PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE …

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PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN –NEERJA SHAH Case of: MR. VIDHYADHARA P NV/s BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Complaint No:BNG-G-005-1920-0072 Award No: IO/(BNG)/A/GI/0162/2019-20

1 Name & Address of the Complainant Mr. Vidhyadhara PN S/o PM Narayana Gowda, Halesomarasanahalli Village Chamarahalli Post, Kolar BENGALURU – 563 101 Mobile No:9538994493 E-mail: [email protected]

2 Policy No. Type of Policy Duration of Policy/Policy Period

OG-19-9906-1801-00026681 Private Car Package Policy 21.06.2018 to 20.06.2019

3 Name of the Insured/ Proposer Name of the policyholder

Mr. Vidhyadhara PN Self

4 Name of the Respondent Insurer Bajaj Allianz General Insurance Company Limited

5 Date of Repudiation NA

6 Reason for repudiation NA

7 Date of receipt of Annexure VI A 19.08.2019

8 Nature of complaint Inordinate delay in claim processing and Short Settlement of Claim

9 Amount of claim ₹. 79,770/- (including compensation of ₹. 63,000/-)

10 Date of Partial Settlement 03.08.2019

11 Amount of relief sought ₹. 79,770/- (including compensation of ₹. 63,000/-) plus interest

12 Complaint registered under Rule no 13 (1) (b) of Insurance OmbudsmanRules, 2017

13 Date of hearing/place 10.10.2019/Bengaluru

14 Representation at the hearing

a) For the Complainant Self

b) For the Respondent Insurer 1. Mr. Bhaskar, Asst Manager 2. Mr. Syed Basha, Dy. Manager

15 Complaint how disposed PARTIALLY ALLOWED

16 Date of Award/Order 14.10.2019

17. Brief Facts of the Case:

The complaint emanated from the short settlement of claim for damages to the Insured’s vehicle. Complainant approached the GRO of Respondent Insurer (RI), however the claim was not settled in full. Hence, the Complainant approached this Forum for settlement of his claim. 18. Cause of complaint: a. Complainant’s argument:

The Complainant had insured his Ford Figo 1.4 Duratorq Diesel EXI car (2012 model) bearing

Registration no KA 03 MQ 7440 with RI vide policy no OG-19-9906-1801-00026681 from 21.06.2018 to

20.06.2019 for Insured Declared Value (IDV) of ₹. 5,36,326/-.

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The Complainant submitted that while he was travelling from his office in ITPL to his residence in

Halesomarasana Halli on 14.05.2019, at about 6.00 PM, near Haralakunte Village, the vehicle passed

over big stone on the road, followed by dashboard display warning for lube oil and vehicle stopped

immediately. Complainant intimated Ford Dealer and vehicle was towed to Metro Ford,

Lingarajapuram, on the following day. A claim was preferred on the RI vide claim no OC-20-1701-1801-

00002187. Surveyor was deputed and after inspection of vehicle dt 16.05.2019, Sump damage and

Under Chasing Scoring marks were found. During dismantling, it was further observed that Engine

Assembly, Gear Box and Driver Kit Assembly was also damaged.

Complainant was orally denied claim by RI on the ground that he had not taken “Engine Protector”

Add On cover. On his insistence for written confirmation and thereafter repeated follow ups, RI

agreed to consider the claim on 06.06.2019. Complainant contended that there was inordinate delay

of 31 days for claim registration despite giving benefit of 15 days for Grievance Resolution as per

Motor Insurance Hand book. Thereafter vehicle was repaired and delivered on 03.08.2019.

Complainant gave brief summary of expenses incurred on various heads:

Job No. Description Parts Amount Labour

Amount

Total GST

Amount Total Amount

40000 CARRY OUT 220000 KM SERVICE 2127.4

406.7 2534.1

50000 REPLACE DRIVE BELT KIT 2454.23

552.58 3006.81

60000 ATTEND TO SUMP DAMAGE 99401.43 27960.08 27351.86 154713.37

80000 5TH GEAR BOX SEALING 8335.23

2177.42 10512.65

Total 112318.29 27960.08 30488.56 170766.93

Complainant further submitted that total cost of vehicle was ₹.7,50,000/- and IDV value was ₹.

5,36,326/-, but RI has applied depreciation of 40% for Metal, 50% for Plastic and 0% for labour

expenses and subject to salvage value @4% of ₹. 3,685/-, approved ₹. 99,638/- and balance ₹.

71,128.93/- was paid by him.

Complainant submitted that

(a) Salvage Amount deducted from claim amount was not mentioned in the policy document; and

(b) Surveyor has failed to consider that Job no 40000 (Service), 50000 (Drive Belt replacement) and

80000 (Gear Box sealing fixing) are all part of the impact of Job no. 60000 (Sump damage);

and contested that same are payable.

Aggrieved with the short settlement of claim and the poor response from the RI, the Complainant

approached this Forum for settlement of his claim for Rs. 79,770/- plus interest (which includes Rs

13,086 after deduction towards depreciation along with Interest plus compensation of Rs.63,000/-

(@Rs 2,000/- per day for 31 days delay)).

b. Insurer’s argument:

The Respondent Insurer in their Self Contained Note (SCN) dated 20.09.2019, whilst admitting the

insurance, submitted that they had deputed an IRDAI licensed surveyor who in his Provisional Survey

Report stated that damage to Oil Sump had impacted the oil strainer which led to damage of Engine

Internal parts. Further, Surveyor in his report submitted that complainant has replaced additional

parts which are not relevant to the damage and which falls under periodic service maintenance as

vehicle has driven for 220193 kms and hence are not payable. The assessed loss for parts was ₹.

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1,16,855/- and subjected to depreciation amount of ₹. 45,501/-, while assessed loss for labour was ₹.

32,969/-. Of the net assessed amount, Salvage Amount @ ₹. 3,685/- was deducted and compulsory

excess of ₹. 1,000/- imposed as per terms and conditions of the policy.

Further RI contended that complainant had given his consent to Surveyor assessed amount and

denied allegation of deficiency in service and requested for dismissal of complaint with compensatory

costs payable to it.

19. Reason for Registration of complaint:

The complaint falls within the scope of Insurance Ombudsman Rules, 2017and so, it was registered.

20. The following documents were placed for perusal:

a. Complaint along with enclosures, b. SCN of the Respondent Insurer along with enclosures and c. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.

21. Result ofthe personal hearing with both the parties(Observations & Conclusions):

The forum has perused the documentary evidence available on record.

During the personal hearing, both the parties reiterated their earlier submissions.

Complainant vehemently contested that RI has been trying to misguide him regarding his claim and

evaluated the claim for damages in bits and pieces by considering transmission damage and

subsequent service expenses independent of engine damage. Complainant stated that he had insured

his vehicle in full and not on part by part basis.

Complainant produced clarification from Dealer for replacement of disputed parts, which is

reproduced below:

Job No.

Description of Goods Remarks

40000 5W30 - ENGINE OIL was replaced due metal partical was in oil , even servicing was carried out 40000 2S6Z6731C - FILTER OIL

40000 2S6Z6734B - GASKET DRAIN PLUG

Regular Service Item 40000 2S6Z9601B - FILTER AIR CLEANER *

40000 AS6Z19N619C - FILTER A/C FRESH AI

40000 1216529 - WASH FLUID POUCH

40000 W704450S300 - STRAPWIRING

40000 I TAPE - INSULATION TAPE

50000 2S696C301DA - VBELT- RPP As customer complaint found damaged in drive belt and related pullys

50000 2S6Z8678A - PULLEY

50000 2S6Z6A228A - TENSIONER ASSY

60000 W700344S309 - NUT WHEEL wheel nut for sliped

60000 6N2Z8B081C - HOSE RADTR SUPLY TNK Collant hose was having cark

60000 W704450S300 - STRAPWIRING

60000 5N1Z1104B - HUB FRONT WHEEL Found there was bearing internal damage so hub and bearing need to be replace 60000 ACPZ1215A - BEARING FRT HUB OUT

60000 6N2917B718AC - KNOB CONTROL

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80000 6S6Z15520A - SWITCH ASY REV LMP Found there was issue in gear engaging so child parts was replaced in gear box

80000 2S6Z7534A - SPRING CLUTCH CABLE While sudding apply of clutch to stop the vehicle due to weekage the slave cylinder has got leakage and bearing was damaged

80000 7N2Z7B546B - CLUTCH ASSEMBLY

80000 BE8Z7A564A - CLUTCH SLAVE CYL

80000 E4ZZ7A044B - INSERT 3RD &4TH SPEE

Found there was issue in gear engaging so child parts was replaced in gear box

80000 81TZ7A044B - INSERT SYNCHRONISER

80000 YS4Z7109CA - SPRING TRANS SYNCHRO

80000 YS4Z7109AA - SPRING TRANS SYNCHRO

80000 1S6Z7223AA - GSKT TRANS GR SH CON

Furthermore complainant submitted that salvage value was imposed upon him by RI/surveyor without

forming part of terms and conditions of the policy. RI has agreed to settle the deducted amount

subject to taking over the damaged parts from the complainant.

The forum has heard both the parties during personal hearing and observes that the clarification letter

provided by complainant is untenable as the loss has been assessed by an IRDAI approved Surveyor. RI

contested that they have considered the claim for Engine damage only. Any consequential damage to

transmission gear due to engine damage is not payable as per Sec I(2)(a) terms and conditions of the

policy.

The forum also notes that as per Section I(3) of the policy terms and conditions, complainant is

entitled to “reasonable cost of protection and removal to the nearest repairer and redelivery to the

insured but not exceeding in all Rs 1500/- in respect of one accident.” Therefore towing charges are

payable subject to submission of bills by complainant and as per maximum limit stated in the policy. RI

informed that since bills were not submitted by complainant, the same were not reimbursed.

Complainant is therefore advised to submit towing bill for seeking reimbursement towards such

expense.

As regards the request of the Complainant for compensation, the same is beyond the jurisdiction of

this Forum and the Complainant is at liberty to approach the appropriate authority.

AWARD

Taking into account of the facts and circumstances of the case and upon scrutiny of the documents submissions made by both the parties,the forum finds that RI has settled the claim as per assessment of technically competent IRDAI Surveyor and hence this forum does not wish to interfere with quantum of claim settled. Furthermore the forum directs RI to settle expenses deducted for salvage and towing charges subject to surrendering of damaged parts and submission of towing bill respectively by the complainant, as per the terms and conditions of the policy along with interest @ 6.25% + 2% from the date of receipt of last necessary documents to the date of payment of claim, as per regulation 16 (1) (ii) of Protection of Policy holders’ Interests of IRDAI Regulations, 2017 issued vide notification dated 22.06.2017 The Complaint is PARTIALLY ALLOWED.

22) Compliance of Award:

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The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17 (6) of the

Insurance Ombudsman Rules, 2017, whereunder the Respondent Insurer shall comply with the Award

within 30 days of the receipt of the Award and shall intimate compliance of the same to the

Ombudsman.

Dated at Bengaluru on the day of 14th day of October, 2019 (NEERJA SHAH)

INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – NEERJA SHAH

In the matter of: Shri VENKATRAMAN S V/s HDFC ERGO INSURANCE COMPANY LIMITED

Complaint No: BNG-H-018-1920-0083 Award No: IO/BNG/A/HI/0167/2019-20

1 Name & Address of the Complainant Mr VENKATRAMAN S C3-905, L&T South City Apartments, Arakere Mico Layout, BENGALURU – 560 076 Mobile No. 9884719545 E-mail id: [email protected]

2 Policy No. Policy period Type of Policy

2311 1002 3338 5301 001 12.09.2018 to 11.09.2019 Private Car Package Policy


Shri Venkatraman S Self

4 Name of the Respondent Insurer HDFC ERGO General Insurance Company Limited

5 Date of Repudiation 12.08.2019

6 Reason for repudiation/rejection Misrepresentation of facts

7 Date of receipt of Annexure VI A 23.09.2019

8 Nature of complaint Non Settlement of Pre-Hospitalisation Expenses

9 Amount of claim Approx ₹.20,000 to 25,000/-

10 Date of Partial Settlement NA

11 Amount of relief sought Approx ₹.20,000 to 25,000/- plus compensation for delay

12 Complaint registered under Rule no 13 (1) (b) of Insurance Ombudsman Rules, 2017

13 Date of hearing/place 24.10.2019 / Bengaluru



b) For the Respondent Insurer Mr Suresh Gukanti, Manager

15 Complaint how disposed Allowed


17. Brief Facts of the Case The complaint emanated from the rejection of claim on the ground that the there were damages pertaining to previous claim made by the Insured and therefore misrepresentation of facts. The

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Complainant had taken up with the Grievance department of the Respondent Insurer (RI) but same was not considered favourably. Hence, the Complainant has approached this Forum.

18. Cause of complaint: a. Complainant’s argument: Complainant submitted that he had preferred a motor claim (vehicle reg. No TN-22-CC-6764) vide

claim no C230019209349 dt 08.08.2019 under policy no 2311100233385301001 with RI. The accident

happened while he was parking his car in office basement car park. Thereafter survey was done at

Surya Nissan Marathahalli workshop, but he was informed that the claim was rejected as the vehicle

had pre-existing damages. Complainant submitted that he had represented to RI stating he had

claimed for damages only on left side of the car, but surveyor has cited all damages on right side too.

He further submitted photos of vehicle emphasizing new damages (notably near front door – rear left

door boundary section). He admitted to pre-existing damages and contested that same were not

claimed in present claim.

b. Insurer’s argument: The Respondent Insurer in its Self Contained Note (SCN) dt 22.10.2019 admitted insurance and subsequent claim. RI submitted that post submission of claim, surveyor was appointed to ascertain the damage. Surveyor in his survey report dt 15.10.2019 assessed net loss of ₹.54,300/- mentioning that damages to RR Bumper, LHS Front Bumper, Fron/Rear door, LH Quarter panel and front bumper, RH fender portion, H/L RH needed repair, replacement and painting. After detail verification of pre-claim history, RI found that few of the damages claimed were pre-existing and found in another claim no C230019007821. Based on above facts, RI repudiated claim on 12.08.2019. However, since complainant admitted to pre-existing damages, RI re-visited the claim which were relevant to current cause of loss and agreed to consider damages pertaining to Rear LH door, Quarter panel, Bumper assembly and rear tail lamp assembly.

19. Reason for Registration of complaint:

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so, it was

registered.

20. The following documents were placed for perusal:

d. Complaint along with enclosures, a. SCN of the Respondent Insurer along with enclosures along with the enclosures and e. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII A.

21. Result of the personal hearing with both the parties(Observations & Conclusions):

The dispute is with regard to repudiation of entire motor claim by RI.

This Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing.

On intervention of this forum, RI has agreed to consider the claim for damages which are relevant to present cause of loss. During personal hearing, RI estimated the claim liability to approx ₹.24,362/- (plus ₹.3,200/- towards replacement of LH door if need arises during repairs) based on original surveyor estimate report. Since RI has agreed to settle the claim as per terms and conditions of the policy for above, the forum does not wish to go into the merits of the claim.

In view of the above, the Forum directs the RI to settle the claim as agreed.

The Complaint is Allowed.

A W A R D

Taking into account facts of the case, the submissions made by the RI agreeing for the settlement,

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Forum directs the Respondent Insurer to settle the claim as per the terms and conditions of policy along with interest @ 6.25% + 2% from the date of receipt of last necessary documents to the date of payment of claim, as per regulation 16 (1) (ii) of Protection of Policy holders’ Interests of IRDA Regulations, 2017 issued vide notification dated 22.06.2017.

Hence, the complaint is ALLOWED.

22. Compliance of Award: The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award within 30 days of the receipt of the Award and shall intimate compliance of the same to the Ombudsman.

Dated at Bengaluru on the 25th day of October, 2019.

(NEERJA SHAH)


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN- NEERJA SHAH

IN THE MATTER OF: MR. PAVAN KUMAR B V/s ROYAL SUNDARAM GENERAL INSURANCE COMPANY LIMITED

Complaint No: BNG-G-038-1920-0065 Award No.: IO/(BNG)/A/GI/0168/2019-20

1 Name & Address of the Complainant Mr. Pavan Kumar B # 14/1, 1st H G Cross Subbanna Garden Rear K V V Scholol (Pores Golden Nest) BENGALURU – 560 040 Mobile # 97430 44164 E-mail: [email protected]

2 Policy No. Type of Policy Duration of Policy/ Policy Period

VPC1092276000100 Private Car Package Policy 07.03.2019 to 06.03.2020


Mr. Pavan Kumar B

4 Name of the Insurer Royal Sundaram General Insurance Company Limited

5 Date of repudiation 07.06.2019

6 Reason for repudiation Engine damage due to failure of engine inner parts

7 Date of receipt of Annexure VI- A 30.07.2019

8 Nature of complaint Rejection of Motor OD claim

9 Amount of claim ₹. 2,70,000/- 10 Date of Partial Settlement NA

11 Amount of relief sought ₹. 2,70,000/- + Interest

12 Complaint registered under Rule no: 13 (1)(b) of Insurance Ombudsman Rules, 2017

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b) For the Respondent Insurer Mr. B Suneel, A H

15 Complaint how disposed Partially Allowed


17. Brief Facts of the Case: The complaint emanated from the repudiation of the motor car own damage claim on the grounds that the engine got damaged due to failure of inner parts. Despite representing to the Respondent Insurer (RI), his claim was not settled. Hence, the Complainant approached this Forum for settlement of his claim.

18. Cause of Complaint:

a) Complainant’s arguments:

The Complainant obtained the cited policy covering his Hyundai Verna CRDi 1.6 SX car no. KA 02 MK

3273 for the period from 07.03.2019 to 06.03.2020 for an Insured Declared Value (IDV) of

₹.17,50,000/-. His car was involved in an accident and the repair estimate was to the tune of ₹. 9.50

lakhs.

The Complainant was proceeding to Dharmasthala on 09.05.2019 with music and boss on. Enroute

while overtaking a lorry, suddenly the accelerator did not function. Then he stopped the music and

found the engine oil spilled out. He immediately attempted to bring the vehicle to halt to the left side

of the road. On opening the bonnet, it was found that engine oil was leaking. It was about 2.00 AM.

He could not get any help from the insurance company. Toll Police helped him to tow the vehicle to

Advith Motors Private Ltd., Hasan. After explaining the issues and providing the relevant documents,

he left for Dharmasthala.

Surveyor inspected the vehicle after 3 days. He enquired with Insurance officials as the repair work

did not commence after 10 days. It was suggested to wait for another 2/3 days as the matter was

being by their higher officials. Subsequently after a month, the RI rejected the claim vide their letter

dated 07.06.2019 stating that engine was damaged due to failure of its inner parts.

The Complainant approached the Respondent Insurer for consideration of the claim citing the above

reasons. However, his claim was not reconsidered.

Hence, the Complainant approached this Forum for settlement of his claim.

b) Respondent Insurer’s Arguments:

The Respondent Insurer in their Self Contained Note dated 15.10.2019 received by the Forum on

21.10.2019, whilst confirming the policy issuance, submitted that upon claim intimation, an IRDA

licensed surveyor, Mr. C Harish was deputed to assess the loss. In his report dated 05.06.2019, the

surveyor submitted that due to failure of internal parts engine got damaged. Since the damage to

engine inner parts was due to mechanical failure, the same was not payable as per exclusion stating

‘’The Company shall not be liable to make any payment in respect of:- (a) consequential loss,

depreciation, wear and tear, mechanical or electrical breakdown, failures or breakages;’. The engine

did not suffer due to any accidental means. Hence the claim was not admissible and there was

deficiency of service.

The Respondent Insurer prayed for dismissal of the present complaint.

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19. Reason for Registration of complaint:-


registered.

20. The following documents were placed for perusal.

b. Complaint along with enclosures, c. Respondent Insurer’s SCN along with enclosures and d. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): The issues which requires considerations are whether (1) the damages to engine bottom portion was caused due to an accident, (2) the policy covered damage to internal parts of the engine due to accident and (3) there was deficiency on the part of the insured to take preventive measure to avoid further damage. 21.1. During the personal hearing, both the parties reiterated their earlier submissions. 21.2.1. RI rejected the claim on the ground that the engine suffered damages due to failure of its internal parts. When RI’s Representative was requested to explain how engine internal parts suffered damage without engine oil being drained out, they could not substantiate how the internal parts of engine got damaged which resulted in damage to engine, in the absence of leakage of lubricant, engine oil. 21.2.2. The Complainant was asked to explain how the bottom portion of the engine got damaged when the vehicle moved on national highway which is free of obstructions. Except the bottom portion of the engine, no other part(s)/assembly(ies) was/were found damaged. He submitted that the bottom portion of the engine could have probably hit the hump on the road and we could have damaged the bottom portion of the oil sump. 21.2.3. The Complainant further submitted that there was a crack and the same was shown in one of the photographs. When he was questioned how such big hole appeared in the photos seen to the bottom portion of the engine (oil sump), he submitted that he was informed by the repairers the hole was caused whilst dismantling the engine for repairs. As the surveyor arrived belatedly, they got engine removed from its fixtures before his arrival. He further added that the vehicle was taken on hoist and the said crack was shown to the surveyor. 21.2.4. The RI’s representative reiterated that pistons were burnt/damaged to such an extent that the vehicle would have run after draining of the engine oil and the same was supported by the photographs. To a query whether such crack could have developed due to manufacturing defect, he stated that it was not due to manufacturing defect. 21.3.1. The Forum notes that the vehicle ran for about 150 kms before it came to a halt. Starting the journey with such crack, the vehicle would have not have travelled for such a long distance. This crack would have been developed enroute. Probably the vehicle could have been either moving fast on a speed breaker without manoeuvring it as it should be, and the said crack would have developed. 21.3.2. The Complainant was asked to explain why the vehicle was not stopped when the warning signal glows in the dashboard after the oil level reaches below its designated level. He submitted that there was a provision to dim the dashboard glows and he did so.

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21.3.3. However the glow of the oil sump indicator would have to glow which no manufacturer will allow to dysfunction as the very purpose of providing such warnings are defeated if they are allowed to dysfunction. Hence, it is evident that the Complainant did not follow the warning indicator of engine oil reaching less than the desired level which amounts to deficiency on his part which also contributed for said damage. However upon noticing the damage, the insured arranged towing of the vehicle which could be considered that the insured had taken adequate measures to prevent further loss upon noticing the damage. 21.3.4. Thus neither RI could explain to the satisfaction of the Forum that internal parts of engine could get damaged without the engine oil being drained out to substantiate their rejection of the claim nor the Complainant could explain to the satisfaction of the Forum that the engine bottom portion got damaged when the vehicle was moving on a plain surface. 21.3.5. The Forum does not accept the Complainant’s version that the bottom portion of the engine got damaged in the workshop. Having intimated the RI he should have waited for a reasonable period for the surveyor to and assess the damage instead of directing the repairers to dismantle the same. Forum notes that the appointed surveyor reached the workshop within stipulated time limit of 72 hours. It is the regular job of authorised workshop to await the inspection of the surveyor before proceeding for repairs. This is deficiency on the part of the workshop which goes against the Complainant. 21.3.5. Forum notes as explained in the foregoing that the vehicle would have developed enroute crack due to some impact i.e., accidental external means. Hence the Forum extends benefit to settle the claim at 50:50 if the damage to engine was caused due to continuing of the journey after the engine oil got drained from the oil sump and the same was covered under the policy. 21.4.1. It is noted from the policy copy that Aggravation cover (IRDAN102A0001V01201314) is provided. 21.4.2. RI did not provide the coverage details of the add-ons covered under the policy in the terms and conditions submitted to the Forum. Hence the Forum found from website of RI that ‘Aggravation (Damage) Cover Clause is available. It is noted therefrom that ‘The aggravation cover which is also called as Engine Protector covers the damages caused inter-alia to Engine and Gear box caused by leakage of lubricating oil/coolant due to any accidental means and their internal parts, transmission or differential inner parts due to any accidental means’. 21.4.3. As the vehicle was driven after the engine oil got drained out and the said crack being the source for oil drain would have been caused enroute due to accidental external means and the said crack was not due to manufacturing defect, the loss becomes payable under the policy. 21.5. Therefore the rejection of the claim is unjustified and the Forum extends benefit at 50:50. 21.5. SCN was received 2 days before the personal hearing. Had it been submitted earlier, the Forum would have sufficient time to scrutinize it elaborately. RI is advised to ensure to submit SCN sufficiently in advance.

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A W A R D Taking into account of the facts and circumstances of the case and the submissions made by

both the parties and documents submitted during the course of the Personal Hearing, the

Respondent Insurer is advised to settle the claim at 50% of the admissible claim as per the terms

and conditions of the policy.

The Complainant is advised to comply with the requirements of the Respondent Insurer for

settlement of the claim.

The Complaint is Partially Allowed.

22. Compliance of Award:




Ombudsman.

Dated at Bangalore on the 25th day of October, 2019

(NEERJA SHAH)

INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA

(UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN- NEERJA SHAH

In the matter of: MR. SHARATH K V/s ROYAL SUNDARAM GENERAL INSURANCE COMPANY LIMITED Complaint No: BNG-G-038-1920-0069

Award No.: IO/(BNG)/A/GI/0169/2019-20

1 Name & Address of the Complainant Mr. Sharath K # 74, Kallugophalli Village BIDADI HOBLI & POST – 562 109 Ramanagar Tq & Dt., Mobile # 9900009005 E-mail: [email protected]


VPC1017026000100 Private Car Package Policy 22.08.2018 to 21.08.2019


Mr. Sharath K

4 Name of the Insurer Royal Sundaram General Insurance Company Limited


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6 Reason for repudiation Misrepresentation of NCB

7 Date of receipt of Annexure VI- A 12.08.2019

8 Nature of complaint Rejection of claim on the basis of NCB

9 Amount of claim ₹. 21,00,000/- approximately


11 Amount of relief sought IDV of ₹. 11,50,000 /- 12 Complaint registered under Rule no: 13 (1)(b) of Insurance Ombudsman Rules, 2017




b) For the Respondent Insurer Absent

15 Complaint how disposed Partially Allowed


17. Brief Facts of the Case: The complaint emanated from the repudiation of the motor car own damage claim for misrepresentation of the fact with regard to No Claim Bonus (NCB). Despite representing to the Respondent Insurer that he was neither asked to disclose about NCB nor submitted any form regarding the same, his claim was not settled. Hence, the Complainant approached this Forum for settlement of his claim. 18. Cause of Complaint:


The Complainant obtained the cited policy covering his Renault Koleos 4x4 car no. KA 51 MD 2444 for

the period from 22.08.2018 to 21.08.2019 for an Insured Declared Value (IDV) of ₹. 11,50,000/-.

The said insured vehicle was involved in an accident at about 2.30 AM on 10.03.2019. It was reported

to Station House Officer, Kengeri Traffic PS vide letter dated 10.03.2019. As per the said report, when

Dr. Bharat along with Dr. Prabhur and Dr. Haresh were proceeding from Srinivasapura Cross to Mysuru

Road. Near Ishwaiah Bar on RR Nagar Main Road, while moving on a hump, the vehicle went out of

the control and toppled on its left. As a result, the car sustained damages on its front, back, top and

both sides.

The claim was denied vide RI’s letter dated 07.05.2019 stating that a claim was reported under the

previous policy. However NCB was availed without disclosing the same which amounted to

misrepresentation and hence the claim was repudiated.

The Complainant represented to RI stating that while renewing the policy, he was not asked about

NCB and no proposal form was signed by him agreeing to any conditions. Though the policy was

obtained on 22.8.2018, he did not receive any communication from RI for recovery of NCB and only

after 2 months of reporting the claim, he was informed about the payment of NCB. He requested RI to

review their decision as it was not fair to disallow the claim on the grounds of availing NCB. However,

his claim was not reconsidered.

Hence, the Complainant approached this Forum for settlement of his claim.


The Respondent Insurer has not submitted their Self Contained Note.

Page 13 of 151



registered.


e. Complaint along with enclosures, f. Respondent Insurer’s SCN along with enclosures and g. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): The issues which requires consideration are (1) whether the complainant was asked or submitted any declaration about NCB whilst taking the policy, (2) whether the disclosures made in declaration provided in the claim form would amount to mis-representation, and (3) whether the Complainant discharged his obligation of disclosing about the claim in the previous policy whilst taking this policy

21.1.1. The RI was absent during the personal hearing.

21.1.2. The Complainant reiterated his earlier submissions.

21.1. In view of the submission of the complainant that he did not declare any NCB or provide any confirmation about the NCB, the Forum sought the following from the Respondent Insurer:

1. Copy of the proposal form collected while providing the insurance coverage. 2. Any specific declaration obtained from the Insured with regard to NCB? 3. Did they write to the previous insurer for claim history/NCB confirmation? Was it prior to

accident? 4. Did they write to the Insured about the wrong declaration of NCB or when did they ask the

Insured to pay back the NCB amount? 5. Did they notice the alleged wrong declaration of the NCB prior to accident?

