proceedings before the insurance ombudsman (under …

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN State of Gujarat and Union Territories of Dadra, Nagar Haveli and Daman & Diu

(Under Rule No: 16 / 17 of the Insurance Ombudsman Rules, 2017) OMBUDSMAN: M.VASANTHA KRISHNA

Case of Mr. Nishant S. Patel Vs. The New India Assurance Co. Ltd. Complaint Ref. No. AHD-G-049-1718-0565

Award No. IO/AHD/A/GI/0074/2019-2020

1 Name & Address of the Complainant

Mr. Nishant S. Patel B-39, Samrajya Part-I, Munj Mahuda, Akota, Vadodara-390020

2 Policy No: Type of Policy Policy period Insured’s Declared Value (IDV)

22150231150100004392 Commercial Vehicle Package Policy 08.09.2015 to 07.09.2016 INR 12,00,000

3 Name of the insured Name of the policyholder

Mr. Nishant S. Patel Mr. Nishant S. Patel

4 Name of the insurer The New India Assurance Co. Ltd.

5 Date of Repudiation 17.01.2017

6 Reason for Repudiation Breach of Policy Conditions Nos.1 and 5

7 Date of receipt of complaint 11.05.2017

8 Nature of complaint Rejection of claim

9 Amount of claim INR 12,00,000

10 Date of Consent 21.07.2017

11 Date of receipt of SCN 28.07.2017

12 Amount of relief sought INR 12,00,000

13 Complaint registered under Rule no. 13(1) (b) of the I ORules, 2017.

14 Date of hearing/place 09.01.2019 / Ahmedabad

15 Representation at the hearing: For the Complainant For the Insurer

Mr. Nishant S. Patel Mr. M.A. Pathan

16 Complaint how disposed Award

17 Date of Award/Order

18 Brief facts of the case: The Complainant had insured his Heavy Goods Vehicle Dumper No. GJ 06-XX-1772 under Commercial Vehicle Package Policy with the respondent insurance company for IDV of INR 12,00,000. The insured vehicle was stolen on 28.11.2015 when it was parked at Fartikui Godown, Vadodara. The complainant’s claim for the theft of the vehicle was repudiated by the respondent citing condition no. 1- delay in intimation and condition no. 5 – failure to safeguard the vehicle from loss or damage - of the Policy. Aggrieved with the rejection of the claim, he represented to the Grievance Dept. of the insurer but there was no positive outcome. Hence he has approached the Forum for relief. 19 Argument’s during the Hearing:- (A) Complainant’s argument: The complainant submitted that the insurance company had rejected the claim stating that there was delay in intimation of his claim to them by 9

days and complaint was lodged at Police Station after 134 days. The complainant submitted that his driver had locked and parked the insured vehicle at business spot on 28/11/2015 at 3.00 PM and the next day (on 29/11/2015) the watchman came on duty and found the vehicle was missing. The complainant came to know about the theft of the dumper through the watchman on 29/11/2015. He tried to lodge a police complaint for the heft of his vehicle immediately. However, the police refused to accept his complaint. Therefore, he wrote a JANVA JOG letter dated 30.11.2015 to the Police Station, Dabhoi, Vadodara about the theft of the vehicle and the complaint was registered by police authorities only on 13.04.2016. The complainant submitted that his claim was genuine and requested the Forum to order the insurer to settle the same. (B) Insurer’s argument: The insurance company submitted that intimation of theft had to be given immediately to the insurance company and police authorities as per policy Condition No. 1, which reads as under : “Notice shall be given in writing to the company immediately upon the occurrence of any accidental loss or damage and in the event of any claim and thereafter the Insured shall give all such information and assistance as the company shall require. In case of theft or other criminal act which may be the subject of claim under this policy the Insured shall give immediate notice to the Police and cooperate with the company in securing the conviction of the Offender.” The respondent pointed out that the complainant had intimated them only 9 days after the theft of the vehicle and FIR with the Police was lodged after 134 days. The respondent submitted that they had rightly repudiated the claim under policy condition No.1 of the policy. The respondent insurer has also rejected the claim under Policy condition no. 5, on the basis of the statement of the driver of the vehicle that the cabin lock was not working. Condition no. 5 of the Policy reads as under: “The insured shall take all reasonable steps to safeguard the vehicle insured from loss or damage and to maintain it in efficient condition and the company shall have at all times free and full access to examine the vehicle or any part thereof or any driver or employee of the insured, in the event of any accident or breakdown of the vehicle.” 20. Reason for registration of Complaint: The Complaint has been registered under Rule 13(1) (b) of the Insurance Ombudsman Rules, 2017 which deals with disputes due to total or partial repudiation of claims by insurers. 21. The following documents were placed for perusal:

Complaint letter to the Forum

Annexure VI A (consent) submitted by the complainant

Policy copy with terms and conditions

Repudiation letter of the insurer dated 17/01/2017

Copy of FIR no. 1/67/2016 dated 13/04/2016

Janva Jog

Investigation Report

Panchnama

Self-contained Note (SCN) of the insurer

Statement of Mr. Satishbhai Govindbhai Vasava dated 19/12/2015 22. Result of hearing with both parties (Observation & Conclusion: Based on the submission of parties as above and the material made available to this Forum, the following observations are made.

