7. general=ind.personal accident claim

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Pages (24) AHMEDABAD

OFFICE OF THE INSURANCE OMBUDSMAN (GUJARAT)

2nd Floor, Ambica House, Nr C.U. Shah College, Ashram Road, Ahmedabad-380014 Phone : 079-27546840, 27545441 Fax : 079-27546142

SYNOPSES OF AWARDS 2008-09

Half Year: OCT 2008 TO MAR 2009

7. GENERAL=IND.PERSONAL ACCIDENT CLAIM

Award dated 04-11-2008

Case No.11-005-0160-09

Dr. A.S.Abani Vs. Oriental Insurance Co.Ltd.

Personal Accident Policy and Mediclaim Policy

The Complainant met with an accident and preferred claim on both

the policies. Complainant treated by Orthopedic Surgeon who advised to

take rest for 3 weeks while Respondent has allowed TTD for 2.5 weeks

and as a result dispute is about short payment of Rs.2,500/-. The claim

for Rs.1598/- under mediclaim policy was rejected on the ground that

there was no hospitalization for a minimum period of 24 hours.

The treating Orthopedic Surgeon who had examined the

complainant personally, has recommended rest for 3 weeks is justifiable

through treating papers. Therefore complaint is partially succeeds and

directed to settle the balance payment of Rs.2,500/- as TTD and

Respondent’s decision to disallow claim under Mediclaim policy is upheld

without any relief to the complainant.


Case No.11-003-0107-09

Mr. Darshak S. Shah Vs. National Insurance Co.Ltd.

Personal Accident Policy

The complainant was covered under Personal Accident Policy

issued by above referred Insurer and met with an accident on 27-09-

2007 at Ahmedabad resulting into deep incised wound on internal aspect

of foot extending on dorsum of foot just below the ankle right foot.

Claim lodged for 74 days salary as compensation from 27-09-2007

to 9.12-2007 but on the basis of treating doctor’s certificate, Respondent

issued a voucher for Rs. 45,000/- i.e. 9 weeks salary (@ Rs.5000/week).

Complainant refused to accept this amount. As per Employer’s

certificate, complainant was on leave from 27-09-2007 to 9-12-2007 but

reason for leave was not mentioned. Thereafter, Medical Referee of the

Respondent opined that considering the nature of injuries and other

treatment, recommended to pay Rs.38,750/-i.e. from 27-09-2007 to 20-

11-2007 and accordingly the Respondent sent a revised voucher.

Complainant pleaded that since he could not attend this normal

duties during the above mentioned period and he should be paid TTD for

the entire period he was absent from duty.

Considering the certificate issued by the employer and Clause (f) of

the policy condition, Forum directed to the Respondent to pay TTD for

the period from 27-09-2007 to 09-12-2007.


Case No. 11-004-0240-09

Mr. K.S. Christian Vs. United India Insurance Co.Ltd.

P.A.Claim

TTD Claim was repudiated on the grounds that the

TTD was not due to accidental injury but due to implant failure as

reported by the operating surgeon.

The documents on record proved that the complainant

had history of fall on road and history of operation in same shoulder

before 5 months as per the discharge care.

The doctor has recorded that fracture of Humerous left with

breakage of callous and loosening of the screws and bending of plate.

The claim arises was not due to failure of implant but due to

second accident occurred as there was formation of callous.

The complaint succeeded and respondent was directed to settle the

TTD claim equal to the sum paid for first claim.


Case No.11-002-0223-09

Mrs. Leeladevi Dharampal Agrawal Vs. The New India

Assurance Co.Ltd.


A death claim under P.A policy of the insured was repudiated

for the insured’s relative did not lodge the FIR for accident immediately

which was done after two months. Post Mortem was not done for

ascertaining the death was due to accident or otherwise and the

insured’s relative declared cause of death due to “old age”.

On verification of the documents it was revealed that the insured

was treated initially in the nearby hospital and then shifted to Reksha

Orthocare Hospital and Medilink hospital and then shifted to residence.

Thereafter he died end course of event narrated above was factually

correct. The FIR was lodged after 20 days of funeral of insured. The

municipal records of Birth and Death confirmed that the death was due

to old age.

In the result complaint was dismissed.


Case No. 11-004-0296-09

Mr. Jawahar J Sheth Vs. United India Insurance Co.Ltd.


A claim was lodged for TTD (Temporary Total

Disability) as the insured met with accident resulting into fracture left

foot.

The Orthopediacion applied bandage and advised rest

with some precautions for 3 weeks.

The TTD for 3 weeks was rejected the claim on the

grounds that the investigator of the respondent when visited the clinic he

was found attending the patients and was without any bandage on the

left foot. On meeting the insured subsequent to this who was regularly

attending the work without break established that injuries sustained was

such that it did not create the hurdle in performing regular duties and

did not require the bed rest.