The Respondent Insurer did not provide the said information. 21.2. The Forum notes from GR 27 of erstwhile India Motor Tariff (IMT) that the NCB confirmation should be sought within 21 days of obtaining insurance which reads as under: “Notwithstanding the above declaration, the Insurer allowing the NCB will be obliged to write to the policy issuing office of the previous Insurer by recorded delivery calling for confirmation of the entitlement and rate of NCB for the particular Insured and the previous Insurer shall be obliged to provide the information sought within 30 days of receipt of the letter of enquiry failing which the matter will be treated as breach of tariff on that part of the previous Insurer. Failure of the Insurer granting NCB should write to the previous Insurer within 21 days after granting the cover will also constitute as breach of tariff”.

Non-compliance of the IMT provisions would amount to breach of the same. 21.3.1. The policy was taken on 22.08.2018 whereas the accident occurred 10.03.2019 i.e., after about 7 months of taking the policy. RI did not make efforts to find out the veracity of NCB declaration given by the Complainant which caused violation of the above provision. 21.3.2. RI had also an option to obtain the details of claims experience of the previous policy from the website of Insurance Information Bureau of India (governed by IRDAI) immediately after issuance of the policy which they failed to do. RI did not produce any evidence of calling for the claim details from the previous insurer and their reply while finalising the subject policy. Thus RI failed to discharge the

Page 14 of 151

obligation cast upon them to ascertain the NCB particulars of the previous insurer within the timeline and to recover the NCB amount from the Complainant, if he was not entitled for the same. 21.4.1. During the personal hearing, the Complainant confirmed that a claim was preferred in the previous policy but the same was not informed by the Agent through whom the policy got renewed by submitting a copy of the previous policy. However he reiterated that no proposal form was obtained by RI whilst renewing the policy and hence the same not disclosed to them. However he also failed to discharge his obligation to disclose about the claim in the policy even though the proposal form was not collected by RI. 21.4.2. In view of the failure on the part of the both the parties in discharging their obligations, the Forum feels it appropriate to settle the claim in the ratio of 75:25 i.e., the Respondent Insurer shall settle 75% of the admissible claim.

A W A R D

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

both the parties and documents submitted during the course of the Personal Hearing, the

Respondent Insurer is advised to settle @ 75% of the admissible claim amount as per the terms

and conditions of the policy. The Complainant shall submit the relevant documents/bills for

settlement of the claim, as sought by the Respondent Insurer.

The Complaint is Partially Allowed.





Ombudsman.

Dated at Bangalore on the 25th day of October, 2019

(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – NEERJA SHAH In the matter of Shri JOYSON IVAN FERNANDES V/s HDFC ERGO GENERAL INSURANCE COMPANY LIMITED

Complaint No: BNG-G-018-1920-0064

Award No.: IO/(BNG)/A/GI/0160/2019-20 1 Name & Address of the Complainant Shri JOYSON IVAN FERNANDES

# 403, Sri Sai Nivas Enclave 9th Cross, Anantnagar – II, Electronic City BENGALURU NORTH – 560 100 Mob.No. 81052 39720 Mail ID : [email protected]

Page 15 of 151

2 Policy Number Type of Policy Duration of Policy/ Policy Period

2311 2018 5312 3300 000 Private Car Comprehensive Policy 04.08.2017 to 03.08.2018


Shri Joyson Ivan Fernandes Self

4 Name of the Insurer HDFC ERGO General Insurance Company Limited


6 Reason for repudiation Damages not relevant to cause of accident

7 Date of receipt of the Annexure VI-A 18.07.2019

8 Nature of complaint Rejection of claim

9 Amount of claim ₹.10,50,000/-

10 Date of Partial Settlement N.A.

11 Amount of relief sought Settlement of claim and compensation with interest

12 Complaint registered under Rule no: 13 (1) (b) of Insurance Ombudsman Rules, 2017




b) For the Respondent Insurer Mr V R Jayashekara - Manager Litigation & Claims Mr C R Suresh – Manager, Motor Claims



17. Brief Facts of the Case: The complaint emanated from the rejection of claim on the ground that the damages to the vehicle is not due to accident as stated by the Complainant. The Complainant had taken up with the Grievance department of the Respondent Insurer (RI), who had also not considered his request favourably. Hence, the Complainant has approached this Forum. 18. Cause of Complaint: a) Complainant’s arguments: The Complainant’s submission was that he had insured his 2016 model Scoda car bearing Registration No. KA-01-MN-7119 for an IDV (Insured’s Declared Value) of ₹.10,80,000/- with ‘Zero’ depreciation and ‘Return to invoice’ clauses with the above mentioned RI. On 12.07.2018 night, he was going towards Hebbal and while avoiding hitting a 2 wheeler dragged the car to left and ended up hitting the under construction drainage beside the road. He was stuck inside the car and people around came to his help and got him out of the car. After taking photos, the car was towed to the dealer’s garage on the same night. He submitted all the documents required by the RI/Surveyor/Investigator and inspite of several follow up and extending full co-operation, there was no response. Finally, his claim was rejected on assumed facts and myths. Then, he approached the GRO for reconsideration but the same was in vain. Hence, he approached

this Forum.

b. Respondent Insurer’s Arguments:

The Respondent Insurer submitted in their Self-Contained Note dated 24.09.2019 admitting the

insurance with Engine protection cover, cost of consumables and emergency assistance, preferring of

claim with an estimate for ₹.12,32,291/- and their rejection. It is submitted that post receipt of claim,

an IRDA approved surveyor was appointed who had assessed the loss at ₹.10,61,900 and observed

that the damages do not correlate to the loss. RI submit that concurred with the observations of the

surveyor and as there were inconsistency, they had appointed an investigator. The investigator has

made the following observations:

Page 16 of 151

As per Complainant’s version, vehicle was towed to the garage on 12.07.2018, whereas the

vehicle was reported to the garage on 14.02.2018

Damage impact of the bonnet is not matching with concrete stone where insured car rested

Rear left wheel differs from the rest 3 wheels

Left portion of the car had a damage and deep cut scratched on both the doors, whereas no

hard portion to the road to have such impact on car

Complainant has stated that he car was toppled to its right side, whereas no damages seen to

the right side mirror and right windows

Regardless of the severity of the impact, air bags were not deflated

The Complainant shared the photographs taken by him at 22.23, whereas the vehicle met with

accident at 22.20 and he was stuck inside the vehicle was 30 minutes

The towing vehicle arrive 60 minutes after the accident, whereas the image shared by the

Complainant at 23.28 towing vehicle had already arrived

Towing bill produced is not genuine as the said business was closed as on date of accident.

As there were lot of inconsistencies and the loss had no relevance to the cause of accident, claim was

repudiated.


The complaint falls within the scope of the Insurance Ombudsman Rules, 2017.


h. Complaint along with enclosures, i. Respondent Insurer’s SCN along with enclosures and j. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A

21. Result of personal hearing with both the parties (Observations & Conclusions): The dispute is for rejection of claim of the ground that the cause of loss is not relevant to the damages. The Complainant submitted that he is an Automobile engineer and reiterated his contentions in the Complaint and drew the attention of this Forum to the CD submitted by him. He explained the sequence of events resulting in damages to the vehicle. He clarified that if the seat belt remains intact there is possibility of non ejaculation of air bag. He stated that he had submitted all the supporting photographs and that an assurance to settle the claim on ‘Total Loss’ was given by the RI’s representative in presence of Mr C R Suresh – Manager, Motor Claims, who was present during the hearing and the same was not disputed by the RI. RI reiterated their contentions mentioned in their Self contained note and vehemently submitted that there is no possibility of such damage as narrated by the Complainant at that place. It was explained that by oversight date is mentioned as 14.02.2018 and the same should be read as 14.07.2018. As regards the contention of the Complainant that the RI had assured settlement, it was contended that subsequent to the offer, new facts came to their knowledge and hence the decision of repudiation was taken. This Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing.

Page 17 of 151

RI is relying on investigation report dated 23.02.2019. It is not in dispute that the vehicle had met with an accident. It cannot be defined that the accident should result in a particular type and extent of damages. It is the possibility and probability of the damages depending on the circumstances. In the instant case as narrated by the Complainant, the vehicle toppled resulting in damages. In particular, when the owner/driver is travelling in the vehicle, it is not fair to expect him to narrate as to how and to what extent the vehicle was damaged as he will be inside the vehicle. He will be able to narrate only on the basis of probability and possibility. RI contended that the damages to the Insured vehicle do not correlate to the loss mentioned in the claim form, whereas the surveyor has assessed the loss at ₹.10,61,400/- considering the damages which are relevant to the extent of damages. In view of the above, the Forum extends the benefit in favour of the Complainant and directs the RI to settle the claim as per the terms and conditions of policy. No order as to payment of interest. The Complaint is Allowed

A W A R D

Taking into account of the facts and circumstances of the case, the documents the oral submissions made by both the parties, the Forum extends the benefit in favour of the Complainant and directs the RI to settle the claim as per the terms and conditions of the policy. No order as to payment of interest. Hence, the complaint is ALLOWED.


The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award within 30 days of the receipt of the Award and shall intimate compliance of the same to the Ombudsman.

Dated at Bangalore on the 11th day of October, 2019.

( NEERJA SHAH)

INSURANCE OMBUDSMAN



OMBUDSMAN – NEERJA SHAH In the matter of: MR. ALOK MISHRA Vs BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Complaint No: BNG-G-005-1920-0070 Award No: IO(BNG)/A/GI/0161/2019-20

1 Name & Address of the Complainant Mr. Alok Mishra Flat No. B 1002, Pride Spring Field Apts, Uttarahalli, BENGALURU – 560 061 Mobile No.: 7337878943 E-mail: [email protected]

Page 18 of 151


OG-20-9906-1802-00037785 Two Wheeler Package Policy 10.05.2019 to 09.05.2020

3 Name of the Insured/Proposer Name of the Insured Person

Mrs. Alora Mishra (Wife) Self


5 Date of Repudiation NA

6 Reason for repudiation NA

7 Date of receipt of Annexure VI-A 23.08.2019

8 Nature of complaint Short settlement of the claim

9 Amount of claim ₹. 25,711/-

10 Date of Partial Settlement 12.08.2019

11 Amount of relief sought ₹. 20,000/-

12 Complaint registered under Rule no. 13 (1) (b) of Insurance Ombudsman Rules, 2017



a) For the Complainant Absent

b) For the Respondent Insurer Mr. Bhaskar, Asst. Manager Mr. Syed Basha, DM

15 Complaint how disposed Dismissed


17. Brief Facts of the Case: - The complaint emanated from the short settlement of the two wheeler claim. Respondent Insurer (RI) has paid only ₹. 13,800/- against the bill amount of ₹. 25,711/-. Hence, the Complainant approached this Forum for settlement of his balance claim amount. 18. Cause of Complaint: - a) Complainants argument: The Insured obtained the cited policy from RI for the period from 10.05.2019 to 09.05.2020. Complainant submitted a claim with RI for the damages caused to his two wheeler Activa (registered in his wife’s name) on 06.06.2019. The bill is around ₹. 28,000/- out of which claim amount evaluation was around ₹. 23,000/- of which RI paid only ₹. 13,000/-. As per insurance details it should be 75% of the evaluated value as the vehicle is more than 3 years but less than 4 years old. It is further submitted that he has not got delivery of the vehicle. b) Respondent Insurer’s Arguments:

The Respondent Insurer, in their Self Contained Note dated 30.08.2019 whilst admitting the insurance coverage, submitted that claim was preferred for the damages caused to the two wheeler of the complainant on 06.06.2019. The surveyor was immediately appointed who assessed the damage to the extent of ₹. 13,800/-. It is submitted that amount assessed by the surveyor was agreed by the complainant through mail 26.06.2019 and the same is credited on 12.08.2019 towards full & final settlement. It is submitted that the claim was settled as per the terms and conditions of the policy and complainant is not entitled for any further amount from RI. Hence, the Respondent Insurer prayed for dismissal of the complaint.

19. Reason for Registration of Complaint: -

The Complaint was registered as it falls within the scope of the Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal: - a. Complaint along with enclosures, b. SCN of the Respondent Insurer along with enclosures along with the enclosures and

Page 19 of 151

c. Consent of the Complainant in Annexure VI A & Respondent Insurer in Annexure VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): -

The issues which require consideration is whether there is any short settlement of the claim.

Complainant was absent during the personal hearing.

During the personal hearing, representative of RI reiterated their earlier submissions.

The Complainant in his complaint letter to this forum mentioned that as per policy schedule, amount

payable should be 75% of the evaluated value as the vehicle is more than 3 years but less than 4 years

old.

The Forum noted from the final survey report dated 18.06.2019 that surveyor has assessed the net

amount of loss as ₹. 13,800/- (which includes both parts and labour charges).It is observed from the

report that the surveyor has assessed the loss without prejudice. For metal parts, the depreciation is

25% and for plastic parts depreciation is 50% whereas labour charges are allowed completely without

any deduction which is as per section I: Loss or damage to the vehicle insured, of the policy schedule.

It is also noted from the mail sent by the complainant through his email id ([email protected])

that he agreed with the ₹. 13,800/- as final settlement for the insurance.

The forum observed that the assessment done by the surveyor is correct and RI had paid the same to

the complainant. The forum is in accordance with the decision of RI and hence, the complaint is

dismissed.

AWARD Taking into account of the facts and circumstances of the case and upon scrutiny of the documents

submitted by both the parties, the rejection of the claim by the Respondent Insurer is found to be

in order and in consonance and does not require any interference at the hands of the

Ombudsman.

The Complaint is Dismissed.

Dated at Bengaluru on the 11th day of October, 2019 (NEERJA SHAH)


mailto:[email protected]

Page 20 of 151


OMBUDSMAN – Mrs NEERJA SHAH In the matter of Shri SANJAY PATEL V/s BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Complaint No: BNG-G-005-1920-0066

Award No.: IO/(BNG)/A/GI/0163/2019-20 1 Name & Address of the Complainant Shri SANJAY PATEL

No. 155, , Yediyala V & P, Hullahalli Hobli Nanjangud Taluk, MYSORE District – 571 315 Mob.No. 99012 95634 / 9844609035 Mail ID : [email protected]


OG-19-4400-1803-00000002 Passenger Carrying – 4 Wheeler 31.10.2018 to 30.10.2019


Shri Sanjay Patel Self


5 Date of repudiation/rejection 28.01.2019

6 Reason for repudiation Delayed intimation and discrepancy in driver’s name

7 Date of receipt of the Annexure VIA 01.08.2019

8 Nature of complaint Rejection of claim

9 Amount of claim Damage caused to vehicle

10 Date of Partial Settlement N.A.

11 Amount of relief sought Loss to vehicle repair cost not estimated





b) For the Respondent Insurer Mr Bhasker.T- AM & Mr Syed Basha - DM

15 Complaint how disposed Allowed in Part


17. Brief Facts of the Case: The complaint emanated from the rejection of claim for the damages to the car on the ground that the owner cum driver was not having a valid Driving Licence (DL) to drive LMV-Cab as on the date of accident. Despite his taking up the matter with the GRO of Respondent Insurer (RI), the claim was not settled and hence, he has approached this Forum to get his claim. 18. Cause of Complaint: a. Complainant’s arguments: The Complainant’s submission was that he is the registered owner of 2016 model Nissan motor cab bearing registration number KA-02-AF-5885 for an Insured’s Declared Value (IDV) of ₹.7,65,000/-. His vehicle met with an accident on 18.12.2018. As he took yellow board vehicle for the first time and had no experience, he had submitted all the documents to the RI and his claim was rejected on the ground that he is not authorised to drive the said vehicle. Due to his financial difficulty, he had given the vehicle on lease to another person and he is responsible for the accident. The said lessee had absconded after the accident and hence, he gave his DL to the RI. Then, he approached the GRO for reconsideration but the same was in vain. Hence, he approached

this Forum.


Page 21 of 151

The Respondent Insurer submitted their Self-Contained Note dated 14.08.2019 admitting insurance of

the vehicle as Commercial Package policy. The intimation about the accident to vehicle on 18.12.2018

was given on 03.10.2019, which is violation of conditions of policy. As per the claim documents, the

driver was not authorised to drive LMV-Transport vehicle, whereas he was authorised only to drive

LMN Non-transport vehicle and is violation of Sec 3 (1) of MV Act and hence, claim was repudiated.

The Complainant had stated that he himself was driving the vehicle and after the repudiation of the

claim stated that the vehicle was given on lease and was driven by someone. The said mis-

representation constitutes fraud within the meaning of section 17 and is breach of section 18 of Indian

Contract Act. RI had deputed an independent surveyor who had assessed the loss at ₹.2,52,176/-

subject to the terms and conditions of the policy. RI contend that the repudiation of claim is as per the

terms and conditions of policy.




k. Complaint along with enclosures, l. Respondent Insurer’s SCN along with enclosures and m. Consent of the Complainant in Annexure VI-A & and Respondent Insurer in VII-A

21. Result of personal hearing with both the parties (Observations & Conclusions): The dispute is for rejection of claim on the ground that the complainant was driving the vehicle and his Driving licence was not valid as on the date of accident. On perusal of the document available on record, it is noticed that the Complainant was authorised to drive LMV upto 28.11.2026 and LMV – Transport upto 23.07.2018, whereas the accident took place on 18.12.2018. The DL for transport has been renewed after the accident and valid upto 29.01.2022. The hon’ble Supreme Court in Civil Appeal No.5826 of 2011 – Mukund Dewangun Vs Oriental Insurance Company has held that that a person authorised to drive LMV Motor car can also drive LMV Motor cab and Forum relying on the said judgement holds that the Complainant cannot be penalised for the same and the rejection is not in order. During the personal hearing, the Complainant reiterated his contentions and submitted that he was not aware of procedures and due to panic there was confusion in submitting the information. As the Lessee was absconding, he was advised by the dealer to submit that he was driving the vehicle at the time of accident. The Complainant followed the advice without any malafide intention. RI reiterated their contentions and contended that their decision is based on the documents on record and the terms and conditions of policy. Attention of the RI was drawn to the above decision of the hon’ble Supreme court, RI submitted that the following fresh facts have come to light after registering the complaint with this office:

The Complainant had mentioned in the claim form that he himself was driving the vehicle.

After the repudiation of claim he mentioned that that the vehicle was given on lease and was driven by someone else, which is misrepresentation of facts.

The Forum on perusal of the documents on record has noted that the Complainant had entered into a rental agreement with Shri R Ravinandan for the period 09.09.2018 to 09.03.2019. As per the said

Page 22 of 151

agreement, the maintenance of the vehicle is by the owner and in case of an accident, the lessee should make good the loss in case of an accident to the vehicle and the said person is absconding after the accident. The RI has failed to produce any evidence/document to establish that the vehicle was driven by a person who is not authorised to drive at the relevant time of accident. Forum observed that the ground of repudiation has been changed by the RI after receipt of notice from this office and the same is not acceptable. Forum considering the merits of the Complaint, directs the RI to settle the claim for 50% of the assessed loss as per the terms and conditions of policy. The Complaint is allowed in part.

A W A R D Taking into account of the facts and circumstances of the case, the documents and the oral submissions made by both the parties, the Forum considering the merits of the Complaint, directs the RI to settle the claim for 50% of the assessed loss as per the terms and conditions of policy. The Complaint is allowed in part.

23) Compliance of Award:

The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the

Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award


Ombudsman.

Dated at Bengaluru on the 16th day of October, 2019.

( NEERJA SHAH) INSURANCE OMBUDSMAN



OMBUDSMAN- NEERJA SHAH In the matter of SHRI SANDEEP G PUJARI V/s ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED

Complaint No: BNG-G-020-1920-0081 Award No.: IO/(BNG)/A/GI/0165/2019-20

1 Name & Address of the Complainant Shri SANDEEP G PUJARI # 132, Madhura Chetana Colony Near SBI School, Kusugal Road H U B B A L L I – 580 023 Mob.No. 88929 20011 Mail ID : [email protected]


3004/MI-06827588/00/000 Package Policy (Commercial Vehicle-Pass Carrying) 29.12.2018 to 28.12.2019


Shri Sandeep Pujari Self

Page 23 of 151

4 Name of the Respondent Insurer ICICI Lombard General Insurance Company Limited

5 Date of repudiation/rejection 01.06.2019

6 Reason for repudiation/rejection Permit not valid as on date of loss


8 Nature of complaint Rejection of Motor Claim

9 Amount of claim ₹.7,26,351/-


11 Amount of relief sought ₹.7,26,351/- + costs

12 Complaint registered under Rule no: 13(1)(b)of Insurance Ombudsman Rules, 2017




b) For the Insurer Varsha Nair, Manager – Legal Mr Sanjeev K S, Claims Manager, Motor



17. Brief Facts of the Case: The complaint emanated from the rejection of claim for damage to the vehicle on the ground that the vehicle was not having a valid permit as on the date of loss. Despite his taking up the matter with the GRO of Respondent Insurer (RI), his request was not reconsidered and hence, he has approached this Forum to get compensation. 18. Cause of Complaint:

a. Complainant’s arguments: The Complainant’s submission was that he had insured his 2018 model

Maruti Ertiga for an IDV (Insured’s Declared Value) of ₹.9,48,125/- with the above mentioned RI as a

Passenger carrying vehicle with ‘NIL depreciation clause. He purchased the above vehicle and obtained

a temporary permit for tourist passenger carriage from RTO. For obtaining ‘Speed Governor’ was

mandatory and the dealer had no stock till the validity of Temporary permit. He paid all India permit

fee including penalty/fine on 24.04.2019. His vehicle met with accident on 24.04.2019 at about 1.30

AM, had submitted an estimate for ₹.7,26,350.62 and the same was assessed for total loss. His claim

was rejected on the reason ‘Permit not valid at the time of accident’.

He submit that he learnt after purchasing the vehicle that the said vehicle cannot be registered under

tourist permit. He contends as to how the RI agreed to give insurance coverage without installation of

speed governor and alleges malicious intentions of dealer and insurer. Hence, he approached this

Forum for justice.


The Respondent Insurer submitted in their Self-Contained Note dated 15.10.2019 admitting the

insurance coverage, preferring of claim and their rejection. It is stated that on receipt of claim

intimation, RI had deputed surveyor to assess the loss. It was observed by him that the vehicle had

temporary registration and the same had expired on 24.04.2019. The investigation also revealed that

the vehicle was registered after the accident whereas it had run 16524 Kilometers within 4 months. As

the vehicle was used in violation of policy terms and conditions and in contravention of 39 of Motor

vehicles act, claim was rejected and RI has relied on the decision of Narinder Singh Vs New India

Assurance Company Limited decided on 04.09.2014.



Page 24 of 151


a. Complaint along with enclosures, b. Respondent Insurer’s SCN along with enclosures and c. Consent of the Complainant in Annexure VI-A & and Respondent Insurer in VII-A

21. Result of personal hearing with both the parties (Observations & Conclusions): The dispute is for rejection of claim on the ground that the vehicle was not having a valid permit as on the date of accident. The Complainant reiterated his contentions in the complaint and has put the blame on the dealer and RI and RI reiterated their contentions and submitted that they relied on section 39 of MV act. As reliance is placed on Motor vehicles act, the relevant section is reproduced:

Section 39 in The Motor Vehicles Act, 1988 Necessity for registration.—No person shall drive any motor vehicle and no owner of a motor vehicle shall cause or permit the vehicle to be driven in any public place or in any other place unless the vehicle is registered in accordance with this Chapter and the certificate of registration of the vehicle has not been suspended or cancelled and the vehicle carries a registration mark displayed in the prescribed manner: Provided that nothing in this section shall apply to a motor vehicle in possession of a dealer subject to such conditions as may be prescribed by the Central Government.

Forum noted that as per the policy under the head ‘Limitations as to use : The policy covers use only under a permit within the meaning of the Motor Vehicle Act, 1988 or such a carriage falling under Sub section 3 of Section 66 of Motor Vehicle Act, 1988.

This Forum has perused the documentary evidence available on record and noted that the vehicle was purchased on 29.12.2018, temporary permit obtained for the period 29.12.2018 to 28.01.2019 and insured from 29.12.2018. The vehicle met with an accident on 24.04.2019 at about 1.30 AM, whereas the all India permit fee was paid on 24.04.2019, which is after the accident. Hence, the vehicle was not having a valid registration and also valid permit as on the date of accident. Forum has perused the decision of the hon’ble Supreme Court of India in Civil Appeal No. 8463/2014 decided on 04.09.2014, where the facts of the case are identical. Forum is relying on the decision of hon’ble Supreme Court in Civil appeal No.2253 of 2018 decided on 17.05.2018, wherein appeal filed by the owner of the vehicle challenging the rejection on the ground that the vehicle had no valid permit as on the date of accident was dismissed. As the Complainant has failed to establish that the vehicle was having a valid permit as on the date of loss, the Forum concurs with the decision of the RI in rejecting the claim as per the terms and conditions of policy. The Complaint is Dismissed.

A W A R D Taking into account of the facts and circumstances of the case and the submissions made by both

the parties and documents submitted during the course of the Personal Hearing, the decision of

the Respondent Insurer is in consonance with the terms and conditions of the policy and does not

warrant any interference at the hands of the Ombudsman.

Hence, the Complaint is Dismissed. Dated at Bangalore on the 24th day of October, 2019.

(NEERJA SHAH) INSURANCE OMBUDSMAN


Page 25 of 151


OMBUDSMAN – Mrs NEERJA SHAH In the matter of Smt JAYALAKSHMI V/s STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED

Complaint No: BNG-H-044-1920-0192

Award No.: IO/(BNG)/A/HI/0109/2019-20

1 Name & Address of the Complainant Smt JAYALAKSHMI 3/1, Opp. to Anjali Convent, 2nd Main, 10th Cross Srinivasanagara, Sunkadakatte BENGALURU – 560 091 Mob.No. 99644 7419 Mail ID : [email protected]


P/141135/04/2019/000226 Mediclassic Accident Care (Individual) Insurance Policy

24.09.2018 to 23.09.2019


Smt Jayalakshmi Self

4 Name of the Respondent Insurer Star Health and Allied Insurance Company Limited


6 Reason for repudiation Claim within waiting period


8 Nature of complaint Repudiation of claim

9 Amount of claim ₹.75,000/-


11 Amount of relief sought ₹.75,000/-





b) For the Respondent Insurer Mr Mahadevan, Consultant Dr. Umadevi.M.P, Sr. Manager



17. Brief Facts of the Case:

It is a case of repudiation of mediclaim on the ground that the treatment is for degenerative disease

and not covered until 2 years of continuous coverage. The Complainant took up the matter with the

Grievance Cell of the Respondent Insurer (RI) and the same was not considered favourably.



The Complainant’s submission was that she obtained the policy with the RI from 24.09.2018. During January 2019, while climbing stairs carrying a bucket full of clothes, she slipped and sustained injury. After Scan and MRI, her doctor advised surgery and gave quotation for ₹.1,20,000/-. Her request for cashless was denied and RI advised her to approach for reimbursement. As she was not having money,

Page 26 of 151

she got the operation done at St. Martha’s Hospital, Bengaluru by paying ₹.55,000/-. Her claim was rejected. The approach to Grievance also did not yield any result and hence, the Complainant had approached this Forum.


RI submitted their Self Contained Note dated 19.09.2019 admitting coverage for ₹.2,00,000/-, preferring of claim for ₹.53,244/- during the 5th month of policy. The Complainant had submitted a request for cashless facility. On perusal of claim documents, it is observed from the consultation paper dated 25.01.2019 that the patient had dislocation 4 week back. As previous treatment records and MRI report was not available, cashless request was denied. She was admitted to St. Martha’s Hospital on 14.02.2019 with history of fall about 5 weeks ago. She was diagnosed as ‘Left Shoulder Periarthritis and type 3 SLAP Tear’. Subsequently, the Complainant submitted papers for reimbursement and on perusal of the MRI report did not confirm injury. As per discharge summary, the patient had undergone treatment for Musculoskeletal System.

As the treatment was primarily for degenerative disease of Musculoskeletal System during the 1st year of policy, claim was rejected as per Exclusion No. 3 of the policy. The claim was rejected as per the terms and conditions of policy.

Hence, RI has requested to absolve them from the complaint made.


