State Consumer Disputes Redressal Commission
Icici Lombard General Insurance Co. ... vs Smt. Kaushalya Bahuguna on 10 August, 2023
Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023
80 of 2016 Vs.
Sh. Devi Prasad Bahuguna (deceased)
Smt. Kaushalya Bahuguna & Others
STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARAKHAND, DEHRADUN
Date of Admission : 26.04.2016
Date of Final Hearing : 28.07.2023
Date of Pronouncement : 10.08.2023
First Appeal No. 80 / 2016
ICICI Lombard Gen. Insurance Co. Ltd.
Branch Office: Municipal No. 447, IIIrd Floor
Opp. Hotel Great Value, Dehradun
Through Authorized Representative Sh. Vivek Negi
(Through: Sh. Yogesh Sethi, Advocate)
.....Appellant
VERSUS
Sh. Devi Prasad Bahuguna (deceased)
1/1. Smt. Kaushlaya Bahuguna W/o Sh. Radha Krishan Bahuguna
(Mother)
R/o Village Dhantri, Patti Gaja, Tehsil Dunda, Uttarkashi
1/2. Smt. Smita Bahuguna W/o Late Sh. Devi Prasad Bahuguna
1/3. Master Aditya Bahuguna S/o Late Sh. Devi Prasad Bahuguna
Both R/o III/10, Block-B, Kotwali Campus, Paltan Bazar, Dehradun
(Through: Sh. Suresh Gautam, Advocate)
..... Respondent Nos. 1/1 to 1/3
Coram:
Ms. Kumkum Rani, Judicial Member II
Mr. B.S. Manral, Member
ORDER
(Per: Ms. Kumkum Rani, Judicial Member II):
This appeal has been directed against the judgment and order dated 09.12.2011 passed by the learned District Consumer Disputes Redressal 1 Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others Forum, Dehradun (hereinafter to be referred as the District Commission) in consumer complaint No. 93 of 2010 styled as Sh. Devi Prasad Vs. I.C.I.C.I. Lombard General Insurance Co. Ltd., wherein and whereby the complaint was allowed.
2. The facts giving rise to the present appeal, in brief, are as such that the complainant was working as permanent employee in the year 2002 as Sub-Inspector in the Police Department. The Department took a group insurance policy of 69 employees / officials and officers of Police Department from the opposite party - Insurance Company wherein the name of the complainant is included as Sl. No. 43. Each and every insured police employee / official and officers had paid Rs. 60/- as premium and the policy No. 4005/0004402 was issued. As per the terms and conditions of the group insurance policy, if the insured employee gets permanent disability due to loss of one eye and is unable, then the insured amount to the tune of Rs. 1,05,000/- shall be payable. During election of student union of Gurukul Kangri, Haridwar on 30.11.2005, the complainant was deputed as police employee to maintain law and order. During election, an incident of stone pelting took place. The complainant had sustained injury in his left eye, for which he had been in continuous treatment, but he has not got relief and the sight of the left eye was permanently lost due to such injury. It is also averred that as per condition No. 2, the claim should be submitted within 30 days alongwith documents to the office of opposite party. After the treatment of complainant's left eye, doctors found that the said eye could not be recovered, hence on dated 07.01.2009 he was examined in front of CMO, Dehradun for loss of the sight of left eye, wherein sight of his left eye was found to have lost during his medical examination and a disability certificate was issued from the CMO, Dehradun on dated 07.01.2009. The opposite party has rejected his claim considering it time barred, because the complainant has not informed about the incident within 2 Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others 30 days from the date of incident. The complainant has averred that as per insurance policy, there was a condition that as per the insurance policy, the claim was payable subject to the permanent disability of eye, but in the complainant's case, the disability certificate was issued on dated 07.01.2009 from the CMO office, Dehradun and immediately he contacted to the office of the opposite party. The complainant was the policy holder of policy No. 4005/0004402, hence he is the consumer of the opposite party. In the said policy, the complainant has also paid the premium of Rs. 60/-, which was deducted from his salary and was paid to the office of opposite party. But the act of the opposite party of not paying the claim of the complainant, the opposite party has committed deficiency in service. The complainant has dispatched a notice through his advocate on dated 24.02.2010, but no reply was given, hence the complaint was filed before the District Commission.
3. The opposite party has filed its written statement on record that it is true that the policy No. 4005/0004402 was issued to the Uttarakhand Police Department. The complainant has alleged to have been injured on 30.11.2005 and filed his complaint on 14.01.2009 with the Nodal Office on the ground that he has been declared as permanently disabled on dated 07.01.2009, hence his limitation shall be construed from the date of issuing of the Medical Certificate. But the complainant has not informed about the incident to the office of the opposite party within 30 days, whereas as per the terms and conditions of the policy if the claim is received within the time as narrated in the policy, then the insured amount shall be payable to the insured. It is further averred that there is no deficiency in service on the part of the opposite party; the complainant has given the information on dated 07.01.2009 about the incident alleged to have occurred on dated 30.11.2005. The claim as well as the complaint is time barred, hence the same is not maintainable and is liable to be dismissed.
3Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others
4. The District Commission after taking into consideration the material available on record passed the impugned judgment and order on dated 09.12.2011 wherein it is held as under:-
";g ifjokn miHkksDrk laj{k.k vf/kfu;e dh /kkjk &12 ds vUrxZr foi{kh dEiuh ds fo:) LohÑr fd;k tkrk gSA foi{kh dEiuh dks funsZf"kr fd;k tkrk gS fd og ifjoknh dks bl vkns"k ds ,d ekg ¼30 fnu½ ds vUnj :i;s 1]05]000-00 dh /kujkf"k ifjokn çLrqr djus dh frfFk ls Hkqxrku dh frfFk rd 9% lkykuk nj ls C;kt ds lkFk vnk djsaA mUgsa ;g Hkh funsZf"kr fd;k tkrk gS fd og ifjoknh dks :i;s 25]000-00 dh /kujkf"k okn O;; ds :i esa Hkh vnk djsaA"
5. On having been aggrieved by the impugned judgment and order, the present appeal has been preferred by the opposite party as appellant, alleging that the impugned judgment is illegal and is unsustainable in the eyes of law. The District Commission has failed to exercise the jurisdiction vested in it by law and has exceeded the jurisdiction vested in it by law thereby committed gross material illegality and irregularity. It is further averred that the impugned judgment is against the facts and merits of the case. The District Commission has committed a manifest error of law in construing that the complaint was not only time barred, but infact the claim was time barred. It is further stated that the claim form was submitted after a lapse of 30 days from the receipt of the complaint and the claim itself became time barred, hence the complaint is not maintainable and tenable. The District Commission has passed the impugned judgment in contravention in the mandate provisions of law, therefore, it is liable to be set aside.
4Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others
6. We have heard learned counsel for both the parties and perused the material available on record.
7. Learned counsel for the appellant has contended that the District Commission has failed to appreciate the fact that since the Nodal Office failed to furnish the claim form even after the 30 days from the receipt of complaint, the claim itself became time barred and as per the terms and conditions of the policy, which could not under any circumstances be reassessed by eh District Commission and the appellant has rightly rejected the same in the provisions of policy. It is further argued that the respondent
- complainant even till date has not filed the requisite forms and formalities required for the registration of the claim as per the rules and regulations. Therefore, the repudiation order of the claim of respondent is as per policy and there is no deficiency in service.
8. Learned counsel for the respondent Nos. 1/1 to 1/3 has advanced their arguments that disability certificate has been issued from the office of CMO, Dehradun to the complainant on dated 07.01.2009, therefore, the cause of action for submitting the claim form to the appellant - insurance company has arisen on dated 07.01.2009. It is further averred that the information about the incident of occurrence was given to the office of the appellant within 30 days from the date of issuance of disability certificate and there was no delay in intimating the matter to the office of the appellant, hence, the impugned judgment is perfect and justified as well as liable to be affirmed.
9. We have perused the records available before us.
10. It is an admitted fact that the respondent - complainant has expired during the pendency of the appeal, hence his legal heirs were impleaded as 5 Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others respondent Nos. 1/1 to 1/3 in the appeal. It is an admitted fact that the complainant was working as Sub-Inspector of Uttarakhand Police Department as permanent employee since 2005 and it is also an admitted fact that the Police Department has taken a group insurance policy vide No. 4005/0004402 wherein 69 police employees / officials and officers had paid the premium of Rs. 60/- per month to the Insurance Company. It is also not disputed that the complainant was not insured in the above mentioned policy of the appellant - insurance company. In the appeal, no dispute has been raised that the incident of stone pelting did not take place on dated 30.11.2005. It is also not disputed that the complainant was deputed on 30.11.2005 as police employee to maintain the law and order in the student union election of Gurukul Kangri, Haridwar. The documentary evidence has been placed by the complainant before the District Commission which has proved that the complainant was injured in the stone pelting incident and he was examined by Eye Surgeon. The medical reports (paper Nos. 6/5 to 6/7 of the District Commission record) have also revealed that the complainant was continuously examined by the Eye Surgeon. Paper No. 6Kha/15 of the District Commission's record has been issued by the Deputy Superintendent of Police to the Senior Superintendent of Police wherein it is clearly mentioned that the complainant had obtained the injury of his eye on dated 30.11.2005 during his duty hours for maintaining law and order in the election of student union, Gurukul Kangri, Haridwar and the left eye of the complainant was permanently disabled through the stone pelting incident on the said date. Paper No. 6Kha/18 (of the District Commission's record) was issued from the S.S.P. office Dehradun to the deceased - complainant mentioning that his insurance claim was repudiated by the insurance company on account of three year's delay in sending the claim to the insurance company.
6Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others
11. The repudiation order dated 30.07.2009 (paper No. 6Kha/19 of the District Commission's record) of the appellant - insurance company is available on record of the District Commission wherein the complainant's claim was repudiated only on one ground that "The claim should be intimated within the three months of the occurrence of the event, failing to which company shall not be liable to pay the claim.". In the said repudiation order, no other ground was mentioned and the only ground for repudiating the claim of the complainant was that the claim was given to the insurance company with the delay of more than three months.
12. Learned counsel for the appellant has attracted our attention to the terms and conditions of the insurance policy wherein it is provided as under:
"The incident given rise to the claim will be intimated alongwith claim form and other documents by the Nodal Officer within 30 days of the incident."
13. Here it is pertinent to mention that the insured claim amount of the loss of one eye was to be paid on submission of disability certificate and on the date, i.e. 30.11.2005, the doctor, i.e. CMO Office, Dehradun has not issued disability certificate to the complainant and on the date, i.e. 30.11.2005 the one eye of the deceased - complainant was not permanently lost as per medical report / medical certificate and when the sight of the claimant is not permanently lost on the date of occurrence, i.e. 30.11.2005 and if had the claim been submitted about the permanent loss of the sight of one eye on 30.11.2005, then the claim would be premature. In our view, a claim before the insurer should be filed when the cause of action has arisen, but on the date of 30.11.2005, no cause of action arisen for filing the insured claim for permanent loss of one eye.
7Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others
14. As per the terms and conditions (paper No. 6Kha/10 of the District Commission's record) the following documents are to be provided in support of the claim when it is filed:-
Duly completed claim form F.I.R.
Death certificate in case of death claims from a competent Authority designated by State Government Post mortem reports or Panchnama Certificate from designated Nodal Officer confirming the status of the Claimant.
Doctor's certificate confirming the percentage of disability Medical Certificate and Original Bills for Claiming medical Re-imbursement certified by the Doctor of M.D. Level.
As per above terms and conditions, the claim form could not be submitted without Doctor's certificate confirming the percentage of disability. As per record, Doctor's penal of the CMO office had issued such disability certificate on dated 07.01.2009, hence on such basis, the complainant was not in position to submit claim within 30 days from the date of incident. Therefore, there was no occasion for the complainant to intimate the incident to the office of the opposite party because no disability certificate was issued to the complainant. Apart from it, in the appeal the claim was alleged to be time barred because it was submitted after 30 days but in repudiation order, delay has been alleged of three months. Thus, there is gross contradiction between the pleadings of the insurer. Thus, we are of the view that the claim is not time barred and the claim is not in contravention of any terms and conditions of the insurance policy. Therefore, the repudiation order is not in accordance with the terms and conditions of the group insurance policy issued to the Police Department.8
Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others
15. Learned counsel for the appellant has also raised the contention that the requisite forms and formalities required for the claim were not completed by the insured to the Nodal Officer, but here it is pertinent to mention that as per the repudiation order, the claim of the complainant was not repudiated on such ground, hence such plea is not tenable and sustainable. No other plea and argument has been submitted on behalf of the appellant - insurance company.
16. Thus, we are of the considered view that the repudiation order is not justified and the appellant has committed manifest error of law by repudiating the claim. We also finds that there was deficiency in service on the part of the appellant. The finding of the District Commission is perfect and justified.
17. Thus, we are of the definite opinion that the District Commission has properly exercised the jurisdiction vested in it and the impugned judgment is passed in accordance with law as well as on the basis of the terms and conditions of group insurance policy. There is no perversity and infirmity in the finding of the impugned judgment, hence the impugned judgment is liable to be affirmed. Accordingly, the appeal is liable to be dismissed.
18. Appeal is dismissed. Impugned judgment and order dated 09.12.2011 passed by the District Commission, Dehradun is hereby affirmed. No order as to costs of the appeal.
19. A copy of this Order be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986 /2019. The Order be uploaded forthwith on the website of the Commission for the perusal of the parties. The copy of this judgment alongwith original record of the District 9 Appeal No. ICICI Lombard Gen. Ins. Co. Ltd. 10.08.2023 80 of 2016 Vs. Sh. Devi Prasad Bahuguna (deceased) Smt. Kaushalya Bahuguna & Others Commission be sent to the District Commission concerned for record and necessary information.
20. File be consigned to record room along with a copy of this Order.
(Ms. Kumkum Rani) Judicial Member II (Mr. B.S. Manral) Member Pronounced on: 10.08.2023 10