Thus it was established that the TTD did not become

applicable in the case and complaint was dismissed.


Case No. 11-014-0271-09

Mr. Bhupendra Shah Vs. Cholamandalam M.S.

Gen.Ins.Co.Ltd.

Private Car Package Policy

The car was damaged due to deluge after heavy rain. The claim

lodged was rejected on the grounds that damage was not due to deluge

but was due to normal wear and tear.

The documents revealed the fact as under.

The car had run for 86000 Km. The surveyor opined that the

deluged water was not found in the tank and tank with petrol and oil

was not up to the level more over the complainant withdrawn the claim

in between.

From the above facts it is justified that the damage was not

due to deluge but only due to break down due to normal wear and tear.

The complaint was dismissed.


Case No. 11-002-0317-09

Mr. Hiren N Patel Vs. The New India Assurance Co.Ltd.


The TTD Claim for 10 weeks was offered as per medical

referee against claim for 15 weeks.

On mediation both the parties agreed for TTD for 12.5 weeks

to resolve the issue.

Complaint was closed on compromise.


Case No. 11-004-0228-09

Mrs. Indiraben T. Patel Vs. United India Insurance Co.Ltd.


The P.A. Claim (TTD) of the insured was partially settled by the

Respondent on the grounds that TTD for 10 week against 55 weeks.

The documents revealed that insured was seriously injured from

12-06-2005 to 25-07-2005 and looking to multiple injuries was advised

rest for 6 to 12 months but he died on 01-07-2006.

Respondent’s medical referee opined that death was due to medical

reasons. The patient in view of injuries should recover in 1 to 1.5 months

and informed that TTD is because of high B.P and diabetes.

Since the insured suffered TTD from date of assault i.e. 11-06-

2005 till date on 01-07-2006. The total TTD payable comes to 55 weeks

and not 10 weeks as assured by Respondent being sole and direct cause

of assault.

Respondent was directed to settle claim for TTD for 55 weeks.


Case No.11-004-0312-09

Mr. Azhar A Hawawala Vs. United India Insurance Co.Ltd.


Claim for TTD was repudiated by Respondent on the grounds

of TTD not related to accident.

The documents and pleading in the matter revealed that the

insured had earlier on accident resulting into -------tear and was

advised for surgery at the time which was not done as insured

wanted second medical opinion.

The claim lodged subsequently was settled for hospitalization

but not TTD on the evidence for second accident was not

submitted and it was only it was only because of delay in surgery

which was confirmed.

Thus the complaint was dismissed.


Case No.14-002-0340-09

Mr. Manoj K Mehta Vs. The New India Assurance Co.Ltd.


Claim for TTD was offered for lesser amount than that of

demand amount for TTD.

The documents revealed that the operating Surgeon

recommended 8 weeks rest after hospitalization. The Respondent offered

TTD as per the Surgeon’s certificate. The complainant required TTD for

17 weeks, the time till he remained on leave from work.

Since the Respondent’s offer was as per rules based on Surgeon’s

certificate for 8 weeks found justified the complaint was dismissed.


Case No. 11-004-0244-09

Mr. Rajendrakumar M. Maloo Vs. United India Insurance Co.

Ltd.


P.A claim was repudiated on the ground of difference in

name of the deceased insured.

Documents revealed that name appearing in the policy was

Anupama Maloo however as per the records the deceased person is

shown as Snehaleta. The two names being different the Respondent

rejected the claim stating that the deceased person is not insured under

the subject policy.

The Respondent failed to produce the Proposal form which

was required to confirm if it is wrongly typed or otherwise. Secondly

Respondent did not provide any evident as to how Anupama was

incorporated in the policy as spouse of the policy holder. The

complainant’s submission of large documents sufficiently proved that

the name of the spouse is Snehaleta and not Anupama Maloo.

The marriage affidavit issued by Govt. authorities shows spouse name is

Snehaleta. I.T returns and LIC policy also showed that the name is

Snehaleta only. The Respondent could not provide any evidence to stand

their case.

The Respondent was directed to settle the claim with interest.


Case No. 12-012-0242-09

Mr. Jayant M Ruwala Vs. ICICI Lombard General

Insurance Co. Ltd.

Personal Care Policy

The one year accident Insurance was given to the complainant on

the basis of telephonic dialogue (Tele marketing) whereby getting the

verbal comment the insured was given insurance of 40 Lakh blocking his

credit card for the premium amount which was payable in EMI.

The Complainant decided to cancel the policy after 4 months but

refund was disallowed as the request was received late.

However as per IRDA provisions the written consent to Dictaphone

recorded talk was not obtained in 15 days by Respondent the contract

was viewed as unconcluded contract and Respondent was directed to

refund amount received by him through Credit Card.


Case No.14-002-0353-09

Mr. D.C. Kharidiya Vs. The New India Assurance Co. Ltd.