A) The vehicle was stolen on 28/11/2015 and the complainant reported the matter to the Police by JANVA JOG on 30/11/2015, two days after the theft. However, the Police registered the FIR only on 13/04/2016, 134 days after the theft. In the opinion of the Forum, the complainant cannot be held responsible for the delay in Police registering the FIR, since on his part he had promptly informed the Police of the incident. B) The complainant informed the insurance company about the theft only 9 days after the occurrence and the company has rejected the claim on the ground of delayed intimation under condition no.1 of the Policy. However, the company failed to obtain the explanation of the complainant for the delay in intimating the claim to them, before they took the decision to reject the claim. This is violative of the guidelines given by IRDAI vide their circular no. dated As per said guidelines of IRDAI, claims should not be denied merely on the ground of delay in intimation, unless insured’s explanation is obtained for such delay and the delay is material to the claim. In Civil Appeal No. 15611 of 2017- Om Prakash V/s Reliance General Insurance & Another. Hon'ble Supreme Court has observed thus:-

"It is common knowledge that a person who lost his vehicle may not straightaway go to the Insurance Company to claim compensation. At first, he will make efforts to trace the vehicle. It is true that the owner has to intimate the insurer immediately after the theft of the vehicle. However, this condition should not bar settlement of genuine claims particularly when the delay in intimation or submission of documents is due to unavoidable circumstances. The decision of the insurer to reject the claim has to be based on valid grounds. Rejection of the claims on purely technical grounds in a mechanical manner will result in loss of confidence of policy-holders in the insurance industry. If the reason for delay in making a claim is satisfactorily explained, such a claim cannot be rejected on the ground of delay. It is also necessary to state here that it would not be fair and reasonable to reject genuine claims which had already been verified and found to be correct by the Investigator. The condition // 12 // regarding the delay shall not be a shelter to repudiate the insurance claims which have been otherwise proved to be genuine. It needs no emphasis that the Consumer Protection Act, aims at providing better protection of the interest of consumers. It is a beneficial legislation that deserves liberal construction. This laudable object should not be forgotten while considering the claims made under the act. Hence the Forum holds that the rejection of the claim by the insurer on account of delay in intimation is not valid. C) The insurer has also invoked condition no. 5 of the Policy to reject the claim on the ground that the complainant did not take reasonable care to protect the insured vehicle from loss or damage. This was based on the statement made by Mr. Satishbhai Govindbhai Vasava, supervisor of the complainant on 19/12/2015 to the investigator deputed by the insurer to the effect that the cabin of the insured vehicle was not properly locked due to defect in locking system statement. This finding of the investigation and the statement made by the supervisor have not been refuted by the complainant, although they form the basis of the claim repudiation and hence the Forum believes the statement to be true and relies upon the same. If there was a defect in the locking system of the cabin of the insured vehicle, such a defect was a material factor for the theft of the vehicle and therefore, the insurer is justified in rejecting the complainant’s claim under condition no. 5 of the Policy. In view of this the complaint is not admitted.

https://indiankanoon.org/doc/1733066/

AWARD Taking into account the facts & circumstances of the case and the submissions made by both parties during the course of hearing, the Forum is of the opinion that the insurer was justified in rejecting the claim of the complainant under condition no. 5 of the Policy and their decision does not warrant any interference by the Forum.

23. If the decision of the Forum is not acceptable to the complainant, he is at liberty to approach any other Forum/Court as per laws of the land against the respondent insurer. Dated at Chennai on 1st day of October, 2019.