The complaint falls within the scope of the Insurance Ombudsman Rules, 2017


a. Complaint along with enclosures, b. Respondent Insurer’s SCN along with enclosures and c. Consent of the Complainant in Annexure VIA & and Respondent Insurer in VII A

21. Result of personal hearing with both the parties (Observations & Conclusions): The present dispute is for rejection of claim on the ground that the treatment for musculoskeletal system during the 1st year of policy and not payable under exclusion no.3 of the policy. This Forum has perused the documentary evidence available on record and the submissions made by both the parties during the personal hearing. The complainant reiterated her contentions in the complaint and submitted that she went to the hospital as she was injured accidentally. The RI reiterated their contentions stated in SCN and submitted that their decision was based on the medical records and as per the terms and conditions of policy. The consultation report dated 25.01.2019 of Dr S Janardhan indicates that the patient history of dislocation 4 weeks back. The impression as per MRI report of Padmashree Advanced Imaging Services dated 29.01.2019 is ‘suggestive of adhesive capsulitis, with type II SLAP lesion involving the gleniod labrum’. As per the discharge summary of St. Martha’s hospital patient was diagnosed to have ‘Left Periarthritis’. As per the information available on public domain ‘The condition usually develops spontaneously as a painful shoulder without any definite relation to injury, but in 20 to 30 per cent of the cases it may be associated with very definite injury such as a fall on the shoulder or after a fracture of the wrist’.

Page 27 of 151

The RI has not produced any document/evidence to establish that the treatment is for degenerative disease of Musculoskeletal system. The Forum extends the benefit in favour of the Complainant and directs the RI to settle the claim as per the terms and conditions of policy with interest. The complaint is Allowed.

A W A R D Taking into account of the facts and circumstances of the case, the documents the oral submissions made by the RI, this Forum is of the opinion that the decision of the Respondent Insurer in rejecting part of the claim for hospitalisation is not in accordance with the terms and conditions of policy and not found to be in order. This Forum directs the Respondent Insurer to settle the claim as per the terms and conditions of policy along with interest @ 6.25% + 2% from the date of receipt of last necessary documents to the date of payment of claim, as per regulation 16 (1) (ii) of Protection of Policy holders’ Interests of IRDA Regulations, 2017 issued vide notification dated 22.06.2017. Hence, the complaint is ALLOWED.

22. Compliance of Award: The attention of the Complainant and the Respondent Insurer is hereby invited to Rule 17(6) of the Insurance Ombudsman Rules, 2017, where under the Respondent Insurer shall comply with the Award within 30 days of the receipt of the Award and shall intimate compliance of the same to the Ombudsman.

Dated at Bengaluru on the 03rd day of October, 2019.

(NEERJA SHAH) INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF M.P. &

C.G.

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Mrs. Phoolmati Shah…..……………………………………….. Complainant

V/S

The National Insurance Co. Ltd ……………………….……………Respondent

COMPLAINT NO: BHP-G-048-1819-0036 ORDERNO: IO/BHP/A/GI/0083/2019-2020

1. Name & Address of the

Complainant

Mrs. Phoolmati Shah,

Thana-Waidhan, Teh.&Dist.Singrauli

2. Policy No:

Type of Policy

Duration of policy/Policy period

32120031166165001140

Private car package policy

09.10.2016 to 08.10.2017

Page 28 of 151

Mrs. Phoolmati Shah (Complainant) has filed a complaint against The National Insurance

Co. Ltd.(Respondent) alleging rejection of vehicle claim.

Brief facts of the Case -The complainant has stated that her vehicle No. MP-66-C-1419

was insured with respondent from 09.10.2016 to 08.10.2017. Vehicle got stolen on

27.10.2016 for which an FIR No. 0309/2016 was lodged by the driver of the vehicle at

Police Station Chitrangi. The driver of the vehicle on the way gave lift to two

unknown persons on the way and after sometime driver had stopped the vehicle near

village Basaniya, Thana Chitrangi for nature’s call. On his return he found that the

vehicle was not seen at spot and stolen by those unknown persons. He lodged the claim

with the respondet but respondent had repudiated the claim. The complainant has

approached this forum for payment of his claim.

The respondent in their SCN have stated that as per FIR the insured did not take

proper precautions regarding safety of his vehicle which is in clear violation of condition

Nof.4 of private car package policy. The vehicle was driven by the driver of complainant

who permitted unknown persons as passengers on rent to travel in the vehicle and had

not taken any precaution to safeguard the safety of the vehicle.

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

respondent, while respondent have filed SCN with enclosures.

3. Name of the insured

Name of the policyholder

Mrs. Phoolmati Shah

-same-

4. Name of the insurer The National Insurance Co. Ltd

5. Date of Repudiation/ Rejection 04.05.2018

6. Reason for Repudiation/

Rejection

Violation of policy condition

7. Date of receipt of the Complaint 28.05.2018

8. Nature of complaint Non settlement claim

9. Amount of Claim Rs.4,38,500/-

10. Date of Partial Settlement --

11. Amount of relief sought Rs.4,38,500/-

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

2017

13. Date of hearing/place On 01.10.2019 at Bhopal

14. Representation at the hearing

For the Complainant Mr Bhagwandas Shah, Husband

For the insurer Mr O P Gupta, Sr Divisional Manager

15. Complaint how disposed Dismissed

16. Date of Award/Order 01.10.2019

Page 29 of 151

I have heard both the parties at length and perused paper filed on behalf of the

complainant as well as the Insurance Company.

The claim under above policy was repudiated on the ground that the driver of the vehicle

had allowed unknown persons to travel on rent in the vehicle and when he had gone for

nature’s call he had not taken steps to ensure proper safety of the vehicle which is

violation under Clause No.4 of the policy conditions. FIR No.0309/2016 under Section

379 was lodged on the written application by the driver of the vehicle, Mr Ambika

Prasad Shah on 27.10.2016 at 18.25 hrs at police station, Chitrangi. In written complaint

given to police station, it has been mentioned that on the date of incidence he was going

for some personal work and when he was going from Bus Stand to Chitrangi, two

persons met him and told that their relative is ill at Chitrangi and they sat in the middle

row of the vehicle. At 1115 hrs when he reached Gram Basaniya, he stopped the vehicle

for urination on the side of the road, then unknown persons had started the vehicle and

got stolen the vehicle with registration certificate. In complaint to this forum, the

complainant has mentioned that his driver stopped the vehicle and after getting down the

unknown persons, locking the vehicle, went for latrine and took the keys with him. After

some time when he returned from latrine the vehicle was not there. The complainant had

not mentioned the above facts mentioned in the complaint to this forum in FIR. It is

pertinent to mention here that in the FIR there is no mention of locking the vehicle,

getting the unknown persons out of the vehicle and taking the key by the driver. No

proof of above facts could be produced by the complainant. Hence from FIR it is evident

that the driver of the vehicle had not taken proper security to safeguard the vehicle and

was apparently careless in this respect. Clause No. 4 of the policy condition states that

the insured shall take all reasonable steps to safeguard the vehicle from loss or damage

and to maintain it in efficient condition and the company shall have at all time free and

full access to examine the vehicle or any part thereof or any driver or employee of the

Insurer. In the event of any accident or breakdown the vehicle shall not be left unattended

without proper precautions being taken to prevent further damage or loss and if the

vehicle be driven before the necessary repairs are effected any extension of the damage

or any further damage to the vehicle shall be entirely at the insured’s own risk. As in this

case the driver of the vehicle had not taken any steps to safeguard the vehicle and was

careless in this respect, the complainant has violated the above condition of the policy.

Page 30 of 151

In view of above facts and circumstances, I come to the conclusion that the respondent

has rightly repudiated the claim as the complainant has violated the terms and conditions

of the policy. Therefore the complaint is liable to be dismissed.

The complaint filed by Mrs Phoolmati Shah stands dismissed herewith.

Let copies of the award be given to both the parties.

Dated : Oct 01, 2019 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman

Mr. Anil Edwin…………………..……………..………………….…….. Complainant

V/S

United India Insurance Co.Ltd…………………………….…..………...…Respondent

COMPLAINT NO: BHP-G-051-1819-0051 ORDER NO: IO/BHP/A/GI/ 0087 /2019-

2020


Complainant

Mr. Anil Edwin,

T 10, Parshaw Stuti colony,

Krishna Nagar, Coach Factory Road,

Bhopal

2. Policy No:

Type of Policy


1911013117P105357812

Private Car Package Policy

07.07.2017 to 06.07.2018



Mr. Anil Edwin

-same-

4. Name of the insurer United India Insurance Co. Ltd.

5. Date of Repudiation/ Rejection --


Rejection

--


8. Nature of complaint Partial Repudiation of motor claim

9. Amount of Claim Rs.80,000/-

10. Date of Partial Settlement 11.04.2018

11. Amount of relief sought --

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


For the Complainant Mr Anil Edwin

For the insurer Mr Ashish Khatri, Sr Branch Manager



Page 31 of 151

Mr. Anil Edwin (Complainant) has filed a complaint against United India Insurance Co.

Ltd. (Respondent) alleging partial repudiation of claim.

Brief facts of the Case - The complainant has stated that his Swift Desire Car MP 04 CP

5785 was insured with the respondent company vide above policy. On 19.10.2017 at

around 3.05 am on the Indore Bhopal highway his vehicle met with accident while he

was trying to avoid a cow on the road and in the process his car overturned and fell in the

nearby field. At the time of incidence, he was alone in the car and nobody was there with

him who could help him. He got scared as the car overturned and his BP shooted up and

he was feeling restless. So immediately after informing police in writing, arrangements

were made to send him to his home and as it was midnight he had left the car at the

accident site. The next day morning around 7 am he had informed the insurance agent

and insurance officials about the accident and around 11am on the directions of the

insurance officials, when he had gone to the accident site, he found that the stereo tape,

speaker, battery, stepny, head test, ESM etc. were missing from the car. The keys of the

car were also not there and dash board was also broken. So he had immediately given a

report of the missing items at Aasta Police station and had later got his car by crane to the

workshop at Bhopal. Mr Mahendra Jaiswal, Surveyor was appointed by the respondent

company to assess the loss due to the accident. The surveyor visited the work shop only

once between October 20017 to March 2018 and took photos and tried to asses the

damage/ loss through mobile phone. Complainant requested the surveyor to asses the loss

on total loss but the same was not done. The surveyor submitted his survey report to the

United India Insurance Co. by assessing the loss of Rs.2,92,500.24 on repair basis against

the estimated loss of Rs.3,50,524.00. When the complainant enquired about the less

assessment from surveyor and Insurance Company they said that the amount of stolen

items have been deducted. When the complainant gave written request for payment of

stolen items they said you may go to Ombudsman office or Consumer forum. They

further informed the complainant that Rs.2,64,000/- is the final amount as per the zero

depreciation policy. The complainant further states that the claim amount

Rs.2,92,500.24 has been changed to Rs.2,64,000/-. When the issue was raised with the

surveyor, it was informed that 12% salvage amount is deducted on amount of

Rs.2,92,000/-. Thus approximate amount of Rs.2,70,000/- is passed as claim amount on

zero depreciation basis, thus a financial loss of Rs.80,000/- suffered by the complainant.

The complainant has approached this forum for payment of balance amount of his claim.

Page 32 of 151

The respondent in their SCN have stated that the vehicle reported to have met with

an accident on 20.10.2017 at Aashta-Chinhota Jod near Aashta Indore Bhopal Highway.

As per insured and claim form some cow suddenly came in front of the vehicle and save

the cow, the vehicle met with accident and turned upside down 4 times thus causing

damages. After the accident, insured left the vehicle unattended and went to Police

station, Aashta. Claim is approved by the respondent for Rs.2,70,254 and paid to

workshop My Car, Bhopal through NEFT on 11.04.2018. Insured is claiming as per his

letter dated 22.02.2018 for the stolen items which were missing / stolen when insured had

left the vehicle unattended on the spot. This claim was repudiated under policy

Condition No. 4 of the policy terms and conditions.

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

respondent, while respondent have filed SCN with enclosures.

I have heard both parties at length and perused paper filed on behalf of the complainant

as well as the Insurance Company.

Above policy was issued for vehicle No.MP04-CP-5785 for the period from 07.07.2017

to 06.07.2018 by the respondent which was a Package Policy. As per complainant, on

19.10.2017 at 3.05 AM his vehicle met with an accident when he was trying to save a

cow. He lodged the claim before the respondent which was partially settled for an

amount of Rs,2,70,000/-. He had informed the respondent’s Agent & Officials and when

he reached the site for picking up the vehicle at about 11 AM, he saw that car stereo tape,

speaker (4Nos.), battery, stepny, headtest, ESM, etc. were stolen from the vehicle for

which he made complaint with the police. The respondent had denied the claim sought

for the reimbursement of the stolen articles which was repudiated as per Policy Condition

No. 4 stating that the complainant had left the vehicle unattended without taking proper

precaution to prevent further damages or loss to the vehicle. Condition No.4 of the policy

states that in the event of any accident or breakdown, the vehicle shall not be left

unattended without proper precautions being taken to prevent further damage or loss and

if the vehicle be driven before the necessary repairs are effected any extension of the

damage or any further damage to the vehicle shall be entirely at the insured’s own risk.

The representative of the respondent has argued that after incidence the injured vehicle

was left unattended by the complainant which caused further damage as certain articles

were stolen and under such circumstances, stolen items are not covered when the vehicle

is left unattended. In this case it is admitted fact that the vehicle after incidence was left

Page 33 of 151

unattended and without proper safeguard for approx. 8 hours. As per above condition of

the policy, it is obligatory on the part of the complainant to ensure proper safety so as to

prevent any further loss to the vehicle, which was not adhered to. Hence as per policy

condition, complainant is not liable for reimbursement for amounts of stolen articles.

Complainant has argued that besides amount of stolen articles, replacement of certain

damaged parts were not allowed by the respondent. The representative of the respondent

opposed the above argument and argued that as per survey report and policy terms and

conditions, amount was settled and paid to the complainant. As per note dated

26.03.2018 of the respondent the claim amount has been settled for Rs.2,70,254/- (cost of

parts after applying depreciation and labour charges) after deducting policy excess

amount of Rs.1,000/- and salvage value of Rs.12,224/-. During hearing, complainant

could not give the details of the articles and their amount for which payment has not been

made, besides the stolen articles. Records available on file goes to show that the

respondent has calculated the payable claim amount as per terms and conditions of the

policy and the same has been paid to the complainant.

In view of the above facts and circumstances, I come to the conclusion that the

respondent company has acted in accordance with the terms and conditions of the policy

and needs no interference by this forum. Therefore complaint is liable to be dismissed.

Complaint filed by Mr Anil Edwin stands dismissed herewith.

Let copies of Award be given to both the parties.



Mr. Vinod Tiwari ………...…………………………………….. Complainant

V/S

United India Insurance Co. Ltd ………………………..………..Respondent

COMPLAINT NO: BHP-G-051-1819-0151 ORDER NO: IO/BHP/A/GI/ 0108 /2019-

2020


Complainant

Mr. Vinod Tiwari,

F 6/13, Char Imli, Bhopal

2. Policy No: 1918003116P112974905

Page 34 of 151

Mr. Vinod Tiwari (Complainant) has filed a complaint against United India Insurance Co. Ltd.

(Respondent) alleging rejection of theft claim.

Brief facts of the Case - The complainant has stated that his vehicle No. MP-04-XM-6678

was covered under above policy issued by the respondent. His vehicle was stolen on

08.07.2017. He gave oral intimation to the respondent’s agent and respondent company

and FIR was also lodged. He submitted all the documents in respondent’s office but

respondent rejected his claim on the ground of late intimation. Complainant further stated

that he could submit documents with some delay due to ill health of his father. The

complainant has approached this forum for redressal of his grievance.

The respondent in their SCN have stated that vehicle No. MP-04-XM-6678 was

insured under above policy for the period 30.12.2016 to 29.12.2017. Their office

received intimation of above mentioned vehicle for theft claim on dated 11.08.2017. The

intimation was delayed by 33 days from the date of theft. FIR was lodged on 08.07.2017.

Claim was repudiated because of breach of policy condition No.1.

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

while respondent have filed SCN with enclosures.

Type of Policy


Motor Cycle/Scooter Package Policy

30.12.2016 to 29.12.2017



Mr. Vinod Tiwari

-same-

4. Name of the insurer United India Insurance Co. Ltd

5. Date of Repudiation/ Rejection 13.02.2018


Rejection

Late intimation and breach of policy

condition No.1


8. Nature of complaint Rejection of theft claim

9. Amount of Claim --



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

2017

13. Date of hearing/place 30.10.2019 at Bhopal


For the Complainant Mr Vinod Tiwari

For the insurer Mr G S Chhabra, Divisional Manager



Page 35 of 151

I have heard both the parties at length and perused papers filed on behalf of the complainant as

well as the Insurance Company.

Vehicle No.MP04-XM-6678 was insured from 30.12.2016 to 29.12.2017 under policy

No.1918003116P112974905. Above vehicle was stolen on 08.07.2017 for which a claim

was lodged by the complainant which was repudiated on 13.02.2018 by the respondent

stating that intimation of theft dated 08.07.2017 was given to the respondent on

11.08.2017 i.e. after 33 days of theft which is belated and is breach of policy condition

No.1. Respondent has filed photocopy of motor claim intimation dated 11.08.2017 filed

by the complainant. A photocopy of letter of complainant dated 07.03.2018 addressed to

the respondent is also on record in which complainant had stated that he was not aware of

policy condition No.1 hence delayed intimation was given. This letter also shows that

intimation was given belatedly by complainant. Policy condition No.1 states that 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 this case

complainant had given intimation of theft almost after a delay of 33 days and as per above

condition immediate intimation of theft was necessary to be given and complainant had

violated the above condition. Hence repudiation of claim is in accordance with the terms

and conditions of the policy. In the result complaint is liable to be dismissed.

The complaint filed by Mr Vinod Tiwari stands dismissed herewith.

Let copies of the order be given to both the parties.



Page 36 of 151

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 Mrs. K M Ramamani Vrs. Cholamandalam MS General Insurance Co.Ltd.

COMPLAINT REF: NO: BHU-G-012-1718-0177

AWARD NO: IO/BHU/A/GI/ /2019-20

1. Name & Address of the Complainant

Mrs. K M Ramamani W/O Mr. D Brahmanand Pattnaik, Station Road, Gunupur, S.O. Rayagarda, Odisha. Pin- 765022 9246335262

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

5573/97218419/000/00 (Private car Package Policy) 20.06.2016 to 19.06.2017 (DoA: 24.10.2016) IDV Rs.4,94,418/-

3. Name of the insured Name of the policyholder

Mrs. K M Ramamani Mrs. K M Ramamani

4. Name of the insurer Cholamandalam MS General Insurance Co.Ltd., Bhubaneswar

5. Date of Repudiation 30.03.2017

6. Reason for repudiation Mis-representation of facts and non-disclosure of material information.


8. Nature of complaint Vehicle damage claim repudiation


10. Date of Partial Settlement Not Applicable

11. Amount of relief sought 15,00,000/- including mental agony, loss for delay & interest

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

15 Complaint how disposed U/R 17 of 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 a

Toyota Etios Private car bearing No- OD 18 A 4040, which was insured by Cholamandalam MS

General Insurance Co.Ltd for IDV of Rs.4,94,418/- for the period from 20.06.2016 to

19.06.2017. Unfortunately, the car met with an accident on 24.10.2016 near Khurda at about

9.45 AM. The loss was assessed by the surveyor for Rs. 2,63,863/-. The insurer after scrutiny

of the claim documents have repudiated the claim under the ground of Mis-representation of

facts and non-disclosure of material information. She (the complainant) has appealed to the

Page 37 of 151

insurer’s Grievance Cell for reconsideration of the case, but 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: the claimant has delayed intimation to

the insurer by 17 days. The Police were informed about the accident on 03.11.2016, and the

grounds explained by the insured is not a valid ground for delay in intimation. The insured

misrepresented about the number of occupants in the car and about the injury to them.

Further the insured provided wrong information about the manner as to how the accident

took place. In the light of the above, the insurer closed the file for mis-representation of facts

and non-disclosure of material information.

18. a) Complainant’s Argument: -She states that her husband Shri D Brahmanand Patnaik

along with 3 other persons namely Mr. Praveen Kumar Patnaik (son), Mr. Raj Kishore Das and

the driver Shri Surjya Prakash Pattnaik were in the car at the time of accident. The vehicle got

damaged but did not cause any external injury to any of the persons in the car. After the

accident, her husband and the driver were given first aid at Khurda Medical and subsequently,

all of them returned to Gunupur (around 400 KM away from Khurda) who were under shock.

Her husband and the driver had been to Vishahapatnam for medical consultation on cardiac

issues. She submitted medical papers in this regard. And after her husband’s health became

stable, the driver lodged the case before the Khurda PS on 03.11.2016. The information was

given to the vehicle dealer, who has delayed intimation to the insurer.

b) Insurer’s Argument: - The claim is repudiated on the ground of

misrepresentation of facts and non-disclosure of material information:

(i) The case was intimated to the police after 17 days of accident for which the

insured clarifies that the delay was because of injury to the driver. The insurer does not

accept the given reason as a valid ground for delay in intimation to the police.

(ii) The insured stated that there was no injury to anybody during the accident,

but the insurer has got the injury reports of her husband and the driver, which is

misrepresentation of facts.

(iii) The time of accident in the copy of intimation to the Police is 9.40 AM and the

time recorded by the Police is 9.45 PM. Which are different from each other. This is a clear

case of misrepresentation.

(iv) The intimation to Police records that the car was dashed by a tipper, but the

police record shows that to save the cow the vehicle dashed with the culvert. This is also a

case of misrepresentation.

(v) The intimation to Police says that the driver was alone travelling but as per FIR

another two persons were in the car during the accident.

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

2017.


Page 38 of 151

a. Photocopies of insurance certificate cum policy schedule

b. Photocopies of Police documents

c. Photocopies of vehicle documents.

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 finds that the there was a delay in lodging information with the Police

by 17 days and a delay in intimating the insurer. It is also found that the versions in respect of

nature of accident, time of accident, number of occupants in the vehicle at the time of

accident are different in different documents.

Dated at Bhubaneswar on 14th day of October, 2019 INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

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. Pramod Chandra Pradhan Vrs. ICICI Lombard General Insurance Co.Ltd. COMPLAINT REF: NO: BHU-G-020-1718-0175



Mr. Pramod Chandra Pradhan Plot no- DDL-1029, Phase II, Dumduma HB Colony, Bhubaneswar. Odisha 9861068333


3005/2011125416/00/0000000699 Motor Package Policy (No-OD 33 H 8908)- Honda Activa Period: 20.07.2016 to 19.07.2017 (DoL- 21.12.2016) IDV Rs.61,534/-


Mr. Pramod Chandra Pradhan Mr. Pramod Chandra Pradhan

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

delay in intimation to the police and the insurer is in violation of policy terms and

conditions. Moreover, the complainant had provided documents carrying different

versions of statements for the same incident, which amounts to misrepresentation of

facts. These are not in line with the policy terms and conditions. In view of the

above, the complainant shall not be entitled for any benefit under the policy.

Hence, the complaint stands dismissed.

Page 39 of 151

4. Name of the insurer ICICI Lombard General Insurance Co.Ltd.

5. Date of Repudiation 06.04.2017 (Theft Claim)

6. Reason for repudiation

Violation of policy terms and conditions: The insured’s gross negligence of leaving the vehicle unattended with the key in the ignition.


8. Nature of complaint Two-wheeler Theft claim


10. Date of Partial Settlement Not Applicable

11. Amount of relief sought Rs.61,534/-


13(1)b

13. Date of hearing/place 15.10.2019, Bhubaneswar



For the insurer Shri Suresh Das, Manager- Legal

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


17. a. Brief Facts of the Case/ Cause of Complaint: - The Complainant is the owner of the two-wheeler- Honda Activa which is insured by ICICI Lombard General Insurance Co Ltd for the period from 20.07.2016 to 19.07.2017 under package policy for IDV Rs. 61,534/-. Unfortunately, when the complainant was in the market, on 21.12.2016 the vehicle was stolen while it was parked. The complainant reported the matter to the Police as well as the insurer. The Police has closed the case as True but no clue basis. The claimant vide his letter dated 24.12.2016, addressed to the insurer, has stated that he had kept his 1st key set in the dickey along with some other important documents and handed over the 2nd key to the insurer. In one affidavit dated 24.12.2016, the complainant has declared that “at the time of loss, the insured vehicle was parked keeping the starter key into the dickey”. In the same affidavit, he also requested the insurer to settle the claim on non-standard basis. The complainant submitted all the necessary documents to the insurer for settlement of the claim, but the latter repudiated the claim as No Claim under the ground of violation of policy terms and conditions. Being aggrieved on repudiation of the claim, the complainant filed an appeal before this Forum for redressal

b. Insurer’s pleading: - The Insurer submits that the claimant has tendered only one key of the

stolen vehicle. The insurer also states the complainant had given the notarized statement in writing

that he had left the other key along with the vehicle at the time of theft. The insurer claims that the

insured did not take sufficient care. This is a violation of terms and conditions of the insurance policy,

which states ‘the insured shall take reasonable steps to safeguard the vehicle from loss or damage’. In

view of the above, the claim is rejected.

18. a) Complainant’s Argument: - He states that he has submitted all the documents as required

by the Surveyor S K Associates for settlement of the claim, but it is a matter of regret that instead of

claim settlement the insurer issued a letter expressing “No Claim”. The claimant, in one affidavit dated

24.12.2016, has declared that “at the time of loss the insured vehicle was parked keeping the starter

key into the dickey”. In the same affidavit, he also requested the insurer to settle the claim on non-

standard basis.

Page 40 of 151

b) Insurer’s Argument: - The insurer claims that the insured did not take sufficient care. This

is violation of Policy terms and conditions. which states ‘the insured shall take reasonable steps to

safeguard the vehicle from loss or damage’. The insurer has submitted copies of two different

judgements passed by National Consumer Disputes Redressal Commission {in the case of (i) the

Oriental Insurance Co Ltd Vs. K K Valsalan and (ii) Devinder Kumar Vs National Insurance Co Ltd} in

support of their stand for repudiation. The insurer submits that the complainant failed to comply with

the policy terms and conditions as he left the key with the vehicle and therefore, pleaded to absolve

them of the liability.

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


a. Photocopies of insurance certificate cum policy schedule

b. Photocopies of Police reports

c. Photocopies of vehicle documents.

d. Photocopies of NCDRC orders as submitted by the insurer

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

gone through all the documents submitted relating the complaint and heard both the parties. The

forum records that there is no two opinions about the theft of the vehicle and finds that the

complainant had earlier stated that the 2nd key was in the dickey and had requested the insurer for

settlement of the claim on non-standard basis. But subsequently on a search he got the 2nd key from

his home. He informed the Forum that he did not know that the 2nd key was in his home and wrongly

thought that the same was kept in the dickey. The insurer wanted to verify the genuineness of these

keys from a Forensic lab and on verification submitted the lab report. The report has explained that

both the keys are different and cannot be used in the same lock-set. The Forum has examined the

report and found that it is not possible to establish now if the lockset can be opened by these keys or

not since the stolen vehicle is not recovered. Moreover, there is every possibility of finding differences

between these two keys; as in normal situations one key is kept idle while the other key is in use. So,

the differences could also be due to single usage of a particular key and non-usage of the other key.

Further the differences are also found to be minor in nature.

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(6) of Insurance Ombudsman Rules,2017, the Insurer shall comply

with the award within 30 days of the receipt of the award and shall intimate the

compliance of the same to the Ombudsman.

AWARD


by both the parties during the course of hearing, the insurer is hereby directed to settle

the claim on non-standard basis at 75% of the IDV and pay the claim to the

complainant subject to deduction of applicable Policy Excess and collection of necessary

RTA related documents.

Hence, the complaint is allowed accordingly.

Page 41 of 151

b. As per the Rule 17(7) the complainant shall be entitled to such interest at a rate per

annum as specified in the regulations framed under the Insurance Regulatory and

Development Authority of India Act 1999, from the date of the claim ought to have been

settled under the regulations, till the date of payment of amount awarded by the

Ombudsman.

c. As per Rule 17(8) of the said rules and award of the Insurance Ombudsman shall be

binding on the Insurers.