The P.A. Claim was settled partially by the Respondent.

The complainant wanted TTD claim for 14.3 weeks based on

certificate of the doctor but offer was made by Respondent for 10 weeks

TTD based on Panel doctor’s opinion.

From the documents on record it was established as per treating

doctor two months and 5 days the time spent in hospital hence entitled

for 9 weeks TTD and medical expenses totaling Rs.12,600/- as per policy

clause and accordingly Respondent was directed to settle the claim.


Case No. 11-005-0323-09

Mrs. Sangita K Jain Vs. Oriental Insurance Co. Ltd.


Death claim lodged for insured member when Motor bike was hit

by unknown vehicle.

The claim was repudiated alleging that the insured was discharged

from hospital against medical advice after accident and Post mortem

report was not submitted.

From the analysis of material on record it was established that

though the post mortem was not done the circumstantial evidence in the

form of injuries sustained by the insured were sufficient (which were

recorded on admission in hospital).

Since Post Mortem was not necessary as per policy condition

clause 2 (which is required if death is doubtful).

The repudiation was unjustified as such Respondent was directed

to settle the claim.

BHUBANESWAR

INDIVIDUAL PERSONAL ACCIDENT POLICY

BHUBANESWAR OMBUDSMAN CENTER

Complaint No.11-003-0324

Sri Ratnakar Jena Vrs

National Insurance Co. Ltd., Bhubaneswar Do-I

Award dated 08th

July, 2008

Complainant had taken a Personal Accident with Medical Expenses policy with National

Insurance Company Ltd. He met with an accident and lost his eyesight in left eye.

Insurance company has not settled the claim, even though all documents have been

submitted.

Hon’ble Ombudsman heard the case on 12.05.2008 where both parties were

present. After hearing the complainant and perusing the documents Hon’ble Ombudsman

held that the insurance company has not bothered to settle the claim when documents

have been submitted and there is permanent loss of 80% eye sight in left eye as per the

District Medical Board and hence directed the insurance company to pay 50% of Sum

Assured to the complainant within one month of receipt of the consent letter.

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



Smt Jamunamani Sahu Vrs

ICICI Lombard General Insurance Co. Ltd.,

Visakhapatnam Branch

Award dated 20January,2009

Complainant’s husband had taken a personal accident policy with ICICI Lombard

General Insurance Company Ltd and during pendency of the policy died due to an

accident. Complainant preferred a claim with the insurer and submitted all documents

But the claim has not been settled by the insured even though one year has passed.

Hon’ble Ombudsman heard the case on 20.01.2009 where both parties were

present. After hearing both parties and perusing the documents directed insurance

company to settle the claim within two months of receipt of the recommendation and also

instructed complainant to hand over the copy of discharge certificate within 15 days to

the insurance company.

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



Smt Malati Devi Vrs

Bajaj AllianzGeneral Insurance Co. Ltd., Kolkata Branch

Award dated 23rd

December, 2008

Complainant is the mother and nominee of Late Anjali Bala Dash who had taken a

Personal Accident Policy with Bajaj Allianz General Insurance Company Ltd. Insured

died by drowning and Insurance company has not settled the claim in favour of the

nominee, even though all documents have been submitted taking the plea that the

accidental death aspect is not ascertained through supplied documents.

Hon’ble Ombudsman heard the case on 30.09.2008 where insurance company

was not present and the self content note from his side high lighted that the accidental

death is not supported by documents. After hearing the complainant and perusing the

documents, Hon’ble Ombudsman held that the death of insured by drowning is proved

through the police report and acceptance of the same by the court. Insurance company

has neither challenged the report nor has produced any evidence to prove other wise.

Hence directed the insurance company to pay Rs50, 000/- to complainant within one

month of receipt of the consent letter.

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

.

Chandigarh Ombudsman Centre

CASE NO. GIC/443/Chola/11/09

Meenu Rai Vs. Cholamandalam General Insurance

Order dated 12.01.09 PERSONAL ACCIDENT

FACTS: Ms. Meenu Rai stated that by virtue of the fact that they had availed a

loan from M/S Dhiwan Housing Finance Corp. Ltd., M/S Cholamandalam General

Insurance Co. had insured the life of her husband.Her husband died on 23.03.08 due to

the reaction of some medicine. FIR was duly lodged. Claim was also filed with the

insurance company which however rejected the claim on the grounds that her husband

had died due to Myocardial infarction. It was further stated by the complainant that

without any report from pathology department how could it be presumed that the cause of

death was heart attack. However from the copy of repudiation letter dated 27.08.08

written by Cholamandalam General Insurance Co. it appears that the “cause of death”

certificate confirmed and concluded that insured died due to Myocardial Infarction.

Parties were called for hearing on 12.01.2009.

