Insurers. Dated at Bhubaneswar on the 4thnd day of February 2022 INSURANCE OMBUDSMAN


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 MR. TRILOCHAN SAHOO Vrs. FUTURE GENERALI INDIA INSURANCECOMPANY NLIMITED

COMPLAINT REF: NO: BHU-G-016-2122-0185 AWARD NO: IO/BHU/A/GI/ /2021-22


Mr. Trilochan Sahoo, S/o Somanath Sahoo, C/o Prahallad Sahoo, At/Po/Ps-Daspalla, Dist Nayagarh, Odisha. Cell no.6371078873


HFB21261, Private Car Package Policy Hyundai Xcent-2015 12 months 11/04/2015 to 10/04/2016, Model-OD-12-7677 IDV-Rs.6,42,686/- DOL-09/06/2015 as per plaint and 07/06/2015 as per survey report and claim form


Mr Trilochan Sahoo Mr Trilochan sahoo

4. Name of the insurer Future Generali India Insurance Company Limited

5. Date of Repudiation 29/03/2016 Not applicable 6. Reason for repudiation


08/11/2021

8. Nature of complaint Non settlement of balance amount

9. Amount of Claim Rs.73,756/- Plus Interest

10. Date of Partial Settlement 29/03/2016

11. Amount of relief sought Rs.73,756/- Plus Interest


13(1)b



a) For the Complainant Not appeared

b) For the insurer Mr. Debidutta Mohanty through phone



17. a. Brief Facts of the Case/ Cause of Complaint: -The complaint had insured his Hyundai Xcent-2015 Model Private Car bearing Registration no. OD-12-7677 with Future Generali India Insurance Company Limited for the period 11/04/2015 to 10/04/2016 vide Private Car Package policy no. HFB21261 for an IDV of Rs.6,42,686/-. The vehicle was registered on 05/05/2015 and met with an accident on 07/06/2015 while going from Bhubaneswar to Phlulbani. On receipt of intimation from complainant Insurer had engaged Er Dharanidhar Das for assessment of loss. Er Das assessed the loss for Rs.1,89,000/- after inspection of vehicle at the authorized workshop of M/s Aditya Car Care Pvt Ltd after deduction of depreciation, salvage and policy excess. On receipt of discharge voucher for Rs.1,89,000/- the amount was paid to workshop as it was a cash less settlement. Being aggrieved on less settlement of claim the complaint had approached Hon’ble High Court vide WP(c) No.28867 of 2021 who had disposed the case on 22/09/2021 with a direction to dispose the representation of petitioner in accordance with law within a period of 3 months from the date of receipt of certified copy of the order by passing a reasoned order. b. The insurer, in its self-contained note, has admitted insurance of vehicle and loss within policy period. On receipt of intimation, they had engaged and independent IRDA approved insurance surveyor and loss assessor Er Dharanidhar Das. After inspection the car minutely the surveyor, had taken photographs of the car as proof of loss as per norms. After considering the loss associated with the incident in question and as per insurance byelaws and in consultation with the said workshop surveyor had assessed the loss for Rs.1,89,000/- out of total repaired bills of Rs.2,55,546/-. They had further stated that manufacturing year of car is of 2015 and policy is a normal comprehensive policy without any zero-depreciation cover. On receipt of discharge voucher duly signed by complainant the amount of Rs.1,89,000/- was paid on 29/03/2016 vide NEFT reference no.4440U16090011633 to Aditya

Car Care Pvt Ltd as it was a cashless settlement. As the present complaint is based on false and misleading grounds it should be dismissed. 18. a. Complainant’s Argument: - Though the vehicle met with an accident within policy period, and he has got less amount to the tune of Rs.73,756/- he is entitled to get the said amount. b.Insurer’s Argument: - They had processed the claim as per surveyor’s report and after getting loss voucher discharged by complainant had paid Rs.1,89,000/- to Aditya Car Care Pvt Ltd and there was no deficiency on their part. 19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017. 20. The following documents are placed in the file. Photocopies of Policy, & policy wordings, RC book, Survey report, claim form, discharge voucher submitted by Insurer and Photocopies of Hon’ble High court order submitted by complainant. 21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully gone through all the documents relating the complaint and heard the party/ies present during the hearing. The complainant was sent a notice vide letter dated 12.01.2022 under speed post to attend the hearing. It is verified from postal tracking and found that the notice is delivered to the complainant on 15.01.2022. He was informed by the office over phone at 10.40 AM today requesting him to attend the hearing. Since the complainant did not appear the hearing, an attempt was taken to contact the complainant through phone, but his mobile was switched off at the time of hearing, therefore, non-appearance of the complainant is recorded. The insurer informed that they have settled the claim as per surveyor’s report, where the depreciation is deducted as per policy terms and conditions. The insurer further stated that the amount preferred under this forum is related to depreciation, policy excess and salvages, which are not payable under the policy.

AWARD

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

party/ies present during the course of hearing, it is recorded that the complainant is given

reasonable opportunity to place his case before the forum, but he failed to avail the

opportunity. The Forum examined the complaint and related documents filed by both the

parties. The Forum also examined the surveyor’s assessment and found that the insurer has

deducted the claim towards depreciation on plastic, rubber and fibre parts, which are as

per policy terms and conditions. Accordingly, the Forum does not consider any merit in the

complaint and therefore, the complainant is not entitled for his claim under this complaint.

Accordingly, the complaint stands dismissed.

Dated at Bhubaneswar on the 11th day of February 2022 INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH

(Under Rule 13 r/w 16/17 of the Insurance Ombudsman Rules, 2017)

Insurance Ombudsman: Shir Atul Jerath

Case of Ved Parkash V/S Magma HDI General Insurance Co. Ltd.

Complaint Ref. NO: CHD-G-030-2122-0133


Shri Ved Parkash

S/o Sh. Ram Kumar, H. No.- 43, Gali No.- 11,

Jawahar Nagar, Hisar, Haryana-125001

2. Policy No:

Type of Policy

Duration of policy/Policy period

P0020400002/4107/106410

Motor Insurance

23-07-2019 to 22-07-2020

3. Name of the insured

Name of the policyholder

Ved Parkash

Ved Parkash

4. Name of the insurer Magma HDI General Insurance Co. Ltd.

5. Date of Repudiation 29.09.2020

6. Reason for repudiation Misrepresentation and non-registration of

vehicle.

7. Date of receipt of the Complaint 02-08-2021

8. Nature of complaint Incorrect denial of claim


10. Date of Partial Settlement N.A

11. Amount of relief sought Claim amount + interest

12. Complaint registered under

Rule no: Insurance Ombudsman Rules,

2017

Rule 13 (1)(b) – any partial or total repudiation

of claims by an insurer

13. Date of hearing/place 13.01.2022/Online hearing


For the Complainant Shri Ved Parkash, the complainant

For the insurer Shri Anirudh Devraj

15 Complaint how disposed Award under Rule 17

16 Date of Award/Order 07.02.2022

17. Brief Facts of the Case: Shri Ved Parkash (hereinafter, the complainant) has filed this complaint

against Magma HDI General Insurance Co. Ltd. (hereinafter, the insurers) alleging incorrect denial of

claim.


a) Complainant’s argument: He timely submitted all the claim documents with the company and had handed over the two keys of the vehicle to the surveyor but the insurance company still rejected the claim. The complainant further sought the intervention of this forum for payment of claim along with interest.

b) Insurer’s Argument: In the SCN, insurance company stated that vehicle number HR17B2980 got theft on 15-09-2019. FIR number 32908 dated15.09.2019 was registered at PS Shalimar Bagh, Delhi. Matter was assigned for investigation to M/s Triple Tracer & investigation on basis of investigation report claim has been repudiated on the grounds of non registration of vehicle in accordance with section 39 motor vehicle Act, 1988 and on ground of misrepresentation of Actual Facts. As per the available details and investigation carried out it was revealed that last user cum driver Umesh Kumar was not present at loss location as he was unable to answer the route, toll tax details etc during this entire journey from Hisar to Delhi. Narration of alleged incident and date of loss as per statement of both insured and driver are different. Insured driver inspite of many requests did not come forward to narrate the loss, route, toll plaza details coming on his way during the journey. The claim through investigator PLH Solution and services. During the same period M/s PLH Solution and services were investigating one more case of motor theft of insured Sakir assigned to them by the insurer M/s Magma HDI GIC Ltd. During the course of investigation, they received information that the said vehicle (Truck bearing registration number HR55X1947) of the insured Mr. Sakir, has been recovered by the IGIS Crime Branch New Delhi.

As per the information received from IGIS Crime branch, they had arrested 4 persons including the

insured Mr. Sakir and had recovered the insured vehicle bearing registration number HR55X1947

from them. On interrogating the accused they informed that they had tampered the vehicle

number, engine number and chassis number and sold the vehicle. Currently the vehicle was playing

on RJ11GB5483 number. Post selling the vehicle they lodged the FIR with the PS Dwarka North.

New Delhi U/s 028444/2020 on dted 11/08/2019. When they retrieved the copy of the FARD it was

known that the accused Sakir had other 3 accused were involved in such activites of tampering the

vehicle. Engine and chassis number and selling the vehicles and subsequently lodging the fake FIR’s

or helping others to lodge fake FIR’s against money. Insured Mr. Sakir informed police that he along

with one of his acquaintance Mr. Khurshid and his known Mr. Ved Prakash who is resident of

Bhiwani, Haryana had lodged fake FIR about theft of JCB( HR 171090) of Mr. Ved Prakash with the

Shalimar Bagh Police Station. Mr. Sakir informed that Mr. Khurshid had sold the JCB in Mewat. Mr.

Sakir futher stated that he can help police in arresting Mr. Khurshid.

19. Reason for Registration of Complaint: Incorrect denial of claims and cancellation of policy.

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): Case called for

hearing, both the parties are present and recall their arguments as noted in Para 18 above.

The complainant stated that despite submission of all the documents insurers denied the theft claim

of his JCB on the ground of non-registration of vehicle. He further submitted that fee for registration

of vehicle was timely submitted to the dealer.

The representative of the insurance company submitted that at the time of accident the vehicle was

not registered in accordance with section 39 of Motor Vehicle Act, 1988 and due to misrepresentation

of actual facts the claim was repudiated vide their letter dated 29.09.2020. He further informed that

in some other theft case, the company procured a document from IGIS Crime Branch Delhi in context

to a claim which was lodged by the owner of an insured vehicle viz. Mr. Sakir, S/o Naseer, residing at

Mewat, Haryana. In the confessional statement made by the Sakir, Mr. Ved Parkash filed a false FIR

and insured vehicle was sold at Mewat.

During online hearing, the complainant was advised to submit the proof of payment for registration

of the vehicle. Further insurers were advised to submit the documents in support of their contentions.

In response, the complainant vide mail dated 13.01.2022 has placed on record the receipt dated

24.07.2019 for Rs,156,100/- issued by the State Transport Department which shows that necessary

fee for Registration of vehicle was paid him on 24.07.2019 though as per R.C its registration date is

31.12.2019. Insurers have also placed on record a copy of letter dated 14.01.2022 sent to the Joint

Commissioner of Police, Delhi on 17.01.2022. In the captioned complaint to police, insurers stated

that during investigation in some other theft case, they procured a document vide DD no 08 dated

06.11.2020 from IGIS Crime Branch Delhi in context to a claim which was lodged by the owner of that

insured vehicle viz. Mr. Sakir. In the confessional statement made by Sakir, Mr. Ved Prakash had filed

a false FIR and the insured vehicle was sold at Mewat. On the basis of confessional statement,

insurance company has prayed to police for reinvestigation for the offences committed by the accused

Mr. Ved Parkash, who with an illegal intention has committed a fraud on the complainant company.

In view of the representation made by the insurers for reinvestigating the case, the complainant is

pre-mature for decision on merits. Therefore, complainant is rejected and no relief is granted.

Award

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

parties during the course of hearing, the complaint is hereby rejected being devoid of merits.

( Atul Jerath )

Insurance Ombudsman

7th February, 2022




Case of Ashok Kumar Chadha V/S The United India Insurance Co. Ltd.



Shri Ashok Kumar Chadha

S/o Lt. Sh. Sat Dev Chadha, H. No.- 731,

Sector-12, Panchkula, Haryana

2. Policy No:

Type of Policy


1122003115P105458070

Motor Policy

07-08-2015 To 06-08-2016



Ashok Kumar Chadha

Ashok Kumar Chadha

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


6. Reason for repudiation Non submission of cancelled R.C


8. Nature of complaint Incorrect closure of claim

9. Amount of Claim Rs.246919/- on net of salvage basis without R.C

10. Date of Partial Settlement N. A

11. Amount of relief sought IDV Rs.3,50,000/- less Rs.1000/- + Interest +

compensation for harassment



2017



13. Date of hearing/place 13.01.2022/Online Hearing


For the Complainant Shri Ashok Kumar Chadha, the complainant

For the insurer Shri Nipun Khurana

15 Complaint how disposed Award under Rule 17


17. Brief Facts of the Case: Shri Ashok Kumar Chadha (hereinafter, the complainant) has filed this

complaint against The United India Insurance Co. Ltd. (hereinafter, the insurers) alleging incorrect

denial of claim.


a) Complainant’s argument: An own damage claim of Tata Manja Car bearing Regd. No. HR26 F-0020 filed with the insurers was approved and asked to get the Registration Certificate of the vehicle cancelled for settlement of claim. Insurers vide letter dated 17.05.2018 communicated that R.C may be cancelled from RTO otherwise; the claim of the said car shall be closed as No Claim. The complainant could not comply with the requirement due to peculiar unavoidable family circumstances. The complainant approached Registration Authority where it was told that in case the registration certificate of the car in question viz. HR26F-0020 was got cancelled, he will not be able to retain the said special number which is paid/VIP number, therefore when he purchased a new Hundai i20 car, he got the said RC Number HR26F-0020 reassigned to the said new car by getting a substituted number HR-70D-0198 allotted to the said Tata Manja Car qua which the claim was pending .The complainant sent a letter dated 20.04.2021 of the Registration Certificate of the newly assigned Registration Numbers of Tata Manja Car as well as Hundai i20 car to the insurance company requesting them to issue a fresh letter for cancellation of registration number HR70D-0198 without which cancellation of R.C is not possible. The insurance company is neither issuing the requisite letter nor making payment of claim of complainant. The insurance company has closed the claim wrongly and has caused wrongful gain to themselves In the peculiar circumstances stated above, it is necessary that the insurance company may be

directed to issue the necessary letter for cancellation of R.C number HR-70D-0198 now assigned

to the said Tata Manja car to enable applicant to get the RC cancelled and direction to the

company for payment of claim with interest upon compliance of the said condition by

complainant.

b) Insurer’s Argument: The vehicle bearing Registration Number HR-26-F-0020 covered under motor policy valid from 07.08.2015 to 06.08.2016 had met with an accident on 21.06.2016. The claim had been approved by the competent authority on 23.08.2016 for an amount of Rs. 246919/- on net of salvage basis. The insured had been conveyed the decision regarding the approval of claim vide their letter No. MDO/CHD/2016 dt.23.08.2016 originally addressed to RTO, Haryana State, Chandigarh and endorsing a copy of the same to the insured inter-alia advising him for cancellation of R.C of the said vehicle to enable them to proceed further in the matter. The insured had again been reminded vide their letter No. MDO/CHD/2016/12576 dated 07.02.2016 for compliance of formalities already conveyed vide their letter dated 23.08.2016. Since they had no response from the insured the claim in question had been closed/ repudiated on 29.06.2017 after giving sufficient opportunity to the insured for compliance. After a elapse of approximately four years they had again received a representation dated 22.04.2021 from the insured narrating therein the circumstances leading to non-compliance of said formalities. It is pertinent to mention here that by this time inspite of their communication vide various letters to get the R.C cancelled, the insured had informed that he has got the Registration Number i.e HR-26-F-0020 shifted to new vehicle and had acquired new Regd. Number HR-70-D-0198 for the ill-fated vehicle insured with them with Regd. No HR-26-F-0020. Further no such vehicle with Regd. Number HR-70-D-0198 is insured with them, hence the letter for cancellation of the said registration certificate cannot be issued. Moreover, they are surprised to receive a copy of letter dated 17.05.2018 from the insured alleged to have been written by them to him, but as per insurer’s record no such letter has been issued by them and seems to be an act of malafide intention to turn the dice in his favour. In view of the circumstances narrated it is evident that the insured had been given ample opportunity to get the needful done i.e Cancellation of R.C. And submit proof thereof to enable insurers to proceed further in the matter, yet insured failed to comply with the formalities and did not respond for approx. four years rendering the claim time barred. Hence the claim decision of the competent authority to repudiate the claim in question is correct and justified.

19. Reason for Registration of Complaint: Incorrect closure of claim.





hearing, both the parties are present and recall their arguments as noted in Para 18 above. The

complainant stated that claim for his Tata Manja Car bearing Registration No HR-26-F-0020 was

approved by the insurance company but he could not get the R.C cancelled due to family

circumstances. He got the said RC Number HR26F-0020 reassigned to a new car by getting a

substituted number HR-70D-0198 and requested insurance company to issue a fresh letter for

cancellation of registration number HR70D-0198 without which cancellation of R.C is not possible. The

representative of the insurance company submitted that complainant has approached them after five

years and is asking for cancellation of new registration number HR70D-0198 which is not insured under

the policy. It has been observed that complainant’s vehicle bearing Regd. No HR26F-0020 insured

under motor policy had met with an accident 21.01.2016. The claim was approved on net of salvage

basis without R.C. The company wrote letters dated 23.11.2016 / 07.12.2016 to the insured informing

approval of claim and completion of formalities. The insured was requested to get the R.C of the said

vehicle cancelled from the RTO and submit the cancellation certificate within 7 days and incase the

same is not done, file would be closed as no claim. The insurers also sent another letter dated

17.05.2018 on the same lines as per their earlier letters. The complainant the vide his letter dated

20.04.2021 informed the insurers that he has transferred the old R.C No HR 26 F -0020 on his new

purchased vehicle i20 sports model 2021 and RTO has issued new R.C number HR 70 D 0198 and

requested for a new letter for cancellation of R.C of HR70 D 0198. In the captioned case, the

complainant was duly informed by the insurance company vide their letters dated 23.11.2016,

07.12.2016 & 17.05.2018 for cancellation of R.C. The complainant himself did not act and comply with

the requirements of the approved claim in spite of reminders since 23.11.2016. No case is made out

against the insurers as they had approved the claim as per policy terms and had duly informed the

complainant for compliance of formalities. Therefore, complaint is rejected being devoid of merits and

no relief is granted.

Award



(Atul Jerath)

Insurance Ombudsman

7th February, 2022

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH (Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)

Insurance Ombudsman- Shri Atul Jerath

Case of Akash Garg v/s Royal Sundram General Insurance Co. Ltd.

Complaint Ref no: CHD-G-038-2122-0159

1. Name & Address of the Complainant Akash Garg

H No. 1050, First Floor

Sector 15, Panchkula

2. Policy No:

Type of Policy


VPC1287033000100

Pvt Car Package Policy

07.02.2020 to 06.02.2021



Sh. Akash Garg

Sh Akash Garg

4. Name of the insurer Royal Sundram General Insurance


6. Reason for repudiation Damages are not relevant to accident


8. Nature of complaint Non-payment of claim.

9. Amount of Claim Rs 1,63,100/-

10. Date of Partial Settlement Not Applicable

11. Amount of relief sought Rs 1,63,100/-

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 20.01.2021/ Online hearing


For the Complainant Shri Akash Garg , Complainant

For the insurer Sh Jitender Kumar

15 Complaint how disposed Award under rule 17


17. Brief Facts of the Case: Akash Garg, (hereinafter, the Complainant) has filed this complaint

against Royal Sundram General Insurance (hereinafter, the Insurers), alleging non-payment of his

Motor claim.


a) Complainant’s argument: On 24.08.2021, Shri Akash Garg complained that he filed Claim no.

PV00711144 against Royal Sundram General Insurance Co. under policy no. VPC1287033000100. As

he stated in claim form while my brother was coming back to Panchkula from Sunam, a big stone hit

his car under body which created a loud noise. He immediately stopped the car for checking. AS the

vehicle was not in a position to drive and there was no good workshop nearby, he got the vehicle

towed to workship in Panchkula for repair. The Insurance Company rejected his claim vide letter

dated 19.01.2021. The reason being the damages not attributed to accident but mechanical failure.

The Insurance Company was failed to give reasonable explanation that how they had come to such

conclusion. He approached their Grievance Cell, which was never replied despite of number of

reminders.

b) Insurers’ argument: As Per SCN, Claim intimation was received on 24.12.2020 about the

accident that took place on 20.12.2020 with the noting that insured’s brother was driving the vehicle,

suddenly a big stone hit the underbody and there was a big sound below the car and vehicle stopped

and towed to the workshop.

There is delay of 5 days in claim intimation without any reasonable reason. Survey was conducted by

Sh Jitender Kumar who collected the required documents from the insured. On scrutiny of survey

report, it is observed that this is a mechanical failure and no loss by external means and internal parts

damaged the engine completely. So the surveyor recommended the case for the denial of the claim

with the following observations:-

1. That this is a mechanical failure case and no loss by external means; and the internal parts damaged

the engine completely and recommended for denial of the claim.

2. Damage to cover engine block are not relevant to COA and no impact found in under body and

nearby like oil sump drive shaft lower arm and front bumper damage not relevant.

3. It is submitted that as per the wordings of the Policy attached as annexure 04 it is clear that “The

Company shall not be liable to make any payment in respect of: - (a) consequential loss, depreciation,

wear and tear, mechanical or electrical breakdown, failures or breakages;”. And the Claim was found

inadmissible as the loss/damages was because of mechanical failure and was not caused by any

accidental external means; which is not covered in the policy and accordingly the claim was

repudiated, and the insured was informed by RPAD letter dated 19 Jan 2021.

4). Thus, it is amply clear that the answering insurance Company was all the time vigilant and ready to

consider the admissibility of the Claim but unfortunately the loss of the damaged vehicle could not be

considered under the policy because of the above mentioned reasons. It is very much clear that there

was no sign of deficiency in service on the part of the insurance company even though the insured

filed a complaint before your good office on the frivolous and pointless, which is in the light of above

facts liable to be dismissed.

5. . It is submitted that if the Hon’ble authority finds that there should be some further detailed

investigation regarding the damages/cause of loss, the answering insurer is ready to go for further

inspection/investigation/loss assessment, in presence of the authority/any person duly appointed by

the authority and the insured.

The answering insurance company assures to take reasonable decision on the admissibility of the

claim as per the outcome of above mentioned inspection/investigation. Therefore, it is submitted that,

there is no deficiency of service on the part of the answering insurance company. Since, based on the

documents, statement of the driver of the vehicle, and the surveyor’s report the claim of the damage

of the vehicle is not payable and the claim is rightly repudiated. The insured failed to take the proper

care of the vehicle and filed to maintain the vehicle in efficient condition. The complainant has not

approached this Hon’ble Forum with clean hands, his claim is not covered under the policy terms and

conditions, and he approached this forum without disclosing the true facts. It is therefore, humbly

prayed that the Hon’ble Ombudsman may be pleased to dismiss the complaint and also prayed to

allow any other relief which the Hon’ble authority find reasonable in favors of the answering insurance

company.

19. Reason for Registration of Complaint: Non-payment of Motor claim.




21. Result of Video Conferencing with both parties (Observations & Conclusion): Case called for


During Online hearing the complainant has stated that his car was met with accident on 24.12.2020.

He got the car towed to Panchkula for repair to M/s Ultimate Hyundai. But there was problem in

cashless by the Company. On the advice of GM of Royal Sundram, he took his car to Car Experts. But

his car remains standing at Car expert without any repair. He keeps on reminding the insurer but he

got no response. After 20 days he got repudiation letter dt 19.01.2021 that The Insurance Company

rejected his claim as damages not attributed to accident but mechanical failure.

He further stated that he was driving his car from the last 6 years and he was not facing any problem

till accident. If it is mechanical fault it would have come to notice earlier during 6 years. On

20.12.2020, while coming from Sunam to Panchkula, his car was hit by a stone from below resulting

in huge sound. Furthermore, he stated that as the repair cost was about 1.75 lacs, the Insurer is

making stories. The repairer has dismantled the vehicle without his permission.

The representative of the Company has informed that accident took place on 20.12.2020 and

intimation of claim was given on 24.12.2022. Insured had took the vehicle to M/s Ultimate Hyundai

for repair, who refused to repair as they were aware that the claim will not be payable, . Insured

contacted his sales team of our company to tell him Ultimate Hyundai has refused to repair, please let

him know where he can repair the vehicle. He was well informed that loss will be ascertained only

after inspection.

Estimate was made on 25.12.2020 at Car Experts for 161500/- and survey was made next day. No spot

photographs were taken by the insured. Insured had informed them that his car was taken to his

friends' house whereas the complainant has said that his vehicle was taken directly to workshop. On

inspection observed that engine was overheated and two connecting rods were broken which cannot

be broken with stone. They keep on asking the insured to tell the exact cause of loss. But he keeps on

repeating the same reason. Moreover If vehicle was towed, engine cannot be damaged.

The complainant was asked to give all the correspondence held with the insurance Company along

with estimate and cash memo of payment made to the workshop. The complainant provided the

same to this Forum on 17.02.2022.

Keeping in view of the above, it is observed that the survey of the accident was done by motor in

house surveyor whereas regulations provide for deputation of independent surveyor where the

estimate loss is about Rs. 1 lac. Further if this was a case of mechanical failure the authorized dealer

M/s Ultimate Hyundai was the most appropriate workshop to comment on the root cause of accident.

On examination of various documents available in file including the copy of complaint, SCN filed by

insurance company and submissions made by both the parties at the time of online hearing, it is seen

that the complainant's accidental claim has been wrongly repudiated by insurance company on the

grounds that the loss has occurred due to mechanical failure which is not substantiated by any sound,

valid or logical reasons. The subject vehicle is 6 year old and no documentary evidence is provided to

substantiate the findings of the insurers.

The Insurance Company has taken the plea of mechanical failure purely on the assumptions that two

connecting roads cannot be damaged with stone as stated by the complainant in the claim form. The

insurer has thus assumed and presumed that this is the case of mechanical failure. The said conclusion

is far-fetched, arbitrary, unilateral and without any sound logic. Accordingly based on the discussions

and facts above, the repudiation of claim by insurer is not justified. The Insurance Company is directed

to reassess the claim and settle the claim subject to policy terms and conditions within 30 days from

the receipt of award copy.

AWARD

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

parties during online hearing, insurance Company is directed to re assess the claim subject to

terms and conditions of the policy within 30days from the receipt of award copy.

(Atul Jerath)

Insurance Ombudsman

Dated: 17.02.2022




Case of Neeraj Kumar V/S HDFC ERGO General Insurance Co. Ltd.



Shri Neeraj Kumar

S/o Sh. K.L. Sharma, Vill.- Chokhla, P.O.-

Damkhari, Teh. & Distt.- Solan,

Himachal Pradesh-0

2. Policy No:

Type of Policy


2315203632406700000

Motor Policy

27-09-2020 To 26-09-2021



Neeraj Kumar

Neeraj Kumar

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

5. Date of Repudiation N.A

6. Reason for repudiation N.A


8. Nature of complaint Short payment of claim

9. Amount of Claim

10. Date of Partial Settlement Rs.71761/- dated 04.08.2021

11. Amount of relief sought Balance Claim

12. Complaint registered under Rule 13 (1)(b) – any partial or total repudiation



2017



For the Complainant Shri Vikesh Sharma, Brother

For the insurer Ms. Khushmani Kaur, Dy.Manager Legal

15 Complaint how disposed Recommendations under rule 16


17. Brief Facts of the Case: Shri Neeraj Kumar (hereinafter, the complainant) has filed this complaint

against HDFC ERGO General Insurance Co. Ltd. (hereinafter, the insurers) alleging incorrect

settlement of claim.


a) Complainant’s argument: The complainant spent Rs. 2.80 lacs approximately on the repair of his accidental vehicle. While pursuing the settlement of claim, he was conveyed that No claim Discount @ 40% had been allowed to him. This discount was allowed by the insurance company arbitrarily without his knowledge and any undertaking from his end. As a layman he was not aware of nomenclature of this discount. But at the time of settlement of claim when he was in need of compensation, surprising revelations were coming from their end in order to delay and cut short his due. He was told that he had been allowed a no claim discount of 45% by them for which complainant was not entitled and for which they are going to penalize him now by reducing the claim amount for the said rate of 45% from the assessed amount apart from the one sided assessment for which he had lot of reservations. He has been released an amount of Rs.71761/-by the company in his account on 04.08.2021. The complainant sought the intervention of this forum for payment of due balance amount of Rs.2.09 lacs approximately with interest and penalty.

b) Insurer’s Argument: The complaint pertains to insurance claim under Goods Carrying Comprehensive Policy having policy no. 2315 2036 3240 6700 000 valid from 27/09/2020 to 26/09/2021. The copy of policy along with its terms and conditions is attached as Annexure-A. That the claim under dispute relates to OD claim of the insured vehicle which was insured under the aforementioned policy under the name of the complainant. That as alleged in the complaint, the insured vehicle met with an accident and the claim is settled after deduction made against the false NCB declaration. It may be submitted at the out-set that the claim of the complainant has already been settled in as much as the answering respondent paid a sum of Rs. 71761.29/-, on account of repair liability of the vehicle, to the insured. It is also pertinent to mention here that the amount paid is made after due discussion with the insured. Thus, no cause of action lies against the answering respondent and nothing is left further to decide against the answering respondent, and thus the present complaint comes to a rest against the answering respondent. It is pertinent

mention here that the contract of insurance is a contract of indemnity, once the amount of indemnity has been made to the insured, who accepts the same without any protest, and then there is no deficiency on the part of the Insurance Company. That at the time of policy procurement the insured declared that he was entitled for 45% of NCB discount and on the basis of same the policy was issued to the insured. However, after verification it was found that the insured has claimed Rs. 4375/- against the loss happened on 14/12/2019 from the previous insurer, i.e Oriental Insurance Co. However, the same was never intimated to us. Therefore, the respondent issued a letter requesting him for clarification and for shortfall of premium. But, the insured never turned up for anything. That as during verification the respondent was appraised that the complainant was not entitled to any NCB as the declaration given by the complainant at the time of taking the policy was found incorrect which forfeited him from taking any benefit under the policy. During verification it was confirmed that the complainant had already filed the claim against the previous policy and thus was not entitled for NCB benefits. The complainant has deliberately suppressed this material fact that he had already filed a claim against his previous policy and took undue benefit of NCB from the answering respondent, with the obvious purpose to mislead the insurance company and to get enriched unjustly. The complainant had given a false declaration in this regard intentionally and deliberately in order to cause wrongful gain to him and wrongful loss to the insurer and wrongly taken the benefit of No Claim Bonus from the insurer despite the fact that the complainant is not entitled for the same. Further, it is mentioned in the policy schedule that “Policy Holder declares that no claim has been made in the previous year policy. If declaration found incorrect, benefits under the present policy in respect of own damage section will stand forfeited.” It is worthwhile to mention here that as there was wrong NCB declaration, the respondent did not out rightly rejected the whole claim, but instead deducted the valid amount and paid the rest of the amount.

19. Reason for Registration of Complaint: Incorrect settlement of claim





hearing. Both parties are present and recall their arguments as noted in Para 18 above.

During the online hearing, it was enquired from the insurance company whether in the view of

the facts emerging they would like to re-look at the claim and arrive at an agreement. The

representative of the insurer offered to reconsider and settle the claim as per terms and conditions

of the policy. The same was also agreed upon by the complainant during online hearing. The

Insurance company vide their mail dated 01.02.2022 confirmed that they are ready to reverse the

deduction made towards NCB falsification after adjusting the discount which was given to the

complainant in his premium. The payable amount comes out to be Rs.59172/-. The complainant

vide mail dated 09.02.2022 accepted the offer.

Accordingly, an agreement by way of conciliation has arrived at between the insurer and

complainant, which I consider as fair and reasonable for both the parties.

In the light of the amicable settlement of complaint between the Parties, the complaint is

disposed- off with a direction that the company shall comply with the agreement and shall send a

compliance report to this office within 30 days after the receipt of award copy for information and

record.

Award

The complaint is resolved in terms of agreement of conciliation arrived at between the

complainant and insurers as stated above. Accordingly, both the parties should implement this

agreement within 30 days.

(Atul Jerath)

Insurance Ombudsman

10thFebruary, 2022

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH (Under Rule 13 r/w 16/17 of The Insurance Ombudsman Rules, 2017)

Insurance Ombudsman: Shri Atul Jerath

Case of Pawan Kumar V/S Cholamandalam MS Gen. Insurance Co.

Complaint Ref. No. : CHD-G-012-2122-0177

1. Name & Address of the Complainant Shri Pawan Kumar

S/o Sh. Balwan Singh,

Village-Pur, Bawani Khera

Distt.- Bhiwani Haryana- 127032

2. Policy No:

Type of Policy


3408/00032452/000/000

Standalone OD policy for Pvt. Car

12.08.2020 to 11.08.2021



Pawan Kumar

Pawan Kumar

4. Name of the insurer Cholamandalam MS Gen. Insurance Co. Ltd.


6. Reason for repudiation Willful misrepresentation


8. Nature of complaint Repudiation of claim

9. Amount of Claim Rs.380678/- (Assessment by final surveyor)

10. Date of Partial Settlement NA

11. Amount of relief sought Vehicle repair cost



Rule 13 (1)(b) – any partial or total repudiation of

claim by an insurer

13. Date of hearing/place 03.02.2022 / Online hearing


For the Complainant Mr.Pawan Kumar

For the insurer Mr.Kuldeep Singh



17) Brief Facts of the Case: Shri Pawan Kumar, the Complainant), has filed this complaint against the

Cholamandalam MS Gen. Insurance Co. Ltd. for non settlement of motor claim.

18) Cause of Complaint:

a) Complainants argument: His vehicle met with an accident on 8th April, 2021 for which he has given

information to insurance company, then surveyor conducted the survey of his vehicle, having repair

estimate of Rs. 15 lakh approx. After survey of the vehicle, surveyor told him that this vehicle is not

repairable and his claim will be settled on total loss and they have sent his claim for salvage auction

to process further. After three months company appointed an investigator, who come on the spot

place and asked to show the marking of animal which was collided with his car. After three months,

how the marking may be found on running road. He provided his car spot photo which was taken by

himself, in which damages and loss are clear. He also provided all documentary proof of his vehicle

running conditions like service history and toll tax receipt. Now company repudiated his claim without

giving any justified reason.

b) Insurers’ argument: The complainant has intimated with regard to accidental loss to the vehicle on

08.04.2021 and intimation was given on 14.04.2021 with the remarks that suddenly a stray cow came

in front side the car due to which car got unbalanced and hit the divider. Company has deputed Mr.

Ravinder Kumar, Surveyor to assess the loss and thereafter matter was referred for forensic

examination by OCILABS with the consent of insured Pawan Kumar. As per report dt. 09.07.2021

issued by OCILABLS, the key forensic findings is:

1. Mechanical Impact

a. Multiple mechanical impacts had been detected in the frontal portion of vehicle with no

linkage of transmission of force.

b. The mechanical impacts on the various parts of the vehicle like bonnet, bumper and

windshield are not justify the damage caused through a single impact collision. Hence impact claimed

by complainant is occurred in different calamity which happened in different time.

c. The engine was examined during physical inspection and it had been pound that multiple

points of impact in the radiator and engine nozzle areas. The impacts are also visible on the

water body and coolant area. The degree of impact and the area of the damage indicates

external man-made creation of such dents on the engine area of the vehicle.

2. Spot Location

a. The spot location of collided vehicle was analyzed and no decomposed remains of animal

had been found.

b. The lateral side detachment of the bumper created a doubt about the nature of impact as

the centre impact caused by the edges of divider never caused the lateral impacts on the

bumper. The impact on the lateral sides of the bumper seems to man-made created though,

its pieces scattered on the ground are not showing linkage of impact caused by the

stationary divider.

3. Sequence of Impacts

a. The edges of the divider are sharp while as the impact on body frame including radiator portion

and bumper are wider. The area of impact or damage on frontal portion of the vehicle with respect

to the dimensions of the edges of the divider indicates that the vehicle was collided with the divider

many times in to & fro manner.

b. The windshield had a small radial cack towards the left side(co-driver side) which are surrounded

by large irregular cracks. The right side area had no cracks. The formations of the cracks had no linkage

of transmission of the force during collision as the bonnet had major impacts towards right side

however the left side area of the glass was broken.

c. No sequence of impacts has been observed from the point of losing the control over the vehicle till

the toppling on the ground.

4. Point of Impact

a. Multiple points of impact has been observed in the vehicle.

b. No signs of natural accidental marks are observed.

5. Intentional Marks

a. Intentional marks/dents has been observed in the collided vehicle.

b. Intentional accident established during the process of forensic collision investigation.

Forensic Opinion

“On the basis of forensic collision investigation findings, it is concluded that the accident/collision in

the vehicle bearing registration no HR-36-V-0003 at a location Delhi-Hisar Bypass, Near Nissan Agency,

Haryana on 8th April 2021 was a fabricated accident intended for fraudulent claims.”

Therefore, the claim of the complainant was repudiated.

19) Reason for Registration of Complaint:- Non settlement of claim.

20) The following documents were placed for perusal.



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

Case called, both parties were present and recall their arguments as noted in Para 18 above.

Complainant informed that his vehicle got accident on highway and a team came from company after

three months of accident for enquiry. He admitted that forensic investigation was done in his presence

but underlined that they found mobil on road and even got cow’s heir from damaged vehicle which

confirm his version. He also stated that prior to this also, company has not paid his earlier claim

expenses for which he has to pay from his pocket.

Insurance company reiterated their stand of SCN that damages were not correlated with version of

accident. They informed that intimation of claim was given after five days of accident and due to doubt

regarding cause of loss, besides the surveyor, an investigator was also deputed. Subsequently it was

also decided to get forensic investigation done in the case. Insurance company admitted that surveyor

has only assessed the loss without giving his opinion regarding cause of loss which indicates deficiency

on the part of surveyor. Company informed that forensic investigation was done in the presence of

complainant with his written consent, specific photographs shown in forensic report were provided

by complainant himself.

During the hearing, instructions were given to company to provide investigation report and

clarifications on few points like reasons of appointment of forensic expert at such a later stage, SOPs

and methodology used by them, International standards purported to have been used by them during

such forensic investigation. The Insurance company replied vide e-mail dt. 11.02.2022 and supplied

part, a sketchy detail on clarifications sought especially with regards forensic investigation. The

insurers provided certain additional documents which were neither provided by them in the SCN nor

during the course of online hearing but these additional documents were very critical as they provided

information about previous claims of the complainant as well as his claim history.

The insurers vide the subject communication informed and shared with this forum, investigation

report dt. 20.04.2021 of current claim, investigation report dt.13.11.2020 and repudiation letter dt.

22.04.2021 pertaining to previous similar claim preferred by the complainant. The consent form of

complainant for carrying out forensic investigation in this case under reference were also shared with

this forum.

The insurers while reiterating the contents of their SCN, provided few additional, new facts

summarized below:

- Insured removed the vehicle from spot of the accident and intimated was given delayed to avoid spot

survey.

- Damages of the car were not matching with cause of loss as mentioned by insured in claim form or

his statements.

- No police report relating to accident lodged despite that the car sustained heavy damages.

- No injury to driver and co-driver of the vehicle despite heavy damages to the vehicle.

- Technical aspect of the damages was also recommended.

The insurers also reported that the complainant has also previously lodged a claim with similar damages with date

of loss as 17.10.2020 which was repudiated by the company on ground of misrepresentation, damages not

matching with the cause of loss and also submitted the investigation report for the same.

The Company further informed that it has also come to their knowledge that the said vehicle was previously

insured with HDFC ERGO general insurance company and complainant lodged one damages claim against them

showing accident dated 02-02-2020. However the complainant has taken all precautions not to disclose this fact

to any of the investigator, forensic expert or surveyor of the insurance company. Moreover he has never disclosed

this fact to this forum also. Looking to the above facts and circumstances it became necessary for them to conduct

a forensic examination to check the genuineness of facts. Accordingly forensic investigator was appointed on 19-

06-2021 who conducted detailed examination of the basis of: - 1. Forensic investigation of vehicle 2. Sampling

3. Statements of required persons.

Forensic investigator OCILABS submitted its report on 09-07-2021 with the findings that the claim damages to

the vehicle are unnatural one and these are manmade damages. The report is admissible in the court of law U/sec

45 of Indian Evidence Act-1872 as mentioned on the top of the report itself. Finding of Forensic investigator is

already mentioned in detail through SCN of the insurance company. Prior to conducting forensic investigation a

duly signed consent form was obtained from the complainant. As per Insurance company they have taken a

decision to repudiate the claim of the complainant on the basis of mis-representation of facts and it appears that

the complainant is habitual of filing own damage claims by molding facts as it is clear that complainant has

continuously filed 3 damages claim i.e. for alleged accident dated 02-02-2020 with HDFC ERGO General

Insurance, for alleged accident date 17-10-2020 and alleged accident dated 08-04-2021 against Chola MS General

Insurance company. However during the proceedings before this forum complainant has never disclosed these

facts and tried to mold the facts at every level. In view of all this, company requested to dismiss the complaint by

exonerating the insurance company from liability in respect of present claim. OD claim of complainant has been

repudiated by insurance company on the basis of deliberate and willful misrepresentation by insured regarding

the cause of loss. On careful examination of complaint, SCN, documents on record, additional documents

provided by insurer vide e-mail dt. 11.02.2022 and considering submission made by both the parties during online

hearing it has been observed that there are sufficient evidences on record to substantiate the stand of insurance

company in the matter to justify their decision to repudiate the claim as per terms and conditions of the policy and

it does not require any interference. Accordingly, the complaint shall deserve to be rejected.

AWARD

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

during the course of online hearing, the said complaint is hereby dismissed on merits and no relief is

granted.

(Atul Jerath)

Insurance Ombudsman

February 21, 2022

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH (Under Rule 13 r/w 17 of The Insurance Ombudsman Rules, 2017)


Case of Ashish Kumar v/s Universal Sompo General Insurance Co.

Ltd. Comp

laint Ref. No: CHD-G-052-2122-0205

1. Name & Address of the Complainant Shri Ashish Kumar, S/o Sh. Shri Shamsher Singh, VPO-

Adiyana (48), Panipat

Mobile No.- 9991863814

2. Policy No:

Type of Policy


2371/61413808/00/000

Private Car Package Policy, IDV-Rs 14,90,000/-

14/07/2020 to 13/07/2021



Ashish Kumar

Ashish Kumar

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

5. Date of Repudiation Not applicable

6. Reason for repudiation Not applicable


8. Nature of complaint Deduction of claim

9. Amount of Claim Rs 4,23,434/--

10. Date of Partial Settlement Rs. 10,44,566/- dated 20-07-2021

11. Amount of relief sought Rs 4,23,434/--




claim by an insurer

13. Date of hearing/place 31-01-2022/ Online hearing


For the Complainant Shri Ashish Kumar, Complainant

For the insurer

15. Complaint how disposed Award under rule

16. Date of Award/Order 31-01-2022

17. Brief Facts of the Case: Shri Ashish Kumar (hereinafter, the Complainant), has filed this complaint

against Universal Sompo General Insurance Co. Ltd (hereinafter, the Insurers) for undue repudiation

of his Motor claim.


a) Complainant’s argument: On 04-10-2021, Shri Ashish Kumar had filed a complaint that on

12.12.2020 around 7:15 PM, while his friend Mr. Azad Singh who was driving his vehicle was returning

from Bijnaur, Uttar Pradesh, the electrically operated Outside Rear-view side Mirror (ORVM) got hit &

damaged by a truck coming from the opposite direction near Badsu, Sikandarpur, Dist-Muzaffarnagar,

Uttar Pradesh. Thereafter he observed that the smoke was coming out of AC (Air Conditioner) Blower

which suddenly converted into heavy fire without giving him any opportunity to douse the fire and

engulfed the entire vehicle within no time. Somehow he managed to escape safely from the burning

car. Meanwhile the truck driver fled away from the spot and my car turned into ashes. The incident

was reported very next day, i.e. on 13.12.2020 to the nearest police station Ratanpuri, Dist-

Muzaffarnagar, Uttar Pradesh vide GD No.: 022 dated 13.12.2020 and to the nearest Fire Station.

The vehicle was fully burnt beyond repairable condition, therefore the surveyor had recommended

for the claim settlement as Total Loss. On 30.03.21, the insurance company asked him to prepare

the consent for Rs.13,19,000 against the IDV Rs.14,90,000 to which he strongly protested as in Total

Loss claim settlement he should have been paid his vehicle IDV including salvage. On 31.03.21, in such

a helpless situation with no option left, I had submitted all the required documents including the

cancelled Registration Certificate & the consent letter of Rs 13,19,000 to the insurance company.

The insurance company responded vide email dated 10.06.21, 16.06.21 & 24.06.21 where-in

it abruptly and drastically revised his Total Loss claim settlement amount with significant and

irrelevant deduction of Rs 4,23,434/- based on their some unfair concocted theory about the cause of

loss and justifying the deductions by quoting some weird clauses which shockingly belongs to Standard

Fire and Special Perils Insurance Policy and hence asked for the revised consent letter.

The same is reproduced as below

“We refer to the subject claim and acknowledge the receipt of your concern made to Authorities vide

mail dated 09-06-2021 for non-settlement of vehicle no. HR-06-Z-2801.As per investigation and

forensic findings captioned vehicle caught fire due to short circuit in electrical wiring which was the

cause of fire. As Fire in electrical Wiring is the Proximate Cause the same is not payable under policy

terms and condition — (1) Proximate cause definition: The cause having the most significant impact

in bringing about the loss under a first-party property insurance policy, when two or more

independent perils operate at the same time (i.e., concurrently) to produce a loss.

EXCEPTIONS TO SECTION I - The Company shall not be liable to pay (a) for loss of use, depreciation,

wear and tear, Mechanical or electrical breakdown, failures or breakages.

…………………………. We would further like to state that any failure of electrical or mechanical systems

are excluded from coverage and the short circuiting of wiring is a failure of electrical system. In view

of the above stated fact, the following is the claim computation of insurer’s liability as per terms and

condition of the policy:-

IDV ( Insured declared value) Rs 14,90,000

Less Cost of complete Wiring Rs 4,23,434 (Unlawful deduction)

Less Wreck Value Rs 20,000

Less Compulsory Deductible Rs 2,000

Liability on CTL Basis Rs 10,44,566

Complainant raised various issues on email to company but company didn’t changed their stand of

payment. Coupled with the burden of paying EMIs it was becoming very painful and tough for me to

bear the unfair pressure mounted by the insurance company resulting in the fear of closure of my

claim. Thus under protest I had again submitted all the required documents including the cancelled

Registration Certificate & the revised consent letter of Rs 10,44,566 to the insurance

company. On 20.07.21 I had received the partial settlement claim amount of Rs 10,44,566 vide

UTR/transaction no. UTIBR52021072000337639. He requested to kindly look into this matter and

directs the insurance company for the release of balance payment.

b) Insurers’ argument: In the SCN (Self- Contained Note), insurance company stated at complainant had availed a Private Car Package Policy for his vehicle bearing registration no-HR-06-Z-2901, bearing policy no. 2371/61413808/00/000 having policy validity period from 14/07/2020 to 13/07/2021. It is the case of the Insured that a front coming TP truck hit the insured vehicle rear view mirror so due to short circuit the insured vehicle caught fire. Subsequently the accident claim was intimated to the respondent company for which claim form was submitted and Claim No. CL20134942 was generated. As per terms and conditions of the Policy, respondent company appointed Deepak Kumar to Survey the loss of the Insured vehicle. As per the damages sustained by the insured vehicle, their appointed Surveyor had assessed the loss to the tune of Rs. 10,44,566/- and they had processed payment to the Insured on 20-07-2021 vide NEFT reference no- UTIBR52021072000337639. Insurance company stated that as per their policy terms and conditions they had disbursed the surveyed

amount and have delivered our services to the Insured so his allegation of not paying him the correct amount is based on baseless grounds and the Complaint deserves to be dismissed. In the light of above submission, there was no deficiency on the part of insurer, as the claim was repudiated as per terms and condition of the insurance policy and accordingly the claim is not tenable.

19. Reason for Registration of Complaint: - Deduction of claim.

20. The following documents were placed for perusal.



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

Case called, both parties are present and recall their arguments as noted in Para 18 above.

Complainant stated that he was tested positive for Covid-19 on 07-12-2020 and he got admitted at

Sanjivani Hospital, Sirsa on 09/12/2020 and got discharged from hospital on 14-12-2020. He even got

his mediclaim from Royal Sundram General Insurance Company for hospitalization expenses. His

policy from insurance company is a benefit policy and he has fulfilled all the conditions of policy.