Dated at Bhubaneswar on the 15th day of October, 2019 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. Satya Ranjan Jena Vrs. M/S National Insurance Co Ltd

COMPLAINT REF: NO: BHU-G-048-1718-0284



Mr. Satya Ranjan Jena Plot No- K-7/477, Kalinga Vihar, Patrapada, Khandagiri Bhubaneswar-751019. Mobile: 9438487471, 6370372081


163200/31/16/6100002097. Motor Package Policy. IDV Rs.8,20,000/- 01.08.2016 to 31.07.2017 ( DoA- 07.05.2017) Prev. Policy: 01.08.2015 to 10.06.2016 with HDFC Ergo


Mr. Satya Ranjan Jena Mr. Satya Ranjan Jena

4. Name of the insurer M/S National Insurance Co Ltd


6. Reason for repudiation Misrepresentation of material facts and violation of declaration in Proposed insurance.

7. Date of receipt of the Complaint

16.01.2018

8. Nature of complaint Repudiation of Motor Own Damage Claim


10. Date of Partial Settlement Not Applicable as the Claim is repudiated

11. Amount of relief sought Rs.46,510/-


13(1)b

13. Date of hearing/place 21.10.2019, Bhubaneswar



Page 42 of 151

For the insurer Mr. Pradip Sarkar, Manager

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


17. a. Brief Facts of the Case/ Cause of Complaint: - The complainant is the registered owner of a ‘Honda City’ Private car of 2014 model which is insured with M/S National Insurance Co Ltd under Package Policy for an IDV of Rs.8,20,000/- for the period from 01.08.2016 to 31.07.2017. Unfortunately, the said vehicle met with an accident on 07.05.2017 near Chandikhol. The Complainant reported the matter to the insurer, who in turn appointed a Surveyor (Shri H S Parida) to assess the loss. The surveyor submitted the report on 22.05.2017 with an assessment of loss for Rs.39,000/- after adjusting policy excess, deductibles and salvage value. The Complainant submitted the claim related documents to the insurer for settlement of the claim. The complainant also submitted the bills on 25.05.2017. The insurer, vide mail dated 06.02.2018, wrote to the previous insurer (HDFC Ergo GICL) to confirm if there was any claim during the previous policy period. HDFC Ergo GICL vide its mail dated 07.02.2018 confirmed that a claim was reported and the complainant was not eligible for NCB at renewal. The Bhubaneswar Regional Office of the Insurer, vide its letter dated 05.12.2017, informed the complainant that he was not eligible for NCB, but has availed 25% NCB by giving a wrong information and declaration at the time of taking the policy. The insurer states that since there is a misrepresentation of material fact, they are not liable for the loss. The complainant, not being satisfied with the repudiation of the claim, has appealed before this forum for redressal. 18. a) Complainant’s Argument: - The complainant, in his reply to the insurer vide his

letter dated 03.11.2017, has informed that he insured his Car by providing all documents like

RC Book, Licence, Previous Policy copy to the insurer’s agent, who in turn calculated and

infirmed the applicable premium. But the agent never asked him about the previous year’s

claim nor told him anything about the NCB. He states that this was never brought to his notice

and had he been informed about it; he would have gladly paid the amount. He has also

mentioned about his willingness to pay the differential amount and has requested for

settlement of the claim.

b) Insurer’s Argument: - The Insurer, in its Self-Contained Note, has explained that as

proposed and declared (as to the NCB under previous policy) by the insured, NCB @ 25% had

been allowed under the policy. Subsequently, on verification, it was found that there was

claim under previous policy, which is also confirmed by the previous insurer. The insurer

states that they have followed all underwriting formalities in accordance with GR-27 of the

Indian Motor Tariff (IMT). In view of the above, they repudiated the claim vide letter dated

05.12.2017.

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

20. The following documents are placed in the file.

a. Photocopies of insurance Policy, Proposal form

b. Photocopies of vehicular documents

c. Photocopy of GR 27 on NCB

d. Photocopy of Survey Report, Bills

Page 43 of 151

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

carefully gone through all the documents and papers relating the complaint and heard both

the parties on 21.10.2019. The sole point of dispute on claim is due to granting NCB for which

the complainant is not eligible. The insurer states that the insured had a claim in his previous

policy with the previous insurer but the said matter was not disclosed in the proposal form as

a result of which the insurer granted NCB. And therefore, on the basis of misrepresentation of

facts, the insurer denied the claim. The complainant, during hearing, informed that he was

not aware of anything about NCB but he had disclosed the previous policy details and about

the claim previous insurer to the concerned agent who after the facts had calculated the

premium and filled up the form for my signature. With all good faith I signed the proposal and

received the policy. The Forum examined the provisions applicable for allowing NCB under

Indian Motor Tariff (IMT). It is found that the policy was effective from 01.08.2016 and the

accident took place on 07.05.2017. The insurer wrote to the previous insurer on 06.02.2018

after a long time of the accident, which was replied on 07.02.2018 by the previous insurer.

There is every reason to believe that had the insurer acted as per Rule 27 of the IMT, probably

they could have taken necessary recourse on underwriting of the risk. However, the insurer

during hearing, showed a copy of the letter as written to the previous insurer on 31.07.2016,

but could not substantiate that the said letter was sent by recorded delivery, which is

required under Rule 27 of the IMT and non-compliance of which is termed as breach of Tariff.

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

provisions of Insurance Ombudsman Rules, 2017:

d. According to Rule 17(6) of Insurance Ombudsman Rules,2017, the Insurer shall

comply with the award within 30 days of the receipt of the award and shall

intimate the compliance of the same to the Ombudsman.

e. As per the Rule 17(7) the complainant shall be entitled to such interest at a rate

per annum as specified in the regulations framed under the Insurance Regulatory

and Development Authority of India Act 1999, from the date of the claim ought to

AWARD


by both the parties during the course of hearing, the Forum did not find anything to

disbelieve the complainant, rather observed lapses on the part of the insurer in

complying with the provisions of IMT. Had the insurer taken the same spirit of

collecting information at the time of underwriting as done after the loss had taken

place, the situation would have been completely different. As such the insurer failed to

comply with their own norms under the IMT, which gave rise to this grievance.

Considering the facts and merits of the case, the insurer is directed to settle the claim

and pay Rs.39,000/- to the complainant, as assessed by the Surveyor, towards full and

final settlement of the claim subject to the bills submitted by the complainant.

Hence, the complaint is allowed accordingly.

Page 44 of 151

have been settled under the regulations, till the date of payment of amount

awarded by the Ombudsman.

f. As per Rule 17(8) of the said rules and award of the Insurance Ombudsman shall

be binding on the Insurers.

Dated at Bhubaneswar on 21st day of October, 2019 INSURANCE OMBUDSMAN


PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN- Dr. D.K. VERMA Case of Mr. Ram Niwas Goel V/S Bajaj Allianz General Insurance Co. Ltd.

COMPLAINT REF. NO: CHD-G-005-1819-0838

1. Name & Address of the Complainant Mr. Ram Niwas Goel House No.- 341, Sector-13-17, Huda, Panipat, Haryana- 0 Mobile No.- 9416019508


OG-18-9906-1801-00075838 Motor Policy 09-11-2017 To 08-11-2018


Giriraj Textiles Industries Giriraj Textiles Industries

4. Name of the insurer Bajaj Allianz General Insurance Co. Ltd.


6. Reason for repudiation Damages not co-relate with accident

7. Date of receipt of the Complaint 12-02-2019

8. Nature of complaint Repudiation of claim

9. Amount of Claim Rs. 34000/-

10. Date of Partial Settlement NA

11. Amount of relief sought Not mentioned

12. Complaint registered under Rule no: Insurance Ombudsman Rules, 2017

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

13. Date of hearing/place 10-09-2019 / Chandigarh


For the Complainant Mr. Ram Niwas Goel, Complainant

For the insurer Mr. Shivalik Thaman, Senior Executive Mr. Vinod Sharma, Senior Executive

15 Complaint how disposed Award

16 Date of Award/Order 04-10-2019

17) Brief Facts of the Case: On 12-02-2019, Mr. Ram Niwas Goel had filed a complaint vide which he informed that he has taken

policy of his veh.no. HR-06U-3408 valid from 09.11.17 to 08.11.18. It got accident on night of 27.07.18.

Page 45 of 151

He took his vehicle to New Harbhagwan Motor, G.T.Road, Panipat, who Saturday on that day, assured

to register the claim on Monday. Complainant himself register the claim through toll free number.

Estimate of Rs. 56000/- was prepared, to which complainant was not agreed so he bright his vehicle to

Sagar Motors. They prepared estimate of Rs. 34000/- and informed surveyor, who advised to send bill

to him. The same was sent by Sagar Motors to him, but Surveyor refused to approve the claim. As per

complainant, company was ready to pay Rs. 56000/- at Jai Bhagwan Motors, but are refusing to give

Rs. 34000/-.

On 13-03-2019, the complaint was forwarded to Bajaj Allianz General Insurance Co. Ltd. Regional

Office, Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 12-04-2019.

As per SCN submitted by insurance company, as per complaint, on 27.07.18 at about 8/9 P.M. tyre of

the car ditched into Pit hole which result into vehicle got un-control and dashed against pole and

result into damage to Front Bumper, underbody, front windshield, front LHS headlights. On 03.08.18,

claimant bring the alleged incident into the knowledge of the company who during investigation came

to the conclusion that damages were not correlate with the cause of loss. As per complainant car

dashed against the pole, but surveyor found no pole on the spot. As per complainant pole dashed

against mirror which result into damage to windshield but photographs clearly shows that said

damage to windshield was not result to dash against pole.

As per repudiation letter dt. 10.08.18, company observed that claimed damages do not correlate to

the cause of loss mentioned in the claim form. The vehicle has old and accumulated damage on it.

Further son of insured was not able to show the pole with which vehicle was got damaged.

The complainant was sent Annexure VI-A for compliance, which reached this office on 26-03-2019.

18) Cause of Complaint:

a) Complainant’s argument: Complainant stated that insurance company has arbitrarily

repudiated his genuine claim. He requested for payment of his claim amount.

b) Insurers’ argument: Insurance Company reiterated their version as per the submitted SCN and

requested for dismissal of complaint. Insurance Company stated that complainant is not able

to justify exact cause of accident because physical damage to vehicle does not correlate with

the narration of circumstances of loss given by the insured person.

19) Reason for Registration of Complaint: - within the scope of the Insurance Ombudsman Rules,

2017.

20) The following documents were placed for perusal.

a) Complaint to the Company b) Copy of Policy Document

c) Annexure VI-A d) Reply of the Insurance Company

21) Result of Personal hearing with both parties(Observations & Conclusion)

On perusal of complaint, documents in file, SCN of insurance company and submission made by both

the parties during personal hearing it is observed that complainant has given complaint on account of

repudiation of his claim by the insurance company on the ground that damages doesn’t match with

cause of accident. The policy period is from 09-11-2017 to 08-11-2018. There is no dispute with regard

to accident of the vehicle by either party. As such, only dispute remains, whether the damages as

claimed by the complainant commensurate with cause of the loss is payable as per terms and

Page 46 of 151

conditions of policy as per claim form submitted by the complainant. As per repudiation letter dated

10-08-2018, claim has been repudiated because “as per physical inspection of the vehicle the claimed

damages do not correlate to the cause of loss mentioned in the claim form. The vehicle also has old

and accumulated damage on it. Based on the inspection finding the surveyor contacted you and

requested you to show the spot of loss, however spot shown by your son, he wasn’t able to show the

pole with which vehicle got damage.” Complainant on other hand stated that damages are due to the

cause as narrated in the loss. Since, it is a busy road the pole might have been shifted by concerned

authorities. On going through the documents available in the file, it is seen that insurance company

repudiation is not justified because insurance company has not provided any substantial document

like survey report, photographs which could confirm damages. Moreover, merely because pole is not

there on the spot is not proper ground for repudiation. Insurance company has miserably failed to

prove the contents taken in repudiation letter with supporting documents. Insurance Company is

hereby directed to pay admissible claim amount on the basis of assessment made by surveyor subject

to terms and condition of policy to the complainant within 30 days from the receipt of award copy.

AWARD

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

the parties during the course of personal hearing, pay admissible claim amount on the basis of

assessment made by surveyor subject to terms and condition of policy is hereby awarded to

be paid by the Insurer to the Insured, towards full and final settlement of the claim.

Hence, the complaint is treated as closed.

Dated at Chandigarh on 4th day of October 2019.

D.K. VERMA

INSURANCE OMBUDSMAN


INSURANCE OMBUDSMAN- Dr. D.K. VERMA Case of Mr. Deepak Kumar V/S IFFCO-TOKIO General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Deepak Kumar S/o Sh. Rajbir Singh, VPO- Pardhana, Tehsil- Irsana, Panipat, Haryana-0


94409847 Motor Policy 09-10-2015 To 08-10-2016


Mr. Deepak Kumar Mr. Deepak Kumar

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

5. Date of Repudiation NA

6. Reason for repudiation N A


8. Nature of complaint Non payment of claim

9. Amount of Claim Not provided


Page 47 of 151

11. Amount of relief sought Not provided





For the Complainant Mr. Rajbir Singh, Complainant’s Father

For the insurer Mr. Rohitash, Senior Executive



17) Brief Facts of the Case: On 16-02-2019, Mr. Deepak Kumar had filed a complaint that his Maruti Wagon R car no. HR06J/4994,

Model 2002 got stolen on 25.11.15 from Delhi. The theft was reported to Shalimar Bagh Thana, Delhi,

with FIR No. 020606. All the documents were submitted to insurance company within 7 days of the

theft, untraced report of the car was pending. He got untraced on 10.10.17, but insurance company is

saying that file is closed.

On 15-03-2019, the complaint was forwarded to IFFCO-TOKIO General Insurance Co. Ltd. Regional

Office, New Delhi, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office at the time of personal hearing.

As per letter dt.27.02.19 issued by insurance company, they have approved the claim for Rs.80,000/-

subject to submission of few documents. As per this letter claim has been approved after a deduction

of 25% for claim reopening and non submission of second original key of the vehicle. The claim was

earlier closed due to non submission of required documents and no response from insured. But later

on after compliance of documents and receiving discharge voucher, complainant has been already

made a payment of Rs 80,000/-. Hence, there is no pending amount for said claim and decision is

taken as per terms and condition of policy.


a) Complainant’s argument: Complainant requested that inspite of compliance of various

requirements relating to documents he has been paid less claim. He requested for payment of

his balance claim amount.

b) Insurers’ argument: Insurance Company stated that deduction was made due to non-

submission of second key of vehicle. Insurance Company reiterated that they have already

paid claim after receiving proper affidavit, consent letter and clean discharge voucher. They

requested for dismissal of complaint.


2017.




21) Result of Personal hearing with both parties (Observations & Conclusion): I have gone

through the various documents available in the file including the copy of complaint filed by

complainant and also submissions of both complainant and insurance company at the time of

personal hearing. The issue to be decided is whether deduction of 25% of claim amount by

insurance company is justified or not? Insurance company stated that due to non-compliance

Page 48 of 151

case was closed and upon compliance a deduction of 25% was made for claim reopening and

non submission of second original key of the vehicle. Insurance Company stated that after

receiving affidavit, proper consent and clean discharge voucher to complainant satisfaction,

they have made the payment of Rs 80000/- as assessed by independent surveyor.

Complainant representative informed that he has received Rs 80000/- on account of this

insurance claim. With regard to discharge voucher same doesn’t hold ground because

complainant has failed to bring on record any proof of his protest for claim amount being

given by insurance company in discharge voucher. Further, no query / protest letter has ever

been written/ brought on record by complainant in protest for above deposited amount.

Hence, the decision of the insurance company is in order. Keeping in view the above facts, the

said complaint is hereby dismissed and no relief is granted.

AWARD

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

parties during the course of personal hearing, the said complaint is hereby dismissed on merits.



D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017) INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Ms. Gurpreet Kaur V/S Tata AIG General Insurance Co. Ltd.


1. Name & Address of the Complainant Ms. Gurpreet Kaur House No.- 1, Maple Manor, 33-B, Flower Enclave, Ludhiana, Punjab-0 Mobile No.- 9417006150


015696093801 Motor Policy 04-04-2018 To 03-04-2019


Ms. Gurpreet Kaur Ms. Gurpreet Kaur

4. Name of the insurer Tata AIG General Insurance Co. Ltd.


6. Reason for repudiation Consequential loss





11. Amount of relief sought Rs. 72958/-

Page 49 of 151





For the Complainant Mr. Surinder Pal Singh

For the insurer Mr. Mahipal Chaudhary



17) Brief Facts of the Case: On 18-01-2019, Ms. Gurpreet Kaur had filed a complaint regarding her car no. PB08BH/0090 which

remained under repairs with Globe Automobiles Pvt. Ltd, Ludhiana from 07.08.18 to 15.12.18 for want

of approval of the claim. After all efforts/requests, insurance company failed to settle the claim. M/s

Globe Auto. Had under compelled circumstance had gone ahead of repair the car without the

approval of the claim from the insurance company and had submitted insured a bill of Rs. 72958/-

which he had paid in cash under protest to get his car released from them. Complainant requested for

their legitimate claim denied by insurance company.

On 30-01-2019, the complaint was forwarded to Tata AIG General Insurance Co. Ltd. Regional Office,

Noida, for Para-wise comments and submission of a self-contained note about facts of the case, which

was made available to this office on 25-02-2019.

As per SCN submitted by insurance company, a claim was intimated to their call centre on 02.08.18. As

per claim form submitted by insured, the manner of claim stated was ‘ Car was going near St. Paul

Mittal School road, car was stopped on the road and smoke started coming out of the front side of the

car, passerby came and tried to stop the smoke and fire by putting water’. Without prejudice to the

above, the loss was assessed to the tune of Rs. 30670/-. However as per observation of the surveyor,

he did not find any external damage on the vehicle as well as the wiring harness as claimed. No signs

of smoke marks, burnt marks were observed inside the engine compartment, which is contradictory

with the cause of loss. In minutely examining one module was found damaged due to electrical

breakdown. Hence it was inferred that the damage to wiring harness resulted due to electrical failure

which does not fall under the preview of standard motor policy. In view of above, it was clear that loss

falls under exclusion clause 2(a), Section – 1 of the policy, which read that, the company shall not be

liable to make any payment in respect of consequential loss, depreciation, wear and tear, mechanical

or electrical break down, failures or breakages’.



a) Complainant’s argument: Complainant stated that after all efforts/requests, insurance

company rejected her claim and she requested for settlement of her genuine claim.

b) Insurers’ argument: Insurance Company stated that the company shall not be liable to make

any payment in respect of consequential loss, depreciation, wear and tear, mechanical or

electrical break down, failures or breakages as per clause 2(a) section-1 of policy.

Page 50 of 151

19) Reason for Registration of Complaint:- within the scope of the Insurance Ombudsman Rules,

2017.




21) Result of Personal hearing with both parties (Observations & Conclusion):

I have gone through the various documents available in file including the copy of complaint,

repudiation letter of insurance company dated 03.10.2018 and SCN submitted by insurance company.

The complainant was represented by her father-in-law at personal hearing on 10.09.2019 who

reiterated the contents of complaint and also requested for payment of accidental claim that has been

denied by insurance company. As per insurance company the claim has been rejected in accordance

with terms and conditions contained in exclusion clause 2(a) section-1 of policy. On perusal of various

documents it is seen that in the claim form filed by complainant the description of damage has been

shown as “car was going near St. Paul Mittal School Road, car was stopped on the road and smoke, fire

started coming out of the front side of the car and passerby came and tried to stop smoke & fire by

putting water”. As per surveyor report & observations of surveyor no external damage to the vehicle

was found and no sign of smoke was observed inside the engine compartment since the cause of fire

in vehicle was determined to be due to electrical break down, the loss falling under exclusion clause

2(a) section-1 that reads as under “ The company shall not be liable to make any payment in respect

of: consequential loss, depreciation, wear and tear, mechanical or electrical break down, failures or

breakages” is not covered under terms and conditions of policy. Even the photographs enclosed by

complainant along with complaint shows only the problem relating to the electrical circuit. No

photograph evidence for damage of vehicle has been produced by complainant. It confirms cause of

fire in instant case was electrical failure and not accident, the same being supported by statement of

complainant. In view of above this Forum doesn’t find any reasons to find any discrepancies. The

complaint is accordingly dismissed.

AWARD


parties during the course of personal hearing, the case is dismissed.


Dated at Chandigarh on 10th day of September, 2019.

D.K. VERMA

INSURANCE OMBUDSMAN

Page 51 of 151


INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Ankit Arya & Shravan Kumar Arya V/S IFFCO-TOKIO General Ins. Co. Ltd. COMPLAINT REF. NO: CHD-G-023-1819-0855

1. Name & Address of the Complainant Mr. Ankit Arya & Shravan Kumar Arya House No.- 192-B, Mahesh Nagar, Ambala, Haryana- 0, Mobile No.- 9996606868


M2371711 Motor Policy 04-08-2018 To 03-08-2019


Mr. Ashok Mehta Mr. Ashok Mehta

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


6. Reason for repudiation Change of Ownership not endorsed



9. Amount of Claim Rs.156167/-







For the Complainant Mr. Shravan Kumar Arya, complainant

For the insurer Mr. Subhash Jha, Chief Manager



17) Brief Facts of the Case:

On 28-02-2019 Shravan Kumar Arya, father of Mr. Ankit Arya, had filed a complaint that intimation of

accident of veh. No. DL-8CAE-5642, lodged in the intervening night dt. 20/21.10.18 and said damaged

vehicle was carried to Velocity Automobiles Pvt Ltd., Ambala City on 21.10.18. They handed over the

claim papers in r/o Sh. Ashok Mehta, the car owner at the time of accident to surveyor Sh.

A.K.Chatwal. Thereafter, surveyor required the accident-information questionnaire through the

affidavit of Mr. Ankit Arya, who has custody of car, which was supplied through the affidavit dt.

31.10.18. On 15.12.18, complainant handed over the copy of NOC dt. 13.12.18 to surveyor, received

from transport authority Wazirapur, Delhi in favor of Sh. Ankit Arya. In this way the ownership remains

in favour of Sh. Ashok Mehta till dt. 13.12.18, as NOC not received for change in ownership. That’s

why the endorsement of insurance cannot be done in favour of Ankit Arya, because till the time they

got the NOC, they can’t apply for getting the vehicle registered in the name of Ankit Arya. Further, the

owner Sh. Ashok Mehta was out of country at that time, so the sale documents could not be signed by

Sh. Ashok Mehta, the owner the vehicle. So the ownership was with Sh. Ashok Mehta till 13.12.18,

Page 52 of 151

they got NOC. So the claim was filed in the name of Sh. Ashok Mehta at the time of accident and all

necessary documents have been submitted in the name of Sh. Ashok Mehta, the owner of car on the

date of accident. Now the accidental vehicle DL-8CAE-5642 has been transferred with new number

HR-85B-9846 in the name of Ankit Arya. Endorsement cannot be issued before change in registration,

so the issue of car ownership was automatically starts after getting new RC from registering authority.

They applied for name endorsement in insured policy on 07.02.19, but decision for endorsement has

not taken till then by insurance company. Complainant requested for payment of his justified claim.

On 15-03-2019, the complaint was forwarded to IFFCO-TOKIO General Insurance Co. Ltd. Regional



As per SCN submitted by insurance company, pursuant to the claim lodged by complainant Sh Ankit

Arya regarding damages of his vehicle (Hyundai Verna) registration number- DL-8CAE-5642, they have

deputed surveyor Chhatwal & Associates. On perusal of survey report and documents on records,

company found that Sh. Ankit Arya purchased the said vehicle from its previous owner Sh. Ashok

Mehta on 27.03.18. The policy in question was taken with inception 04.08.18 in the name of Sh. Ashok

Mehta by concealment of facts that the vehicle is already sold to Sh. Ankit Arya, who has possession of

vehicle. This material fact was not disclosed to company while procuring the policy and not informed

to them till the date of accident i.e. 21.10.18. Hence on the date of accident there is no contract of

insurance with the claimant Sh. Ankit Arya, as such company repudiated the claim lodged by him.

Company clarified that even after purchase of policy in the name of Sh. Ashok Mehta, they have not

received any request either from the transferor or from the transferee to change the ownership of

policy in the name of complainant i.e. Sh. Ankit Arora, till the date of accident i.e. 21.10.18, which was

necessary as per GR 17 of IMT. Intimation of repudiation of claim was given to complainant vide letter

dt. 07.02.19.



a) Complainant’s argument: Complainant stated that he has purchased vehicle from Sh. Ashok

Mehta and he had already applied for NOC but as renewal was due so policy was renewed by

paying premium from complainant pocket. RC and policy were in the name of Mr. Sh. Ashok

Mehta as on date of accident. He requested for payment of his claim since no formal

agreement for sale was in existence at the time of accident and the vehicle continued to be in

name of Sh. Ashok Mehta.

b) Insurers’ argument: Insurance Company stated that their repudiation is made as per policy

terms and condition and requested for dismissal of complaint.


2017.





I have gone through the various documents available in file including the copy of complaint filed by Sh.

Shravan Kumar Arya father of Mr. Ankit Arya( owner of accidental vehicle), copy of policy, copy of

affidavit of sale, SCN filed by insurance company and also submissions made by both complainant and

insurance company during personal hearing. I have also gone through the no claim letter wherein the

Page 53 of 151

claim has been denied by insurance company due to non insurable interest at the time of accident.

There is no dispute as such with regard to accidental vehicle and the repairs undertaken towards the

accidental damage. On perusal of documents it is seen that insurance company has taken their stand

that complainant doesn’t have any insurable interest in the accidental vehicle. The vehicle was being

registered in the name of Sh. Ashok Mehta at the time of accident and the policy was in the name of

Sh. Ashok Mehta. It was argued by insurance company that the vehicle was sold to Sh. Ankit Arya as is

evident from affidavit dated 27.03.2018. The consideration amount for same was duly received by the

seller of the vehicle i.e. Sh. Ashok Mehta who had also affirmed that the said vehicle was free from all

sorts of encumbrances after 27.03.2018 and he had also given no objection for transfer of vehicle in

the name of transferee as per affidavit. The contention of complainant that since the vehicle was not

transferred in name of Sh. Ankit Arya in the absence of NOC is contradictory to the affidavit dated

27.03.2018 wherein it is clearly indicated that the transferor has no objection for transfer of vehicle in

the name of Sh. Ankit Arya. It is also surprising to see that the renewal premium of policy was paid by

Sh. Ashok Mehta for the year 2018-19. The insurance company has also not received any request

either from the transferor or from the transferee to change the ownership of policy in the name of

complainant i.e. Sh. Ankit Arya till the date of accident i.e. 21.10.2018, which was necessary as per GR

17 of IMT. It is also evident that nowhere Mr. Ashok Mehta has given loss intimation or complaint

pertaining to his vehicle claim. Since it is evident that vehicle has been purchased by complainant and

all documents like RC and policy is in name of previous owner at the time of accident is sufficient to

show non-insurable interest of complainant at the time of claim. Hence, the decision of the insurance

company is in order. Keeping in view the above facts, the said complaint is hereby dismissed and no

relief is granted.

AWARD





D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Jaswinder Singh V/S The New India Assurance Co. Ltd. COMPLAINT REF. NO: CHD-G-049-1819-0719

1. Name & Address of the Complainant Mr. Jaswinder Singh S/o Sh. Sher Singh, R/o Village- Mehmadpur, Tehsil- Bassi Pathana, District- Fatehgarh Sahib, Sirhind Fatehgarh Sahib, Punjab-0

Page 54 of 151


36010031160100002241 Motor Policy 12-11-2016 To 11-11-2017


Mr. Jaswinder Singh Mr. Jaswinder Singh

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


6. Reason for repudiation Vehicle was sold to other person



9. Amount of Claim Rs. 4,50,000


11. Amount of relief sought Rs. 4,50,000



13. Date of hearing/place 06-08-2019 , 13-09-2019/ Chandigarh


For the Complainant 06-08-2019 , 13-09-2019 Mr. Jaswinder Singh, Complainant

For the insurer 06-08-2019 , 13-09-2019 Absent

15 Complaint how disposed Award + interest



On 01-01-2019, Mr. Jaswinder Singh had filed a complaint vide which he informed that he is the owner

of canter (truck) no. PB23M-7521, which was insured with New India Assurance Co.Ltd from

12.11.2016 to 11.11.2017. On 31.03.17, the said canter was involved in an accident. FIR no. 0127 dt.

31.03.17 lodged by the brother of deceased (driver of other vehicle). Insurance company vide its letter

dt. 29.03.18 has repudiated the claim of the applicant on the ground that as per their investigation,

vehicle was sold to Sh.Inderpal Singh. As per complainant, in fact, Sh.Inderpal Singh is a transporter

and is running business of transportation of goods on commission basis under the name and style of

Delux Transport Corporation in Ludhiana. This canter was also attached with the said transporter for

transporting the goods booked by him. The vehicle no. PB23M/7521 is still in the possession of the

complainant and the ownership is also in his name. Even after the accident, the vehicle was released

by the complainant on supardari from the Ld. Court. There is no sale and the insurance company has

wrongly repudiated the claim without any basis. Complainant requested for payment of his claim.