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

that as per the terms and conditions of the policy only personal accidental claims were

payable which should be caused by external violent means. In this case no external injury

was visible which resulted in the death of complainant husband. Hence the claim was

repudiated on the ground of the death being natural and not due to personal accident.

DECISION: Held that the contention of the insurer that the death was natural and not

caused by an accident is justified. The repudiation of the claim is therefore in order, No

further action is called for. The complaint is dismissed.

Chandigarh Ombudsman Centre

CASE NO. GIC/451/UII/11/09

Kulwinder Kaur Vs. United India Insurance Co. Ltd.

Order dated 12.02.09 PERSONAL ACCIDENT

FACTS: Smt. Kulwinder Kaur’s husband was the holder of a personal accidental

policy worth Rs. 5.00 lakh under the Pravasi Bharatiya Bima Yojana 2006. Her husband,

late Sh. Charanjit Singh passed away on 14.05.2007 as a result of road accident at Abu

Dhabi. Claim was lodged with the insurance company but the claim was repudiation on

the grounds that section 64 VB had been violated. It was further stated by her that while it

was true that the cheque that had been paid towards premium was dishonoured, this

matter was between the insurance company and the corporate agent. However, the

corporate agent prepared a demand draft in lieu of the dishonored cheque and sent it to

the company. The amount was credited to the company’s account on 08.12.2006 whereas

her husband passed away on 14.05.2007. Parties were called for hearing on 12.02.09.

FINDINGS: During the course of hearing the insurer clarified that this was a policy

called Pravasi Bharatiya Bima Yojana 2006. Under this policy Indians who are serving

abroad are covered for a limited period on payment of insurance premium. A certificates

is issued by the agent to the person who is immigrating after receiving the premium. The

date of commencement of the insurance cover is either the date of receipt of premium or

the date of departure whichever is later. In this case Sh. Charanjit Singh had given the

premium to the agent. The agent deposited the same with the insurer through a cheque

which unfortunately was dishonored. A demand Draft was later on given which was

credited to the company’s account on 07.12.06 whereas the Sh Charanjit Singh had left

India on 30.11.06. Since the premium was received after the date of commencement of

the insurance cover the claim was repudiated under section 64 VB of Insurance Act.

DECISION: Held that Sh. Charanjit Singh had given the premium in time and it was

the duty of the agent to deposit the same with the insurer. A certificate of insurance had

been issued by the agent on receipt of the payment of premium in cash. The insured

cannot be held liable for error on the part of the agent. It should be the liability of the

insurer being the principal especially when they had not cancelled the certificate during

the life time of the insured. The demise of the insured is within the policy period and the

complainant being the nominee is entitled to the insured amount.

CHENNAI

Chennai Ombudsman Centre

Complaint No.IO(CHN) 11.08.1170 / 2008-09

Rajesh Mahadevan

Vs

Royal Sundaram Alliance Insurance

AWARD No. 069 /2008-09 dated 19/12/2008

The complainant Mr S Rajesh Mahadevan and his father were covered under the PA policy of Royal Sundaram

Alliance Insurance Company Ltd.(RSA) for the period 12/01/2007 to 11/01/2008. On 03/02/07, the father

of the complainant died as a result of a fall in his house. The insurer rejected the claim on the grounds

that at the time of death, the age of his father was more than the maximum age stipulated under the

policy. The insurer contended that as per the terms of the policy it is applicable to persons between the

age group of 18 and 70 Years (completed years). The cover automatically ceases to operate on

the Insured Person completing 70 years of age. the policy was only to be issued to persons in the

age group 18-70 years of age. Since the insured died less than a month after inception of cover,

due to fall in the bathroom, they had arranged for investigation which revealed that the age of the

insured person was more than 70 years at the time of taking the policy, he had not been keeping

good health and had been hospitalized for a major ailment just before taking the policy. The

nominee had submitted as proof of age church records, nut it was found that even in this record,

the year of birth had been changed /overwritten from 1932 to 1937. Hence, the claim was

repudiated.

The case thus came up for hearing on 23/09/2008.

Documents which included the Policy copy , Nomination Form , Death Certificate,

Accident Register, Post Mortem Report, Legal Heir certificate, FIR, Inquest Report,

Investigation Report, Discharge summary of Vadamalayan Hospital, Register of Deaths

of St. Mary’s Cathedral, Letter of Parish Priest of St. Mary’s Cathedral, Family details

issued by St.Mary’s Cathedral, Madurai Arch Diocese , Copy of Form 6 for inclusion in

the voter’s list, Copy of Voter’s list of Tiruparamkundram Loksabha constituency,

Clarification Letter from Vadmalayan Hospital, Letter from the person who accompanied

Mr Sadanantham to the hospital were examined.