(M.VASANTHA KRISHNA) Insurance Ombudsman

Mr. Nishant Singh ..………………….……………………..……………….. Complainant

V/S

IFFCO TOKIO General Insurance Co.Ltd……………….…………….…...…Respondent

COMPLAINT NO: BHP-G-023-1819-0052 ORDER NO: IO/BHP/A/GI/ 0085/2019-2020

1. Name & Address of the

Complainant

Mr. Nishant Singh,

Ater Road Bhind

Gwalior

2. Policy No:

Type of Policy

Duration of policy/Policy period

96977698

Endorsement Commercial Vehicle Package

Policy

11.03.2016 to 10.03.2017

3. Name of the insured

Name of the policyholder

Mr. Nishant Singh

-same-

4. Name of the insurer IFFCO-TOKIO General Insurance Co.Ltd.

5. Date of Repudiation/ Rejection 19.07.2017

6. Reason for Repudiation/ Rejection Non submission of requirements

7. Date of receipt of the Complaint 20.06.2018

8. Nature of complaint Non settlement of motor claim

9. Amount of Claim --

10. Date of Partial Settlement --

11. Amount of relief sought Rs.1,50,000/-

12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule 2017

13. Date of hearing/place On 03.10.2019 at Bhopal

14. Representation at the hearing

For the Complainant Mr Vikrant Singh, Brother

For the insurer Mr Raghunandan Prasad Shukla, Sr

Manager

15. Complaint how disposed Recommendation

16. Date of Award/Order 03.10.2019

Mr. Nishant Singh(Complainant) has filed a complaint against Iffco-Tokio General

Insurance Co. Ltd.(Respondent) alleging non settlement of claim.

Brief facts of the Case -The complainant has stated that his vehicle no. MP 09 TA 7092

met with an accident. Complainant incurred expenses towards repairing of vehicle. After

final survey respondent company repudiated the claim stating the reasons vide their letter

22.01.2018 that vehicle was not produced for re-inspection along with replaced parts,

Repairer bill not provided to surveyor, NEFT details of insured not provided and

endorsement request was not done at RTO /Insurer for vehicle class. The complainant has

approached this forum for payment of his claim.

The respondent in their SCN have stated that the vehicle of complainant met with an

accident on 17.02.2017 and after deputation of Surveyor for assessment of loss who

completed the assessment and submitted his report later certain discrepancies were

observed i.e. Vehicle was not produced for re-inspection, repair bills were not submitted

for final settlement, bank details were not given. Also certain parts were replaced through

outside dealer’s point and were not produced for verification. Hence on the basis of non-

submission of documents and formalities claim is repudiated.

The complainant has filed complaint letter, Annex. VI A and correspondence with

respondent, while respondent have filed SCN with enclosures.

I have heard both the parties and perused papers filed. During course of hearing, both the

parties has filed joint application (Mediation Agreement) duly signed by the complainant

and the representative of respondent mentioning therein about settlement of the matter

willingly and mutually and agreed to settle the subject matter of the complaint as follows–

The Complainant has agreed to get the vehicle produced for inspection before the

respondent to enable him to assess the loss. The Respondent has agreed to re-open the

claim after getting the vehicle inspected and process the claim as per terms and conditions

of the policy. The Respondent and complainant have also agreed to co-ordinate with

surveyor for inspection purposes.

As matter within parties has resolved mutually, hence the complaint is decided in terms of

mediation/mutual agreement between both the parties.

Let copies of this order be given to both parties.

Dated: Oct 03, 2019 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA, BHUBANESWAR

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – SHRI SURESH CHANDRA PANDA

CASE OF Mr. Himanshu Sekhar Prusty Vrs. Royal Sundaram General Insurance Co Ltd. COMPLAINT REF: NO: BHU-G-038-1718-0251

AWARD NO: IO/BHU/A/GI/ /2019-2020

1. Name & Address of the Complainant

Mr. Himanshu Sekhar Prusty S/O Mr. Ramachandra Prusty, Khandapada Road, H. No-1 Jagannath Vihar, Nayagarh. Odisha. 752069 9439003705

2. Policy No: Type of Policy Duration of policy/Policy period

VGC0459308000100 Package Policy from- 04.05.2017 to 03.05.2018 with IDV Rs.24,79,000/- (DoA- 06.06.2017)

3. Name of the insured Name of the policyholder

Mr. Himanshu Sekhar Prusty Mr. Himanshu Sekhar Prusty

4. Name of the insurer Royal Sundaram General Insurance Co Ltd., Bhubaneswar

5. Date of Repudiation 09.10.2017

6. Reason for repudiation

Mis-representation of fact with regard to previous insurer and damages claimed by the complainant


8. Nature of complaint Road Accident: Own Damage Claim

9. Amount of Claim Rs.24,79,000/-

10. Date of Partial Settlement Claim is repudiated

11. Amount of relief sought Rs.19,50,000/-(as the damage vehicle’s cost i.e. salvage value is approx. Rs.5,00,000/-)

12. Complaint registered under Rule no: of IO rules

13(1)b

13. Date of hearing/place 14.10.2019, Bhubaneswar


For the Complainant Self

For the insurer Shri Binit Pattnaik, Manager

15 Complaint how disposed U/R 17 of the Insurance Ombudsman Rules, 2017

16 Date of Award/Order 14.10.2019

17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant is the owner of one

Ashok Leyland Truck bearing No- OD 07 J 2771, which was insured with M/S Royal Sundaram

General Insurance Co Ltd., Bhubaneswar (through M/S Visista Insurance Broking Services Pvt

