award no.io/koc/a/gi/0001/2021-2022 proceedings of the

AWARD NO.IO/KOC/A/GI/0001/2021-2022

PROCEEDINGS OF

THE INSURANCE OMBUDSMAN, KOCHI

(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF

THE INSURANCE OMBUDSMAN RULES, 2017)

Complaint No. KOC-G-042-2021-0222

PRESENT: Ms. POONAM BODRA

INSURANCE OMBUDSMAN, KOCHI.

AWARD PASSED ON 17.05.2021

1. Name and Address of the complainant

: Mr. Arjun S

Elapatharayil House, Pathiyankara,

Thrikkunnapuzha P O, Alapuzha -

690515

2. Policy Number

: 419014/31/20/001131

3. Name of the Insured

: Mr. Arjun S

4. Name of the Insurer

: Shriram General Insurance Co. Ltd.

5. Date of receipt of Complaint

: 07.12.2020

6. Nature of complaint

: Rejection of motor claim

7. Amount of relief sought

: --

8. Date of hearing

: 04.03.2021

9. Parties present at the hearing

a) For the Complainant

: Mr. Arjun S (Online)

b) For the Insurer : Mr. Peeyush Jain (Online)

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding rejection of motor claim. The complainant, Mr. Arjun S is the policyholder.

1. Averments in the complaint are as follows:

The Complainant stated that he had taken insurance from the respondent insurer for his vehicle Maruti Ertiga ZXI, from

14.8.2019. This vehicle was involved in an accident on 13.11.2019, and as per the surveyor, the vehicle was a total loss.

All those documents which were required were submitted with the respondent insurer. The claim settlement is

pending.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that a policy bearing

no.419014/31/20/084425 for the period 14.8.19 to 13.8.20, for the vehicle bearing reg. no. KL 05 AM 2774. Upon

receiving the intimation of the accident, an IRDA approved surveyor appointed conducted the survey of the vehicle.

The survey report was subjected to pending documents & clarifications. Even after various reminders through letters,

sms & whatsapp the following documents were not produced. So also the vehicle was not brought for the final survey.

It is further submitted that as the reminder letters dated 3.2.19, 24.4.19, 1.5.20 & 10.5.20, were not replied by the

complainant. As there were no deficiency in services from the respondent insurer, the claim is to be dismissed.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that his vehicle bearing Reg. No.

KL 05 AM 2774, was involved in an accident on 13.11.2019, while giving way to the oncoming vehicle. The vehicle fell,

into the nearby river and was totally damaged. The co travelers including the complainant had injuries and were

treated in the nearby hospital and after treatment, were taken to their native places by ambulance. Almost all those

documents requested by the respondent insurer were submitted. Further the complainant submitted that the

damaged vehicle was removed only after a few days as he was not having sufficient funds. The Respondent Insurer

submitted that a surveyor was deputed for surveying the motor vehicle which was involved in the accident. The survey

report was submitted subject to pending documents & clarifications. Several reminders were sent to the complainant

for submitting the pending documents which were required for processing the claim, but was not responded.

During the course of the hearing, clarifications were directed to be addressed:-

1. The Complainant was directed to submit the following documents within 7-days: i).The running record of the vehicle

ii). Injury details of the passengers iii). clarification as to how the passengers were taken to their respective native

places iv). Airport gate pass or toll fee paid(receipt).

2. The respondent insurer was directed to report back after 7-days, with the details of their assessment of the

damaged vehicle.

3. The reason for the delay in survey of the damaged vehicle ( i.e. date of accident :13.11.19, allotment of

survey:19.12.19, date of survey:13.2.20).