On 18-01-2019, the complaint was forwarded to The New India Assurance Co. Ltd. Regional Office,

Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the case,

which was made available to this office on 31-01-2019.

As per SCN submitted by insurance company, veh.no. PB23M/7521 was insured with them w.e.f.

12.11.16 to 11.11.17 in the name of Mr. Jaswinder Singh. He lodged the claim with them regarding

damage of said vehicle in accident. Mr.R.P.Bhasin & Co, Surveyor was deputed for assessment of loss

and M/s Royal Associates, Investigator was deputed for investigation of the matter. M/s Royal

investigator vide his report dt. 19.03.18 confirmed that Mr.Jaswinder Singh is insured and registered

owner of said vehicle but he is not the actual owner of the vehicle and he had given the said vehicle to

Page 55 of 151

Mr.Inderpal Singh resident of Khanna in 2016. Mr.Jaswinder Singh has admitted said facts vide his duly

signed statement dt. 20.02.18. So Mr.Jaswinder Singh, the applicant has no insurable interest in the

vehicle. So, as per terms and conditions of the policy, the claim was repudiated vide letter dt.

29.03.2018.



a) Complainant’s argument: Complainant stated that he is still owner of vehicle and even got his

vehicle released from the court of Sh. Rajat Sharma (JMC), Karnal. Insurance company has

merely repudiated the claim on the basis of statement given to investigator. Investigator told

him that claim would be paid early if statement is given according to his requirement. He

requested for payment of his claim.

b) Insurers’ argument: Absent.


2017.





I have gone through the various documents available in file and also considered the submissions made

by complainant at the time of personal hearing. The claims filed by complainant for his vehicle

accident has been denied by insurance company due to reasons that the complainant has sold the

vehicle and doesn’t hold insurable interest. According to insurance company the Mr.Jaswinder Singh is

insured and registered owner of said vehicle but he is not the actual owner of the vehicle and he had

given the said vehicle to Mr.Inderpal Singh resident of Khanna in 2016. Mr.Jaswinder Singh has

admitted said facts vide his duly signed statement dt. 20.02.18. So Mr.Jaswinder Singh, the applicant

has no insurable interest in the vehicle and therefore the said claim has been denied. Whereas

according to complainant. Mr. Inderpal is a transporter and his other vehicles along with vehicle in

question were kept near his office as he is allotting job for his vehicle. On going the papers and

document available in the file, it is seen that claim has been repudiated because complainant has

given written statement to deputed investigator of insurance company. Whereas there is no sale deed

or legal document which could establish that vehicle has been sold to Mr. Inderpal Singh. Moreover,

superdari of the vehicle has been given to the complainant by JMIC, karnal vide order 19.04.2017

which clearly establishes that complainant is still the owner of vehicle. Insurance company plea and

decision of repudiation that vehicle has been sold to Mr Inderpal Singh in 2016 is not based on totality

of facts. Further, non- appearance of company official in the case despite two opportunities given to

them shows their casual approach towards handling of customer’s grievances and also indicates that

insurance company has nothing to say in the matter. Therefore, insurance company is directed to

settle the claim as per assessment made by surveyor subject to terms and conditions of policy along-

with 5% simple interest from the date of repudiation i.e. 29.03.2018 within 30 days from the receipt of

award copy.

Page 56 of 151

AWARD


parties during the course of personal hearing, as per assessment made by surveyor subject to

terms and condition of policy along-with 5% simple interest from the date of repudiation i.e.

29.03.2018 within 30 days from the receipt of award copy is hereby awarded to be paid by the

Insurer to the Insured, towards full and final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Mohan Lal V/S Bajaj Allianz General Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-005-1819-0608

1. Name & Address of the Complainant Mr. Mohan Lal S/o Sh. Hukam Chand, R/o Prachi Road, Model Town, Teh.- Pehowa, Distt.- Kurukhsetra, Pehowa, Haryana-0 Mobile No.- 9728089881


OG-15-1201-1801-00008559 Motor Policy 21-02-2015 To 20-02-2016


Mr. Mohan Lal Mr. Mohan Lal

4. Name of the insurer Bajaj Allianz General Insurance Co. Ltd.


6. Reason for repudiation Queries document not provided



9. Amount of Claim Rs. 56145/-(as per survey report)





13. Date of hearing/place 22-07-2019, 19.08.2019, 13.09.2019 / Chandigarh


Page 57 of 151

For the Complainant 22-07-2019, 19.08.2019, 13.09.2019 Mr. Harsh Garg, Complainant’s son

For the insurer 22-07-2019, Absent 19.08.2019, Insurance Company requested for next date 13.09.2019 Mr. Vinod Sharma, Assistant Manager Mr. Shivalik Thaman, Executive Claims

15 Complaint how disposed Award + interest



On 13-11-2018, Mr. Mohan Lal had filed a complaint that his vehicle no. HR-41F-5315, which was

insured from Bajaj Allianz General Insurance Company Limited, has met with an accident. He gave

intimation to insurance company but they have rejected his claim. Complainant requested for

payment of his claim.

On 28-11-2018, the complaint was forwarded to Bajaj Allianz General Insurance Co. Ltd. Regional

Office, Chandigarh, for Para-wise comments and submission of a self-contained note about facts of the


As per SCN submitted by insurance company, Mr.Mohan Lal got Private car Package policy effective

from 21.02.15 to 20.02.16. As per claim intimation on 14.12.15 due to fog and low visibility, the

oncoming car could not be seen by complainant and in order to save complainant quickly steered the

vehicle due to which he lost the control over the steering and went off the road and struck on a big

stone which result into damage to vehicle. It is noted that accident took place on 14.12.2015 and

complainant is providing the invoices dt. 17.06.2015, which is prior to the accident date. It shows the

malafide intention on the part of the complainant to grab false claim. He failed to provide the

supporting invoice and repair work is done without the approval of surveyor. Further, on inspecting

the vehicle, it was found that old parts were fixed in the car.


a) Complainant’s argument: Complainant’s son stated that his genuine claim has been

repudiated by insurance company on flimsy ground. He has completed all claim related

formalities as per the terms and condition of the policy. He has given all claim related

document to surveyor. He requested for payment of his claim.

b) Insurers’ argument: Insurance Company stated that they have rightly repudiated the claim in

the light of documents and investigation. They firmly stressed the contents of SCN and

requested for dismissal of complaint.


2017.



Page 58 of 151



I have gone through the various documents available in file and also considered the submissions made

by complainant’s representative and insurance company at the time of personal hearing. The claims

filed by complainant for his vehicle accident has been denied by insurance company vide repudiation

letter dated 29.02.2016 which reads that “letter sent to you on 09.02.2016 and 22-02-2016 for which

your good-self have failed to submit any reply till date. Therefore in the absence of any response from

your side we have no other option except to repudiate the claim.” Policy period is from 21-02-2015 to

20-02-2016. Vehicle met with an accident on 14.12.2015 and vehicle got repaired from M/s Bharat

Motors, Pehowa. Insurance company in the SCN pointed that invoice number I20150000753 dated 26-

11-2015, invoice number I12050000837 dated 11-12-2015, invoice number GDI-1516-00174 dated 17-

06-2015, invoice number I12050000185dated 17-06-2015 which are prior to the date of accident date.

On going through these counter sale invoices of M/s Triumph Auto service Private service Private

Limited, Gurgaon, it is seen that said firm is a wholesale dealer and is selling vehicle parts to its

retailer M/s Bharat Motors, Pehowa. It is a transaction between the dealer and a retailer which has no

concern with the complainant. M/s Mehar investigation which was deputed by insurance company

has found the accident to be genuine on the basis of cause of loss, spot verification, driver

confirmation and TP injury details. On going through the papers, compliance letters, SCN, and

document available in the file, it is seen that insurance company is taking a different stand which is not

ever conveyed to complainant. Insurance company cannot have two standards for repudiation of one

claim. Insurance company plea and decision of repudiation that bills are prior to accident is not based

on totality of facts. Therefore, insurance company is directed to settle the claim as per assessment

made by surveyor subject to terms and conditions of policy along-with 5% simple interest from the

date of repudiation i.e. 29.02.2016 within 30 days from the receipt of award copy.

AWARD


parties during the course of personal hearing, as per assessment made by surveyor subject to

terms and condition of policy along-with 5% simple interest from the date of repudiation i.e.

29.02.2016 within 30 days from the receipt of award copy is hereby awarded to be paid by the

Insurer to the Insured, towards full and final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Ajender Sharma V/S Cholamandalam MS Gen. Ins.Co. Ltd. COMPLAINT REF. NO: CHD-G-012-1819-0710

Page 59 of 151

1. Name & Address of the Complainant Mr. Ajender Sharma S/o Sh. Mahavir Sharma R/o Ramgali No.- 2, Uttam Nagar Gohana, Sonipat, Haryana- 131409 Mobile No.- 9812858606


3362/01279287/000/00 Motor Policy 18-11-2016 To 17-11-2017


Mr. Ajender Sharma Mr. Ajender Sharma

4. Name of the insurer Cholamandalam MS Gen. Ins. Co. Ltd.


6. Reason for repudiation Misrepresentation of facts



9. Amount of Claim Rs. 1,95,000/-


11. Amount of relief sought Rs. 1,95,000/-(IDV)



13. Date of hearing/place 06-08-2019, 13-09-2019 / Chandigarh


For the Complainant 06-08-2019, 13-09-2019 Mr. Ajender Sharma, Complainant

For the insurer 06-08-2019, 13-09-2019 Mr. Kuldeep Singh Panesar, Claim Manager Mr. Pardeep Pathak- Legal Manager



17) Brief Facts of the Case: On 28-12-2018, Mr. Ajender Sharma had filed a complaint that his Tata Nano car no. HR 11F/8065 is

insured from Chola MS Gen.Ins. Co. from 18.11.2016 to 17.11.2017. His friend Sumit took his car and

had an accident on Panipat Byepass Gohana on 26.01.2017. The Company’s surveyor Mr.Yogesh took

all the documents. Every time Complainant asked, insurance company makes an excuse of

investigation. He requested for payment of his claim.

On 04-01-2019, the complaint was forwarded to Cholamandalam MS Gen. Ins. Co. Ltd. Regional



As per SCN, submitted by insurance company, OD claim under pol. no. 3362/01279287/000/00 was

repudiated on 06.04.2017 on the ground of ‘misrepresentation and non cooperation with

investigator’. There has been a deliberate and willful misrepresentation on insured part regarding the

cause of loss, as damage to the vehicle are old/pre existing and not one arising out of accident as

represented by insured. As per insurance company, their investigator already requested to insured to

provide all details regarding accident but same has not been furnished till date of repudiation. As such

insurance company repudiated the claim as per the terms and conditions of the policy.

Page 60 of 151



a) Complainant’s argument: Complainant stated that his genuine claim is not settled by the

insurance company despite his best efforts and completing required documents. He requested

that his claim may be settled.

b) Insurers’ argument: Insurance Company reiterated the stand taken in SCN and requested for

dismissal of complaint.


2017.





On carefull examination of the various documents available in file including the copy of complaint,

SCN submitted by the insurance company alongwith two investigation report and submission made by

both the parties during two dates of personal hearing i.e 06-08-2019, 13-09-2019, it is observed that

there is no dispute by either party that vehicle met with an accident at 9.30 am 26.01.2017. In the

personal hearing on 06-08-2019 insurance company pointed out that there is misrepresentation and

non cooperation from complainant with investigator during investigation. Complainant has not given

any details/ chance for meeting with driver at the time of accident to investigator. Car was not

produced for inspection at workshop Priya Automobile, Rohtak. But on the other hand, complainant

stated that the grounds of repudiation taken by insurance company are not justified. He has given all

details pertaining to driver at the time of investigation. Accordingly, insurance company was

instructed to complete the investigation with the instruction to complainant for co-operating with

insurance company in each aspect. Next date of hearing was fixed for 13-09-2019. Insurance company

on next date of hearing also pleaded that complainant has not co-operated with them and has not

given chance to investigator for meeting the driver as driver could not be found on given address.

Complainant again reiterated that given address is correct and insurance company was given every

opportunity to meet the driver. This forum cannot keep the case open indefinitely so case is taken up

for decision on merits on the basis of documents available in file.

On going through repudiation letter dated 06-04-2017 of insurance company, it is seen that insurance

company has repudiated the claim on ground that “it is evident that there has been a deliberate and

willful misrepresentation on your part regarding the cause of loss, as the damages to the vehicle are

old, rusted/ pre-existing and not arising out of an accident as represented by you.” Insurance company

relied on various ground for their repudiation letter stand. They stated that complainant

misrepresentation is proved on various counts like two investigation reports of M/s Lawman

Associates and M/s Ozone Care investigator. They stated that owner of the vehicle did not allowed

them to meet with the driver and even refused to provide the contact number. Owner of the vehicle

did not give his written statement to them at the time of their investigation. Complainant and other

person available at Priya Motors misbehaved with the investigation team and refused to provide the

accident details name of the driver at the time of accident and even refused to show the accident spot

of this vehicle. In the presence of the above detailed facts and finding the case is false and fabricated

Page 61 of 151

and registered owner of the vehicle was found to be non cooperative in investigation. As per M/s

Ozone care investigator, statement recorded in the writing name of the driver is Mr. Sumit Kumar has

been written by complainant himself. During investigation it was also found that in one of the theft

case reported for vehicle number HR-12V-1177, Mahindra Quanto at Chola Mandalam General

Insurance Company limited Mr. Ajender Sharma has given a statement himself that Priya Automobile,

sonipat road, District Rohtak is a fraud workshop its owner Mr Vikram and Mr Surender keep changing

the name of their workshop and keep frauding people.

On going through the various documents available in the claim file, investigation report of lawman

associates and also M/s Ozone care investigator, it is seen that there is no dispute with regard to

vehicle at M/s Priya Automobile, Rohtak. But there are glaring discrepancies with regard to accident

detail and the submissions during personal hearing given by the complainant. As per the complainant

his vehicle is lying at Priya automobile Rohtak. Estimate of M/s Priya Automobile, Rohtak submitted by

complainant to the insurance company amounts to Rs 348055/-. On the other hand, Mr. Ajender

Sharma himself has accepted and given in writing to the company that subject workshop is a fraud

workshop. Further, no chance was given to the insurance company or investigator to inspect the

accidental vehicle at Priya Automobile Rohtak. Complainant plea that workshop is having vehicle

inside doesn't hold ground since the same was never shown to the company for inspection inspite of

chance given to him. Further, it is also seen that driver statement which is unsigned has been written

by complainant himself clearly indicating that complainant is reluctant to produce driver for statement

before the insurance company. Hence, insurance company decision to repudiate the claim on the

basis of fact that there has been a deliberate and willful misrepresentation on part of complainant

regarding the cause of loss is in order. Keeping in view the above facts, the said complaint is hereby

dismissed and no relief is granted.

AWARD





D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017) INSURANCE OMBUDSMAN- Dr. D.K. VERMA

Case of Mr. Pankaj Kayathwal V/S HDFC ERGO General Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-018-1819-0816

1. Name & Address of the Complainant Mr. Pankaj Kayathwal House No.- 241, Sector- 30, Faridabad, Haryana- 121003 Mobile No.- 9953555369

2. Policy No:

Type of Policy

2311202138595600000

Motor Policy

Page 62 of 151

Duration of policy/Policy period 28-03-2018 To 27-03-2019



Mr. Pankaj Kayathwal

Mr. Pankaj Kayathwal

4. Name of the insurer HDFC ERGO General Insurance Co. Ltd.


6. Reason for repudiation Damages not match with cause of accident





11. Amount of relief sought Rs. 33000/- + punitive damage charges

12. Complaint registered under

Rule no: Insurance Ombudsman Rules,

2017

Rule 13 (1)(b) – any partial or total repudiation

of claim by an insurer



For the Complainant Mr. Pankaj Kayathwal, Complainant

For the insurer Ms. Shweta Pokhriyal, Assistant Manager




On 02-02-2019, Mr. Pankaj Kayathwal had filed a complaint vide which he informed that his Maruti

Ciaz VDI+ Model car met with an accident on 03.01.19 near Crusher Zone while going to Ghitorni from

his residence at Faridabad. In the rush, a lorry/truck which was just ahead of his car, reversed to take a

U-turn. This vehicle was loaded with building rubbish, while reversing, the rear part hit his car’s front

bumper and at the same time, due to the impact, a piece of brick fell off from the vehicle onto his

car’s windscreen near the base and the windscreen incurred a crack. Due to the sudden impact, his car

got slightly pushed back and it hit the front iron bumper of a SUV behind his car, due to this impact,

his car bumper (which was slightly damaged earlier and was repaired thoroughly) also got damaged.

On 5th January, which was a Saturday, his car was serviced and it was thereafter washed. Due to

Saturday, HDFC Ergo was closed but in any case insurance company was intimated by the Maruti

body-shop division incharge. After service, while he was waiting at the customer lounge, an

independent surveyor appointed by company came and met him. On 08th Jan. he received an e-mail

from HDFC Ergo, through Maruti Nexa regarding closure of his Motor Claim, in which it is written that

‘the statements made by you in the claim form tantamount to misrepresentation of material fact and

is in violation of the declaration made by you at the time of submitting the claim form. Hence we

Page 63 of 151

hereby inform you that we are repudiating the above claim in keeping with our rights under the policy

and closing the file with respect to the same on the grounds of ‘Policy Voided for Misrepresentation’.

Complainant claimed that his claim is 100% genuine and true. He also raised few queries regarding

validity of his motor policy for remaining period.

On 28-02-2019, the complaint was forwarded to HDFC ERGO General Insurance Co. Ltd. Regional

Office, Noida, for Para-wise comments and submission of a self-contained note about facts of the

case, which was made available to this office on 18.09.19.

As per SCN submitted by insurance company, Mr. Manmeet Singh Makkar, Surveyor conducted survey

of insured vehicle on 05.01.19 which met with an accident on 03.01.19. Surveyor found few

discrepancies in the case. As per insured, a truck had hit the insured vehicle from the front side, but

ground clearance of truck does not match with the height of damages sustain on bumper. Vehicle can

be seen damages on the right hand side and there are no damages on the front side of the vehicle, as

such damage to front windshield also not happened in so called event. Moreover, complainant has

also mentioned that when the car was hit from the front, it was pushed back, which means impact

should be severe leaving the frontal portion of the vehicle damaged, but there was no such damage

on the car. In rear portion, vehicle was hit by Sumo, so tail lights, dickey and rear bumper should be

affected from behind. But it was observed that these were damaged from the lower and side portions

which is not co-relating with the manner of accident. In view of this, company concluded that the

complainant’s claim tantamount to misrepresentation. So claim was repudiated and communicated on

08.01.2019.



a) Complainant’s argument: Complainant stated that rear portion of the loaded truck hit the

front portion of the vehicle and a brick fell which cracked the windscreen. Steel rod of the

back SUV hit the rear bumper of the vehicle which caused the loss. He has never

misrepresented the facts or nature of accident. He requested for payment of his claim.

b) Insurers’ argument: Insurance Company reiterated their stand of SCN and requested for

dismissal of complaint on merit.


2017.





After going through the complaint, SCN, submissions made by both the parties during personal

hearing, it has been observed that there is no dispute with regard to damage of the vehicle in the

accident. Only issues remains whether cause of accident is genuine or not? As per the insurance

company, the front damages are not co-relating with the version of losses since there is no damage on

Page 64 of 151

front side of the vehicle viz on bonnet, front grill and front bumper from front side was intact. So loss

to the windscreen also not happened in so called event. On other hand, during personal hearing

complainant presented the photographs of his vehicle in workshop to show that front bumper also got

damaged and stated that cause narrated by him is totally true and there is no misrepresentation of

facts on his part. On going through the documents available in the file it is seen that the date of

accident is 03-01-2019 and final survey has been done by Mr. Mukesh Kumar Aggarwal, who has

assessed the loss for Rs 21599/-. Policy period is from 28-03-2018 to 27-03-2019. Previous policy was

from National under Maruti tie-up from 28.03.17 to 27.03.18. Photographs clearly shows the damage

to front bumper and moreover insurance company couldn’t produce any evidence/ document to

prove misrepresentation by complainant with regard to cause of accident. Insurance company

repudiation is not based on totality of facts and documents. Therefore, insurance company is directed

to pay Rs 21599/- as per terms and condition of policy within 30 days from the receipt of award copy.

AWARD


parties during the course of personal hearing, Rs 21599/- subject to terms and conditions of policy

is hereby awarded to be paid by the Insurer to the Insured, towards full and final settlement of the

claim.



D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Sham Lal Dadahu V/S The Oriental Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-050-1819-0803

1. Name & Address of the Complainant Mr. Sham Lal Dadahu Sham Lal C/o Arvind Garg, VPO- Dadahu, Renukaji, Himachal Pradesh- 173022 Mobile No.- 9418018067


261702/31/2017/6597 Motor Policy 31-03-2017 To 30-03-2018


Mr. Sham Lal Dadahu Mr. Sham Lal Dadahu

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


6. Reason for repudiation Permit not valid at time of accident


Page 65 of 151




11. Amount of relief sought Rs. 2,50,000/-





For the Complainant Mr. Arvind Kumar, Complainant’s Son

For the insurer Mr. Shivan Goyal, Senior Branch Manager


16 Date of Award/Order 16-10-2019.


On 31-01-2019, Mr. Sham Lal Dadahu had filed a complaint that his truck no. HP71/0482 got accident

on 08.11.17. He submitted all documents after on the spot and final survey to B.O.Nahan. But they

rejected his claim saying that basic permit is not available, although fee of same was already

submitted with RTO BO Nahan. This is negligence of RTO. Complainant requested for payment of his

claim.

On 28-02-2019, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office,



As per SCN submitted by insurance company, Goods Carrying Commercial Vehicle Tata Tipper was

insured with them for the period 31.03.17 to 30.03.18. The said vehicle unfortunately met with an

accident on 08.11.17 at 2.0 P.M. near Barag, Bhootmari due to brake failure as the vehicle lost control

and hit with the hill and got damaged. On receipt of claim intimation, spot and final surveyors were

deputed for the spot inspection as wells as assessment of the loss respectively. Insurance company

asked for permit but insured not produced the same. In the absence of the permit, insurance company

tried to get the permit particulars verified from the concerned authority through the investigator, if

the verification was possible with the help of the Vehicle Registration No. The investigator vide his

report dt. 09.08.18 & 19.12.18 had confirmed that the permit was not valid as on date of loss which

had already expired on 04.11.14. Opportunity given to insured to comments on the observation but he

never respond, as such the claim was repudiated and same was conveyed vide registered letter dt.

07.01.19.



a) Complainant’s argument: Representative of complainant during the personal hearing

reiterated that his genuine claim is being denied by the company on flimsy grounds which

have no relevance to the case. He had deposited the fee in RTO office for renewal of his

vehicle permit prior to accident. There is delay on part of RTO in making permit and he has no

role in such delay. He requested that his claim may be paid.

Page 66 of 151

b) Insurers’ argument: Insurance Company stated that there repudiation is as per terms and

conditions of the policy. They requested for dismissal of complaint.


2017.





On going through the complaint, SCN and submission made by both the parties during personal

hearing, it is observed that there is no dispute with regard to accident of vehicle number HP-71-0482,

Goods Carrying Commercial Vehicle Tata Tipper. Only dispute remains with regard to the validity of

permit at the time of accident. Insurance Company has mainly taken the plea that complainant’s

vehicle permit was not valid as on date of loss which had already expired on 04.11.14. Complainant on

other hand strongly objected to insurance company stand and stressed that he had already applied for

permit with RTO prior to accident of vehicle. He submitted the proof of the receipt in support of his

version. On going through the various documents in the file, it is seen that period of insurance is from

31.03.17 to 30.03.18, date of registration of vehicle is 05.11.08 and vehicle met with an accident on

08.11.17. Only bone of contention remains whether the permit is valid or not on the date of accident

or not? On going through letter of RTO for the passing permission in respect of vehicle no HP-71-0482,

it is clearly mentioned that requisite fee for renew of permit for Rs 3900/- vide receipt no NA13986

dated 18-05-2016 has been deposited in the RTO Nahan office. As per this letter complainant was

directed to produce vehicle before concerned board of inspection for passing immediately after the

issue of this letter. But complainant was informed by RTO that “permit may be obtained / got renewed

from this office immediately after the fitness of your said vehicle.” But in the instant case, permit was

never renewed with the RTO. The insurance company has also referred to report of investigator dated

09.08.2018 based on the RTO Sirmaur report that the permit was not valid on date of accident. Hence,

the decision of insurance company is in order. Keeping in view the above facts, the said complaint is

hereby dismissed and no relief is granted.

AWARD


the parties during the course of personal hearing, the complaint is dismissed.



D.K. VERMA

INSURANCE OMBUDSMAN

Page 67 of 151



Case of Mr. Jarnail Singh V/S The New India Assurance Co. Ltd. COMPLAINT REF. NO: CHD-G-049-1819-0789

1. Name & Address of the Complainant Mr. Jarnail Singh S/o Sh. Mohinder Singh, R/o Kutti Chownk, Guru Har Sahai, Firozpur, Punjab- 152022 Mobile No.- 9914835447


36100231160300001947 Motor Policy 21-01-2017 to 20-01-2018


Mr. Jarnail Singh Mr. Jarnail Singh



6. Reason for repudiation NA


8. Nature of complaint Less claim paid


10. Date of Partial Settlement 19.03.18






For the Complainant Mr. Jarnail Singh, Complainant

For the insurer Mr. Naresh Joshi, Senior Assistant



17) Brief Facts of the Case: On 12-02-2019, Mr. Jarnail Singh had filed a complaint about theft of his vehicle no. PB05AD/6127

insured for Rs. 5,51,674/- IDV. The vehicle was stolen in the month of November 2017. He completed

all claim formalities and his claim was settled for Rs. 5,20,000/- vide letter dt. 19.03.18. The vehicle

was insured for Rs. 5,51,674/- while company settled the claim for Rs. 5,20,000/- which is against the

policy terms and conditions. Complainant requested for balance claim amount of Rs. 30,674/-.(IDV less

excess clause).

On 27-02-2019, the complaint was forwarded to The New India Assurance Co. Ltd. Regional Office,



Page 68 of 151

As per SCN submitted by insurance company, the complainant had insured veh. no. PB05AD/6127 for

sum insured of Rs. 5,51,674/-. They had received theft claim of this vehicle on 03.11.2017. While going

through the claim file, the competent authority has observed that IDV of the vehicle is not fixed as per

motor tariff norms. As per motor tariff IDV of the 2016 model should be 20% less of the invoice value.

So competent authority has approved claim for Rs. 5,20,000/- (after deduction of Rs. 1000/- excess)

and same was paid to the insured.




insurance company despite his best efforts and despite completing requirements. He

requested that his claim may be settled in full.


dismissal of complaint.


2017.





After examination of the various documents available in file including the copy of complaint, SCN

submitted by the insurance company and submission made by both the parties during personal

hearing, it is observed that there is no dispute by either party about theft of vehicle on 03.11.2017 and

admissibility of claim as per terms and condition of policy. Only issue remains that insurance company

pointed that IDV of the vehicle in policy is not taken as per Indian Motor Tariff. In the policy IDV is

taken Rs 5,51,674 but as per IMT it has to be Rs 5,21,000/- since new vehicle invoice value is Rs

6,50,700/-. But on the other hand, complainant stated that this ground taken by insurance company is

not justified since it is their renewal only and premium has been paid after consideration of all facts.

On going through the DCC note placed in the file, it is seen that insurance company is only highlighting

about IDV of vehicle but nowhere is it taking into account the extra premium which has been paid by

complainant at the time of insurance. Further, policy is renewed in the same company. So, Insurance

Company cannot take the shelter with regard to IDV of vehicle after duly acceptance of proposal and

underwriting the policy by their office at the time of claim. Deduction from IDV by insurance company

at the time of claim is highly arbitrary and unwarranted. Hence, Insurance Company is directed to pay

Rs 30674/- subject to terms and condition of policy to the complainant within 30 days after the receipt

of award copy.