Ltd) for the period from 04.05.2017 to 03.05.2018 under package policy. Unfortunately, the said

truck met with an accident on 06.06.2017 near Nuagaon, Machheli- NH 57. The complainant

states that the vehicle was loaded with cement and apprehending loss to the cement due to

rain, he shifted the cement bags anticipating rain and then lifted the damaged vehicle by a

hydra crane as it was a busy road. He also informed the matter to the insurer. He kept the truck

in a safe place. The insurer appointed the Surveyor Mr. Bibhudutta Roy, who assessed the loss

for Rs.17,00,000/- as the net liability of the insurer. However, the insurer, vide mail dated

09.10.2017, has denied the claim as they found there was a mis-representation of fact with

regard to previous insurer and the damages claimed by the complainant. Being aggrieved on

repudiation of the claim, the complainant filed an appeal before this Forum for redressal.

b. On the other hand, the insurer pleads that: - while verifying the claim documents,

there arose a doubt regarding the previous policy details given by the insured at the time of the

proposal, since the dates mentioned in the policy copy appeared to be overwritten/pasted

over. Hence to confirm the previous policy, the respondent company sought the details of the

policy (no- 55100131140100005649) from the New India Assurance Co ltd, the previous insurer.

The previous insurer confirmed that the policy pertaining to the above said policy number was

issued to one Mr. Minaketan Pradhan, for his Tata Piaggio/Ape cargo vehicle and the period of

insurance was from 07.02.2015 to 06.02.2016. Hence, it is clear that the complainant has

forged a policy to show his vehicle as continuously insured whereas it is clear from the

document shared by the previous insurer that the policy issued by them is totally unrelated to

the complaint and pertains to a different insured vehicle/different owner.

18. a) Complainant’s Argument: - The complainant in his letter dated 06.09.2017 addressed

to the insurer, states that in regard to the previous policy, the original policy was forcibly taken

by Motor Vehicle Flying Squad near Andhra Pradesh Border after that he tried to collect the

copy of the policy from the agent. The agent gave him a xerox copy of the original policy, which

was submitted to the insurer at the time of purchasing insurance. He tried in all possible ways

but unfortunately could not get the policy document. Under the above circumstance, he had

requested the insurer to settle the claim.

b) Insurer’s Argument: - The insurer submits that it is clear that the complainant, herein

by a gross misrepresentation, has taken the policy by representing the insured vehicle as one

which is under continuous insurance, whereas the reality is different. The insurer states that

they could have taken steps to get the vehicle inspected prior to policy issuance, had the

complainant disclosed any break-in-insurance, since any damage to the insured vehicle prior to

policy inception cannot be accepted as a risk by them. Previous policy details are a material fact

in underwriting any risk, which has been misrepresented by the complainant which is in gross

violation of the principle of utmost good faith by the complainant. Hence, they have repudiated

the claim.

The insurer further states that under the above circumstances, both in fact and in law,

the complaint is liable to be dismissed and they have not breached any contractual obligation

or committed any deficiency in repudiating the claim and the complainant is thus not entitled

to any relief in respect of the present complaint.

19. Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal.

a. Photocopies of insurance (present policy)

b. Photocopies of insurance (previous policies) in the name of Mr. Minaketan

Pradhan and the complainant.

c. Photocopies of vehicle documents and copy of the survey report

21. Result of hearing with both parties (Observations & Conclusion): - This Forum has

carefully gone through all the submitted documents relating to the complaint and heard both the

parties. The Forum has observed that the complainant, at the time of submission of proposal to

Cholamandalam MS General Insurance Co ltd for renewal, had submitted copy of the policy

issued by the New India Assurance Co Ltd for the period from 04.05.2016 to 03.05.2017.

Cholamandalam MS General Insurance Co ltd, on enquiry with the previous insurer, has found

that the said policy issued by the previous insurer pertains to one Mr. Minaketan Pradhan and

against a three-wheeler, but not in the name of the complainant against his truck. The Forum has

examined both the documents and found both to be different.

Dated at Bhubaneswar on 14th

day of October, 2019

INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

AWARD

Taking into account the facts and circumstances of the case and the submissions made

by both the parties during the course of hearing, the Forum is of the opinion that the

document submitted by the complainant to the insurer for insurance is against the basic

principles of insurance on utmost good faith and therefore, the complainant is not

entitled for any benefit under the policy.

Hence, the complaint stands dismissed.