It was seen that both parties to the dispute were unable to produce incontrovertible

evidence to prove their contentions as correct. The insurer had relied upon Ration Cards

issued in 1998 and 2005, Medical record of Vadamalayan Hospital and Investigation

Report to conclude that the Mr Sathananthan was over 70 years of age at the time of

proposing for insurance. The Complainant had relied upon application for inclusion in

Voter List, Electoral Roll Post Mortem Certificate and Church records. But it was seen

that the year of birth of the deceased had been corrected from 1932to 1937

Those documents prior to insurance and lodging of claim namely the Ration Card and

Hospital record of Vadamalayan Hospital corroborate each other and indicate age of the

deceased to be over 70 years. All these were subsequently got corrected by the nominees

but without any basic document or basis for the rectification.

It was held that no materials have been produced by the complainant which makes the

decision of the insurer to reject the claim as unjustified

The complaint was dismissed.

Chennai Ombudsman Centre

Case No.IO(CHN) 11.03.1414/2008 – 09

Mrs. R.V. Geetha

vs

National Insurance Co. Ltd

Award No.108 dated 31/03/2009

The Complainant Mrs R.V Geetha had been covered under Group

Personal Accident Policy of the insurer through Road Safety Club.

The complainant fell down at home and was hospitalized for Left

Ankle Fracture during the policy period. The complainant lodged a

claim with the insurer for Rs.15,100/-. The insurer informed the

Road Safety Club regarding inadmissibility of the claim since policy

was obtained after the accident. The complainant had not been

informed either by the Road Safety Club nor the insurer in spite of

her taking up the issue with the respective authorities.

It was established by the insurer that the issue of the certificate to

the complainant has been made in an irregular manner, not in

keeping with the established norms for issue of insurance

certificates and in contravention of Sec 64 VB which stipulates that

premium has to be collected in full before the assumption of the risk

by an insurer. Since the complainant did not attend the hearing, no

records are available to establish that the premium had been

remitted by the complainant before the fall on 10/05/2007 and

before the assumption of the risk. No treatment details for the

period prior to the surgery have also been produced i.e from

10/05/2007 to 17/05/2007. Further the complainant is employed

as nurse in the hospital in which she had taken treatment and the

hospital authorities have not cooperated in furnishing leave records

to the insurer. Insurer has substantiated with records that there

was irregularity in the manner in which the certificate has been

issued and the complainant failed to produce any evidence that

accident had happened after commencement of cover. Hence, the

stand of the insurer rejecting the claim on the grounds that

coverage was obtained after the accident is in order and the

complaint is dismissed.

DELHI


Case No.GI/215/NIA/08 In the matter of Smt. Saroj Kalvi Vs

The New India Assurance Company Limited.

ORDER dated 14.11.2008

Smt. Saroj Kalvi had lodged a complaint with the Forum on 18.07.2008 that her

Late husband Shri V.S. Kalvi was a Development Officer in LIC of India and he had met

with an Road Accident on 06.03.2003 as a result of which he died. His employers LIC of

India had taken 24 hours Personal Accident Policy with New India Assurance Co. Ltd.

and he was covered for Rs.200000/-. The New India Assurance Co. Ltd. has repudiated

his claim since the claim was lodged after 4 years of the date of accident. The Insurance

Company has also not provided for this claim that the rejection of the claim because of

not making any provision and the accounts being closed is not correct and she should be

paid the claim. The delay in filling of the claim was on account of LIC of India

Divisional Office, because of their not knowing that such policy existed and as such there

was delay in filling the claim. Although she was appointed on compassionate grounds by

LIC of India but at the time of death of her husband she was not employed. She only

came to know later on when one of the deceased employee’s relative had lodged a claim

under the Personal Accident policy with the Insurance Company. Divisional Office of

LIC of India had been pursuing the matter with the New India Assurance Co. Ltd. and

they have recommended that the claim was genuine and all documents were submitted by

their Bikaner Office. However, by not considering the claim, the purpose of the scheme

itself appears to be getting defeated. LIC of India has recommended that the claim may

be paid. The Insurance Company informed them that they have rightly repudiated the

claim.

At the time of hearing the representative of the complainant informed the Forum

that Shri V.S. Kalvi who was working as a Development Officer in LIC of India met with

an accident and died on 06.03.2003. LIC of India, his employers has taken 24 Hours

Personal Accident Policy and his wife had preferred a claim which was rejected by the

Insurance Company. LIC of India in their letter dated 08.10.2007 informed the New

India Assurance Co. Ltd. that their Bikaner Office was not aware of Group Personal

Accident Policy and as such there was a delay in submission of the papers. The

representative requested the Forum that the claim may be paid.

The representative of the Insurance Company informed the Forum that claim

intimation from LIC of India was received on 12.10.2007 whereas Shri V.S. Kalvi had

expired on 06.03.2003. Since the claim was reported very much delayed, it was a

violation of policy terms and conditions where the matter has to be reported immediately.

As such they have rejected the claim as there existed no liability as no provision has been

made for this claim.

