Chandigarh Ombudsman Center CASE NO. GIC/027/NIC/14/09 L.C

CHANDIGARH

Chandigarh Ombudsman Center

CASE NO. GIC/027/NIC/14/09

L.C. Mittal Vs. National Insurance Co. Ltd.

Order dated 16.05.08

FACTS: Shri. L.C. Mittal had taken a Personal Accident Policy for the period from 30.03.07 to 29.03.08.

He met with an accident on 23.09.07. He submitted all the claim papers to the insurer in March 2007.

However, his claim has been rejected by the insurer on the ground that though the accident took place

on 23.09.07, but he proceeded on his employment on 25.09.07 just after two days after accident as

stated by the insurer. The insurer has stated that as per policy the compensation for TEMPORARILY

TOTAL DISABLEMENT is payable only “if such injury shall be the sole and direct cause of temporary total

disablement then so long as the insured shall be totally disabled from engaging in any employment

occupation of any description whatsoever, a sum at the rate of one percent (1%) of the capital sum

insured stated in the Schedule as existing at the inception of the policy hereto per week”. Hence as per

insurer the insured did not remain “TEMPORARY TOTALLY DISABLED” as a consequence of the accident

and therefore any claim for TEMPORARY TOTALLY DISABLED does not become payable to him. Parties

were called for hearing on 16.05.08.

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

been continuing with his work relating to new policies as insurance agent and was activity engaged in

getting 4 new policies issued. Thus his earning capacity was not totally gone. Hence, he could not be

covered in the category of temporary total disablement. Accordingly, the claim was repudiated.

DECISION: Held that as per clause 4(f) of the terms and conditions of the policy, the disablement

has to be total and there would be total loss of income also. In this case, the complainant had procured

4 fresh policies and hence earned commission there from. Hence the contention of the insurer that this

was not a case of temporary total disablement and there was no loss of income as well is justified.

Therefore, the repudiation is in order.

CHENNAI

Chennai Ombudsman Centre

Case No.IO(CHN) 11.02.1010/2008 – 09

Smt. Mariammal

vs

The New India Assurance Co. Ltd

Award No.033 dated 11.08.08

The complainant’s husband Mr. R. Megavernam, was covered under Rasta Apatti Kavach (Road

Safety Insurance) policy . The insured suffered a fall at his house and subsequently succumbed

to injuries. The insurer rejected the claim on the grounds that cause of death was injury due to

fall under the influence of alcohol.

The complainant has not produced any evidence to establish that her husband had not been

under the influence of liquor on the day on which he fell down and sustained grievous injuries.

The reasons stated by the complainant as to why she had stated incorrect facts or signed a

factually incorrect statement supposedly given to her by the police authorities are unconvincing.

It is confirmed through FIR that the insured was under the influence of alcohol at the time

accident. It is found that post mortem was conducted after two days from the date of

occurrence of death. Because of the delay in conducting the post mortem traces of

alcohol if any could not be established. As per doctor’s opinion, the body will wash

away all traces of alcohol within a period of ten to twelve hours, meaning no trace can be

detected after twelve hours. The complainant could not establish with proof that the

insured was not drunk at the time of accident. In view of the same, the complaint was

dismissed.

Chennai Ombudsman Centre

Case No.IO(CHN) 11.04.1043/2008-09

Mrs. Kondammal

vs

United India Insurance Co. Ltd

Award No.040dated 13.08.08

The complainant’s husband had taken Road Safety Package Policy from the insurer for a sum insured

of Rs. One lakh. The insured was attacked when he was on a visit to his house site. As a result of

injuries sustained in the attack, the insured died. His wife filed a claim with the insurer for the death

of her husband.

The insurer rejected the claim on the grounds that the death has not occurred due to road accident.

As per the wordings of the terms and conditions of the Road safety package Policy, the cover is

for accidental death as opposed to death caused due to disease or self inflicted injuries. If the

intention of the insurer was to cover only death due to road accident, then the policy wordings

should be suitably modified to reflect the true intention of the drafter of the policy. The cover in

its present form covers any bodily injury resulting solely and directly from an Accident (not ‘Just’

road accident) caused by outward, violent and visible means.

The pre requisite of Accident is satisfied in the instant case and the insurer was directed to settle

the claim in full for Rs 1.00 lac (Rupees one lakh only) as per other terms and conditions of the

policy . The complaint is allowed.

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

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SYNOPSES OF AWARDS YEAR: 2008-09

FROM 01.04.2008 TO 30.09.2008

AHMEDABAD OMBUDSMAN CENTRE

Case No.11-004-0339-08

Mr.Jayantilal N.Mirani vs. United India Insurance Co.

Award dated 15.04.08

Individual Personal Accident Policy. Dispute was raised when claim lodged for Temporary Total Disablement

by the complainant for to be settled for 5 weeks as against claimed 54 days.

The material on record and hearing of both sides, facts were revealed.

Complainant met with an accident and facture of base of metacarpal left with fracture of distal phalynx

thumb. The treatment was given and treating doctor after the operation recommended 8 weeks rest. The

complainant also consulted other orthopedician subsequently who advised further rest. The employer of the

complainant confirmed the absenteeism on medical ground for 54 days.