4. Non conduct of an investigation to probe into the cause of the accident.

A. The complainant responded vide e-mail date 12.4.21, with his submissions:-

1. Taxi Booking details :Booking through Facebook Chat(no documentary evidence submitted)

2. Running record of the vehicle :Lost in the accident(no documentary evidence submitted)

3. Clarification on how the co travelers in the vehicle

were taken to their destination :Ambulance (Receipt attached)

4. Injury details of co travelers :1. Mr.Adarsh (admitted:MCH, Alappuzha)

: 2.Mr.Arjun S(Not Admitted)

:3.Mr.Manjideth(OP ticket lost)

:4.Mr.Vishnu(OP ticket lost)

5. Airport Gate Pass : Not submitted(Lost)

6. Photographs of the damaged vehicle: submitted

B. The respondent insurer did not come up with their analysis of the claim and had not responded .

4. I heard the complainant and the respondent insurer and had gone through the records submitted by them. In this

complaint, the complainant`s commercial motor vehicle Maruti Ertiga ZXI, bearing reg. no. KL 05 AM 2774, was

involved in an accident while giving way to a vehicle which came from the opposite direction. The vehicle fell into the

river. It is observed that the prudent insurer instead of conducting the motor survey immediately on receipt of the

information of the accident , did allot for survey only on 19.12.20 and the survey was conducted on 13.2.20, i.e. after 3

months, of the accident, thereby chances of valuable information about the incident might have been lost . The

delayed appointment of the survey was not explained or clarified. Secondly, an investigation was not conducted to

throw more light into the incident. As per the Survey Report submitted, the assessed value of motor vehicle on `repair

basis` is given as Rs.4,41,588/-,( IDV of the vehicle is Rs.5,50,000/-). The assessed value worked out to more than 80%

of the IDV of the said vehicle, which tantamount to `Total Loss`. After the hearing on 4.3.20, the respondent insurer

was given 7-days time to report back with clarifications on the all the above mentioned, but failed to report back

within time frame instead requested for another 4 to 5 days more time vide their mail dated 27.4.21, for searching for

the appropriate value of the vehicle. The complainant could not submit FIR copy, witness details, copies of hospital OP

tickets of two co-travelers, Airport gate pass/toll receipt/ running details of the vehicle etc., since they were reportedly

lost or unavailable, which would have made the claim more stronger. The details/explanations therefore provided by

both the parties lacked clarity. Hence taking into consideration the available records/documents/ explanations

provided by both the parties and the time that had elapsed after the accident; in the interest of justice I find it

appropriate to direct the respondent to pay the assessed the claim amount of Rs.4,41,588/-,on `Total Loss Basis` as per

the policy terms and conditions.It is observed that the said motor vehicle is hypothecated to Mahindra & Mahindra

Finance Co. Ltd., Kochi.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.4,41,588/ , as per the policy

terms & conditions, within the period mentioned hereunder. No cost.

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30

days of receipt of the award and intimate compliance of the same to the Ombudsman.

Dated this the 17th day of May 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

AWARD NO.IO/KOC/A/GI/0002/2021-2022

PROCEEDINGS OF









: Mr. Paul Kochukunjan

The White House, Near HP Petrol

Pump, Thuvanoor, Kechery P.O,

Thrissur 680501

2. Policy Number

: 3392/30020647/000/00


: Mr. Paul Kochukunjan


: Cholamandalam MS Gen. Insu.Co. Ltd


: 01.01.2021


: Rejection of theft claim


: --

8. Date of hearing

: 08.02.2021


a) For the Complainant

: Mr. Muhammed Sabith (Online)

b) For the Insurer : Mr. Aneesh(Online)

AWARD


complaint is regarding rejection of theft claim. The complainant, Mr. Paul Kochukunjan is the policyholder.