Page 69 of 151

AWARD


the parties during the course of personal hearing, Rs 30674/- is hereby awarded to be paid by

the Insurer to the Insured, towards full and final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN


INSURANCE OMBUDSMAN- Dr. D.K. VERMA Case of Mr. Raj Kumar Sheokand V/S The Oriental Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Raj Kumar Sheokand House No.- 271/17, Ram Rai Gate, Gujran Street, Jind, Haryana- 126102 Mobile No.- 9650550043


215700/31/2017/126002 Motor Policy 04-01-2017 To 03-01-2018


Mr. Ankur Sheokand Mr. Ankur Sheokand

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


6. Reason for repudiation Driver under influence of liquor



9. Amount of Claim Rs. 611626 lacs Car insurance IDV + Driver insurance


11. Amount of relief sought Rs. 611626 lacs Car insurance IDV+ Driver insurance + Interest





For the Complainant Mr. Raj Kumar Sheokand, Complainant

For the insurer Mr. Ashok Kumar Baroka, Deputy Manager




Page 70 of 151

On 29-01-2019, Mr. Raj Kumar Sheokand had filed a complaint that insurance company has rejected

claims of his son’s Motor Vehicle insurance by referring to a ‘possibility of alcoholic intoxication’

mentioned in the post-mortem report. As he was sure that his son never had alcohol or any kind of

drug, authorities approached Forensic Science Lab (FSL) to have a detailed analysis of the sample sent

to them by the post-mortem doctor. The FSL confirmed that there was no common poison or drug in

the any of the samples. But insurance company rejected even the FSL Report while considering the

‘possibility’ comment in the post-mortem.

On 28-02-2019, the complaint was forwarded to The Oriental Insurance Co. Ltd. Regional Office,


which was made not made available to this office till the date of hearing.



a) Complainant’s argument: Complainant during his personal hearing reiterated that his son’s

genuine claim is being denied by the company on flimsy grounds which have no substantial

basis. He requested that his claim may be paid.

b) Insurers’ argument: Insurance Company stated that there repudiation is as per terms and

condition of the policy. They requested for dismissal of complaint.


2017.




21) Result of Personal hearing with both parties(Observations & Conclusion) :

On going through various documents available in the file including the copy of complaint, submissions

made by both complainant & insurance company during personal hearing (No SCN submitted by

insurance company), it is observed that the complainant vehicle met with an accident on 03-09-2017

at 5.30 pm near Jind. In this accident Mr. Ankur Sheokand s/o Mr. Raj Kumar Sheokand and Mr. Rajesh

Kumar s/o Sh. Suraj Bhan died. The facts are not disputed by insurance company. The insurance

company while denying the claim vide repudiation letter has taken recourse to exclusion clause

wherein no accidental claim is payable if the vehicle is driven by person under the influence of alcohol.

It has mainly placed reliance upon the Post-mortem report of Civil Hospital Jind and investigation

report of their investigator Sh. Gita Ram Parmar. As per the PMR report no BKB/30/2017 for Late Mr.

Ankur Sheokand s/o Mr. Raj Kumar Sheokand of Civil Hospital Jind which mentions under column “any

other finding” that “vomiting smelling of alcohol and acetone” were coming. It further states that

cause of death in this case is “head injury and hemorrhagic shock, chest injury sustained in accident

possibly in some intoxication.” Investigation report also confirms about the same contents in respect

of both occupant i.e Late Mr. Ankur Sheokand s/o Mr. Raj Kumar Sheokand and Late Mr. Rajesh Kumar

s/o Sh. Suraj Bhan. Complainant produced Forensic Science Laboratory report of Sunaria, Rohtak

which clearly depicts that “no common poison could be detected” in samples of Late Mr. Ankur

Page 71 of 151

Sheokand s/o Mr. Raj Kumar Sheokand and Late Mr. Rajesh Kumar s/o Sh. Suraj Bhan. Insurance

company has nothing to counter this document. Moreover, the insurance company has not

undertaken any investigation with reference to the alcohol content in blood to determine whether the

same was within permissible limit or not or whether the person driving the vehicle was under the

influence of alcohol. Even the post mortem report relied upon insurance company doesn’t

categorically confirm the presence of alcohol but only opines that there is possibility of intoxication.

As such the insurance company has not produced any evidence in support of repudiation of claim. The

decision of insurance company is not justified. Non-submission of SCN by insurance company also

reflects their casual approach in the dealing with grievance of complainant at the time of claim

settlement. Hence, the insurance company is directed to pay assessment made by final surveyor i.e. Rs

611626/- and PA owner-driver claim subject to terms and condition of the policy within 30 days after

the receipt of award copy.

AWARD


the parties during the course of personal hearing, Rs 611626/- ( Final surveyor assessment) and

PA owner-driver claim subject to terms and condition of policy is hereby awarded to be paid by

the Insurer to the Insured, towards full and final settlement of the claim.



D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Pardeep Kumar V/S The United India Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-051-1819-0848

1. Name & Address of the Complainant Mr. Pardeep Kumar S/o Sh. Jugal Kishore, House No.- 230, Sherpur Khurd, Adjoining Suvidha Woolen Mill, Ludhiana, Punjab-0 Mobile No.- 9876185501


200602/31/16P/104410149 Motor Policy 04-07-2016 To 03-07-2017


Mr. Pardeep Kumar Mr. Pardeep Kumar

4. Name of the insurer The United India Insurance Co. Ltd.

Page 72 of 151


6. Reason for repudiation Many discrepancies/misrepresentation



9. Amount of Claim Rs. 7.0 lacs


11. Amount of relief sought Rs. 7.0 lacs





For the Complainant Mr. Pardeep Kumar, Complainant

For the insurer Mr. Kulwant Singh, Senior Branch Manager



17) Brief Facts of the Case: On 07-01-2019, Mr. Pardeep Kumar had filed a complaint that his innova car no. PB10DT/4247 was

stolen from Delhi on 17.04.17 and his nephew Mr. Aman Singla immediately informed the police

authorities as well as insurance company in Delhi. Insurance company’s investigator Mr. Balbir Singh

Behl already proved that the claim is genuine. But after one and half year, he got a letter dt. 24.08.18

from Ahmedgarh office that his claim was repudiated with some irrelevant reasons.

On 14-03-2019, the complaint was forwarded to The United India Insurance Co. Ltd. Regional Office,

Ludhiana, for Para-wise comments and submission of a self-contained note about facts of the case,


Insurance company vides their SCN, only forwarded claim file, without any self contained note. As per

repudiation letter dt. 24.08.18, claim was repudiated on following grounds:

1) Insured vehicle was left unattended for a period of 6 days on road side which is breach of Clause 4 of policy.

2) 2nd Key of vehicle has not been submitted by the insured as he has misplaced the second key few years back .He did not take step to recover the same nor reported to police which is gross negligence and violation of condition no. 4.

3) Date of theft informed to RTO Ludhiana is 19.08.17 whereas date of intimation informed to insurance company is between 17.04.17 to 23.04.17.

4) As per written statement of Mr. Aman Singla, he alongwith his business partner went to Ahmedabad via Jaipur and returned to Delhi on 23.04.17 around 10 A.M. As per FIR, Driver went to Ahmedabad and Nagpur then returned to New Delhi on 23.04.2017. Whereas, Air ticket of Aman Singla (Driver) from New Delhi to Nagpur is on 21.04.17 and return is on 23.04.17. But in statement of Mr. Aman Singla and FIR, date of leaving New Delhi is 17.04.2017 and nothing is mentioned about 21.04.17 leads to misrepresentation.

5) As per written statement of insured Mr. Pardeep, Driver Aman Singla is running a business of Iron trading and as per written statement of Mr. Aman Singla, he in business of merchant trading of high altitude Medical plant, is also contradictory statements leads to misrepresentation.

6) As per insured’s explanation placed in the claim file, Mr. Aman alongwith friend left for Ahmedabad by road from Delhi on 17.04.17 and reached Ahmedabad on 18.04.17 then both returned from Ahmedabad by road via Jaipur on 19.04.17 and reached Delhi on 20.04.17 in

Page 73 of 151

late night. In morning of 21.04.17 at 9.00 AM Aman alongwith friend took the flight to Nagpur and returned on 23.04.17 to Delhi.



a) Complainant’s argument: Complainant requested for payment of his claim since repudiation

of claim by insurance company is not as per terms and condition of policy.

b) Insurers’ argument: Insurance Company reiterated their stand of SCN. Complainant was

expected to take utmost care and safeguard for protecting his insured vehicle as per terms

and condition of the policy. Insurance Company had rightly repudiated the claim.


2017.




21) Result of Personal hearing with both parties (Observations & Conclusion)

On going through the complaint, SCN submitted by the insurance company and submission made by

both the parties during personal hearing, it has been found that complainant has been filed by the

complainant on the ground that claim has been repudiated by insurance company on flimsy grounds.

As per documents it is seen that Veh. Innova 2.5 VX, IDV-7 Lacs, Model-2012 was duly covered under

said policy of insurance from 04.07.16 to 03.07.17. Vehicle was stolen from Delhi on 17.04.17. There is

no dispute that complainant has parked his vehicle near his relatives house on roadside and went for

business for some days. In the instant case, as per complainant, he came back from Ahmedabad on

20.04.2017 late night to his relative house where car was parked and went early to Nagpur but he

never checked his parked vehicle. FIR has been filed on 23.04.2017 at PS Paschim Vihar. As per policy

terms and condition complainant was expected to take utmost care and steps for safeguarding of his

insured vehicle. Date of theft informed to RTO Ludhiana is 19.08.17 whereas date of intimation

informed to insurance company is between 17.04.17 to 23.04.17. There are lots of discrepancies in the

date of loss and also the statement of insured Mr. Pardeep Kumar & Mr. Aman Singla. Further, leaving

the vehicle unattended on roadside for six days is breach of policy clause 6. Hence, the decision of the

insurance company to repudiate the claim is in order. Keeping in view the above facts, the said

complaint is hereby dismissed and no relief is granted.

AWARD





D.K. VERMA

INSURANCE OMBUDSMAN

Page 74 of 151



Case of Mr. Rohit Boora V/S HDFC ERGO General Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-018-1819-0845

1. Name & Address of the Complainant Mr. Rohit Boora House No.- 41, New Friends Colony, Model Town, Panipat, Haryana- 132103 Mobile No.- 9728164044


2311201371812401000 Pvt. Car package policy 13.04.17 to 12.04.18


Mr. Rohit Boora Mr. Rohit Boora



6. Reason for repudiation Non-submission of documents.


8. Nature of complaint Non- payment of claim








For the Complainant Mr. Rohit Boora, Complainant

For the insurer Ms. Shweta Pokhriyal, Assistant Manager



17) Brief Facts of the Case: On 21-02-2019, Mr. Rohit Boora had filed a complaint that his car no. HR06AF/4937 was met with an

accident on 14.02.18. All documents were completed but insurance company has not settled the

claim. Loss was major & total loss, so Surveyor Manmeet Singh Makkar denied him for the repairing of

the vehicle. Surveyor initially denied providing copy of survey report but when complainant visited the

surveyor house alongwith 4-5 friends then the surveyor gave him the copy of survey report. As per

complainant, working of the surveyor is not fair for the client and he submitted the report against him.

Surveyor even mentioned that the RC and DL has been verified, then mentioning that DL was not

produced by the client. Surveyor mentioned that the cause of loss is not justified but till now he

surveyor has not discussed the same with him. As per complainant his claim is genuine and payable as

per insurance policy conditions and requested for payment of his claim.

Page 75 of 151




As per SCN submitted by insurance company, insured vehicle met with an accident on 14.02.18. Sh.

Manmeet Singh Makkar, Surveyor conducted the survey on 14.02.2018. After the survey, surveyor

issued multiple reminder letters to complainant requesting him to submit the documents like claim

form, bank details, bank details, ID proof, police reports, Spot snaps, explain cause of loss in details

giving loss to LHS, loan a/c statement, details of TP Vehicle involved. But complainant failed to submit

the relevant documents. Therefore, the claim was closed vide letter dt. 21.03.18 since the

complainant failed to submit the documents. Besides this, as per survey report, damages of insured

vehicle are not related with cause of accident. The vehicle damages were not fresh. Air cleaner &

engine parts were filled with dust. The LHS body loss was not accidental in nature.




insurance company despite his best efforts and completing required documents. He requested

that his claim may be settled.


dismissal of complaint on merit.


2017.





After going through the complaint, SCN, submissions made by both the parties during personal

hearing, it has been observed that there is no dispute with regard to damage of the vehicle in the

accident on 14.02.2018. Only issues remains whether cause of accident is genuine or not? As per the

insurance company, the left hand side damages are not co-relating with the version of losses since air

cleaner and engine parts were filled with dust. So loss to the left hand side has not happened in said

accident. Insurance Company stated that complainant was requested to submit the documents like

claim form, bank details, bank details, ID proof, police reports, Spot snaps, explain cause of loss in

details giving loss to LHS, loan a/c statement, details of TP Vehicle involved. But complainant failed to

submit the relevant documents. On other hand, during personal hearing complainant stated that

cause narrated by him is totally true and there is no misrepresentation of facts on his part. On going

through the documents available in the file it is seen that the claim has been closed by the insurance

company due to non-compliance of certain mandatory documents like claim form, bank details, bank

details, ID proof, police reports, Spot snaps, explain cause of loss in details giving loss to LHS, loan a/c

Page 76 of 151

statement, details of TP Vehicle involved. In the instant case date of accident is 14-02-2018 and final

survey has been done by Mr. Manmeet Singh Makkar, who has not assessed the loss in absence of

documents. Policy period is from 13.04.17 to 12.04.18. Previous policy was also from same company

and renewal was done in time. On going through the documents available in the file, it is seen that as

per complainant a stray animal came in front of vehicle and in order to save animal, vehicle hit with

rear side of trolla. From the photographs attached in the file it is clearly seen that damage are in multi-

direction when the vehicle has hit trolla straight then damages has to be in straight line and in one

direction only. But in instant case, hood of car is also damaged and badly crumbled. Front assembly

and carrier assembly of vehicle is badly damaged on one side whereas right light and head light of

vehicle are safe. Investigation in the case done by M/s Perfect Investigators also concludes that nature

and cause of accident are not matching with losses to the vehicle. Further, there is also no dispute that

complainant has not complied with the requirements of insurance company. It is seen that various

indispensible documents to explain cause of loss in details giving loss to LHS, loan a/c statement,

details of TP Vehicle involved are necessary for processing and examining the admissibility of claim. In

the instant case, there is no dispute that complainant has not made the compliance of various

documents which were pre-requisite for deciding the admissibility of claim. Insurance company can’t

be made scapegoat of misdeeds of complainant with regard to admissibility of claim. In view of the

facts and discussions as above, the repudiation of claim by insurance company is just and proper.

Hence, complaint is hereby dismissed and no interference required in decision of insurance company.

AWARD





D.K. VERMA

INSURANCE OMBUDSMAN


INSURANCE OMBUDSMAN- Dr. D.K. VERMA Case of Mr. Vishnu Narain Gupta V/S HDFC ERGO General Insurance Co. Ltd.


1. Name & Address of the Complainant Mr. Vishnu Narain Gupta House No.- 183/4, Jain Mohalla, Panipat, Haryana-0 Mobile No.- 9812638908


2311202030195900001 Motor Policy 07-01-2018 to 06-01-2019


Mr. Vishnu Narain Gupta Mr. Vishnu Narain Gupta


Page 77 of 151




8. Nature of complaint Partial claim paid as per co. some damages not correlate with accident


10. Date of Partial Settlement Not provided






For the Complainant Mr. Vishnu Narain Gupta, Complainant

For the insurer Shweta Pokhriyal, Assistant Manager- Legal



17) Brief Facts of the Case: On 25-02-2019, Mr. Vishnu Narain Gupta had filed a complaint that an accident took place with his car

in the fog which was insured under zero depreciation cashless pol.no. 2311202030195900001. There

was a heavy fog so he couldn’t see anything and suddenly his car jumped off the divider and got

damaged heavily from the front side on 03.02.2019. He gave his car to Hyundai authorized service

centre Sawan K. Motors Pvt. Ltd. which is a registered cashless service provider of HDFC Ergo Ltd. The

surveyor had passed the whole claim (including compressor) and repair work got started around

05.01.19. But even after 1.5 months insured not able to get his car from the service centre, as service

centre said that the insurance company has disallowed the air conditioner compressor of his car which

was broken in the accident and asking him to pay Rs.22000/- immediately to get back his car. The

heavy damage of the car has resulted in the loss of the compressor. Complainant requested for help in

the matter.




As per SCN submitted by insurance company, complainant’s insured vehicle met with an accident on

03.01.2019 and surveyor Sh.Manmeet Singh Makkar conducted the survey on 04.01.2019. As per the

photographs, it appears as if the compressor has been pierced by a sharp object and has been

resultantly damaged. However, during the survey it was observed that there was no sharp metal

object in front of the compressor (size 02 cm*05 cm) which could pierce through the compressor. In

view of this, damage to the compressor was not found co-relating with the cause of accident and

hence the same was disallowed. Insurance company has paid the assessed amount of Rs. 56488/-

after all the permissible deductions, to the workshop.



Page 78 of 151

a) Complainant’s argument: Complainant stated that insurance company has arbitrarily

deducted claim amount and have paid less amount for his genuine claim. He requested for

payment of his balance amount.

b) Insurers’ argument: Insurance Company stated that admissible claim amount has been paid as

per visible damages and as per survey report based on the nature and extent of accident.

Hence, requested for dismissal of complaint.


2017.





On perusal of complaint, documents in file, SCN of insurance company and submission made by both

the parties during personal hearing it is observed that complainant has given complaint on account of

partial deduction of his claim by the insurance company on the ground that damages doesn’t match

with cause of accident. The policy period is from 07-01-2018 to 06-01-2019. There is no dispute with

regard to accident of the vehicle by either party. As such, only dispute remains, whether the damages

as claimed by the complainant commensurate with cause of the loss is payable as per terms and

conditions of policy as per claim form submitted by the complainant. On going through the claim form

column of cause of accident, due to heavy fog he could not see divider and vehicle hit with a divider

causing damages. Final survey has been done by Sh. Manmeet Singh Makkar. On going through his

survey report in his remarks no 2 which states that “the insured demanded compressor while checking

compressor, it was found that impact was on the front side of compressor.” Main plea which surveyor

took is that “No sharp object in front of compressor which could pierce through the casing”. In the

instant case, place of survey is at M/s Sawan K Motors, Panipat. No spot photographs were taken or

attached by insurance company. Further, surveyor never visited the accidental site/ spot to verify

about the genuineness of damages. Complainant also informed that road widening work is going on in

between GT Road, Delhi-Panipat. Hence, insurance company has erred in disallowing payment for

compressor without seeing the totality of facts. The insurance company is directed to settle the

balance claim subject to terms and conditions of policy within 30 days after the receipt of award copy.

AWARD


parties during the course of personal hearing, the insurance company is directed to settle the

claim subject to terms and conditions of policy within 30 days after the receipt of award copy.



D.K. VERMA

INSURANCE OMBUDSMAN

Page 79 of 151



Case of Mr. Lovkesh Dhawan V/S The National Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-048-1819-0700

1. Name & Address of the Complainant Mr. Lovkesh Dhawan House No.- 4735, St. 15, Durga Puri Haibowal Kalan, Ludhiana, Punjab-0 Mobile No.- 8427545005


39010231166205208227 Motor Policy 23-03-2017 To 22-03-2018


Ms. Priya Ms. Priya

4. Name of the insurer The National Insurance Co. Ltd.


6. Reason for repudiation Under condition no.4 (Not take reasonable steps to safeguard the vehicle)



9. Amount of Claim IDV – Rs. 21150/-





13. Date of hearing/place 26-08-2019, 13-09-2019, 09-10-2019 / Chandigarh Chandigarh


For the Complainant 26-08-2019, 13-09-2019, 09-10-2019 Absent

For the insurer 26-08-2019

Absent

13-09-2019, 09-10-2019

Mr. Ravinder Sidana, Divisional Manager




On 21-12-2018, Mr. Lovkesh Dhawan had lodge the complaint that he had filed a claim of theft of

motor cycle no. PB10DP327, Hero Splendor Pro, and completed all formalities of insurance company.

But National Ins. Co. Ltd. did not give him any clearness regarding his claim. They always made a new

act and did not give any positive response in this matter.

Page 80 of 151

18) As per SCN submitted by insurance company, Mr. Lovkesh Kumar, Insured’s son parked motor

cycle in a deserted which is located behind his place of work which is the Negligence and gross

violation of Motor Package Policy condition no. 4 which states that the insured shall take all

reasonable steps to safeguard the vehicle from loss or damage. As per repudiation letter place of

parking was not a safe place and two vehicles get stolen at the same time. Moreover, initially driver

thought that the vehicles were towed away by traffic police which indicate that it was unauthorized

place for parking

19) Neither the complainant nor his representatives appeared for the personal hearing on 26-08-2019,

13-09-2019 and 09-10-2019. The case is thus, dismissed in default and closed due to non-perusal of

case by complainant.


D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Thuru Ram V/S The New India Assurance Co. Ltd. COMPLAINT REF. NO: CHD-G-049-1920-0018

1. Name & Address of the Complainant Mr. Thuru Ram Village- Saidowal, PO.- Chasma, Pathankot, Punjab- 145025 Mobile No.- 7696305151


14010331180100015727 Motor Policy 17-10-2018 To 16-10-2019


Mr. Thuru Ram Mr. Thuru Ram



6. Reason for repudiation Vehicle not registered at time of accident





11. Amount of relief sought Not mentioned





Page 81 of 151

For the Complainant Mr. Hiralal (Son)

For the insurer Mr. Surinder Pal



17) Brief Facts of the Case: On 12-04-2019, Mr. Thuru Ram had filed a complaint he purchased new Swaraj Tractor on 17.10.2018, which was insured from New India Assurance Co.Ltd. His tractor met with an accident on 13.11.2018 and approx. estimate was of Rs. 49000/-. But claim was rejected by insurance company. As per company’s letter dt. 14.01.19, as vehicle was not registered at the time of accident, so the said claim is not payable.



a) Complainant’s argument: Complainant stated that the claim has been rejected by insurance

company and he requested for settlement of his claim.

b) Insurers’ argument: Insurance Company stated that the claim has been rejected as per policy

terms and conditions of policy.


2017.





On examination of various documents available in file including the copy of complaint, no claim letter

and submissions made by both representative of complainant and representative of insurance

company, it is seen that claim filed by complainant for the accident of his tractor on 13.11.2018 has

been rejected by insurance company vide repudiation letter dated 14.01.2019 on the basis of the

surveyor report because of the fact that vehicle was not registered at the time of accident as RC being

a mandatory requirement the said claim was non payable. On perusal of documents it is seen that

Swaraj Tractor purchased by complainant on 17.10.2018 duly covered under said policy no.

14010331180100015727 from 17.10.2018 to 16.10.2019 vide registration dated 13.11.2018 met with

an accident and was having a temporary registration at the time of accident as per survey report

dated 04.01.2019. The vehicle was insured and was having temporary registration which is valid for

one month from the date of purchase and duly covered the said tractor purchased by Mr. Thuru Ram.

As such denial by insurance company is not in order, the insurance company is directed to settle the

claim as per assessment made by surveyor within 30 days after receipt the copy of award.

AWARD


parties during the course of personal hearing, the insurance company is directed to settle the

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claim as per assessment made by surveyor within 30 days after receipt the copy of award.

Hence, the complaint is treated as closed

Dated at Chandigarh on 21st day of October, 2019.

D.K. VERMA

INSURANCE OMBUDSMAN


INSURANCE OMBUDSMAN- Dr. D.K. VERMA Case of Ms. Satvinder Kaur V/S The United India Insurance Co. Ltd.


1. Name & Address of the Complainant Ms. Satvinder Kaur House No.- 7831/1, St. No.-9, New Janta Nagar, A.T. I. Road, Ludhiana, Punjab-141003 Mobile No.- 9878464271


2014013117P117138090 Motor Policy 27-02-2018 To 26-02-2019


Ms. Satvinder Kaur Ms. Satvinder Kaur

4. Name of the insurer The United India Insurance Co. Ltd.


6. Reason for repudiation National permit not submitted



9. Amount of Claim Rs. 5 lakh


11. Amount of relief sought Rs. 5 lakh





For the Complainant Mr. Sukhvinder Singh (Son)

For the insurer Mr. Raj Kumar Kataria



17) Brief Facts of the Case: On 28-03-2019, Ms. Satvinder Kaur had filed a complaint that they have lost their Maruti Suzuki Swift

Desire VDI no. PB09AA/5643 on 24.04.18 at New Delhi. The car was theft from Malviya Nagar, New

Delhi at early morning time between 1 a.m. to 5 a.m. timings. They went to New Delhi on 22.04.18 to

drop his son at IGI who went to Canada and they were the guests of her Daughter in Laws aunt at

Malviya Nagar where they parked the car near the market area of Malviya Nagar. They first stayed at

her younger daughter in law’s brother’s house at Hardev Nagar at Delhi for breakfast on 22.04.18 and

after lunch went to Malviya Nagar. Sunny Bharadwaj, the resident of Malviya Nagar went withthem to

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drop her son to airport and he parked the car in the market area of Malviya Nagar at 12.30 am on

24.04.18. After they went to see the car in morning for early departure to Ludhiana, they found the

car is stolen and then went to complaint in Malviya nagar Police Station. They had commercial permit

of this car for Punjab State as she was about to start to drive the car in her city with Uber but used the

car for dropping her brother which was a personal use of the car and does not require All India Permit

which is the reason that insurance company denied their claim. Complainant requested for help to get

some sort of reward.

On 04-04-2019, the complaint was forwarded to The United India Insurance Co. Ltd. Regional Office,

Ludhiana, for Para-wise comments and submission of a self-contained note about facts of the case,

which was made available to this office on 22.04.19.

As per SCN submitted by insurance company, claim for the theft of the vehicle was intimated to them

on 25.04.18 through email. Investigator Mr. R. V. Singh was appointed for investigation of the claim.

While processing the claim, insured was asked for submitting the National Permit as vehicle was theft

at New Delhi. After sending three registered reminders although insured has provided the state permit

which is valid in the state of Punjab only but insured failed to provide the National Permit which is

mandatory document for plying the vehicle outside the state of Punjab as vehicle is registered as

passenger carrying commercial vehicle. As insured has not provided the required document till that

date, after taking legal opinion in the matter, insurer closed the file as no claim and insured was

informed about the same vide regd. Letter dt. 03.10.18.



a) Complainant’s argument: Complainant represented by her son during personal hearing and

stated that the claim has been rejected by insurance company and he requested for payment

of his claim.

b) Insurers’ argument: Insurance Company stated that the claim has been rejected as per terms

and conditions of policy.


2017.




21)Result of Personal hearing with both parties (Observations & Conclusion):

On perusal of various documents available in file including the copy of complaint, SCN submitted by

insurance company, no claim letter and submissions made by both complainant and insurance

company, it is seen that the Maruti car with registration no. PB-09-AA-5643 was duly covered under

policy no. 2014013117P117138090 and the above vehicle was stolen from Malviya Nagar, New Delhi

on 24.04.2018. The complainant has informed to insurance company and to police station, Malviya

Nagar, New Delhi by lodging a FIR on 24.04.2018. The car was having a commercial permit for Punjab

State. The claim filed by complainant on account of loss of car to the insurance company was made no

claim vide letter dated 03.10.2018 due to non submissions of documents including National Permit

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which was requirement for taking vehicle out of State wherever the same was registered. As per

permit verification report dated 28.08.2018 the vehicle was registered vide permit no. 2224/motor

Cab/Ldh/2018 which was valid upto 10.04.2023 for the entire State of Punjab. It is seen from

documents that insured has failed to provide the National Permit which is mandatory document for

plying the vehicle outside the state of Punjab as vehicle is registered as passenger carrying commercial

vehicle. As insured has not provided the required documents till date, after taking legal opinion in the

matter, Insurer closed the file as no claim and insured was informed about the same vide reg. letter

dated 03.10.18. In view of above no claim/ repudiation of claim by insurance company is in order and

doesn’t call for any interference. The case is dismissed.

AWARD


parties during the course of personal hearing, the case is dismissed.


Dated at Chandigarh on 25th day of October, 2019.

D.K. VERMA

INSURANCE OMBUDSMAN



Case of Mr. Surender Dalal V/S Future Generali India Insurance Co. Ltd. COMPLAINT REF. NO: CHD-G-016-1920-0135

1. On 20-08-2019, Mr. Surender Dalal had filed a complaint in this office against Future

Generali India Insurance Co. Ltd for not giving approval to get his accidental vehicle repaired at dealer under policy no. V5897069.

2. This office pursued the case with the insurance company to re-examine the complaint and they agreed to reconsider the claim.