Respondent pleaded that as per their medical referee, 4 weeks rest is maximum enough for the ailment. On

representation seemed, medical referee informed his for 5 weeks an indemnity contract.

Award was given directing respondent to settle claim for 54 days as complainant was disabled from enjoying

any employment.

________________________________________________________________


Case No. 11-004-0338-08

Smt.Pushpaben J.Mirani vs. United India Insurance Co.


Individual Personal Accident Claim. Dispute was raised as the claim for TTD (Total Temporary Disablement) as

settled for 4 weeks when claimed for 54 days.

Documents on record and personal hearing revealed the following facts.

The complainant met with an accident resulting into fracture of 8th rib left side without hydro and head injury

causing multiple abrasions. The consulting Orthopedician and after operation recommended rest for 4 weeks, but the

complainant’s plea that she was disabled for 54 days.

The Respondent’s medical referee recommended maximum 3 weeks rest for TTD.

On the fact that there is a vide gap in compensation offered vis-à-vis demand, the insured being house wife

and in absence of further follow up or treatment, it is difficult to give exact date of attending normal duties and mean

in extremes has to be drawn. Thus awarded by directing the respondent to pay claim for 35 days.

Complaint partially succeeds.

________________________________________________________________


Case No.21-001-0373-08

Mrs. K.D.Bhat Vs. LIC of India


Death Claim case. Dispute was raised under RPG Rules 1998 for repudiation of claim.

The documents on record and personal hearing of both the sides it was obtained.

DLA died within 5 months of proposing for Insurance. Claim for Rs.7, 98,940/-. The enquiry and

investigation revealed that DLA died, not disclosed the correct information of income signed by him which was

observed by respondent as breach of utmost good faith and rendered contract invalid.

Complainant pleaded that respondent was bent upon repudiating contract. As they could not put any

infirmity on the part of complainant this reason was posed. The DLA was holding BPL ration card which is given for

persons having income less than Rs.11000/- but stated income was Rs.90,000/-. The affidavit filed by DLA and

confirmed by office of Food and Civil supply confirm income of Rs.3500/- (annual). Business Pan-Bidi shop.

The case was disposed as fails to prove the evidence is beyond the scope of forum, without decision and

suggested to approach appropriate forum.

________________________________________________________________


Case No. 11-003-0380-08

Shri V.K.Patel Vs. National Insurance Co.Ltd.


Two Wheeler Package Policy. The dispute was raised because the claim lodged for Vehicular accident in which

the vehicle was damaged as also the DLA died on the spot. Claim for damage of vehicle was admitted but claim for

Personal Accident cover to owner driver was repudiated.

The facts came on surface after material on record being verified and Personal Hearing of both the sides are

as under:

The P.A Claim was repudiated as the related claim papers were submitted after 22 months of accident as

against time limit of 1 month.

Complainant’s plea that he had intimated about damage of vehicle and death of driver-owner on the spot

under the package policy and was waiting for the response. He was under impression that both claims will be settled

by Respondent and was unaware of rules, for two separate intimation for separate claims.

It was confirmed that the vehicle claim was settled and cheque was issued in favour of DLA though death

was intimated. The Respondent is aware of this but did not act.

Award given, directing Respondent to settle P.A Claim in 15 days from the receipt of consent from complaint.

________________________________________________________________


Case No.11-004-0393-08

Shri Gautamkumar J Sheth Vs. United India Insurance Co.


Personal Accident Claim (TTD). Dispute was raised as the above claim was repudiated.

The documents on record and personal hearing of both sides, following things come up.

The Complainant met with an accident on 14-11-2006 and intimation was given. He could not submit claim

form along with doctor’s certificate for continuing treatment. Both sides were in regular correspondent. Complainant

expressed his inability to submit treating doctor’s certificate as he was not fully cured. Since the claim was registered

the respondent could not keep the file open for indefinite period. Thus the case was closed as “No Claim” and

informed him.

It was made clear that quantum of TTD will be as per terms of policy and decision to reopen the file should

be construed that TTD claim amount will be decided from date of accident to date of submission to which respondent

agreed and no formal award is pronounced.


Case No.11-004-0414-08

Mr.Manilal N.Patel Vs. United India Insurance Co.Ltd.


The Complainant had taken personal accident policy. The claim was lodged for Temporary Total

Disablement which was repudiated. The facts revealed on the basis of documents submitted and hearing of both the

sides are :

Dispute lies with regard to whether Temporary Total Disablement for which claim has lodged is due to

accident or not. The complainant, while he was on pilgrimage to Thirupati Balaji, while climbing the stairs fell down

and injured his leg. After preliminary treatment, he returned by train and at this time his leg was in bad condition and

was taken to hospital directly from station. In the hospital the leg was amputed below knee due to gangrene.

The complainant being known diabetic the injury resulted into vascular necrosis of dorsum of foot (called as

diabetic foot). The complainant had injury from spikey stone in left foot as Thirupati and developed diabetic foot and

accidental injury is ruled out.

The case was dismissed.

