State Consumer Disputes Redressal Commission
The Oriental Insurance Co.Ltd. Through ... vs Smt. Lalita Bai & Anr. on 8 July, 2013
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION,
PANDRI, RAIPUR(C.G.)
Appeal No.FA/12/39
Instituted on : 28.01.2012
The Oriental Insurance Company Ltd.,
Through : Sr. Divisional Manager,
Divisional Office No.1, Madina Building,
Raipur (C.G.) ... Appellant.
Vs.
1. Smt. Lalita Bai, W/o Late Shri Anuj Ram,
R/o : Mongra Basti, P.S. Banki Mongra,
P.O.Banki Mongra, Tahsil - Katghora, Dist. Korba (C.G.)
2. S.E.C.L.,
Through : Dy. Chief Executive Manager,
Gevra Area, Tahsil - Katghora, Dist. Korba (C.G.)
Area Head Quarter - S.E.C.L., Gevra Area,
Tahsil - Katghora, District - Korba (C.G.) ... Respondents.
PRESENT: -
HON'BLE SMT. VEENA MISRA, PRESIDING MEMBER
HON'BLE SHRI V.K.PATIL, MEMBER
HON'BLE MS. HEENA THAKKAR, MEMBER
COUNSEL FOR THE PARTIES: -
Shri R.N. Pusty, for appellant.
Shri Mukesh Sharma, for respondent No.1.
Shri O.P. Agrawal, for respondent No.2.
ORDER
Dated : 08/07/2013 PER: - HON'BLE SHRI V.K. PATIL, MEMBER This appeal has been filed by the appellant/Insurance Company having been aggrieved by the order dated 29.12.2011 of District Consumer Disputes Redressal Forum, Korba (C.G.) in Complaint Case No.56/2010, whereby complaint of the complainant, alleging deficiency in service on the part of the appellant/Insurance Company towards //2 // non-payment of claim amount under Group Janta Personal Accident Policy, has been allowed.
2. Briefly stated facts of the case, necessary for disposal of the appeal, as per averment of the complainant, are that her deceased husband was insured under a Group Janta Personal Accident Policy taken out by his employer OP-2/ S.E.C.L. with the OP-1 / Insurance Company under Policy No.47/2000/00257 for Rs.5,00,000/- covering the period from 16.10.1999 to 15.10.2009 and premium thereof was deducted from his salary. Husband of the complainant died on 09.06.2005 due to a road accident, intimation of which was given immediately to OP-2/Employer and an application seeking appointment in service on compassionate ground and other death benefits such as P.F., gratuity were also filed with it and she was given appointment also thereby. An application for insurance claims for Rs.5,00,000/- was filed with the OP-1 / Insurance Company but the same was not settled. A notice through an Advocate was sent to OPs on 03.08.2007 and 26.09.2008 but was of no avail; hence the consumer complaint was filed before the District Forum.
3. The complaint was earlier dismissed by Learned District Forum against which she had filed Appeal No.740/2009 before this Commission and after having considered the case, the appeal was allowed setting aside the order of Learned District Forum and the case was remanded back to the Learned District Forum vide order dated 09.04.2010 with the direction to the complainant to file claim and relevant papers with the //3 // Insurance Company which she accordingly complied. Her claim was repudiated by the Insurance Company on the ground that claim intimation was not given immediately about the death of her husband so she again filed consumer complaint before Learned District Forum and prayed for seeking direction to the OP-1/Insurance Company to pay her the insured amount Rs.5,00,000/- along with interest @ 18% p.a. from the date of filing complaint i.e. 02.11.2007 along with compensation of Rs.1,00,000/- towards mental agony and also compensation including cost of litigation as may be considered appropriate.
4. OP-1/Insurance company in it's reply, while denying other averments of the complaint, averred that the group insurance policy issued for the employees of OP-2 was cancelled by giving notice to the employer as per policy condition no.5 so the nominee of the deceased employee was not entitled to get any benefit under the policy. Initially the complaint of the complaint was dismissed so an appeal was filed challenging the order which was allowed by this Commission with the direction to the complainant to file claim along with relevant papers with the OP-1/Insurance Company for consideration, which she complied accordingly. OP-1/Insurance Company repudiated the claim on the ground that intimation about the death of late Anuj Ram was not given promptly depriving it the vital right of investigation to ascertain bonafides of the claim and intimation about repudiation of claim was //4 // communicated to the complainant by Regd.Post vide letter dated 28.07.20010.