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017) OMBUDSMAN – K.B. SAHA

CASE OF: : Complainant MR.KRISHNA DEBNATH VS NATIONAL INSURANCE CO.LTD. COMPLAINT REF NO: GUW-G-048-1920- 0050 : Award No

1. Name & Address of the Complainant MR.KRISHNA DEBNATH PATHERKANDI;KARIMGANJ


200502/31/16/6300003573 MOTOR POLICY 18/03/2017 TO 17/03/2018

3. Name of the insured Name of the policyholder

MR.KRISHNA DEBNATH

4. Name of the insurer NATIONAL INSURANCE COMPANY LIMITED

5. Date OF OCCURANCE OF LOSS/CLAIM 13/01/2018 6. DETAILS OF LOSS Rs.283500/-

7. REASON FOR GRIEVANCES Rules 17(6) of the Insurance ombudsman Rule 2017

8.a 8.b

Nature of complaint Date of receipt of the complain

REPUDIATION OF MOTOR THEFT CLAIM 29/07/2019

9. Amount of Claim Rs.283500/-

10. Date & Amount of Partial Settlement NIL 11 Amount of relief sought RS.283500/-

12. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati, 30/09/2019


For the Complainant MR.KRISHNA DEBNATH

For the insurer MS.ANTARA SAIKIA

15 Complaint how disposed Through personal Hearing

16 Date of Award/Order 30/09/2019

17) Brief Facts of the Case: Mr. Krishna Debnath had a Bolero PICK-UP van bearing registration no. AS-11/BC-0905 .The vehicle was insured with National Insurance Company Limited. The vehicle was stolen on 13/01/2018 at midnight from parking near Patherkandi Motor stand in front of Manju Bakery. On 14/01/2018 he informed Patherkandi police Station. Every correspondence was made with the insurance company. But the complainant was unduly late in bringing out the duplicate Fitness Certificate & in submitting within specified time & before submitting the same Insurance Company declared the claim as NO CLAIM.

18a) Complainant’s argument: As the car was stolen from the parking near the residence of the owner and not

in use for commercial purpose, the validity of Fitness can not be the deciding factor. Complainant mentioned in

his statement that both Samrat Deb & Rifan Uddin are his vehicle staff. Samrat Deb is his regular driver.

18 b) Insurers’ argument: Insurance Co. repudiated the claim on the following grounds:-

1) An insured vehicle must be kept in a garage or in some secured place for its safety so that burglers

/miscreants doesn’t get easy access to the vehicle for the theft, but the vehicle was parked near Manju Bakery

on the open road side before theft which is mentioned in every documents as well a Final Police Report. This is a

gross violation of insurance policy condition no.5.

2) The police report says that the driver Rehan Uddin s/o Mausak Ali handed over the keys to the

Claimant/Insured after parking the vehicle near Manju Bakery at 8.00PM on 13.01.2018 whereas the insured

gave a self written statement stating that the driver was Samrat Deb and the vehicle was parked at 9.00 PM and

also the same is mentioned in the investigation Report.

3)The date of theft of the vehicle is 14.01.2018 at 2.30 AM. It was intimated on 15.01.2018.The Fitness

Certificate validity commenced from 19.01.2018 to 18.01.2019 and the vehicle was physically inspected by MVI

Homen Das of Cachar District on 19/01/2018 ie,5 days after the occurrence of the event. This means that the

vehicle was not stolen at all the investigation Report mentioned about the invalidity of Fitness Certificate. This

was informed to the insured by the investigator. The submitted Fitness Certificate doesn’t cover the claim

intimated. The complainant could not giving satisfactory explanation for this glaring discrepancy.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule after proper approval from honorable

ombudsman13 (1) (b).

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N

Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for hearing on 30/09/2019 .The complainant Mr. Krishna Debnath himself was present and the insurer was represented by Mrs. Antara Saikia.

DECISION

We have taken in to consideration the facts and circumstances of the case from the documentary as well as

verbal submission made by the claimant and representative of Insurance Co. We have also gone through the

records. The insurance company repudiated the claim as there are many discrepancies regarding Fitness

Certificate, Driver & about parking place. The complainant produced one certificate from DTO Cachar as a

proof . It was written in the certificate that due to technical problem in their system the certificate was not

issued on 18/01/2018 but was issued on 19/01/2018. But the insurance Co. refuses to accept that because

the certificate was not duly sealed & it had taken a long time for verification. On 29/10/2019 they have

produced enough proof that the Fitness Certificate was issued on 18/01/2018 with serial no 8629. This

certificate does not explain how the vehicle was inspected by the MVI after the same was stolen. There is a

various doubt regarding the genuineness of the Fitness. As the forum does not have the machinery to

ascertain the genuineness of the fitness certificate which is the deciding factor of the case, the forum

directs the insured to approach any other forum, he feels appropriate for Redressal of his grievance.

Hence, the complaint is treated as closed.

Dated at- Guwahati, The 30 th

day of September 2019.