3. Mr. Surender Dalal confirmed through email 18-09-2019 that insurance company has given

approval for repair of his vehicle from desired dealer under the policy number V5897069. So now his grievance has been redressed and he wants to withdraw his complaint.

4. In view of the above, no further action is required to be taken by this office and the

complaint is disposed off accordingly.

Dated : 23.10.2019 (Dr. D.K. VERMA) PLACE: CHANDIGARH INSURANCE OMBUDSMAN

Page 85 of 151

PROCEEDINGS OFTHE INSURANCE OMBUDSMAN, DELHI

(UNDER RULE NO: 16 (1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman- SHRI SUDHIR KRISHNA

Case of Ms.RichaVerma V/S HDFC ERGO General Insurance Company Ltd.

Complaint Ref: NO: DEL-G-018-1920-0010

Case No: GI/HDFC/05/19

1. Name & Address of the Complainant Ms. RichaVerma H.No. 58-C, Sudan Garden, New RoshanPuraExtn. Najafgarh, New Delhi-110043

2. Policy No. Type of Policy Policy term/Policy Period

2311202309144100001 Motorclaim 05.07.2018 to 04.07.2019

3. Name of the insured Name of the policy holder

Ms. RichaVerma Ms. RichaVerma

4. Name of insurer HDFC ERGO General Insurance Company Ltd.


6. Reason for Grievance


8. Nature of Complaint Non settlement of Motor claim

9. Amount of Claim

10. Date of Partial Settlement

11. Amount of Partial Settlement

12. Amount of relief sought

13. Complaint registered under Rule no: Insurance Ombudsman rules

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

14. Date/Place of hearing 04.10.2019


a) For the Complainant ABSENT

b) For the Insurer Ms. SwetaPokhriyal, Asstt, Manager (Legal)

16. Date of Award/Order Award/11.10.2019

17. Brief Facts of the Case

Ms. RichaVerma (hereinafter referred to as the complainant) had filed the complaint against the decision of HDFC ERGO General Insurance Company Ltd. (hereinafter referred to as respondent Insurance Company) in the letter dated 22.02.2019 allowing only partial approval of the claim for the damages to the insured vehicle no. HR-26-DF-2096.


a) Complainant's Argument: The complainant stated that her vehicle no. HR-26-DF-2096 met with an accident on 09.02.2019 when a car coming from backside over took in a wrong way and touched whole left side hitting it badly from front corner side also. The surveyor had not allowed the damaged parts on the ground that the damages were not correlating with the accident whereas all the damages were of the same accident and not earlier one.

b) Insurer's Argument: The Insurance Company vide its SCN OF THE INSURANCE COMPANY dated 14.08.2019 stated that during survey, it was observed that the damages mentioned in the claim form and on physical verification of the vehicle, the damages related to the accident i.e. Front bumper repair, LHS Fender repair and LHS Head Light repair were allowed. The other damages like LHS Front door/rear door, quarter panel and rear bumper were not allowed as these damages do not correlate with the

Page 86 of 151

accident. The said damages were accumulated in the present claim hence were not allowed. As per Survey Report, the complainant took the delivery of the vehicle from the repairer without getting the said repaired.The complainant was told to repair the vehicle, present the same for re inspection and submit the bill for settlement of the claim. The documents sought were necessary to decide the genuineness of the claim. However, the complainant failed to provide the same. The Insurance Company further reiterated that the claim had never been rejected but had been closed due to non-submission of documents.

19. Reason for registration of Complaint:-Non settlement of Motor claim, as stated in Para 18(a) above,.

20. The following documents were placed for perusal. a) Copy of policy. b) Copy of RC/DL/GRO letter c) Copy of Approval letter

21. Result of hearing with both parties (Observations and Conclusion).

Complainant is absent today and was also absent during the last hearing of 23.8.2019. Heard the

Respondent and perused the documents.

Respondent states that they had written a letter to the Complainant on 7.3.2019, requesting to submit

the repair bills, copy of driving licence and produce the vehicle for inspection. However, the

Complainant did not reply to this letter even though reminders were also issued by the Respondent.

Therefore, the Respondent issued the closure letter dated 25.3.2019. In the meanwhile, the

Complainant made an application to Insurance Ombudsman, Chandigarh on 19.3.2019, who forwarded

the same to this office.

It is apparent that the Complainant has not been willing to co-operate with the insurer in the matter and

it would not be just and proper for me to step into the shoes of the insurer for settlement of the claim of

the Complainant. Accordingly, I make the following award.

Award

The complaint is hereby rejected.

(Sudhir Krishna)

Insurance Ombudsman, Delhi

11th

October 2019




Case of Sh. Kamal Dev V/S Bajaj Allianz General Insurance Company Ltd.

Complaint Ref: No: DEL-G-005-1920-0009

Case No: GI/BAJAJ/04/19

1. Name & Address of the Complainant Sh. Kamal Dev H.No.88, DDA Flats, Safdarjang Enclave, New Delhi- 110029

Page 87 of 151


OG-19-9906-1801-00060797 Motorclaim 13.09.2018 to 12.09.2019


Sh. Kamal Dev Sh. Kamal Dev

4. Name of insurer Bajaj Allianz General Insurance Company Ltd.




8. Nature of Complaint Non- settlement of motorclaim


10. Date of Partial Settlement -------------

11. Amount of Partial Settlement -------------




14. Date/place of hearing 04.08.2019/Delhi


c) For the Complainant Sh. Kamal Dev

d) For the Insurer ShriSriramMadhavKommu, Executive (Legal)



Sh. Kamal Dev (hereinafter referred to as the “complainant”) had filed the complaint against the repudiation of his motor insurance claim by Bajaj Allianz General Insurance Company Ltd. (hereinafter referred to as the Respondent Insurance Company), vide letter dated 13.12.2018and subsequent communications.


a) Complainant's Argument: The complainant stated that his vehicle was stolen on 18.09.2018. He lodged the FIR and informed the Insurance Company about the theft of the vehicle. He submitted all the documents alongwith both the keys to the Insurance Company but the Insurance Company had repudiated his claim on the ground of minor issue of submission of duplicate key. He informed the Insurance Company that one original key was provided by the seller to him and the other key was acquired by him from the market to safeguard the only original key in Case of loss.

b) Insurer's Argument: The Insurance Company vide its SCN OF THE INSURANCE COMPANY dated 20.08.2019 stated that on verification of keys from the forensic examination, submitted by the complainant, it was found that claimed original key was duplicate, unused and belonged to different lock. Initially the complainant in his written statement stated that both the original keys were provided to him by the dealer and he was using only one key. Later on when the Insurance Company asked him about the duplicate key, he gave the statement that only one key was given by the dealer and the other key was acquired by him from the market to safeguard the only original key in Case ofloss.

Page 88 of 151

The complainant had not submitted the original keys of the vehicle by the virtue of it could be inferred that he had not taken reasonable steps to safeguard the vehicle which was a violation of policy condition no. 4 which states that “The Insured shall take all reasonable steps to safeguard the vehicle from loss or damage and to maintain it in efficient condition.” Hence, it was construed that the material facts have been misrepresented to the Insurance Company, and false key had been submitted for concealment and suppression of material facts.

19. Reason for registration of Complaint:- Repudiation of claim, as stated in Para 18 (a) above.

20. The following documents were placed for perusal. a) Copy of policy. b) Copy of FIR/Untrace/GRO letter/Rejection c) SCN OF THE INSURANCE COMPANY/Forensic Report/Owner statement


The Claimant states that he had stated in his letter dated 22.9.2018 that he had received two

original keys while purchasing this used car from M/s Royal Car Zone, Faridabad, though

subsequently in his letter dated 11.12.2018, he had stated that he had received only one key and

had got the second key made from the market. Claimant admits to making a wrong statement in

his letter dated 22.9.2018, but says that he had made that statement under mental stress as the

car was stolen only 58 days after the purchase.

I discount the emphasis of the Respondent on the issue of keys because it was a used car,

purchased only 8 weeks before and the stress situation of the claimant at that time. I also note

that the Insurer has not disputed the fact of theft of the car. Accordingly, I make the following

award.

Award

In the circumstances stated above, I over-rule the repudiation of the claim as conveyed to the Claimant

by the Respondent vide letter dated 18.1.2019 and allow the claim to be settled at 75 per cent of the

IDV, which is Rs.5,64,294/- less Rs.2,000/- towards compulsory deductible, which works out as

Rs.4,21,220/-. Accordingly, the Insurer M/s Baja Allianz General Insurance Company should pay to the

Claimant Sh. Kamal Dev a sum of Rs.4,21,220/- in full and final settlement of the claim, within 30 days.

(Sudhir Krishna)


11th

October 2019

Page 89 of 151

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI



Case ofSh. Krishan Kumar V/S HDFC ERGO General Insurance Company Ltd.


Case No: GI/HDFC/18/19

1. Name & Address Of The Complainant Sh..Krishan Kumar H.NO. 219, H-3, Sultan puri, New Delhi- 110086


2312100164972001000 Motorclaim 07.01.2018 to 06.01.2019


Sh. Krishan Kumar Sh. Krishan Kumar

4. Name of insurer HDFC ERGO General Insurance Company Ltd.




8. Nature of Complaint Repudiation


10. Date of Partial Settlement ----------

11. Amount of Partial Settlement ----------

12. Amount of relief sought Rs.40000/-



14. Date of hearing 04.10.2019/Delhi


a) For the Complainant Sh..Krishan Kumar

b) For the Insurer Ms. ShwetaPokhriyal, Asstt. Manager (Legal)



Sh. Krishan Kumar (herein after referred to as the complainant) had filed the complaint against the decision of HDFC ERGO General Insurance Company Ltd. (herein after referred to as respondent Insurance Company) alleging wrong rejection of motor claim.


a) Complainant's Argument: The complainant stated that his vehicle was stolen on 12.08.2018. Next day he lodged the FIR and informed the Insurance Company about the theft of the vehicle. By mistake he submitted the key of another vehicle alongwith the other documents. When he got the no claim letter and the ground of rejection for mismatching of keys, he found the original key of the stolen vehicle at his residence and approached the Insurance Company alongwith the original key of the stolen vehicle. He was told that the claim had been closed. Hence, he had approached this forum for relief.

b) Insurer's Argument: The Insurance Company vide its SCN OF THE INSURANCE COMPANY dated 20.08.2019 stated that the complainant had submitted two keys which were different from each other in morphological shapes. The complainant tried to manipulate the Insurance Company in order to extract public money. That the said conduct on the part of complainant tantamount to misrepresentation of facts in order to get his claim. Hence the claim was closed as per condition no 8 of the policy terms and

Page 90 of 151

conditions which states that “The due observance and fulfillment of the terms, conditions and endorsement of this policy in so far as they relate to anything to be done or complied with by the insured and truth of the statements and answers in the said proposal shall be conditions precedent to any liability of the company to make any payment under this policy”.

19. Reason for registration of Complaint:- Non settlement of motor claimas stated in Para 18 (a) above

20. The following documents were placed for perusal. a) Copy of policy b) Copy of FIR/GRO letter c) Copy of Rejection/claim form/survey report d) Scn of The Insurance Company


The Claimant says that he had submitted two keys of the stolen two-wheeler to the insurer, of which one

was the original but the other was a wrong key, submitted by mistake. He is willing to submit the correct

second key at any time.

The Respondents say that once they receive the second key from the Claimant, they would compare the

same with the already submitted key and if the second key is found to match the first original key, they

would settle the claim within 20 days.

In the facts and circumstances of the case, I make the following award.

Award

I allow the complaint in the following framework:

The Claimant shall submit the correct second key to the Respondents within next 3 days, whereafter the

Respondents shall settle the claim within next 20 days.

(Sudhir Krishna)


11th

October 2019

Page 91 of 151


(UNDER RULE NO:16 (1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)


Case Of Sh.GauravKochar V/S Bajaj Allianz Generali Insurance Company Ltd. Complaint Ref: DEL-G-005-1920-0003

Case No: GI/Bajaj/02/19

17. Brief Facts of the Case-

Sh.GauravKochar (hereinafter referred to as the complainant) had filed the complaint against the decision of the

Bajaj Allianz Generali Insurance Company Ltd. (hereinafter referred to as respondent Insurance Company)

alleging non-settlement of Motorclaim.

18. Cause of Complaint-

a) Complainant's Argument:-The complainant hasstated that his car was stolen on intervening night of

03.11.2018 and 04.11.2018. He complied with submission of all the required documents and papers

in support of his claim as desired by the Surveyor/Investigator as well as by the Insurance Company.

Still, the Insurance Company had denied the claim on the ground of availing NCB. He had clarified

and explained his point and agreed to deposit the NCB with penalty, if any, or deduction of NCB out

of claim settlement but till date the Insurance Company had not settled his claim.

b) Insurer's Argument:-The Insurance Company vide its SCN dated 05.08.2018 stated that after getting

the intimation of theft of the vehicle, the case was investigated. As per the verification of claim

documents, it was found that the policy was renewed with 25% NCB as declared by the complainant

and it was mentioned in the declaration that if the declaration was found to be false then all the

benefits under the Section 1 (damage to the vehicle) of the policy shall be forfeited. On verification

of the policy, it was revealed the insured had obtained a claim under the previous policy and thus

1. Name & Address of the Complainant Sh.GauravKochar C-89, Road No. 40, Shivaji Park, Punjabi Bagh East, New Delhi-110026


OG-18-1101-1801-00016441 Motor Insurance Policy 18.11.2017 to 17.11.2017

3. Name of the insured Name of the Policy holder

Sh.GauravKochar Sh.GauravKochar

4. Name of the insurer Bajaj Allianz Generali Insurance Company Ltd.


6. Reason for repudiation


8. Nature of complaint Non-settlement of Motorclaim


10. Date of Partial Settlement

11. Amount of Partial Settlement




14. Date of hearing/place 16.10.2019/Delhi


For the Complainant Sh. GauravKochar

For the insurer Sh. Shyama Vats, Manager (Legal)

16. Complaint how disposed/ date of Award/Order

Award/17.10.2019

Page 92 of 151

was not entitled to any NCB in the new policy. The Insurance Company had written letters to the

complainant asking for clarification as to why his claim should not be repudiated, but there was no

response from the complainant. Hence, the Insurance Company was compelled to repudiate the

claim of the insured based on the wrong NCB declaration under the policy.

19. Reason for registration of Complaint:-Non-settlement of motorclaim as stated in Para 18 (a) above.


a) Policy Copy

b) Invoice/GRO letter

c) Rejection Letter/SCN/Investigator’s report/NCB confirmation from the Insurance Company.

21. Result of hearing of both parties (Observations and Conclusion):-

During the course of hearing on 16th

October, 2019, both the parties agreed by mutual agreement

through mediationto settle the claim on non-standard basis, i.e. 75% of IDV less the NCB amount

of Rs.5238/- and Compulsory deductible of Rs.1000/- and an additional excess of Rs.1000/-. Both

the parties have signed the Mediation Agreement and submitted before this office.

In view of the settlement between both the parties, the complaint is hereby disposed off.

(Sudhir Krishna)


17th October 2019

PROCEEDINGS OFTHE INSURANCE OMBUDSMAN, DELHI (UNDER RULE NO:16 (1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman- SHRI SUDHIR KRISHNA Case of Sh.Liyakat V/S The Oriental Insurance Company Ltd.

Complaint Ref:: DEL-G-050-1819-0642

Case No: GI/OIC/351/18

1. Name & Address of the Complainant Sh.Liyakat H. No.-51, Village Rewasan, Distt. Nuh, Mewat, Nuh, Haryana-122107


271601/31/2016/3559 Motor Insurance Policy 21.01.2016 to 20.01.2017


Sh.Liyakat Sh.Liyakat

4. Name of the insurer The Oriental Insurance Company Ltd


6. Reason for repudiation ------------------


8. Nature of complaint Non-settlement of motorclaim


10. Date of Partial Settlement -----------------

11. Amount of Partial Settlement -----------------




14. Date of hearing/place 04.10.2019/Delhi


Page 93 of 151


Sh.Liyakat (hereinafter referred to as “the complainant”) had filed a complaint against the decision of the

Oriental Insurance Company Ltd. (hereinafter referred to as “the Respondent Insurance Company” of “the

Insurer”) alleging non-settlement of claim under Motor Insurance Policy mentioned above.


a) Complainant's Argument:-The complainant stated that his Tata Tipper Truck No HR 74A 7528 was stolen on

14.11.2016. Immediately he lodged the claim with the Insurance Company. FIR of the theft was registered with

the intervention of the Sub-Divisional Judicial Magistrate (SDJM) of the area. He complied all the requirement

of the Insurance Company but the claim had not been settled by the Insurance Company till date.

b) Insurer's Argument:-The Insurance Company vide its SCN OF THE INSURANCE COMPANY dated

10.09.2019 have stated that the vehicle was stolen on 14.11.2016. The complainant informed the Insurance

Company on 18.01.2017 i.e. after a delay of 66 days and the FIR was also lodged on 29.12.2017 i.e. after a gap

of 46 days. As per Policy Condition No.1, the insured had to inform the Insurance Company immediately upon

occurrence of any accident 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 this case, the insured had informed the

Insurance Company after a gap of more than two months and even the FIR was also lodged after a gap of 46

days. Hence, the claim was repudiated as per policy condition No.1 and condition No.5. The Insurance

Company further stated that the complainant had filed the case (Case No. CPA/18/26) which was being taken up

by their Legal Cell, Gurugram. Now the Insurance Company had informed the Office of the Insurance

Ombudsman vide its mail dated 22.08.2019 that the next date of hearing is on 27.09.2019 in PLA, Nuh and last

date of hearing was 12.07.2019. Further, the matter is still pending in the Court and has not withdrawn by the

complainant till date.

19. Reason for registration of Complaint:-Non settlement of Motor Theft claim, as stated in Para 18 (a) above.


a) Policy Copy

b) Rejection/FIR/Untrace/FR

c) Representation of Grievance

d) Self Contained Note of the Insurance Company/Investigation Report


The Respondent states that the claim was repudiated because the Complainant neither lodged the FIR with the

Police nor made a complaint on ‘100 ‘for theft soon after the alleged theft that took place on 14.11.2016.

Complainant states that he had given a written complaint to the Police on 15.11.2016 and failing to get quick

redress, he wrote petitions to the Deputy Superintendent of Police and to the District Superintendent of Police

on 13.12.2016. When he still failed to get a redress, he approached the Sub Divisional Judicial Magistrate

(SDJM), who directed the Police on 22.12.2016 to file the FIR, following which, his FIR was filed on 29.12.2016.

The Police filed the Final Report reporting that the vehicle was untraced, before the SDJM on 8.8.2017 and the

SDJM ordered for acceptance of the same on 2.12.2017. Complainant has submitted copies of these

documents, which are available with the Respondent also. The Complainant further stated that he had

withdrawn the case from the PLA, Nuh and submitted the copy of withdrawal dated 09.08.2019 from PLA, Nuh.

For the Complainant ShriLiyakat

For the insurer Shri Anil Kumar, Branch Manager


Award/14.10.2019

Page 94 of 151

Complainant states that he had informed of the theft to the Respondent Insurer by email on 15.11.2016 at

05.26 pm. Subsequently, the Insurer had written to the Complainant on 29.10.2018 seeking original FR copy

and reasons for delay in filing the FIR. The Complainant had replied to this letter on 31.10.2018 stating that he

was given only copy of the FR and that the delay in filing FIR was due to refusal of the police officials to file the

FIR and finally the FIR could be registered only after he approached the SDJM who had then directed the police

to register the FIR. The Insurer again asked him on 1.11.2018 asking reasons for not lodging complaint with

Police on 100. The Complainant replied on 1.11.2018 that his Driver was illiterate and did not do so.

Considering all the documents stated above, I am convinced that the Complainant had made enough efforts to

lodge complaints with the authorities concerned and had informed the Insurer also, in reasonable time.

Accordingly, I make the following award:

Award

I allow the complaint and direct the Respondent Oriental Insurance Co. Ltd. to admit the claim in full

amounting to Rs.19,47,000/- which is the IDV of the vehicle recorded in the Policy No.

271601/31/2016/3559 Account Liyakat, within 30 days.

(Sudhir Krishna)


14th

October 2019

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI (UNDER RULE NO: 16 (1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)


Case of Mr. Khalid V/S Bajaj Allianz General Insurance Company Ltd.


Case No: GI/Bajaj/19/19

1. Name & Address of the Complainant Mr. Khalid C-499, Jahangir Puri, New Delhi- 110033


OG-18-1149-1801-00075308 Motor claim 15.11.2017 TO 14.11.2018


Mr. Khalid Mr. Khalid





8. Nature of Complaint Non-settlement of Motor claim


10. Date of Partial Settlement ---------

11. Amount of Partial Settlement ---------


13. Complaint registered under Rule no: Insurance Ombudsman rules, 2017

Rule 13(1)(b) – any partial or total Repudiation of claim, as stated in Para 18 (a) above. s by an insurer

14. Date of hearing/ Place of hearing 10.10.2019 /Delhi


Page 95 of 151

a) For the Complainant Mr. Khalid

b) For the Insurer SriramMadhavKommu, Executive (Legal)


17. Brief Facts of the Case: Mr. Khalid (herein after referred to as the complainant) had Filed a complaint

against the decision of the Bajaj Allianz General Insurance Company Ltd. (herein after referred to as

respondent Insurance Company) alleging non- settlement of claim under Motor Insurance Policy

mentioned above.


c) Complainant's Argument: The complainant stated that his vehicle hit the railway railing while saving the

dog on 20.10.2018. He and his brother, who was sitting on the side seat were also injured during the

accident. The vehicle was totally damaged. He informed the Insurance Company about the said loss

and their investigator came for investigation of the said loss. The investigator misguided him to show

his brother Mr. Bahav as driver so that he could get the full claim not only of the vehicle but also of

medical expenses incurred towards treatment of the Mr. Bahav. Ultimately he wrote the same thing in

the claim intimation whereas he was driving the vehicle at that time. Later on the Insurance Company

had repudiated his claim on the ground that he had deliberately suppressed the material facts by giving

the wrong information about the driver.

d) Insurer's Argument: The Insurance Company vide its SCN dated 03.10.2019 have stated that

after getting the loss intimation, the case was investigated. As per Investigator’s Report, the insured

had bought the vehicle which was given as a gift to her sister on her marriage as dowry. On 20.10.2018,

the insured and his brother-in-law were going to see his uncle. The vehicle was driven by Abdul Bahav.

At around 7.30 pm suddenly a dog came in front of the vehicle. In order to save the vehicle, he turned

the vehicle and the left side of vehicle hit railway railing. The driver side got damaged badly and the

driver Mr. Abdul Bahav, whose head hit the steering wheel, was seriously injured.Mr. Bahav gothis

treatment at City Hospital, Farukkhabad. As the driver Mr. AbdulBahav was not having the driving

license, the insured gave his licence.

It was observed that at the time of accident the vehicle was driven by Mr. Abdul Bahavnot by the

insured Mr. Khalid Khamruddin.As per their call center/claim form, the complainant had indicateddriver

of the vehicle was Mr. Khalid Khamruddin. Hence, the complainant had suppressed the material facts

for the obvious purpose of misleading the Insurance Company to influence admissibility of the claim.

Keeping in view the above violations of the terms and conditions of the Insurance Policy which states

that: “Any person including the insured Provided that a person driving holds an effective driving licence

at the time of the accident and is not disqualified from holding or obtaining such a licence”. As the

driver was not having the valid driving licence at the time of accident, the claim was repudiated.

19. Reason for registration of Complaint: - Repudiation of claim, as stated in Para 18 (a) above.


a) Copy of policy.

b) Copy of RC, DL, Bail Papers, Estimate, vehicle release order.

c) Copy of SCN, Investigator’s report, Owner’s statement. .

Page 96 of 151


Complainant says that he was misguided by the Insurance Surveyor to write that his brother in law Mr.

Abdul Wahab (Bahav) was driving the vehicle, whereas in reality he (complainant) was driving.

However, the Affidavit dated 06.12.2018 cannot be discounted. Shri Abdul Wahab has suffered serious

injuries and was hospitalized at Farrukhabad City Hospital on the same day i.e. 20th October 2018.

Complainant was not so seriously injured. Further, the Insurer shows pictures of the air bags of the

damaged vehicle, with blood spots on airbag, which show that the driver was grievously injured.

Therefore, the evidence show that Mr. Abdul Wahab (Bahav) was driving the vehicle and this is also

stated in the Affidavit of the complainant. Hence, the claim is not payable under the policy.

Award The complaint is hereby rejected.

(Sudhir Krishna)


14th October 2019



Ombudsman- SH.: SUDHIR KRISHNA

Case of Sh. Anil Sharma V/S Bajaj Allianz General Insurance Company Ltd.

Complaint Ref: No: DEL-G-005-1920-0046

Case No: GI/BAJAJ/32/19

1. Name & Address of the Complainant Sh. Anil Sharma

RZ-135/253, JagdambaVihar, West Sagarpur, New Delhi- 110046

2. Policy No.

Type of Policy

Policy term/Policy Period

OG-18-9906-1843-00012342

Motorclaim

22.08.2017 to 21.08.2019


Name of the policy holder

Sh. Anil Sharma

Sh. Anil Sharma





8. Nature of Complaint Non-settlement of motorclaim


10. Date of Partial Settlement N.A.

11. Amount of Partial Settlement N.A.

12. Amount of relief sought Rs.18450

13. Complaint registered under Rule no:

Insurance Ombudsman rules 2017

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

insurer

14. Date of hearing/ Place of hearing 18.10.2019/Delhi


a) For the Complainant Sh. Anil Sharma

b) For the Insurer Sh. Shyama Vats, Manager (Legal)

16. Date of Award/Order Award

Page 97 of 151

17.Brief Facts of the Case:

Sh. Anil Sharma (herein after referred to as the complainant) had filed the complaint against the decision

of the Bajaj Allianz General Insurance Company Ltd. (herein after referred to as respondent Insurance

Company) alleging non- settlement of motor claim.


a) Complainant's Argument: The complainant stated that his bike met with an accident on

09.03.2019. He took his bike to authorized Bajaj Dealer and informed the Insurance Company

about the said accident. The bike was surveyed on 11.03.2019 where Bajaj Auto told the

Surveyor that Chassis is not available in their stock, and accidented one was not even repairable

as Bajaj Auto has stop manufacturing the same. The complainant told the Insurance Company

to replace or repair his vehicle back to running condition with performance fitness certificate

from Bajaj Auto or give him the claim for total loss. But till now, the Insurance Company had

not settled his claim.

b) Insurer's Argument: The Insurance Company vide its SCN dated 15.10.2019 stated that after

getting the loss intimation from the insured, the surveyor was deputed to assess the loss. The

surveyor R & H Associates assessed the loss for an amount of Rs.8997/-. The assessment was

done looking after the depreciation of the various damaged parts of the vehicle as per the age of

the vehicle. The insured was asked to get the vehicle repaired and submit the bills for claim

settlement. But the insured neither submitted his consent for the assessed amount nor submitted

the repair bills for payment of the claim. In the absence of any communication from the

insured, the Insurance Company was left with no other option but to close the claim without any

payment.

19. Reason for registration of Complaint: - Repudiation of claim, as stated in Para 28 (a) above.


a) Copy of policy.

b) Copy of Estimate,

c) Copy of Requirement letters, Survey Report, SCN of the Insurance Company.


I heard both the parties, the complainant as well as the Insurance Company. While going through the

Insurance Policy, it is observed that this is not a Zero Depreciation Policy. Therefore, as per Policy

Conditions, the vehicle being over ten years old, the depreciation rate would be 50%. Hence, the insurer

was justified in not accepting the claim for reimbursement at 100%.

Award

The complaint is rejected.

(Sudhir Krishna)


21st October 2019

Page 98 of 151

PROCEEDINGS OFTHE INSURANCE OMBUDSMAN, DELHI (UNDER RULE NO: 16 (1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN: SHRI SUDHIR KRISHAN

Case of Sh. Vikrant KumarYadav V/S The Oriental Insurance Company Ltd.

ComplaintRef.No: DEL-G-050-1920-0054

Case No: GI/OIC/34/19

1. Name & Address of the Complainant Sh. AmitYadav H.No. 91, Sector-1, Ghaziabad, UP- 201002


211200/31/2019/116177 Motorclaim 06.09.2018 to 05.09.2019


Sh. Vikram Kumar Yadav

Sh. AmitYadav

4. Name of insurer The Oriental Insurance Company Ltd.




8. Nature of Complaint Non-settlement of motor claim


10. Date of Partial Settlement ---------

11. Amount of Partial Settlement ----------


13. Complaint registered under Rule no: Insurance Ombudsman Rules 2017

Rule 13(1)(b) – any partial or total Repudiation of claim.