After hearing both the parties and on examination of the documents submitted,

Smt. Saroj Kalvi had lodged a complaint with this Forum that her late husband Shri V.S.

Kalvi was working as Development officer in LIC of India died as a result of road

accident on 06.03.2003. She was not aware that LIC of India had taken a 24 hours PA

policy and only when she came to know of the same, she immediately filed the claim on

New India Assurance Co. Ltd. The Insurance Company has rejected the claim because of

late intimation of the claim. I have gone through the papers and find that Smt. Saroj

Kalvi had informed the New India Assurance Company vide letter dated 12.10.2007

whereas the death of Shri V.S. Kalvi occurred on 06.03.2003 which is more than 3 years

after his death and she having no knowledge that his employers had taken Personal

Accident cannot be accepted to condone the delay of three years. Shri V.S. Kalvi’s

employers must have settled his terminal dues where the cause of death must have been

mentioned and their recommendation to pay the claim being genuine shows the

negligence on the part of the employers who should have guided Smt. Saroj Kalvi to file

the claim with New India Assurance Co. Ltd. well in time and as such I am, therefore,

constrained not to agree to condone the delay and I am therefore of the opinion that the

Insurance Company has rightly repudiated the claim.

GUWAHATI

GUWAHATI OMBUDSMAN CENTRE

Complaint No. 11-011-0131/08-09

Mr. Sunil Tanti

- Vs -

The Bajaj Allianz General Insurance Co. Ltd.

Policy No. OG-05-2401-9960-00000041

Award dated : 13.02.2009

The Complainant, Mr. Sunil Tanti procured a policy through Golden Multi

Services Club of Golden Trust Financial Services covering the period from

30.05.2005 to 29.05.2010. Mr. Tanti sustained injuries due to an accidental fall

during the period covered under the policy who became permanently disabled

due to such injuries. A claim was lodged under the policy but the Insurer has

repudiated the claim due to non submission of required documents. Being

aggrieved, the Complainant approached this forum for redressal.

The Insurer insisted the following documents in connection with his claim :-

1) Disability Certificate from the District Medical Board

2) Copy of the Voter Identity Card of the Insured

3) Copy of Ration card of the Insured

4) Attested copy of FIR and Final Investigation report of Police

During hearing, the representative of the Insurer said that the Complainant has

failed to produce all such required documents and finding no scope to settle

the claim, the Insurer has closed the claim file. He has further stated that

although the Complainant claimed to have suffered from disability and had

lodged the claim but he has failed to produce any certificate in proof of

sustaining permanent disability. Mr. Sunil Tanti, in his statement, stated about

sustaining head injuries due to accidental fall and according to him, that injury

causes him disabled. He was treated at the Sanjivani Diagnostics & Hospital

wherefrom he had procured two certificates. The above Hospital diagnosed his

sufferings to be “Alleged history of fall with left temporo-parietal lobar

hematoma with motor aphasia and right hemiplegia”. The Hospital Authority

discharged him with advice to go for Physiotherapy and report in the

Hospital for review after six weeks from 06.01.2008. The certificate issued by

the Sanjivani Diagnostics & Hospital discloses only that the injuries may cause

Permanent Disability. The certificate produced by the Complainant has failed

to prove sustaining any permanent disability at the present moment.

The Insurer, due to non submission of required certificates, repudiated the

claim and I see no scope to interfere with the decision of the Insurer. The

complaint is treated as closed.

Guwahati Ombudsman Centre

Case No.11/011/0074/08-09 Smt. Kamaleswari Das

-Vs-

Bajaj Allianz General Insurance Co. Ltd.

Policy No. OG-07-2401-9960-00000003

Award dated = 27.10.2008

Mr. Khargeswar Das, husband of the Complainant, was covered under the

above “Group Personal Accident Insurance Policy” issued by the above Insurer for

Sum Assured of Rs.50,000/- for the period from 01.05.2007 to 30.04.2008. The

Insured expired on 22.06.2007 due to injuries sustained in a motor vehicle

accident. The claim lodged with the Insurer had been repudiated on the ground

that there was marked variation in the signatures of the L/A between the proposal

form and the PAN Card. The Insured had obtained the policy by

misrepresentation, which in turn, amounted to breach of the principle of utmost

good faith, hence the claim is not tenable. Being aggrieved, the Complainant

approached this forum for redressal.

The contention of the Insurer is that the signature of the Deceased / Insured

given in the proposal form dated 24.01.2007 did not match with that of the

signature given in his PAN Card. The Insurer has obtained opinion from the

Document Expert who observed that there was marked variation in the signatures

of the Deceased as stated above.