_______________________________________________________________


Award dated 08-08-2008

Case No.11-002-0032-09

Mr.Rajash J.Patel Vs. New India Assurance Co.Ltd.

Personal Accident Policy. Claim for hospitalization against accidental injuries was

settled for lower amount than claimed amount.

The claim of accidental injuries while taking bath in Narmada River was settled for

Rs.26, 927/-. Again for same injury under same policy in same year the claim was lodged.

Claim was repudiated for subsequent claim for knee injury arising out of same accident.

The Complainant got injured in Rt. Knee and treated for hairline crack of Tibial plate on

22-12-2005 and advised 13 weeks rest. The TTD for 13 week was settled by Respondent on

the basis of fitness certificate. As the inconvenience in movement and pain persisted he was

operated for ACL reconstruction.

Respondent’s plea that there was no external on outside accidental injury and was only

due to previous injury. The Respondent’s plea and repudiation was upheld. Case was

dismissed.



Case No.11-004-0013-09

Smt.Champaben K.Patel vs. United India Insurance Co.Ltd.

The Motor (Personal Accident) policy claim against the death of the insured lodged by

the complainant was repudiated by the Respondent as the grounds that valid driving license

was not produced by the complainant.

The fact in the case that compulsory personal accident cover shall be applicable under

both liability only and package policies. The owner of insured vehicle holding effective driving

license is turned as Owner Driver for the purpose of this section cover is provided to owner-

driver whilst driving the vehicle including mounting into/dismounting from the vehicle or traveling

in the insured vehicle as co-driver.

The Respondent agreed for the concept and agreed for early settlement of claim as

soon as complainant submits effective driving license of owner as per provision of MV act GR-

36.

The complaint thus succeeds.

________________________________________________________________________



Case No.11-003-0060-09

Mr.Chandubhai B.Prajapati vs. National Insurance Co.Ltd.

Personal Accident Policy. The Complainant lodged claim against his hospitalization for

accidental injuries was partially settled as Permanent Partial Disablement to the extent 61%.

Complainant derived to have TTD (Temporary Total Disability) benefit for 104 weeks.

Respondent’s contention was that they have made full payment for PTD (Permanent

Total Disability) as per terms and conditions as the disability comes under PPD and not TTD.

The documents on record shows that treating doctor has given TTD for 1 year and not

issued fitness certificate but advised to get certificate for assessment of disability which confirm

PPD up to 61%.

In view of the above, the claim settled for PPD was found to be correct and case was

dismissed.



Case No.11-005-0064-09

Smt.Geetaben S.Patel Vs. Oriental Insurance Co.Ltd.

Motor Own Damage and Personal Accident Policy. Claim was lodged by the

complainant for accidental death of the insured and total loss damage of vehicle insured which

was inordinately delayed by the Respondent.

The Complainant pleaded that even after requesting the loss and submission of papers

the claims were not settled and same now should be settled with interest for delay.

On the basis of documents on record and hearing of both parties, it was observed that

the subject vehicle was not available for inspection for 45 days besides that it was removed

from material site. The P.A claim voucher was sent for Rs.2.00 Lacs which was not discharged

for demand of interest. Finally the salvage parts were not handed over along with R.C.book

which was to be submitted after termination of HPA with ICICI bank which are mandatory

requirement, complainant admitted the facts.

The award was given that interest is in due as delay is on the part of complainant and

that claim shall be settled immediately for P.A and OD will be settled after submitting Salvage

and R. C. Book.

________________________________________________________________________



Case No.11-005-011-09

Mr.Kamlesh P.Raval Vs. Oriental Insurance Co.Ltd.

The insured member under the Personal Accident Policy was hospitalized for 5 days

after felling down in the house and claim was lodged for Rs.1,886/- against hospitalization.

The Claim was settled for Rs.535/- by the Respondent.

The Complainant pleaded that the expenses are more than settled claim not even

covering medical expenses.

The Respondent made it clear that the claim was Personal Accident Claim and

settlement is for TTD as per policy conditions which say that amount payable of the comes

to 1% of Sum Insured + 25% of the such arrived amount as the relief. Since the insured

was hospitalized for 5 days, this amount comes to Rs.535/- and is correct. Since it is not

mediclaim the complainants contention is wrong.

The forum clarified the facts to the complainant. However mediated to the Respondent

to make TTD for one week which comes to Rs.625/- to which both parties agreed and case

was disposed.

_____________________________________________________________



Case No.11-003-0124-09

Mr.Rajesh R.Thakkar Vs. National Insurance Co.Ltd.

The complainant was covered under Group Personal Accident Policy by the employer.

The Complainant met with accident and was hospitalized for which he incurred

expenses of Rs.2,915/-.

The Claim was repudiated as the intimation to the Respondent was not given in time.

The Complainant pleaded that he had informed to the employer who in turn informed to

the Respondent late for which he should not be penalized by repudiation.

Though the facts were confirmed this forum mediated with Respondent who agreed to

settle claim for Rs.2,500/- and both the parties consented.

The case was disposed.

_____________________________________________________________

END OF SYNOPSIS-APRIL’08 TO SEPT’08