Further, insurance company investigator (M/s Golden Eyes Health Solutions LLP) never visited his

village, and they never met his father. Statement taken by investigator is not correct. He also stated

that payment has been made by his brother since he didn’t have any debit card and purchased policy

online. The denial of claim based on non-existence of complainant’s insurable interest is also not

correct. He requested for payment of his claim.

During online hearing, the company was advised to explore the possibility of review of the claim to

arrive at an agreement. Insurance Company reiterated their stand of SCN and stated that their

repudiation decision is in order.


insurance company, submissions made by both the parties at the time of online hearing and

complainant’s email dated 03-12-2021 (documents relating to Royal Sundram General Insurance

Company mediclaim payment), it is seen that the complainant claim for covid-19 has been denied by

insurance company vide letter dated 28-01-2021. The denial has been done due to reasons there was

mis-presentation and concealment of exact details by the insured person or anyone acting on his/her

behalf to obtain any benefit under this policy. Insurance company pointed that during verification

neighbours of the Shri Gurpreet Singh confirmed that he was not admitted in the hospital and did not

have COVID. Further, patient father’s Shri Milkha Singh gave statement that his son living with him in

his village and his health is good and he was never admitted in any hospital since last 6 months.

In the instant case, there is no denial by either party that complainant has got his mediclaim from

Royal Sundram General Insurance Company Ltd for hospitalization expenses at Sanjivani Hospital. But

this version of complainant doesn’t hold ground since there is no specific condition/ term under the

Corona Rakshak policy wherein it is mentioned that benefit claim shall be admissible if complainant

gets claim under regular mediclaim policy. Complainant’s contention that investigator never visited

his village and didn’t took his father’s statement. But his version is not supported by concrete and

cogent documents whereas insurance company annexed the statement of complainant’s father shri

Milkha Singh which states that “Shri Gurpreet is his son. He is working in private hospital. Everybody

in his family is healthy. No one in his family has contracted Covid. His all-family members are healthy.

There are five family members in his family. All family members are healthy for last six months. Their

family members don’t have any pre-existing disease. No members of his family have been admitted in

the hospital. I have read all the statement. I am giving all the statement as per my knowledge.”

Based on above discussion and facts, shows that the denial of claim for complainant by insurance

company is in order and no relief is granted. Hence, the case is dismissed and is devoid of any merit in

the light of document presented by insurance company.

AWARD


parties during online hearing, the case is dismissed.

Hence, the complaint is treated as closed.

(Atul Jerath)

Insurance Ombudsman

January 27, 2022

OCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH (Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)

Insurance Ombudsman- Shri Atul Jerath

Case of Rahul Raina v/s Bajaj Allianz General Insurance Co.

Complaint Ref no: CHD-G-005-2122-0231

1. Name & Address of the Complainant Shri Rahul Raina S/o Sh. Dwarika Nath Raina,

R/o Flat No.-25, Block-M,

Near F.C.I Godown, Nagrota, Jammu

Mobile- 8837590674

2. Policy No:

Type of Policy


OG-21-1204-1801-00001752

Private Car Package Policy, IDV- Rs 2,06,479/-

07-09-2020 to 06-09-2021



Rahul Raina

Rahul Raina

4. Name of the insurer Bajaj Allianz General Insurance Co. Ltd.

5. Date of Repudiation 01-02-2021 (No claim)

29-07-2021 (Repudiation letter after re-open)

6. Reason for repudiation Misrepresentation of facts.


8. Nature of complaint Repudiation of claim.

9. Amount of Claim Rs 95,782/- as per repair bill


11. Amount of relief sought Rs 95,782/- as per repair bill




claim by an insurer



For the Complainant Shri Rahul Raina, Complainant

For the insurer Shri Saurabh Khullar

15 Complaint how disposed Award under rule -17

16 Date of Award/Order 25-02-2022

17. Brief Facts of the Case: Shri Rahul Raina (hereinafter, the Complainant) has filed this complaint

against Bajaj Allianz General Insurance Co. Ltd (hereinafter, the Insurers), alleging wrong repudiation

of his motor claim.


a) Complainant’s argument: On 08-11-2021, Shri Rahul Raina complained that accident of his

vehicle took place in Panjtirthi area of Jammu city. He had approached to insurance company office,

and they have deputed surveyor on that spot and to check all the formalities. In the meanwhile, due

to some reason at his home, he couldn’t do follow- up of his case. He approached insurance company

on January 30 but they even didn't told him that his case has been closed by them on Jan 30 even at

that time but rather told complainant to submit the documents and Affidavit of first class Magistrate

also. In the meanwhile, he has called to Bajaj call center they told him that his case has been closed in

Jan month. After that he approached to their office again and told them on what basis my case has

been closed. It was told to him that due to non availability of complainant not attending their call they

had closed the case. He gave them full reason of delay. At that time, it was told that they will reopen

his case after this financial year 2020-2021. He once again submitted all the documents to them

including affidavit which was notarized and attested. They deputed a team for survey to the accident

place told complainant that within a week time claim amount will be credited in his account.

In the meantime, insurance company has sent him a letter in which they have mentioned

misrepresentation of facts. They stated that car has entered in workshop on 12-09-2020 which is

baseless. He attached a Renault company security entrance register in that it clearly depicts the day

and time on which his vehicle entered a workshop which clearly shows that they are not interested to

give him claim. He requested this forum to take appropriate action regarding his case and give

directions them to release his claim amount.

b) Insurers’ argument: In the SCN, insurance company stated that the complainant has not

disclosed the material facts regarding the claim and is merely twisting the true facts in order to gain

undue advantage. That Insured Rahul Raina took the Private Car Package Policy from answering

respondent vide policy no OG-21-1204-1801-00001752. On 15-09-2021, Insured was driving his car

Number JK-02-BR-5773 and coming towards Dogra Hall Side from Nagrota and at about 6:10 PM, one

scooty came and dashed against the Complainant Car due to which he suffered loss. It is pertinent to

mention that incident took place on 15-09-2021 was reported to insurance company with delay of 9

days. After intimation of claim insurance company appointed Shri.Ranjeet Singh, investigator, who

conducted the investigation and during investigation Complainant confirmed that one scooty dashed

against his vehicle but failed to provide any details, accordingly their investigator visits Police Station

Panjtirthi and inquired the matter about the accident but Munshi of Police station failed to provide

any information due to no details. It is pertinent to mention here that complainant failed to provide

any details which confirm that any accident is took place, even as per his version no FIR is filed by him.

As per version of insured, he was in custody and got bail on 28-01-2021 but complainant failed to provide any details regarding his bail documents or criminal case which creates doubt in the mind of insurer. Further, it is apt to note that as per version of Insured one scooty dashed the car and damages to the car, seem that are not due to hit with scooty. Further, during

investigation it was found that as per the record of Jammu Autowheels Pvt Ltd (Renault Jammu) vehicle entered at workshop on 12-09-2020 and Complainant show the accident on 15-09-2020 and mis-represent the facts with Insurance Company. Accordingly, Insurance Company issued the letter dated 05-01-2021, 15-01-2021, 22-01-2021 and 28-01-2021 but complainant failed to reply on same and accordingly insurance Company close the claim after issuing the letter dated 01-02-2021. Afterward insured requested the Insurance company to re-open the claim and submit the affidavit that there is no loss to 3rd party and accordingly insurance company issued a letter dated 14-07-2021 for clarification but insured failed to submit any explanation on the ground of Misrepresentation of the facts and violation of duties of utmost good faith and accordingly insurance company vide letter dated 29-07-2021 repudiated the claim. As per the record of Jammu Autowheels Pvt Ltd (Renault Jammu) submitted by complainant

before Honb’le Ombudsmen regarding vehicle entry on 20-09-2020 have no genuineness, it

is apt to note that Complainant failed to reply to the letter of answering respondent issued

vide dated 29-07-2021 and provide the below documents for verification. It is further apt to

note as per attached record vehicle entered in Jammu Autowheels 20-09-2020 which fall on

Sunday and further personally inquired by answering respondent by calling on number

7051522203, it was updated by executive that on Sunday workshop remain closed, therefore

they humbly requested to dismiss the complaint as same filed with malafide intention and

produce the fake record to mis-guide this forum. Because of the above-mentioned facts,

insurance company is not liable to pay any claim to the complainant.

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




21. Result of Video Conferencing with both parties (Observations & Conclusion):

Case called for hearing. Both parties are present and recall their arguments as noted in Para 18 above.

During Online hearing, complainant stated that his car Renault kwid, model 2016 met with an accident

on 20 September 2020 and he gave accident intimation to the insurance company on same day. He

left his vehicle in authorized workshop on 20-09-2020 and survey of the vehicle was done on 24-09-

2020. His vehicle met with an accident with scooty which was driven by underage person. There was

no police report and no injury to the occupant of the vehicle. He doesn’t know about the number of

the vehicle. But he could produce witness who was a passer-by. Due to police custody, he could not

complete formality and when he came out of custody, inspite of completion of formalities his claim

has not been paid. He requested for payment of his claim.

During the online hearing, the insurance company stated that accident took place on 15-09-2020 in

the claim form and affidavit. In the claim form, complainant stated that person ran away after hitting

his vehicle. The damages of the car don’t correlate with scooty accident since driver side is badly

damaged. Further, as per records of the Jammu Auto-wheels Pvt Limited his vehicle came to garage

on 12-09-2020 whereas on enquiry with dealer, it has been informed that workshop remains closed

on Sunday and 20-09-2020 falls on Sunday. Therefore, there is misrepresentation on the part of the

complainant and accordingly claim has been repudiated by them vide letter dated 29-07-2021.

On examination of various documents available in file including the copy of complaint, SCN filed by insurance company and submissions made by both complainant and insurance company at the time of online hearing, it is seen that the complainant claim has been denied by the insurance company on the ground of misrepresentation. Ongoing through the claim form submitted by the complainant it is seen that complainant has intimated that his vehicle met with an accident on 15-09-2020 at 6.45 pm. As per claim, “due to rash and wrong driving of scooty drive. He hit my car in wrong side due to overtaking in blind curve at Panjtirthi, Jammu.” Whereas, while going through the e-stamp certificate number IN-JK06168132361040T dated 15-04-2021 purchased by the complainant states that the vehicle met with an accident on 15-09-2021. Further, the complainant version that his vehicle met with an accident on 20-09-2020 and job card can’t be entertained in the light of this notarized affidavit by advocate Shri Surjit Singh.




AWARD




(Atul Jerath)

Insurance Ombudsman

February 25, 2022



Case of Gaganpreet Singh v/s Universal Sompo General Insurance Co.

Complaint Ref. No: CHD-G-052-2122-0220

1. Name & Address of the Complainant Shri Gaganpreet Singh,

H. No.- 157, Ward No.- 54, Millerganj

Ludhiana

Mobile No.- 8728913913

2. Policy No:

Type of Policy


2311/61810311/00/000


09/09/2020 to 08/09/2021



Gaganpreet Singh

Gaganpreet Singh


5. Date of Repudiation 05-10-2021

6. Reason for repudiation Damages do not correlate with the cause of loss



9. Amount of Claim Rs18,000/- approximately


11. Amount of relief sought Rs18,000/- approximately




claim by an insurer



For the Complainant Shri Gaganpreet Singh, Complainant

For the insurer Shri Prashant Shukla

15. Complaint how disposed Award under rule 17


17. Brief Facts of the Case: Shri Gaganpreet Singh (hereinafter, the Complainant), has filed this

complaint against Universal Sompo General Insurance Co. Ltd (hereinafter, the Insurers) for undue

repudiation of his Motor claim.


a) Complainant’s argument: On 21-10-2021, Shri Gaganpreet Singh had filed a complaint that

insurance company refused to pay his claim by saying that the damages are old but they are fresh as

per as discussed with their surveyor Mr. Japneet Singh (9814813094). He told complainant that

insurance company is able to give his claims by front and back side and argue with him. After that they

refuse his claim which is not ethical. Person insures their vehicle to get the benefit from the insurance

company, but surveyor language and company language are different. Both have misbehaved and

done harassment to him. He requested to take action against Universal Sompo Company as

their surveyor and insurance company language are different and help him to get my claim.

Complainant have attached pictures of accidental vehicle with complaint which clearly shows that all

damages are fresh there are not any old damages. He requested to kindly look into this matter and

directs the insurance company for the release of his payment.

b) Insurers’ argument: In the SCN (Self- Contained Note), insurance company stated at complainant had availed a Private Car Package Policy for his vehicle bearing registration no. PB-10-FX-9993, bearing policy no. 2311/61810311/00/000 having policy validity period from 09/09/2020 to 08/09/2021. It is the case of the Insured that to save insured vehicle from a ditch, the driver of the insured vehicle applied brakes due to which a rear coming truck got hit at the rear side of the insured vehicle. Meanwhile, the driver of the insured vehicle got hesitated and steered the insured vehicle turned towards left side and got hit with a roadside railing and again when the driver of the insured vehicle steered the insured vehicle, it got hit with a stray animal and further got hit with railing from the right side.

Subsequently the accident claim was intimated to the respondent company for which claim form was

submitted and Claim No. CL21108938 was generated. After the intimation of claim, as per terms and

conditions of the Policy, respondent company appointed Japneet Singh to Survey the loss of the

Insured vehicle. As per the Survey report all the damages do not correlate with the cause of loss. It

had been observed that as per the narration of the incident by the Insured in the claim form, those

damages were not consistent and did not tally with the damages on the vehicle. Hence, the damages

claimed were old in nature and accumulated. The Complainant had been trying to mislead the case

and get the claim for the old damages as well which is strictly against the Company’s policy and the

insurance company has rightly repudiated the claim vide letter dated 05/10/2021. In the light of above

submission, there was no deficiency on the part of insurer, as the claim was repudiated as per terms

and condition of the insurance policy and accordingly the claim is not tenable.

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






Complainant stated that the repudiation done by the insurance company is not justified. He requested

for payment of his claim.






that the complainant vehicle claim for has been denied by insurance company vide letter dated 05-

10-2021. The denial has been done due to reasons that as per the narration of the incident by the

Insured in the claim form, those damages were not consistent and did not tally with the damages on

the vehicle.

In the instant case, as per complainant to save insured vehicle from a ditch, the complainant applied brakes due to which a rear coming truck got hit at the rear side of the insured vehicle. Meanwhile, the complainant steered the vehicle turned towards left side and got hit with a roadside railing and again when the complainant steered the vehicle, it got hit with a stray animal and further got hit with railing from the right side. Complainant stated that at the time of driving his vehicle speed was at 120. Ongoing through the claim photographs annexed by the complainant and by insurance company along with the survey report of independent surveyor Shri Japneet Singh, it is seen that truck has hit the vehicle from the rear, but the photographs clearly show no severe damage and impact on the back side of the vehicle. Further, there is no severe damages on the vehicle when it hit with the roadside railing. It clearly depicts that the cause of accident doesn’t relates to the damage because if complainant was driving at 120 and the vehicle hitting from the rear would have caused severe damage because vehicle has skidded too

which means that insured vehicle speed was high and not slowed down yet. It clearly shows that damages of the vehicle don’t correlate with the cause of accident.




AWARD




(Atul Jerath)

Insurance Ombudsman

February 25, 2022

Copy to: 1) The Complainant.

2) The Insurance Company.



Case of Mohender Kumar Kaushik v/s Universal Sompo General Insurance Co.

Ltd. Comp


1. Name & Address of the Complainant Shri Mohender Kumar Kaushik,

S/o Shri. Hari Kumar Sharma,

Pana- Dalan, V.P.O. Bapora,

District- Bhiwani

Mobile No.- 9811547394

2. Policy No:

Type of Policy


USGI/WEBAG/0673065/00/000


17/07/2020 to 16/07/2021



Mohender Kumar Kaushik

Mohender Kumar Kaushik


5. Date of Repudiation Not applicable

6. Reason for repudiation Not applicable


8. Nature of complaint Delay in payment of claim

9. Amount of Claim Payment of claim

10. Date of Partial Settlement Rs. 1,15,750/- dated 30-01-2022

11. Amount of relief sought Payment of claim




claim by an insurer



For the Complainant Shri Mohender Kumar Kaushik, Complainant


15. Complaint how disposed Award under Rule-17


17. Brief Facts of the Case: Shri Mohender Kumar Kaushik (hereinafter, the Complainant), has filed

this complaint against Universal Sompo General Insurance Co. Ltd (hereinafter, the Insurers) for delay

in payment of his Motor claim.


a) Complainant’s argument: On 26-10-2021, Shri Mohender Kumar Kaushik that he made complaint

to the national helpline for consumers (ministry of consumer affairs, Govt. of India) made online

on 23-09-2021 and its contents reads “Delay in processing of claim. More than two months have

passed since the claim was made. However, no progress has been made in this regard. My car is not

in running condition. It is lying idle with the Maruti agency at Bhiwani, Haryana from 01/08/2021. I am

facing hardships due to non availability of my car which is very vital for meeting my daily needs and

work requirements. I am not able to attend my professional requirements which involve frequent

travelling. This is causing me all round difficulties including financial, mental and physical. You are

hereby requested to do the needful in this regard at the earliest."

In its response the company (Universal Sompo) has stated that it will resolve the issue within 10 days.

After that it said the company has acted as per the company policy terms. He has asked the insurer

repeatedly via emails as to what action they have taken and also to provide me a copy of final status

of my claim. In response the company has repeatedly denied him giving the final status of the claim

saying that the investigation in this regard is still pending. It contradicts its own version where it has

said that the company has acted as per policy terms. It is apparent that this is a case of harassment of

consumer. The insurer has not acted upon his insurance claim for so much long time. He is extremely

hopeful that this forum will understand his plight and act accordingly to compensate him in this regard.

b) Insurers’ argument: In the SCN (Self- Contained Note), insurance company stated that complainant had availed a Private Car Package Policy for his vehicle bearing registration no. HR-16-T-7514, bearing policy no. 2311/64129259/00/000 having policy validity period from 17/07/2021 to 18/07/2022. It is the case of the Insured that on 01.08.2021 while moving suddenly a bull came in front of the insured vehicle and the Insured applied sudden brake due to which the insured vehicle got imbalanced and went down to the drain. The accident claim was intimated to the respondent company for which claim form was submitted and Claim No. CL21077625 was generated. It is alleged from the complainant that the insurance company has not settled insured’s claim.” After the intimation of claim, as per terms and conditions of the Policy, respondent company appointed Magnum Insurance Surveyor and loss assessors to Survey the loss of the Insured vehicle. The survey was assessed to the tune of Rs. 115,750.10 and insurance company had processed the claim accordingly on 30-01-2022. The claim was neither closed nor repudiated but was under the process and the claim has been rightly released as per the survey assessment. Thus, they have rightfully processed the claim in favour of the Complainant and no liability whatsoever lies on them. Therefore, they requested this forum to dismiss the complaint of the complainant.

19. Reason for Registration of Complaint: - Delay in payment of claim.





Case called for hearing. Both parties are present and recall their arguments as noted in Para 18 above.

During the online hearing, insurance company stated that they have paid the claim of the complainant

as per the independent survey report of M/s Magnum Insurance Surveyor and loss assessors which

was assessed for Rs 115,750.10. Accordingly on 30-01-2022, this amount was transferred in

complainant bank account.

Complainant stated that he has received above amount in his bank account but his repair bills were

more than Rs two lakhs. He requested this forum for balance payment of his claim.

Complainant has complained to this forum with regard to non-payment of his claim and same has

been paid by insurance company. But complainant was dissatisfied with the claim payment amount

by insurance company. Further, insurance company has not provided details about the deduction to

him under above subjected claim.

As such Insurance Company is directed to provide deduction details made under the above claim of

complainant within 15 days after receipt of award copy and also shall send a compliance report to this

office for information and record.

AWARD

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

parties during the course of personal hearing, Insurance Company is directed to provide

deduction details made under the above claim of complainant within 15 days after receipt of

award copy and also shall send a compliance report to this office for information and record.

(Atul Jerath)

Insurance Ombudsman

Feburary 21, 2022




Case of Arun V/S Bharti AXA General Insurance Co. Ltd.



Shri Arun

664/21, Vishal Nagar, Rohtak,

Haryana- 124001

2. Policy No:

Type of Policy


11846707

Motor Policy

15-02-2020 to 14-02-2021



Arun

Arun

4. Name of the insurer Bharti AXA General Insurance Co. Ltd.

5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Non settlement of Motor Claim

9. Amount of Claim IDV is Rs.445186/-


11. Amount of relief sought Not mentioned





13. Date of hearing/place 11.02.2022


For the Complainant Mr.Arun

For the insurer Mr.Ashay Mahajan

15 Complaint how disposed Recommendation under rule 16


17. Brief Facts of the Case: Shri Arun (hereinafter, the complainant) has filed this complaint against

Bharti AXA General Insurance Co. Ltd. alleging incorrect denial of OD claim.


a) Complainant’s argument: His car met with accident on 12.01.2021 and he raised a claim, but till

date nothing has happened inspite of repeated communication. In April 2021, his claim has been

closed by the company without any settlement of discussion with insured. On his repeated requests,

company provided few courier slips out of which only one has details in system from DTDC which

stated that courier failed and returned back. Not a single letter has been received by him from

company. Mr. Ankur investigator stated him that his claim is closed and he cannot do anything in this.

After registration of claim in IRDA one third party investigator approached him for statement of

incident and took pictures of incident place. Now after almost 5 months Bharti Axa stated that his

investigation is going on. Company only provided fake courier slips.

b) Insurer’s Argument: Insurance Company vide e-mail dt. 12.01.2022 informed that upon perusal of

the complaint and allied documents, the company has taken a decision to honor the claim of the

complainant as per policy terms and conditions. The surveyor assessment of the insured vehicle is Rs.

524367/- whereas the IDV of the insured vehicle is Rs. 445186/-. As such final payable amount comes

to Rs. 445186/- i.e. IDV of the insured vehicle.

19. Reason for Registration of Complaint: Non settlement of OD claim






Complainant informed that his OD claim was closed in April by insurance company. Representative of

insurance company informed that Bharti AXA General Insurance Co.Ltd. has merged with ICICI

Lombard Co. Ltd., after which, the claim has been reviewed and company has decided to pay the claim

on total loss basis which has been informed to complainant also. Complainant accepts the offer of

insurance company. Thus an agreement of conciliation could be arrived at between the Complainant

and the Insurers, which I consider as fair and reasonable for both the parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the

Complainant and the Insurers. Accordingly, the Company should pay admissible claim amount on

total loss basis as per terms and conditions of the policy within 30 days of receipt of award as per

section 17(6) of Ombudsman Rules, 2017.

( Atul Jerath )

Insurance Ombudsman

February 15, 2021




Case of Kamlesh Chauhan V/S Tata AIG General Insurance Company Limited



Smt. Kamlesh Chauhan

W/o Shri N.S. Chauhan

Chaitanya Apart., Block-A, Lower Totu,

Shimla (HP)-171011

Mobile No.- 9418587333

2. Policy No:

Type of Policy


3100610642

Motor

05.10.2020 to 04.10.2021



Ms. Kamlesh Chauhan

Ms. Kamlesh Chauhan

4. Name of the insurer Tata AIG General Insurance Company Limited

5. Date of Repudiation N.A

6. Reason for repudiation N.A


8. Nature of complaint Incorrect settlement of claim

9. Amount of Claim Rs.1,15,000/- (Balance claim)





2017





For the Complainant Mrs. Kamlesh Chauhan, the complainant

For the insurer Ms. Nidhi Batra



17. Brief Facts of the Case: Smt. Kamlesh Chauhan (hereinafter, the complainant) has filed this

complaint against Tata AIG General Insurance Company Limited (hereinafter, the insurers) alleging

incorrect settlement of claim.


a) Complainant’s argument: Her Vehicle was insured for Rs.3,39,956/-met with an accident in Oct 2020 and was totally damaged. After submitting all the relevant documents, they were given an understanding that total insured claim excluding Rs.1000/- shall be reimbursed i.e. Rs.2,23,956/- through financer and Rs.115000/-through buyers on account of salvage. But to surprise that the amount of salvage which was assured to be paid has not been paid till date due to which she has been put to huge loss as the vehicle is totally damaged/totally lost in accident and can’t be repaired at all. Despite completing all the formalities as conveyed by the company from time to time no positive response to release the pending amount of Rs.115000/- has been shown/conveyed by the company.

b) Insurer’s Argument: The claim for damages to Vehicle no. HR63 E 2888 vehicle was intimated to insurance company for accident dated 01.01.2021 and the claim was registered vide claim no. 7210592744. The claim process was initiated. After the intimation of the loss, the insurance Company appointed an independent IRDA licensed surveyor, M/s B & S surveyor to inspect the vehicle and assess the loss. During inspection, it was noted that the cost of repair of Insured vehicle was falling to be more than 75% of IDV. Copy of survey report is annexed as Annexure.2. In view of above, the loss was discussed with the insured and after her consent vide affidavit dated 19.03.2021, the claim was settled on net of salvage basis for Rs. 2,23,956/- . The Copy of consent letter/ affidavit is annexed as Annexure 3. It is specifically submitted that the insured consented to the settlement of the claim on her own free will and she herself was responsible to take whatever decision she deemed fit regarding the damaged car. This responding Insurance Company has already paid the claim towards full and final settlement and discharged its full liability for the claim made, after obtaining a clean discharge from the insured. The contents of the complaint are admitted with respect to insurance of the vehicle and vehicle meeting with an accident and subsequent settlement of the claim to the tune of Rs. 2,23,956/-. Rest of the contents are wrong, hence denied. The contents of supra paras are reiterated here. The complainant be put to strict proof of the averments. The claim of the complainant has been paid towards full and final settlement with respect to the damages resulting from accident with free consent of the insured. Now the company is not liable for any other payment whatsoever. In the facts and circumstances of the above stated submissions. The insurance company is not liable for any compensation as the claim already stands paid with respect to damages resulting from accident. All above submissions are hereby read in accordance with annexure marked in this SCN and it is prayed that the complaint of the insured be dismissed.

19. Reason for Registration of Complaint: Incorrect settlement of claim.






The complainant stated that she has received claim amount of Rs.223956/-from the insurers but the

amount of Rs. 115000/- towards salvage which was assured to be paid has not been paid to till date.

The representative of the insurance company submitted that insured’s motor claim has been settled

on net of salvage basis for Rs. 2,23,956/- as per her consent letter/affidavit. They have already paid

the claim towards full and final settlement and discharged its full liability for the claim made after

obtaining a clean discharge from the insured.

In the consent letter referred by the insurers which is duly signed and notarized, it is specifically stated

by the complainant that “My vehicle had met with an accident on 02.01.2021 for which I have lodged

a claim with TAGIC Ltd. My/Our claim has been worked upon and I have negotiated and kept the

salvage with me for Rs.1,15,000/- and I am aware that that the said amount and compulsory excess

clause (under section-1) for Rs.1000/- is deductible from the settlement amount and I have consented

for the same. I hereby agree to accept the full and final settlement of my claim on “net of salvage/cash

loss basis for Rs.2,23,956/-. This consent is given by me/us after clearly understanding the mode of

settlement of claim. I/We also agree to the condition that my/our policy will stand cancelled

immediately upon settlement. I/We also confirm that I shall not raise any dispute/issue against the

settlement of this claim”.

In view of the observations made in Para 18b above and consent letter of the complainant the demand

for payment of Rs.115000/- towards salvage from insurers is not justified. The claim has been rightly

settled by the insurers after obtaining proper consent and does not warrant any interference in the

matter. The complainant is rejected being devoid of merits and no relief is granted.

Award



(Atul Jerath)

Insurance Ombudsman

11th February, 2022




Case of Anil Kumar V/S HDFC ERGO General Insurance Co. Ltd.



Shri Anil Kumar

S/o Sh. Virender Singh, H. No.- 2090, Shiv

Nagar, Rohtak, Haryana-124001

Mobile No.- 9466009765

2. Policy No:

Type of Policy


2311201730321902001

Motor Claim

01-04-2019 To 31-03-2020



Anil Kumar

Anil Kumar



6. Reason for repudiation Non-submission of documents


8. Nature of complaint Non-settlement of claim

9. Amount of Claim Rs.410000/-


11. Amount of relief sought Rs.410000/-



2017





For the Complainant Shri Anil Kumar, the complainant

For the insurer Shri Manoj Prajapati, Manager Legal



17. Brief Facts of the Case: Shri Anil Kumar (hereinafter, the complainant) has filed this complaint

against HDFC ERGO General Insurance Co. Ltd. (hereinafter, the insurers) alleging non-settlement

of theft claim of his vehicle.


a) Complainant’s argument: His vehicle was stolen on 21.01.2021. The complainant received a letter on 27.02.2020 from the insurance company to submit the documents otherwise claim file will be closed. He submitted some documents to Surksha Enterprises, the investigators on 28.01.2021 and rest of the documents were sent to the company on 02.03.2020. But he could not submit

Untrace report, F.I.R, Subrogation cum indemnity bond because of closure of court due to covid. He received untrace report on 19.01.2021 and on the same date sent it along with remaining three documents to company address by post. There was no response from the insurers for nine months. He was informed by insurers through e-mail dated 22.09.2021 that file cannot be re-opened against which he registered complaint with IRDAI on 27.09.2021. Thereafter he received a call from the company seeking request letter for reopening of case which was sent through mail. The insurance company has refused to reopen the file and told him to approach the Ombudsman office.

b) Insurer’s Argument: That the present complaint pertains to insurance claim under Private Car Comprehensive Policy bearing policy number 2311 2017 3032 1902 001 which was valid from 01.04.2019 to 31.03.2020. It is submitted that the policy was issued subject to the terms and conditions and so any liability which may arise under the policy is always subject to and restricted by the terms and conditions. It is further submitted that the terms and conditions of the policy have been duly assessed and approved by the IRDAI. That Complainant had submitted the claim vide claim form dated 28.01.2020 with respondent company and as per submitted claim documents and Investigation Report it was noted that complainant on the afternoon of 21.01.2020 at around 12:30 PM the Complainant Mr. Anil Kumar came from Rohtak Haryana as he had go to Rail Bhawan, Delhi regarding some work, had parked the vehicle at Brigadier Hoshiyar Singh Metro Station, Bahadurgarh, Jhajjhar, Haryana and locked it properly and went to Delhi via Metro. On the same right at around 08:30 PM when the Complainant returned back to place, where the Complainant vehicle was parked, he found that the insured vehicle was missing from it parked place. The copy of Claim from and Investigator report and other documents are annexed. That, post reviewing the documents it was noted that provided documents is not sufficient to process the claim hence a query vide letter dated 23.07.2020 was raised and the complainant did not submit the requisite documents to process the claim after repeated reminders to the complainant to provide the complete requisite papers for adjudicate the claim but the complainant failed to do so. It is further submitted that when the answering opposite party did not receive any response from the side of complainant, the claim of the complainant was closed vide letter dated 29.09.2020 due to below mentioned document are required pending

19. Reason for Registration of Complaint: Incorrect denial of claim.






During the online hearing, it was enquired from the insurance company whether in the view of the

facts emerging they would like to re-look at the claim and arrive at an agreement. The representative

of the insurer offered to reconsider the claim as per terms and conditions of the policy subject to

submission of the required documents. The same was also agreed upon by the complainant during

online hearing.

Accordingly, an agreement by way of conciliation has arrived at between the insurer and complainant,

which I consider as fair and reasonable for both the parties.

In the light of the amicable settlement of complaint between the Parties, the complaint is disposed-

off with a direction that the company shall comply with the agreement and shall send a compliance

report to this office within 30 days after the receipt of award copy for information and record.

Award




(Atul Jerath)

Insurance Ombudsman

11th February, 2022




Case of Harsh Kumar Laroiya V/S The United India Insurance Co. Ltd.



Shri Harsh Kumar Laroiya

S/o Mrs. Raj Rani, H. No.- B-XXXIV-3202,

St. No.-5, New Tagore Nagar, Ludhiana,

Punjab-141001

Mobile NO.- 9814007657

2. Policy No:

Type of Policy


2009004220P111535257

Motor Claim

11-01-2021 To 10-01-2022



Raj Rani

Raj Rani



6. Reason for repudiation Not payable as per policy



9. Amount of Claim


11. Amount of relief sought Settlement of claim



2017





For the Complainant Shri Harsh Kumar Laroiya, the complainant

For the insurer Shri Manmohan Singh, Asstt. Manager

15 Complaint how disposed Award under rule 16/17


17. Brief Facts of the Case: Shri Harsh Kumar Laroiya (hereinafter, the complainant) has filed this


denial of claim.


a) Complainant’s argument: He had taken the personal accident policy of his late mother from insurers. She fell down in washroom on dated 30.03.2021 resulting her pelvic bone got fractured and took treatment from DMC Hospital. Insurers settled the loss with cashless facility amounting to Rs.1,50,000/-. His mother was discharged from hospital on 09.04.2021 and unfortunately

expired on 30.04.2021. The complainant had taken the P.A Policy from insurers and lodged bed rest claim from 30.03.2021 to 30.04.2021. The Insurance Company deputed Dr. T.L Gupta for bed rest opinion. He recommended the genuine-ness of the bed rest claim. Thereafter, they deputed investigator Shri Baldev Singh who visited complainant’s residence and also to his mother’s shop who used to run Glam & Elegance for the last 25 years and took snap of the shop. He demanded some kind of obligation but the complainant refused to fulfill his demand as the case was genuine. Investigator deliberately rejected the case after giving his findings that the insured did not suffer from any financial loss due to the bed rest. The complainant has sought the intervention of this forum for resolution of his grievance.

b) Insurer’s Argument: it is admitted fact that an Injury Claimof Insured Smt. Raj Rani was reported under Table-IV-Temporary Total Disablement (Weekly Compensation) for the period from 30/03/2021 to 30/04/2021 and treatment taken from DMC Hospital, Ludhiana and given by Dr. Rajnish Garg. It is admitted fact that proximate cause of Bed Rest under the above claim of PA Policy is sudden & accidental and she was admitted in DMC Hospital, Ludhiana for treatment. But the deputed Investigator vide their investigation Report BSNA/IR/2021/1110 dated 26/06/2021 (Received on 05/07/2021) concluded that proximate cause of death of Mrs. Raj Rani is due to Asthma disease and not due to accident injuries. Company penal doctor Sh. T.L. Gupta has also given his recommendation for bed rest from 30/03/2021 to 30/04/2021. In this regard our claim officer asked from the insured through concerned development officer for income proof and other required documents of the insured but the same were not made available. Hence to establish these facts of the claim, M/s. B.S. Narang & Associates, investigator were deputed. The deputed investigator through his investigation report no.BSNA/IR/2021/1110 dated 26/06/2021 (Received on 05/07/2021) concluded that:- “In this case the insured did not suffer any loss of income due to her bed rest on account of accident. He futher confirmed that handloom sale shop claimed to be run by deceased insured, is not practically there. In fact, beauty parlor, attached with sale of little number of ladies readymade garments located on the said shop, is being run by Mrs. Shama Laroiya wife of the claimant/nominee. Further investigator also confirmed from the statements of the claimant/nominee, discharge summary of hospital as well as based on other evidences that the proximate cause of death of Mrs. Raj Rani is due to Asthma disease and not due to accidental injuries. In this situation, the relevancy of ITR having or not having does not matter, as such the claim of the insured does not become maintainable under the policy which he recommended for denial and file be closed as no claim”. With regard to the comments of the complainant on investigator, we state that deputed Investigator M/s. B.S. Narang & Associates is empaneled investigator of the company, retired as Assistant Manager and investigators/surveyors are empaneled by our higher offices on the basis of expertise and competency and they are independent body. In this regard, we may also add that insurance contracts came into force on the basisof material information/statement/declaration given by the insured at the time of insurance and it is based on utmost good faith. At the time of claim, the onus to prove the material facts lies with the insured. Subsequently, it is on the part of the insured to prove these given facts, at the time of claim. In this case, the claimant failed to prove earning income.





21. Result of Personal hearing with both parties (Observations & Conclusion): Case called, both

parties were present and recall their arguments as noted in Para 18 above.

The Complainant informed that his mother fell down in washroom on dated 30.03.2021 resulting

her pelvic bone got fractured and took treatment from DMC Hospital. The claim for temporary

total disablement under P.A policy denied by the insurers for the reason that insured did not

suffer any financial loss during the rest period in spite of recommendation about the genuineness

and bed rest claim by Dr. T.L Gupta from whom the insurer’s had sought the opinion.

As per representative of Insurance Company, claim is not admissible as the insured was not

running any business and did not suffer any loss of income on account of accident due to her bed

rest. The proximate cause of death of complainant’s mother is due to asthma disease and not

due to accidental injuries.

The insurance company denied the claim vide their letter dated 09.07.2021 on the grounds that

insured did not suffer any financial loss due to bed rest and proximate cause of insured’s death

is Asthma and not accident. The policy of insured is being renewed by the insurers since many

years as she was earning 50% CB under the policy. The insurance company has not placed on

record the copy of proposal form or any other document to prove any mis-statement on the part

of insured. The claim refusal merely on the report of investigator that insured was not running

any business & did not suffer any financial loss is not sufficient to deny the liability.

The alleged cause of death of the insured by asthma is taken as a ground for refusal of claim for

weekly compensation under the policy but the insurers in their own letter dated 20.08.2021 sent

to complainant admitted that proximate cause of bed rest under the claim of P.A Policy is sudden

and accidental and she was admitted in DMC hospital for treatment.

The company panel doctor has also given recommendation for bed rest from 30.03.2021 to

30.04.2021. However, In the claim denial letter insurance company has also not referred to any

policy condition due to the violation of which the claim is not admissible. Moreover the Insurance

Company after many years of the subject P.A policy being enforce is now raising the objections

as to profession of the insured person and misrepresentation is also not justified.

In view of facts of the case and above discussion, decision of insurance company to repudiate the

claim is not justified. The insurance company is directed to pay the admissible injury claim

number 2009004221C050002001/1 under policy no. 2009004220P111532688 of insured Smt. Raj

Rani reported under table IV- temporary total disablement (weekly compensation) for the period

from 30.03.2021 to 30.04.2021 and treatment taken from DMC, Ludhiana and given by Dr. Rajnish

Garg as per policy terms and conditions within 30 days from the receipt of award’s copy.

AWARD


during the course of online hearing, the insurance company is directed to pay the admissible injury

claim number 2009004221C050002001/1 under policy no. 2009004220P111532688 of insured Smt.

Raj Rani reported under table IV- temporary total disablement (weekly compensation) for the period

from 30.03.2021 to 30.04.2021 and treatment taken from DMC, Ludhiana and given by Dr. Rajnish Garg

as per policy terms and conditions within 30 days from the receipt of award’s copy.

(Atul Jerath)

Insurance Ombudsman

15thFebruary, 2022




Case of Pardeep Kumar Aery V/S The United India Insurance Co. Ltd.



Shri Pardeep Kumar Aery

S/o Sh. Sukhdev Dutt, VPO- Ajouli, Distt.- Una,

Himachal Pradesh-0

Mobile No.- 9216811600

2. Policy No:

Type of Policy

2016003119P11134100

Motor Claim

Duration of policy/Policy period 22-11-2019 to 21-11-2020



Pardeep Kumar Aery

Pardeep Kumar Aery



6. Reason for repudiation D/L not valid



9. Amount of Claim


11. Amount of relief sought Claim amount



2017





For the Complainant Shri Pardeep Kumar Aery, the complainant

For the insurer Shri Raj Kumar Kataria, Divisional Manager



17. Brief Facts of the Case: Shri Pardeep Kumar Aery (hereinafter, the complainant) has filed this


denial of claim.


a) Complainant’s argument: His vehicle met with an accident on 26.10.2020. All the claim formalities were completed but insurance company rejected claim on the plea that Hazardous goods license

of the driver is valid but not endorsed on endorsed on license. He submitted that heavy license is valid up to 31.08.2021 and hazardous license is valid from 08.02.2020 to 07.02.2022. The Indian Govt. Ministry of road transport and highway MVL section clear that validity of documents under the motor vehicle Act 1988 and central central motor vehicle rules1989, the validity of the driving license which have expired since 1st Feb 2020 or would expire 30 Sept 2020, the same may be treated to be valid till 30th Sept. 2021. If licenses are not renewing govt. that how it is possible to endorsement of license due to covid. Further there is not any such practice to endorse the hazardous license with HMV in Punjab at the time of accident. Therefore, both the licenses were prepared separately by concerned department. Even as per the information received through RTI Govt of India, ministry of road transport and highway, it is clarified that renewal of the hazardous license shall be subject to condition that the driver undergoes one day refresher course of prescribed syllabus which the driver in that case already gone through as it is clear from his hazardous license. They have also passed us less amount of lining of tanker for which we have paid Rs.1,77000/-. The matter for review was sent to grievance department of company, but they rejected.

b) Insurer’s Argument: A claim was reported under policy no 2016003119P111134100 with date of accident on 26/10/2020. Spot survey was done by SLA Mr Rajesh Narula and final survey was done by SLA Mr Vikas Trikha. As per claim documents, vehicle was carrying caustic soda/lye in the insured vehicle at the time of accident which is categorized as Hazardous Goods as per the Motor Vehicles Act. Vehicle was being driven by Mr Sanjeev Kumar holding Driving License no PB-1220090096920. There was no endorsement in the driving license of the driver for carrying hazardous category goods. So, driver was not authorized to drive the said vehicle carrying hazardous goods as he was not holding valid and effective driving license. This is a gross violation and breach of policy terms and conditions under Motor Vehicle Act, as per Rule 3 of Central Motor Vehicle Rule, 1989.Therefore claim was repudiated as driver was not holding valid and effective DL to drive hazardous goods carrying vehicle. Office also obtained legal opinion from advocate Mr Jatinder Pal Singh and he has also opined that claim is not payable and liable to be repudiated as per law. He has also mentioned various judgments of Hon’ble National Commission and Hon’ble Allahabad High Courts which substantiates repudiation on ground that mere obtaining training certificate is not enough and endorsement on DL is mandatory requirement and cannot be waived off. Also, complainant mentions about circular of Ministry of Road transport and Highways dated 30/03/2020 which states that vehicular documents whose extension of validity could not be processed due to lockdown and which have expired since 1st February 2020, same may be treated to be valid. But in this case DL was never endorsed so there is no question of extension of validity. So, above mentioned circular states about extension of validity of existing documents but do not waive off the requirement for issuance of new documents. So, this claim doesn’t fall under the purview of this circular.





21. Result of Personal hearing with both parties (Observations & Conclusion): Case called, both parties

were present and recall their arguments as noted in Para 18 above.

The Complainant stated that claim of his tanker has not been paid by the insurers on the ground

that the license of the driver is not endorsed for hazardous goods. We have filed the RTI and there

is no such procedure in the state of Punjab.

As per representative of Insurance Company, the claim is not admissible as there was no

endorsement in the driving license of the driver for carrying hazardous category goods. So, driver

was not authorized to drive the said vehicle carrying hazardous goods as he was not holding valid

and effective driving license. This is a gross violation and breach of policy terms and conditions

under Motor Vehicle Act, as per Rule 3 of Central Motor Vehicle Rule, 1989.Therefore claim was

repudiated as driver was not holding valid and effective DL to drive hazardous goods carrying

vehicle.

The complainant has placed on record a copy of the RTI reply to Shri Surinder Kumar, the driver

of the vehicle at the time of accident, from CPIO Ministry of Road Transport and Highways (MVL

Section) New Delhi dated 16th August, 2021 wherein it is stated that “provided that in case of

license to drive a transport vehicle carrying goods of dangerous or hazardous nature be effective

for a period of three years and renewal thereof shall be subject to the condition that the driver

undergoes one day refresher course of the prescribed Syllabus”. Rule 137(Table III) of CMVR

contains the class labels & list of hazardous goods for the transporting. Implementation of CMVRs

and MV Act including issue of driving license comes under the purview of state Transport

Department; Hence, your RTI application is being transferred to the Transport Commissioner

Govt. of Punjab under section 6(3) of the RTI Act to provide the information available with them

and necessary action in this regard. The complainant has not produced any further reply received

from the Transport Commissioner Punjab but during the online hearing on 11.02.2022 stated that

there is no such procedure of endorsing the license in Punjab. So, he was advised to provide

documentary evidence to prove his contention that licensing authority in Punjab do not accept

application for endorsement of hazardous license. He was further advised to apply online for the

same and provide the screen shot but has not provided the same till date.

The driving license which the driver Sh. Sanjeev Kumar had obtained on 22.05.2009 was valid for

transport vehicle up to 31.08.2021. There is no material on the record to show that the aforesaid

driving license was valid for driving a vehicle carrying hazardous goods. Rule 9(1) of the central

vehicle rules, prescribes the educational qualification for driver of the goods carriage carrying

dangerous or hazardous goods. A person seeking to drive a goods carriage carrying dangerous or

hazardous goods is require to possess a certificate of having successfully passed a course

consisting of syllabus given in the rule. Sub-Rule (2) of the said rules requires the holder of a

driving license possessing the aforesaid minimum educational qualification to make an

application in writing. Sub-Rule (3) of the said rule provides that the licensing authority, on receipt

of the application shall make an endorsement in the driving license of the applicant, to the effect

that he was authorized to drive a goods carriage carrying goods of dangerous or hazardous nature

to the human life. There is no evidence of valid endorsement in

driving license issued to Sh. Sanjeev Kumar on 22.05.2009 bearing the requisite endorsement in

terms of sub-rule (3) of Rule 9. By allowing the driver without a valid driving license to drive a

tanker carrying hazardous goods, the complainant violated the terms and conditions of the policy.

Therefore, the claim denial decision of the insurer is justified and does not warrant any

interference.

Award



(Atul Jerath)

Insurance Ombudsman

18thFebruary, 2022




Case of Satyavati V/S HDFC ERGO General Insurance Co. Ltd.



Smt. Satyavati

W/o Sh. Suresh Dangi, House No.- 318, Omaxe

City, Rohtak, Haryana-124001

Mobile No.- 9813190300

2. Policy No:

Type of Policy


231120421115950000

Motor Claim

08-07-2021 to 07-07-2024



Satyavati

Satyavati



6. Reason for repudiation Misrepresentation of facts/ invalid driving

license



9. Amount of Claim Rs.520637/-


11. Amount of relief sought



2017





For the Complainant Smt. Satyavati, the complainant

For the insurer Shri Manoj Prajapati, Manager Legal



17. Brief Facts of the Case: Smt. Satyavati (hereinafter, the complainant) has filed this complaint

against HDFC ERGO General Insurance Co. Ltd. (hereinafter, the insurers) alleging incorrect denial

of claim.


a) Complainant’s argument: Her car met with an accident on 17.08.2021 and as per insurance policy terms and conditions her claim is payable. But the insurance company has rejected the claim.

b) Insurer’s Argument: That the present complaint pertains to insurance claim under Private Car policy which was valid from 08.07.2021 to 07.07.2024. The Complainant had submitted the claim vide claim form dated 28.08.2021 with respondent company and as per submitted claim documents, Investigation Report and Surveyor report and as per Surveyor's Assessment of Loss of Rs. 5,20,637/- of complainant. It is further submitted that as per documents available it was noted that as per insured statement on dated 17.08.2021, Mr. Rishab went to Medical Mod for brought something along with insured son and his friend. When they reached before 2Kms from insured residence suddenly a bunch of cow came in front of the vehicle. Due to that user lost his control over the vehicle and IV collided with the tree and then the bunch of bricks and overturned. At the time of accident Mr. Rishab was driving the IV insured son friend Mr. Vikas was seated on the conductor seat and insured son Mr. Vivek seated on the rear seat. In this accident only Mr. Vikas sustained injury on his hand but no medical treatment has been taken by him. It is further noted that as per available documents claim was not found payable and rejected due to Delay in Intimation, Misreprentation of Facts and Invalid Driving License as per policy terms and conditions and same was communicated to Complainant vide letter dated 04.10.2021.







During the online hearing, it was enquired from the insurance company whether in the view of the

facts emerging they would like to re-look at the claim and arrive at an agreement. The representative

of the insurer offered to reconsider the claim as per terms and conditions of the policy subject to

submission of the required documents. The same was also agreed upon by the complainant during

online hearing. The Insurance Company vide their mail dated 25th February,2022 confirmed that they

have received the documents and after reviewing the same they are ready to settle the claim as per

policy terms and conditions.

Accordingly, an agreement by way of conciliation has arrived at between the insurer and complainant,

which I consider as fair and reasonable for both the parties.

In the light of the amicable settlement of complaint between the Parties, the complaint is disposed-

off with a direction that the company shall comply with the agreement and shall send a compliance

report to this office within 30 days after the receipt of award copy for information and record.