The Complainant stated that his goods carrying vehicle DOST PLUS, KL 46S 2368, was stolen from their godown

(Parapuram – Kadangod) between 16.30PM on 8.1.19 & 8.30AM on 9.1.19. A complaint was filed on 9.1.19 with the

Erumapetty Police Station. The FIR No. issued was 0011/2019. The vehicle was bought under finance from Syndicate

Bank. The insurance agreement with the Syndicate Bank was that the claim amount will go to the bank and the vehicle

loan will be terminated. The claim is lying pending though all documents were submitted. As per the insurer`s reply

dated 4.6.20, the delay was due to reduced staff on account of Covid. Later the claim was repudiated.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the vehicle was

insured for the period 4.4.18 to 3.4.19 for an IDV of Rs.5,78,949/-. For the alleged loss dated 8.1.19, the claim

intimation was received on 11.1.19. A few documents were requested for vide regd. Letter dated 3.12.19, 19.2.20, such

as purchase invoice, repair bills, theft intimation letter to NCRB with postal receipt, RC particulars after theft with

stolen remarks, AML, FC, Police final report, court approved final report, original policy/cover note, original keys, letter

of subrogation, letter of indemnity, RTO forms 28, 29, 30, original RC, Discharge Voucher, Financier NOC, Form 35 etc.

Due to non submission of the said documents, the claim was closed on 6.3.20. Even after the closure of the claim, a

mail was send on 14.10.20, to the complainant for the mandatory documents but still the following were not received:

postal receipt , AD card for the copy letter to NCRB, RC particulars, RC details after theft, form 26, NOC & form 35. The

claim was thus closed on non-submission of documents.

3. I heard the Complainant`s representative and the Respondent Insurer. The Complainant`s representative submitted

that the complainant`s goods carrying vehicle DOST PLUS, KL 46S 2368, purchase under finance from Syndicate Bank,

Ariyannur, was stolen from their godown (Parapuram – Kadangod) between 16.30PM on 8.1.19 & 8.30AM on 9.1.19.

The FIR No. issued by the Erumapetty Police Station was 0011/2019. Even after submitting all necessary documents,

the claim was rejected. Form no.35 was not submitted as the bank finance had to be closed. The respondent insurer

submitted that the following documents were requested to be submitted for processing the claim: - purchase invoice,

repair bills, theft intimation letter to NCRB, with postal receipt, RC particulars after theft with stolen remarks, AML,

Fitness Certificate, Police final report, Court approved final report, original policy/cover note, original keys, letter of

subrogation, letter of indemnity, RTO forms 28,29,30, original RC, Discharge Voucher, Financier NOC, Form 35 etc. Due

to non- submission of these documents, the claim was closed on 6.3.20. A mail was again sent on 14.10.20, to the

complainant for the following mandatory documents:- postal receipt , AD card for the copy letter to NCRB, RC

particulars, RC details after theft, form 26, NOC & form 35. Since these were not received, the claim was closed.

During the hearing, the complainant was directed to submit the following documents:- Postal receipt & AD card for the

copy of the letter to NCRB, Completed RTO-forms-26,28,28,30, to the respondent insurer within 7-days from the date

of hearing and the respondent insurer on receipt of the same, to report with their analysis of the claim.

Though the respondent insurer vide email dated 7.4.21, informed that the above said documents were not submitted,

communicated vide email dated 15.4.21, that RTO form. no.26, copy of RC particulars after theft & vehicle loan

statement from the financier was handed over to them. The respondent insurer later vide email dated 20.4.21,

communicated the admissibility of the claim subject to the submission of relevant records/documents. Further the

respondent insurer by email dated 22.4.21, informed that mandatory documents required for processing the said

claim was submitted by the Complainant except for the Postal receipt and AD card for the copy of letter to NCRB. The

admissible claim amount worked out and submitted is as follows:-

IDV of the vehicle :Rs. 5,78,949/-

Less compulsory deductibles :Rs.500/-

Admissible amount :Rs.5,78,449/-

4. I heard the complainant`s representative as well as the respondent insurer and had gone through the records

submitted by them. In this complaint of non settlement of the theft claim, where the goods carrying vehicle DOST

PLUS, KL 46S 2368, parked in front of the complainant`s godown (Parapuram – Kadangod) was stolen between

16.30PM on 8.1.19 & 8.30AM on 9.1.19 , on considering the facts and the situation, the respondent insurer is directed

to pay the admissible claim amount of Rs.5,78,449/- , as per the terms & conditions of the policy . It is observed that

the above said vehicle is hypothecated to Syndicate Bank, Thrissur.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.5,78,449/- , as per the

policy terms & conditions, within the period mentioned hereunder. No cost.