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, GUWAHATI

(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES 2017) OMBUDSMAN – K.B. SAHA

CASE OF: Complainant MRS TANVI CHAMARIA VS SHRIRAM GENERAL INSURANCE CO LTD. COMPLAINT REF NO: GUW-G-042-1920- 0058: Award No

1. Name & Address of the Complainant MRS.TANVI CHAMARIA


324016/31/18/012286 IDV RS.800000/- MOTOR THREE WHEELERS PACKAGE POLICY 18/11/2017 TO 17/11/2018

3. Name of the insured MRS.TANVI CHAMARIA

Name of the policyholder MRS TANVI CHAMARIA

4. Name of the insurer SHRIRAM GENERAL INSURANCE COMPANY LTD.

5. Date OF OCCURANCE OF LOSS/CLAIM 18/02/2018 6. DETAILS OF LOSS RS.211038/-

7. REASON FOR GRIEVANCES Rules 17(6) of the Insurance ombudsman Rule 2017

8.a 8.b

Nature of complaint Date of receipt of the complain

REPUDIATION OF MOTOR ACCIDENT CLAIM 13/09/2019

9. Amount of Claim Rs.211038/- 10. Date & Amount of Partial Settlement NIL

11 Amount of relief sought Rs.266038/-(VEH REP.RS.211038+MENTAL PAINRS.50000+COST OF TRAVELLINGRS.5000.

12. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(b)

13. Date of hearing/place O/o Insurance Ombudsman Guwahati, 17/10/2019


For the Complainant SRI RAMESH KR.CHAMARIA

For the insurer MR. RAJENDRA DUTTA

15 Complaint how disposed Through personal Hearing

16 Date of Award/Order 17/10/2019 17) Brief Facts of the Case: Mrs Tanvi Chamaria had a Tipper(Diesel) bearing Reg No.AS-09/AC-2972 which is a commercial public carrier’s vehicle insured with Shriram General Insurance Co. Ltd. The said vehicle met with an accident on 18/02/2018 while carrying earth of 5 cm each in two trips vide Challan No.36 & 37.The complainant lodged a complaint before the insurance company on the same day & accordingly insurance co surveyed the damaged vehicle on 19/02/2018 on the spot of the accident. The surveyor assessed the loss of Rs.53792/-. The insurance company further issued a letter dt.23.04.2018 to the complainant to submit the Royalty Slip. The complainant submitted the same to the insurance company. After getting those slips the insurance co. informed the complainant through e-mail dt 20/06/2019 that they are unable to consider the claim reasoning that her vehicle was overloaded at the material time of accident.

18a) Complainant’s argument: The complainant was very much surprised and shocked that the insurance co. has

repudiated the claim on the ground that the vehicle was overloaded at the time of accident. Those allegations are

completely false & fabricated. It was not at all over loaded at the time of accident. So according to her the claim is genuine

which the Co. wrongly repudiated.

18 b) Insurers’ argument: Insurance Co. submitted that after registering the claim Surveyor was appointed for the

assessment of loss. The surveyor assessed the net liability of Rs.53792 of the insurer subject to policy term & condition. It is

further submitted that insurance company issued letters on dated 20.03.18,16.04.18 & 23.04/18 to insured to submit the

following documents to start repairing the vehicle and produce for Reinspection and also provide below mention claims

documents-

1) Original Royalty Slip

2) Dealer bills with cash receipts

3) Adhaar Card

It is further submitted that as per royalty slip submitted by the insured, Vehicle was overloaded at the time of accident. As

per Registration certificate carrying capacity is 10,360 kgs only but at the time of accident vehicle was carrying 15200 kgs.

So it is clear that at the time of accident vehicle was overloaded and it is violation of policy condition and Motor Vehicle Act.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017 (Rule after proper approval from

honorable ombudsman13 (1) (b).

20) The following documents were placed for perusal. a) Complaint letter b) Annexure – VI A c) Copy o the policy d) Annexure VII A e) S C N

Result of hearing with both parties (Observations & Conclusion):- Both the parties were called for hearing on17/10/2019.The complainant was represented by her Husband Mr.Ramesh Kr.Chamaria and the insurer was represented by Mr. Rajendra Dutta.

DECISION We have taken in to consideration the facts and circumstances of the case from the documentary as well as verbal

submission made by the claimant and representative of Insurance Co. We have also gone through the records. Insurance

Co. repudiated the claim as the vehicle was overloaded at the time of accident, though the surveyor assessed the loss

for Rs.53792. But from the submission of the complainant it is proved that the vehicle was carrying earth of 5 C.M. each

in two trips. Insurance Co. wrongly presumed that both the challans were issued for a single trip. The complainant’s

Representative insisted that (i) it is absurd that two challans of same material would be issued for the same trip. ii )

since earth moving is done in off-road and kachha site no dumper (let above a 8/10 year old dumper)can carry earth

with its approved load. Hence the question of carrying overload does not arise. So, apparently the cause of repudiation

is untenable.

Under the circumstances & in order to ensure fairness to the complainant the Forum directs the insurance Company to

pay as per surveyor’s assessment Rs.53792/- which is agreed by both the insured’s representative & the insurance

company during the course of hearing.