Award




(Atul Jerath)

Insurance Ombudsman

28th February, 2022

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH (Under Rule 13 r/w 16/17 of The Insurance Ombudsman Rules, 2017)


Case of Dharmender Thakur v/s Go Digit General Insurance Co.


1. Name & Address of the Complainant Shri Dharmender Thakur

Vill.- Ghasitpur, P.O.- Mukerian,

Distt.- Hoshiarpur

Mobile No.- 9915008111

2. Policy No:

Type of Policy


D030987806

Digit Private Car Policy, IDV- Rs 1,98,000/-

20-03-2021 to 19-01-2022



Dharmender Thakur

Dharmender Thakur

4. Name of the insurer Go Digit General Insurance Co. Ltd


6. Reason for repudiation No correlation with cause of loss and old damage



9. Amount of Claim 22000/- approximately


11. Amount of relief sought Rs 22,000/- approximately




claim by an insurer



For the Complainant Shri Dharmender Thakur, Complainant

For the insurer Shri Sandeep, Assistant Manager



17. Brief Facts of the Case: Shri Dharmender Thakur (hereinafter, the Complainant), has filed this

complaint against Go Digit General Insurance Co. Ltd (hereinafter, the Insurers) for undue repudiation

of his vehicle claim.


a) Complainant’s argument: On 24-11-2021, Shri Dharmender Thakur had filed a complaint that the

right side of complainant vehicle having registered number PB 070756 met with an accident on 7th

October 2021 at approx 8:30 p.m on Talwara Road Mukerian with other side car passing complainant

suddenly turned his vehicle to his site but due to some deep pits on the road. There was no police

report there was no harm to anybody, but Insurance Company rejected the claim because bumper

was crashed before the accident. He stated that the decision to refuse the claim is not justified

because if bumper was scratched then how they can refuse to give claim of the whole vehicle. He

requested this forum to intervene in the matter and direct the insurance company to pay his claim

which he has paid from his own pocket.

b) Insurers’ argument: In the SCN (Self- Contained Note), insurance company stated that company has issued “DIGIT PRIVATE CAR POLICY “bearing No. D030987806 with coverage from 20th Mar 2021 to 19th Mar 2022 to the complainant for the vehicle bearing PB-07AC-0756. The vehicle of the complainant allegedly met with an accident on 07th Oct 2021. However, the intimation regarding the same was given to the Company on 09th Oct 2021 i.e. after a delay of 2 days. The inordinate delay affects our right to correctly analyze the admissibility of loss. The same is breach of condition 1 of the policy issued to you, relevant portion of which is as follows; “Notice shall be given in writing to the company immediately upon the occurrence of any accidental loss or damage in the event of any claim and thereafter the insured shall give all such information and assistance as the company shall require”. Notwithstanding the said delay, the Company registered the claim under claim bearing No.202100211211 and set into motion the process of claim settlement. The company has promptly informed the complainant about the procedure to be followed to enable us to process the claim. The surveyor was appointed to assess the loss and ascertain the true cause and nature of loss. It is

submitted that, the surveyor after inspecting the photos submitted through self-survey link concluded

that the damages are old and pre-existing. The insured vehicle on 04th Aug 2021 claimed for damages

on the left-hand side and shared color photographs for inspection in which old wear, tear and dents

were noticed on the right-hand side of the vehicle. The Color Photographs of claim no.1 and Claim

no.2 were attached for reference. Comparing photos from both the claim it was observed that since

the vehicle is a 2011 registered vehicle has undergone normal wear and tear over time and to make

wrongful gains from insurance company the complainant have exaggerated the old damages on the

right side which were also present exactly at the same spot during the first claim. Also the manner of

accident is not consistent with the nature of loss. The complainant is claiming for the same damages

which were already pre-existing in nature. There is willful misrepresentation of facts as to the cause

of loss. The complainant has willfully misrepresented the manner of loss and the damages sustained

to make wrongful gains.

Insurance company vide letter dated 9th Oct 2021 and 11th Oct 2021 requested complainant to

provide for documentary evidence showing the exact cause of loss, the complainant was given 7 days

time to support his claim with any document or reason for further consideration. The complainant

failed to provide any reasonable justification to the above-mentioned letter seeking reason for further

processing of the claim, the company owing to the observation made from the available documents

and information shared the complainant side has left us with no other option but to repudiate the

claim. All these aspects where informed to the Complainant vide letter dated 18th April 2021.They

submitted that, there is no deficiency of services on the part of Company, on the contrary the

Complainant has not approached this Hon’ble Forum with clean hands, there is willfull breach of the

Policy terms and conditions and willful breach of the important principle of Insurance i.e., the principle

of Indemnity.

Therefore, in view of the above submissions and documents produced on record, insurance

company humbly prayed to dismiss the Complaint.







Complainant stated that his accidental claim repudiation done by the insurance company is not

justified. He requested for payment of his claim.






that the complainant vehicle claim for has been denied by insurance company vide letter dated 11-

10-2021. The denial has been done due to reasons because vehicle has undergone normal wear and

tear over time and to make wrongful gains from insurance company the complainant has exaggerated

the old damages on the right side which were also present exactly at the same spot during the first

claim. Also, the manner of accident is not consistent with the nature of loss. The complainant is

claiming for the same damages which were already pre-existing in nature. There is willful

misrepresentation of facts as to the cause of loss. In the present claim the molding of the door are

shown broken whereas it should have broken when the vehicle is dashes with another vehicle. In the

present claim damages of right side are again claimed by the complainant. As such those damages

were not consistent and did not tally with the damages on the vehicle.

Ongoing through the claim photographs annexed by the complainant and by insurance company, it is seen that the photographs clearly show no severe damage and impact on the right side of the vehicle. Further, the damages on the right side of vehicle are similar as it was in August 2021. It clearly shows that damages of the vehicle don’t correlate with the cause of accident.




AWARD




(Atul Jerath)

Insurance Ombudsman

February 25, 2022



Case of Naresh Kumar v/s Universal Sompo General Insurance Co.


1. Name & Address of the Complainant Shri Naresh Kumar, S/o Sh. Ramesh Chander, #

211/11, Ahirka, Bye Pass Panipat

Jind-126102

Mobile No.- 9812720721

2. Policy No:

Type of Policy


2311/63864138/00/000


03/06/2021 to 02/06/2022



Naresh Kumar

Naresh Kumar



6. Reason for repudiation Mechanical Failure not covered



9. Amount of Claim Rs 3,26,955/- as per surveyor report


11. Amount of relief sought Rs




claim by an insurer



For the Complainant Shri Naresh Kumar, Complainant




17. Brief Facts of the Case: Shri Naresh Kumar (hereinafter, the Complainant), has filed this complaint

against Universal Sompo General Insurance Co. Ltd (hereinafter, the Insurers) for undue repudiation

of his Motor claim.


a) Complainant’s argument: On 26-11-2021, Shri Naresh Kumar had filed a complaint that he is having

a Maruti Ignis model 2019 bearing a number HR-31M-6787. On 30-06- 2021, he came to Sirsa for some

personal work and while coming back at Bhuna- Hisar bypass Bridge suddenly due to technical fault

his vehicle got unbalanced and his car got struck with a road divider. In this accident there was no

damage to any property or person. He only received minor injury for which it took private treatment.

He also stated that there is no pending case of any type for this accident. He has also intimated to the

police helpline Centre for this accident. After this accident, he left his vehicle at the Maruti workshop

but three months have passed but the insurance company or surveyor has not given any direction for

starting the work. He requested that his vehicle repair may be started.

b) Insurers’ argument: In the SCN (Self- Contained Note), insurance company stated at complainant had availed a Private Car Package Policy for his vehicle bearing registration no.HR-31-M-6787, hypothecated with HDFC Bank Ltd. bearing policy no. 2311/63864138/00/000, having policy validity period from 03/06/2021 to 02/06/2022. It is the case of the Insured that his vehicle due to mechanical failure suddenly got uncontrolled and hit a divider resulting into damages sustained by the IV. Subsequently the accident claim was intimated to the respondent company on 02/07/2021 for which claim form was submitted and Claim No. CL21052176 was generated. It is alleged from the complainant that the insured company has not settled insured’s claim. After the intimation of claim, as per terms and conditions of the Policy, respondent company

appointed Varinder Kumar Bhatia to survey the loss of the Insured vehicle. As per the survey report,

at the time of accident the insured vehicle was not road worthy. On delving into the vehicle history, it

came to their knowledge that in the month of Dec. 30, 2020, the Insured was advised by the authorized

repairer to replace the Brake pads, Brake disc, both clipper pins, Brake shoe, Brake drum and Right-

hand suspension arm but the Insured had denied to get the repair done. Additionally, the Brake system

of the insured vehicle was inspected physically and it was clear from the vehicle history that the

insured vehicle was not road worthy which had been affirmed by our Surveyor in the Survey report

post his visit to the repair workshop M/s Shakti Motors, Sirsa Road where the Insured had brought the

insured vehicle for getting it repaired. They stated that the Surveyor had observed that the damages

were not directly relevant to the cause of loss which had been mentioned in the claim form. The parts

of the vehicle which were observed to be worn out completely were included in the service history

where the Insured was asked to get those repaired. Hence, owing to this situation, where the Insured

had not taken reasonable caution and care towards the insured vehicle, and insurance company is not

liable to pay the claim. Furthermore, the technical opinion of the Surveyor was that the accident had

occurred due to non-replacement of the brake parts which were completely worn out.

The Insured had also mentioned in his statement to the Police Authorities that the said accident

happened due to mechanical failure in the vehicle which itself proves that there was gross negligence

on your part which resulted into the said incident. The act of the Insured of not getting the insured

vehicle repaired on time which led to occurrence of the accident violates the policy terms and

condition no. 3 which states that, “The insured shall take all reasonable steps to safeguard the vehicle

from loss or damage and to maintain it in efficient condition and the Company shall have at all times

free and full access to examine the vehicle or any part thereof or any driver or employee of the insured.

In the event of any accident or breakdown, the vehicle shall not be left unattended without proper

precautions being taken to prevent further damage or loss and if the vehicle be driven before the

necessary repairs are effected any extension of the damage or any further damage to the vehicle shall

be entirely at the insured’s own risk”. Insurance company is not liable to make payment in respect of

consequential loss, depreciation, wear and tear, mechanical or electrical breakdown, failures and

breakage as per Section 1 (5)(a) of Private Car Package Policy. Hence, the claim has been rightly

repudiated vide letter dated 05/10/2021.

In the light of above submission, there was no deficiency on the part of insurer, as the claim was repudiated as per terms and condition of the insurance policy and accordingly the claim is not tenable.







Complainant stated that insurance company has wrongly repudiated his claim on the flimsy grounds

of mechanical failure. He is constantly getting his vehicle serviced from authorized service dealer. He

requested for payment of his claim.





insurance company, submissions made by both the parties at the time of online hearing, email

attachment by complainant vide email dated 24-02-2022 and also email of insurance company, it is

seen that denial has been done by the insurance company on the ground of mechanical failure and

they also presented the job card/ service record of vehicle wherein they remarked that complainant

refused to get his brakes repaired. They also annexed photographs in their support.

On the other hand, complainant produced the service record of workshop where he is regularly getting

his vehicle serviced. Further, he also pointed that since the parts were not available and due to paucity

of time he refused to leave his vehicle.

It is observed that insurance company has made too many assumptions at their own to repudiate the

claim of the insured. No policy clause compels owner of vehicle to follow the recommendations of

workshop, if any, who otherwise confirmed that there was no mechanical or electrical fault at the time

of service. In view of all this, decision of insurance company to repudiate the claim of complainant is

neither justified nor correct.

AWARD


during the course of hearing, admissible claim as per terms and conditions of the policy, is hereby

awarded to be paid by the Insurer to the Insured, towards full and final settlement of the above case

within 30 days of receipt of award as per section 17(6) of Ombudsman Rules, 2017.

(Atul Jerath)

Insurance Ombudsman

February 25, 2022



Case of Birender Singh v/s Iffco-Tokio General Insurance Co.

Ltd. Comp


1. Name & Address of the Complainant Shri Birender Singh S/o Sh. Azad Singh Kadian,

Advocate, Arya Nagar, Jhajjar

Mobile No.- 9416466546

2. Policy No:

Type of Policy


MG914416

Two-wheeler package Policy

17-11-2020 to 16-11-2021



Birender Singh

Birender Singh

4. Name of the insurer Iffco-Tokio General Insurance Co. Ltd

5. Date of Repudiation Not Applicable

6. Reason for repudiation Not Applicable.


8. Nature of complaint Premium not as per GR of IMT

9. Amount of Claim Rs 3405/- plus GST


11. Amount of relief sought Rs 3405/- plus GST



Rule 13 (1)(g) – any partial or total repudiation of

claim by an insurer



For the Complainant Shri Birender Singh, Complainant

For the insurer Shri Ishaan



17. Brief Facts of the Case: Shri Birender Singh (hereinafter, the Complainant), has filed this complaint

against Iffco-Tokio General Insurance Co. Ltd (hereinafter, the Insurers) for undue charging of

premium for policy which is not in conformity with GR of Indian Motor Tariff.


a) Complainant’s argument: On 23-11-2021, Shri Birender Singh had filed a complaint that as per IMT

rule GR 16 the minimum Premium for vehicle specially design or modified for the use of the blind

handicapped and mentally challenged person will be Rs 25 per vehicle and as per IMT Rules GR 33 in

case of vehicle is specifically designed/modified for the use of blind, handicapped and mentally

challenged person a discount of 50% may be allowed on the own damage premium in respect of both

privately owned vehicle and vehicles owned and used by institution engaged exclusively in the services

of the blind, handicapped and mentally challenged persons. The discount is to be allowed only in

respect of such vehicles which have been suitably endorsed in the Registration Certificate by the RTA.

The insurance company charged Rs 4,966/- for one year comprehensive + 4 year third party (Rs 44

1.76 OD charges + Rs 3,285 Third party Insurance + 350 personal accident + GST). The same is being

charged from normal vehicles which show they are not providing any concession to differently abled

persons on vehicles specifically designed/ modified for the use of blind, handicapped and mentally

challenged persons. While there is a provision of 50% on own damage under GR-33 and Rs 25/- per

year for third party under the GR 16. So they should grant a 50% discount on OD premium RS 441.76/-

and Rs 100/- (Rs 25 per year X 4). He stated that the insurance company has overcharged

approximately 3285 -100 and Rs 441-221i.e approximately Rs 3405 + GST charges thereon. He

requested a refund of the overcharged premium amount from the insurance company.

b) Insurers’ argument: Insurance company stated in SCN that they have complied with the provision of IMT and have given a discount of 60% to the complainant in the own damage section which is more than as per GR-33 and accordingly the complaint is not tenable. 19. Reason for Registration of Complaint: - Policy not in conformity with GR of Indian Motor Tariff.





Case called for hearing, both the parties are present and recall their arguments as noted in Para 18

above.

Complainant stated that he has not been given discount as per provision of the GR 16 and 33 of the

Indian Motor Tariff by the insurance company inspite of his fulfilment of criteria as per laid down rules.

He requested for refund of his excess charged premium under the vehicle policy.

During online hearing, the insurance company was advised to explore the possibility of review so as

to arrive at an agreement. Insurance Company reiterated their stand of SCN and stated that their

underwriting of the complainant policy is in order.

Ongoing through the compliant document, SCN filed by insurance company and submission made by

both the parties during the online hearing, it is seen that in the instant case complainant pleaded that

the insurance company while issuing the policy has not given him discounts which are as per the

provisions of General Regulation 16 and 33 of Indian Motor Tariff. Insurance company on the other

hand, stated that they have already given a discount of 60% to the complainant in their own damage

section.

In the instant case there is no dispute that complainant fulfils the mandatory requirement of IMT

provisions of GR 16 and 33. Only disputes remain whether insurance company has given these

discounts or not in the policy.

On perusal of facts of the case, SCN of the insurance company, submissions made by both parties

during the online hearing and the policy document issued to the complainant it is evident that

although the company has given underwriting discount of 60% the insurer representative could not

clarify whether this discount includes the mandatory discounts as per GR 16 and GR 33 of the Indian

Motor Tariff. Moreover the same is also not reflected on the face of the policy.

Accordingly the insurance company is directed to correct the policy in line with provisions of GR 16

and GR 33, send the desired endorsement to the complainant and refund any excess premium charged

from the complainant within 30 days after the receipt of award copy.

AWARD


parties during online hearing, insurance company is directed to correct the policy in line with

provisions of GR 16 and GR 33, send the desired endorsement to the complainant and refund

any excess premium charged from the complainant within 30 days after the receipt of award

copy.

(Atul Jerath)

Insurance Ombudsman

February 25, 2022




Case of Ujjwal Verma V/S ICICI Lombard General Insurance Co. Ltd.



Shri Ujjwal Verma

H. No.- 51/26, Civil Hospital, Karnal

Haryana

2. Policy No:

Type of Policy


3001/199522969/00/B00

Motor Policy

20-05-2020 to 19-05-2021



Ujjwal Verma

Ujjwal Verma

4. Name of the insurer ICICI Lombard General Insurance Co. Ltd.

5. Date of Repudiation NA



8. Nature of complaint Non settlement of motor OD Claim

9. Amount of Claim Rs. 8,00,000/-


11. Amount of relief sought Rs. 8,00,000/- + pakring charges Rs.50,000/-







For the Complainant Mr.Ujjwal Verma

For the insurer Mr.Karan Bagdai



17. Brief Facts of the Case: Shri Ujjwal Verma (hereinafter, the complainant) has filed this complaint

against ICICI Lombard General Insurance Co. Ltd. (hereinafter, the insurers) alleging incorrect denial

of claim and termination of policy.


a)Complainant’s argument: His car met with an accident on 15.02.2021 at Karnal. He intimated

insurance company who appointed a surveyor on next day. He provided all relevant documents to him

but after that thousand a time, he called him, sent messages but not replied back by him. Last week

he informed that his car has been totally damaged and they have to put it on auction after that they

will settle his claim within 10 days. On enquiry, on 29.06.2021 he got a mail from the company that

his claim is under process. Later CSM Mr. Amritpal A. Singh said that IDV is on higher side and prices

of his car are not according to market value. He provided all the purchasing documents to him, when

he brought his car which was like a new car. Mr.Amritpal Singh last week made him call and wants to

settle claim for Rs. 3.5 lacs although he spent 8 lac for this car.

b)Insurer’s Argument: The complainant had taken a Private Car Package Policy under policy number

3001/199522969/00/B00 for the period from May 20, 2020 to May 19, 2021 via online mode through

Easy Policy Insurance Web Aggregator Pvt. Ltd. The insured vehicle is of 2009 and the complainant is

the fourth owner of the vehicle The complainant had filed an own damage claim and as per the

allegation of the complainant, the vehicle in front of the insured vehicle (IV) applied an emergency

brake due to which IV hit the front vehicle & accordingly caused damages. The said incident took place

on February 15, 2021 at around 09:30pm near Skoda Showroom GT Road, Karnal. Post receipt of claim

intimation, a surveyor was duly appointed by the Company to conduct the survey of the damaged

vehicle and assess the loss. The surveyor on assessment of IV had allowed the damages that are

relevant with the nature & cause of loss. Accordingly, the assessment was prepared basis on the

estimate received and the final liability was assessed to Rs.479842/-.

Also as per the principle of indemnity insurance the Company’s liability will not be more that

actual purchase value of the vehicle subject to terms and condition of the policy and coverage

thereof. Further we would even like to reiterate the relevant policy clause for your ready

reference which states:

CONDITIONS

This Policy and the Schedule shall be read together and any word or expression to which a

specific meaning has been attached in any part of this Policy or of the Schedule shall bear the

same meaning wherever it may appear.

3. The Company may at its own option repair reinstate or replace the vehicle or part thereof

and/or its accessories or may pay in cash the amount of the loss or damage and the liability

of the Company shall not exceed:

For total loss / constructive total loss of the vehicle -the Insured's Declared Value (IDV) of the

vehicle (including accessories thereon) as specified in the Schedule less the value of the wreck.

b. For partial losses, i.e. losses other than Total Loss/Constructive Total Loss of the vehicle

actual and reasonable costs of repair and/or replacement of parts lost/damaged subject to

depreciation as per limits specified.

In the lights of the above conditions & unavailability of the purchase invoice/sale deed with

transaction details, the Company had offered below options to the complainant in order to

settle the claim:

1: The Company will pay an amount of Rs.350000 and retain the IV towards the full and final

settlement of the claim.

2: Replacement of car with same make & model or equivalent cost of same make & model.

3: Repair the insured vehicle and submit the invoice copy to Company and thereafter the claim

will be processed as per the terms and conditions of the policy

Further Company draw the attention towards the fact that the IV is of 2009 and the

complainant is currently the fourth owner. Also with the depreciation cost in consideration it

is always evident that with each passing year the IDV of the vehicle falls and do not increase.

Thereafter the Company vide reminder letter dated August 07, 2021 & August 24, 2021 had

asked the complainant to submit the requisite documents in order to process the claim as per

the terms and conditions of the policy. However, the complainant was/is reluctant to provide

“Vehicle Purchase Invoice along with transaction details & Previous year policy”. Hence the

Company had closed the claim and the same was duly intimated vide closure letter dated

September 21, 2021. On receipt of the complaint, the Company had once again approached

the complainant in order to submit the requisite documents and thereafter the complainant

vide mail dated January 22 had stated on the mail that he made cash payment to his friend

i.e. seller of the IV and he did not get any Insurance policy along with it. We would like to draw

your attention towards the ‘delivery-cum-receipt’ which is on the letter head of Ms. Car

Dealer Association stamped by Ms. Vishvkarna Motor submitted by the complainant which

states that name of the seller is Mr Devinder Singh and total payment shows as Rs.800,000/-

. It is pertinent to note that as per the complainant, he has made the entire payment in cash.

However, after receipt of the same, the complainant nor seller nor the dealer is contactable.

Hence company had sent a mail to the complainant about the same. We hereby enclose the

delivery-cum-receipt & mail as Annexure- ‘G’ for your ready reference.

On the basis of above submissions, it is evident that the Company’s liability under the said

claim is only limited to the extent of terms and conditions of the policy, which the Company

is ready to pay and settle from the day it was been claimed by the Complainant. However, the

Company shall bear no liability regarding garage parking charges and other incidental charges

in connection therewith. The complainant is reluctant to accept any of the above offers given

by the Company and is adamant on IDV. In the lights of the above submission, it is therefore

submitted that the complainant should shall accept any of the above mentioned offers given

by the Company in order to settle the claim as per the terms and conditions of the policy, in

absence of the same the Hon'ble Ombudsman may be pleased to dismiss the complaint and

absolve us from the liability.

19. Reason for Registration of Complaint: Non settlement of OD claim.






Complainant informed that his vehicle got accident on 15th Feb.2020 but insurance company has not

paid his claim and concerned surveyor even not picking up his phone. Complainant reiterated their

stand of SCN and underlined that Vehicle is of year 2009 model, complainant is fourth owner and IDV

has been taken on higher side taking advantage of non capping of IDV in taking their online policy.

According to company, they asked for previous insurance details and purchase proofs from

complainant but he could not provide satisfactory reply in this regard. However company repeated

their offer of settlement to insured like either he take lump sum Rs.3,50,000/- and vehicle will be

retained by company, or he arrange repair of vehicle or company will arrange replacement of car with

same make and model. But complainant objected to offer of company and reiterated that he suffers

loss of Rs. 8 lac, as such he should get IDV of the vehicle as claim amount.

As per policy document, Volks Wagon car no HR51AE/1200, model 2009 of Mr.Ujjwal Verma is insured

with IDV of Rs. 890820/-. Surveyor has assessed the OD claim of this vehicle for Rs.4,79,841.93. As per

relevant policy condition, the insured vehicle shall be treated as a CTL if the aggregate cost of retrieval

and/or repair of the vehicle, subject to terms and conditions of the policy, exceeds 75% of the IDV of

the vehicle. As the loss assessed is much below 75% of IDV, insured’s demand for total loss is not

correct. Offers of insurer for settlement of this claim are as per policy terms and conditions. But, on

categorical enquiry, complainant out rightly rejected the offers of insurance company during the

hearing and repeated his demand to get IDV of vehicle against settlement of his claim.

As company has offered above mentioned three types of settlement to complainant, which are as per

policy terms and conditions, as such no deficiency has been observed on behalf of the company.

Complainant’s demand of IDV of vehicle as claim amount is neither justified nor as per policy terms

and conditions. In view of all this discussion, stand of insurance company in above said claim is justified

and it does not require any interference. Accordingly, the complaint shall deserve to be rejected.

However this award will not restrict insurance company to settle the claim as per terms and conditions

of the policy, if complainant agrees to any of their offer within a reasonable period.

AWARD

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

parties during the course of online hearing, the said complaint is hereby dismissed on merits and

no relief is granted.

( Atul Jerath )

Insurance Ombudsman

February 24, 2022

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 13 r/w 16 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Krishan Dabas Versus Universal Sompo General Insurance Company Ltd.

Complaint Ref. No.: DEL-G-052-2122-0265

1. Name & Address of the Complainant Shri Krishan Dabas,

H. No. 73, VPO Pooth Khurd, Delhi-110039

2. Policy No:

Type of Policy


USG/WEBAG/0211416/00/000

Motor- Private Car Package Policy

29.03.2019-28.03.2020



Krishan Dabas

Krishan Dabas

4. Name of the insurer Universal Sompo General Insurance Company

Ltd.

5. Date of repudiation 27.04.2021

6. Reason for repudiation Non-submission of documents

7. Date of receipt of the complaint 06.01.2022

8. Nature of complaint Closure of claim

17. Brief Facts of the Case: Shri Krishan Dabas (hereinafter referred to as the Complainant) has filed this

complaint against the decision of the Universal Sompo General Insurance Co. Ltd. (hereinafter referred to

as the Insurers) alleging incorrect closure of the theft claim of his private car.


a) Complainant's Argument: The Complainant had taken the Private car package Policy for his Mahindra XUV

500 with Registration No.DL-1-CP-2422 from the Insurers for the period 29.03.2019 to 28.03.2020. The

vehicle was stolen between 23.03.2020 and 24.02.2020 when it was parked at plot no.154/50 Pooth Khurd.

He lodged FIR with P.S. Bawana on 25.03.2020. He intimated the insurers on 24.03.2020 and filed his claim

against the policy. The Untraced report was issued by Delhi District Court, on 28.01.2021. He pursued the

Insurers since May 2020 for settlement of his claim. However, the Insurers closed his claim as there was a

delay in submitting the Untraced Report. He represented against the decision of the insurer and submitted

the Untrace Report of police with them. But they maintained their stand and did not consider the claim.

He then approached this forum for relief.

Case of Krishan Dabas Versus Universal Sompo General Insurance Company Ltd.


b) Insurers Argument: The Insurers in their SCN of 02.02.2022 have stated that the Complainant had taken

a Private Car package policy covering his SUV. The said vehicle was stolen when parked 100 meters away

from his shop. He had intimated the insurers about the theft of the car. Thereafter the claim form was

submitted by him. The Respondent appointed an independent investigator to verify the loss. In order to

assess and analyse the admissibility of the claim, the insurer called for the previous policy, service record,

original RC, DL of the driver who last parked the car and other documents. Since he failed to provide the

same, they referred to policy terms and conditions whereby due observance and fulfillment of those must

be complied by the insured. They repudiated the claim but at the same time have reserved their right to

amend the present version if new facts are brought to their notice.

19. Reason for registration of Complaint: Rejection of claim.


a) SCN, Insurance policy, Investigation report

b) FIR, Untraceable Report.

c) Letter to GRO.

9. Amount of claim Rs 8,97,000/-

10. Date of partial settlement NA

11. Amount of partial settlement NA

12. Amount of relief sought Rs 8,97,000/-

13. Complaint registered under Rule No. of

the Insurance Ombudsman Rules, 2017

Rule 13(1) (b) – any partial or total repudiation of

claim by insurer.

14. Date of hearing/place 07.02.2022, Delhi, Online, Via WebEx

15. Representation at the hearing For the complainant Shri Krishan Dabas, the complainant

For the insurer Ms Sobha Sagarika Panda, Management Trainee

16. Date of Award/Order Recommendation under Rule 16/ 07.02.2021

21. Result of hearing of the parties (Observations and Conclusion):

Case called. Parties are present and recall their arguments as noted in Para 18 above.

At this stage, the Insurers inform that they have since received the documents from the Complainant

and offer to reopen the claim and settle it as per the terms and conditions of the Policy, and seek the

cooperation of the Complainant in securing any further documents that they might require for

processing the claim. The Complainant accepts this offer. Thus an agreement of conciliation could be

arrived at between the Complainant and the Insurers, which I consider as fair and reasonable for both

the parties.

Award


Complainant and the Insurers. Accordingly, the Insurers shall reopen the claim and settle it as per the

terms and conditions of the Policy, and the Complainant shall provide any further documents that the

Insurers might require for processing the claim.

Parties should implement this agreement within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

February 07, 2022




Case of Narender Sharma Versus National Insurance Company Ltd.


17.Brief Facts of the Case: Shri Narender Sharma (hereinafter referred to as the Complainant) has filed

this complaint against the decision of National Insurance Company Ltd. (hereinafter referred to as the

Insurers) alleging wrong repudiation of claim.


a) Complainant's Argument: The Complainant has stated that he left his car DL-3C-CM-0130 at

repairer’s workshop on 31.08.2021 for repair work and change of seat covers & accessories.

Unfortunately, the car was stolen on 07.09.2021 from repairer parking place opposite Savitri

Nagar Kali Masjid in Malviya Nagar where the car was parked. FIR was lodged on 07.09.2021

and intimation of theft claim was also given to Insurance Company on same day. All relevant

documents including Claim Form, FIR &, Court Closure Report, etc. and information were

given to Investigator deputed by Insurers. But Insurance Company repudiated the claim on

11.11.2021 stating that the claim had arisen under contractual liability and was not payable

1. Name & Address of the Complainant Shri Narender Sharma 624, Bans Mohalla, Ghitorni New Village, Delhi-110030

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

39020031211146413038 Private Car Package Policy 24.04.2021 to 23.04.2022

3. Name of Policy Holder Name of Insured

Narender Sharma Narender Sharma

4. Name of the Insurer National Insurance Company. Ltd.


6. Reason for repudiation Loss arising out Contractual Liability not payable as per General Exception 2 of the Policy


8. Nature of complaint Repudiation of Claim

9. Amount of Claim Rs. 220000/-

10. Date of partial settlement N.A.

11. Amount of partial settlement N.A.

12. Amount of relief sought Rs. 220000/--

13. Complaint registered under Rule No. of the Insurance Ombudsman Rules, 2017

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



For the complainant Shri Narender Sharma, the complainant

For the insurer Smt. Sarita Yadav, Manager (Claims), DO-7, Janpath

16. Date of Award/Order Award under Rule 17/ 10.02.2022

as per General Exception 2 of the policy. Complainant represented his case on 12.11.2021

but did not get the claim. Therefore, he has approached this forum for relief.

Case of Narender Sharma Versus National Insurance Company Ltd.


b) Insurer's Argument: The Insurers in their SCN dated 01.02.2022 that the Maruti Ecco car

Regd. No. DL-03C-CM-0130, was given for the accessory’s installation on dt. 31.08.2021 and

the vehicle was parked in front of the Accessories Shop. In the night of 07.09.2021 at about

3.30 a.m. to 4.00 a.m. the vehicle got stolen from the accessories shop. Insured lodged FIR

at Police Station, Malviya Nagar on 07.09.2021 and Insurers received intimation of theft

claim. They deputed Investigator M/s Laxman Dass Arora & Associates on 09.09.2021 to

investigate and find facts for the case. On receipt of investigation report and claim

documents, Insurers securitized the same minutely and it was observed that the vehicle was

stolen from the shop of M/s. Riyazuddin Works where the vehicle was parked for installation

of accessories. The incident seemed to be come under Contractual Liability and as per

General Exception 2 of the policy, The Company shall not be liable to pay the claim arising

out of any Contractual Liability. Hence Insurance Company has rightly repudiated the claim

in accordance with terms and conditions of the policy.

19. Reason for registration of Complaint: Repudiation of claim.


a) Investigation Report

b) Repudiation Letter

c) FIR/Court Closure Report and GRO



The vehicle was handed over by the Complainant to the repairer and it got stolen while it was with the

repairer. As per settled principles, the repairer became the bailee or custodian of the vehicle so long it

was under his custody and was responsible for its safety. Therefore, the Insurers were justified in

repudiating the claim vide General Exception 2 stated in Para 18b above. Pursuantly, the complaint

shall deserve to be rejected.

Award

The complaint is rejected.

(Sudhir Krishna) Insurance Ombudsman

February 10, 2022

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI (Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)


Case of Mohit Sharma versus ICICI Lombard General Insurance Company Ltd.


1. Name & Address of the Complainant Shri Mohit Sharma D-577, Street No.3, Ashok Nagar, Shahdara, Delhi-110093

2. Policy No. Type of Policy Policy term/policy period

3005/49767139/40746/000 Two Wheeler Package Policy 10.01.2021 to 09.01.2022

3. Name of the insured Name of the policy holder

Mohit Sharma Mohit Sharma

4. Name of insurer ICICI Lombard General Insurance Co. Ltd.


6. Reason for grievance Repudiation of Claim



9. Amount of claim Rs.30,918/-



12. Amount of relief sought Rs. 30,918/- as per Form VI

13. Complaint registered under Rule No. of the Insurance Ombudsman Rules 2017

Rule 13(1)(b)- Any partial or total repudiation of claims by an Insurer

14. Date of hearing 17.02.2022

Place of hearing Delhi, Online Video Conferencing via Cisco WebEx


For the complainant Shri Mohit Sharma, the complainant

For the insurer Shri Karan Bagdai, Legal Manager


17. Brief Facts of the Case: Shri Mohit Sharma (hereinafter referred to as the

Complainant) has filed this complaint against the decision of ICICI Lombard General

Insurance Company Ltd. (hereinafter referred to as the Insurers) alleging wrong

repudiation of claim.


a) Complainant's Argument: On 11.02.2021, his two-wheeler No. DL-5S-BA-9669 was

stolen, which his brother Mr. Rohit Sharma has parked in front of Swami Sharad

Anand College, Alipur, Delhi and went to Indian Bank, between 10 am to 12.10 pm.

An FIR was filed at Alipur Police Station on the same day and also intimated to the

Insurance Company. He has submitted all the documents to the Insurance

Company but the insurers repudiated his claim objecting that both the keys are

original but cannot be used in same lockset thus mentioned in the repudiation

letter dated 29.06.2021 that the statements given regarding availability of keys

differs in content and sequence which is contradictory in nature. He approached

grievance department of the Insurers on 09.10.2021 but received no positive and

relevant response from them. So he preferred his complaint before this forum.

b) Insurer's Argument: The Insurance Company, vide Self Contained Note dated

11.02.2022 stated that the Complainant had taken a two wheeler package policy

for his vehicle Hero Motocorp Splendor plus for IDV 30,918/- vide policy no.

3005/49767139/40746/000 for the period 10.01.2021 to 09.01.2022. On receipt of

claim intimation the Company duly appointed an investigator to investigate the

claim. During the course of investigation, the complainant had handed over two

keys to the investigator. On receipt of the keys, the investigator had recommended

for forensic analysis of the keys. As per forensic report both the keys are original

manufacture made, one of the key is used for 4000 strokes and the other key is unused. As

per dimensional analysis, side gear profiles of both the keys are different, both the keys

cannot be used in the same lockset. Thus as per observations made during the

investigation, the statements given by the complainant regarding the availability of

keys differs in content and sequence which seems to be contradictory in nature.

Thus it is very clear that he has misrepresented the facts regarding originality and

usage of the submitted keys, which has resulted into the rejection of the claim as per

terms and conditions of the policy.



a) Copy of policy.

b) Copy of GRO Letter, Forensic report, Claim form.

c) SCN of the Insurer along with enclosures.

21. Result of hearing with the parties (Observations and Conclusion):


The Complainant states that he had given original keys. However, the Insurers had got

the keys verified through a forensic examination and found that both the keys cannot be

used in the same lockset. The Insurers state that as both the original keys of the vehicle were not

available, one key might have been left in the vehicle itself, which could have led to the loss,

whereas the Complainant misrepresented the facts in this regard. Hence they repudiated the claim.

The Insurers agree to share the forensic report with the Complainant. In these

circumstances, it is concluded that the Complainant had not provided the both original

keys of the Insured Vehicle to the Insurers and hence the Insurers were justified in

repudiating the claim. Pursuantly, the complaint shall have to be rejected.

Award


(Sudhir

Krishna)

Insurance

Ombudsman

February 17, 2022



Case of Akhil Baluja versus The Oriental Insurance Company Ltd.


1. Name & Address of the Complainant Shri Akhil Baluja House No.100, Pocket-H/34, Sector 3 Rohini, Delhi-110085


211200/31/2020/1674 Private Car Package Policy 01.04.2019 to 31.03.2020


Akhil Baluja Akhil Baluja

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


6. Reason for grievance Claim closed for non - acceptance of approved amount


8. Nature of complaint Claim closed for non - acceptance of approved amount

9. Amount of claim Rs. 10,00,000/-



12. Amount of relief sought Rs. 10,00,000/- as per Form VI






For the complainant Shri Akhil Baluja, the complainant

For the insurer Smt. Jasvir Rana Bajad, AM, D.O.-2, Karol Bagh, Delhi


17. Brief Facts of the Case: Shri Akhil Baluja (hereinafter referred to as the complainant) has

filed this complaint against the decision of the Oriental Insurance Co. Ltd. (hereinafter

referred to as the Insurers) alleging incorrect closure of claim for non-acceptance of

approved amount.


a) Complainant's Argument: On 17.08.2019, his Car No. HR26CF3744 was stolen from the

parking in front of Honda Bike Showroom, Pocket H-34, Sec 3 Rohini at around 02.01 am

to 06.30 am. An FIR was filed at Rohini Police Station on the same day and also intimated

to the Insurance Company. He submitted all the documents and also non-trace order in

Nov. 2019 but did not receive any response from insurers. He followed up in the month

of Jan.20 and Feb.20 and then Surveyor was appointed on 12.02.2020. Though surveyor

shared the report with the company but he did not receive any update from them. He

again followed up on 27.04.2020 and put forward the mail to the Grievance cell of the

Company. The Company again asked for various other documents in a piecemeal basis,

which he provided. Still the Company closed his claim on 27.01.2021. He approached the

Grievance Department of the Insurers again on 31.01.2021. As he did not receive

positive response from the Insurers, he preferred his complaint before this forum.

Case of Akhil Baluja versus The Oriental Insurance Company Ltd.



11.02.2022 stated that the Complainant had taken a Private car package policy for his

vehicle Toyota Etios HR 26 CF 3744 vide policy no. 211200/31/2020/1674 for the period

01.04.2019 to 31.03.2020. On receipt of claim intimation the Company appointed

investigator to assess the loss. Investigator vide report dated 29.02.2020 concluded the

theft of the car as genuine but made remarks on the IDV of the vehicle. The said policy

was taken from Policy Bazaar with an IDV of Rs.4,55,016/-. However, insured submitted

the purchase bill of vehicle from M/S Easter Industries for Rs.94,695/-. Subsequently the

IDV was checked online for the same vehicle which came in the range from Rs.3,36,086/-

to Rs.3,56,874/-. The insured was offered Rs.3,40,800 on 15.01.2021 subject to

compliance of post approval formalities and then Final Notice sent to insured on

27.01.2021 and claim closed due to Non- compliance of Post approval formalities.



a) Copy of policy.

b) Copy of GRO Letter, Claim form.




The Complainant had purchased the subject insured vehicle (IV) from his employer M/s

Ester Industries on 01.06.2017 as a used car for a sum of Rs. 94,695. He got the vehicle

insured for Rs. 4,55,016 through the online portal Policy Bazaar for the period from

01.04.2019 to 31.03.2020. The IV got stolen on 17.08.2019. He filed claim for the loss of

the IV. The Insurers on 24.07.2020 offered to settle the claim on Replacement Basis

Indemnification by way of providing a car of same make and model citing Condition No.

3 of the Policy. The Complainant disputed this offer and asked for payment of IDV. The

Insurers conducted investigation into the IDV and assessed the value of the car as in the

range from Rs.3,36,086 to Rs.3,56,874 and accordingly offered to settle the claim for Rs.

3,40,800 on 15.01.2021. The Complainant did not accept this offer and hence the

Insurers closed his claim. The Complainant has now submitted this complaint seeking for

payment of the IDV in full. The Complainant states that the IRDAI guidelines support his

claim.

The complaint will have to be examined in the framework of the subject Policy. The

Insurers had determined the sum payable after making investigations in regard to the

IDV. Condition No. 3 of the Policy authorises the Insurers to decide as to whether to

settle the claim of a total loss by way of repairs, reinstatement, or replacement, or

settlement in cash for a sum not exceeding the IDV less the value of the wreck.

Therefore, there was no error on the part of the Insurers vis-à-vis the Policy provisions.

Pursuantly, the complaint shall deserve to be rejected.

Award


(Sudhir

Krishna)

Insurance

Ombudsman

February 17,

2022

PPROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI (Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)


Case of Ankit Kumar Versus ICICI Lombard General Insurance Company Ltd.


1. Name & Address of the Complainant Shri Ankit Kumar 700/45, G.No.15, V Block, Vijay Park, Maujpur, Delhi-110053




Ankit Kumar Ankit Kumar



6. Reason for grievance Claim closed for non –submission of requisite documents (Repair invoice)


8. Nature of complaint Claim closed for non –submission of requisite documents (Repair invoice)

9. Amount of claim Rs.2,64,561/-



12. Amount of relief sought Rs.2,64,561/-as per Form VI






For the complainant Shri Ankit Kumar, the complainant

For the insurer Shri Karan Bagdai, Legal Manager 16. Date of Award/Order Award under Rule 17/17.02.2022

17. Brief Facts of the Case: Shri Ankit Kumar (hereinafter referred to as the


Insurance Company Ltd. (hereinafter referred to as the Insurers) alleging unfair

closure of his claim on the ground of non-submission of requisite documents

(Final Repair Invoice).


a) Complainant's Argument: On 14.12.2020, the Complainant’s brother was

driving the insured vehicle (IV) at the time of accident. After the accident, he left

his car at M/s Viraj Automobiles Pvt. Ltd. for repairs, who gave estimate of

Rs.4,82,975/- for the repairs. The survey was done on 21.12.20 and report was

submitted on 10.06.2021, which is after more than 5 months. Further surveyor

did not consider so many damaged parts of subject vehicle deliberately to show

the repair cost below 75% of IDV. According to survey report, the estimate of

repair came to

Case of Ankit Kumar Versus ICICI Lombard General Insurance Company Ltd.


Rs. 2,00,044 and if cost of damaged parts disallowed by the surveyor Rs. 74,091

is added, then the aggregate cost of repair would be 103% of IDV. So his claim

should be considered for Constructive Total Loss, as the aggregate cost of

retrieval and repair of the IV exceeds 75% of IDV, vide GR -8 of Indian Motor

Tariff. Further salvage being the property of insurer so the insurer should keep

the salvage and there should be no deduction. He followed up for the same, but

the company has closed his claim on 29.06.2021 since they have not received the

final repair invoice. He approached the Grievance Department of the Insurers on

16.09.2021. As he has not received positive response from the insurance

company, he preferred his complaint before this forum.


16.02.2022 stated that the Complainant had taken a Private car package policy

for his vehicle Volkswagen Polo DL8CY1210 vide policy number 3001/W-

106964271/00/000 for the period from June 30, 2020 to June 29, 2021. On

receipt of claim intimation, a surveyor was duly appointed to conduct the survey

and to assess the loss. During the conversation with the Garage/dealer (Viraj

Automobiles Pvt. Ltd.) and the insured, the insured was made aware about the

liability of the Company as well as his own liability to get the insured vehicle

repaired. The estimate was prepared by the Garage for Rs. 4,82,975. The

estimate prepared was on a higher side as it did not take into account

depreciation, salvage, and consumables etc. On receipt of the estimate, the

surveyor had assessed the parts minutely and on the basis of the policy coverage,

the surveyor assessed the liability of the Company as Rs. 1,25,203 after taking

into account depreciation, taxation, salvage, consumables and disallowed parts.

It is also highlighted that the insured is currently the second owner of the vehicle

and model is of 2012. It is also evident from the photographs that the vehicle is

only partly damaged from the right hand side and the rest of vehicle is intact.

Also as per the surveyor findings, the engine assembly was also found intact. Thus

the insured vehicle is repairable and the allegation of insured with regards to the

vehicle being a total loss is totally unjustifiable. As per the surveyor’s assessment,

the necessary parts were allowed and the parts, which were disallowed were

mainly the parts which the Complainant wants to replace by himself. Hence it is

submitted that the Complainant is trying to take undue advantage of the

situation and wants the Company to pay the full amount alongside the

depreciation cost and the additional parts. The Company vide letter dated March

18 & April 17, 2021 had informed him that the claim can be only processed on

receipt of invoices. However, the insured was reluctant and was not ready with

the same. Thereafter, the Company vide letter dated June 29, 2021, had

informed the complainant that the claim is closed in the records. In the light of

the above submissions, it is evident that the Company’s liability under the said

claim is only limited to the extent of terms and conditions of the policy, which

the Company is ready to pay and settle from the day it has been claimed by the

Complainant. However, the Company shall bear no liability regarding garage

parking charges and/or any other incidental charges in connection therewith.



a) Copy of policy.

b) Copy of GRO Letter, Claim form. c) SCN of the Insurer along with enclosures.



The Complainant states that as per his assessment, the vehicle is beyond repairs and

therefore the Insurers should reimburse him the full IDV treating it as a case of Total

Loss. The Insurers had got the damaged vehicle surveyed and after examining the report

of the Surveyor, they determined that vehicle was repairable and, accordingly, they had

proposed to reimburse the cost of repairs after adjusting for depreciation, salvage

value, and Policy excess, as per the Policy Terms & Conditions. This action of the Insurers

was in line with the terms & conditions of the Policy and there was no error on the part

of the Insurers. Therefore, the complaint shall deserve to be rejected.

Award


(Sudhir

Krishna)

Insurance

Ombudsman

February 17,

2022




Case of Madhusudan Kumar Sah versus National Insurance Company Ltd.

Complaint Ref. No.: DEL-H-048-2122-0781

1. Name & Address of the Complainant Shri Madhusudan Kumar Sah 4/13, Ashok Nagar, 2nd Floor, Tilak Nagar, Delhi-110018

2 Policy No:/Certificate No. Type of Policy Duration of Policy/Policy Period

360300502010001497 Parivar Mediclaim Policy 30.06.2020 To 12.06.2021


Madhusudan Kumar Sah Madhusudan Kumar Sah

4. Name of the insurer National Insurance Company Ltd.


6. Reason for repudiation Claim Repudiation under Policy Clause 5.5- Fraud



9. Amount of claim Rs. 134892/-



12. Amount of relief sought Rs. 134892/-



14. Date of hearing/place 22.02.2022, Delhi, Online, Via WebEx & WhatsApp


For the complainant Shri Madhusudan Kumar Sah, the complainant

For the insurer Shri P Krishna Kumar, Deputy Manager, DO-8

16. Date of Award/Order Award under Rule 17/22.02.2022

17.Brief Facts of the Case: Shri Madhusudan Kumar Sah (hereinafter referred to as the Complainant) has

filed this complaint against the decision of the National Insurance Company Ltd. (hereinafter referred to

as the Insurers) alleging wrong repudiation of Mediclaim.

18.Cause of Complaint:

a) Complainant's Argument: The Complainant has stated that he was hospitalized in Tayal Nursing Home,

Delhi from 28.02.2021 to 06.03.2021 for treatment of Covid-19 and incurred hospitalization expenses

Rs. 95900/-. Later, he filed reimbursement claim on 09.03.2021 for amount Rs. 134892/- against

hospitalization expenses and medicines. But Insurance Company repudiated the claim under policy

clause -5.5: Fraud, stating that Insurers shall not be liable to make any payment of a claim if such claim

be in any manner fraudulent or supported by any fraudulent means or device whether by the insured

person by any other person on his behalf. Complainant wrote to GRO on 22.11.2021 but claim was not

paid. Therefore, he has approached this forum for relief.

b) Insurer's Argument: The Insurers in their SCN dated 02.02.2022 have stated that the Complainant was

admitted in Tyagi Nursing Home, Delhi, which is Non PPN Hospital on 28.02.2021 and intimation of

claim was given to TPA on 01.03.2021 vide email. Patient was discharged from the

Case of Madhusudan Kumar Sah versus National Insurance Company Ltd.