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30

days of receipt of the award and intimate compliance of the same to the Ombudsman.


Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

AWARD NO. IO/KOC/A/GI/0004/2021-2022

PROCEEDINGS OF









: Mr. Siji Varghese

Niravath House, Kuthukuzhy P O,

Kothamangalam Pin-686691

2. Policy Number : 761604319100005982


: Mr. Siji Varghese


: The New India Assurance Co. Ltd.


: 12.02.2021


: Extension of policy


: --

8. Date of hearing

: 19.04.2021


c) For the Complainant

: Mr. Siji Varghese (Online)

d) For the Insurer : Ms. Hyma Soman (Online)

AWARD


complaint is Extension of policy. The complainant, Mr. Siji Varghese is the policyholder.


The Complainant submitted that he is the owner of Stage carriage vehicle insured with the respondent insurer bearing

Registration KL 44 D 8797 operating on the route Thodupuzha-Kothamangalam having Policy

No.7616043190100005982 . The period of insurance coverage is up to 22.08.2020. Due to Covid-19 the Government of

India implemented complete lockdown from 23.03.2020 onwards. So he was not able to conduct service from

23.03.2020 to 24.05.2020. The honourable chief minister of Kerala issued an order to extend the insurance policy for

two months. He was also entitled to get that privilege and hence his policy period is to be extended up to 23.10.2020,

paying an additional premium of Rs.185/- and he has paid the same on 16.06.2020. Due to the spread of Covid-19 in

the state he was unable to conduct the service as there was lack of passengers and employees. The complainant was

forced to laid down his vehicle from 01.07.2020 to 31.12.2020 by submitting needful documents and necessary fees to

the joint RTO, Kothamangalam. As the situation gradually became favourable to conduct service, he decided to operate

his vehicle from 01.01.2021 onwards. For that he informed the joint RTO, Kothamangalam and got laid up certificate

from RTO Muvattupuzha on 04.01.2021 to produce before the insurance company to extend his policy for the laid up

period of 115 days. But the respondent insurer refused to extend the policy. He took another policy from United India

Insurance Company on 14.01.2021 with premium amount of Rs.64000/-. In this panic situation it was a huge amount to

him. So the complainant requests this forum to issue an order to refund the premium amount for 115 days actually

entitled by him from the respondent insurer.

2. The Respondent Insurer entered appearance and filed a self-contained note. It is submitted that the policy availed by the insured was a Commercial Vehicle Liability Only Policy with Policy No: 76160431190100005482 an Ashok Leyland Bus. The Policy period was 23.08.2019 to 22.08.2020. The insured vehicle was laid up due to covid situation. Insured has given complaint for not giving extension for the second time

The policy availed by the insured was a Commercial Vehicle Liability Only Policy with Policy No: 76160431190100005482 an Ashok Leyland Bus. The Policy period was 23.08.2019 to 22.08.2020 According to GR.31 “expiry date of the current period of insurance under the policy may be extended for a period equal to the period the policy remained suspended on account of the layup” also GR.31 also states that the period of lay-up / suspension of policy shall not extend beyond twelve months from the expiry date of the policy period in which the lay-up has commenced The details of each policy as follows 76160431190100005482 - KL-44-D-8797 The original period of Insurance is from 01/08/2019 to 31/07/2020. The insured has submitted a laidup request from 24/03/2020 to 23/05/2020 and the policy was extended for 69 days. And on 04/01/2021 the insured has submitted another laidup request from 01/07/2020 to 31/12/2020, but as the policy was only till 22/08/2020 laidup extension was not given since there are only 53 days in the policy period for the second laidup and as per GR.31 laidup benefit should be given when there is a minimum laidup of two months. In this cases the insured has applied for laidup after the original policy period whereas the GR.31 clearly states that the extension can be only given for the period equal to a period the policy remains cancelled owing to the laidup We also refer to the judgment from honourable High Cour of Kerala (WP(C). No.22273 OF 2020(H)) where in a similar case the extension was not allowed beyond the original policy period.