Hence, the complaint is treated as closed.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017.

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of the receipt of the acceptance

letter of the Complainant and shall intimate the compliance to the Ombudsman.

Dated at- Guwahati, The 17th

day of October 2019

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA

CASE ABHAY BHATNAGARV/S THE ORIENTAL. INS. CO. LTD.

COMPLAINT REF: NO JPR- G- 051- 1920-0091

AWARD NO: IO/JPR/GI/A/1920/0029

1. Name & Address of the Complainant Sh. Abhay Bhatnagar, Jaipur

2. Policy No:

Type of Policy

Duration of policy/Policy period

IDV

211200/31/2019/115375

Passenger Carrying Commercial Veh. Package

Motor Insurance

25.08.2018 to 24.08.2019

Rs. 2.70 Lakh

3. Name of the insured

Name of the policyholder

Abhay Bhatnagar

Abhay Bhatnagar

4. Name of the insurer THE ORIENTAL. INS. CO. LTD

5. Date of Repudiation 05.08.2019

6. Reason for repudiation Not Valid DL for Transport vehicle


8. Nature of complaint Non settlement of claim

9. Amount of Claim Rs. 64070-

10. Date of Partial Settlement NA

11. Amount of relief sought Rs 64070/-

12. Complaint registered under

Rule no: of IOB rules

13 i (b)

13. Date of hearing/place 10.10.2019 / Jaipur


For the Complainant Sh. Abhay Bhatnagar

For the insurer Ms. Meenu Sachdeva, Dy.Mgr.

15 Complaint how disposed Award in favour of the complainant

16 Date of Award/Order 10.10.2019

17) Mr. Abhay Bhatnagar(herein after referred to as the complainant) had filed a complaint

against the decision of The ORIENTAL INSURANCE COMPANY LTD.(Jaipur) (herein

after referred to as the respondent Insurance Company) alleging non settlement of vehicle

accident claim.

18) Cause of Complaint:

Complainant’s argument: Mr. Abhay Bhatnagar, the Complainant had taken the passenger

carrying commercial vehicle (Redi GO T (O)) Policy No. 211200/31/2019/115375 for the period

from 25.08.2018 to 24.08.2019 for the IDV of Rs 2.70 Lakh for his Vehicle No. RJ14TE 0616

from The Oriental Insurance Co. Ltd. The insured vehicle met with an accident on 08.06.2019

and the claim was informed to the Insurance Company. The survey job was conducted and the

Insurance Company denied the claim on account of DL not valid for transport vehicle the

submitted DL was valid for LMV and MCWG only. Aggrieved, he requested the insurer,

including its GRO dated 30.07.2019 to reconsider the claim but failed to get any relief.

Thereafter, he preferred a complaint to this office for resolution of his grievance.

Insurers’ argument:- The insurer stated in their SCN that the insured vehicle was insured with

them in the category of Passenger Carrying vehicle not exceeding 6 passengers. At the time of

the accident vehicle was being driven by the driver ( DL no. RJ19 20090327691)holding Light

Motor Vehicle and MCWG License (Non transport category), which was valid for private car

vehicle only, whereas the insured vehicle was registered as a passenger carrying vehicle which

comes in Light Transport Vehicle category and need an LTV license with badge to drive the said

vehicle. The driver of the vehicle was not having effective and valid driving licence at the time

of accident on 08.06.2019 hence the Company is not liable to pay the claim.Due to non

submission of LTV license with badge no. the above claim was repudiated under the terms and

conditions of the policy.

19) Reason for Registration of Complaint: - Case of Non settlement of claim-Repudiation

of Motor claim

20) The following documents were placed for perusal.

a) Complaint letter

b) Policy copy, conditions, RC copy

c) Survey report , LMV DL validity guidelines

d) Form VI A duly signed by the complainant.

e) SCN and a form VIIA duly signed by the Insurance Company

21) Result of hearing with both parties (Observations and Conclusion) :- Both the parties

appeared in the personal hearing and reiterated their submissions. The complainant submitted

that the driver of his taxi was holding a DL valid for LMV only. The complainant submitted that

the Insurance Company rejected the claim on the norms of LMV licence an driving LTV vehicle.

The Insurance Company stated that as per policy condition limitation as to use, the claim was

repudiated due to non submission of “LMV licence with badge” as per requirement of the policy.

I have perused the documents placed on the record and oral submissions made during the

hearing. The complainant submitted a copy of the circular issued by Rajasthan Govt. Transport

Deptt regarding LMV licence, which reads, “a driver is holding licence to drive light motor

vehicle, he can drive a transport vehicle of such class” .The complainant submitted a copy of

circular from Rajasthan Govt. Transport Deptt. No. प (51) परि/नियम/भ/ु2006/पार्ट /9096 dated

30.04.2018 which directed compliance of directions as issued by Ministry of Road and Transport

Highways .