Complaint Ref. No.: DEL-H-048-2122-0781

hospital on 06.03.2021 and lodged reimbursement claim of Rs. 134892/- with TPA Safeway on

13.03.2021. On receipt of queries reply from complainant, TPA conducted investigation of the claim.

On scrutinizing the claim documents and investigation report, discrepancies were found as under: No

proper temperature and SPO chart was maintained. Even temperature, SPO and BP was not measured

by the hospital when the patient visited for treatment in emergency. In the RTPCR test report, the CT

point was only 25 (Less moderate value), Ultrasound report was also normal, Bill & Cash receipts issued

by hospital did not contain GST/PAN number. Payment made by cash mode, even though the patient

was staff member of the hospital, but no discount or concession was given to him. Patient is also an

employee of Tyagi Nursing Home in the Pharma Department. Address in policy is same as that of the

Tyagi Nursing Home. Other discrepancies were like difference in signature of IPD nurse, overwriting in

vital chart in value and dates, etc. Looking to these points, claim was repudiated u/s 5.5-Fraud, which

“states that the company shall not be liable to make any payment in respect of any claim if such claim

be in any manner fraudulent or supported by any fraudulent means or device whether by insured

person or by any other person acting on his behalf”. Hence claim was rightly rejected in accordance

with policy terms and conditions.

19. Reason for registration of Complaint: Repudiation of Mediclaim.


d) Discharge Summary

e) Repudiation

f) GRO



The Insurers had conducted investigation into the claim and found that the vital readings of the

patient, including Ultrasound and CT, were nearly normal and many discrepancies such as difference

in signature of IPD nurse, overwriting in vital chart in value and dates, etc. In these circumstances,

the Insurers were justified repudiating the claim under ‘Clause 5.5-Fraud’. Pursuantly, the complaint

shall deserve to be rejected.

Award



February 22, 2022




Case of Rahul Khatri versus Bajaj Allianz General Insurance Company Ltd.


1. Name & Address of the Complainant Shri Rahul Khatri 1036/3, Pana Paposiyan, Narela, New Delhi-110040 Mob: 9999113743

2. Policy No:/Certificate No. Type of Policy Duration of Policy/Policy Period

OG-19-1130-1801-00000329 Private Car Package Policy 20.07.2018 To 19.07.2019


Rahul Khatri Rahul Khatri

4. Name of the insurer Bajaj Allianz General Insurance Company Ltd.


6. Reason for repudiation Non-disclosure of Material Facts, Misrepresentation










17.Brief Facts of the Case: Shri Rahul Khatri (hereinafter referred to as the Complainant) has filed this

complaint against the decision of Bajaj Allianz General Insurance Company Ltd. (hereinafter referred to

as the Insurers) alleging wrong repudiation of Motor Theft Claim.


c) Complainant's Argument: His Skoda-Laura Car Regd. No. DL-13C-1655 was stolen on 18.10.20218 night

from Ramlila Ground, Narela. FIR was lodged at Narela-Rohini e-Police Station on 19.10.2018 and

intimation of theft claim was also given to Insurers. He submitted all relevant documents including FIR,

Untraced Report, Claim Form, etc. and information to Investigator deputed by the Company. He visited

several times Insurer’s office for claim status but no satisfactory reply was given. Later he received

repudiation letter stating that he had willfully misrepresented the material facts at the time of

insurance and at the time of claim for wrongful gain. He wrote to GRO on 10.12.2019 but claim was

not paid. Therefore, he has approached this forum for relief.

d) Insurer's Argument: The Insurers in their SCN dated 02.02.2022 have stated that on receipt of claim

intimation of Skoda Laura Car Regd. No. DL13C1655, Insurers deputed Investigator namely M/s Shailja

Insurance Services for finding the facts of the case and cause of theft/loss of the

Case of Rahul Khatri versus Bajaj Allianz General Insurance Company Ltd.


vehicle. On scrutinizing the claim documents and investigation report, it was observed that IDV of the

vehicle was taken on high price for 9 years old Skoda Laura 2009 model as Rs. 850000/- while as survey

of market value of the same model was Rs. 2 lakh to 3 lakh maximum. Insured with the help of others

had taken policy from Bajaj Allianz for a third hand vehicle and had fabricated the documents of

delivery note on high value of the vehicle for claiming higher income against lower investment in an

old car. As per statement of previous owner Mr. Nitin Sharma that he had sold his car to Mr. Rahul

Khatri for Rs. 150000/- and documents of sale (delivery receipt) for Rs. 900000/- was a forged and false

document. This confirmed that the Complainant had intentionally misrepresented the actual value of

the vehicle and had also prepared the document, which was not confirmed by signee to be valid. The

keys of the vehicle were not original but duplicate. The vehicle due to inbuilt immobilizer system cannot

be opened with any other keys. Thus, it can be assumed that the complainant had not taken reasonable

steps to protect the vehicle from theft or loss, which clearly violated the policy condition 4. Therefore,

claim was rightly repudiated in accordance with policy conditions that the Complainant had willfully

misrepresented the material facts at the time of insurance and at the time of claim for wrongful gain.

19.Reason for registration of Complaint: Repudiation of Motor Theft Claim.

20.The following documents were placed for perusal:

g) Investigation Report

h) Repudiation

i) GRO

21.Result of hearing of the parties (Observations and Conclusion):



For the complainant Shri Rahul Khatri, the complainant

For the insurer Shri Shyama Charan Vats, Legal Manager

16. Date of Award/Order Recommendation under Rule 16/22.02.2022

At this stage, the Insurers offer to make a payment of Rs. four lakh to the Complainant in full and final

settlement of the claim, within 30 days. The Complainant accepts this offer. Thus an agreement of

conciliation could be arrived at between the Complainant and the Insurers, which I consider as fair and

reasonable for both the parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the Complainant and

the Insurers. Accordingly, the Insurers shall make a payment of Rs. four lakh to the Complainant in full and

final settlement of the claim, within 30 days.


February 22, 2022




Case of Lalit Gupta Versus Liberty General Insurance Company Ltd.


1. Name & Address of the Complainant Shri Lalit Gupta K-106, Agarsen Apartments, 66 IP Extension, Patparganj, New Delhi-110092

2. Policy No:/Certificate No. Type of Policy Duration of Policy/Policy Period

201120020119701091700000 Private Car Package Policy 16.03.2020 to 15.03.2021


Lalit Gupta Lalit Gupta

4. Name of the insurer Liberty General Insurance Company Ltd.


6. Reason for repudiation False declaration of No Claim to avail NCB






17.Brief Facts of the Case: Shri Lalit Gupta (hereinafter referred to as the Complainant) has filed this

complaint against the decision of Liberty General Insurance Company Ltd. (hereinafter referred to

as the Insurers) alleging wrong repudiation of Motor Theft Claim.


e) Complainant's Argument: His Maruti Ertiga Car Regd. No. DL-14AC-8147 was stolen on 10-

11.02.2021 night from Patel Nagar, Delhi. He lodged FIR at Patel Nagar Police Station on

11.02.2021 and intimated to Insurance Company regarding theft of vehicle. All documents i.e.,

Claim Form, FIR, Court Closure Report, Keys etc. and other information were submitted to

Investigator/ Insurance Company whenever they required. But the Insurance Company repudiated

the claim via mail dated 30.09.2021 stating that insured had availed NCB on false declaration of

No Claim under previous policy. The Complainant wrote to GRO on 06.10.2021 but did not receive

the claim. Therefore, he has approached this forum for relief.

f) Insurer's Argument: The Insurers in their SCN dated 17.02.2022 have stated that on receipt of

claim intimation of Maruti Ertiga Car Regd. No. DL14CD8147, Insurers deputed Investigator

Case of Lalit Gupta Versus Liberty General Insurance Company Ltd.


namely M/s Jain for finding the facts of the case and cause of theft/loss of the vehicle. On

scrutinizing the claim documents and investigation report, it was observed that complainant had

availed NCB 25% on false declaration of ‘No Claim’ during taking the policy whereas there was

claim under previous year policy issued by Iffco Tokio GIC. As per GR27 of Motor Tariff, insurers

sent mail to Iffco Tokio, the previous Insurers of the subject vehicle for NCB confirmation on

31.03.2020 and received mail on 02.07.2020 from them to the effect that there was claim under

the expiring policy of subject vehicle. This was breach and violation of principles of utmost good

faith and disclosure of material facts, as complainant had taken benefit of NCB on false

declaration and misrepresentation. Therefore, the claim was repudiated in accordance with

policy terms and condition. Demand letter was issued to insured on 16.07.2020 for NCB recovery

for difference of premium in accordance with the process mandated under GR 27 of India Motor

tariff, after obtaining written confirmation of claim from previous insurers. However, the

Complainant failed to pay the same and hence benefit of Section 1 stood forfeited.

19.Reason for registration of Complaint: Repudiation of Motor Theft Claim.


j) Investigation Report

k) Repudiation Letter






For the complainant Shri Lalit Gupta, the complainant

For the insurer Ms Shraddha Kinare, Corporate Legal Manager

16. Date of Award/Order Recommendation under Rule 16/25.02.2022

l) GRO



At this stage, the Insurers offer to settle the claim at 75% of the IDV, that is, Rs. 5,17,500, subject

to the adjustment of Rs. 4,594 towards the NCB dues and Rs. 1,000 towards Policy Excess, the net

amount being Rs. 5,11,906, in full and final settlement of the subject matter. The Complainant

accepts this offer. Thus an agreement of conciliation could be arrived at between the Complainant

and the Insurers, which I consider as fair and reasonable for both the parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the Complainant

and the Insurers. Accordingly, the Insurers shall settle the claim at Rs. 5,11,906, as per details given

above, in full and final settlement of the subject matter.


(Sudhir Krishna)

Insurance Ombudsman February 25, 2022



Case of Kavita Garg versus ICICI Lombard General Insurance Company Ltd.

Complaint Ref. No.: DEL-G-020-2122-0261 1. Name & Address of the Complainant Smt. Kavita Garg

3163/229, Chander Nagar, Trinagar, Delhi -110035


3005/19576912/00/000 Two Wheeler Package Policy 01.03.2020 to 28.02.2025


Kavita Garg Kavita Garg


5. Date of repudiation 29.06.2021 6. Reason for grievance Repudiation of Claim



9. Amount of claim Rs.



12. Amount of relief sought Rs. 60,000/- as per Form VI






For the complainant 1. Smt. Kavita Garg, the complainant 2. Shri Sanyam Garg, s/o the complainant

For the insurer Shri Karan Bagdai, Legal Manager 16. Date of Award/Order Recommendation under Rule 16/ 04.02.2022

17. Brief Facts of the Case: Smt. Kavita Garg (hereinafter referred to as the


Insurance Company Ltd. (hereinafter referred to as the Insurers) alleging wrong

repudiation of claim.


a) Complainant's Argument: On 01.04.2021, her two-wheeler No. DL-8-SCU-1325

was stolen, which she had parked outside the Maharshi Dhyanchand Park B3

near Sabzi Mandi between 7.30 am to 7.55 am. An FIR was filed at Keshav Puram

Police Station on the same day and also intimated to the Insurance Company. She

has submitted all the documents to the Insurance Company but the insurers

repudiated her claim objecting that the keys are not original. She alleged that the

company is making false allegation regarding originality of the keys in order to

not settle the claim. She approached Grievance Department of the Insurers on

04.08.2021 but received no positive and relevant response from them. So she

has preferred her complaint before this forum.


28.01.2022 stated that the Complainant had taken a two wheeler package policy

for her vehicle Honda Motorcycle (Activa G) for IDV 53,517/- vide policy no.

3005/195769212/00/000 for the period 01.03.2020 to 28.02.2025. On receipt of

claim intimation the Company duly appointed an investigator to investigate the

claim. During the course of investigation, the complainant had handed over two

keys to the investigator. On receipt of the keys, the investigator had

recommended for forensic analysis of the keys. As per forensic report, the keys

are of similar nature and can be used in the same lockset, however the

manufacturing of the keys is not originally made by the official company. The

attributes of the key differs from the OEM standards. It is pertinent to note that

the complainant has fabricated the keys with an intention to wrongly take

advantage from the Insurance Company. As per observations made during the

investigation, the statements given by the Complainant regarding the availability

of keys differs in content and sequence, which seems to be contradictory in

nature. Thus it is very clear that she has misrepresented the facts of the case

which has resulted into the rejection of the claim as per terms and conditions of

the policy.



a) Copy of policy.

b) Copy of GRO Letter, Forensic report, Claim form.




At this stage, the Insurers offer to pay a sum of Rs. 40,000 to the Complainant in full and

final settlement of the claim within 30 days. The Complainant accepts this offer. Thus

an agreement of conciliation could be arrived at between the Complainant and the

Insurers, which I consider as fair and reasonable for both the parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between

the Complainant and the Insurers. Accordingly, the Insurers shall pay a sum of Rs. 40,000

to the Complainant in full and final settlement of the claim within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

February 4, 2022




Case of Amit Kumar Panghal Versus ACKO General Insurance Company Ltd.


1. Name & Address of the Complainant Shri Amit Kumar Panghal, H.N. 376, Sector 10, Near Vita Booth. Gurgaon 122001


DCCR00348525293/00 Motor 12.12.2020-11.12.2021


Amit Kumar Panghal Amit Kumar Panghal

4. Name of the insurer ACKO General Insurance Company Ltd.


6. Reason for repudiation No Insurable Interest


8. Nature of complaint Rejection of motor theft claim


10. Date of partial settlement NA

11. Amount of partial settlement NA



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


15. Representation at the hearing For the complainant Shri Amit Kumar Panghal, the complainant

For the insurer Shri Rajesh Dhane, Sr. Director & Head (Litigation)

17.Brief Facts of the Case: Shri Amit Kumar Panghal (hereinafter referred to as the Complainant) has

filed the complaint against the decision of ACKO General Insurance Company Ltd. (hereinafter

referred to as the Insurers) alleging wrong rejection of his motor theft claim.


a) Complainant's Argument: The Complainant had insured his vehicle, a Honda City ZX bearing Registration

no. HR 26AG4342 with the Insurers from 12.12.2020 to 11.12.2021 under Private Car Package policy.

The vehicle was used by his cousin Amarjeet Singh Panghal in Rohtak. The vehicle was stolen from

outside residential premises of Amarjeet Singh situated at Model Town, Rohtak on 25.12.2020. The FIR

was lodged with P.S. Civil Lines on the same date and intimation was given to the insurer also. The claim

was registered by the latter and a surveyor later approached Amarjeet Panghal. Shri Amarjeet was

wrongly directed by the surveyor to file the claim though the ownership of the vehicle was with the

Complainant. The insurer rejected the claim on the grounds that the vehicle was sold by the

Complainant three years before the theft and had no insurable interest in the stolen vehicle. Further,

the vehicle and insurance were not transferred in the name of the new owner and no insurable interest

lay with him either. The Untraced report of the vehicle was given by ACJM, Rohtak on 25.11.2021. He

had represented to the

Case of Amit Kumar Panghal Versus ACKO General Insurance Company Ltd.


insurer’s grievance cell against the rejection but they refused to reconsider the claim. He has now

approached this office to get relief.

b) Insurer’s Argument: The Insurers in their SCN of 01.02.2022 have stated that they had issued the

policy online as per request of the complainant. Amarjeet Singh had lodged the claim with them on

27.12.2020 and they appointed an independent investigator to verify and assess the loss. The

investigation revealed that Amarjeet Singh had no insurable interest in the stolen vehicle and the

same was apprised to him. Amarjeet Singh gave them a notarized stamped statement stating that

the vehicle was purchased by him from the complainant three years before the reported loss.

Further, the complainant had also given them a statement that RC and Insurance policy were not

transferred as it was a family matter. The transfer of RC and Insurance policy is a mandatory

requirement under MV Act. There is a violation of the provision of GR 17 of India Motor Tariff

whereby the transferee has to apply for transfer of Insurance Policy within 14 days of the transfer of

vehicle with RC details and pay a requisite fee. The transferee will then be provided with a new

proposal form for Own Damage Section and the policy will incorporate the benefits for which he will

be entitled. Thus there was no insurable interest and there is no deficiency on their part as regards

the complaint. They have refuted the statement of the complainant that he never sold the vehicle to

Amarjeet Singh and that surveyor had suggested the latter to state that he owned the vehicle. They

maintain that they are justified in not indemnifying the complainant within the policy terms and

conditions.

19.Reason for registration of Complaint: Rejection of claim.



a) SCN, Policy, Investigation Report.

b) GR 17 of IMT, FIR, FR.

c) Letter to GRO.



The claim was filed by Shri Amarjeet Singh, who had informed the Insurers through a notorised

affidavit that he had purchased the vehicle from the Complainant 3 years ago for a consideration

of Rs. 2.80 lakh. However, the RC and the Insurance policy were not duly transferred. Therefore, as

on the date of the loss, the vehicle was still in the name of the Complainant, whereas the claim was

filed by Shri Amarjeet Singh, who was the de facto owner of the vehicle, but had not got the RC and

the Insurance policy duly transferred in his name. In these circumstances, the Insurers were

justified in repudiating the claim. Pursuantly, the complaint shall deserve to be rejected.

Award


(Sudhir Krishna)

Insurance Ombudsman

February 07, 2022




Case of Arvind Sikka Versus Go Digit General Insurance Company Ltd.


17.Brief Facts of the Case: Smt. Arvind Sikka (hereinafter referred to as the Complainant) had

filed this complaint against the decision of Go Digit General Insurance Company Ltd. (hereinafter

referred to as the Insurers) alleging inadequate settlement of the own damage claim of her car.


g) Complainant's Argument: The Complainant had insured her vehicle, Toyota Corolla Altis bearing

Registration no. HR 51 AE 7284 with the Insurers under Digit Private Car Package policy. The

vehicle met with an accident on 20.11.2021 and it was taken to the repairer Regent Motors and

Go Digit representative surveyed the vehicle. The complainant has stated that the insurer did not

allow the amount pertaining to the damage sustained by the vehicle on the left side. They have

not allowed the same as she did not take spot photographs at the time of the accident. The other

vehicle involved in the accident had fled the spot and there was no traffic cop present at that

time. She represented against the decision of the insurer but they did not agree to pay the balance

amount. She then approached this forum for relief.

1. Name & Address of the Complainant Smt. Arvind Sikka, 812, Sector 14, Faridabad -121007


D033611221

Motor 15.07.2021-14.07.2022


Arvind Sikka Arvind Sikka

4. Name of the insurer Go Digit General Insurance Company Ltd.

5. Date of repudiation NA



8. Nature of complaint Inadequate settlement of claim.

9. Amount of claim Rs 16520/-

10. Date of partial settlement 02.12.2021

11. Amount of partial settlement Rs 2963/-

12. Amount of relief sought Rs 13557/-


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


15. Representation at the hearing For the complainant Smt. Arvind Sikka, the complainant

For the insurer Shri Sandeep Mohanty, Asst. Manager (Corporate Legal)


Case of Arvind Sikka Versus Go Digit General Insurance Company Ltd.


h) Insurer’s Argument: The Insurers in their SCN of 03.02.2022 have stated that the Complainant on

22.11.2021 gave the intimation of accident. They appointed a surveyor who visited the workshop

to ascertain and assess the loss. The Complainant had stated that the vehicle had met with the

accident on a busy roundabout, sustained damage on the front side as the vehicle ahead applied

the brake and another vehicle on the left side dashed against the insured vehicle. However a

closer examination of the photographs shows that the damages on the left side were old. Thus

they did not allow the repair charges of the front left side door, fender and front bumper. These

damages did not tally with the cause of loss. They made a payment of Rs.2912/- towards the

repairs to the workshop. The narration of the accident as given by the Complainant does not

match with the damages and there is no supporting evidence either. They have stated that they

are justified in disallowing the expenses incurred for repairing the said damages. They have

denied any deficiency of service on their part.

19. Reason for registration of Complaint: Inadequate payment of claim.


a) SCN, Policy, Photographs.

b) Vehicle repair order, Vehicle delivery order.

c) Letter to GRO.



The Insurers had appointed a Surveyor to ascertain and assess the loss. After obtaining the report of

the Surveyor, the Insurers concluded that the Right side damages were tallying with the claimed

cause of loss and were reimbursed. However, the Left hand side damages were not tallying with the

claimed cause of loss and hence were disallowed. The documents submitted by both the parties do

not give any justification to disagree with the settlement of the claim, which was based on the report

of the surveyor. In these circumstances, the complaint shall deserve to be rejected.

Award


(Sudhir Krishna) Insurance

Ombudsman February 07, 2022




Case of Abin R versus United India Insurance Company Ltd.


1. Name & Address of the Complainant Shri Abin R 11 E, Pocket-I, Dilshad Garden, Delhi-110095


1014813120P110087698 Motorcycle/Scooter Standalone Own Damage Policy 13.12.2020 to 12.12.2021


Abin R Abin R

4. Name of insurer United India Insurance Company Ltd.


6. Reason for grievance Rejection of Motor Claim


8. Nature of complaint Rejection of Motor Claim

9. Amount of claim Rs.5,781/-



12. Amount of relief sought Rs.5,781/- as per Form VI






For the complainant Shri Abin R, the complainant

For the insurer Shri Manu P, Asst. Manager, DO-2, Trivandrum

16. Date of Award/Order Recommendation under Rule 16/ 18.02.2022

17. Brief Facts of the Case: Shri Abin R (hereinafter referred to as the complainant) has filed this

complaint against the decision of United India Insurance Company Ltd. (hereinafter referred

to as the Insurers) alleging wrong rejection of Motor Claim.


a) Complainant's Argument: He purchased the subject Own Damage Policy for two-wheeler

Regn. No. KL 22N 5853 in December 2020 from the official website of the Insurance Company.

He created login with his details and entered the vehicle details including the correct RC

Owner name in the portal but the policy was generated in his name after the premium

payment. He noticed it and tried calling their toll-free number but in vain and thought it would

be ok. He registered claim on 15.07.2021 after the vehicle met with accident on 13.07.2021

and survey was completed after Public Grievance complaint. He submitted other documents

as required by the Insurers but his claim was rejected on the grounds that the name on the

policy document (himself, Abin R) and the name on the RC (wife’s name, Jnana NJ) were

different. Insurers had no objections in generating the policy with incorrect names, accepting

the premium, doing the survey of damaged vehicle and asking for further documents for

processing but had objections in

Case of Abin R versus United India Insurance Company Ltd.


settling the claim. He complained to IRDAI but the Insurers still did not consider the claim.

Hence, he approached this office for relief.

b) Insurer's Argument: The Insurance Company, vide Self Contained Note has stated that the

Complainant Shri Abin R had taken policy through online and claimed for Motor own

damage claim in OD Hub Delhi, who deputed the surveyor for assessment of loss. The

Surveyor assessed the loss for Rs.3,467/- after deduction of excess. On verification of vehicle

documents, it was found that RC owner of the vehicle KL 22N 5853 was in the name of Jnana

N J. Hence the claim was repudiated on the basis of no insurable interest of

insured/Complainant in the policy. They also cancelled the Policy as per insured’s request

and refunded the premium Rs. 64/- on 17.11.2021. The Insured had taken the online policy

for his wife’s vehicle entering all the details and did not approach them for correction of

name of registered owner after taking the policy.

19. Reason for registration of Complaint: Rejection of Motor Claim.


a) Copy of policy.

b) Copy of Rejection Mail, GRO, Registration Certificate.

c) SCN of the Insurers along with enclosures.



At this stage, the Insurers offer to settle the claim on non-standard basis at 75% of the assessed loss

of Rs. 3,467. The Complainant accepts this offer. Thus an agreement of conciliation could be arrived

at between the Complainant and the Insurers, which I consider as fair and reasonable for both the

parties.

Award


Complainant and the Insurers. Accordingly, the Insurers shall settle the claim on non-

standard basis at 75% of the assessed loss.



February 18, 2022




Case of Gandharv Rana versus National Insurance Company Ltd.


17.Brief Facts of the Case: Shri Gandharv Rana (hereinafter referred to as the Complainant) has filed

this complaint against the decision of National Insurance Company Ltd. (hereinafter referred to as the

Insurers) alleging wrong repudiation of claim.


c) Complainant's Argument: He had taken the policy for his Hyundai Creta-2019 Car Regd. No.

HR26DX9145 through PolicyBazaar from National Insurance Co. Ltd. The vehicle was stolen on

19.02.2021 morning around 4.50 to 5.00 a.m. FIR was lodged on the same day. Insurance Company

was also intimated and all documents i.e. Claim Form, FIR, Final Report, Court Closure Order, RC, etc.

and other information were submitted as and when asked by Investigator and Insurance Company.

But Insurance Company repudiated the claim stating that pre-inspection was not done while taking

the policy, claim was not filed on time, vehicle was not safely parked & locked, etc. He submitted

clarification of each query but the claim was not paid. He wrote to GRO on 21.12.2021 but did not

get the claim. Therefore, he has approached this forum for relief.

1. Name & Address of the Complainant Shri Gandharv Rana 18-D, DDA Flat, Mansarovar Park, Shahdara, Delhi-110032

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

36140031206801584978 Motor-1 Year OD Policy 19.02.2021 to 18.02.2022

3. Name of Policy Holder Name of Insured

Gandharv Rana Gandharv Rana

4. Name of the Insurer National Insurance Company. Ltd.


6. Reason for repudiation Notice of claim not given immediately, reasonable steps to safeguard the vehicle from loss not taken and false declaration & concealment of facts in the proposal form


8. Nature of complaint Repudiation of Claim







14. Date of hearing/place 22.02.2022, Delhi, Online, Via WebEx & WhatsApp


For the complainant 1. Shri Gandharv Rana, the complainant 2. Shri Harendra Singh, F/o the complainant

For the insurer 1. Ms Vandana Chawla, Manager, DRO-2, Delhi 2. Ms Saroj Kshetrapal, Asst. Manager, DO-1, Gurgaon

16. Date of Award/Order Award under Rule 17/22.02.2022

d) Insurer's Argument: The Insurers in their SCN dated 03.02.2022 that the Hyundai Creta Car Regd. No.

HR26DX9145 was initially insured from HDFC ERGO in the name of Mr. Bhajan Lal with policy no.

Case of Gandharv Rana versus National Insurance Company Ltd.


2311100743025200000 for period 26.02.2020 to 25.02.2021. The subject vehicle was purchased by

Gandharv Rana on 27.11.2020 and the RC was transferred in his name on 15.01.2021 but no

endorsement to the effect of change of ownership was done in HDFC ERGO Policy and the vehicle

was uninsured for its Own Damage portion for a period of around 1 month. Complainant purchased

new Policy (Stand-alone OD Cover) from the Insurers through Online Portal of PolicyBazaar.com vide

policy no. 36140031206801584978 for period 19.02.2021 to 18.02.2022, covering the same vehicle

by giving false declaration in the proposal form. Theft claim intimation was given on 22.02.2021 i.e.

after 3 days of theft and investigator M/s Delta Detective were deputed for investigation of claim. On

receipt of investigation report, claim documents and investigation report were scrutinized and it was

found that Insured avoided pre-inspection by concealment of facts in the proposal form submitted

to policy bazaar while taking the policy. Pre-inspection was mandatory in case of change of ownership

of the vehicle. Pre-inspection was also mandatory while taking Add-On cover, which increase the

liability of Insurers. In CCTV Footage produced by the Complainant, the vehicle Registration No. was

not visible. Therefore, claim was repudiated under violation of “(a) Policy Condition 1- Notice of loss

was not given immediately on occurrence of theft. (b) Violation of Policy condition 4- The insured did

not take all reasonable steps to safeguard the vehicle from the loss or damage. Whereas the vehicle

was parked in the vacant area outside insured’s house. Violation of Policy Condition 8- There were

false declaration and concealment of facts in the proposal form submitted by the insured”. Hence the

claim was rightly repudiated in accordance with terms and conditions of the policy.

19.Reason for registration of Complaint: Repudiation of claim.


m) Investigation Report

n) Repudiation Letter

o) FIR/Court Closure Report and GRO

21.Result of hearing of the parties (Observations and Conclusion):


The Complainant had taken the Policy from the portal policybazaar effective from 19.02.2021 00.00

hrs and reported that theft had occurred after 5 hours of the commencement of the Policy, but

informed the Insurers about the theft after 3 days, on 22.02.2021. The Insurers conducted investigation

into the claim and found that the Insured avoided pre-inspection by concealment of facts in the

proposal form submitted through policy bazaar while taking the policy. In the proposal form, the

Complainant had misrepresented the details of the previous ownership and previous insurance

particulars. In these circumstances, the Insurers were justified in holding that the Complainant had

misrepresented the facts and in repudiating the claim on the grounds of the Policy conditions stated in

para 18b above. Pursuantly, the complaint shall deserve to be rejected.

Award



February 22, 2022

PROCEEDINGS BEFORE

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

OMBUDSMAN – SOMNATH GHOSH CASE OF:: Complainant :Mr. BARNALI SAIKIA VS RELIANCE GENERAL INSURANCE CO.LTD.

COMPLAINT REF NO: GUW-G-035-2122-0078: Award No

1. Name & Address of the Complainant MRS.BARNALI SAIKIA

2. Policy No:

Type of Policy

SUM INSURED


TRG/00063128

PRIVATE CAR PACKAGE POLICY

RS.705348

12/04/2020 TO 11/04/2021



MRS.BARNALI SAIKIA MRS.BARNALI SAIKIA

4. Name of the insurer RELIANCE GENERAL INSURANCE CO.LTD.

5. DETAILS OF LOSS RS.249591/-

6. REASON FOR GRIEVANCES. PARTIAL SETTLEMENT

7.a

7.b

Nature of complaint

Date of receipt of the complaint

PARTIAL SETTLEMENT

18/01/2022

8. Amount of Claim RS.156000/-

9. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(a)

10. Date of hearing/place 22/02/2022


• For the Complainant MR. HIRANYA BORAH

• For the insurer Mr.JOSHOBONTO KOTOKY & MR.PRADIP

MUKHERJEE

12 Complaint how disposed AWARD


17) Brief Facts of the Case: Mrs. Barnali Saikia had a Private Car package policy with Reliance

General Insurance Co. Ltd. On 18/03/2021 her Toyota Innova Car bearing registration no

AS02N4418 had met with an accident when Insured was driving towards Koliabor from Nagaon

town at the place namely Singimari. Insurance Co. appointed one surveyor. But the insured is

dissatisfied with the extent of loss arrived by the surveyor as the Gargya Toyota has charged the

total bill of Rs.249591 and the surveyor has approved the amount of Rs.88779/-.

18 a) Complainant’s Argument: The complainant stated that accident of her Toyota Innova was genuine.

The surveyor also visited the spot of the accident and also discussed the happening of loss with the local

residents & the surveyor allowed the replacement of Hood, Front Bumper, Mirror RHS AND LHS and Front

Windscreen glass with rear of roof. She also stated that the surveyor has not shared the reasons of

disallowed items as the surveyor was directly dealt with the workshop.

18 b) Insurers’ argument: The Insurance Co. stated in their SCN that the surveyor has appointed and assessment was made in which front bumper already repaired by screw previously. The surveyor has found that LH support was found heavily rusted and repaired, LH side head lamp was old in nature and found damaged and the reflector was yellowish in nature. The rear both sides lamp and doors of the vehicle was damaged and the same are not consistent with the cause of loss and as such the following request for repairs were disallowed. The surveyor on his assessment found that the damages as the insured claiming are pre existing damages and same does not coincide with the nature of loss as mentioned in the claim form. The insurance co. also stated the surveyor on his assessment found that the damage does not coincide with the nature of loss as mentioned in the claim form. 19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule

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

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N

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

for hearing on22/02/2022 .The complainant was represented by Mr. Hiranya Borah Husband of the complainant(Online) and the insurer was represented by Mr. Joshobonto Kotoky & Mr. Pradip Mukherjee (online).

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

as well as verbal submission made by the claimant and representative of insurance co. We have also gone through the records. During the course of Hearing the complainant insured stated that the insurer has wrongly deducted his claim amount. He mentioned that after his vehicle met a frontal accident, there were further damages while retrieving the vehicle. However he also admitted that the vehicle did not require towing and there were some earlier damages in the front side.

The representative of the insurance co. stated that the survey was done by IRDA licensed surveyor and claim amount paid by them is as per the loss assessment by the surveyor. Items

damaged which are not as per the accident occurred or which are rusted and having pre-existing damages have not been allowed as per process.

This Forum have taken note of the submission made by the contesting parties & do not find any deficiency on the part of the respondent insurance co.

Hence the complaint is treated as closed. Dated at Guwahati the 22nd Day of February 2022

PROCEEDINGS BEFORE

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

OMBUDSMAN – SOMNATH GHOSH CASE OF:: Complainant :Mr .DEBORSHI KUMAR NATH VS HDFC ERGO GENERAL INSURANCE

CO.LTD.

COMPLAINT REF NO: GUW-G-018-2122-0074: Award No

1. Name & Address of the Complainant MR.DEBORSHI KUMAR NATH ,NAGAON

2. Policy No:

Type of Policy

SUM INSURED


2312202872613500000

MOTOR INSURANCE

RS.107512/-

17/07/2019 TO 16/07/ 2020



MR.DEBORSHI KUMAR NATH MR.DEBORSHI KUMAR NATH

4. Name of the insurer HDFC ERGO GENERAL INSURANCE CO.LTD.

5. DETAILS OF LOSS Rs.107512/-

6. REASON FOR GRIEVANCES. DENIAL OF CLAIM

7.a

7.b

Nature of complaint

Date of receipt of the complaint

DENIAL OF CLAIM

03/01/2022

8. Amount of Claim RS.107512/-

9. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(a)

10. Date of hearing/place 16/02/2022


• For the Complainant MR.DEBORSHI KUMAR NATH

• For the insurer MS SASWATA BANERJEE

12 Complaint how disposed AWARD


17) Brief Facts of the Case: The complainant Mr.Deborshi Kumar Nath had a Motor two-wheeler policy with

HDFC ERGO GENERAL INSURANCE CO.LTD for a BAJAJ AUTO PULSOR. On 26/10/2019 he could notice that

the said vehicle was missing from his campus. So he lodged an FIR before the Jalukbari Police Station. After

that he informed and submitted all the required documents to the insurance Co. within two months of the

incidence except the Final Police Report. Mr. Nath received the Final Report from the Court on 04/12/2020

and he submitted it to the surveyor on 05/12/2020. When he enquired about the status of the claim after

few days of submission of Final Report, he was informed that the delay for processing of claim was due to

deficiency of staff during pandemic. But on 28/06/2021 from the surveyor he could know that the claim was

rejected due to delay of Final Report Submission. Finding no alternatives he sent a legal notice dated

12/08/2021 through an advocate to the HDFC ERGO & on 25/08/2021 HDFC ERGO GENERAL INSURANCE CO.

sent him a reply to legal notice dated 12/08/2021 and stated that the policy holder did not submit the

certified FIR and FINAL REPORT, RC particulars and service History of the Vehicle and also stated that the

said company is yet to receive any of the aforementioned documents.

18 a) Complainant’s Argument: As stated in point No.17

18 b) Insurers’ argument: The Insurance Co. stated in their SCN that ,on receipt of the claim intimation, the complainant was sought to submit the claim form and other documents vide letter dated 29/01/2019 and reminder letter dated 26/10/2019,23/01/2020 was issued to the complainant regarding some of the documents and amongst them, he had submitted several documents ,but he had not submitted the below mentioned documents in spite of repeated reminders and hence the claim of the complainant was closed for non cooperation. Below mentioned documents pending from insured a) RC particular b) Last service history of the vehicle c) Certified FIR and final report. 19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule

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

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N

Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for hearing on 16/02/2022 .The complainant was represented by Mr. Deborshi Kumar Nath(Online) And the insurer was represented by Ms.Saswata Banerjee (online).

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

well as verbal submission made by the claimant and representative of insurance co. We have also

gone through the records. During the course of the Hearing , the Complainant Insured stated that

immediately after the Theft of his insured two wheeler, he had lodged FIR with Police and

intimated to the Insurer. All available documents were provided to the Investigator appointed by

the Insurer who has investigated the matter. However the Insurer had Closed his claim due to non-

receipt of Police Final Report which is beyond his control and the delay could also be explained

due to Covid related restrictions. He informed that the Police Final Report is available and

submitted to Insurer and therefore his claim should be settled.

The representative of the Respondent Insurance Company stated that the claim was Closed due to

non-submission of RC Particulars, Last service History of the Insured vehicle and Certified copy of

FIR and Police Final Report. However, she admitted that Service History of the vehicle was not a

mandatory requirement. She was also unable to reply as to why the Insurer did not take any

initiative to obtain the RC Particulars having got the RC copy and the Certified copy of Police Final

Report having got a photocopy.

This Forum has taken the initiative to appoint an Investigator to obtain the RC Verification from the

DTO Office and found the same to be genuine. A copy of the same is attached with this Order. The

Complainant Insured has further mailed a certified copy of the Final Police Report to this Forum

which is found in order. The chronology of events is given hereunder;

• The Theft happened on the night of 25.10.19 and Detected on 26.10.19

• FIR lodged on 26.10.19 and Insurance Company intimated on 26.10.19

• Report dated 07.04.20 of Investigator appointed by Insurance Company confirms that the

Theft appears Genuine

• Final Police Report confirming the FIR but having no clue on the culprits put up and duly

Accepted by the SDJM on 04.12.20 and notified on 05.12.20.

In view of the above, this Forum finds no reason for continued non-payment of the claim. The

Respondent Insurance Company is Directed to settle the claim on payment of Rs 107512 being the

IDV less applicable Policy Excess. The Insurance Company is also Directed to intimate the Theft to

the concerned office of the Transport Department as per procedure.

The Complaint is hereby treated as CLOSED.

The attention of the complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rule 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 of the same to the Ombudsman.

Dated at Guwahati the 18th Day of February 2022

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017(as amended till date) OMBUDSMAN – Mr. RAJIV DUTT SHARMA

CASE SANTOSH KUMAR GARG V/S IFFCO TOKIO GENERAL INSURANCE COMPANY LIMITED. COMPLAINT REF: NO JPR- G- 023- 2122-0193

AWARD NO: IO/JPR/GI/A/2122/00 1. Name & Address of the Complainant Mr. Santosh Kumar Garg , Jaipur

2. Policy No:

Type of Policy


Sum Insured

MK466275

Private Car Package Policy

12.07.2021 to 11.07.2022

Rs. Rs.228120

Name of the insured


Sh Santosh kumar Garg

Sh Santosh kumar Garg

4. Name of the insurer IFFCO TOKIO General Insurance Company Limited


6. Reason for repudiation Deduction of Voluntary Excess amount from the claim

amount.


8. Nature of complaint Partial settlement


10. Date of Partial Settlement Rs. 4649/- paid



Rule no: of IOB rules

13 i (b)

13. Date of hearing/place 23.02.2022/ Jaipur Video conferencing Go to meeting


a) For the Complainant Sh Santosh kumar Garg

b) For the insurer Mr. Peeyush jain, Sr Executive



17) Brief fatcts of the Case.: Mr.SANTOSH KUMAR GARG (herein after referred to

as the complainant) had filed a complaint against the decision of IFFCO TOKIO General

Insurance Company Limited (herein after referred to as the respondent Insurance Company)

alleging deduction of an amount Rs 15000/- the voluntary excess from Motor vehicle

accident claim amount .The Insurance Company is insisting to deposit the voluntary excess

amount for removal of the clause which will be applicable for next renewal and not on the

current policy..


(a)Complainant’s argument; Mr. Santosh Kumar Garg submitted that his Hundai I 20

Magna CRDI RJ-14-CP-8174 was insured from IFFCO TOKIO General Insurance

Company Limited under the Policy No.MK466275 for the period from 12.07.2021 to

11.07.2022 for a sum insured of Rs. 228120. The complainant submitted that he had filed a

claim for his vehicle for Rs. 23500/- where as the insurance company approved only Rs.4600/-

after deducting Rs. 15000/- from the claim amount which was deducted against the voluntary

excess opted at the time of taking the policy by the insured. The Insurance Company has written

to the complainant to deposit Rs.15000 for removal of the voluntary excess. The complainant

approached to GRO for reconsideration of the Motor claim, but he could not get any relief from

the Insurance Company. Being aggrieved the complainant approached this forum for redressal

of his grievance.

(a) Insurer’s argument: - The Insurance Company submitted in its SCN dated

17.02.2022 that the said car was insured with respondent and a claim was lodged by the

customer on 08.11.2021 claiming that vehicle sustained damages on 08.11.2021 .Mr. Siddharth

Sharma Surveyor was appointment to assess the loss. He submitted his report of Rs.4649/- after

deducting applicable depreciation and voluntary excess as per policy condition. The Insurance

Company further submitted that at the time of policy inception insured had taken the discount

of voluntary excess (IMT 22A) from the policy premium .Voluntary excess in the questioned

policy is Rs.15000/- and the claim has been dealt with diligently by the Insurance Company as

per policy conditions, survey report and in accordance with the provision of IMT

22A.Insurance Company has appealed to dismiss the complaint as it devoid of any merit.

19) Reason for Registration of Complaint: - Case of partial settlement of insured vehicle

claim


a) Complaint Letter

b) Policy copy and policy conditions, GRO letter

c) Rejection letter

d) Survey Report

e) Form VI A duly signed by the complainant.

f) SCN and Annex VII A duly signed

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

parties appeared in the personal hearing through videoconference and reiterated their

submissions. The complainant submitted that he was a customer with the respondent since last

3 years through DSA, however he renewed his current policy through a online link. During

policy issuance through policy bazaar a popup for voluntary discount for discount for Rs. 800/-

was noted. The complainant availed the same and policy was generated. His insured vehicle

met with an

accident at Dausa and the survey was done. He paid Rs. 23500/- and collected the vehicle

whereas the Insurance Company settled the claim for Rs. 4649/- and deducted Rs. 15000/-

towards voluntary deductible. He submitted that at the time of policy issuance he was not aware

of the same clause and there were no details of deductible applicable. Now he requested the

Insurance Company to collect the discount and allow his the amount deducted but Insurance

Company refused for it. The Insurance Company submitted that in the instant case the claim

was subject to voluntary deduction for an amount of Rs. 15000/- as per policy IMT clause 22A.

The insured exercised the option for the same and availed a discount for Rs. 802/-.The vehicle

met with an accident after 4 months of issuance of the policy and the insured never raised any

objection towards coverage, add-on and exclusion of the policy.

On perusal of the documents placed on the record and submission made during the video

hearing, it is observed that the complainant exercised option to avail discount of Rs. 802/-. He

has obtained the policy through online portal through a link. The Insurance Company share the

screen shots describing policy issuance process and it was found that at the pop up of voluntary

deduction (i) it was mentioned that an additional amount which you agree to pay at the time

of claim in exchange of reduced premium for Rs. …. The amount is over and above the

mandatory deductible for every claim. The offer made by the insured for refund of Rs. 802/-

for the said claim cannot be considered as any change subsequent to the claim will not modify

any condition in the instant claim. The Insurance Company also submitted copy of policy and

it was found that at page no. 2 it was specifically mentioned that voluntary deductible for Rs.

15000/- under section 1 shall apply. In view of the facts and circumstances, I find no reason

to interfere with the impugned order. The complaint is dismissed.

Accordingly, the complaint is hereby dismissed.

21)


provisions of Insurance Ombudsman Rules, 2017:

c. According to Rule 17(5) of Insurance Ombudsman, A copy of the award shall be sent to

the complainant and the insurer named in the complaint. Rules, 2017.

Place: Jaipur. Rajiv Dutt Sharma

Dated: 24.02.2022 Insurance Ombudsman

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017(as amended till date) OMBUDSMAN – Mr. RAJIV DUTT SHARMA

CASE RAMCHANDRA JAT V/S NUNIVERSAL SOMPO GEN. INSURANCE CO. LTD. COMPLAINT REF: NO. JPR-G-052-2122-0196

AWARD NO: IO/JPR/GI/A/2122/00 1. Name & Address of the Complainant Mr.Ramchandra Jat, Iedava(Nagaur)

2. Policy No:

Type of Policy


Sum Insured

2311/61856240/00/000

Private Car insurance Policy

17.09.2020 to 16.09.2021

Rs.1100000/-



Mr. Ramchandra Jat

Mr Ramchandra Jat

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


6. Reason for repudiation Cause of loss do not collaborate with the accident .


8. Nature of complaint Non settlement of claim.


10. Date of Partial Settlement NIL




13 i (b)

13. Date of hearing/place 28.02.2022/ Jaipur Video conferencing Go to meeting


a) For the insured Mr Ram Chandra Jat

b) For the insurer Sh Prashant Shukla

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 complaint is hereby dismissed.



17) Brief fatcts of the Case.: Mr. Ram Chandra Jat ( herein after referred to as the

complainant) had filed a complaint against the decision of Universal Sompo General

Insurance Co.Ltd. ( herein after referred to as the respondent Insurance company) alleging

Non-Settlement of his Motor accident claim of vehicle No. MH-01-AX-3474 covered under

Pol. No. 2311/61856420/00/000 for Rupees 1100000/-.


(a) Complainant’s argument: Mr. Ram Chandra Jat submitted that his private car Skoda

Superb.reg. No. Mh-01-AX-3474 was insured from Unversal Sompo General Insurance Co.

Ltd. under the Policy No. 2311/61856420/00/000 for the period from 17.09.2020 to 16.09.2021

for a sum insured of Rs.1100000/- The complainant submitted that he had filed a claim for his

vehicle for which burnt in fire for Rs.11,00,000/-. The said claim has been rejected by the

respondent co. vide their letter dated 14.12.2021 on ground that claim did not collaborate with

the accident. The complainant approached GRO of the Company vide his letter dated

17.12.2021 for reconsideration of the claim, but he could not get any relief from the Insurance

company. Being aggrieved the complainant approached this forum for redressal of his

grievance.

Insurer’s argument: - The Insurance Company submitted in its SCN dated 25.02.2022 that

the said four-wheeler vehicle SOKDA bearing registration No. MH-01-AX-3474 was insured

as a private car under insurance policy No.2311/618564220/00/000 of IDV Rs.11,00,000/-

from Universal Sompo General Insurance Company Ltd from 17.09.2020 to 16.09.2021. The

subject vehicle met with an accident on 11.08.2021 when it was coming from Shivpuri to Kota

at around 04.15 A.M. The respondent company stated that, after claim intimation Mr. Vinod

Kumar Jain Surveyor was appointed to assess the loss and Shri Piyush Sharma independent

investigator was appointed to verify the actual facts of accident .The respondent Company in

their SCN submitted that the vehicle was totally burnt and the brother of complainant was not

injured. Insurance company noted the negligence in maintenance as the vehicle was not

serviced for more than 4 years. The place was a lonely and jungle area where the incident took

place . No toll receipts were provided by the complainant which could prove passing of vehicle

from Shivpuri to kota. The vehicle was in a Partnership dissolution agreement and no sale

agreement or mode of payment was provided by the complaint. During investigation it was

observed that the mobile of the brother /driver’ google timeline did not match with the written

statement. During investigation it was also found that fire would not have originated in the

engine compartment of the vehicle. Evidence of mechanical failure was lesser. As per RC

book the insured is the third owner and model belongs to year 2011 and as per authorized

valuation services the market price of the vehicle is between Rs. 145947 to Rs.723000/- On

looking into vehicle insurance previous history it was found that the value of vehicle on sales

dated 25.09.2020 was Rs. 575000/- and the IDV has taken just double which should be lesser

that previous years.

19) Reason for Registration of Complaint: - Case of Non settlement of insured vehicle claim


g) Complaint Letter

h) Policy copy and policy conditions, GRO letter

i) FIR, Rejection letter, investigation report

j) Form VI A duly signed by the complainant.

k) SCN and Annex VII A duly signed

21.) Result of hearing with both parties (Observations and Conclusion) :- Both the

parties appeared in the personal hearing through videoconference and reiterated their

submissions. The complainant submitted that the vehicle was purchased during a Partnership

dissolution agreement before 4-5 years back. The complainant did not get insured the vehicle

for last 3-4 years though model of his vehicle was 2011. The complainant submitted that he

has filed the claim with all claim documents, but Insurance Company rejected the claim .He

was not aware of the reason of rejection. The Insurance Company submitted that cause of

accident mentioned in the claim form do not collaborate with the accident. It was not proved

that the fire was accidental.

On perusal of the documents placed on the record and submission made during the video

hearing, it is observed that current IDV of the value was Rs. 11 lakh where as as per transfer

of ownership details the vehicle was sold for an amount of Rs. 5.75 lakh vide auction date

25.09.2020. The vehicle was uninsured for previous 3-4 years. The Insurance Company had

investigated the case and concluded that the damages to the vehicle do not corroborate with

the cause of accident. The matter was not reported to FIR and Google timeline does not

match statement of the driver. The vehicle was over insured as the Complainant has taken

IDV of the vehicle on higher side; the Insurance Company is directed to refund the premium

for the value over insured. In view of the fact that reasons of accidental fire is not

substantiated I find no reason to interfere with the impugned order. The complaint is

dismissed.