- It is also to be noted that as per GR.31 the permit of the vehicles has to be suspended which are undergoing laidup for availing the laidup benefit in insurance policy has been waived of by the company owing to the current situation at RTOs.

- Considering the facts stated we request the honourable ombudsman to dismiss the complaint as we cannot violate the terms of Indian Motor Tariff.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that the period of insurance coverage of his vehicle was up to 22.08.2020. Due to Covid-19 complete lockdown was implemented from 23.03.2020 onwards, he was not able to conduct service from 23.03.2020 to 24.05.2020. He was also entitled to get that privilege and hence his policy period is to be extended up to 23.10.2020, paying an additional premium of Rs.185/- An additional premium of Rs.185/- was paid on 16.06.2020. He requested the insurance company to extend his policy for the laid-up period of 115 days. But the respondent insurer refused to extend the policy. The Respondent Insurer submitted that the original period of Insurance

was from 01/08/2019 to 31/07/2020. The insured has submitted a laid-up request from 24/03/2020 to 23/05/2020 and the policy was extended for 69 days. And on 04/01/2021 the insured has submitted another laid up request from 01/07/2020 to 31/12/2020, but as the policy was only till 22/08/2020 laid up extension was not given since there are only 53 days in the policy period for the second laid up and as per GR.31 laid up benefit should be given when there is a minimum laid up of two months. According to GR.31 “expiry date of the current period of insurance under the policy may be extended for a period

equal to the period the policy remained suspended on account of the layup” also GR.31 also states that the period of

lay-up / suspension of policy shall not extend beyond twelve months from the expiry date of the policy period in which

the lay-up has commenced

4. I heard both the complainant and the respondent insurer. On scrutiny of the records it is found that initially laid up

extension of 69 days from 24.03.2020 to 23.05.2020 was allowed to the complainant. Later when he had applied for

laid up extension from 01.07.2020 to 31.12.2020, it was not allowed as there was only 53 days in the policy period for

the second laid up. The policy was only till 22.08.2020. (from 01.07.2020 to 22.08.2020). As per the GR-31, laid up

benefit should be given when there is a minimum period of two months. Hence as per the GR- 31, the respondent

insurer cannot allow the extension. The decision of the respondent insurer is right and as per the General Regulation

framed by the Government. Hence I do not want to interfere in to the decision.

In the result, an AWARD is passed for Dismissal of the complaint.


(POONAM BODRA)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,Kolkata

(States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands)

(UNDER RULE NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman Name:P.K.RATH

CASEOFCOMPLAINANT– SHRI TAPAN KUMAR JANA

VS

RESPONDENT: THE ORIENTAL INSURANCE CO. LTD.

COMPLAINT REF: NO: KOL- G-050-2021-0117

AWARD NO: IO/KOL/A/GI/0008/2021-2022

1.

Name &Address OfThe Complainant Shri Tapan Kumar Jana S/O. Late Chittarajan Jana, Deulpota; P.O : Barbasudevpur, P.S: Sutahata, Dist : Purba Medinipur, PIN : 721 645.

2.