During hearing, the representative of the Insurer stated that the proposal for

the policy was procured with signature of the Insured and the Insurer thereafter

issued the policy. It is thus established that the proposal form was signed and

submitted by the Insured Khargeswar Das before the Insurer for procuring the

policy. The copy of the PAN Card has also been produced and according to the

Insurer, their expert Mr. R.K. Das, after due examination, observed that there is

marked difference between the signatures in the proposal form and the signature

in the PAN Card. Admittedly the PAN Card is not a part of the policy of

contract and it is related to Income Tax Department. From the statement of the

representative, it is clear that the Insurer collected the proposal form from the

Insured with his signature and that appears to be sufficient for us to see that it

was he who submitted the proposal form. There may be a variation in the

signature given on the PAN Card and this is matter to be seen by the Income

Tax Department and that should not affect settlement of the claim. Cancellation of

the policy and repudiation of the claim on the ground of detecting marked

differences in the above signatures appears to be unjustified and refusal to settle

the claim appears to be without any principle, when the policy was issued after

procuring the proposal form from the Insured. The decision of repudiation of the

claim is set-aside.

The Insurer was asked to settle the claim.

KOCHI

OFFICE OF THE INSURANCE OMBUDSMAN, KOCHI

Complaint No.IO/KCH/GI/11-002-134/2008-09

Shri Abdul Kareem

Vs

The New India Assurance Co.Ltd.

AWARD DATED 23.09.2008

The complainant is the holder of a personal accident insurance policy which

covers medical expenses arising out of road accident only. He raised a claim for Rs.80,666.48 but the same was repudiated by the insurer on the ground that there

was considerable delay in reporting the matter to police and the insurer. It was submitted by the insurer that the policy covers medical expenses arising out of road accident only. The indemnification is limited to road accident only and

subject to terms and conditions. The policy incorporates conditions of driving licence, immediate notice to police and insurer, police report, etc. to confirm that

the benefit reach the right person only. Here in this case, the alleged accident

occurred on 30.12.2007. The claim was intimated on 07.01.2008. The claim form and other bills were submitted on 25.01.2008. GD extract of Aluva Police

Station was produced only on 19.02.2008. Also in the absence of an FIR registered with the police within the stipulated time, they are not in a position to

honour the claim. It was submitted on behalf of the insured that immediate notice could not be given to the insurer and the police as the insured was in an

unconscious state for few days after accident. But it is to be noted that the patient was discharged on 03.01.2008 with an advice to reach the hospital on 05.01.2008 for suture removal. If the patient was in an unconscious condition for days after

accident, he could not have been discharged on 03.01.2008 with an advice to

reach hospital on 05.01.2008. Hence this contention cannot be accepted.

Another contention of the insured is that the matter was reported to the hospital authorities and it was noted in the discharge summary. It was the duty of

hospital authorities to report to the police, which they didn’t do. But it is to be noted that discharge summary only states the reason as ‘alleged RTA’. No other details are given. Even though one adjournment was given, as requested, on

behalf of the complainant, he failed to produce copy of accident-cum-wound register kept by the hospital authorities or copy of case sheets. Hence the

materials available are not sufficient to substantiate the case that the complainant had sustained injury in a road accident. The complaint is, therefore, liable to be

DISMISSED.

OFFICE OF INSURANCE OMBUDSMAN, KOCHI


Shri K.J.Joseph

Vs

National Insurance Co.Ltd.

AWARD DATED 31.12.2008 The complainant and his family were covered under a mediclaim policy for the period 23.2.2007 to 22.02.2008. On account of running nose, his wife was admitted to hospital on 24.12.2007 and the claim was repudiated on the ground that there was no active line of treatment from the hospital and hospitalization was only for investigation and lab test, which is excluded as per Cl.4.10 of policy condition. It was submitted on behalf of the insurer that out of the total bill amount of Rs.6,025/-, only Rs.95/- was spent for treatment. The other amounts were for lab test, scan, bed charges, etc. During hospitalization, she was given only some antibiotic and antihistaminics tablet, which costs only Rs.95/-. Hence it is very clear that there was no active line of treatment from

the hospital and hospitalization was only for conducting lab test, scan, etc. The exclusion clause 4.10 is very specific that hospitalization for such purpose is not covered under the policy and the complaint is, therefore, DISMISSED.

OFFICE OF THE INSURANCE OMBUDSMAN, KOCHI


Shri K.Sasikumar

Vs

ICICI Lombard General Insurance Co.Ltd.

AWARD DATED 24.02.2009

The motor vehicle TVS Apache bearing No.KL-22-486 belonged to Late Smt.Sailaja,

wife of the complainant, which was insured with ICICI Lombard for the period

31.07.2006 to 30.07.2007 for which cover note No.D 2709188 was issued by the

insurance company. While issuing the cover note, it was informed that the policy

certificate would be given within one week of accepting premium. But policy

certificate was not issued at all. On 24.04.2007, Smt.Sailaja died in a traffic

accident. The petitioner issued legal notice asking for issue of policy document in

order to claim insurance benefit. As his persistent effort failed, he approached this

forum for justice.