Accordingly, the complaint is hereby dismissed.

22)



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 complaint is hereby dismissed.

d. According to Rule 17(5) of Insurance Ombudsman, A copy of the award shall be sent to

the complainant and the insurer named in the complaint. Rules, 2017.

Place: Jaipur. Rajiv Dutt Sharma

Dated: 03.03.2022 Insurance Ombudsman

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands)

(UNDERRULENO.16/17OFTHEINSURANCEOMBUDSMANRULES,2017)

Ombudsman Name: SHRI P.K.RATH

CASEOFCOMPLAINANT– SHRI DINESH AGARWAL

VS

RESPONDENT: RELIANCE GENERAL INSURANCE CO. LTD.

COMPLAINT REF: NO: KOL-G-035-2122-0125

AWARD NO:IO/KOL/A/GI/0062/2021-2022

1.

Name &Address OfThe Complainant

Shri Dinesh Agarwal 7, Ganesh Chandra Avenue, 5th floor Kolkata – 700 013.

2.

Type Of Policy: Life / Health / General Policy Details:

Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term 99179202374

0023417 410875 02-11-2020 01-11-2021 One year Single

3. Name of insured Shri Dinesh Agarwal

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

5. Date of receipt of the Complaint 14-Dec-2021

6. Nature of Complaint Repudiation of claim

7. Amount of Claim 4,17,317.00

8. Date of Partial Settlement

9. Amount of relief sought 4,17,317.00

10. Complaint registered under Insurance Ombudsman Rules 2017

Rule 13 (1)(b) - any partial or total repudiation of claim by the insurer

11. Date of hearing Place of hearing

02-Feb-2022 Kolkata


a)For the Complainant Shri Dinesh Agarwal

b)For the Insurer Ms. Ankita Bose

13. Complaint how disposed By conducting online hearing

14. Date of Award 10-Feb-2022

Brief Facts of the Case:

The complainant-cum-insured has stated in the complaint that on 20-10-2020, the insured purchased Maruti S. Presso VXI Car and insured the car with Reliance General Insurance Company for the period from 02-11-2020 to 01-11-2021. The Reliance General Insurance Company have tie-up with Dewars Garage.

On 22-12-2020 at about 10.00 P.M, Md. Irshad Ansary, the insured’s friend, was going with the said vehicle when suddenly one unknown vehicle dashed the insured’s vehicle from front side and due to Air Bag, life of Md. Irshad Ansary saved but the vehicle damaged completely.

The vehicle was inspected by the deputed Surveyor of the Insurance Company at the nearest Maruti Garage and an estimate of loss/damage was prepared and the loss/damage has been assessed to a tune of Rs.4,17,317.00. The car was purchased at a sum of Rs.4,70,000.00 and the loss/damage of the car is assessed for Rs.4,17,317.00. Hence, the damaged vehicle is required to be replaced by a new one whereas the Insurance Company has informed the insured on 18-03-2021 that the loss has been taken place on 16-12-2020 whereas intimated on 22-12-2020. Thus, on the ground of mis-representation under Condition No.1 of the Policy, the claim has been repudiated.

The Insurer has stated in their self-contained that the insured mentioned the date of loss as 22-12-2020 in the claim form. The Surveyor assessed the loss for Rs.3,49,758/-. As per Investigation Report, the insured stated the date of loss was on 17-12-2020 at about 10.00 PM. As per Claim Form and intimation, the date of loss was stated as 22-12-2020. The photographs of the damaged vehicle were forwarded to the staff by the Manager on 16-12-2020. The statement of the insured clearly amounted to mis-representation in respect of date of loss. Hence, as per Policy Condition No.1 and Clause No.6, the claim was repudiated.

Contention of the complainant:

The complainant-cum-insured has stated in the complaint that the insured purchased the Private Car Package Policy from Reliance General Insurance Company for the period from 02-11-2020 to 01-11-2021. On 22-12-2020, the insured vehicle met with an accident and damaged completely. Md. Irshad Ansary informed nearest Police Station on 23-12-2020. The loss has been assessed at Rs.4,17,317/-. But the Insurance Company repudiated the claim for misrepresentation of accident date.

Contention of the Respondent:

The representative of the Insurance Company has stated in the hearing that the claim has been repudiated for misrepresentation of accident date. As per claim form, the accident is on 22-12-2020 whereas as per Investigation Report, the accident date is on 17-12-2020. The photographs of the damaged vehicle were forwarded to the staff by the Manager on 16-12-2020.

Observation and conclusions:

It is observed that the complainant has attended the hearing physically at this office premises whereas the representative of the Insurance Company has attended the hearing online. The complainant has stated what he already stated in his complaint letter submitted to this office. The representative of the Insurance Company has stated that the claim has been repudiated as per Policy terms and conditions.

It is found from the submitted documents as well as submissions made by both the parties during the course of hearing that the Insurance Company has repudiated the claim for misrepresentation the date of accident. The insured has mentioned the date of loss as 22-12-2020 in the claim form whereas as per insured’s written statement, the date of accident is on 17-12-2020. Besides, as per photographs of the damaged vehicle forwarded to the staff was on 16-12-2020.

AWARD

Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing and after going through the documents on record, it is observed that the Insurance Company has repudiated the claim for misrepresentation of the date of accident.

It is found from the submitted documents and submissions made by both the parties during the course of hearing that the decision of repudiation of claim made by the Insurance Company is correct and justified. Hence, the complaint is dismissed without any relief to the complainant.

“If the decision is not acceptable to the complainant, he/she is at liberty to approach any other

Forum/Court as per Law of the Land against the Respondent Insurer.”

Dated at Kolkata on 10th Day of February, 2022 P K RATH

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 Complainant: Mr. Akbar Ali VS

Respondent: Shriram General Insurance Co. Ltd. (Jaipur)

COMPLAINT REF NO: KOL-G-042-2122-0141

AWARD NO:IO/KOL/A /GI/ 0068 / 2021-2022

1. Name & Address of the Complainant Mr. Akbar Ali Visual Securas Limited, AD-239, Sector-I, Salt Lake City, Kolkata – 700064

2. Type of Policy: Private Car Policy Number Sum Assured From Date To Date DO

C Premium Policy

Term Paying Term

334027/31/22/000900 1,70,834/- 20/06/2021 19/06/2022

3. Name of the insured M/s Visual Securas Ltd, 4. Name of the insurer Shriram General Insurance Co. Ltd. (Jaipur) 5. Date of Receipt of the Complaint 07-Jan-2022

6. Nature of Complaint Repudiation of Claim 7. Amount of Claim 8. Date of Partial Settlement 9. Amount of relief sought 80% of the Estimate: Rs.1,61,875/-

10. Complaint registered under IOR-2017 13 (1) (b) 11. Date of hearing

Place of hearing 22-February-2022 Kolkata

12. Representation at the hearing a) For the Complainant Mr. Akbar Ali b) For the insurer Mr. Siddharth Pandey

13. Complaint how disposed By Conducting online Hearing

14. Date of Award/Order 28-February-2022


Regn. No. & Make :: WB02AD/2070, Hyundai i-10, 2013, Period of Insurance :: 20.06.2021 to 19.06.2022 IDV :: 1,70,834/- Date of Accident :: 04/12/2021.

The complainant lodged complaints against the Insurance Company in connection with repudiation of Own Damage Claim of the aforementioned car. Hence, this complaint lodged with this office for settlement of claim.


The complainant stated that:

(i) The i-10 Car No.WB02AD/2070 met with an accident on Saturday the 4th December, 2021 at 1.20 noon as stated in the G.D dated 4th December, 2021to New Town Police Station. Then the Car was taken by a Rocker at Park Circus.

(ii) The next day being a Sunday they could not send the in Car at the Service

Centre, and intimated to Shriram General Insurance Co. Limited. On Monday the 6th December, 2021the Car was again taken to Birati, Hyundai Service Station toed by a rocker.

(iii) Company rejected the claim by stating:

“… you have intimated loss on dated 22/09/2021. We appointed Mr. SONU KUMAR YADAV for final survey. We came to know from our appointed surveyor from Survey report and photographs that all damages are pre-existing and running in nature also no external impact found on the vehicle. Hence we cannot consider your claim. This is to bring it to your notice that with reference to your caption claim, we are closing the captioned claim as ‘No Claim’. Hence there has been deliberate and wilful misrepresentation from your side that you are deliberately suppressed the facts for wrongful motive by making above said claim on us. Hence we close this claim file as REPUDIATED on above grounds.”

The Surveyor, Mr Sudipta Ghosh – Surveyor from Shriram Insurance came and inspected the car. Thereafter, Senior Government Surveyor - Mr. Biplab Hazra inspected the damaged Car on 09.12.2021; but they are not aware of Mr Sonu Kumar Yadav have inspected their vehicle. The intimation of loss was given on 05.12.2021 and NOT on 22.09.2021.

(iv) The Claim has been rejected on the ground “there has been deliberate and

wilful misrepresentation from your side that you are deliberately suppressed the facts for wrongful motive by making above said claim on us.” They have enough evidences to substantiate that the incident/accident is an actual fact and there is NO fabrication.

The car got overturned up-side down at the Accident Spot and witnessed by Police Men who were on duty at that time. Traffic Inspector Mr in Gautam Paul has already narrated them the fact which they have kept in silence.

(v) As alleged “that all damages are pre-existing and running in nature” such

Statement from an Insurer is not at all accepted and seems they are bypassing their responsibilities by giving lame excuses.

(vi) Company said “Also no external impact found on the vehicle”. Hence,

indirectly they have agreed and accepted that there were internal damages like Engine, Radiator, tire & steering etc. etc…

(vii) Hyundai has given the Estimate of Loss for Rs.1,61,875/- which they have not

disclosed. Company has not asked for the technical Report from O/c. Newtown or DC traffic, Newtown. The Hyundai Service Centre, Gauripur, Birati- is charging the garage rent @ Rs.500/- per day with effect from December 20, 2021 the same will be at the cost and consequences including the Recker (Toeing) Chareges involved in this incident / accident.

Claim for Rs.161,875/- towards Spare Parts & Labour Charges including Recker (Toeing) Charges of Rs.10000/- & Garage Rent Of Rs. 6000/- as on date. Grand Total: Rs.177875/-.

Being aggrieved and dissatisfied with the Non-settlement of claim by the Insurance Company, the complainant has approached this office for redressal of his grievance. The complainant has also given his unconditional and irrevocable consent to the Insurance Ombudsman to act as a mediator between himself and the insurance company and to give recommendation as per consent form.


The Insurance Company vide their SCN (Self Contained Note) has stated that: (i) On receipt of the intimation of accident on 06.12.2021 after 2 days delay,

company registered the case and appoint IRDA approved surveyor Mr. Biplab Hazra to carry out the survey of the vehicle. (Annexure no 2) After the survey he submitted his preliminary survey report of Rs 90535/- as per policy term and conditions and IMTs and found that damages are old and not fresh in nature i.e. damages were pre - existing in nature.

(ii) After the survey made by IRDA appointed independent surveyor it was found

that all damages were pre-existing and no external impact found on the vehicle. It was found that there have been deliberate and wilful misrepresentations on insured part. Photographs of the vehicle clearly shows rust and scratches on the vehicle.

(iii) Vide their letter dated 14/12/2021 Company intimated to insured regarding

no claim of the claim as there has been deliberate and wilful misrepresentation from complainant.

(iv) The complaint as there is misrepresentation & deliberately facts are supressed

for wrongful gain by the insured end.

The Insurance Company has also given their consent to the Insurance Ombudsman to

act as a mediator between the Complainant and themselves and to give his

recommendation for the resolution of the complaint.


Both the parties heard during the hearing and following documents were placed for perusal:

(a) Complaint letter along with annexures, (b) Policy Copy, (c) Annexure–VI-A & (d) Self Contained Note from the insurer.

AWARD Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of hearing & after going through the documents on record it is observed that the repudiation is in consonance with the policy issued to the Complainant. Hence, the complaint is dismissed without any relief to the complaint. If the decision is not acceptable to the Complainant, She/He is at liberty to approach any other Forum/Court as per Law of the Land against the Respondent Insurer. Dated at Kolkata on the 28TH Day of February 2022. P. K. RATH

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

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 Complainant: Mr. Sandipan Bhattacharyya VS

Respondent: EDELWEISS GENERAL INSURANCECO LTD

COMPLAINT REF NO: KOL-G-058-2122-0127

AWARD NO:IO/KOL/A /GI/ 0064 / 2021-2022

1. Name & Address of the Complainant Mr. Sandipan Bhattacharyya Jambuni, Ward No. 6, Bolpur, Dist. Birbhum, Pin - 731204

2. Type of Policy: Private Car Package Policy Policy Number Sum Assured From Date To Date DO

C Premium Policy

Term Paying Term

900143264 5,54,000/- 05/01/2020 04/01/2021

3. Name of the insured Mr. Sandipan Bhattacharyya 4. Name of the insurer EDELWEISS GENERAL INSURANCECO LTD 5. Date of Receipt of the Complaint 16-Dec-2021

6. Nature of Complaint Repudiation of Claim because of NCB issue 7. Amount of Claim 8. Date of Partial Settlement 9. Amount of relief sought Rs.4,33,000/-

10. Complaint registered under IOR-2017 13 (1) (b) 11. Date of hearing

Place of hearing 07-February-2022 Kolkata

12. Representation at the hearing c) For the Complainant Mr. Sandipan Bhattacharyya d) For the insurer Ms. Akanksha Sharma & Chandan Ku Chowdhury

13. Complaint how disposed By Conducting online Hearing

14. Date of Award/Order 15-February-2022


Policy Name :: Edelseiss Private Car Stand-Alone Own Damage Insurance

Policy Policy Type :: Property Insurance: Private Car Motor Insurance, Vehicle Details :: WB 45 D 7518, Hyundai Grand I-10, 2019 Model, Period of Insurance :: 05/12/2020 to 04/12/2021, Sum Insured :: Rs.5,54,000/-, Date of Accident :: 12/09/2021.

The complainant lodged complaints against the Insurance Company in connection with repudiation his Own Damage Claim of his car. Hence, this complaint lodged with this office for settlement of claim.


The complainant stated that:

(i) He has renewed his motor insurance policy for second year from this company.

(ii) The concerned person asked him to provide the previous policy details to renew the existing policy and he submitted it.

(iii) They had never asked him regarding NCB details of Previous Policy. As a new

car owner, he was also not aware of the NCB rules and they have also not explained him at the time of the policy renewal.

(iv) The policy had been issued through online. Hence, he did not sign any physical

proposal letter regarding the same.

(v) He had made actual payment which they had asked him to do so through online link. They had not sent him any mail regarding the policy premium break up because they had checked from his previous policy as they told.

(vi) Now one major accident took place and his car badly damaged. He lodged his

claim and submitted all necessary documents to the surveyor for the same.

(vii) His claim rejected by stating declaration of wrong NCB in Proposal Form.

(viii) As per confirmation from the company: they had sent him a letter to his registered address by speed post to pay NCB recovery premium amount of Rs.1,501/-. A single speed post where delivery subject not mention neither it is mentioned to whom it has been delivered. This does not suffice company’s responsibility towards intimate client properly. He has asked for email communication details which they have failed to provide.

He had asked for email communication details which they failed to provide. Neither any courier details of repeated reminded is there.

(ix) The company rejected his claim purposefully. They used his faith and ruined

his life. They have unethically sold the policy to him

(x) The company has sent him renewal notification and again NCB Benefits included in spite of knowing all facts.

Being aggrieved and dissatisfied with the Non-settlement of claim by the Insurance Company, the complainant has approached this office for redressal of his grievance. The complainant has also given his unconditional and irrevocable consent to the Insurance Ombudsman to act as a mediator between himself and the insurance company and to give recommendation as per consent form.


The Insurance Company vide their SCN (Self Contained Note) has stated that: (i) A claim was lodged with the Company stating that the policyholder had met

with an accident on September 12, 2021, while travelling from Durgapur, wherein the car was hit by another car on turning point. The Company had registered the claim with claim number 600000000040224 and initiated its investigation.

(ii) In due course of investigation, the Company noted that a letter dated February

26, 2021 on falsification of No Claim Bonus was already issued to the policyholder wherein he was clearly informed that as per the proposal form submitted by the policyholder no claim was availed from the previous insurer i.e., HDFC Ergo General Insurance Co. However, during routine check with the previous insurer it was found out that policyholder had a claim settlement from the previous insurer.

(iii) After acknowledging the existence of aforementioned misrepresentation of

facts, the policyholder was specifically informed that the Company would not be able to give benefits under the Own Damage section of the new policy or pay any claim under this section and in order to continue the benefits, he must bring the vehicle for inspection before March 14, 2021 and pay an inspection fee of Rs.250 and to further pay a premium amount of Rs. 1501/- that falls

short. The letter dated February 26, 2021 along with proof of delivery are enclosed here with as Annexure R3 and Annexure R4 respectively.

(iv) That the policyholder had availed 20% NCB from the Company in spite of

having experience of one claim on previous policy with M/s HDFC Ergo General Insurance Co. Ltd. Availing a discount (No Claim Bonus) in premium by means of incorrect details is a violation of condition no 8 of terms and conditions of the motor policy which is reproduced as under:

“The due observance and fulfilment of the terms conditions and endorsement of this Policy in so far as they relate to anything to be done or complied with by the Insured and the truth of the statements and answers in the said proposal shall be conditions precedent to any liability of the Company to make any payment under this Policy.”

The Policy terms and conditions are enclosed as Annexure R5.

(v) That the policyholder had not complied the aforementioned requirements till the date of submission of claim, basis which the claim was repudiated via email dated September 18, 2021.

(vi) Hence, there is no error on part of Edelweiss General in assessing the claim of

the complainant as the same was rejected on the grounds of misrepresentation and violation of the terms and conditions of the policy. Hence, the present complaint is liable to be dismissed on account of being devoid of any merits.

(vii) In view of the above facts the present complaint completely lacks merit and is

liable to be dismissed immediately.

The Insurance Company has also given their consent to the Insurance Ombudsman to

act as a mediator between the Complainant and themselves and to give his

recommendation for the resolution of the complaint.


Both the parties heard during the hearing. The Complainant, during the hearing, submitted that he had provided the policy details at the time of renewal. But the company did not verify the NCB and waited till the accident occurred. Following documents were placed for perusal:

(a) Complaint letter along with annexures, (b) Policy Copy, (c) Annexure–VI-A & (d) Self Contained Note from the insurer.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of hearing & after going through the documents on record it is observed that the premium amount has been raised by the company on the basis of previous policy details provided by the complainant. Hence, rejection of the only on the NCB ground is not justified. In view of the above, the Insurer’s repudiation is set aside and the Insurance Company is directed to admit the claim and settle the claim to the extent of Rs.4.33.000/-, as per terms and conditions of the policy, less NCB, along with interest as per Rule 17(6) of the IRDAI Act 1999 towards full and final settlement of the claim. The Company is also directed to provide the Assessment / deduction details to the Complainant. 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:

(a) 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.

(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 Kolkata on the 15th Day of February 2022. P. K. RATH

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

ISLAND PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW

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

Mrs. Urvashi Dwivedi…………..……....………………. Complainant

V/S

National Insurance Co. Limited…………..………..…………Respondent

COMPLAINT NO. LCK-G-048-2122-0148 ORDER NO. IO/LCK/A/GI/0032/2021-22

1. Name & Address of the Complainant Mrs Urvashi Dwivedi,

2/496, Vivek Khand, Gomtinagar,

Lucknow-226010

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

45150031191143900524


01.07.2019 to 30.06.2020

3. Name of the life insured


Late Mohit Dwivedi

4. Name of the insurer National Insurance Company Limited

5. Date of Repudiation/Rejection --

6. Reason for repudiation/Rejection --


8. Nature of complaint Non settlement of OD Claim

9. Amount of Claim --


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 04.02.2022 at Lucknow


e) For the Complainant Present [through whatsapp video call]

f) For the insurer Present [ Mr. Anjan Banerjee thru virtual hearing ]

15. Complaint how disposed Award


17. Mrs. Urvashi Dwivedi (Complainant) has filed a complaint against National Insurance

Company Limited (Respondent) alleging non settlement of her husband’s motor claim.

18. Brief Facts Of the Case:- The complainant’s husband late Mohit Dwivedi got his maruti

wagon R No:UP-32-DF-5193 insured with respondent for period 01.07.2019 to 30.06.2020.

Her husband died in a road accident on 22.07.2019. Her husband’s PA Claim has been settled

for Rs.15 lacs. For settlement of own damage claim the respondents demanded NOC from

parents of late Mohit Dwivedi alongwith Succession Certificate. As per complainant, she has

provided


both the required documents to the respondent insurance company on 15.09.2021 but her

own damage claim has not been settled till date.

In their SCN/Reply dated 10.01.2022, the respondents have mentioned that an own damage

claim for vehicle No:UP-32-DF-5193 was intimated by the complainant Mrs. Urvashi Dwivedi

an 30.07.2019 and on the same date a PA claim was also intimated. The claim amount of

Rs.1500000/- was disbursed through named cheque issued in the name of nominee under PA

Section of the policy i.e. Mrs. Urvashi Dwivedi. As far as claim under own damage section is

concerned the policy does not provide nomination feature, hence at various junctures it was

informed to the complainant as well as her representative [brother] that the own damage

claim is admissible subject to submission of a valid succession certificate issued by competent

authority/court. A succession certificate valid for monetary value upto Rs.5000/- was

provided by the claimant but was not admissible since the claim amount stands greater than

Rs.5000/- {Rs.47892/-in this case}. The respondents have further submitted that as soon as

they receive a valid succession certificate from the claimant, they will disburse claim amount

to her.

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

VIA duly filled/signed submitted by the complainant while respondent filed SCN along with

enclosures.

20. I have heard the complainant through whatsapp video call on her whatsapp number

8299603211. I have also heard the respondent representative through videoconferencing and

perused the record.

Findings:-

21. Vehicle No. UP-32-DF-5193 was insured with the respondents. Complainant’s husband

Shri. Mohit Dwivedi was owner of the vehicle who expired on 22.07.2019 in a road accident.


Personal Accident claim for Rs. 15.00 lakhs was paid by the respondents but the own damage

claim was not paid. Respondents representative submits that they owe the liability to pay the

claim but due to non submission of the succession certificate by the complainant, same is not

paid.

22. Complainant submits that despite his best effort complainant never communicated her to

submit the succession certificate. Records show that in the SCN there is no mention of the

date wherein letter is sent to the complainant for submission of the succession certificate. No

such letter is annexed with the SCN. It shows that the respondents officers are unduly

harassing the complainant and not made the payment. It is a deficiency of the service by the

respondents which should be properly dealt with by the competent authority of the

respondents by fixing the liability of the concerned officers after holding an enquiry. However

a claim can only be paid after succession certificate is submitted. Accordingly complaint is

liable to be allowed.

Order:-

23. Complaint is allowed. Complainant is directed to submit the succession certificate to the

respondents. Thereafter respondents shall make the payment within 7 day from the date of

submission of the succession certificate.

24. Let a copy of this judgement be sent to the General Manager of National Insurance

Company Limited for appropriate action as referred in the body of this judgment.

25. Let copy of the award be sent to both the parties.

Dated : 04.02.2022 Justice (Retd) Anil Kumar

Srivastava

Place : Lucknow Insurance Ombudsman

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P AND UTTARAKHAND UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – SH. C.S. PRASAD CASE OF SH. SHASHANK VISHNOI V/S. NATIONAL INSURANCE CO. LTD.

COMPLAINT REF: NO.: NOI-G-048- 2122 - 0186 AWARD NO:

1. Name & Address of the Complainant Sh. Shashank Vishnoi 18/24, Bara Gauhar Ali, Khirni ki Sarai, Aligarh Uttar Pradesh - 202001. Ph. No. 8800567821

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

35101031191144118442 Long Term Package policy - 3 years (Private Vehicle) 28.08.2019 to 27.08.2022 Rs.6,63,016/- (1st YEAR IDV) Rs.5,58,330/- (2nd YEAR IDV) Rs.4,88,538/- (3rd YEAR IDV)


Sh. Shashank Vishnoi Sh. Shashank Vishnoi

4. Name of the insurer National Ins. Co. Ltd.

5. Date of Repudiation --

6. Reason for repudiation --


8. Nature of complaint Private Vehicle


10. Date of Partial Settlement N.A.

11. Amount of relief sought Total cost of vehicle Rs.8.3 lakh + Rs.5 lakh for mental harassment as per Annex VI A

12. Complaint registered under IOB Rules, 2017

13 (1) b

13. Date of hearing/place 11.02.2022 / Noida


a) For the Complainant Sh. Shashank Vishnoi

b) For the insurer Sh. R S Rawat, Sr.Divisional Manager



17) Brief Facts of the Case :- Sh. Shashank Vishnoi, the Complainant had taken Long Term

Package policy - 3 years (Private Vehicle) bearing No. 35101031191144118442 covering his Maruti baleno 2019 from National Insurance Company Ltd. for the period from 28.08.2019 to 27.08.2022 with IDV of Rs.6,63,016/- (1st YEAR IDV), Rs.5,58,330/- (2nd YEAR IDV), Rs.4,88,538/- (3rd YEAR IDV). His claim was not settled by the Insurance Company. Aggrieved, he requested the insurer including its GRO to reconsider the claim but failed

to get any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.

18) Cause of Complaint :-

a) Complainant’s Argument :- Sh. Shashank Vishnoi, the Complainant stated in his complaint that his vehicle met with an accident on 9th July 2021 near Bijnor U.P. when he was traveling from Aligarh to Bijnor.

His vehicle repair estimate cost is around Rs.8,22,000/- which is more than the cost of IDV (even more than the vehicle cost) but the surveyor and the Insurer forced him to repair the vehicle whereas as per the company’s policy, it should be a total loss. After too much discussion, the insurance company agreed to total loss but at the IDV value whereas RTI is covered in his policy. On 13th September 2021, the Insurer stated over the phone that the company would pay him Rs 6.5 Lacks and they would pay Rs.70,000/- after sale of salvage. As per his policy, the Company cannot deduct his salvage even then he agreed on this amount.

b) Insurer’s Argument: The Insurer stated in their SCN that the claim of accidental vehicle no.DL-10 CN-0160 of Maruti Baleno is registered of accident dated 9.7.2021. This claim is approved by the Competent Aurhority for Rs.6,22,604/- on total loss (NOS) without RC vide mail dated 17.12.2021 addressed to them.

They have vide mail dated 21.12.2021 addressed to complainant requested to comply post payment formalities of his claim and a copy of the same is also dispatched through post. On receipt of required documents from the complainant, the claim payment shall be released by them. The insured has not submitted any of the documents i.e. cancellation of RC, Bank details, NOC from Bank etc. so far.

19) Reason for Registration of Complaint: - Delay in settlement of motor claim. 20) The following documents were placed for perusal:-

a) Complaint letter b) Policy copy c) Form VI A duly signed by the complainant. d) SCN of the case.

21) Observations and Conclusion :- Both the parties appeared for personal hearing through

video call and reiterated their submissions. The Complainant Sh. Shashank Vishnoi, the Complainant reiterated that his vehicle met with an accident on 9th July 2021. His vehicle repair estimate cost was more than the cost of IDV but the surveyor and the Insurer forced him to repair the vehicle whereas as per the company’s policy, it should be a total loss. After too much discussion, the insurance company agreed to total loss but at the IDV value whereas RTI is covered in his policy. On 13th September 2021, the Insurer stated over the phone that the company would pay him 6.5 Lacks and pay Rs.70,000/- after sale of salvage. As per his policy, the Company cannot deduct his salvage even then he agreed on this amount.

The Insurance Company reiterated that the vehicle was repairable but the complainant insisted for total loss. Therefore, the claim is approved by the Competent Authority for Rs.6,22,604/- on total loss (NOS) without RC. The Insurer clarified that the vehicle is in second year and the IDV of the vehicle is Rs.5,58,330/-. The policy covers Return To Invoice coverage. Therefore, the Invoice price of the vehicle AT Rs.6,97,911/- is considered. Difference between the Invoice price and the IDV is Rs.1,39,581/- which is allowed by the Insurer. Two years Registration Charges for Rs.6513.86, Road Tax for Rs.600/- and OD Premium (considering for unexpired period of policy) subject to maximum of 10% of current Invoice Price for Rs.6,579/- which comes total amount of Rs.13,692.86 were also allowed by the Insurer. The Insurance Company deducted the amount of Rs.18,000/- for missing parts in the Insured vehicle. The Salvage value of the vehicle is Rs.70,000/-. The Excess Clause of Rs.1,000/- was also deducted. The Insurance Company is ready to settle the claim for Rs.6,22,604/- + Rs.70,000/- as salvage value to the Insured. On receipt of required documents from the complainant, the claim payment shall be released by them. The insured has not submitted any of the documents i.e. cancellation of RC, Bank details, NOC from Bank etc. so far. Therefore, they could not release the claim amount to the complainant. During the course of hearing, it was directed to the complainant that he should be available with the Insurer at the time of disposing off the salvage of his vehicle and submit the above mentioned required documents to the Insurer for settlement of his claim. The Complainant was ready to do the same. Ongoing through the documents exhibited and the oral submissions made by both the parties, it is observed that the complainant had not submitted the required documents to the Insurer. The complainant was directed to submit the above mentioned required documents to the Insurer and the Insurance Company is directed to pay the admissible claim amount to the complainant within 15 days after receiving the above mentioned documents under intimation to this forum.

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 complainant was directed to submit the above mentioned required documents to the Insurer and the Insurance Company is directed to pay the admissible claim amount to the complainant within 15 days after receiving the above mentioned documents under intimation to the undersigned.

The complaint is treated as disposed off accordingly.

22) If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty

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

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


a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.

Place: Noida. C.S. PRASAD Dated: 16.02.2022 INSURANCE OMBUDSMAN (WESTERN U.P. & UTTARAKHAND)

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. SHAILENDRA SINGH V/S UNIVERSAL SOMPO GENERAL INS. CO. LTD.

COMPLAINT REF: NO: NOI-G-052-2122-0185 AWARD NO:

1. Name & Address of the Complainant Mr. Shailendra Singh, Flat No. 404, Unione Residency, Akbarpur, Behrampur, Ghaziabad, UP-201003.


USGI/POSWEB/0193188/00/000 Goods Carrying Package Policy 29.011.2019 to 28.01.2020


Mr. Shailendra Singh Mr. Shailendra Singh

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

5. Date of Repudiation/No claim 16.12.2021

6. Reason for repudiation Non submission of documents


8. Nature of complaint Motor


10. Amount of Partial Settlement n.a.

11. Amount of relief sought Rs. 20,00,000/-

12. Complaint registered under IOB rules

13 (1) (b)

13. Date of hearing/place 14.02.2022 at Noida – online hearing


• For the Complainant Mr. Shailendra Singh, Self

• For the insurer Ms. Shobha Sagnika Panda



17) Brief Facts of the Case: This complaint is filed by Mr. Shailendra Singh against Universal Sompo General Insurance Co. Ltd., for closing his motor vehicle theft claim as ‘No Claim’.


a) Complainant’s argument: The complainant had taken Goods Carrying Package Policy for his truck Regn. No. HR-55 S-5297, Year of Mfg. 2013, IDV Rs.20,00,000/-, from Universal Sompo General Insurance Co. Ltd., for the period from 29.01.2019 to 28.01.2020. On 31.03.2019, his driver parked the truck near his warehouse at Noida, but on 01.04.2019 morning the truck was not found. He reported the incident to the policy by dialing 100 no. and informed the police station. FIR was lodged on 09.04.2019 and the final order by the Court was issued on 01.11.2019. They reported the claim with the insurance company on 01.04.2019. He submitted all documents to the investigator appointed by the insurance company. But the insurance company closed the file as No Claim by giving reason of non-submission of claim documents. He had also submitted Indemnity Bond and Letter of Subrogation for Rs. 20,00,000/- (IDV of the vehicle) but they insisted him to file bond for Rs. 15,50,000/- which he submitted on 15.10.2020. b) Insurers’ argument: The insurance company submitted their SCN dated 11.01.2022 wherein they stated that the complainant had availed a Goods Carrying Package Policy for his vehicle bearing registration no. HR-55-S 5297, bearing policy no. 23151593844228/00/001 having policy validity period from 29101/2019 to 2810112020. The subject vehicle got stolen on 31.03.2019. Subsequently the claim was intimated to the respondent company for which claim form was submitted and Claim No. CL19000135 was generated. lt is alleged from the complainant that the insured company has not settled insured's claim. But there was no deficiency of service or unfair trade practice on the part of the insurance company. The insurance company further stated that after the intimation of claim, as per terms and conditions of the Policy, they appointed Suraksha Enterprises to investigate the loss of the Insured vehicle. The appointed investigators issued letters dated 0l/06/2019 and 25/12/2019 to the Complainant to submit the requisite documents but the documents were not forthcoming due to which the claim was closed on l6/l2/202l due to non-submission of documents. 19) Reason for Registration of Complaint: - Repudiation of claim 20) The following documents were placed for perusal.

a) Complaint letter b) Discharge Summary c) Policy document d) SCN 21) Observations and Conclusion: - The complainant and the representative of the insurance company were present for an online hearing on 14.02.2022. The complainant stated that the insurance company closed the case of theft of his truck whereas he had already submitted all required documents to the insurance company. The insurance company reiterated that the complainant did not submit certain documents viz. Service history, copy of GR, etc. During the hearing, it was noted that the complainant had submitted all the essential documents which were relevant to the motor theft case viz. Registration of Call made to police @100 PCR dated 01.04.2019, Request to police authorities to get FIR registered dated 4.4.2019, Police Final Court dated 25.7.2019 and Court Order dated 01.11.2019, Letter of Subrogation, RC, DL,

Permit and KYC documents, etc. The insurance company reiterated that they required NOC of the financier and KYC documents of the complainant. On going through the documents exhibited and the oral submissions made by both the parties during the hearing, a gross negligence on the part of the insurance company was noted that despite submission of documents, the insurance company had not paid the claim for the theft that took place on 01.04.2019. The insurance company is directed to pay the claim immediately as per the terms and conditions of the policy on receipt of NOC from the financier and KYC documents of the complainant. The complaint is closed.

AWARD


the parties, the insurance company is directed to pay the claim as per the terms and

conditions of the policy consequent upon receipt of NOC from the financer and KYC

documents of the complainant.

The complaint is closed.

22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty to

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

23. 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 thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.


PROCEEDINGS BEFORE


OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. PAWAN YADAV V/S SBI GENERAL INSURANCE CO. LTD.


1. Name & Address of the Complainant Mr. Pawan Yadav 484, Gali NO. 11, Near CRPF Camp, Pragati Vihar, Khora Colony, Ghaziabad-201001.


0000000024216548 Private Car Insurance Policy 09.09.2021 to 08.09.2022


Mr. Pawan Yadav Mr. Pawan Yadav

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

A5. Date of Repudiation Not repudiated

6. Reason for repudiation Not repudiated


8. Nature of complaint Motor

9. Amount of Claim

10. Amount of Partial Settlement



13 (1) (b)



a. For the Complainant Mr. Pawan Yadav, Self

b. For the insurer Ms. Chynicka Modie



17) Brief Facts of the Case: This complaint is filed by Mr. Pawan Yadav against SBI General Insurance Co. Ltd. for not providing additional benefits in the policy.


Complainant’s argument: The complainant had taken private car insurance for his vehicle Alto K10, Regn. No. UP 16 BB 2220, year of manufacturing 2015, issued for the period from 09.09.2021 to 08.09.2022. At the time of taking the policy, insurance company committed him to provide ZERO Dep. Benefit along with PA to Owner & Driver and Engine Guard benefit cover in policy on premium the premium of Rs.10792/- but the insurance company did not provide insurance after 6-7 days of follow-up by excluding committed benefits. He escalated his complaint to the higher authorities they refused to provide committed benefits by giving excuses of their technical error.

Insurers’ argument: The Insurance Company in their SCN dated 12.01.2022 submitted that the complaint had been made for issuance of Engine Guard cover and Depreciation Reimbursement cover in the Private Car Insurance Policy bearing no. 0000000024216548. They submitted that these add-on covers were not available, where vehicles age was more than 5 years, hence the benefit of the said covers was denied to the complainant. The policy issued to the vehicle No.UP-16-BB-2220 which was manufactured in 2015. The said policy was effective from 09/09/2021 to midnight 08/09/2022, subject to its terms and conditions and any claim is admissible in adherence to the same. The Private Car Package Insurance Policy was IRDAI approved product bearing UIN: IRDAN144RP0005V03201112. In the said Private Car Package Insurance Policy’s additional covers like Engine Guard cover and Depreciation Reimbursement cover were not available, where vehicles age was more than 5 years. A copy of the aforesaid IRDAI product approval letter along with Company’s Internal Rate Guide stated the same. Further, in conformity with the aforesaid provision, a Private Car Insurance Policy bearing no. 0000000024216548 was issued to Complainant upon receipt of advance premium of Rs. 10,779/- on 03/09/2021. Subsequently, the Customer Care of the Company received a request from the complainant to incorporate certain additional covers in the policy, which included Depreciation Reimbursement, Engine Guard and PA Owner Driver. Immediately, on receipt of the aforementioned request, Company’s Customer Care team probed regarding issuance of additional covers in subject policy, as requested by the Complainant. Accordingly, the Complainant was informed that additional cover for PA Owner Driver was duly issued in the subject policy, however Engine Guard cover and Depreciation Reimbursement cover were not issued as these covers are only applicable for the vehicles with manufacturing year equal to or less than 5 years. In present case, insured vehicle Maruti Suzuki Alto&K10, bearing registration number UP-16-BB-2220 was manufactured in 2015. Meanwhile, the complainant registered a complaint with IRDAI seeking resolution of the aforementioned non-issuance of additional covers in the subject policy. Accordingly the Complainant was informed through Company’s Customer Complaints Management Unit (CCMU) response dated 14/10/2021 that cover for PA Owner Driver was included in the subject policy but Depreciation Reimbursement and Engine Guard cover were only applicable for the vehicles with manufacturing year equal to or less than 5 years. Further, they requested him to provide them with copy of cancelled cheque in the name of the policy holder, for enabling us to arrange the excess premium refund of Rs. 382/-. Which they had erroneously received excess premium of Rs. 382/- from the complainant.

19) Reason for Registration of Complaint: - not adding the add-on benefits in the policy. 20) The following documents were placed for perusal.

a) Complaint letter b) Policy document c) IRDA guidelines d) SCN

21) Observations and Conclusion: - The complainant and the representative of the insurance company were present for an online hearing on 14.02.2022. The complainant stated that the insurance company charged the premium, but did not provide add-on cover and issued the policy after 6-7 days of charging the premium. The insurance company reiterated the complainant renewed the policy online and opted for add-on covers of ZERO Dep. Benefit along with PA to Owner & Driver and Engine Guard benefit and paid the premium. Since the

vehicle’s age was more than 5 years, year of manufacturing as 2015, the benefit of the said covers was denied to the complainant. There was a technical error hence the policy was not generated on the spot. The complainant requested their customer care to incorporate additional covers in the policy viz. Depreciation Reimbursement, Engine Guard and PA Owner Driver. He was immediately informed that additional cover for PA Owner Driver was duly issued in the subject policy, but Engine Guard cover and Depreciation Reimbursement cover were not issued as these covers are only applicable for the vehicles with manufacturing year equal to or less than 5 years. He was also requested to provide them with copy of cancelled cheque in the name of the policy holder, for refund of excess premium of Rs. 382/-, which was erroneously received from the complainant. On going through the documents exhibited and the oral submissions made by both the parties during the hearing, it has been noted that the subject vehicle Regn. No. UP 16 BB 2220 was manufactured in the year 2015. At the time of renewal of policy i.e. on 09.09.2021, its age was more than 5 years. The complainant opted online for additional covers for Engine Guard and Zero Dep. along with other add-on covers and paid the premium. The policy was issued without Engine Guard and Zero Dep. Add on cover according to the IRDA File & Use circular. PA cover was added in the policy. It is also on record that the insurance company asked the complainant on 14.10.2021 to submit his cancelled cheque so that they could refund the excess premium of Rs. 382/- which was wrongly charged at the time of renewal of the policy. I see that the add-on covers for Engine Guard and Zero Dep. cannot be added in the insurance cover for the said vehicle as it is more than 5 years old. The insurance company acted as per the guidelines of IRDAI and policy terms and conditions. I see no reason to interfere with the decision of the insurance company. The complainant is directed to comply with the requirement of the insurance company of providing a cancelled cheque for refund of excess premium.


AWARD

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

made by both the parties, I see no reason to interfere with the decision of the

insurance company. The complainant is directed to comply with the requirement of

the insurance company of providing a cancelled cheque for refund of excess

premium.


22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty to approach any other Forum/Court as per laws of the land against the respondent Insurer.


PROCEEDINGS BEFORE


OMBUDSMAN – SHRI C.S. PRASAD CASE OF Mr. GAJENDRA SINGH V/S TATA AIG GENERAL INSURANCE COMPANY LTD.



Mr. Gajendra Singh, Village & P.O. Chaumashahpur, Thana Fatehpur Sikri, Agra, UP-283110.


3100951733 Bundled Auto Secure – Private Car Policy 29.01.2020 to 28.01.2021


Mr. Gajendra Singh Mr. Gajendra Singh

4. Name of the insurer Tata AIG General Insurance Co.


6. Reason for repudiation Violation of limitations to use


8. Nature of complaint Motor individual

9. Amount of Claim Rs. 5,67,468/- as per Annexure VI A

10. Date of Partial Settlement Nil



13 (1) (b)

13. Date of hearing/place 14.02.2022 at Noida – Online hearing


a. For the Complainant Mr. Gajendra Singh, Self

b. For the insurer Ms. Nidhi Kalra



17. Brief Facts of the Case: This complaint is filed by Mr. Gajendra Singh against M/s Tata AIG General Insurance Co. Ltd. for repudiation of accidental claim of his vehicle.

18. Cause of Complaint: Complainant’s argument: The complainant had purchased Private Car Package Policy from Tata AIG which was issued from 29.01.2020 to 28.01.2021, for his new vehicle Mahindra Bolero P Regn. No. RJ 14 UG 6455. The said vehicle was driven by his younger brother and his brother-in-law and cousin brother were accompanying him on 5.9.2021. On the way from Dwarka Expressway to Danvapur Chowk the driver applied emergency brake to save a street dog and the vehicle overturned due to dis-balancing. His brother and co-passengers sustained injuries in this accident. The insurance company wrongly stated that the vehicle was

on route from Delhi to Agra as the accident took place at Dwarka Expressway. The insurance company also mentioned that my vehicle was being used as commercial vehicle which was false. His vehicle was towed by Yadav Crane Services from Dwarka Expressway to Tiger Eye.

Insurers’ argument: The Insurance Company in their SCN dated 07.01.2022 stated that the complainant submitted claim for damages to the insured vehicle on 06/09/2021 for accident dated 05/09/2021 and the claim was registered and process was initiated. The insurance company appointed an independent IRDA licensed surveyor to inspect the vehicle and assess the loss. Also, it appointed an independent investigator to check and verify the details of submission of the complainant. During processing of claim, the complainant provided few documents along with duly filled and signed claim form and a self written and signed statement wherein he informed that the vehicle was driven by his brother, Mr.Vishwanath Pratap Singh at the time of accident. Also, he had given the vehicle for hire and reward to four persons who were travelling in insured vehicle from Agra, UP to Gurugram, Haryana by paying Rs. 3500/- fare. After the accident, the passengers sustained minor injuries and ran away from the spot. Without admitting any liability under the policy, the loss was assessed for Rs. 3,02,612/-. On scrutiny of Investigation report, survey report, documents and statement, it was noted that the act of the insured stands in violation of policy condition with respect to limitation as to use which states as follows:- a) Being used otherwise than in accordance with the limitation as to use or

b) Being driven by or is for the purpose of being driven by him/her in the charge of any person other than a driver as stated in driver’s clause. Limitations as to use: The policy covers use of vehicle other than a) Hire and rewards other than for the purpose of driving tuitions b) carriage of goods …. In view thereof, a letter dated 22/09/2021 was sent to the complainant seeking clarification for subject violation. However, in absence of any satisfactory reply, the claim was finally repudiated vide letter dated 30/09/2021. As per the claim form, the vehicle was driven by the complainant himself at the time of accident. The vehicle was being driven for hire and reward against policy terms and conditions. The complainant was giving false and misleading statements in order to take benefit under the policy which also stands in violation of declaration signed by insured on claim form. 19) Reason for Registration of Complaint: -Repudiation of claim 20) The following documents were placed for perusal. a) Complaint letter b) Policy document c) Claim form d) SCN e) Survey Report f) Investigation Report 21) Observations and Conclusion: - The complainant’s brother and the representative of the insurance company were present for an online hearing on 14.02.2022. The complainant stated that the insurance company forced him to write written statement by altering the cause of accident and later on denied paying the claim. The insurance company reiterated

that consequent upon the investigation of the accident, it was noted that some documents viz. duly filled and signed claim form and a self written and signed statement whereby the complainant informed that the vehicle was driven by his brother at the time of accident. His brother had given the vehicle for hire and award to four persons who were travelling in insured vehicle from Agra, UP to Gurugram, Haryana by paying Rs. 3500/- fare. The passengers attained minor injuries also. By this act, the complainant violated the policy condition with respect to limitation as to use as mentioned in the insurance policy. On going through the documents exhibited and the oral submissions, I find various ambiguities/disparities in the statements of the complainant. In the claim form, the complainant wrote that his younger brother was driving the vehicle and a truck in front of his vehicle applied sudden brakes and his vehicle overturned after colliding with the truck. On the other hand, he wrote in the complaint letter that his brother was driving the vehicle and to save a dog, the driver applied emergency brake resulting overturning of the vehicle. The insurance company repudiated the claim for the reason that the vehicle was being used for hire/award which is the violation of policy condition with respect to limitation. This fact is proven from the written documentary evidence signed by the complainant where he stated that his brother was a taxi driver and he paid his younger brother to drive the vehicle. His brother plied the vehicle for hire and reward in local, Agra, Jaipur, etc and earned apprx Rs 15000 to 20000. On the date of accident, his brother was driving the said vehicle from Agra to UP to Gurgaon by charging Rs.3500/- from four passengers. A truck above the said vehicle applied sudden brake and accident happened. All persons sustained minor injuries but the passengers ran away and his brother was taken to a local hospital in Gurgaon. Further, it is also on record that the investigation report of Bulls Eye Detectives dated 22.9.2021 had concluded in his report that the vehicle met with an accident on 5.9.21. This is a case of Hire & Reward, the private registered vehicle was being used in passenger carrying and at the time of accident passengers were sitting in the vehicle. A private vehicle cannot be used to make money out of it. This is the violation of terms and conditions of the policy. The driver lodged Non Cognizable Offence Information Report (NCR) on 27.9.2021 at Gurugram where he narrated the story as the cause of accident was a dog. The complainant had no proof to show that the statement he gave in writing was imposed upon him forcefully. The insurance company had rightly repudiated claim under the clause for violation of policy condition with respect to limitation as to use: a) Being used otherwise than in accordance with the limitation as to use or b) Being driven by or is for the purpose of being driven by him/her in the charge of any person other than a driver as stated in driver’s clause. Limitations as to use: The policy covers use of vehicle other than a) Hire and rewards other than for the purpose of driving tuitions. I see no reason to interfere with the decision of the insurance company to repudiate the claim. The complaint is closed.

AWARD

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

by both the parties, I see no reason to interfere with the decision of the insurance

company to repudiate the claim.




PROCEEDINGS BEFORE


OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. DEEPAK JOSHI V/S UNIVERSAL SOMPO GENERAL INS. CO. LTD.