Type Of Policy: Life / Health / General

Policy Details: Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term 311900/31/20

18/1274 6,00,000 28-Sep-2017 27-Sep-2018 69240 One year One time

3. Name of insured Tapan Kumar Jana

4. Name of the insurer The Oriental Insurance Company Limited

5. Date of receipt of the Complaint 22-Mar-2021

6. Nature of Complaint Non-settlement of claim

7. Amount of Claim 1039900

8. Date of Partial Settlement

9. Amount of relief sought 1039900

10. Complaint registered under Insurance Ombudsman Rules 2017

Rule 13(1)(b) – any partial or total repudiation of claims by an insurer

11. Date of hearing Place of hearing

19-Apr-2021

Kolkata

12. Representation at the hearing

a)For the Complainant Shri Tapan Kumar Jana

b)For the Insurer Shri Biplab Das

13. Complaint how disposed By conducting online hearing

14. Date of Award 10-May-2021

Brief Facts of the Case:

As stated in the complaint, the insured vehicle met with an accident on 29-12-2017 at Purulia. The Insurance

Company deputed a surveyor to assess the loss. The insured lodged claim for Rs.10,39,900/- but the

Insurance Company settled the claim for Rs.1,39,500/-. The insured did not accept the claimed amount.

Hence, the Insurance Company closed the claim as per norms. The Insurance Company has stated in their

Self Contained Note that on receipt of Surveyor Report, the Insurance Company has deputed an Investigator

for verification of cash memos/bills issued by Maa Bargabhima Motor Parts, Midnapore, amounting to

Rs.8,83,350/- and investigations revealed that the Bill was false/fake and as such the same was not allowed

by the Insurance Company. Finally, the claim has been settled for Rs.1,39,500/- and Insurer issued Discharge

Voucher (DV) amounting to Rs.1,39,500/- towards full and final settlement of the claim. But the insured did

not duly sign and submit the DV to the Insurance Company. Hence, the Insurance Company has closed the

claim.

Contention of the complainant:

The complainant has stated in the hearing that he has submitted a written statement towards his submission

and except it he has nothing else to say. In the written statement the complainant has reiterated what he has

already stated in his written complaint letter submitted to this office.

Contention of the Respondent:

The representative of the Insurance Company has stated in the hearing that on receipt of the Surveyor Report,

the Insurance Company has appointed an Investigator for verification of the bill for Rs.8,83,350/- issued by

Maa Bargabhima Motor Parts. It is observed from the Investigator Report that there is no shop in the name of

Maa Bargabhima Motor Parts. At the same address, there is another shop named, Devi Bargabhima Motor

Parts. The mobile number is also in the name of the owner of a separate entity - Agni super Bus. The owner

of Devi Bargabhima Motor Parts has stated that the signature on the bill and cash memo does not pertain to

his shop. Hence, the Insurance Company has settled the claim for Rs.1,39,500/- but the Insured did not

submit the discharge voucher duly signed to the Insurance Company as he is not agreeable to this lesser

amount. As such, the claim has been closed as per norms.

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 in the

hearing that he has submitted a written statement as submission. The representative of the Insurance

Company has stated that the Insurance Company has settled claim for Rs.1,39,500/- after deduction of Bill

for Rs.8,83,350/- which is not genuine. Since the insured did not submit the discharge voucher duly signed to

the Insurance Company, the claim has been closed as per norms.

AWARD

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

during the hearing and after going through the documents on record, it is observed that though the

insured had lodged claim for Rs. 10,39,900/- against the reimbursement of repairing cost of the vehicle

damaged in accident but prima facie, it appears that identity of the entity - Maa Bargabhima Motor Parts

– which has issued the Bill of Rs 8,83,350/-, is not genuine. As such, the amount of Rs 1,39,500/- settled

by the Insurance Company, after making necessary deductions and adjustments, seems to be justified. In

view of the aforesaid, the settlement of claim made by the Insurance Company is upheld and the

complaint is dismissed without any relief to the complainant. The complaint is thus disposed of in favour

of the Insurance Company.

Dated at Kolkata on 10th Day of May, 2021 SHRI P K RATH

INSURANCE OMBUDSMAN

award no.io/koc/a/gi/0001/2021-2022 proceedings of the

Documents