AHMEDABAD OMBUDSMAN CENTRE. Case No

Transcription

1 AHMEDABAD OMBUDSMAN CENTRE Case No Dr. Manish R. Shah V/s. Tata AIG General Insurance Co. Ltd. Award dated 10 th October 2012 Repudiation of loss suffered under Travel Care Classic Ins. Policy A claim lodged by the Complainant for Rs.20,248/- for cancellation of Hotel booking, Cab booking, Food charges, Telephone charges with interest was repudiated by the Respondent giving reason that the expenses incurred does not fall within the scope of policy. Due to covered reasons such as illness, injury or death of the passenger, the copassengers or their immediate family if trip gets cancelled, the Insurer will pay. Hence the complaint fails to succeed. ************************************************************************************** AHMEDABAD OMBUDSMAN CENTRE Case No Mr. Dharamchand D. Kothari Vs. Future Generali Insurance Co. Ltd. Award dated 1 st March 2013 Repudiation of claim under Overseas Travel Policy Complainant treated for chest pain at USA and claimed 1000 U.S. Dollars which was repudiated by the Respondent as per policy Exclusion Clause No.5 giving reason that complainant fails to submit required documentary evidences to prove the treatment taken from USA except Cash Receipt of 1000 U.S dollars. On scrutiny of available documents, it proved that the treatment could have been on OPD basis hence the forum also denied the claim. **************************************************************************************

2 AHMEDABAD OMBUDSMAN CENTRE Case No Mr. Maheshchandra N. Parikh Vs. The New India Assurance Co. Ltd. Award dated 6 th March 2013 Non settlement of HHI Policy Complainant lodged a claim for house breaking and burglary loss was rejected as No Claim on the basis of Surveyors Report that the claimant has no right for his claim of theft or Burglary or housebreaking since the policy did not cover these perils. Complainant could not prove that his policy covered housebreaking or burglary or theft perils so complaint dismissed. ************************************************************************************** CHANDIGARH OMBUDSMAN CENTER CASE NO. GIC/351/OIC/11/11 Adarsh Kumar Sehgal Vs. Oriental Insurance Company Ltd. ORDER DATED: Miscellaneous FACTS : A complainant had obtained coverage of his jewellery, including four gold chains, against All Risks insurance under House-holders policy. Thereafter, one chain was lost and its claim was denied by the Company. FINDINGS : During the course of the hearing, complainant had said that while in Shimla (Himachal Pradesh), where he had gone to attend a marriage, one gold chain was lost and its claim was not paid by the Company on the ground that instead of required document, i. e., FIR, a Daily Diary Report (DDR) was provided. The complainant had contended that local Police was informed in time and decision to record loss of gold chain in DDR was of Police, which he could not influence. On his part, representative of the Company had explained that as per Claim Manual of

3 Company, in such cases FIR is a mandatory document for processing the claim, hence the lodged claim was denied. DECISION : The insurance Company was directed to settle the claim as per its admissibility under the terms & conditions of the policy because submitted documents revealed that subsequent to the issuance of DDR, Police had carried out necessary investigation into the matter, which was followed by issuance of No Trace Report. **************************************************************************************

4 DELHI OMBUDSMAN CENTRE Case No.GI/368/NIC/11 In the matter of Sh. Ravinder Singh. Vs National Ins. Co. Ltd. AWARD DATED : REFUND OF PREMIUM ON A/C OF DOUBLE INSURANCE 1. This is a complaint filed by Sh. Ravinder Singh (hereinafter referred to as the complainant against National Ins. Co. Ltd. (hereinafter referred to as respondent insurance company) relating to refund of premium. 2. Complainant submitted that his vehicle with registration no. DL-8C-H-4777 was insured vide policy no for the period of to for which premium was paid of Rs.8,810 vide cheque no dated company informed him that such cheque was misplaced and he was required to issue a fresh cheque by the company therefore he issued another cheque bearing no dated 22.may.2007 for the same amount. He further mentioned in the complaint that on the basis cheque dated 22.may Company had issued a fresh policy bearing no for the period to Thus company had issued two policies of the same vehicle on receipt of two cheques on different dates. When he pointed out this fact to the company, the company had issued him refund on short period basis for Rs.5,265 vide cheque dated instead of Rs. 8, Representative of the company stated that mistake was committed by the company. Company had already issued refund for an amount of Rs.5, I have considered the submissions of the complainant as well as of the representative of the company. Admittedly two policies were issued in respect of