1. Name & Address of the Complainant Mr. Deepak Joshi, H.No. 1044, Prakash Nagar, Khora Colony, Ghaziabad, UP-201309.


USGI/WEBAG/0579411/00/B00 Two Wheelar Package Policy 17.01.2021 to 16.01.2022


Mr. Deepak Joshi Mr. Deepak Joshi

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

5. Date of Repudiation 02.08.202117.12.2021

6. Reason for repudiation Misrepresentation of material fact


8. Nature of complaint Motor individual

9. Amount of Claim Not mentioned

10. Amount of Partial Settlement n.a.

11. Amount of relief sought Not mentioned


13 (1) (b)



• For the Complainant Mr. Deepak Joshi, Self

• For the insurer Mr. Prashant V Shukla



17) Brief Facts of the Case: This complaint is filed by Mr. Deepak Joshi against Universal Sompo General Insurance Co. Ltd., for repudiation of accidental damages claim for his bike.


a) Complainant’s argument: The complainant’s father was an owner of Bajaj Two-wheeler Pulsar Bike, Regn. No. DL-07-BP-6915, year of mfg. 2012. The said vehicle was being used by Mr. Deepak Joshi, complainant. He registered an accidental claim on 26/11/2021 for the accident that took place on 23/11/2021. The insurance company rejected his claim for the reason that the damages were old and rusted.

b) Insurers’ argument: The insurance company submitted their SCN dated 02.02.2022 wherein they stated that after the intimation of claim, as per terms and conditions of the policy, they appointed IRDA licensed independent Surveyor, Harmik Singh to Survey the loss of the insured vehicle. As per the Survey Report, the vehicle was inspected at workshop while it was identified that the damages were old in nature. The complainant was posed with questions regarding the said accident/ cause of loss

along with whether FIR had been lodged, he admitted in the email dated 27.11.2021 that no FIR had been lodged. Furthermore, it had been identified by the Surveyor that the cause of loss in the email was found to be non-satisfactory and damages were not in sync with the date of loss provided. The damages which had been sustained to the IV during the accident were old in nature, multiple and was not relevant to the cause of loss. Thus, on due perusal of the Survey report, there had been gross misrepresentation of material facts which was also a violation of the declaration made by the complainant at the time of submitting the claim form. Hence, the claim had been rightly repudiated vide letter dated l7/l2/2021. 19) Reason for Registration of Complaint: - Repudiation of claim. 20) The following documents were placed for perusal.

a) Complaint letter b) Policy document c) SCN d) Survey Report & photographs

21) Observations and Conclusion: - The complainant and the representative of the insurance company were present for an online hearing on 24.02.2022. The complainant stated that the insurance company repudiated his accidental damages claim of his bike for the reason that the damages were old. He further stated that the bike was nine years old and there would be rust in the internal parts of the vehicle but could the insurance company have any valid reason to prove that the damages were old and rusted. The insurance company reiterated that the surveyor who assessed the loss mentioned that the cause of loss narrated by the complainant was found to be non-satisfactory and damages were not in sync with the date of loss provided. The damages were old in nature, multiple and was not relevant to the cause of loss, further, there had been gross misrepresentation of material facts which was also a violation of the declaration made by the complainant at the time of submitting the claim form. On going through the documents exhibited and the oral submissions made by both the parties during the hearing, it is noted that the complainant had taken online policy by filling in an online proposal form, hence, pre-inspection of the vehicle was not initiated and the policy was issued on the basis of details provided by the complainant. The proposal form of the complainant proves misrepresentation of the facts as he did not give details of his previous insurance, NCB and claim status. Further, the complainant mentioned the short description of accident/incidence in the claim that the bike skid, slipped and hit the divider. The IRDA licensed surveyor who inspected the had mentioned in his report that the “vehicle was inspected at workshop while found the damages to be multiple and old in nature, asked for the detailed cause of loss along with FIR and spot to which insured denied to have while the detail cause of loss provided in mail is found to be non satisfactory and damages are not in sync with the date of loss provided hence claim being recommended for repudiation.” Since pre-inspection was not done at the time of issuing the policy, the previous damages and new damages to the vehicle cannot be verified, and this forum has to rely on the surveyor’s report and photographs of the accidental vehicle. The accident had taken place and to meet the end of justice, I directed the insurance company to pay the claim for Head Lamp Bracket, Both Headlamps, Headlight and Right Tank Cap and right Footstep which got damaged in the accident as narrated by the complainant.


AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties, the insurer is directed to pay the claim for Head Lamp Bracket, Both Headlamps, Headlight and Right Tank Cap and right Footstep which got damages in the accident as narrated by the complainant.





PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P AND UTTARAKHAND UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – SH. C.S. PRASAD CASE OF SH. DEEPAK GUPTA V/S. BAJAJ ALLIANZ GENERAL INSURANCE.

COMPLAINT REF. NO. : NOI- G- 005- 2122 – 0195 AWARD NO:

1. Name & Address of the Complainant Sh. Deepak Gupta

134, Vijay Nagar, Gali No.5,

Ferozabad, Uttar Pradesh-283203.

Phone. No. 8218019375

2. Policy No:

Type of Policy


IDV

OG-21-3004-1801-00000072


30.06.2020 to 29.06.2021

Rs.2,85,000/-



Sh. Deepak

Sh. Deepak

4. Name of the insurer Bajaj Allianz General Ins. Company


6. Reason for repudiation Claim rejected due to no response from

the Insured





11. Amount of relief sought Rs.2,85,000/- as per Annex. VI A



13 (1) b

13. Date of hearing/place 24.02.2022 / NOIDA


a) For the Complainant Sh. Deepak Gupta

b) For the insurer Sh. Shyama Charan Vats, Legal



17. Brief Facts of the Case :- Sh. Deepak Gupta, the complainant had taken Private Car

Package Policy No. OG-21-3004-1801-00000072 covering his Renault Kwid model 2017, Vehicle No. UP-53-CP-9823 from Bajaj Allianz General Ins. Company for the period from 30.06.2020 to 29.06.2021 with of IDV Rs.2,85,000/-. The Insurance Company has repudiated his claim. Aggrieved, he requested the insurer including its GRO to

reconsider the claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.

18. Cause of Complaint : -

a) Complainant’s Argument :- The Complainant Sh. Deepak Gupta stated in his

complaint that he informed the Insurer about the theft of his car and he had lodged FIR. As a result of the complaint, a Company personnel had visited him and forcibly asked him to write “The vehicle was unlocked a key had left in the car”, otherwise his claim would be delayed, so he wrote it. On the basis of such note, the insurance company rejected his claim.

b) Insurers’ argument:- The insurer stated in their SCN that

1. The present complaint is filed by the complainant without any basis, on wrong and

misrepresented facts, in order to extract reimbursement of the claim in violation of the terms and conditions of the Policy, from the Bajaj Allianz General Insurance Company Ltd. hereinafter referred as the “Opposite Party”.

2. At the outset, the opposite party denies the contents of the complaint to the extent they pertain to the opposite party, in their entirety, except to the extent the same are expressly admitted in the present response.

3. As is evident from the factual matrix of the case, there is no laxity on the part of the opposite party in dealing with the claim for theft of the insured vehicle Renault – Kwid, numbered UP53CP9823put forth by the complainant. It is submitted that the claim of the complainant with respect to the theft of the insured vehicle Renault – Kwid, numbered UP53CP9823was denied by the Opposite Party on reasonable grounds and that too after following the due procedure. Complainant was duly intimated about the company’s inference of claim as put forth by him, but he chose to remain silent on the same.

4. The complainant did not inform the insurance company in time about the incident and did not lodge the claim within a reasonable time as prescribed under the policy terms and conditions. As per the policy terms and conditions the insured is required to intimate the loss to the insurance company immediately but in the present case the intimation of the incident was given after an inordinate and unexplained delay of 03 days which is a fundamental breach of terms and conditions of the policy. The said clause has been reproduced herein below for the reference of the Hon’ble Ombudsman: CONDITIONS This policy and the Schedule shall be read together and any word or expression to which a specific meaning has been attached in any part of this Policy or of the Schedule shall bear the same meaning wherever it may appear. 1. Notice shall be given in writing to the Company immediately upon the occurrence of any accident or loss or damage in the event of any claim and thereafter the Insured shall give all such information and assistance as the Company shall require.

5. As the claim for the theft of the insured vehicle Renault – Kwid, numbered

UP53CP9823of the insured by the complainant, was intimated to the opposite parties, they scrutinized the documents and found that the insured had left the key of the vehicle in the ignition slot of the vehicle, which is a violation of the terms and conditions of the policy. The insured by leaving the key in the ignition slot of the vehicle has not taken reasonable care of the vehicle which has directly led to the theft of the vehicle. As the theft of the vehicle was purely due to the gross negligence of the insured, which is not covered as per the terms and conditions of the policy thus the claim was repudiated as per the terms and conditions of the policy. The relevant clause of the terms and conditions has been reproduced herein below for the reference of the Hon’ble Ombudsman: CONDITIONS This Policy and the Schedule shall be read together and any word or expression to which a specific meaning has been attached in any part of this Policy or of the Schedule shall bear the same meaning wherever it may appear. 4. The insured shall take all reasonable steps to safeguard the vehicle from loss or damage and to maintain it in efficient condition and the Company shall have at all times free and full access to examine the vehicle or any part thereof or any driver or employee of the insured. In the event of any accident or breakdown, the vehicle shall not be left unattended without proper precautions being taken to prevent further damage or loss and if the vehicle be driven before the necessary repairs are effected any extension of the damage or any further damage to the vehicle shall be entirely at the insured's own risk.

6. As the claim was intimated to the insurance company appointed an independent investigation agency named JMD Investigations for getting the correct facts of the case. It was found that the insured had left the key of the vehicle in the ignition slot of the vehicle which directly led to the theft of the vehicle. The finding of the investigation agency has been mentioned herein below for the reference of the Hon’ble Ombudsman: Conclusion: And he parked the vehicle at fair ground around 07:30 PM, those are come just for see, so by mistake he left key in the vehicle steering lock and around 30 minutes at 08:00 PM when he came back then he saw vehicle was not there.

7. During the verification of the documents, the insured was asked to submit his statement for the theft of the insured vehicle. The insured in his statement and in claim form has categorically mentioned and accepted that he left the key of the vehicle in the ignition slot of the vehicle. The insured had violated the terms and conditions of the policy by leaving the key of the vehicle in the ignition slot which had directly led to the theft of the vehicle.

8. The insurance company wrote letters dated 22-Feb-2021 and 02-Mar-2021 to the insured and asked for clarifications with respect to the violation of the terms and conditions of the policy as the key of the vehicle was left in the ignition slot of the vehicle. But the insured chose not to respond to any of the letters and after giving

ample opportunity to the insured the insurance company rightly repudiated the claim of the insured.

9. That the Opposite Party after thoroughly examining the documents submitted by the

complainant have rightly repudiated the claim of the complainant as the theft of the vehicle is due to the negligence of the insured which is a violation of the terms and conditions of the policy. The claim was rightly repudiated vide letter dated 09-Mar-2021 after following due procedure and based on the terms and conditions of the policy.

19) Reason for Registration of Complaint: - Repudiation of motor theft claim


a. Complaint letter b. Policy copy c. Form VI A duly signed by the complainant. d. SCN

21) Observations and Conclusion :- Both the parties appeared for personal hearing through video call and reiterated his submissions. Sh. Deepak Gupta, the complainant reiterated that the Company’s personnel had visited him and forcibly made him to write “The vehicle was unlocked a key had left in the car”. On the basis of such note, the insurance company rejected his claim. During the course of hearing, the Insurance Company could not attend the hearing due to technical problem. Later, the Insurance Company presented his case and clarified that the complainant himself stated in the claim form that he had left one key in Car on 26.11.2020. After receiving intimation alongwith the claim form, the investigator was deputed. Therefore, there is no question that the complainant was forced to give this type of statement. The Insurance Company repudiated the claim of the complainant on the ground of negligence of the insured which is a violation of the terms and conditions of the policy.

I have examined the documents exhibited and the oral submissions made by both the parties. Although the negligence on the part of the insured is established, the incident of theft has not been disputed by the Insurer.

It is a settled law that in the case of theft of vehicle, which is proved by the two legal documents, the breach of condition is not germane as enshrined by the Hon’ble Supreme Court in the case of National Insurance Company Ltd. Vs. Nitin Khandelwal. The Insurance Company is liable to indemnify the owner of the vehicle, because the Insured had obtained comprehensive policy for the loss caused to the Insured. In the instant case, the vehicle was stolen which is confirmed by the Police Authorities. In light of the above discussion, the Insurance Company is directed to settle the claim on sub-standard basis and pay 50% of the IDV to the complainant.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, an award is passed directing the Insurance Company to settle the claim on sub-standard basis i.e. 50% of the Insured Declared Value.



23. 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 thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.


PROCEEDINGS BEFORE


OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. GAURAV GARG V/S. HDFC ERGO GEN. INS. CO. LTD.

COMPLAINT REF. NO.: NOI-G-018-2122-0196 AWARD NO:

1. Name & Address of the Complainant Mr. Gaurav Garg

141, Sukhimal Dasna Gate,

Ghaziabad, Uttar Pradesh-201001.

Ph. No. 8800600031

2. Policy No:

Type of Policy


IDV

2312 2024 6307 8100 000

Two Wheeler Package Policy (5 years)

22.10.2018 to 21.10.2023

Year 1-Rs.52,766/-, Year 2–Rs.47,489/-,

Year 3–42,213/-, Year 4-Rs.36,936/-,

Year 5-Rs.31,660/-



Mr. Gaurav Garg

Mr. Gaurav Garg

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


6. Reason for repudiation Claim closed due to non submission of

required documents




10. Date of Partial Settlement N.A.

11. Amount of relief sought Nothing mentioned in Annex VI A


IOB rules

13 (1) (b)

13. Date of hearing/place 24.03.2022 / NOIDA


a) For the Complainant Mr. Gaurav Garg

b) For the insurer Sh. Aviraaj Singh, Assistant Manager -

Legal Claims



17) Brief Facts of the Case: Mr. Gaurav Garg, the Complainant had taken Two Wheeler

Package Policy (5 years) No. 2312 2024 6307 8100 000 from HDFC Ergo for the period from 22.10.2018 to 21.10.2023 on depreciated value of the vehicle for five years. The Complainant had lodged the claim for his Honda Activa 2018, Vehicle No.UP-14-DV-4775 which was closed by the Insurance Company on the ground of non submission of required documents. Aggrieved, he requested the Insurer including its GRO to reconsider the claim but failed to get any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.


a) Complainant’s argument: The complainant Mr. Gaurav Garg stated in his complaint that his vehicle was stolen on 25.08.2019. He has submitted all the documents to the Insurer except Final Report which was received by him from the honorable Court on 19.08.2021. When he approached the Insurer for settlement of his claim, the Company denied processing the claim on the ground that it is a two year old case and it cannot be reopened.

b) Insurers’ argument: The Insurer stated in their SCN that :

1. That the present complaint pertains to insurance claim under Two Wheeler Package 5

years Policy bearing policy number 2312 2024 6307 8100 000 which was valid from 22/10/2018 to 21/10/2023 having IDV as Rs. 52,766/- It is submitted that the policy was issued subject to the terms and conditions and so any liability which may arise under the policy is always subject to and restricted by the terms and conditions. It is further submitted that the terms and conditions of the policy have been duly assessed and approved by the IRDAI.

2. That as per the claim form submitted and statement given by the complainant it is stated that on 25/08/2019 the insured vehicle was stolen which was parked outside the house i.e. B-82, Ashok Nagar, Nehru Place, Nehru Nagar III, Ghaziabad-201001. The complainant approached the respondent and claimed for the above mentioned theft of the Insured Vehicle vide claim no-C230019237580.

3. That post receipt of the intimation the respondent insurer sought for documents

which were necessary for the proper assessment of the claim through letter dated 15/09/2019, 13/10/2019 & 21/11/2019. However, it is submitted that till date complainant has not submitted all the necessary documents for proper assessment of the claim.

4. That it is submitted that respondent insurer still require below mention necessary documents for proper assessment of the claim:

● Original FIR ● Original Court approved final report ● RTO Forms 26, 28, 29, 30, (Need original, 4 copy of each) ● Indemnity Bond on Rs. 200 stamp paper with 2 witness IDs.

5. That in the present case, basis on the above mentioned facts, the complainant has not submitted the above mentioned documents therefore the respondent insurance company closed the said claim on the ground of non-submission of claim documents and the same was duly intimated to complainant vide letter dated 06/12/2019.

That in view of the aforementioned submissions, it is clear that the claim was processed as per the terms and conditions of the policy and so there is no deficiency in service on the part of the respondent and therefore the present complaint deserves to be dismissed. 19) Reason for Registration of Complaint: - Motor theft claim rejected


a) Complaint letter b) Policy copy c) SCN d) Annexure VI A

21) Observations and Conclusion :- Both the parties appeared for personal hearing through video call and reiterated his submissions. Mr. Gaurav Garg reiterated that his vehicle was stolen on 25.08.2019. He has submitted all the documents to the Insurer except Final Report which was received by him from the honorable Court on 19.08.2021. When he approached the Insurer for settlement of his claim, the Company denied processing the claim on the ground that it is a two year old case and it cannot be reopened. The Insurance Company clarified that they are ready to settle the claim but the below mentioned necessary documents for processing the claim are still pending at the Complainant’s end:

● Original FIR ● Original Court approved final report ● RTO Forms 26, 28, 29, 30, (Need original, 4 copy of each) ● Indemnity Bond on Rs. 200 stamp paper with 2 witness IDs.

I have examined the documents exhibited and oral submissions made by both the parties and find that the Insurance Company is ready to pay the claim after submission of above mentioned documents. Hence, it is directed to the Complainant to submit the above mentioned documents in original as required by the Insurance Company and the Insurance Company is directed to pay the admissible claim amount to the Complainant under intimation to this forum.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, it is directed to the Complainant to submit the above mentioned documents in original as required by the Insurance Company and the Insurance Company is directed to pay the admissible claim amount to the Complainant after receiving of the required documents.





PROCEEDINGS BEFORE


OMBUDSMAN – SHRI C.S. PRASAD CASE OF MR. MANOJ KHANNA V/S THE NEW INDIA ASSURANCE CO. LTD.


1. Name & Address of the Complainant Mr. Vishwendra Pratap Singh R/o Mohalla Ganj, Saket, ETAH (U.P.)- 207121


ITG/83016841 Motor 06-07-2021 to 05-07-2022


Mr. Arun Kumar Mr. Arun Kumar

4. Name of the insurer IFFCO- TOKIO GENERAL INSURANCE CO. LTD.


6. Reason for repudiation Non submission of claim documents

7. Date of receipt of the Complaint 28-10-2021/18-11-2021

8. Nature of complaint Partial settlement of claim

9. Amount of Claim 20,835/-

10. Amount and date of Partial Settlement

18,540/-



13 (1) (b)

13. Date of hearing/place 28-02-2022


a. For the Complainant Mr. Vishwendra Pratap Singh

b. For the insurer Mr. Paritosh Arora

15 Complaint how disposed Dismissed


17) Brief Facts of the Case: This complaint is filed by brother of insured, Mr. Arun Kumar against partial settlement of the Motor claim of their Car No.- UP-82AC4917 which met with an accident but the insurer partially settled their claim. 18) Cause of Complaint: Complainant’s argument:

● Claimant’s brother is a customer of IFFCO TOKIO for his vehicle no.- UP-82AC4917. ● Complaint has been lodged against the insurance company for denying the claim for

most his vehicle’s part and only providing the partial claim. ● The vehicle met with an accident at 2 different incidents as under: -

1st Incident: Location Etah, Damages: - Windscreen, Bumper, Fender sealing, left side fender sealing, underbody damage. The car went off road and the ground was uncertain which caused multiple damages in the front. The rear fender sealing was damaged due to a pole on the road which rubbed the car when the car was disbalanced and going down the road.

● 2nd incident- While driving back to Noida, a bike driver bumped into my car as he felt sleepy.

● The insurance company has refused to provide the claim for underbody, front bumper, fender sealing (from 1st incident) and rear bumper from 2nd incident.

● The claims approved by the insurance company are only rear fender sealing and windshield only and both the damages are from 1st accident but the insurance company arbitrarily charged me the file charges twice despite refusing to provide the claim for 2nd accident completely.

● The claims are denied as follows: - 1st incident- Front Bumper with fender sealing, underbody damage & the 2nd incident – Rear Bumper.

● The insurance company denied the claim of the majority of parts on their own description, acted as a self-judge and refused to provide any justification for doing that.

● The company officials didn’t even inform him, on what authority did they deny the claim. The surveyor of the company said that the claims are old but has no reason to justify the same.

● So, he had 2 questions for the company: - 1. How do they come to the conclusion that the damage is old and which one is new

and which are old? 2. Where did they provide in the policy terms and conditions that old damages will

not be provided and how recent the damages should be. He had already sent a list of question in his mail to the company, none of which were answered.

b) Insurers’ argument: The insurance company submitted their SCN dated 10-02-2021 wherein they submitted their reply as under: -

● It is submitted that the respondent Insurance Company had issued a Pvt. Vehicle Policy for Vehicle No. UP 82AC4917 for the period from 06-07-2021 to 05-07-2021 strictly subject to terms and conditions of the policy.

● That allegedly on 29-07-2021 i.e., date of loss lodged a claim pertaining to the own damage of the above-mentioned vehicle on 07-08-2021 with ITGI vide claim form, Claim No. 37K82672.

● That the claim form had a clear undertaking mentioning as under: - “Undertaking I/We the above named, do hereby to the best of my knowledge and belief, warrant the truth of the foregoing statements in every respect and agree that I/we have made any false or fraudulent statement or there be any suppression or concealment of facts, the claim will be forfeited.”

● That after lodging of claim by insured, ITGI appointed IHSLA’s Rishab Panchal for survey of the claim. The bill raised in the captioned matter was for 20,835/-.

● Surveyor report dated 25-08-2021 was submitted by the Surveyor, assessed the net amount of loss for Rs. 18,540/- without admitting any liability after deducting Rs. 1000/- as excess clause, Rs. 1000/- as imposed excess and Rs. 295/- being consumables from the bill amount of Rs. 20,835/-.

● The same has already been paid by ITGI to the repairer. Under cashless arrangement as full and final settlement, thereafter the vehicle bearing no.- UP82AC4917 was repaired.

● Case Laws regarding importance of Survey Report have also been cited. ● That it is submitted that the claim of insured was diligently dealt by ITGI and the claim

amount as per Surveyor report has already been paid to the claimant/ complainant in full and final settlement of the claim. Thus, the claim of the complainant has duly been settled fully as per the set norms. It is submitted that the present complaint is devoid of any merits and is liable to be dismissed forthwith.

19) Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules 2017. 20) The following documents were placed for perusal.

a) Complaint letter b) Policy document c) Survey Report d) SCN

21) Observations & Conclusion: - Both the parties attended the online hearing on 28-02-2022 and reiterated their submissions. The complainant stated that his brother is a customer of IFFCO TOKIO for his vehicle no.- UP-82AC4917. Complaint was lodged against the insurance company for denying the claim for most of his vehicle’s part and only providing the partial claim. The insurance company denied the claim of the majority of parts on their own description, acted as a self-judge and refused to provide any justification for doing that. Insurer defended their decision on the grounds that allegedly on the date of loss, a claim was lodged by the complainant pertaining to the own damage of his brother’s vehicle. Surveyor, assessed the net amount of loss for Rs. 18,540/- without admitting any liability after deducting Rs. 1000/- as excess clause, Rs. 1000/- as imposed excess and Rs. 295/- being consumables

from the bill amount of Rs. 20,835/. Claim of insured was diligently dealt by ITGI and the claim amount as per Surveyor report has already been paid to the claimant/ complainant in full and final settlement of the claim. Thus, the claim of the complainant has duly been settled fully as per the set norms. Ongoing through the documents exhibited and the oral submissions made by both the parties, it is observed that the Insurance Company has settled the claim on the basis of surveyor’s report on loss assessment. The complainant has not provided any evidence to the insurer or to this forum to brush aside the surveyor’s report. National Consumer Dispute Redressal Commission, in Shiv Vilas Resorts Pvt. Ltd. Vs. United India Insurance Co. Ltd. and S.C in Venkateshwara Syndicate Vs. Oriental Insurance, had held that surveyor’s report cannot be ignored unless supported by credible evidence. The Insurance Company, by repudiating the claim, has not acted beyond the scope of policy conditions. Hence, the Insurance Company’s decision does not warrant any interference by way of Award at present. The Complaint is dismissed. 22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty

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


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SHRI C.S. PRASAD

CASE OF MR. MANOJ KHANNA V/S THE NEW INDIA ASSURANCE CO. LTD. COMPLAINT REF: NO: NOI-G-049-2122-0183

AWARD NO:

1. Name & Address of the Complainant Mr. Manoj Khanna Plot No.- 66, Ist Floor, Shakti Khand-3, Indirapuram


31100031202050003520 Motor 16-12-2020 to 15-12-2021


Mr. Manoj Khanna Mr. Manoj Khanna

4. Name of the insurer The New India Assurance Co. Ltd.


6. Reason for repudiation Misrepresentation/Misdescription/ Concealment of Facts related to accident as well as driver

7. Date of receipt of the Complaint 28-10-2021/18-11-2021

8. Nature of complaint Non- Settlement of claim

9. Amount of Claim Rs. 4,23,517/- (Estimated loss) as per S. Report

10. Amount and date of Partial Settlement N.A.

11. Amount of relief sought Rs. 4.23,517/-


13 (1) (b)

13. Date of hearing/place 21-02-2022, NOIDA


a. For the Complainant Mr. Manoj Khanna

b. For the insurer Ms. Anjali R. Chopra & Mr. Anupam Singh

15 Complaint how disposed Dismissed


17) Brief Facts of the Case: This complaint is filed by Mr. Manoj Khanna against New India Assurance Co. for non-settlement of his Motor claim. 18) Cause of Complaint:

Complainant’s argument: The complainant had taken Motor Insurance Policy for his Vehicle No.- UP-14 EH 2452, KIA Seltos Car, Model- 2029 from New India Assurance Co. Ltd. Against OD cover for the Policy Period- 16-12-2019 to 15-12-2020 and TP cover for the period- 16-12-2019 to 15-12-2022.

● Insured’s vehicle got damaged in an accident on 29-04-2021, ● Surveyor, Mr. Kapil Kumar was appointed by the Insurance and Company for assessment of

loss. ● Surveyor violated the norms of IRDA since he was supposed to assess the actual loss and to

verify the amount claimed by the insured, on the basis of which the Insurance Company settle the loss whereas he failed to discharge his duties as Surveyor.

● Surveyor didn’t justify the facts of the case and denied the legitimate accidental loss of the vehicle and submitted his report to the Company as a result of which the Insurance Company rejected the claim.

● Hence intervention is required from the Hon’ble Ombudsman for settlement of claim as per terms and conditions of the policy.

Insurers’ argument: The insurance company submitted their SCN dated 14-12-2021 wherein they submitted their reply as under: -

● After receiving the claim form from the insured dated 11-05-2021, immediately an independent Surveyor, Sh. Kapil Kumar was deputed for investigation and assessment of the loss and a claim was registered by them vide claim no.- 31100031210390000202.

● As stated by the insured, his vehicle met with an accident on 30-04-2021 around 00:10 AM at night.

● He was returning after buying his medicines for diabetes from Rahul Medicos. The claimant in the claim form has stated during accident, the vehicle was being driven by him.

● However, upon onsite inspection and as per recorded written statement of the Govt. officials in the nearby area, the surveyor found out that the vehicle was being driven by a boy (around 28 to 30 years of age) under the influence of alcohol.

● Further, Rahul Medicos has also given a written statement that during the lockdown in April 2021, the timings of the shop were morning to night 10 pm. And the same was followed on the night of accident i.e., the shop got closed at 10 pm on the night of 29-04-2021 & 30-04-2021 and the same is also verified by the surveyor from the log book of the medical store.

● Hence, the claim was rejected on the grounds of misrepresentation/ hiding of material facts relevant to the claim.

19) Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules 2017. 20) The following documents were placed for perusal.

a) Complaint letter b) Policy document c) Survey Report d) Claim Repudiation Letter e) SCN

21) Observations & Conclusion: - Both the parties attended the online hearing on 21-02-2022 and reiterated their submissions. The complainant stated that he was returning after buying his medicines for diabetes from Rahul Medicos who was his known chemist. Although he had closed his shop, on his request, he opened it and provided him the required medicine. He insisted that the vehicle was being driven by him at the time of accident.

Insurer defended their decision on the grounds that firstly, Rahul Medicos has also given a written statement that during the lockdown in April 2021, the timings of the shop were morning to night 10 pm. And the same was followed on the night of accident i.e., the shop got closed at 10 pm on the night of 29-04-2021 & 30-04-2021 Secondly, upon onsite inspection and as per recorded written statement of the Govt. officials in the nearby area, the surveyor found out that the vehicle was being driven by a boy (around 28 to 30 years of age) under the influence of alcohol. Hence, the claim is not payable and was rejected by them on the grounds of misrepresentation/ hiding of material facts relevant to the claim. Ongoing through the documents exhibited and the oral submissions made by both the parties, it is observed that the Insurance Company has suspected misrepresentation. This case involves intricate question of facts, which requires detailed examination, chief and cross examination of evidence/medical doctors, which is not possible by way of summary trial at this forum. The Insurance Company, by repudiating the claim, had not acted beyond the scope of policy conditions. Hence, the Insurance Company’s decision does not warrant any interference by way of Award at present. The Complaint is disposed accordingly. 22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty to

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


Case Of: Ajay Kumar Saw Vs Bajaj Allianz General Insurance Co Ltd.

Complaint Ref No.- PAT-G-005-2122-0153

Award No. : IO/PAT/A/GI/0023/2021-2022

1. Name & address of complainant Ajay Kr Saw S/O Sri Chet Lal Saw, Flat no. D3, Tagore Palace, Near TAGORE Hill, Ranchi- 834008

2. Policy No: Type of policy Policy Period:

OG-22-1101-1801-00002943 Private Car Package Policy 30/07/2021 to 29/07/2022

3. Name Of Insured/ Name Of Policy Holder

Ajay Kumar Saw Ajay Kumar Saw

4. Name Of The Insurer

Bajaj Allianz General Insurance Co. Ltd.

5 Date of Repudiation

13/08/2021

6. Reason Of Repudiation

Does not fall within policy clause , “Engine protection” as Add on cover

7. Date Of Receipt Of the Complaint

07th of Oct’2021

8. Nature of Complaint

Repudiation of claim

9. Amount Of Claim

90,000/= (Rs Ninety Thousand Only )


Not Applicable

11. Amount of Relief Sought

Rs 90,000/=

12. Complaint registered under rule no.

16/17 of Insurance Ombudsman Rule 2017

13. Date of hearing/Place

08.2.2022 / OIO, Patna through “Go to meeting application”


a) For the complainant

Ajay Kumar Saw

b) For the Insurer Ms Jahanvi Gupta

15. Complaint disposed as

Award

16. Date of award/ order

09/02/2022

Brief facts of the case:

Mr Ajay Kumar Saw had taken Pvt. Car Package policy from Bajaj Allianz General Insurance Co. Ltd.

For the period 30/07/2021 to 29/07/2022 with Add on coverage under “Engine Protector “ &

“Depreciation shield “ and claim had been lodged by the insured by revoking the “Engine Protector “

clause under the said policy and it is well within the policy period. On the basis of claim lodged by

the insured , Surveyor was deputed by the Insurer for assessment of loss, who in turn has confirmed

vide his report that, loss so reported by the insured does not fall under the purview of the policy,

hence not maintainable and accordingly vide letter dated 13/8/2021, insurer has called for

comment from insured ” why his claim would not be repudiated” based on the reporting of final

surveyor and reminder letter on 21/08/2021 were also issued to the insured after given seven days

notice to insured specifically mentioned in their first letter. Subsequent to refusal from the insurer,

the insured as approached Office of Insurance Ombudsman, Patna subsequent to seeking redressal

from the grievance cell of the Insurer.

Cause of Complaint:

Complainants argument: Subsequent to receipt of letter from insurer in the line of non admissibility

on the part of his preferred claim, his contention to that note is that, how his claim cannot be

entertained or rather making it non-admissible, whereas according to him, the vehicle has ran over

water filled potholes, while making his way to Gomia from Hazaribagh, do fall under the add on cover

of “ Engine Protector “ for which he has paid additional premium to that effect. Moreover, surveyor

too has not taken cognizance of the particular add on coverage, thus making his recommendation of

Non admissibility, on the pretext of being does not fall within the purview of policy.

Insurer’s argument: Insurer has subscribed the reporting of final surveyor, who has vey categorically

confirmed in his report that, as the vehicle do not indicate any effect out of ingression of water/

leakage of engine oil resulting out of cause of loss as mentioned in the motor claim form by the

insured.

Wording of “Engine Protector “ stipulates that, “ this policy extends to cover the consequential

damage to internal child part of engine of insured vehicle arising out of water ingression/ leakage of

lubricating oil and / Or damage to gear box of the insured vehicle arising out of leakage of lubricating

oil due of accidental means” if following condition has been observed;

• There is evidence that insured vehicle stopped in water logged resulting into damage to the

internal parts of the engine due to water ingression

• There is evidence of undercarriage damage to engine and/or gear box leading to oil leakage

and resulting into damage to internal parts of the engine and /or gear box

• The loss or damage is not payable under motor policy

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

On account of prevailing condition subsequent to COVID-19, online hearing was conducted through “

Go To Meeting Application” on scheduled date in the office of insurance ombudsman. The parties

were contacted and were asked, if they have any objection on this hearing in view of COVID19

disruption. Both the parties agreed to the same.

During the personal hearing as on 08th of Feb’2022 (through video conferencing),both the parties

reiterated to their respective stand. The respondent alleged that, the claim preferred by the

insured/claimant, does not fall within the purview of policy, including the Add on coverage of Engine

protector clause, against which the claimant had paid the requisite premium, based on the very fact

as submitted by the Final Surveyor” Mr Lalit Kumar Singh” in his report, and accordingly the same was

communicated to insured/claimant. The complainant, had pleaded that by virtue of Add on coverage,

the loss so described in the claim form as cause of loss, must be payable. Further to that, he has also

alleged that the final surveyor might have not taken cognizance of the policy coverage. In due course

of hearing , the claimant also subscribed to the very fact that, his vehicle has indeed visited the garage

of M/S Sudha Motors Ranchi, approximately fifteen days back for few repairing to be carried against

starter motor of the vehicle, which has been specifically pointed out by the concerned surveyor. The

Respondent had brought the surveyor Mr L.K.Singh along to support the respondent on survey report.

The Respondent confirmed that the final surveyor had not assessed the loss neither they could

substantiate their plea of the damage not being covered under policy. The surveyor stuck to his plea

that there was no water ingress mark but could not confirm categorically the reason of damage to

the engine neither he could submit the opinion of Car Co’s Engineer (Maruti Suzuki in this case)

concurring to his finding. In view of above, ground of repudiation by the Respondent is not Tenable.

For redressal of the grievance of the complainant and proper indemnification of loss suffered by the

insured, an expert opinion under the provision of Rule 15.3 of Ombudsman Rules, 2017has to be

resorted to. The respondent was directed to submit list of IRDA, “A” category motor surveyor based

at Ranchi, who could be appointed as expert to examine the issues pointed out by

insured/complainant in the instant case, under the rule cited above. Mr Om Prakash Sharma,

appearing at Sl. No.1 is appointed as an expert to examine the issues pointed out by the parties in this

case and to make clear recommendation for the admissible claim amount under the policy so issued

to the insured/complainant, within a month of

receipt of appointment order from the respondent /Insurer.

Mr Om Prakash Sharma had been one of the three recommended surveyor by the Respondent

insurer vide their mail dated 08/02/2022. The fee payable to the expert shall be borne by the

Respondent/Insurer and it will be in line with GIPSA Circular in force as of today. The respondent

Insurer shall inform the expert accordingly within week of receipt of this award. The decision of the

expert shall be binding on the insurer and the amount of loss Recommended by the said expert shall

be paid within one month of receipt of expert’s report in this case.

AWARD

In consideration of facts and circumstances, submission made by both the parties during the

hearing of complaint, Mr Om Prakash Sharma, Surveyor, is appointed as an expert to examine

the issues pointed out by the concerned parties and to make clear recommendation for

admissible claim amount under the policy issued to the complainant/Insured within a month of

receipt of appointed order from the Respondent Insurer and it will be in line with the GIPSA

circular in force as of Today. The Respondent Insurer shall inform the expert accordingly within

week of receipt of this award. The decision of expert shall be binding on the Insurer and who

shall pay the amount so recommended, by the expert within one month of receipt of expert’s

opinion. The complaint is accordingly disposed off.

SHREE NAGENDRA KUMAR

SINGH

INSURANCE OMBUDSMAN

FOR THE STATE OF BIHAR & JHARKHAND

Case Of: Satnarayan Mahato Vs Reliance General Insurance Co. Ltd.


Award No. : IO/PAT/A/GI/0025/2021-2022

1. Name & address of complainant Satyanarayan Mahato,C/O Shiv Lal Mahato, At: Sankhu, PO-Bela Simri, Begusarai, Bihar

2. Policy No: Type of policy: Policy Period:

991491923110018738 Pvt. Car Package Policy 20.03.2019 To 19.03.2020

3. Name Of Insured Name of Policy Holder

Rajeev Kumar Rajeev Kumar


Reliance General Insurance Co. Ltd.


09.11.2021


Insured not having valid Driving License


10.01.2022



9. Amount Of Claim

Rs 15,00,000/=


No As such


Rs 15,00,000/=






a) For the complainant

Satnarayan Mahato

b) For the Insurer Computer Rath


Award


14.02.2022

. Brief facts of the case:

Mr Rajeev Kumar, the insured, who died in the car accident as on 17.02.2020 and the PA claim had

been lodged by the claimant to the insurer under policy no. 991491923110018738 wef 20.03.2019

To 19.03.2020. Insurer had repudiated the claim as the insured was not having valid driving

license, at the material time of accident, thus how the claimant has approached Ombudsman,

Patna.

Basis of Complaint:

Complainants argument: Insurer has repudiated the PA claim preferred by the claimant and it has

been contended that at the material time of accident, the vehicle was being driven by the driver

named Mr Sanjay Kumar, not his son, who happens to be the Insured. Hence, their preferred claim

be honored, in view of the coverage under policy.

Insurer’s arguments: Insurance company has repudiated the claim, on the pretext that the insured

was not having valid driving license at the material time of accident, based on the investigation

report, which confirms that, driver at the material time of accident had been the insured not Mr

Sanjay Kumar, as claimed by the claimant.






During personal hearing (Online) on 11th of Feb’22, both the parties reiterated to their respective

stand.

The complainant has alleged that, insurance company had repudiated his claim, on the pretext that

Insured, the owner of the vehicle (Mr Rajeev Kumar) does not hold the valid and effective driving

license at the material time of accident, whereas the matter of the fact that the said vehicle being

driven the driver named Mr Sanjay and copy of the driving license was duly submitted to the Insurance

Co. In the

contrary to statement of complainant, Insurer has alleged that , complainant failed to furnish the

driving license of Mr Rajiv Kumar, who is the registered owner of the vehicle and the provision under

Compulsory PA coverage, owner driver license must have valid and effective as on the date of loss. In

absence of the requisite license, coverage is not applicable under the policy and also since the insured

did not hold effective D/L , it amounts to violation of law and policy terms and condition and hence

the claim is not payable, so is the Repudiation.

AWARD

Taking in to account the facts and circumstances of the case and the submission made by the

both the parties, the decision of the Respondent / Insurer is upheld. The complaint is

accordingly disposed off.

SHREE NAGENDRA KUMAR SINGH

INSURANCE OMBUDSMAN

FO RTHE STATE OF BIHAR & JHARKHAND

Case Of: Sanjeev Kumar Vs National Insurance Co Ltd.


Award No. : IO/PAT/A/GI/00 /2021-2022

1. Name & address of complainant Sanjeev Kumar, S/O Vrind Singh, Vill: Chaksurat, P.O.- Nandlalabad, P.S.- Gauri Chak, Patna- 804451

2. Policy No: Type of policy: Policy Period:

170801/31/17/6200002620 Two wheeler Package Policy 19/07/2017 to 18/07/2018

3. Name Of Insured/ Policy Holder

Sanjeev Kumar


National Insurance Co Ltd.


06/09/2019


Non submission of requisite documents.


03/09/2021



9. Amount Of Claim

Rs 61491/=


Not Applicable


Request for reopening of claim and settlement of claim






c) For the complainant

Mr. Sanjeev Kumar

d) For the Insurer Mr. S.K.Choudhary


Award


09/02/2022

Brief facts of the case:

Mr Sanjeev Kumar, Insured intimated theft of his insured vehicle on 11th of Aug’2017, subsequent to

theft of vehicle as on 10th of Aug’2017 and as prudent Insured , he had reported the incident of theft

of his vehicle on 12/08/2017 at the concerned Agamkuan P.S. which is duly reflected in the certified

copy of FIR with No 374/17. Accordingly he had also reported the mater to DTO, Patna, also. As the

claim file stand closed by the Insurer, the insured had approached Office of Insurance Ombudsman,

Patna after seeking redressal from the grievance cell of the Insurer.

Basis of Complaint:

Complainants argument: As informed by the insurer about closing of his preferred claim , Insured

represented his claim by furnishing all the necessary documents, which was sought earlier by the

insurer including the certified copy of FIR and final police report submitted “ True but No clue” stand

duly seen and accepted by CGM and requested Insurance co. for reopening and settlement of claim.

Insurer’s arguments: Insurance company has closed the claim, on the pretext of non compliance on

the part of insured, with assumption that insured is not interested in the claim, by invoking condition

1 & 7 of the policy.






During the personal hearing(Online) on 08th of Feb’22, both the parties reiterated to their respective

stand. The complainant alleged that subsequent to receipt of certified copy of Final Police Report

dated 16/07/2021, in response to FIR lodged vide case no. 374/17 dated 12/08/2017 by the insured,

who in

turn had submitted as on 19/07/2021 to the Regional office. Further, the(Claimant/Insured) had

requested for reopening of claim file and settle his claim, as per policy condition. Mr S.K.Choudhary,

representative of M/S National Insurance Co Ltd. Had contended that, claim was closed as “ NO

CLAIM” on account of Non submission of Final Police report along with all the documents necessary

for settlement of claim. On being asked the Respondent, Whether they had deputed any independent

Investigator for investigating the case and if he had reported any adverse report pertaining to

genuinety of claim, it was duly confirmed by the Respondent that there was no such adverse reporting

and it is being certified as “ True But No Clue” On the basis of above facts and Final Police report duly

seen and certified by the court, which stand submitted to the Insurer, Respondent is directed to make

the payment of claim.

AWARD

Taking in to account the facts and circumstances of the case and the submission made by the

both the parties, The Respondent is directed to make the payment of claim as per policy

condition I.e. IDV (Rs 61491/=) less policy excess applicable if any, within a month’s time from

the date of this order failing which the Respondent has to pay interest on the claim amount for

the period from the date of order till the date of payment. The complaint is accordingly

disposed off.

SHREE NAGENDRA KUMAR SINGH

INSURANCE OMBUDSMAN

FOR THE STATE OF BIHAR & JHARKHAND

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE

(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)

UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN– VINAY SAH

CASE OF Mr. Vivek Kumar Singh v/s Bajaj Allianz General Insurance Company Ltd

COMPLAINT NO: PUN-G-005-2021-0034

Award No IO/PUN/A/GI/ /2021-22

1. Name & Address of the Complainant: Mr. Vivek Kumar Singh, Navi Mumbai

2. Policy No: Type of Policy:

OG-20-1909-1870-00000098

Standalone Own damage Cover for Private Car

3. Policy period: 08.01.2020 to 07.01.2021

4. Insured Declared Value: Rs. 36,00,300/- (Land Rover Discovery-Sport)

5. Date of inception of first policy: Previous policy was with Bharti AXA Gen. Ins.

6. Name of the Policyholder: Vivek Kumar Singh

7. Name of the Insurer: Bajaj Allianz General Insurance Company Ltd

8. Reason for repudiation/Partial Settlement:

Policy related issue. RI promised to provide Return to Invoice cover, but the same has not been incorporated in the policy.

9. Date of receipt of the Complaint: 06.10.2020

10. Nature of complaint: Return to invoice cover should be provided.

11. Amount of Claim: Not applicable

12. Insurance Ombudsman Rule (IOR)2017 under which the Complaint was registered:

13 1(f)

13. Date of hearing/Place: 08.10.2021, Online Hearing. Pune


g) For the Complainant: Himself and Mrs. Kumud Singh (wife)

h) For the insurer: Mr. Irfan Shaikh and Mr. Sachin Pande.

15. Complaint how disposed: Dismissed.

Contentions of the Complainant:

Complainant is the owner of Land Rover Discovery-Sport vehicle with Registration No. MH-43-BN-6550. His previous insurance policy was with Bharti AXA General Insurance which expired on midnight of 07.01.2020. For renewal of policy, he contacted Bajaj Allianz General Insurance Company (RI). Based on the proposal/ Quotation received from the RI, complainant made the payment of premium of Rs. 70,032/- on 31st December 2019. He received soft copy of the policy on 8th January 2020. Ongoing through the policy, Complainant found that Return

to invoice cover is missing in the Policy. The discrepancy was immediately brought into the knowledge of RI and requested them to include Return to invoice cover in the policy.

On 4th February 2020, to resolve the matter, there was a demand from the Respondent to make the vehicle available for inspection. Complainant responded to reason out the requirement of inspection of the vehicle a month after the insurance was issued. There was absolute silence from RI even after repeated reminders. The point of inspection was again raised by Respondent vide mail dated 18th February 2020. Respondent kept on delaying the amendment to the policy by way of not responding to the clarifications sought by the Complainant. The only response from respondent was demanding inspection of the vehicle without providing any reason/clarity on the requirement.

On 14th July 2020, Complainant received an e-mail from respondent informing that the missing RTI cover was removed from the quote with prior confirmation from his side due to high premium. The amendment to the quotation was never discussed with him so there is no chance of it being concurred by him. The high handedness and unprofessional behavior from respondent has been very stressful. This has also created an uncovered risk as the vehicle was in regular use.

Aggrieved with the unprofessional commercial dealings on the part of the Respondent Insurer, Complainant approached to the Forum with the request to pass an order as dim fit and reasonable of the fraudulent behavior of the respondent as a service provider.

Contentions of the Respondent Insurer (RI):

Self Contained Note (SCN) states that the complainant availed a motor policy from respondent for Own damage standalone cover. The Third party cover was already in existence granted by Bharti Axa GIC. The policy was negotiated and as per discussions and negotiations between Complainant & internal sales team of RI the policy was issued. In this case, the sales team had given quotation to the Complainant with RTI [Repairs (should be Return) to Invoice] coverage, but at the time of underwriting the proposal was rejected by underwriters of RI for allowing higher than usual Cash Discount. Accordingly, the sales team had informed the Complainant that policy cannot be issued with quoted RTI coverage under the collected premium amount. Complainant was given an option that if he still wants to go ahead with RTI coverage, then he has to bear extra premium for RTI coverage. However, the Complainant was not ready to pay additional premium for RTI coverage and accordingly informed and consented to Sales Team of RI to finalize the policy without RTI coverage. Thereafter, the sales team issued the policy without RTI coverage. Complainant had given verbal permission to issue the policy without RTI coverage.

Complainant escalated the issue to the Grievance Cell and complainant was offered to provide desired RTI cover on payment of additional premium to which the complainant had agreed. Complainant was also advised to provide re-inspection photos of the vehicle. But at that point of time he was non co-operative to provide photos of the vehicle. For such changes to be effected into the policy, re-inspection of vehicle was necessary. Thus, the opportunity to add RTI cover in the policy was declined by the complainant himself and the respondent is not at fault in such scenario and there is no any deficiency in service from the Respondent. There remains no scope for any remedy for allegations of RTI cover not provided when in fact no any premium was collected for said RTI coverage from complainant under the above referred policy.

Result of personal hearing with both the parties (Observations & Conclusions):

During the personal hearing on 08.10.2021 (through video-conferencing), both Complainant and Respondent Insurer reiterated their respective stand.

Upon going through the documents exhibited and the oral submissions made by both the parties during hearing, Forum has following observations:

1. The origin of dispute is the Quotation issued by Internal Sales team of Respondent Insurer without obtaining pre-approval from their underwriting department. When the underwriting department is the supreme authority to accept or deny or modify any business proposal, the internal sales team should not have released the quotation without approval from them. The lack of synchronizations among the department could have been avoided by way of proper planning and effective after sales service. The Respondent Insurer is cautioned to initiate appropriate and effective measures to avoid recurrence of this type of dislocation and deficiency of service.

2. Later, Respondent Insurer showed willingness to resolve the issue of Return to Invoice (RTI) add-on cover in the policy and advised Complainant to present the vehicle for physical inspection. Complainant did not accede to the request of RI and kept on arguing about the necessity of inspection as policy was renewed without any break and already covered a period of one month. Previous policy of the complainant was not having Return to Invoice cover. When a policy holder is asking for inclusion of new add on cover in the policy, the RI has every right to inspect the vehicle and based on the physical inspection of the subject, risk can be assessed/ evaluated, whether the required cover of Return to Invoice can be granted or not. Had the Complainant been produced the vehicle for physical Inspection, this issue would have been resolved amicably then and there.

It is also necessary to mention here that the complainant is a learned person and should know the meaning of word ‘quotation’, which represents a tentative amount of the thing to be purchased or sold. See the dictionary meaning of word quotation’: a formal statement setting

out the estimated cost for a particular job or service’. In view of this, complainant’s insistence to stick to the quoted amount cannot be acceded to.