5. OP-2/ Employer S.E.C.L. in its reply averred that it had taken out the Group Janta Personal Accident Insurance Policy for the benefit of it's employees on the consent of interested employees and premium was collected thereby and was remitted to the OP-1/Insurance Company and it had neither acted as agent of the Insurance Company nor did collect any amount for such service. On receipt of the claim from the complainant in prescribed form it was forwarded to the Insurance Company as such it was not liable in any way.
6. Learned District Forum after having perused the documents produced before it and heard arguments of parties allowed the complaint and directed OP-1/Insurance Company to pay claim amount Rs.5,00,000/- to the complainant along with interest @ 7 % p.a. from the date of repudiation of the claim i.e. 28.07.2010 till the date of the order within a period of 2 months failing which it would pay interest @ 9% p.a. and will also pay Rs.2,000/- towards cost of litigation.
7. We have perused the documents on record and heard arguments advanced by the parties.
8. During proceedings at appellate stage, counsel for the respondent no.1/complainant has filed an application under Order 41 Rule 27 of CPC for filing affidavit of the respondent no.1/complainant on record as //5 // additional evidence. Arguments heard and the document being relevant in the case has been taken on record.
9. Defence of the appellant/Insurance Company is that the questioned policy had already been cancelled as per condition no.5 of the insurance policy by giving notice to the concerned parties and refund of premium was done much earlier to the accidental death of the deceased Anuj Ram. Such plea is not tenable since this Commission has decided earlier in catena of cases and Hon'ble National Commission has also affirmed the finding that for cancellation of policy, intimation of such cancellation and refund of prorata premium to the individual insured is necessary. Hence the plea of cancellation is not tenable.
10. Another defence of the appellant/Insurance Company is that the complainant was not the nominee of the deceased under the certificate issued to him so was not entitled to receive any amount from it.
11. We observe that as per pay slip of the deceased for the month of February, 2005 (document at page s.no.45) the name of nominee mentioned therein is deceased's wife as "Samarin Bai" whereas the respondent-1/complainant Smt. Lalita Bai is claiming the insurance claim in the capacity of wife also. The respondent no.1/complainant has stated in her affidavit dated 20.06.2012 filed at appellate stage that Smt. Samrain Bai was the first wife of late Anuj Ram and she died on 31.01.1998 and thereafter the deceased had submitted an affidavit with //6 // his employer/OP-2 to incorporate her name as second wife in his service record. The fact that she is the wife of late Anuj Ram is corroborated by documents (at page Sl.No.64 & 65) which is a card issued by respondent no.2 / employer S.E.C.L for medical service purpose. Further the fact of being the wife of respondent / complainant is again fortified by the documents (at page Sl. no.68 & 69), whereby she was appointed in the services of respondent no.2 / employer S.E.C.L subsequent to the death of late Anuj Ram. As per the Ration card (at page sl. No.49) also the respondent no.1 / complainant is the wife of late Anuj Ram and besides herself other six members are also there in the family including father of the deceased, which further supports her version. Although, the name of the respondent no.1/complainant, does not appear in any of the documents as nominee under the policy, but it is apparent on the basis of documents available on record, that she is the wife of Late Anuj Ram so can very well claim insurance amount from the insurance company in such capacity.
12. Another contention of the appellant / Insurance Company is that it had rightly repudiated the claim on the ground of breach of policy condition on account of delayed intimation about death of her deceased husband.
13. Since group insurance policy is a contract between the Insurance Company and the Employer but the employee being the beneficiary of insurance benefit is not provided any terms & conditions of the //7 // insurance policy so the condition of giving intimation about death of the insured by his dependent should have been considered as per merit of the case. In this case the respondent no.1/complainant is an illiterate lady and looking to the facts earlier the case was remanded by this Commission vide order dated 09.04.2010 in Appeal No.740/2009 to the District Forum with the direction that "The Insurance Company is directed to examine such claim and decide the same on its merits as per provision of insurance policy without being affected from the fact that earlier the claim was not preferred by the complainant." Such direction was specific and had attended its finality. Under the situation appellant/Insurance Company should not have repudiated the claim on the ground of late intimation.
14. In view of the observations made here-in-above and facts of the case, we do not find substance in the appeal to succeed therefore it, being not sustainable, is dismissed. No order as to cost of this appeal.
(Smt.Veena Misra) (V.K.Patil) (Ms. Heena Thakkar)
Presiding Member Member Member
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