The Supreme Court in the case of Mukund Dewangan Vs The Oriental Insurance Company

Limited, held that there was no requirement to obtain separate endorsement to drive transport

vehicle and if the driver is holding licence to drive light motor vehicle, he can drive a transport

vehicle of such class without any endorsement to that effect. During the personal hearing, the

Insurance Company submitted that Bajaj Allianz Insurance Company had filed an appeal against

this in Supreme Court. I find that the same was not yet listed, nor any stay has been granted.

Therefore the aforementioned judgement holds good.

Relying on the above judgement, I direct the Insurance Company to settle the claim as

admissible.

Accordingly, an Award is passed with the direction to settle the claim as admissible.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of

Insurance Ombudsman Rules, 2017:

a. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, A copy of the award

shall be sent to the complainant and the insurer named in the complaint.

b. As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30

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

Place: Jaipur SANDHYA BALIGA

Dated: 10.10.2019 INSURANCE OMBUDSMAN

AWARD

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

both the parties during the course of hearing, the Insurance Company is directed to settle

the claim as admissible.

The complaint is treated as disposed off accordingly.

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW (UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Mr. Praveen Kumar…………..……....………………. Complainant V/S

Oriental Insurance Co. Limited…………..………..…………Respondent COMPLAINT NO:LCK-G-050-1718-0183 Order No. IO/LCK/A/GI/0038/2019-20

1. Name & Address of the Complainant Mr. Praveen Kumar 12, Tilak Vihar, Sitapur Road, Lucknow-226020

2. Policy No: Type of Policy Duration of policy/DOC/Revival

221302/31/2017/2511 PCCC-4 Package Policy 29.09.2016 to 28.09.2017

3. Name of the life insured Name of the policyholder

Mr. Praveen Kumar Mr. Praveen Kumar

4. Name of the insurer Oriental Insurance Company Co. Ltd.

5. Date of Repudiation/Rejection ---

6. Reason for repudiation/Rejection ---


8. Nature of complaint Partial repudiation of claim

9. Amount of Claim Rs. 85,656/-

10. Date of Partial Settlement ---

11. Amount of relief sought Rs. 85,656/-

12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule 2017

13. Date of hearing/place On 15.10.2019 at 10.15 am at Lucknow


For the Complainant Mr. Praveen Kumar

For the insurer Mr. Ajay Gupta, Sr.Branch Manager

15. Complaint how disposed Dismissed

16. Date of Award/Order 15.10.2019

17. Mr. Praveen Kumar(Complainant) has filed a complaint against Oriental Insurance Company Limited

(Respondent) alleging over dispute of payment of claim.

18. Brief Facts Of the Case:- The complainant has stated that he was registered owner of bus no. UP41AT3550

and said vehicle was insured by RIC. His vehicle was operated under UPSRTC contract on Lucknow to Gonda

route. His vehicle had met with an accident on 20.03.2017. The claim was intimated to RIC along with repair

estimate of Rs.307839/-. The RIC had deputed the surveyor for assessing the loss. The final bill of Rs. 81,156/-

was raised by the woprkshop. After that the respondent had asked some documents which were also provided

by him. He further stated that he received a letter which was supplied by the surveyor to the workshop for

providing the bifurcation of labour for which he raised a grievance. Aggrieved with the decision of the RIC, the

complainant was not satisfied with the settled amount so he approached this forum.

In their SCN/reply, respondent has stated that the impugned policy was issued to the complainant. On receipt of

the surveyor report, RIC has processed the claim was processed for Rs.34262/- on non-standard basis (due to

non-submission of permit) after applying the depreciation and excess as per aforesaid policy terms and

conditions. RIC had sent a letter dated 13.12.2017 to the insured communicating the approval amount and

submission of discharge voucher duly completed/signed alongwith bank details alongwith acceptance letter of

Rs.34262/- to enable us to release the acceptance amount. But insured has not submitted the acceptance letter

to the RIC till date.

19. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent and copy of

policy document while respondent filed SCN with enclosures.

20. I have heard the representative of the respondent at length and perused paper filed on behalf of the

complainant as well as the Insurance Company.

21. Basically the complaint was made on two counts (1) Delay in settlement of claim and (2) request for

determining the quantum of compensation.

So far as complaint of delay is concerned, claim has already been decided by the respondent on

13.12.2017 which is duly informed to the complainant.

Quantification of compensation, has already been done by the respondent on 13.12.2017. However,

if the claimant is not satisfied with the same, he may approach the Competent Authority for redressal in

accordance with laws and rules. Accordingly complaint becomes infructuous and is disposed off.

22. Let copy of the award be given to both the parties.

Dated : October 15, 2019 (Justice Anil Kumar Srivastava)

Place : Lucknow Insurance Ombudsman

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