In view of the above, forum comes to the conclusion that Complainant missed the opportunity to get the RTI issue resolved by producing the vehicle for physical inspection. Therefore, this Forum does not find any flaw with the action of the Respondent Insurer as the same is as per the terms and conditions of the policy.

Award Follows:

AWARD Under the facts and circumstances, the complaint is devoid of merits, hence dismissed.

Dated: at Pune, on 18th day of February, 2022. VINAY SAH

INSURANCE OMBUDSMAN, PUNE

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

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

OMBUDSMAN –SHRI VIPIN ANAND

In the matter of Sri. T.S.SURESH V/s ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LTD.,

Complaint No: BNG-G-038-2122-033

Award No. : IO/(BNG)/A/GI/ /2021-22

1 Name & Address of the Complainant Sri. T.S. Suresh, No.742, 10th Main Road, 3rd Stage, 3rd Block, Basaveshwaranagar, Bangalore ,Karnataka-560079

2 Policy No. Type of Policy

Duration of Policy/ Policy Period

VPC11521666000100

Private Car Package policy

03.07.2019 to 02.07.2020

3 Name of the Insured/ Proposer


Sri Suresh Srinivas Tirumala

Self

4 Name of the Insurer ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LTD.

5 Date of repudiation 27.06.2020

6 Reason for repudiation Misrepresentation of NCB- policy period curtailed to 01.04.2020 instead of 2.7.2020

7 Date of receipt of Annexure VI-A 02.07.2021

8 Nature of complaint Repudiation of claim

9 Amount of claim Car Repair cos Rs.2,33,416/-

10 Date of Partial Settlement NA

11 Amount of relief sought Repair Rs.2,33,416/- +Rs.25,000/- taxi charges. +mental anguish Rs,1,00,000/- + Rs.20,000/- legal & other charges

12 Complaint registered under Rule no: 13 (1)(a) of Insurance Ombudsman Rules, 2017

13 Date of hearing/place 24.11.2021 / Bengaluru

14 Representation at the hearing

a) For the Complainant Self b) For the Respondent Insurer Mr.Jayakumar-Manager

15 Complaint how disposed Allowed


17. Brief Facts of the Case: The complaint emanated from the rejection of the Motor Vehicle Claim on the ground of misrepresentation of NCB at the time of taking the policy and due to which policy period for comprehensive portion was curtailed to the short period. Despite taking up the matter with the Respondent Insurer (RI), the same was not considered favourably. Hence he approached forum for relief.

18. Cause of Complaint: a) Complainant’s arguments:

The Complainant submitted that he approached insurance agent of the Respondent Insurer (herein in after read as RI) to insure comprehensive motor insurance policy. As per his advice he paid premium of Rs.62,788/ and got insurance done for his vehicle Audi Q3 bearing No. KA-01-MQ-2091. On 15th June 2020 evening at 3.45 pm another vehicle hit his car causing damage. He left the car with the Audi Service centre for the repair. The service centre informed him that the R.I conducted survey and they are waiting for the work approval. Whereas, he received claim rejection from the R.I on 29.06.2020 on the ground of misrepresentation in No claim bonus and informed that revised policy was up to1st April 2020 and not 2nd July 2020 and therefore the loss was not within policy period. He never received any such communication from the R.I and raised grievance with them. On 2nd July 2020 he received a mail from the R.I containing an attachment purporting to be a copy of the letter they sent with the subject Recovery of No Claim Bonus and a suspicious looking postal receipt affixed on it. The letter attached makes a claim on him of Rs.5096 to be paid to them within 15 days towards No Claim Bonus, failing which they would restrict the Own Damage cover under the policy for a shorter period and retain the TP premium for the full year. It may be noted that the letter is dated 21st August 2019 while the postal receipt on it is dated 28th August 2019. The postal receipt merely has name Suresh on it while his name is T.S.Suresh and the address says KHB Colony while he stays at Basaveshwaranagar. This clearly shows that the R.I has attempted to put together and concoct proof and document to validate their repudiation. He further emailed to the R.I on 22nd July 2020 asking for proof of delivery of the letter at Annexure G had still not been furnished and that there is no email correspondence supporting the letter . If the R.I had cancelled or repudiated his comprehensive motor insurance it would have had to return the difference in premium paid by him which was never done. The very fact that the R.I deputed for survey is the prima facie evidence that his policy was valid on that date. Hence their repudiation is fraudulent. His further representation to GRO of RI was not considered favourably. Hence he approached Forum for relief. b) Respondent Insurer’s Arguments: The Respondent Insurer submitted their Self-Contained Note dated 14.07.2021 submitted that, all the allegations and assertions made by the complainant herein are denied in to-to. There is no deficiency of services on the part of the Insurance Company Herein. It is submitted that, the contract of Insurance is based on the principle of “utmost good faith”. As such, it is the duty of the Insured to disclose all material facts which are within the knowledge of the Insured to enable the Insurance Company to underwrite the risk. Immediately upon intimation of the claim, they have appointed the surveyor to assess the claim. In this regard, the surveyor has collected the necessary documents, surveyed the vehicle, and forwarded a well-considered report to us in which as per the damages he assessed the loss to the tune of Rs. 2,25,340. The surveyor report is attached herewith as Annexure-1. That the insured at the time of taking the policy mentioned that No Claim has been taken from the previous insurer i.e., Cholamandalam M S General Insurance Co. Ltd. and availed NCB of Rs.5096 from the answering company. But on checking with the previous insurer, found that the insured had taken a claim from the previous insurer. That after getting confirmation about previous claim, insured was given an opportunity to remit the NCB amount to continue the policy but even after intimation and request through letter dated 21-

08-2019 (sent through Registered Post on 26-08-2019), insured did not deposit the NCB recovery amount. (NCB Amount Recovery Letter - Annexure 02). That when the insured did not deposit/remit the NCB recovery amount, the insurer has the right to cancel the coverage under section I but on goodwill gesture instead of cancelling the whole coverage, insurer only curtailed/shortened the policy period and revised the policy expiry date as 01-04-2020, which was 2-07-2020 originally. The Change in the policy has been duly intimated to the insured vide Registered Post on 29/11/2019. The period of insurance for the Third-Party cover in the policy remains unchanged and will go as per the original policy. (Intimation for Revised Policy Expiry – Annexure.) That an accidental claim was reported to have occurred on 15-06-2020, immediately a Surveyor was appointed, and verification processes initiated. On verification they found that the Policy of insurance was already expired on 01-04-2020 and the accidental damages occurred after the policy expiry, hence the Claim was repudiated and same was conveyed to the insured vide letter dated 27/06/2020. That the contract of the insurance is of Utmost Good faith, but the insured did not disclose all the information correctly at the time of taking the insurance and deliberately hid the fact of previous claim history with previous insurer and taken the benefit of NCB from the answering insurance Company. And also did not deposit the NCB recovery amount after due intimation and also hid the fact of having proper intimation of shortened policy period for section I coverage i.e. coverage for vehicle own damage, thus the insured misrepresented, and the accident occurred after expiry of the policy coverage, therefore the claim was rightly repudiated. The complainant did not approached this Hon’ble Forum with clean hands. Because, he has not followed the basic principle of insurance and deliberately disclosed false facts approaching this Hon’ble Forum. Hence the R.I requested the Forum to absolve them from the complaint. 19. Reason for Registration of complaint:-

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.


a. Complaint along with enclosures,

b. Respondent Insurer’s SCN along with enclosures and

c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A

21. Result of personal hearing with both the parties (Observations & Conclusions):

The hearing was conducted through video conference. The participants confirmed clarity of

audio and video.

Both the parties reiterated their contentions.

The issue which require consideration is whether the rejection of claim is in order.

The Forum notes from the proposal form which is filled electronically and submitted by the

complainant at the time of taking the policy with the R.I that under the ‘Previous History’

Sl.No. 5.’Previous Policy No. 3362/01559723/000/00 is filled and under the column

DECLARATION-NO CLAIM BONUS for the question ‘ Are you entitled to No Claim Bonus

‘ ticked for the bon ‘Yes’. Further declared that ‘I hereby declare that I have not made claim

ticked box under previous policy No.3362/01559723/000/00 issued by cholamandalam

general insurance co ltd. I/We declare that the rate of NCB 25% claimed by me/us is correct

and that no claim has arised in the expiring policy period(copy of the policy enclosed). I/We

further undertake that if this declaration is found to be incorrect, all benefits under the policy

in respect of Section I of the policy will stand forfeited’.

Accordingly the policy issued by the R.I shows 25% No claim bonus under the policy ‘Own

Damage’ column for the period 03.07.2019 to 02.07.2020. The R.I sent mail to the previous

insurer vide mail 15th July 2019 for the confirmation of the NCB pending data upto 15th July

2019 and received reply from them on 08th August 2019. The statement of list sent by the

previous insurer contains NCB confirmation for various policies. The Sl.No.1629 reflects the

policy details of the complainant for the policy period 2018-19 and under the column NCB left

blank with the remarks ‘CLAIM’.

The complainant reiterated that he had not claimed NCB for his previous policy. He paid the

premium quoted by his agent. Grant of NCB is the discretion of the Insurer & he was not aware

of any suppression of facts.

The RI was directed to furnish a signed or authenticated proposal form by this forum within

two working days to confirm the fact that the policy holder had knowingly suppressed material

facts.

The RI has been unable to furnish the same even after 3 months.

There is no proof of delivery of intimation to the complainant regarding curtailment of policy

period from 3.7.19 TO 1.4.2020.by the RI.

Therefore the forum has concluded that the action of the RI in curtailing Insurance period

without intimation to policy holder against the policy T & C.

Therefore, the Forum concludes that the RI is liable for payment of full claim as per Policy T

& C after deducting due premium for NCB non-disclosure if any.

Hence, the complaint is allowed

A W A R D

Taking into account the facts & circumstances of the case and the personal submissions

made by both the parties and the information/documents placed on record, the forum has

concluded that the action of the RI in curtailing Insurance period without proper intimation

to policy holder is against the policy T & C. The Forum concludes that the RI is liable for

payment of full claim as per Policy T & C after deducting due premium for NCB non-

disclosure if any.

The complaint is Allowed.

Dated at Bengaluru on the 28th day of February,2022

(VIPIN ANAND) INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAK



OMBUDSMAN –SHRI VIPIN ANAND

In the matter of Sri. T.S.SURESH V/s ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LTD.,


Award No. : IO/(BNG)/A/GI/ /2021-22

1 Name & Address of the Complainant Sri. T.S. Suresh, No.742, 10th Main Road, 3rd Stage, 3rd Block, Basaveshwaranagar, Bangalore ,Karnataka-560079

Mobile No. 09845039139

E-mail : [email protected]

2 Policy No. Type of Policy


VPC11521666000100

Private Car Package policy

03.07.2019 to 02.07.2020

3 Name of the Insured/ Proposer


Sri Suresh Srinivas Tirumala

Self

4 Name of the Insurer ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LTD.


6 Reason for repudiation Misrepresentation of NCB- policy period curtailed to 01.04.2020 instead of 2.7.2020



9 Amount of claim Car Repair cos Rs.2,33,416/-


11 Amount of relief sought Repair Rs.2,33,416/- +Rs.25,000/- taxi charges. +mental anguish Rs,1,00,000/- + Rs.20,000/- legal & other charges

12 Complaint registered under Rule no: 13 (1)(a) of Insurance Ombudsman Rules, 2017



a) For the Complainant Self b) For the Respondent Insurer Mr.Jayakumar-Manager



17. Brief Facts of the Case: The complaint emanated from the rejection of the Motor Vehicle Claim on the ground of misrepresentation of NCB at the time of taking the policy and due to which policy period for comprehensive portion was curtailed to the short period. Despite taking up the matter with the Respondent Insurer (RI), the same was not considered favourably. Hence he approached forum for relief.


a) Complainant’s arguments: The Complainant submitted that he approached insurance agent of the Respondent Insurer (herein in after read as RI) to insure comprehensive motor insurance policy. As per his advice he paid premium of Rs.62,788/ and got insurance done for his vehicle Audi Q3 bearing No. KA-01-MQ-2091. On 15th June 2020 evening at 3.45 pm another vehicle hit his car causing damage. He left the car with the Audi Service centre for the repair. The service centre informed him that the R.I conducted survey and they are waiting for the work approval. Whereas, he received claim rejection from the R.I on 29.06.2020 on the ground of misrepresentation in No claim bonus and informed that revised policy was up to1st April 2020 and not 2nd July 2020 and therefore the loss was not within policy period. He never received any such communication from the R.I and raised grievance with them. On 2nd July 2020 he received a mail from the R.I containing an attachment purporting to be a copy of the letter they sent with the subject Recovery of No Claim Bonus and a suspicious looking postal receipt affixed on it. The letter attached makes a claim on him of Rs.5096 to be paid to them within 15 days towards No Claim Bonus, failing which they would restrict the Own Damage cover under the policy for a shorter period and retain the TP premium for the full year. It may be noted that the letter is dated 21st August 2019 while the postal receipt on it is dated 28th August 2019. The postal receipt merely has name Suresh on it while his name is T.S.Suresh and the address says KHB Colony while he stays at Basaveshwaranagar. This clearly shows that the R.I has attempted to put together and concoct proof and document to validate their repudiation. He further emailed to the R.I on 22nd July 2020 asking for proof of delivery of the letter at Annexure G had still not been furnished and that there is no email correspondence supporting the letter . If the R.I had cancelled or repudiated his comprehensive motor insurance it would have had to return the difference in premium paid by him which was never done. The very fact that the R.I deputed for survey is the prima facie evidence that his policy was valid on that date. Hence their repudiation is fraudulent. His further representation to GRO of RI was not considered favourably. Hence he approached Forum for relief. b) Respondent Insurer’s Arguments: The Respondent Insurer submitted their Self-Contained Note dated 14.07.2021 submitted that, all the allegations and assertions made by the complainant herein are denied in to-to. There is no deficiency of services on the part of the Insurance Company Herein. It is submitted that, the contract of Insurance is based on the principle of “utmost good faith”. As such, it is the duty of the Insured to disclose all material facts which are within the knowledge of the Insured to enable the Insurance Company to underwrite the risk. Immediately upon intimation of the claim, they have appointed the surveyor to assess the claim. In this regard, the surveyor has collected the necessary documents, surveyed the vehicle, and forwarded a well-considered report to us in which as per the damages he assessed the loss to the tune of Rs. 2,25,340. The surveyor report is attached herewith as Annexure-1. That the insured at the time of taking the policy mentioned that No Claim has been taken from the previous insurer i.e., Cholamandalam M S General Insurance Co. Ltd. and availed NCB of Rs.5096 from the answering company. But on checking with the previous insurer, found that the insured had taken a claim from the previous insurer. That after getting

confirmation about previous claim, insured was given an opportunity to remit the NCB amount to continue the policy but even after intimation and request through letter dated 21-08-2019 (sent through Registered Post on 26-08-2019), insured did not deposit the NCB recovery amount. (NCB Amount Recovery Letter - Annexure 02). That when the insured did not deposit/remit the NCB recovery amount, the insurer has the right to cancel the coverage under section I but on goodwill gesture instead of cancelling the whole coverage, insurer only curtailed/shortened the policy period and revised the policy expiry date as 01-04-2020, which was 2-07-2020 originally. The Change in the policy has been duly intimated to the insured vide Registered Post on 29/11/2019. The period of insurance for the Third-Party cover in the policy remains unchanged and will go as per the original policy. (Intimation for Revised Policy Expiry – Annexure.) That an accidental claim was reported to have occurred on 15-06-2020, immediately a Surveyor was appointed, and verification processes initiated. On verification they found that the Policy of insurance was already expired on 01-04-2020 and the accidental damages occurred after the policy expiry, hence the Claim was repudiated and same was conveyed to the insured vide letter dated 27/06/2020. That the contract of the insurance is of Utmost Good faith, but the insured did not disclose all the information correctly at the time of taking the insurance and deliberately hid the fact of previous claim history with previous insurer and taken the benefit of NCB from the answering insurance Company. And also did not deposit the NCB recovery amount after due intimation and also hid the fact of having proper intimation of shortened policy period for section I coverage i.e. coverage for vehicle own damage, thus the insured misrepresented, and the accident occurred after expiry of the policy coverage, therefore the claim was rightly repudiated. The complainant did not approached this Hon’ble Forum with clean hands. Because, he has not followed the basic principle of insurance and deliberately disclosed false facts approaching this Hon’ble Forum. Hence the R.I requested the Forum to absolve them from the complaint. 19. Reason for Registration of complaint:-







The hearing was conducted through video conference. The participants confirmed clarity of

audio and video.

Both the parties reiterated their contentions.

The issue which require consideration is whether the rejection of claim is in order.

The Forum notes from the proposal form which is filled electronically and submitted by the

complainant at the time of taking the policy with the R.I that under the ‘Previous History’

Sl.No. 5.’Previous Policy No. 3362/01559723/000/00 is filled and under the column

DECLARATION-NO CLAIM BONUS for the question ‘ Are you entitled to No Claim Bonus

‘ ticked for the bon ‘Yes’. Further declared that ‘I hereby declare that I have not made claim

ticked box under previous policy No.3362/01559723/000/00 issued by cholamandalam

general insurance co ltd. I/We declare that the rate of NCB 25% claimed by me/us is correct

and that no claim has arised in the expiring policy period(copy of the policy enclosed). I/We

further undertake that if this declaration is found to be incorrect, all benefits under the policy

in respect of Section I of the policy will stand forfeited’.

Accordingly the policy issued by the R.I shows 25% No claim bonus under the policy ‘Own

Damage’ column for the period 03.07.2019 to 02.07.2020. The R.I sent mail to the previous

insurer vide mail 15th July 2019 for the confirmation of the NCB pending data upto 15th July

2019 and received reply from them on 08th August 2019. The statement of list sent by the

previous insurer contains NCB confirmation for various policies. The Sl.No.1629 reflects the

policy details of the complainant for the policy period 2018-19 and under the column NCB left

blank with the remarks ‘CLAIM’.

The complainant reiterated that he had not claimed NCB for his previous policy. He paid the

premium quoted by his agent. Grant of NCB is the discretion of the Insurer & he was not aware

of any suppression of facts.

The RI was directed to furnish a signed or authenticated proposal form by this forum within

two working days to confirm the fact that the policy holder had knowingly suppressed material

facts.

The RI has been unable to furnish the same even after 3 months.

There is no proof of delivery of intimation to the complainant regarding curtailment of policy

period from 3.7.19 TO 1.4.2020.by the RI.

Therefore the forum has concluded that the action of the RI in curtailing Insurance period

without intimation to policy holder against the policy T & C.

Therefore, the Forum concludes that the RI is liable for payment of full claim as per Policy T

& C after deducting due premium for NCB non-disclosure if any.

Hence, the complaint is allowed

A W A R D

Taking into account the facts & circumstances of the case and the personal submissions

made by both the parties and the information/documents placed on record, the forum has

concluded that the action of the RI in curtailing Insurance period without proper intimation

to policy holder is against the policy T & C. The Forum concludes that the RI is liable for

payment of full claim as per Policy T & C after deducting due premium for NCB non-

disclosure if any.

The complaint is Allowed.

Dated at Bengaluru on the 28th day of February,2022


FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI VIPIN ANAND In the matter of: Shri. Arvind Kanunga Vs. HDFC ERGO General Insurance Company Ltd.


Award No.: IO(BNG)/A/GI/0036/2021-22

1 Name & Address of the Complainant Shri. Arvind Kanunga, No. 6/1, N M Lane, Near Isaac Newton School, Cotton pete, Bengaluru, Karnataka – 560 053

2 Policy Numbers Type of Policy Duration of Policy/ Policy Period

2312 2028 8470 8101 000 Two wheeler Comprehensive Policy 16.08.2020 to 15.08.2021

3 Name of the Proposer/Policyholder Name of the Insured

Shri. Arvind Kanunga, Shri. Arvind Kanunga,

4 Name of the Respondent Insurer HDFC ERGO General Insurance Company Ltd.


6 Reason for repudiation Insured has not taken all reasonable steps to safe guard Insured Vehicle.


8 Nature of complaint Denial of Claim.

9 Amount of claim Rs. 35,000/-

10

Date of Partial Settlement N A

11

Amount of relief sought Rs. 35,000/-

12

Complaint registered under Rule no: 13(1)(b) of Insurance Ombudsman Rules, 2017

13

Date of hearing through Online VC 25.02.2022

14

Representation at the hearing

a) For the Complainant Self

b) For the Respondent Insurer Shri Jamadagni Desai

15

Complaint how disposed Allowed

16

Date of Award/Order 28.02.2022

17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for theft of the Complainant’s Two wheeler - Suzuki Access 125, 2016, having registration number KA 02 JK 4208, (hereinafter referred as Insured Vehicle – IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the

same was not resolved and hence, the Complainant has approached this Forum for resolution of his grievance.

18. Cause of Complaint: - a) Complainants argument: The complainant has submitted that he has obtained a Comprehensive Policy no. 2312 2028

8470 8101 000 for his Two wheeler from HDFC ERGO General Insurance Company Ltd. On

17.09.2020, at around 15.00 hours, IV was parked in locked condition. On the same day at

around 18.00 hours it was noticed that the IV was stolen. The same day he informed the police,

but they have filed FIR on 24.9.2020. Subsequently two keys of the vehicle and all final

documents required by the RI, including ‘Police C’ report, are submitted in January 2021. The

claim is rejected stating that one key of the vehicle is duplicate, but the complainant has given

the keys as obtained at the time purchase of the vehicle, and had no intention of cheating.

b) Respondent Insurer’s arguments: There was a delay of 7 days in filing the FIR, and 14 days delay in submitting the claim

intimation. The complainant has not given the reason for delay in intimation, hence there was

no opportunity to conduct timely investigation. The forensic report states that one of the key is

not original. Hence the claim sounds dubious and is to be repudiated.

19. Reason for Registration of Complaint: - The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal: - a. Complaint along with enclosures,

b. SCN of the Respondent Insurer along with enclosures and

c. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure

VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): -

Personal hearing by the way of Online Video-conferencing through GoToMeeting on

25.02.2022 at 10.30 hours was conducted in the said case. Complainant and Representative of

RI presented their case. Confirmation from all the participants about the clarity of audio and

video was taken and to which the participants responded positively. During the course of

hearing, both parties to complaint reiterated their earlier submissions.

The Forum observed that keys of a vehicle not matching exactly is not unusual, as the wear

and tear of a regularly used key is because of continuous usage while the other remains new as

it is unused. The wear & tear of keys leaves the same impact as that of filing a key, so it cannot

be really distinguished. Also the requirement of ‘production of keys’ is nowhere mentioned in

the policy as a condition of claim, leaving aside producing ‘both original keys’. Even if the

original key is in fact lost, only the negligence in losing the key is established and not

negligence in losing the IV. The police documents have established that the IV was in locked

condition, police conducted the investigation, and also issued final “Non traceable report”

confirming that the case is not fit for further investigation. If any other documents are required,

same can be called for from the complainant. The delay in FIR has been explained as the

complainant was asked to search for stolen vehicle and check CCTV footage, and only at a

later date the police registered FIR. Also the theft has taken place in September 2020, which

was peak period of Corona pandemic, and entire official machinery in the country was

paralysed, hence delay is not a valid reason. If the RI relied on the police reports, then they

need not rely on the forensic reports & come to a different conclusion regarding the claim.

Hence the complaint is allowed.

A W A R D


the parties and documents available on record, the repudiation of stolen vehicle on the unproven

grounds of suspicion about negligence is not in order. The delay in intimation is on valid grounds

and the theft is established by the police records. The RI is directed to settle the claim under the

terms and conditions of the policy. The Complaint is Allowed.

Dated at Bengaluru on the 28th day of February, 2022 (VIPIN ANAND)

INSURANCE OMBUDSMAN


22. Compliance of award:

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

a. The Complainant shall submit all requirements / Documents required for compliance of award within 15 days of receipt of the award to the Respondent Insurer

b. As per Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate the compliance of the same to the Ombudsman.


OMBUDSMAN – SHRI VIPIN ANAND In the matter of: Shri. Ramesh Bettaiah Vs. Bajaj Allianz General Ins Co. Ltd.,

Complaint No: BNG-G-005-2122-0060 Award No.: IO(BNG)/A/GI/0035/2021-22

1 Name & Address of the Complainant

Shri. Ramesh Bettaiah , No. 823, SRS Double Road, Peenya, Bengaluru, Karnataka – 560076


OG-21-9910-1810-00174322 Private Car Package Policy 21.10.2020 to 20.10.2021


Shri. Ramesh Bettaiah Shri. Ramesh Bettaiah

4 Name of the Respondent Insurer Bajaj Allianz General Ins Co. Ltd.,


6 Reason for repudiation Old damages, cause of accident not matching




10 Date of Partial Settlement N A

11 Amount of relief sought Rs. 30,000/-

12 Complaint registered under Rule no:

13(1)(b) of Insurance Ombudsman Rules, 2017

13 Date of hearing through Online VC 15.02.2022



b) For the Respondent Insurer Shri Prabhakar Nayak , Shri. Syed Jilan Basha

15 Complaint how disposed Disallowed


17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for damages sustained to the Complainant’s car, having registration number KA 51 MH 3191 (hereinafter referred as Insured Vehicle – (IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum for resolution of his grievance.

18. Cause of Complaint: - a) Complainants argument: The complainant has submitted that has purchased a Private Car Package Policy for his car through Mandovi Motors, tie-up dealers for Maruthi Suzuki vehicles. There were some minor damages acculated over period. These were reported to Mandovi Motors, as and when the damages were suffered by the IV. These are recorded in the vehicle service records of Mandovi Motors. The Insurance Co., has rejected the claim under the pretext that there was no immediate intimation of loss to the vehicle. They have also stated that old and accumulated damages are not payable, and that information given to the agents about the accident does not amount to the claim intimation to the Insurance co. He has also complained that vehicle manufacturers and vehicle service providers are becoming Insurance agents to sell the policies. They are joining together and misleading the customers by denying the claims.

b) Respondent Insurer’s arguments:

The policy under which the claim falls is OG-21-9910-1801-00174322 from 21.10.2020 to 20.10.2021, was a renewal of previous policy no. OG-21-9910-1801-00174322. The inured has renewed cover under new policy no.OG-22-9910-1801-00124010, period 21.10.2021 to 20.10.2022.

The first claim on the car was registered on 25.05.2019. The relevant damages to the cause of accident allowed were :- RH fender, 2 RH doors, RH quarter panel. The claim amount was settled to the Maruthi tieup repairers. There were some more damages existing on the vehicle, not relevant to the cause of accident. The disallowed old damages were :- LH fender, Dicky Door, LH quarter panel, Rear Bumper.

The Insured registered a second claim on 12.02.2020 no. OC-20-1701-1801-00014008, with the cause of accident as hit from behind by a Innova Car. The damages claimed were for Rear Bumper and LH Quarter Panel. The claim was no admitted since the damages were not relevant to the cause of accident. The Insured took away the vehicle from the garage without repairs and without information to the Insurance Co.

The Insured registered a third claim on 18.08.2021 no. OC-22-1701-1801-00002161, under policy no. OG-21-9910-1801-00174322. For this claim the cause of accident given was: “near Vidhana Soudha, Innova car hit from behind, side body damaged as another car hit “.

The damages claimed were for Rear Bumper and LH Quarter Panel. The claim was rejected because the claimed damages were old and disallowed under the first claim registered on 25.05.2019.

The Insured registered a final claim, with the date of accident on 04.12.2021 no. OC-22-1701-1801-00004837, under policy no. OG-22-9910-1801-00124010. On this occasion the vehicle was taken to Kalyani Motors for repair estimation. Under this claim the cause of accident given was: “Vehicle was hit by one Swift car, behind, damaged dickey door and back bumper.”

The damages claimed were for Rear Bumper and LH Quarter Panel and lower bumper. This claim was accommodated and all the accumulated damages were admitted. The insured was requested to bear a part of loss as the damages were old. The Insured agreed for this offer on 21.01.2022 and the settlement was made to the repairers, by way of compromise.





VII A.







This Forum has perused the documentary evidence available on record and the submissions

made by both the parties during the personal hearing. The dispute is for rejection of claim to

the tune of Rs. 30000/-. The Complainant did not come out with details of the previous damages

already settled by the RI by way of compromise on 21.01.2022, but had highlighted the

rejection of the claim made by him on 09.11.2021.

The RI made a submission that all accumulated damages were settled for Rs. 19061/-, as a

onetime reimbursement, which was consented by the complainant on 21.01.2022. The final

settlement offered was explained as follows during the hearing.

- The share of insured towards damage to dickey door, since the damages were old

Total cost: Rs 10684/-, 75% admitted under claim, share of insured: 25% Rs. 2671/-.

Insured has consented to this vide his mail dated 21st January 2022.

The other deductions as per terms and conditions of the policy are:

- Deduction for salvage Rs. 2564/-,

- Deduction for depreciation Rs. 7997/-,

- Deduction for excess Rs. 1000/-.

The insurer has settled the claim amount to repairers - Kalyani Motors, by paying Rs.19061/-

and the Complainant has taken delivery of the vehicle paying the balance amount.

The vehicle is fully repaired now as confirmed by the complainant during the hearing, and all

the damages to the car, including the old one’s stand repaired.

In effect there is no further claim payable to the complainant.

Accordingly the complaint is disallowed.

A W A R D

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

both the parties and documents available on record, it is evident that a onetime settlement was

already offered by RI on 21.01.2022 which was accepted by the complainant vide his mail dated

21.01.2022.

The Complaint is Disallowed.

Dated at Bangalore on the 28thday of February, 2022 (VIPIN ANAND)

INSURANCE OMBUDSMAN



OMBUDSMAN – SHRI VIPIN ANAND In the matter of: Shri. Varun I Vs. Reliance General Insurance Co. Ltd.



1 Name & Address of the Complainant Shri. Varun I, No. 24/1, Shakthi Nilaya, 2nd Floor, Old 3rd Cross, New 5TH Cross, Srigandhanagar, Hegganahalli, Vishwaneedm Post, Bengaluru,Karnataka – 560091


140122023110043125 Private Car Package Policy 11.11.2020 to 10.11.2021,


Shri. Inbasekaran R Shri. Inbasekaran R

4 Name of the Respondent Insurer Reliance General Insurance Co. Ltd.


6 Reason for repudiation The R C and the policy not transferred in the name of the legal heir.



9 Amount of claim Rs. 8,86,312/-

10


11

Amount of relief sought Rs. 8,90,812/-

12


13


14



b) For the Respondent Insurer Shri Santhosh B L

15


16


17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for accidental damages to the car of the deceased father of the Complainant, having registration number KA 02 MK 9525, (hereinafter referred as Insured Vehicle – IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum for resolution of his grievance.

18. Cause of Complaint: - a) Complainants argument: The complainant has submitted that his father Shri. Inbasekaran R had a Maruti Suzuki Baleno,

2015 model, IDV Rs. 7,50,000/-, no. KA 02 MK 9525. He obtained a Private Car Package

Policy from Reliance General Insurance Co. Ltd. for the period 11.11.2019 to 10.11.2020. The

insured expired on 23.07.2020 due to Covid-19. The Insurance for the vehicle was renewed in

the name of Shri. Inbasekaran R under the new policy no. 140122023110043125, period

11.11.2020 to 10.11.2021. On 21 February 2021, the complainant was driving the IV from

Bengaluru to Arani in Tamilnadu. On the way, while trying to avoid hitting a bike going in the

front, the car dashed against the road divider and suffered damages. The damaged vehicle was

towed to the garage, and submitted a repair estimate of Rs.8,74,653/- to the RI. The

complainant has made efforts to get the vehicle transfer in RTO, but due to Corona pandemic

lockdown situations and also the non-clearance of hypothecation of the IV, the documentation

formalities are still incomplete. The Minsitry of Road Transport & Highways has extended the

validity of all motor vehicle documents under MV Act 1988 and CMV Rules 1989 upto

30.06.2021. The claim was rejected and on the ground that the RC and the policy are not

transferred in the name of the legal heir within 90 days. Aggrieved by the rejection of the claim,

the complainant has approached this Forum for relief.


The Forum noted that the complaint was registered on 25.08.2021, and called for SCN from

the RI. Even after lapse of 7 months and inspite of several reminders the RI has not submitted

the SCN. The Forum has taken a serious note of the attitude of the RI in dealing with the

complaints reported at the Hon. Ombudsman.

19. Reason for Registration of Complaint: -



b. Consent of the Complainant in Annexure VI A &


The forum has taken a serious note of non-submission of SCN by the insurer, Reliance General

Insurance Co. Ltd. till the date of hearing. The Insurance Ombudsman expressed strong

displeasure at the lackadaisical attitude of the Insurer in dealing with Ombudsman Complaints.





hearing, the complainant reiterated his earlier submissions.

The RI submitted that they have given ample opportunity to the complainant to provide the IV

transfer documents. The RI is agreeing to settle the claim on the IV, if the transfer of the RC

of the vehicle in the name of the legal heir of the deceased Insured is submitted.


made by both the parties during the personal hearing. The dispute is for non settlement of claim

for the estimated damages to the tune of Rs. 8,74,635/-, suffered by the IV.

The RI submitted that the payment of claim can be considered on production of RC transfer

documents or, at least the acknowledgement of RTO for having submitted documents required

for completing the RTO formalities. The survey is already conducted but release of report is

waiting for the necessary title documents.

The forum found that the complainant has to overcome some hurdles which are coming in the

way of RC transfer. The challenges are in transferring the title of vehicle which has suffered

accidental damages and the issue of NOC from the bank for change of Title before clearance

of loan. The forum advised the complainant to overcome the hurdles with help of the

consultants well versed with such vehicle title transfer issues.

It was suggested to have a combined meeting with the insurers and the financiers of the IV to

sort out the issues, since they are also having stake in the damaged IV. The forum suggested

that RI can give an undertaking to the Financing bank that the claim would be directly settled

to them or to the garage upon their authorisation, and obtain “title transfer NOC” from the

financiers. On that basis RTO would give RC transfer or a certificate that will help the RI to

proceed with the claim settlement. The Forum fixed the onus of completing the documentation

on the complainant and directed the RI to guide the complainant about the alternatives available

to the complainant under the given circumstances. On completion of the documentations by

the complainant the RI is directed to settle the claim as per terms and conditions of the policy.


A W A R D


both the parties and documents available on record, the repudiation of claim for the damages to

the IV on the ground of non-transfer of RC in the name of legal heir is not correct in the given

circumstances. The onus of completing the required documentation is fixed on the complainant

and the RI is directed to settle the claim under the terms and conditions of the policy post

completion of documentations. The Complaint is Allowed.


INSURANCE OMBUDSMAN







OMBUDSMAN – SHRI VIPIN ANAND In the matter of: Shri. Varun I Vs. Reliance General Insurance Co. Ltd.



1 Name & Address of the Complainant Shri. Varun I, No. 24/1, Shakthi Nilaya, 2nd Floor, Old 3rd Cross, New 5TH Cross, Srigandhanagar, Hegganahalli, Vishwaneedm Post, Bengaluru,Karnataka – 560091


140122023110043125 Private Car Package Policy 11.11.2020 to 10.11.2021,


Shri. Inbasekaran R Shri. Inbasekaran R

4 Name of the Respondent Insurer Reliance General Insurance Co. Ltd.


6 Reason for repudiation The R C and the policy not transferred in the name of the legal heir.



9 Amount of claim Rs. 8,86,312/-

10


11

Amount of relief sought Rs. 8,90,812/-

12


13


14



b) For the Respondent Insurer Shri Santhosh B L

15


16


17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for accidental damages to the car of the deceased father of the Complainant, having registration number KA 02 MK 9525, (hereinafter referred as Insured Vehicle – IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum for resolution of his grievance.

18. Cause of Complaint: - a) Complainants argument: The complainant has submitted that his father Shri. Inbasekaran R had a Maruti Suzuki Baleno,

2015 model, IDV Rs. 7,50,000/-, no. KA 02 MK 9525. He obtained a Private Car Package

Policy from Reliance General Insurance Co. Ltd. for the period 11.11.2019 to 10.11.2020. The

insured expired on 23.07.2020 due to Covid-19. The Insurance for the vehicle was renewed in

the name of Shri. Inbasekaran R under the new policy no. 140122023110043125, period

11.11.2020 to 10.11.2021. On 21 February 2021, the complainant was driving the IV from

Bengaluru to Arani in Tamilnadu. On the way, while trying to avoid hitting a bike going in the

front, the car dashed against the road divider and suffered damages. The damaged vehicle was

towed to the garage, and submitted a repair estimate of Rs.8,74,653/- to the RI. The

complainant has made efforts to get the vehicle transfer in RTO, but due to Corona pandemic

lockdown situations and also the non-clearance of hypothecation of the IV, the documentation

formalities are still incomplete. The Minsitry of Road Transport & Highways has extended the

validity of all motor vehicle documents under MV Act 1988 and CMV Rules 1989 upto

30.06.2021. The claim was rejected and on the ground that the RC and the policy are not

transferred in the name of the legal heir within 90 days. Aggrieved by the rejection of the claim,

the complainant has approached this Forum for relief.


The Forum noted that the complaint was registered on 25.08.2021, and called for SCN from

the RI. Even after lapse of 7 months and inspite of several reminders the RI has not submitted

the SCN. The Forum has taken a serious note of the attitude of the RI in dealing with the

complaints reported at the Hon. Ombudsman.



b. Consent of the Complainant in Annexure VI A &


The forum has taken a serious note of non-submission of SCN by the insurer, Reliance General

Insurance Co. Ltd. till the date of hearing. The Insurance Ombudsman expressed strong

displeasure at the lackadaisical attitude of the Insurer in dealing with Ombudsman Complaints.





hearing, the complainant reiterated his earlier submissions.

The RI submitted that they have given ample opportunity to the complainant to provide the IV

transfer documents. The RI is agreeing to settle the claim on the IV, if the transfer of the RC

of the vehicle in the name of the legal heir of the deceased Insured is submitted.



for the estimated damages to the tune of Rs. 8,74,635/-, suffered by the IV.

The RI submitted that the payment of claim can be considered on production of RC transfer

documents or, at least the acknowledgement of RTO for having submitted documents required

for completing the RTO formalities. The survey is already conducted but release of report is

waiting for the necessary title documents.

The forum found that the complainant has to overcome some hurdles which are coming in the

way of RC transfer. The challenges are in transferring the title of vehicle which has suffered

accidental damages and the issue of NOC from the bank for change of Title before clearance

of loan. The forum advised the complainant to overcome the hurdles with help of the

consultants well versed with such vehicle title transfer issues.

It was suggested to have a combined meeting with the insurers and the financiers of the IV to

sort out the issues, since they are also having stake in the damaged IV. The forum suggested

that RI can give an undertaking to the Financing bank that the claim would be directly settled

to them or to the garage upon their authorisation, and obtain “title transfer NOC” from the

financiers. On that basis RTO would give RC transfer or a certificate that will help the RI to

proceed with the claim settlement. The Forum fixed the onus of completing the documentation

on the complainant and directed the RI to guide the complainant about the alternatives available

to the complainant under the given circumstances. On completion of the documentations by

the complainant the RI is directed to settle the claim as per terms and conditions of the policy.


A W A R D


both the parties and documents available on record, the repudiation of claim for the damages to

the IV on the ground of non-transfer of RC in the name of legal heir is not correct in the given

circumstances. The onus of completing the required documentation is fixed on the complainant

and the RI is directed to settle the claim under the terms and conditions of the policy post

completion of documentations. The Complaint is Allowed.


INSURANCE OMBUDSMAN








OMBUDSMAN – SHRI VIPIN ANAND

In the matter of Shri. Santosh Kumar Gupta Vs. Liberty Gen. Ins. Co. Ltd


Award No.: IO/(BNG)/A/GI/0033/2021-22

1 Name & Address of the Complainant

Shri. Santosh Kumar Gupta Flat No.1203, Block-I (Inverness), Brigade Metropolis, Garudachar Palya, Whitefield Main Road, Mahadevapura, Bangaluru , Karnataka-560048

2 Policy No. Type of Policy Duration of Policy/ Policy Period

201150010121700647900000 Private Car Package policy IDV Rs. 6,01,319/- 03.08.2021 to 2.08.2022,

3 Name of the Insured/ Proposer Name of the policyholder

Shri. Santosh Kumar Gupta Shri. Santosh Kumar Gupta

4 Name of the Insurer Liberty General Insurance Co. Ltd


6 Reason for repudiation Damage to the engine caused by Hydrostatic lock, - Consequential loss not payable.



9 Amount of claim Rs. 5,75,554/- as per the Repair estimate

10

Date of Partial Settlement NA

11

Amount of relief sought Deficiency in service Rs.2,00,000/-,Towing Charges Rs. 3,835/-, conveyance to residence Rs. 2,102/-, Hardships due to delay Rs.1,00,000/-, Estimation Charges Rs. 5,900/-, Parking Charges Rs. 7,021/-, conveyance to office Rs. 5,000/-, Rs.5,75,554/- as per Repair estimate.

12

Complaint registered under Rule no:

13 of Insurance Ombudsman Rules, 2017

13

Date of hearing/place 15.02.2022 / Bengaluru

14



b) For the Respondent Insurer

Smt. Shraddha Kinare, Shri. Sandeep S K & Shri. Anand Sambrani

15


16


17. Brief Facts of the Case: The complaint emanated from the rejection of the Motor Vehicle Claim on the ground of consequential loss and aggravation of loss. Despite taking up the matter with the Respondent Insurer (RI), the same was not considered favourably. Hence he approached this Forum for relief. 18. Cause of Complaint: a) Complainant’s arguments: It was a rainy day on 15.10.2021, the day of accident. The complainant was travelling in the

IV, Honda BR-V, Vehicle no. GJ 05 RA 8357. He was going towards Chikkaballapura along with

his 3 family members. After passing Narasimhapura , there was a small patch of water body.

Since other vehicles were comfortably passing through, the complainant drove through the

water body and reached the other end. The car engine stopped while crossing, the engine oil

leaked fully and car stopped. Claim for damages to the engine is rejected by the RI. The

complainant also could not get the immediate Road Side Assistance services, which was

promised. The RI has ignored the customer’s comforts, safety, coverage of damages in

emergency situations. Aggrieved by the rejection of the claim and also deficiency in the

services of the RI, the complainant approached this Forum for relief.

b) Respondent Insurer’s Arguments: The Respondent Insurer submitted their Self-Contained Note dated 02.08.2022, and made the following points. The water entered into the combustion chamber and has resulted in hydrostatic lock, which has further led to consequential damages/aggravation in further loss. Hence the claim is not admissible. Regarding Road Side Assistance, it is submitted that, due to intervening holidays immediate help could not be arranged. 19. Reason for Registration of complaint:-








15.02.2022 at 12.00 hours was conducted in the said case. The participants confirmed clarity

of audio and video. Both the parties reiterated their contentions.

The issue which requires consideration is whether the rejection of claim is in order. After

examining the documents/ interacting with both parties, it is evident that the loss occurred due

to accidental entry of water in the combustion chamber of the IV. The cause of damage is not

consequential in nature as water entering the engine is a direct insured peril. The damages

suffered by the IV is accidental in nature, which is covered under Section I of the policy and

hence the RI is directed to settle the claim as per terms and conditions of the policy

Hence, the complaint is Allowed.

A W A R D

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

both the parties and the information/documents placed on record, the repudiation of the

claim by the RI is not in order as damages to the IV is due to the peril covered under

policy. Hence the RI is directed to settle the claim as per terms and conditions of the policy.

The Complaint is Allowed.

Dated at Bengaluru on the 28th day of February 2022.




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

OMBUDSMAN – SHRI VIPIN ANAND In the matter of: Shri. Abhishek Diwakar Vs. Universal Sompo Gen. Ins. Co. Ltd.


1 Name & Address of the Complainant Shri. Abhishek Diwakar, 10-602, Shiram Sameeksha Apartments, K V P Nagar, New Gangamma Gudi Police Station Road, Jalahalli East, Bengaluru, Karnataka – 560 001




Shri. Abhishek Diwakar Shri. Abhishek Diwakar

4 Name of the Respondent Insurer Universal Sompo General Insurnce. Co. Ltd.


6 Reason for repudiation Police FIR not submitted.




10


11


12


13


14



b) For the Respondent Insurer Shri Prashant V Shukla

15


16


17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for damages sustained to the Complainant’s car, having registration number MH 20 EY 3182, Honda Amaze (hereinafter referred as Insured Vehicle – IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum for resolution of his grievance.

18. Cause of Complaint: - a) Complainants argument:

The complainant has submitted that he has obtained a Private Car Package Policy no. 2367/64569095/00/000 for his car from Universal Sompo General Insurance. On 23.11.2021, while IV was parked in front of his office, NSIC – Peenya, someone has scratched on the Bonnet, LH Front and Rear Doors, LH Front panel, Dicky and Top. The complainant intimated the incident on 23.11.2021 to Honda Service Station - Akshara Motors- Peenya, which is the Tie-up garage with Universal Sompo General Insurance. The insurance claim help team at Honda Service Station in consultation with the RI confirmed that he has to lodge a complaint to the police and get an acknowledgement and submit the same for admission of the claim. Before lodging the complaint with the police, the insured again requested confirmation from the Manager of Honda Service Center that, only acknowledgement of the police complaint is required and not FIR. The Manager of Honda Service Center checked this requirement from the RI, and confirmed that acknowledgement of the police complaint will resolve the issue. Accordingly acknowledgement of the police complaint was submitted on 24.11.2021.On 27.11.2021, the complainant contacted Shri. Rajesh Muniraj of RI regarding the settlement of the claim, who informed to wait till 30.11.2021. But on 29.11.2021 Shri. Rajesh Muniraj of RI informed that claim is rejected for want of FIR. There after his representation with the GRO was not considered favorably. Hence he approached the Forum for relief.


The RI has admitted the policy and also the damages to the vehicle. The RI has appointed the IRDAI licensed surveyor Shri Preetham Shetty V for the assessment of loss. The survey report is submitted which confirms that the damages are relevant to the cause of accident, and loss is assessed at Rs. 47281/-. The RI is pursuing with the complainant vide letters dated 27.01.2021 and 02.11.2021 for submission of FIR since this was a case of malicious damage. Since FIR is not submitted by the Complainant, the claim remains unsettled.

19. Reason for Registration of Complaint: -The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.




VII A.









to the tune of Rs. 47281/-.

While the RI insisted on the submission of FIR for settlement of the claim, the forum observed

this is not a sufficient reason to reject a claim. The duty of the insured is to lodge a complaint

with the police to avoid such incidences becoming rampant and bring many major losses. The

decision of filing an FIR against such complaints lies with the police and not with the policy

holder. Requiring submission of FIR by the complainant for this kind of minor malicious

damage, where the police is unlikely to register a formal FIR, is an unreasonable expectation

on the part of RI, and also not practical. If any further document is required from the police,

the RI was advised to pursue on their own, as the complainant has already done his duty by

lodging the primary complaint with the police. Considering the ground realities the RI was

directed to settle the claim based on the complaint already lodged with the police acknowledged

by them.

Hence the complaint was allowed.

A W A R D


both the parties and documents available on record, the non-settlement of the claim on non-

receipt of formal FIR in a minor case of malicious scratching of car paint is not in order. The RI

is directed to settle the claim as assessed by the IRDAI licensed surveyor under the terms and

conditions of the policy. The Complaint is Allowed.

Dated at Bangalore on the 28thday of February, 2022 (VIPIN ANAND) INSURANCE OMBUDSMAN







OMBUDSMAN – SHRI VIPIN ANAND In the matter of: Shri. Abhishek Diwakar Vs. Universal Sompo Gen. Ins. Co. Ltd.


1 Name & Address of the Complainant Shri. Abhishek Diwakar, 10-602, Shiram Sameeksha Apartments, K V P Nagar, New Gangamma Gudi Police Station Road, Jalahalli East, Bengaluru, Karnataka – 560 001




Shri. Abhishek Diwakar Shri. Abhishek Diwakar

4 Name of the Respondent Insurer Universal Sompo General Insurnce. Co. Ltd.


6 Reason for repudiation Police FIR not submitted.




10


11


12


13


14



b) For the Respondent Insurer Shri Prashant V Shukla

15


16


17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for damages sustained to the Complainant’s car, having registration number MH 20 EY 3182, Honda Amaze (hereinafter referred as Insured Vehicle – IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum for resolution of his grievance.