It was submitted by the insurer that though the cover note was issued, they have not

received the premium as somebody had played a fraud in issuing the cover note and

they want to conduct enquiry and take legal action. However, they are prepared to

honour the claim and accordingly, they settled the claim for own damage claim.

Regarding Personal Accident claim of Rs.1,00,000/- to be paid as per policy terms

and condition, it was submitted by the insurer that they received claim application

after 90 days of accident and also they have not received the premium. But it is to

be noted that the genuineness of cover note is never disputed by the insurer, though

they suspect some fraud in issuing the same. Also having settled the own damage

claim, the insurer had accepted the existence of a policy. They cannot now turn

round and say that such policy is not in existence. The delay in submitting the claim

is only because of the insurance company not issuing the policy document within 90

days of accident. The complainant sent lawyer notice demanding issuance of policy

document. Hence the insurer cannot deny the claim on the ground that the claim

was submitted late. An award is, therefore, passed directing the insurer to pay the

claim amount of Rs.1,00,000/- with 8% interest and a cost of Rs.5,000/-.

KOLKATA

INDIVIDUAL PERSONAL ACCIDENT POLICY

Kolkata Ombudsman Centre

Case No. 256/14/003/NL/07/08-09

Shri Narendra Kumar Shroff

Vs.

National Insurance Company Ltd

Order Dated : 19.01.2009

Facts & Submissions :

This petition was against delay in settlement of claim under Individual Personal Accident

Policy issued by National Insurance Company Limited (NICL).

The petitioner Shri Narendra Kumar Shroff stated that he had taken a policy from NICL, D.O. IX,

Kolkata. He fell in bathroom on 26.07.2007 due to which he was bed ridden for 3 weeks. He

lodged a claim with the insurance company on 12.09.2007. He had also send a reminder letter to

the concerned Divisional Office of the insurance company on 24.01.2008 but his claim had not

been settled by the insurance company.

According to the insurance company, Shri Narendra Kumar Shroff fell in the bathroom on

26.07.2007 and consulted Dr. S.K.Agarwal thrice on 29.07.2007, 01.08.2007 and 08.08.2007.

The said doctor referred him to Dr. Chandan Pathak, Orthopaedic Surgeon. Accordingly, he

consulted Dr. Pathak on 12.08.2008. Dr. Pathak had given him a course of treatment along with

an advice of bed rest for 3 weeks. No hospitalization was there as per the enclosed paper and as

per statement of Shri Shroff, the complainant vide his letter dated 01.07.2007. Form AC 1 122 (2)

issued by NICL was filled up by Dr. S.K.Agarwal.

DECISION:

The complainant had been given detailed explanation of the features of the policy, since fell in

the bathroom without any external violence was not covered under the policy. Therefore, it was

felt that the insurance company was correct in not settling the claim. Hence, the petition was

dismissed without any relief to the complainant.

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

LUCKNOW

Lucknow Ombudsman Centre

Case No.G-42/11/11/08-09

Smt.Chanda Devi

Vs

Bajaj Allianz General Insurance Co. Ltd..

Award Dated : 4.02.2009

Complaint filed against Bajaj Allianz General Insurance Co. Ltd. by Smt.Chanda Devi in

respect of repudiation of the death claim on the life of her husband Shri.Lal Bahadur.

Facts : Shri.Lal Bahadur, an ex-servicemen, took out a policy from Bajaj Allianz General

Insurance Co. Ltd. for S.A. of Rs.2,00,000/- for period 15.5.05 to 14.5.08. The insured

died on 12.7.07 due to an accident. The respondent repudiated the claim on the ground

that the signature in the proposal form is not that of the policy holder. The contention of

the respondent is that after examining the signature of the DLA in the ex-servicemen

identity card it is found that the signature on the proposal form is not that of the DLA.

Aggrieved with the decision of the insurer the claimant approached this forum giving rise

to the complaint.

Findings : On careful examination of all the documents the forum found that the claim

was rejected by the respondent on contention that as per handwriting expert’s opinion the

DLA’s signature in the ex-servicemen identity card and that in the proposal form differs.

However the signature taken for comparison pertains to document 5 years prior to the

proposal date and there appears no difference in signatures to the naked eye.

Decision : Held that there is no dispute that the policy has been issued in favour of DLA

and is very much in force. With respect to the discrepancy in the signature, to the naked

eye there appears no difference in signatures and the signature taken for comparison are

after a lapse of 5 years and slight variation in signature is inevitable. Moreover

reasonable care should have been taken at the time of proposal and comparison of

signatures at the time of claim when the DLA is not there to defend himself is totally

uncalled for. The repudiation of the claim was, therefore, set aside and the complainant

nominee awarded full sum insure as per terms and conditions of the policy.