5 same vehicle. In my considered view the payment received by the company as premium in respect of the second policy needs to be refunded to the insured. Company is required to refund the entire amount of premium subject to reduction of document charges Rs.100. Insured had not encashed the amount of refund of Rs.5,265 given by the company earlier. Accordingly an Award is passed with the direction to the insurance company to make the payment of Rs. 8,710 (8, documentation charges). 5. The award shall be implemented within 30 days of receipt of the same. The compliance of the award shall be intimated to my office for information & record. 6. Copies of the Award to both the parties. ******************************************************************************** DELHI OMBUDSMAN CENTRE Case No.GI/426/NIA/11 In the matter of Smt. Sarita Arora. Vs New India Assurance Co. Ltd. AWARD DATED : NON SETTLEMENT OF JEWELLERY CLAIM 1. This is a complaint filed by Smt. Sarita Arora (hereinafter referred to as the complainant) against New India Assurance Co. Ltd. (hereinafter referred to as respondent insurance company) relating to non-settlement of loss of jewelry claim. 2. This complaint relates to taking away of the gold chain by someone from the purse of the insured. Complainant stated that while she was eating something in the market and after eating she opened her purse to make payment meanwhile, a boy snatched the purse from her hand and ran away. She chased him. The boy took the

6 gold chain from the small purse and ran away she has informed the police about the incident and also lodged the claim with the insurance company. During the course of hearing complainant pleaded that chain along with pendent was lost. It was insured due to mistake she cannot correctly mention the weight of the chain, instead the weight correct of 25.5gms of gold chain, she had mentioned 2.5gm. Company had denied the claim only on this ground. 3. Representative of the company pleaded that claim was not payable as there was discrepancy in the statement of the party. Matter was investigated by the company and investigator recommended to the insurance company that claim was not payable. Company also filed written reply on wherein, it was mentioned that as per FIR weight of chain was 2.55gm but the weight covered in the policy was 25.55gms and thus company concluded that chain was not covered in the policy. The insured had not clarified the loss whether it was by snatching or by theft and thus it was a suspicious loss. 4. I have considered the submissions of the complainant as well as of the representative of the company. I have also perused investigation report, FIR etc. placed on record. After due consideration of matter I hold that company was not justified in repudiating the claim because insured suffered the total loss as her gold chain along with pendent was taken away by some person from her. Such gold jewelry was insured in the policy against all risk. Complainant had complied all requisite formalities for getting the claim. Therefore company was not justified in repudiating the claim. Complainant had suffered a loss and needs to be compensated as per terms and conditions of the policy. Accordingly an Award is passed with the direction to the insurance company to make payment of Rs.48,000(43400 cost of gold chain+ pendent Rs.4600). 5. The award shall be implemented within 30 days of receipt of the same. The compliance of the award shall be intimated to my office for information & record.