18. Cause of Complaint: - a) Complainants argument:

The complainant has submitted that he has obtained a Private Car Package Policy no. 2367/64569095/00/000 for his car from Universal Sompo General Insurance. On 23.11.2021, while IV was parked in front of his office, NSIC – Peenya, someone has scratched on the Bonnet, LH Front and Rear Doors, LH Front panel, Dicky and Top. The complainant intimated the incident on 23.11.2021 to Honda Service Station - Akshara Motors- Peenya, which is the Tie-up garage with Universal Sompo General Insurance. The insurance claim help team at Honda Service Station in consultation with the RI confirmed that he has to lodge a complaint to the police and get an acknowledgement and submit the same for admission of the claim. Before lodging the complaint with the police, the insured again requested confirmation from the Manager of Honda Service Center that, only acknowledgement of the police complaint is required and not FIR. The Manager of Honda Service Center checked this requirement from the RI, and confirmed that acknowledgement of the police complaint will resolve the issue. Accordingly acknowledgement of the police complaint was submitted on 24.11.2021.On

27.11.2021, the complainant contacted Shri. Rajesh Muniraj of RI regarding the settlement of the claim, who informed to wait till 30.11.2021. But on 29.11.2021 Shri. Rajesh Muniraj of RI informed that claim is rejected for want of FIR. There after his representation with the GRO was not considered favorably. Hence he approached the Forum for relief.


The RI has admitted the policy and also the damages to the vehicle. The RI has appointed the IRDAI licensed surveyor Shri Preetham Shetty V for the assessment of loss. The survey report is submitted which confirms that the damages are relevant to the cause of accident, and loss is assessed at Rs. 47281/-. The RI is pursuing with the complainant vide letters dated 27.01.2021 and 02.11.2021 for submission of FIR since this was a case of malicious damage. Since FIR is not submitted by the Complainant, the claim remains unsettled.





VII A.









to the tune of Rs. 47281/-.

While the RI insisted on the submission of FIR for settlement of the claim, the forum observed

this is not a sufficient reason to reject a claim. The duty of the insured is to lodge a complaint

with the police to avoid such incidences becoming rampant and bring many major losses. The

decision of filing an FIR against such complaints lies with the police and not with the policy

holder. Requiring submission of FIR by the complainant for this kind of minor malicious

damage, where the police is unlikely to register a formal FIR, is an unreasonable expectation

on the part of RI, and also not practical. If any further document is required from the police,

the RI was advised to pursue on their own, as the complainant has already done his duty by

lodging the primary complaint with the police. Considering the ground realities the RI was

directed to settle the claim based on the complaint already lodged with the police acknowledged

by them.

Hence the complaint was allowed.

A W A R D


both the parties and documents available on record, the non-settlement of the claim on non-

receipt of formal FIR in a minor case of malicious scratching of car paint is not in order. The RI

is directed to settle the claim as assessed by the IRDAI licensed surveyor under the terms and

conditions of the policy. The Complaint is Allowed.


INSURANCE OMBUDSMAN







OMBUDSMAN – SHRI VIPIN ANAND In the matter of Smt. Rajasheela Thankaraj S Vs. HDFC ERGO General Insurance Company

Ltd. Complaint No: BNG-G-018-2122-0070 Award No.: IO(BNG)/A/GI/0040/2021-22

1 Name & Address of the Complainant Smt. Rajasheela Thankaraj S , 23/5, Seenu Illam, Ground Floor, First Cross, Sarasvathinagar, Mahadevapura, Bengaluru, Karnataka – 560048




Smt. Rajasheela Thankaraj S Smt. Rajasheela Thankaraj S



6 Reason for repudiation Damages are not due to accidental external means




10


11


12


13


14



b) For the Respondent Insurer Shri Aneesh Bhaskaran, Shri Meghraj

15


16


17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for damages sustained to the Complainant’s car, having registration number KA 51 ME 7132 (hereinafter referred as Insured Vehicle – (IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum for resolution of her grievance.

18. Cause of Complaint: - a) Complainants argument: The complainant has submitted that her car no. KA 51 ME 7132, Renault Duster, 2013 model, IDV 3,01,247/- was insured under the policy of HDFC ERGO General Insurance Company Ltd. On 31.08.2021 the vehicle was damaged in an accident while the IV was coming from Hoody towards Mahadevapura via the three way junction at Garudacharpalya. The IV was stuck between a container lorry and a water tanker tractor. While the lorry was moving a there was a huge noise as if there was a major smash. By blowing the horn the attention of the lorry was drawn for stopping. Then the husband of the complainant tried to come out of the IV, door could not be opened due to close proximity of vehicle on both sides. In this accident the IV suffered damages in steering movements, tyre damage and the door. As a precaution, the IV was taken to a local garage where temporary work like greasing and tag tying on the steering accessories was carried out. Later on the IV was taken to authorised Renault Service Center for a full scale repair. There was an initial surveyor visit who confirmed only damages on door is admissible. Not satisfied with his report, a resurvey was requested. After the second survey, the entire claim was rejected. Aggrieved by this rejection, the complainant has approached this Forum.


The damages are found to be in the nature of accumulation, and not caused in the alleged accident, also not caused by external means. The claim was repudiated on the grounds of misrepresentation.





VII A.







The Forum observed that the two surveys were conducted but came to contradictory

conclusions, since the first survey allowed the damages to the door, the second survey

disallowed the entire damages. The steering rack was not even opened and inspected, alleging

that it was opened elsewhere. It is strange to note that without opening the steering rack the

second surveyor came to a conclusion that the probable damages are due to wear and tear that

could happen to an 8 year old vehicle, on the observation that there were no under chassis

damages. The RI has totally missed the fact that there was a noise of big smash which could

have left an impact damage inside the IV, which is not reported by the surveyors. The forum

discounted both the survey reports and directed the RI to have a relook at the claim. The

complainant submitted that some repairs of streering rack parts were already undertaken since

they are dependent on the IV, nevertheless the vehicle is still not in proper condition on the

steering rack issue. The RI was directed to collect bills paid by the complainant and undertake

a reassessment of the loss, to ensure that all accidental damages in the steering rack are properly

repaired ensuring the safe usage of the IV. The impact damages on the door and tyre is very

much evident and also admitted by the RI in the hearing, the same are to be paid in the claim.

After considering the records and submissions of the parties, the forum directs the RI to rework

the claim assessment by a proper survey and settle under the terms and conditions of the policy.


A W A R D


made by both the parties during the personal hearing Taking into account of the facts and

circumstances of the case and the submissions made by both the parties and documents available

on record, it is evident that claim is rejected without a proper assessment of the loss, as 2

surveyors issued contradictory reports and even directly visible damages were not admitted.

Hence the Forum directed the RI to reassess the loss and settle the claim under the terms and

conditions of the policy.

The Complaint is Allowed .


INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

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

OMBUDSMAN – SHRI VIPIN ANAND In the matter of Smt. Rajasheela Thankaraj S Vs. HDFC ERGO General Insurance Company

Ltd. Complaint No: BNG-G-018-2122-0070 Award No.: IO(BNG)/A/GI/0040/2021-22

1 Name & Address of the Complainant Smt. Rajasheela Thankaraj S , 23/5, Seenu Illam, Ground Floor, First Cross, Sarasvathinagar, Mahadevapura, Bengaluru, Karnataka – 560048




Smt. Rajasheela Thankaraj S Smt. Rajasheela Thankaraj S



6 Reason for repudiation Damages are not due to accidental external means




10


11


12


13


14



b) For the Respondent Insurer Shri Aneesh Bhaskaran, Shri Meghraj

15


16


17. Brief Facts of the Case: - The Complaint emanated from the rejection of claim lodged under the policy for damages sustained to the Complainant’s car, having registration number KA 51 ME 7132 (hereinafter referred as Insured Vehicle – (IV). Inspite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum for resolution of her grievance.

18. Cause of Complaint: - a) Complainants argument: The complainant has submitted that her car no. KA 51 ME 7132, Renault Duster, 2013 model, IDV 3,01,247/- was insured under the policy of HDFC ERGO General Insurance Company Ltd. On 31.08.2021 the vehicle was damaged in an accident while the IV was coming from Hoody towards Mahadevapura via the three way junction at Garudacharpalya. The IV was stuck between a container lorry and a water tanker tractor. While the lorry was moving a there was a huge noise as if there was a major smash. By blowing the horn the attention of the lorry was drawn for stopping. Then the husband of the complainant tried to come out of the IV, door could not be opened due to close proximity of vehicle on both sides. In this accident the IV suffered damages in steering movements, tyre damage and the door. As a precaution, the IV was taken to a local garage where temporary work like greasing and tag tying on the steering accessories was carried out. Later on the IV was taken to authorised Renault Service Center for a full scale repair. There was an initial surveyor visit who confirmed only damages on door is admissible. Not satisfied with his report, a resurvey was requested. After the second survey, the entire claim was rejected. Aggrieved by this rejection, the complainant has approached this Forum.


The damages are found to be in the nature of accumulation, and not caused in the alleged accident, also not caused by external means. The claim was repudiated on the grounds of misrepresentation.





VII A.







The Forum observed that the two surveys were conducted but came to contradictory

conclusions, since the first survey allowed the damages to the door, the second survey

disallowed the entire damages. The steering rack was not even opened and inspected, alleging

that it was opened elsewhere. It is strange to note that without opening the steering rack the

second surveyor came to a conclusion that the probable damages are due to wear and tear that

could happen to an 8 year old vehicle, on the observation that there were no under chassis

damages. The RI has totally missed the fact that there was a noise of big smash which could

have left an impact damage inside the IV, which is not reported by the surveyors. The forum

discounted both the survey reports and directed the RI to have a relook at the claim. The

complainant submitted that some repairs of streering rack parts were already undertaken since

they are dependent on the IV, nevertheless the vehicle is still not in proper condition on the

steering rack issue. The RI was directed to collect bills paid by the complainant and undertake

a reassessment of the loss, to ensure that all accidental damages in the steering rack are properly

repaired ensuring the safe usage of the IV. The impact damages on the door and tyre is very

much evident and also admitted by the RI in the hearing, the same are to be paid in the claim.

After considering the records and submissions of the parties, the forum directs the RI to rework

the claim assessment by a proper survey and settle under the terms and conditions of the policy.


A W A R D


made by both the parties during the personal hearing Taking into account of the facts and

circumstances of the case and the submissions made by both the parties and documents available

on record, it is evident that claim is rejected without a proper assessment of the loss, as 2

surveyors issued contradictory reports and even directly visible damages were not admitted.

Hence the Forum directed the RI to reassess the loss and settle the claim under the terms and

conditions of the policy.

The Complaint is Allowed .


INSURANCE OMBUDSMAN



OMBUDSMAN – SHRI VIPIN ANAND In the matter of: MR. K R MAHESH Vs ROYAL SUNDARAM GENERAL INSURANCE CO.

LIMITED Complaint No: BNG-G-038-2122-0020


1 Name & Address of the Complainant Mr. K R Mahesh Kittur (vill & post) Bettadapura Hobli Periapatna Tq Mysore, Karnataka – 571617


MOQ1201662 Package Policy (Commercial Vehicle) 03.05.2018 to 02.05.2019


Mr. K R Mahesh Mr. K R Mahesh

4 Name of the Respondent Insurer Royal Sundaram General Insurance Co. Limited


6 Reason for repudiation Policy’ condition no. 5 and condition no. 1


8 Nature of complaint Rejection of vehicle theft claim


10


11

Amount of relief sought Rs.4,35,299/- and compensation

12

Complaint registered under Rule no: 13 (1) (b) of Insurance Ombudsman Rules, 2017

13


14



b) For the Respondent Insurer Mr. P Jeevanandham

15

Complaint how disposed Disallowed

16


17. Brief Facts of the Case: - The Complaint emanated from the denial of claim for loss of the insured vehicle. In spite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum.

18. Cause of Complaint: - a) Complainants argument: Complainant got his car i.e. Swift Dzire, having registration number KA-45-9426 (hereinafter referred as Insured Vehicle - IV) covered under the Commercial Car Package policy vide policy number MOQ1201662 from the RI for a period from 03.05.2018 to 02.05.2019 with IDV of Rs.4,35,299/-. IV was attached to OLA Company and it was being driven by hired driver Mr. Raghu. On 14.06.2018 around 6:30 PM a private passenger was picked up by the driver after consulting the owner over telephone and around 7:30 PM he reached Bangalore airport for picking up the relative of that passenger. Since the incoming flight was delayed IV was parked in P-4 parking of KIAL. The driver intimated the complainant that after having tea, he went to the parking lot around 10:30 PM and found that the IV was missing from the place. The complainant rushed to KIAL immediately and they tried to search for the IV but failed. They informed the airport police station at about midnight and they were advised to arrive in the morning on 15.06.2018. A written complaint was submitted to the police station on Friday 15.06.2018. On behest of the police station, the parking lot was inspected by a policeman and it was revealed that the passenger had first shifted the IV and then disappeared completely. The FIR was lodged on 16.06.2018 after collecting all documents asked for by the Police. The same was reported along with a copy of CCTV footage

to the RI. Dates 16.06.2018 and 17.06.2018 being Saturday and Sunday respectively are the holiday for the RI and thus the theft claim for the IV was filed by them on 18.06.2018. The claim was ignored by the RI for more than two years. The RI repudiated the claim on 23.02.2021 stating that there has been misrepresentation with regards to key of the IV, no proper steps taken by the insured to safeguard the vehicle and delay in intimating the claim. Thereafter, on 04.03.2021 he represented to the GRO of the RI for consideration of his claim. Failing to receive any fruitful outcome he approached to this Forum for resolution of his grievance.

b) Respondent Insurer’s arguments: The RI in their Self-Contained Note vide email dated 15.07.2021 whilst admitting issuance of policy submitted that theft claim for the IV was registered vide claim no. CV00022624 and investigator- Mr. S Venugopal was appointed to collect the documents and verify the facts relating to the claim. Upon perusal of the investigation report it is observed that, as per the statement of the Driver, on the date of loss the IV was at the International Airport Parking, Bangalore. The theft therefrom cannot happen without the facilitation by means of handing over key and parking slip to the person with whom he had tea at airport. Thus, the driver not only failed to take the proper care of the IV to safeguard it from the theft but facilitated the theft, thereby violating the condition no. 05 of the policy which reads as follows:

“The insured should take all reasonable steps to safeguard the vehicle from loss….”

Further the insured misrepresented regarding the ignition keys and submitted two different keys

as original which found to be different and doctored as per the forensic investigation.

Based on the investigation and forensic report and the statement of the driver, the theft claim

of the insured was repudiated.




c. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII

A for Ombudsman to act as a mediator.


Personal hearing by the way of Online Video-conferencing through GoToMeeting was

conducted in the said case. Mr. K R Mahesh (Complainant) and Mr. P Jeevanandham

(Representative of RI) presented their case. During the course of hearing, both parties to

complaint reiterated their earlier submissions.


made by both the parties during the personal hearing.

Forum notes that IV‘s registration date is 11.03.2016 and it was plying under OLA company

with driver employed by the Complainant. On 14.06.2018 the driver carried an unknown

passenger to airport after taking the permission over call from IV owner i.e. the Complainant.

Since the Complainant himself authorised a passenger (out of OLA) without any verification.

Further the driver after parking the IV at airport reportedly left the parking slip in IV itself.

Clearly there is gross negligence in safeguarding the IV from loss and condition no. 05 of the

policy is violated. Therefore the IV’s theft claim under the policy is not tenable.

Further the Complainant was asked to provide the Police Investigation report and/ or the Police

final report. The complainant has not provided the same till date. Thus, the driver/owner cannot

be absolved of their negligence and gross irresponsibility in the matter.

A W A R D


both the parties and documents available on record, since the insured Mr. K R Mahesh and driver

Mr. Raghu both have failed in taking reasonable steps to safeguard the insured vehicle bearing

registration number KA-45-9426, the condition number 5 of policy terms and conditions is

violated. Therefore the theft claim under the instant policy is not payable.


Dated at Bangalore on the 07th day of February, 2022




OMBUDSMAN – SHRI VIPIN ANAND In the matter of: MR. K R MAHESH Vs ROYAL SUNDARAM GENERAL INSURANCE CO.

LIMITED Complaint No: BNG-G-038-2122-0020


1 Name & Address of the Complainant Mr. K R Mahesh Kittur (vill & post) Bettadapura Hobli Periapatna Tq Mysore, Karnataka – 571617


MOQ1201662 Package Policy (Commercial Vehicle) 03.05.2018 to 02.05.2019


Mr. K R Mahesh Mr. K R Mahesh

4 Name of the Respondent Insurer Royal Sundaram General Insurance Co. Limited


6 Reason for repudiation Policy’ condition no. 5 and condition no. 1


8 Nature of complaint Rejection of vehicle theft claim


10


11

Amount of relief sought Rs.4,35,299/- and compensation

12

Complaint registered under Rule no: 13 (1) (b) of Insurance Ombudsman Rules, 2017

13


14



b) For the Respondent Insurer Mr. P Jeevanandham

15

Complaint how disposed Disallowed

16


17. Brief Facts of the Case: - The Complaint emanated from the denial of claim for loss of the insured vehicle. In spite of taking up the complaint with the Customer Service Department of the Respondent Insurer (hereinafter referred as RI), the same was not resolved and hence, the Complainant has approached this Forum.

18. Cause of Complaint: - a) Complainants argument: Complainant got his car i.e. Swift Dzire, having registration number KA-45-9426 (hereinafter referred as Insured Vehicle - IV) covered under the Commercial Car Package policy vide policy number MOQ1201662 from the RI for a period from 03.05.2018 to 02.05.2019 with IDV of Rs.4,35,299/-. IV was attached to OLA Company and it was being driven by hired driver Mr. Raghu. On 14.06.2018 around 6:30 PM a private passenger was picked up by the driver after consulting the owner over telephone and around 7:30 PM he reached Bangalore airport for picking up the relative of that passenger. Since the incoming flight was delayed IV was parked in P-4 parking of KIAL. The driver intimated the complainant that after having tea, he went to the parking lot around 10:30 PM and found that the IV was missing from the place. The complainant rushed to KIAL immediately and they tried to search for the IV but failed. They informed the airport police station at about midnight and they were advised to arrive in the morning on 15.06.2018. A written complaint was submitted to the police station on Friday 15.06.2018. On behest of the police station, the parking lot was inspected by a policeman and it was revealed that the passenger had first shifted the IV and then disappeared completely. The FIR was lodged on 16.06.2018 after collecting all documents asked for by the Police. The same was reported along with a copy of CCTV footage to the RI. Dates 16.06.2018 and 17.06.2018 being Saturday and Sunday respectively are the holiday for the RI and thus the theft claim for the IV was filed by them on 18.06.2018. The claim was ignored by the RI for more than two years. The RI repudiated the claim on 23.02.2021 stating that there has been misrepresentation with regards to key of the IV, no proper steps taken by the insured to safeguard the vehicle and delay in intimating the claim. Thereafter, on 04.03.2021 he represented to the GRO of the RI for consideration of his claim. Failing to receive any fruitful outcome he approached to this Forum for resolution of his grievance.

b) Respondent Insurer’s arguments: The RI in their Self-Contained Note vide email dated 15.07.2021 whilst admitting issuance of policy submitted that theft claim for the IV was registered vide claim no. CV00022624 and investigator- Mr. S Venugopal was appointed to collect the documents and verify the facts relating to the claim. Upon perusal of the investigation report it is observed that, as per the statement of the Driver, on the date of loss the IV was at the International Airport Parking, Bangalore. The theft therefrom cannot happen without the facilitation by means of handing over key and parking slip to the person with whom he had tea at airport. Thus, the driver not only failed to take the proper care of the IV to safeguard it from the theft but facilitated the theft, thereby violating the condition no. 05 of the policy which reads as follows:

“The insured should take all reasonable steps to safeguard the vehicle from loss….”

Further the insured misrepresented regarding the ignition keys and submitted two different keys

as original which found to be different and doctored as per the forensic investigation.

Based on the investigation and forensic report and the statement of the driver, the theft claim

of the insured was repudiated.




c. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII

A for Ombudsman to act as a mediator.


Personal hearing by the way of Online Video-conferencing through GoToMeeting was

conducted in the said case. Mr. K R Mahesh (Complainant) and Mr. P Jeevanandham

(Representative of RI) presented their case. During the course of hearing, both parties to

complaint reiterated their earlier submissions.


made by both the parties during the personal hearing.

Forum notes that IV‘s registration date is 11.03.2016 and it was plying under OLA company

with driver employed by the Complainant. On 14.06.2018 the driver carried an unknown

passenger to airport after taking the permission over call from IV owner i.e. the Complainant.

Since the Complainant himself authorised a passenger (out of OLA) without any verification.

Further the driver after parking the IV at airport reportedly left the parking slip in IV itself.

Clearly there is gross negligence in safeguarding the IV from loss and condition no. 05 of the

policy is violated. Therefore the IV’s theft claim under the policy is not tenable.

Further the Complainant was asked to provide the Police Investigation report and/ or the Police

final report. The complainant has not provided the same till date. Thus, the driver/owner cannot

be absolved of their negligence and gross irresponsibility in the matter.

A W A R D


both the parties and documents available on record, since the insured Mr. K R Mahesh and driver

Mr. Raghu both have failed in taking reasonable steps to safeguard the insured vehicle bearing

registration number KA-45-9426, the condition number 5 of policy terms and conditions is

violated. Therefore the theft claim under the instant policy is not payable.






OMBUDSMAN – SHRI VIPIN ANAND In the matter of MR. SIDDARAMESHWARA C R V/s THE NEW INDIA INSURANCE CO.LTD.

Complaint No: BNG-G-049-2122-0046 Award No.: IO/(BNG)/A/GI/0030/2021-22

1 Name & Address of the Complainant Mr. Siddarameshwara C R No.473/1, Hoasbhavi Circle, Davanagere Karnataka - 577001

2 Policy No. Type of Policy Duration of Policy/ Policy Period

31030031200900462175 Bundled Motor Policy for Private car-Enhanced Covers 30.12.2020 to 29.12.2021

3 Name of the Insured/ Proposer Name of the policyholder

Mr. Siddarameshwara C R Self

4 Name of the Insurer The New India Insurance Company Limited

5 Date of repudiation NA

6 Reason for repudiation NA


8 Nature of complaint Partial settlement of motor own damage claim

9 Amount of claim Rs.26,768/-

10 Date of Partial Settlement 04.03.2021

11 Amount of relief sought Rs.16,700/- balance claim + Rs.5,000/- as penalty

12 Complaint registered under Rule no: 13 (1)(b) of Insurance Ombudsman Rules, 2017




b) For the Respondent Insurer Rashmi Lucy Barwa [Sr. Divisional Manager] Rajalakshmi K [Asst. Manager]

15 Complaint how disposed Partially Allowed


17. Brief Facts of the Case: The complaint emanated from the partial settlement of claim by the Respondent Insurer (RI) under the motor policy for private car - Tata Tigor bearing registration number KA-17-MA-3764 (hereinafter referred as Insured Vehicle - IV) towards accidental damage occurred on 24.01.2021.

18. Cause of Complaint: a) Complainant’s arguments:- The Complainant submitted that IV met with an accident during January 2021 and he contacted Policy Bazaar. They asked him to upload the videos and photos of the damaged parts (Bumper & Bonnet). After which a surveyor was appointed online. They spoke to the garage person that if the ‘bonnet cannot be repaired it could be replaced as he did not want to get it repaired as it was his new vehicle’. The surveyor agreed that if condition is bad & it cannot be repaired, it could be replaced. He shared audio recording and the proof of screenshot on their email. Also the labour costs approved was low & when asked the surveyor mentioned that it differs from state to state & will reimburse complete amount with the original bill. After getting the IV repaired he submitted repair bill for Rs.26,678/- out of which the RI settled Rs.8,900/- only. IV was insured on the terms of Bumper to Bumper. When he questioned the surveyor he was informed that bonnet replacement was not given. His representation with the GRO was not considered favourably. Hence he approached the Form for justice.

b) Respondent Insurer’s Arguments:- RI submitted their Self-Contained Note vide mail dated 06.09.2021 along with survey report and claim note supporting documents. They admitted coverage of the IV under instant policy and submitted that the claim for date of accident 24.01.2021 was settled as per surveyor's assessment of Rs.8,950/- after deducting salvage of Rs.50/- i.e. Rs.8,900/-.

19. Reason for Registration of complaint: The complaint falls within the scope of the Insurance Ombudsman Rules, 2017

20. The following documents were placed for perusal: a. Complaint along with enclosures,


c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A for

Ombudsman to act as a mediator.


Personal hearing by the way of online Video-conferencing through GoTo Meet was conducted

in the said case. Complainant and Representative of RI joined using online VC and presented

their case. Confirmation from all the participants about the clarity of audio and video was taken

to which the participants responded positively. Both the parties reiterated their earlier

submissions.

The Complainant stated that the Garage has told the bonnet strength is lost and it cannot come

out accurately if repaired. Because of which they replaced the bonnet and couldn't get it

repaired. He further contended that the surveyor also has given the work approval for the same.

In support of his contention after hearing he submitted a call recording along with estimate

sheet by Garage.


made by both the parties during the personal hearing. The issue before the Forum is whether

the partial settlement for Rs.8,900/- against the claim amount of Rs.26,678/- by the RI is in

order.

Forum finds from the recording of call between surveyor and Garage person that the Surveyor

has clearly said to Garage person that work is to be done as per the approval in his report. Thus

the Complainant’s contention of bonnet replacement being approved by the Surveyor is

untenable.

Forum notes that IV’s inspection for assessing the loss and estimating the liability under the

claim was done through the videos & photos by the mobile application of policybazaar.com.

The Forum has gone through the surveyor report as well as invoice, categorically noted and

observed that the claim is settled based on the surveyor report which is not having the

assessment about the paint cost and Bonnet repair amount. Therefore the RI was advised and

asked to arrive at a suitable admissible amount for the same. The RI has replied vide their email

dated 01.02.2022 which is reproduced as follows:

Particulars Assessment as per

Surveyor Report

Claimed

as per

Bill

Claim relook remarks by the

RI

Payable

Amount Remarks

Parts Front Bumper 2752 2753.00 2753.00

Parts Bonnet Repair Allowed

Replaced

for

8768.00 0.00

Replacement not

allowed by

Surveyor

Parts Mud-liners Not Allowed - - -

Parts Splash Guard Not Allowed - - -

Parts Front Bumper Grill Not Allowed - - -

Parts Total Paints Cost

Details

Unavailable 3799.55 3799.55

Parts Total Consumable Cost - 204.00 0.00 Not Covered

Labou

r Replace Front Bumper 295 300.90 300.90

Labou

r Replace Bonnet 295 361.08 361.08

Opening &

Fitting

Labou

r Repair Front Frame Not Allowed - - -

Labou

r Painting Front Bumper 3304 4745.96 4745.96

Labou

r Painting Front Frame Not Allowed - - -

Labou

r Painting Front Bonnet 3304 5745.42 5745.42 Full cost allowed

Total 9950 26677.91 17705.91

Policy Excess -1000 -2000.00 2 Incidents

Less Salvage -50 -50.00 Salvage

Claim Liability

Claim Paid

8900 Rs.15,655.91/-

Revised

Payable

The RI added that, as stated in the claim form and verbal discussion with insured that the said

vehicle was on its way, hit on the stone and a coconut fell on bonnet and damaged. Also, under

heading Brief Particulars of the accident: of the claim form, the insured has written as “Drive

on the stone & coconut fell on bonnet”. Since 2 incidents are there the excess is deducted twice.

With regard to the repair cost of bonnet the RI stated that the repair of Bonnet was allowed by

way of labour cost for dismantling and reinstalling of the bonnet for Rs.250/- plus 18% GST

& Painting Cost for Rs.2800/- plus 18% GST, which now they have allowed full painting cost

(5745.42) along with opening and fitting charges (361.08).

With regards to the two deductibles (policy excess of Rs.2,000/-), it seems unlikely that two

such incidents as have been described in the claim form, could have occurred simultaneously.

Hence the deduction of Rs.2,000/- by the RI as excess is hereby allowed.

Accordingly, the Forum observes that total allowed amount for the claim shall be

Rs.15,655.91/-. Since the RI has already settled an amount of Rs.8,900/-, the balance amount

of Rs.6,755.91/- is to be paid by the RI.

A W A R D

Taking into account of the facts and circumstances of the case, the documents and the oral

submissions made by both parties, the Respondent Insurer is directed to settle the balance

claim for Rs.6,755.91/- along with interest from the date of submission of the last relevant

document by the Insured till the date of payment of the claim as per Regulation 15(10) of

IRDAI’s Protection of Policyholders’ Interests Regulations, 2017.

Hence, the complaint is Partially Allowed.

Dated at Bengaluru on the 08th day of February, 2021






In the matter of Shri. SURU MOHAN RAO V/s. THE NEW INDIA ASSURANCE CO. LTD. Complaint No: BNG-G-049-2122-0017


1. Shri Suru Mohan Rao submitted a complaint to the Office of the Ombudsman,

Bhubaneswar on 18.11.2000, for the rejection of motor damage claim, on behalf of

Dr. Sriram Suru, who is the policy holder with permanent address of Odisha. The motor

vehicle policy was issued at Delhi office of the Respondent Insurer for the period 2015-

16. The vehicle met with an accident on 18.09.2015 at Berhampur, Odisha. The claim

was closed as ‘Nil Liability’ by the R.I at Berhampur on the ground of non-submission

of required documents till 04.6.2020.

2. The complaint was transferred to the Office of the Ombudsman, Bengaluru, under

Rule No.14 (1) of Insurance Ombudsman Rules 2017.

The Forum has carefully scrutinised the documents and noted that the complainant is not the

policy holder and the documents do not reveal any prima facie authority granted to him to

deal with the complaint.

i) Locus standi of the complainant is not established.

ii) The claim is time barred.

In view of the above, the complaint cannot be entertained under the provisions of Rule No.

13 of Insurance Ombudsman Rules 2017.

Dated at Bangalore on the 8th day of February 2022.


FOR THE STATE OF KARNATAKA Copies to -

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Shri. Suru Mohan Rao,

A-502, Goyal Footprints,

Sampigehalli, R.K. Hegde Nagar,

Thanisandra Road, Bangalore

KARNATAKA -560064

The New India Assurance Company Ltd Regional Office 2-B, Unity Buildings Annexe P. Kalinga Rao (Mission Road) BENGALURU - 560 027.


In the matter of MR. NADEEM AHMED Vs LIBERTY GENERAL INSURANCE LIMITED Complaint No: BNG-G-028-2122-0007


1 Name & Address of the Complainant Mr. Nadeem Ahmed

2341/1, 21st Cross, Lashkar Mohalla

Mysore, Karnataka - 570001

2 Policy Number

Type of Policy


2011-500204-919-700633-00-001


22.12.2019 to 21.12.2020

3 Name of the Policyholder

Name of the Insured

Mr. Nadeem Ahmed

Self

4 Name of the Insurer LIberty General Insurance Limited


6 Reason for repudiation Misrepresentation

7 Date of receipt of the Annexure VI-A 20.04.2021

8 Nature of complaint Repudiation of vehicle damage claim



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

12 Complaint registered under Rule no: 13(1)(b) of Insurance Ombudsman Rules, 2017




b) For the Respondent Insurer Shraddha Kinare - Corporate Legal Manager

15 Complaint how disposed Disallowed


17. Brief Facts of the Case:

The complaint emanated from repudiation of motor claim under Private Car Package Policy with Respondent Insurer (hereafter referred as RI) on the ground of misrepresentation of material fact in the claim form. The Complainant represented to Grievance Redressal Officer (GRO) of RI for consideration of his claim. However his plea was not considered favourably. Hence the Complainant approached this Forum for resolution of his grievance.

18. Cause of Complaint: a) Complainant’s arguments:- The Complainant submitted that his vehicle bearing registration no. KA-14-N-8551 (hereafter referred as Insured Vehicle - IV) was insured with RI vide private car package policy, policy no. 2011-500204-919-700633-00-001 for the period from 22.12.2019 to 21.12.2020 with IDV of Rs.4,35,360/-. On 30.09.2020 the IV was driven by his brother Akmal Pasha having valid DL who was returning from Lashkar Mohalla to reach the residence situated at Tippu Circle. While going suddenly a dog came in between and he lost the control over IV and hit a roadside tree and the car completely got damaged. The claim was reported to the RI and the surveyor did the survey and submitted the report as well. After that the Complainant has repeatedly visited the RI for the claim settlement which was delayed for long time and finally repudiated on vicious, malafide and baseless grounds. Representation to the GRO of the RI has not brought any fruitful result. Therefore he approached this Forum for getting his claim amount from the RI.

b) Respondent Insurer’s Arguments:- RI submitted their SCN vide email dated 28.04.2021, wherein they submitted that a claim was reported for damage to the IV in an accident on 03.09.2020. The cause of loss as mentioned by the complainant/insured was, “while travelling to Philomina Church to Rajeev Nagar near Tippu circle, a dog crossed the road to avoid the car vehicle runaway roadside of the footpath. Finally hit to side of the tree”. Driver at the time of the accident was claimed to be Mr. Akmal Pasha. On intimation of the claim surveyor Mr. A C Mahesh, duly licensed by IRDAI was deputed to inspect the IV and to assess the loss. Surveyor specifically observed that there is no possibility of any under chassis damage and right side doors damage. He also observed that the cause of accident mentioned in the claim form did not relate to the damage in the IV. The surveyor had also visited the spot of accident along with Mr. Akmal Pasha before finalising the report. The surveyor assessed the loss for an amount of Rs.1,25,396/- subject to terms of the Policy.

Following the observations of the Surveyor on the cause of loss, an Investigator Connectfin was appointed to verify the genuineness of accident and the statements made by the Complainant/Insured. The findings of the Investigator & the Surveyor led the RI to the conclusion that the Insured was not revealing truthfully the facts relating to the accident and hence guilty of misrepresentation. The Investigator reported as below:

• The cause of loss was not justified by insured & found discrepancy. • Verification of Google timeline of IV driver reveals that they were not present in the

spot of accident at the time of accident. • The version of accident and place of accident is mismatching. Complainant did not

reveal the actual details & material fact of the accident. No other explanation or

information provided by the Complainant.

Based on observations of the surveyor and the findings of the investigator, the RI denied the claim as per terms and conditions of the policy vide letter dated 07.10.2020.

In the view of their submission the RI prayed for an appropriate order.

19. Reason for Registration of complaint: The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal: a. Complaint along with enclosures, b. Respondent Insurer’s SCN along with enclosures and c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A

21. Result of personal hearing with both the parties (Observations & Conclusions): Personal hearing by the way of online Video-conferencing through GoTo Meet was conducted in the said case. Complainant and Representative of RI joined using online VC and presented their case. Confirmation from all the participants about the clarity of audio and video was taken to which the participants responded positively. Both the parties reiterated their earlier submissions.

During course of personal hearing the Complainant contended that he had a valid DL at the time of the accident but his brother Mr. Akamal Pasa was driving the IV and therefore the claim was lodged with driver name as Mr. Akamal Pasa. The RI was having a doubt that the IV was driven by the Complainant and it could be possible that he did not possess a valid DL and thus the driver name in the claim document was mention as Mr. Akamal Pasa. As the Complainant was also in the IV at the time of accident, to rule out the RI’s doubt the Complainant was asked to submit a copy his DL to the RI.

Further the Complainant contended that he had opted for the Road Side Assistance cover and specifically intimated at the call centre at the time of intimation of the claim that, “it was raining heavily and the IV first hit a stone and then further went ahead hit a footpath and then banged on to a tree.” Post the hearing the RI submitted the Call recording of the claim intimation.

Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing. The dispute is whether the denial of motor claim under the policy is in order or not.

Forum observed from the policy schedule that that Road Side Assistance cover was not opted/obtained. The Call recording reveals that the claim was intimated by the workshop wherein the occurrence of rainfall as cause of accident was not intimated.

Further with regards to Complainant’s contention that he had a valid DL at the time of the accident as per instruction of Forum the RI obtained a copy of same from the Complainant. The DL submitted by was issued on 28.04.2021 whereas the date of loss is 03.09.2020. Therefore the Complainant was asked to clarify if the said DL was a renewed one or a freshly issued one with its supporting document (i.e previous DL or LL as the case may be). Forum did not receive the response till date.

The surveyor in his report and email communication with RI has pointed that Complainant’s representative did not clarify how the under-chassis & right hand side damage occurred while concluding that there is no possibility of such damage. Forum checked the spot photographs wherein neither there was impact found on the tree nor sign of any heavy rainfall.

Forum finds from the claim form dated 05.09.2020 that the date and time of accident is 03.09.2020, 11:45 PM. As per the surveyor report the survey is done on 07.09.2020 which reveals that cause of accident as mentioned in the claim form does not correlate with the nature of damage to the IV. The relevant excerpt of the surveyor report is reproduced below:

Further Forum notes from the Investigator report that there were some blood stain on the bumper of the IV and it is suspected that IV got hit against some animal or a third party. As per driver Mr. Akmal Pasha mobile’ google time line he was 4.4Km away from that accident spot at time of accident. Relevant excerpts of the investigator report as under:

As per the front portion of IV damages, we suspect IV got hit against any metals or a building. Upon investigator visit to the accident spot, he found 02 towing vehicles were parked in that place from past 02 years. Therefore it was suspected Insured had been towed the IV from other place to the accident place. Further found left side and right side door of IV was dented. Insured claims that the damages are old one but as per investigator’s observation they are new one. As per IV driver’s mobile Google timeline he was in Lourdu Nagar. Distance between Lourdu Nagar to Tippu Circle is 4.4 km. Hence the version of accident and place of accident is mismatching. Upon enquiry with Insured and IV driver they denied to disclose the same.

The investigator’s contention that Insured might have towed the IV from other place to the accident place merely based on towing vehicles parked at spot since two years is totally irrelevant and thus untenable.

The findings of the Investigator & the Surveyor led the RI to the conclusion that the Insured was not revealing truthfully the facts relating to the accident and hence guilty of misrepresentation. The Investigator reported as below:

• The cause of loss was not justified by insured & found discrepancy.

• Verification of Google timeline of IV driver reveals that he was not present in the spot of accident at the time of accident.

The RI submitted the evidence of google timeline of Mr. Akmal Pasha’s mobile wherein it shows that he was at Lourdu Nagar at the time of accident. The version of accident and place of accident is mismatching. Complainant did not reveal the actual details & material fact of the accident. No other explanation or information provided by the Complainant.

In view of the above it is abundantly clear that the Complainant has not approached this Forum with clean hands. Hence the Complainant has failed to substantiate the claim under the Policy and the complaint deserves to be dismissed.

A W A R D

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

by both the parties and documents placed on record, there is misrepresentation and

concealing of accident cause. Hence the denial of claim by the RI under Misrepresentation

of Material Fact is found to be in order and in consonance with the terms and conditions

of the policy and does not require any interference at the hands of Ombudsman.


Dated at Bangalore on the 16th day of February, 2022.

(SHRI VIPIN ANAND) INSURANCE OMBUDSMAN


Copies to - Mr. Nadeem Ahmed

2341/1, 21st Cross, Lashkar Mohalla

Mysore, Karnataka - 570001

The Manager,

Liberty General Insurance Co. Ltd.

10th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel

Mumbai – 400013



In the matter of MRS. A K CHITRA Vs HDFC ERGO GENERAL INSURANCE CO. LTD. Complaint No: BNG-G-018-2122-0005


1 Name & Address of the Complainant Mrs. A K Chitra

33, 2nd Cross, M V Nagar, Ramamurthy Nagar

Bangalore, Karnataka - 560016

2 Policy Number

Type of Policy


231120378888810000000


02.11.2020 to 01.11.2021

3 Name of the Policyholder

Name of the Insured

Mrs. A K Chitra

Self

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


6 Reason for repudiation Misrepresentation

7 Date of receipt of the Annexure VI-A 12.04.2021

8 Nature of complaint Repudiation of vehicle damage claim

9 Amount of claim IDV, i.e. Rs.7,76,889/-


11 Amount of relief sought IDV, i.e. Rs.7,76,889/-

12 Complaint registered under Rule no: 13(1)(b) of Insurance Ombudsman Rules, 2017




b) For the Respondent Insurer Aneesh Bhaskaran



17. Brief Facts of the Case: The complaint emanated from repudiation of motor claim under the Private Car Package Policy with Respondent Insurer (hereafter referred as RI) on the ground of suppression and concealment of claim details. The Complainant represented to Grievance Redressal Officer (GRO) of RI for consideration of her claim. However her plea was not considered favourably. Hence the Complainant approached this Forum for resolution of her grievance.

18. Cause of Complaint: a) Complainant’s arguments:- The Complainant submitted that she purchased a vehicle Honda City bearing registration no. KA-01-MQ-7377 (hereafter referred as Insured Vehicle - IV) from Pre-Car-Mart on 30.10.2020 and the IV was insured with the RI vide private car package policy no. 231120378888810000000 for the period from 02.11.2020 to 01.11.2021. The IV was driven by her son Mr. Madan A K on 11.11.2020 and it was totally damaged. The claim was rejected by the RI stating that they have investigated and found the date of accident is 11.11.2020 whereas the same is misrepresented in claim form and in Police FIR as 14.11.2020. Complainant thereafter represented to GRO of RI for consideration of her claim

and submitted therein that the Police FIR was done on 14.11.2020 while the RC transfer was done on 11.11.2020. Since the RC was not received by her, she was misguided by the workshop people that she cannot make any claim. Being unaware of the claim process she listened to workshop people and mentioned the date of accident as 14.11.2020 both in claim form and Police FIR. She submitted to the RI that this misrepresentation happened due to lack of knowledge and misguidance. However her plea was not considered favourably. Hence she approached this Forum for resolution of her grievance.

b) Respondent Insurer’s Arguments:- RI submitted their SCN vide mail dated 07.08.2021, wherein they submitted that as per insured’s claim document, on 14/Dec/2020 at around 02:30 am, while her Son was riding a dog came by, when he tried to avoid the dog he lost the control of his car and the vehicle toppled and hit a tree and damaged his car. However, the driver did not sustain any injuries. They produced the excerpt from the Claim Form as below:

The FIR was registered before Gonikoppa PS vide Crm No. 306/2020 dated 16/Nov/2020. Accordingly Claim No C230020246038 was registered and Surveyor M. S. Guruswamy was appointed to assess the loss and ascertain the damage wherein he assessed the liability on repair/replacement basis of Rs.5,64,772/- subject to the claim admissibility. Thereafter they entrusted the case also for an Investigation to INVEE it was observed that, IV had met with the accident on 11.11.2020 at 02:30 AM near Hathur village, Gonikoppal, Virajpet district, Karnataka when insured’s son Mr. Madhan was driving IV, lost control while avoiding a dog on the road and hit to a tree affecting damages to IV. The Trigger Points that were noted by the Investigator are:

1. Exact date, time and place of accident: on 11.11.2020 at 02:30 AM. 2. No insurable details (with date of transfer). 3. Driver at the time of loss Mr. Madan A K, S/o Kariappa A G. 4. Misrepresentation of facts.

On verification of the Google Time Line on dated 13.11.2020 from 05:00 PM till 14.11.2020 at 05:00 AM, it was noted, Insured son was not around the accident spot as on the date and time of said accident. While scrolling the photo gallery of his phone, the Investigator had noted, the damaged car images were in his mobile phone, but dated 11.11.2020 and not 14.11.2020. Investigator further, states that, when questioned the same to insured’s husband, he confessed to the fact that the actual accident had occurred on 11.11.2020 and this was told as the RC was not transferred to his wife’s name on the date and time of actual accident and hence the date of said accident was changed while making the claim. Based on the documents received, it is evident of a misrepresentation of fact as to the date of the accident. Hence, the RI repudiated the claim as per the policy conditions under ‘Mis-representation of Material facts’ vide repudiation letter dated 05.02.2021. They produced the excerpt of the repudiation letter as follows:

Further, the RI vide their email dated 30.09.2021 submitted that the OD coverage of the IV was cancelled based on the misrepresentation and pro rata premium (i.e. Rs.16,931/-) was refunded back to the insured vide the policy endorsement dated 27.03.2021.

19. Reason for Registration of complaint: The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal: d. Complaint along with enclosures, e. Respondent Insurer’s SCN along with enclosures and f. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A for

Ombudsman to act as a mediator.

21. Result of personal hearing with both the parties (Observations & Conclusions): Personal hearing by the way of online Video-conferencing was conducted in the said case. Complainant and Representative of RI joined and presented their case. Both the parties reiterated their earlier submissions.

During course of personal hearing the complainant was asked for the date on which she applied for the IV RC transfer in her name. She responded that the IV was purchased from Pre-Car-Mart on 30.10.2020 and the application for the RC transfer was handled by Pre-Car-Mart only. The RI was asked to provide the proposal form which they have failed to submit to the Forum. With regards to the basis of policy issuance the RI submitted Form 30 dated 28.10.2020 signed by transferor- Navin A and declaration letter (i.e. policy proposal) dated 29.10.2020 signed by the proposer- Chitra A K (i.e. insured).

Post personal hearing the Complainant on being asked submitted a copy of E-FEE RECEIPT of Bengaluru Central RTO, receipt dated 11.11.2020 for the fee paid towards the IV’s RC transfer. Further, she has informed that an email dated 23.11.2021 was received by her wherein the RI sought the NEFT details to initiate the refund of Rs.16,931/- towards the policy cancellation.

Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing.

Forum notes that the RI issued the policy to the insured even the IV was not transferred or applied for transferred in her name. Therefore the contention of RI that the insurable interest is unavailable at the time of accident is untenable. This is a matter which should have been considered at the time of issuing the policy.

The Forum finds from the claim form dated 19.11.2020 (signed by the Complainant) and FIR dated 16.11.2020 that the reported date of accident is 14.11.2020 whereas the investigator’s report reveals the accident had actually occurred on 11.11.2020 at 02:30 AM.

The Complainant admitted that as the RC was not received by her she was misguided by the workshop people that she cannot make any claim. Being unaware of claim process she

listened to workshop people & mentioned the date of accident as 14.11.2020 both in claim form & Police FIR. Thus, this misrepresentation happened due to lack of knowledge & misguidance to her. However the Forum feels that the IP has seriously erred in giving the wrong date while reporting which is highly irresponsible act. However, Misrepresentation at the proposal stage and at the claim stage are two different things and need to be viewed differently unless there is a clear intention of fraud.

Forum further notes that the RI issued the policy in the name of complainant based on her proposal declaration dated 29.10.2020 and the Form 30 dated 28.10.2020 assuming that she would apply for the IV’s RC transfer in her name. There is no dispute that the Complainant is the actual owner of the IV at the time of accident. Also, there is valid insurance for the IV in her name at the time of accident. The RC was actually transferred on 11.11.2020 whereas the accident took place on same date at 02:30 AM. It is merely a documentation delay in getting the RC transferred in Complainant’s name for which the claim cannot be denied.

Forum notes that policy has been issued based on the Complainant’s Insurable interest in the IV which is continued to be there in the even at the time of accident base of following documentary evidences: (i) IV physically possessed by the Complainant; (ii) Payment receipt revealing the IV being purchased the Complainant; (iii) IV is under hypothecation with the Financier- HDFC Bank and the loan is in the name of the Complainant; (iv) the Form 30 dated 28.10.2020 reveals that the IV was actually being sold by the earlier owner- Mr. Navin A and purchased by the Complainant. Transaction of sale of the IV is established by the remittance of the consideration amount from the financier, HDFC Bank’s account & the Complainant’s account to that of the seller. These evidences are enough to establish the IV’s ownership & insurable interest with the Complainant.

The Forum feels that the basic conditions for settlement of an accidental claim viz. 1. Insurance Coverage of the IV, 2. Insured’s Insurable interest in the IV i.e. proof of IV’s ownership with the insured/claimant, 3. IV driven by the person has valid DL, 4. IV having valid registration to ply on the road (for roadworthiness, name of owner is not important), etc. as on date of accident are adequately satisfied in the case and hence the claim should not be denied.

Under the circumstances, the Forum does not concur with the decision of RI to repudiate the claim and cancellation of OD part of policy on the ground of Misrepresentation of Material Fact. Further, it is cleared that having established the liability under the policy, the RI is directed to arrive at the claim settlement as per the terms and conditions of the policy keeping in view of the IDV and extent of damages suffered by the IV.

A W A R D

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

both the parties and documents placed on record, the Forum notes that there is no

deliberate intention of illegal enrichment under the insurance policy by the Complainant in

mentioning the date of accident as 14.11.2020 instead of 11.11.2020. Though unethical, it

was purely due to the misguidance by the workshop and thus the rejection of claim on the

ground of Misrepresentation of Material Fact is not found to be in order as the change in

date does not alter the eligibility for claim. The ownership of the Complainant is also

adequately established. The Respondent Insurer is directed to reconsider the claim

settlement as per the terms and conditions of the policy keeping in view of the IDV and

extent of damages suffered by the Insured Vehicle.


Compliance of Award:

Attention of the Complainant and the Insurer is hereby invited to the following: a. The Complainant shall submit all requirements/Documents required for compliance of

award within 15 days of receipt of the award to the Respondent Insurer. b. As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the

award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.




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