7 DELHI OMBUDSMAN CENTRE Case No.GI/363/OIC/11 In the matter of Smt. Sudha Aggarwal. Vs Oriental Ins. Co. Ltd. AWARD DATED :NON SETTLEMENT -TRAVEL TAG INS.CLAIM 1. This is a complaint filed by Smt. Sudha Agarwal. (hereinafter referred to as the complainant) against Oriental Ins. Co. Ltd. (hereinafter referred to as respondent insurance company) relating to non settlement of travel tag insurance claim. 2. Complainant stated that she had taken mediclaim policy. She visited from to Policy covered herself and her spouse Sh.H.P Agarwal. Policy was taken by her from travel Agent Karvat Travel Services Pvt Ltd. Barakhamba Road. Through liaison assistant Mr. Roshanlal Chaurasia. While at abroad in Singapore, she fell seriously ill on and she was diagnosed a case of Pelvic Tumer. She got immediate necessary medical treatment and was advised to undergo surgery. She and her husband decided to return to India as soon as possible for surgery and she returned to India on Immediately on return she submitted the claim papers to Sh. Roshan Lal Chaurasia who in turn gave the claim documents along with original medical documents of Singapore by hand to Karvat Travels Service Office (Sh. Naveen) on which scrutinized the documents and confirmed the compliance on for the purpose of the claim. It is further mentioned by her that Karvat Travel Agency was regularly issuing Oriental Overseas mediclaim policies. She further stated that her claim is 100% genuine. She submitted all requisite documents to the agent within a week. She should not be penalized for the delay attributable to agent. During the course of hearing complainant, pleaded that claim was payable but company denied it due to late submissions of the documents. 3. Representative of the company pleaded that claim was not payable as it was submitted very late. 4. I have considered the submissions of the complainant as well as of the representative of the company. I have also perused the letter dated of insurance company along with its enclosure. After due considerationof matter, I hold that company was not justified in denying the claim because delay in

8 submission of the claim documents was not attributable to the insured because she was in bonafied belief. The documents submitted to the liason agent Mr. Roshanlal Chaurasia must have been handed over to the concern office on time. Accordingly an Award is passed with the direction to the insurance company to make the payment of Indian currency equivalent to Singapoori dollars less deductable as per policy terms and conditions. 5. The award shall be implemented within 30 days of receipt of the same. The compliance of the award shall be intimated to my office for information & record. *****************************************************************************

9 DELHI OMBUDSMAN CENTRE Case No.GI/556/NIA/11 In the matter of Dr. Adarsh. Vs New India Assurance Co. Ltd. 1 This is a complaint filed by Sh. Adarsh Kaur Gakhar (hereinafter referred to as the complainant) against New India Assurance Co. Ltd. (hereinafter referred to as respondent insurance company) relating to non-settlement of loss of Gold chain claim. 1. Complainant submitted that she has a house holder insurance policy of New India Assurance Co. Ltd. since The case at present relates to the house holders insurance policy bearing no /48/10/32/ which covers the period from to She filed a loss claim of gold chain with the pendent having Ruby and Diamond stone on with the insurance company. Company had appointed Mr. B.S Agarwal of ABM Engineers & Consultants as surveyor for the claim. She felt harassed by the surveyor. No report was received by her when the claim was not settled. She had approached the Grievance Redressal Officer of the company. The claim was not settled. She has come to this forum with a request to get the claim settled. During the course of hearing, she stated that she lost her variables and filed the claim. The items which were claimed to have been lost were insured for a sum of Rs. 77,000. She approached the police which also submitted untraced report which was given to the company. Company did not respond to her. 3 Representative of the company pleaded that he needed time to prepare the case. Company had filed written reply dated wherein it was mentioned that complaint was received with the company for the nonpayment of claim under house holder policy bearing no /48/10/32/ Loss was intimated on surveyor was sent for investigation but found that proper FIR was not lodged, complainant had not submitted untraced reports under sec-173 from the court, reasonable care to safeguard the property was not taken. The property on which claim is

10 merely missing and on the basis of the observations claim was repudiated and intimated to the insured on I have considered the submissions of the complainant as well as of the representative of the company. I have also perused the written reply of the company which is placed on record. After due consideration of matter, I hold that company was not justified in repudiating the claim because insured had suffered the loss during the currency of the policy of the items which were duly insured in the policy. The insured did whatever she could have done for settlement of the claim. She had approached the police and the police had also given untraced report which she had submitted to the company. In my considered claim was payable and company ought to have honored the commitment made in the policy. Accordingly an Award is passed with the direction to the insurance company to make payment of Rs. 77, The award shall be implemented within 30 days of receipt of the same. The compliance of the award shall be intimated to my office for information & record. ************************************************************************************