14. Date of hearing/Place 30.10.2019/Delhi


c) For the Complainant Sh. AmitYadav, Father of the policy holder

d) For the Insurer Sh. GopalKrishan, Dy. Manager

16. Date of Award/Order 31.10.2019/Award


Sh. AmitYadav (hereinafter referred to as the complainant) had filed the complaint against the

decision of the Oriental Insurance Company Ltd. (hereinafter referred to as the Respondent

Insurance Company) alleging non-settlement of motorclaim of his son.


a) Complainant's Argument: The complainant stated that his son had taken the online motor

policy through Policy Bazar from the Oriental Insurance Company Limited and earlier he had

taken the policy through Policy Bazar from United India Insurance Company Limited. At the

time of applying for the insurance through policy bazar from Oriental Insurance Company

Limited he had mentioned about the previous year claim also. Last year in December 2018 the

vehicle met with an accident and his son submitted all the claim papers to the Insurance

Company but they repudiated his claim on the ground of misrepresentation of facts i.e. NCB

claimed in the policy whereas he was not entitled for the NCB. His son had taken the policy

for the last two years from the policy bazar and giving the benefit of NCB policy was simply

their over slightness. Hence, he wants relief from this forum.

b) Insurer's Argument: The Insurance Company vide their rejection mail dated 28.01.2019 stated

that as per IIB Report, he had taken a claim in the previous policy but at the same time he had

Page 99 of 151

taken the NCB 20% in the current policy. So the claim was repudiated due to

misrepresentation of material facts.

19. Reason for registration of Complaint: -Repudiation of claim, as stated in Para 18 (a) above. .


a) Copy of policy.

b) Copy of, Bill, Estimate, copy of RC, Previous Policy.

c) Rejection mail.

21. Result of hearing with both parties (Observations and Conclusion) I heard both the parties, the complainant as well as the Insurance Company. The Complainant accepts

that he had made a previous claim but his complaint is that the previous policy as well as the current

policy were both taken through Policy Bazaar and the earlier claim too was made through Policy

Bazaar and therefore he should not be blamed for non-disclosure of any previous claims.

Insurer states that they are not in a position to dispute the above noted averments of the Complainant

because all policy proposal documents have remained with Policy Bazaar.

In my opinion, the Insurer cannot wash its hands off regarding the issues related to policy proposal

documents and it must take custody of the same at the time of issue of the policy.

At the same time, I also note that the Complainant can be given only such benefits as would have

accrued to him had he disclosed the previous claim. I make the following award accordingly:

Award

The complaint is allowed on the following terms:

Insurer is directed to settle the admissible claim by reducing the same in the proportion to the

incorrect NCB availed and also recovery of the NCB premium through endorsement, within 30 days.

(Sudhir Krishna)


31st October 2019



OMBUDSMAN- SHRI: SUDHIR KRISHNA

Case of Ms. Sunita V/S Universal Sompo General Insurance Company Limited

COMPLAINT REF: DEL-G-052-1920-0036 CASE NO: GI/Universal/26/19

1. Name & Address of the Complainant Smt. Sunita House No.-B-869, Gali No. -9, Baba Colony, Burari, New Delhi-84


2374/58586012/00/000 Motor Insurance Policy 12.06.2018 to 11.06.2019

Page 100 of 151


Smt. Sunita (hereinafter referred to as the complainant) had filed the complaint against the decision

of Universal Sompo General Insurance Company Limited (herein after referred to as respondent

Insurance Company) alleging non-settlement of motor claim.


a) Complainant's Argument:-

The complainant has stated that her truck number PB11CF 7661 was stolen on 02.12.2018 and FIR was

lodged in PS Swaroop Nagar. The Insurance Company was informed and all the papers that the Insurance

Company asked for were given to them along with the two keys of the truck. Her claim has not been settled

till date. She wrote to the GRO of the Insurance Company on 16.02.2019 but the claim has not been settled

so far. She has now approached the forum for relief.

b) Insurer's Argument:-

The Insurance Company in their SCN stated that Smt. Sunita wife of Sh. Gajendra Chaudhari had bought a

policy for goods carrying truck .This truck was stolen in the intervening night of 1st December 2018 and 2nd

December 2018 from Ibrahimpur. FIR was lodged at police station Swaroop Nagar. The truck was stolen

when the driver Sh. Dhirendra Singh had parked and locked the truck at around 11:00 p.m. and went to

sleep. Theft was discovered the next day when he woke up. The investigation of theft was carried out by

M/s Allied Technical Services. In their report they had stated that the claim amount demanded by the

complainant was much higher than the market value of the same make and model of Tata Motors LPS 2018

vehicle. The amount demanded by the complainant was unreasonable and it could not be fulfilled .The

Insurance Company stated that they gave two reminders to the complainant on 15th May 2019 and 1st June

2019 stating that they were willing to pay the reasonable claim amount as per surveyor’s assessment. As

certain documents were not submitted by the complainant the claim could not be settled. The complainant

did not submit the original RC, fitness, final untraced report, form 28, form 29, form 30, letter of

subrogation, letter of indemnity, discharge voucher ,stolen remark on RC vehicle particulars . Though the


Smt . Sunita Smt . Sunita

4. Name of the insurer Universal Sompo General Insurance Company Limited

5. Date of Repudiation N.A

6. Reason for repudiation N.A


8. Nature of complaint Non settlement of motor claim


10. Date of Partial Settlement N.A

11. Amount of Partial Settlement N.A




14. Date of hearing/place 3.10.2019 at Delhi


For the Complainant Absent

For the insurer Ms. Akansha Agarwal, Sr. Executive ,Motor claims


Award dated 04.10.2019

Page 101 of 151

complainant submitted some of the required document she did not submit blacklist remark on RC

particulars which was essential for settlement of the claim. The claim closure letter was sent to the

complainant on 29th July 2019 stating the reasons for non-settlement of claim.

19. Reason for registration of Complaint:- Non-Settlement of Motor claim.


a) Policy Copy

b) FIR Copy

c) Representation of Grievance


The insurer states that as per the policy document there is no provision that authorizes the insurer to

determine any amount as “reasonable” for settlement of the claim. Accordingly, the amount agreed

as IDV, which is Rs 30 lakhs is to be paid by the insurer, less the excess clause, which is Rs 1500/-

.The insurer should therefore pay Rs29,98,500/-(twenty nine lakhs ninety eight thousand five

hundred) to the claimant within 30 days on submission of required documents to the Insurance

Company by the complainant.

Award

Taking into account 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 for Rs

Rs29,98,500/-(twenty nine lakhs ninety eight thousand five hundred only) on submission of required

documents to the Insurance Company by the complainant within ten days, whereafter the insurer

should settle the claim in next twenty days. If the complainant does not submit the required

documents within ten days, his complaint would be treated as rejected.

(Sudhir Krishna)


14th October, 2019

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, DELHI


OMBUDSMAN- Shri. SUDHIR KRISHNA

Case of Mr. Akash Kataria V/S Royal Sundaram Alliance Insurance Company Limited

COMPLAINT REF: DEL-G-038-1920-0059 CASE NO: GI/Royal/37/19

1. Name & Address of the Complainant Sh. Akash Kataria J-1248, Mangol Puri, Near Indra Park, New Delhi-110083


VPC0961699000101 Motor Insurance Policy 19.03.2019 to 18.03.2020


Sh. Akash Kataria Sh. Akash Kataria

4. Name of the insurer Royal Sundaram Alliance Insurance Company Limited

5. Date of Repudiation N.A.

6. Reason for repudiation N.A

Page 102 of 151


Sh. Akash Kataria (herein after referred to as the complainant) had filed the complaint against the

decision of Royal Sundaram Alliance Insurance Company Limited (herein after referred to as

respondent Insurance Company) alleging non settlement of motor claim.



The complainant stated that his car number DL CAK 5667 was insured with Royal Sundaram .This car met

with an accident on 5.04.2019 and an estimate of Rs 10, 61,723/- was raised by the repairers that was sent

to the Insurance Company for consideration. The IDV of the vehicle was Rs 7,03,800/-. The survey was

conducted by Sh Harish who is a C category surveyor of IRDAI and was not authorized to survey losses

where repair cost is Rs 10 lakh or more. During the inspection of the damaged car by the workshop

engineer and the surveyor it was known that the engine block and body shell were badly damaged but the

surveyor did not either acknowledge the replacement on technical grounds neither gave approval for the

same. The engine half assembly and body shell needed to be replaced and were part of the repair estimate.

He further stated that the surveyor being a C category surveyor was not competent to carry out the survey

and because of him he has been suffering since the last two months. He wrote to the GRO for settlement of

his claim but his claim was not settled. He has now approached the forum for relief.


The Insurance Company in their SCN that the complainant intimated claim on 06.04.2019 and

surveyor Sh Harish Bharija was deputed to carry out the assessment of the loss. The loss was

assessed at Rs 379457/- considering that the vehicle was repairable as the damaged body panel and

child parts were repairable. They sent several reminders to the complainant to produce the bills of

repair and produce the vehicle for re-inspection. The complainant did not respond to their letters

therefore vide letter dated 08.07.2019 they closed the claim and informed the complainant.

19. Reason for registration of Complaint: - Non settlement of motor claim.


a) Policy Copy

b) Representation of Grievance


8. Nature of complaint Non settlement of motor claim









For the Complainant Sh. Akash Kataria

For the insurer Sh.Sachin Rastogi,Asstt. Manager



Page 103 of 151

c) Estimate of repairs

d) SCN


The insurer states that the categorization of surveyors as A, B or C has been done away with by

IRDAI since 2015 and the surveyor deputed for the survey of this vehicle was fully competent for

the task with no relevance for categorization as alleged by the complainant.

The insurer further says that the accident had occurred on 05.04.2019 and the complainant had sent

communication in the matter to the insurer on 06.04.2019.Surveyor was deputed by the insurer on

08.04.2019, who submitted report on 10.04.2019, giving assessment for the repairs of the insured

vehicle as RS 379457/-.The insurer had informed the complainant on 17.04.2019 indicating the cost

of labour charges as Rs 53350/- and also listing the 54 parts that needed to be repaired. This letter

also required the claimant to intimate whilst the repairs in under progress and also intimate if any

more part required to be repaired and submit the final bills on completion of the repairs. However,

the complainant sent response by email but did not comply with the requirements indicated in this

letter despite reminders sent on 17.05.2019 and 07.06.2019.A third reminder was sent on

14.06.2019 and when the complainant still did not reply, a closure letter was sent on 08.07.2019,in

which a final opportunity was given to the complainant to comply with the requirements within 7

days.

On review of the documents submitted by the complainant it is seen that he was insisting on

addition of more parts which were not included in the original letter given by the insurer to the

complainant.

Keeping in view the facts and circumstances made available, I direct the insurer should get a fresh

survey made for the damaged vehicle within 15 days and settle the claim within 10 days of

completion of repairs.

Award

Taking into account 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 get a fresh survey made for the damaged vehicle within 15 days and settle the claim within 10 days of completion of repairs. The complaint is allowed accordingly.

(Sudhir Krishna)


16th October, 2019

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, DELHI


OMBUDSMAN- Shri : Sudhir Krishna

Case of Sh. Alok V/S National Insurance Company Limited COMPLAINT REF: DEL-G-048-1920-0100

CASE NO: GI/NIC/53/19

1. Name & Address of the Complainant Sh. Alok 1249/13, Sachin Medicos, Govind Puri, New Delhi-110019

Page 104 of 151


Sh. Alok (herein after referred to as the complainant) had filed the complaint against the decision of National

Insurance Company Ltd. (herein after referred to as respondent Insurance Company) alleging repudiation of

motor claim.



The complainant stated that he got his Maruti Swift Dzire number DL 1Z 7590 insured with

National Insurance from 25th January 2017 .In the night intervening 17th January and 18th

January 2018 the vehicle was stolen and FIR of the theft was lodged at PS Okhla, bearing

number 1991/18 .The Insurance Company asked for policy certificate, copy of FIR, claim form

and residential proof. These documents were given to them. The Insurance Company in a

letter dated 12th April 2018 asked the reason for leaving the vehicle unattended without any

precautions .He replied that the vehicle was not left unattended and was under the watch of a

guard having duty nearby. The Insurance Company in a letter dated 28 June 2018 3 stated that

the security guards are responsible for internal security of the premises and not for outside

the premises .The distance between the gate of NSCI and service Lane is around 4-5 meters

and it was not possible for the security guard to keep an eye on the vehicle for long time. He

replied that the distance between gate of NSCI and security guard is 4-5 meters which is only

15 feet, whereas the person can watch for more than hundred meters .Insurance Company


35101031166339366567 Motor Insurance Policy 25.01.2017 to 24.01.2018


Sh. Alok Sh. Alok

4. Name of the insurer The National Insurance Company Limited


6. Reason for repudiation Violation of policy condition no. 4


8. Nature of complaint Repudiation of motor claim









For the Complainant Sh. Alok (Complainant)

For the insurer Ms. Meenakshi Singhal,Asstt. Manager



Page 105 of 151

give a show cause notice as to why his claim should not be closed as no claim, on grounds of

misrepresentation of vital facts and violation of private vehicle package policy condition

number 4. The complainant in reply on 9th August 2018 stated and provided the name of

security guard Shri Karan Singh and requested the Insurance Company if there was any

problem in searching the Guard they should contact him but the Insurance Company never

contacted the complainant. The Insurance Company on 26th October 2018 repudiated the

claim on grounds of violation of package policy condition number 4. Now he has approached

the forum for relief.


The Insurance Company in their SCN stated that the statement of the complainant regarding

the incident was, “on 17th Jan 2019 as it was shivering cold the vehicle was giving trouble in

starting and he could not get any help and requested guard of NSCI to look after the vehicle

and left the vehicle at his consent”. The Theft was investigated and during investigations it

revealed that the complainant left the vehicle on 17th January 2018 at around 10:00 p.m. near

Govindpuri Metro Station due to some problem in starting the car. He came back to take his

vehicle the next morning at 9:00 a.m. and found that the vehicle was not there. The

Investigator opined the guards are not responsible for security outside of the premises and it

is not possible for them to keep an eye on the vehicle standing at the distance of 4 to 5

meters. They further stated insurance policy is governed by principle of utmost good faith

where the insured is bound to provide all the relevant details and disclose all material

information .Non disclosure of any relevant information which might have influenced their

decision regarding the admissibility, constitutes concealment of facts and violation of

insurance principle. They stated that the vehicle was stolen in January, there might be dense

fog in the night then why NSCI guard will keep an eye on things of a stranger whether it is at a

distance of 4-5 metres or 100 metres. In the investigation it was found that no such person

named Mr Karan Singh was working with them as guard since 4 to 5 years. There had been

wilful and malafide neglect and carelessness of the insured which constitutes violation of the

private vehicle package policy condition number 4 which states, “the insured shall take all

reasonable steps to safeguard the vehicle from loss or damage and to maintain it inefficient

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 event of any accident or

breakdown, the vehicle shall not be left unattended without proper precautions to be taken to

prevent further damage or loss and the vehicle be driven before the necessary players are

Page 106 of 151

affected any extension of the damage or any further damage to the vehicle shall be entirely at

the insured own risk.” The Insurance Company stated that in the case of Mr Keshav Natthu

Mhatre Vs New India Assurance Company Limited, NCDRC, New Delhi held that the insured

vehicle should not be left unattended without taking proper precautions.

19. Reason for registration of Complaint:- Repudiation of Motor claim.


a) Policy Copy

b) elf Contained Note

c) Repudiation Letter


Parties present and heard. The complainant’s action of leaving the vehicle overnight with a mere request

to some nearby available person, whose identity is very unclear, is not reasonable.

Accordingly, the insurer was justified in repudiating the claim

Award


(Sudhir Krishna)


23rd October, 2019



OMBUDSMAN- Shri. Sudhir Krishna

CASE OF Mr. Sandeep Kumar V/S United India Insurance Company Ltd.

COMPLAINT REF: NO: DEL-G-051-1819-0601

CASE NO: GI/UII/328/18

1. Name & Address Of The Complainant Shri. Sandeep Kumar House No. 104, Block-A, Hari Enclave, Kirari Sulemaan, Nagar Delhi-110086

2. Policy No. Type Of Policy Policy term/Policy Period

22193117P105397606 Motor Policy 22.07.2017 to 21.07.2018.


Shri. Sandeep Kumar Shri. Sandeep Kumar

4. Name of insurer The United India Insurance Company LTd.


6. Reason For Grievance Non Settlement

7. Date of receipt of the Complaint 09.01.2019.

8. Nature of Complaint Non Settlement



11. Amount of Partial Settlement NA


Page 107 of 151


Rule 13(1)(c) – delay in settlement of claims by an insurer

14. Date of hearing 03.10.2019.

Place of hearing Delhi


a) For the Complainant Shri. Sandeep Kumar- Self.

b) For the Insurer Shri. Deepak Ahuja- Dy. Manager.

16. Date of Award/Order 11.10.2019.


Shri. Sandeep Kumar (herein after referred to as the complainant) had filed the complaint

against the decision of United India Insurance Company Ltd. (herein after referred to as

respondent Insurance Company) alleging non settlement of claim.

18. Cause of Complaint: Non Settlement of claim.

a) Complainant's Argument: The complainant, vide his letter dated 09.01.2019, has stated that

his motor cycle no. DL07-S BG-9427 was stolen, as per FIR no. 009373 dated 22.03.2018,

from Haiderpur Metro Station on 21.03.2018. He had submitted all the claim documents to the

Company for Rs.30000/-, but the Insurance Company did not settle his claim. He had

represented his case before the Insurance Company vide his letter dated 01.12.2018 for

payment of his claim for Rs.30000/-, but he got no relief. The Company official verbally

informed him that his claim was closed. He has now approached this forum for relief.

b) Insurer's Argument: In their Self Contained Note, dated 05.08.2019, the Insurance

Company stated that the insured complainant left the motorcycle no. DL07-S BG-9427

unattended near Haiderpur Metro Station, which led to theft. The complainant violated Policy

Condition no. 4, which requires that “ the insured shall take all reasonable steps to safeguard

the vehicle from theft, loss, or damage and shall maintain it in an efficient condition.” In this

case, the aforesaid vehicle was left unattended without proper precautions and the insured did

not take reasonable care and steps to safeguard the said vehicle. Hence, the said claim was

rejected under Condition no. 4 of the policy.

19. Reason for registration of Complaint:- Non Settlement of claim.


a) Copy of policy

b) Copy of FIR, Un-trace Report, NCRB Report, RC, DL etc.

c) Self Contained Note

21. Result of hearing with both parties (Observations and Conclusion):

In the hearing of today on 03.10.2019, the complainant Shri. Sandeep Kumar is present in

person, while the Respondent was represented by Shri. Deepak Ahuja- Dy. Manager. The

complainant had parked the vehicle in an unauthorized place, and therefore it can be

concluded that he did not take proper care to safeguard the insured vehicle from loss, as

required by Condition no. 4 of the Policy. Hence, his complaint is not accepted.

Page 108 of 151

Award

Taking into account facts and circumstances of the case and the submissions made by both the parties during the course of hearing, it is concluded that the complainant did not take proper care to safeguard the insured vehicle from loss, as required by Condition no. 4 of the Policy. Hence, his complaint is not accepted and dismissed accordingly.

Dated:- 11.10.2019. (Sudhir Krishna) INSURANCE OMBUDSMAN

(Delhi)




CASE OF Shri. Ammar Mohammad V/S National Insurance Company Ltd.


CASE NO: GI/NIC/310/18

1. Name & Address Of The Complainant Shri. Ammar Mohammad. C-43, Zakir Bagh Society, Opp. Surya Hotel Annexe, New Delhi-110025


351600/31/17/10000246 Private Vehicle Package Policy 30.09.2017 to 29.09.2018.


Shri. Ammar Mohd. Shri. Ammar Mohd.

4. Name of insurer National Insurance Company Ltd.

5. Date of Repudiation 05.11.2018.

6. Reason For Grievance Repudiation












For the Complainant Rep. by Shri. Mujeebur Rahman- Father.

For the Insurer Shri. Nand Kishore- Dy. Manager


17. Brief Facts of the Case :

Shri. Ammar Mohammad (herein after referred to as the complainant) had filed the complaint against

the decision of National Insurance Company Ltd. (herein after referred to as respondent Insurance

Company) alleging wrong rejection of his claim.

18.Cause of Complaint: Repudiation of claim.

Page 109 of 151

a) Complainant's Argument: The complainant has stated vide his complaint dated 27.09.2018 that

while charging AC gas, the technician went to masjid to offer prayer, leaving the AC gas charging

cylinder inside the car. When he returned, he found that the said gas cylinder blasted inside the

vehicle in question and caused damage to the vehicle. The company rejected his motor claim. He

approached the Grievance cell of the company vide his e-mail dated 19.06.2018 for redressal of his

grievance, but he got no relief. Hence he has now approached this forum for relief.

b) Insurer's Argument: The Insurance Company, vide their Self Contained Note dated 02. 04.2019,

had stated that cause of loss was leaving of the gas charging cylinder inside the locked car by the

garage technician, which blasted in the afternoon, when Temperature of the day was 45.5 degree as

per claim form. The Policy covers use of private vehicle for carriage of Samples or personal luggage.

Since the gas charging cylinder does not fall under the said category, the claim was denied. Under

these circumstances, the workshop was responsible as a Bailee for the damage to the said vehicle.

17. Reason for registration of Complaint:- Repudiation of claim.


Copy of policy.

Copy of Claim Form, Survey Report, DL, photo graphs of car

Copy of Rejection.

Self Contained Note

19. Result of hearing with both parties (Observations and Conclusion) :

During the hearing, the complainant is represented by his father Shri. Mujeebur Rahman and the

Respondent Insurance Company is represented by Shri. Nand Kishore- Dy. Manager.

The Policy terms and conditions do not have any specific clause excluding the bailment that denies

the claim of the complainant. Therefore, the repudiation of the claim is not justified. However

the amount of the claim will be limited to the amount, recommended by the Surveyor, which is

Rs.96552.75, or say Rs.96553/- only.

Accordingly, I over- rule the repudiation made by the Insurance Company vide their letter dated

27.12.2018, and direct the Respondent Insurance Company to reimburse the cost of repairs of the

insured vehicle, which I fix at Rs.96553/- (ninety six thousand five hundred fifty three) only, and

this amount should be paid to the complainant by the Respondent within 30 days.

Award

Taking into account facts and circumstances of the case and the submissions made by both the parties during the course of hearing, I over- rule the repudiation made by the Insurance Company vide their letter dated 27.12.2018, and direct the Respondent Insurance Company to reimburse the cost of repairs of the insured vehicle, which I fix at Rs.96553/- (ninety six thousand five hundred fifty three) only, and this amount should be paid to the complainant by the Respondent within 30 days.

Dated:- 11.10.2019. (Sudhir Krishna)

INSURANCE OMBUDSMAN

(Delhi)

Page 110 of 151




CASE OF Shri. Ram Prasad V/S The New India Assurance Company Ltd.


CASE NO: GI/NIA/367/18

1. Name & Address Of The Complainant Shri. Ram Prasad House No. 1522, Gali No, 9 B, Swatantra Nagar , Narela, Delhi-110040


301010331170100007762 Motor Policy 06.03.2018 to 05.03.2019.


Shri. Ram Prasad Shri. Ram Prasad

4. Name of insurer The New India Assurance Company Ltd.


6. Reason For Grievance Inadequate Settlement


8. Nature of Complaint Inadequate Settlement


10. Date of Partial Settlement 01.02.2019.

11. Amount of Partial Settlement Rs.70200/-







a) For the Complainant Absent

b) For the Insurer Shri. Rajiv Kumar Pathak- AO (D)



Shri. Ram Prasad (herein after referred to as the complainant) had filed the complaint against

the decision of The New India Assurance Company Ltd. (herein after referred to as respondent

Insurance Company) alleging inadequate settlement of his claim.

18. Cause of Complaint: Inadequate Settlement of claim.

a) Complainant's Argument: The complainant, vide his letter dated 19.02.2019, stated that his e-

rickshaw was stolen from the office of Authority when he took his e- rickshaw there for driving

trial. He lodged FIR no.012138 on 13.04.2018 immediately at e- Police Station, Prashant Vihar,

Rohini, Delhi. He submitted his claim for Rs.100700/- out of which the Insurance Company

paid Rs.70200/- only and deducted Rs.30500/- He represented his case before the Insurance

Company vide his letter dated 19.02.2019 for remaining amount of claim for Rs. 30500/-, but

got no relief. He has now approached this forum for relief.

b) Insurer's Argument: The Insurance Company, vide their Settlement sms, dated 01.02.2019,

informed the complainant that they had already paid Rs. 70200/- only as per terms and

conditions of the policy. In their Self Contained Note, dated 20.05.2019, the Insurance

Page 111 of 151

Company stated that they had deducted Rs.30000/- towards Subsidy, given by Delhi

Government; and deducted Rs.500/- towards Compulsory Excess as per terms and conditions of

the Policy.

19. Reason for registration of Complaint:- Inadequate Settlement of claim.


a) Copy of policy

b) Copy of RC,FIR, Untrace Report by NCRB, and Final Report.

c) Copy of claim Settlement Advice.

d) Self Contained Note


The complainant is absent today and was absent during the last hearing as well. The Insurance

Company is represented by Shri Rajiv Kumar Pathak- AO (D). The Insurance Company stated that

they had already paid the said claim for Rs. 70200/- only as per terms and conditions of the policy.

Further, they had deducted Rs.30000/- towards Subsidy, given by Delhi Government; and

deducted Rs.500/- towards Compulsory Excess clause of the Policy.

Keeping in view the fact that the complainant has received the Subsidy from the Government,

which is almost equal to the amount under claim, the said complaint does not appear to be justified.

Award


Dated : 21.10.2019 ( Sudhir Krishna)

INSURANCE OMBUDSMAN

(Delhi)




CASE OF Shri Anil Kumar V/S United India Insurance Company Ltd.

COMPLAINT REF: NO: DEL-G-051-1920-0023.

CASE NO: GI/UII/16/19

1. Name & Address Of The Complainant Shri Anil Kumar. House No. 9 A, Near Shiv Mandir, Auchandi Road, Bawana, New Delhi-110039.


0408003117P103227453 Motor Policy 30.05.2017 to 29.05.2018.


Shri Anil Kumar Shri Anil Kumar

4. Name of insurer United India Insurance Company Ltd.


Page 112 of 151

6. Reason For Grievance Inadequate Settlement


8. Nature of Complaint Inadequate Settlement


10. Date of Partial Settlement 23.07.2018.

11. Amount of Partial Settlement Rs.7260/-







c) For the Complainant Shri Anil Kumar- Self.

d) For the Insurer Shri Harsh Mann- AM & Shri Sunil Saini AO



Shri Anil Kumar (herein after referred to as the complainant) had filed the complaint against

the decision of The New India Assurance Company Ltd. (hereinafter referred to as the

Respondent Insurance Company) alleging inadequate settlement of his claim.


a) Complainant's Argument: The complainant, vide his letter dated 30.04.2019, stated that

his car Regn. No. HR13L6175 was immersed in rain water on road and stopped all of a

sudden due to seizure of the Engine. He lodged damage claim on the Company, and the

Matrix Insurance Surveyors, deputed by company, assessed the loss for Rs.70295/- . Then

company deputed another Surveyor M/s. Uppal and Associates, and paid the labour charges

for Rs.7260/- only and disallowed the replacement of parts. Since the Insurance Company

paid Rs.7260/- only and deducted Rs.63000/-, he represented his case before the Insurance

Company vide his e-mail dated 23.07.2018 for remaining amount of claim, but got no

relief. He has now approached this forum for relief.

b) Insurer's Argument: In their Self Contained Note, dated 20.05.2019, the Insurance

Company stated that they had they had already paid Rs. 7260/- only and deducted

Compulsory Excess as per terms and conditions of the Policy. The final Surveyor

disallowed repair cost of Engine, because mechanical repair of the Engine was not covered

under the policy, and the Insured had

: 2 :

not opted for Add on Engine Protection cover. Hence the Company deducted cost of engine

parts and paid Rs. 7260/- only as per terms and conditions of the Policy.

19. Reason for registration of Complaint:- Inadequate Settlement of claim.


Page 113 of 151

a) Copy of policy

b) Copy of RC, DL, Bill, Copy of Survey Reports.

c) Self Contained Note


Case called. Parties present.

Complainant states that:

a. The first surveyor (Matrix) sent by the insurer had approved the claim for engine seizure, but

company chose to appoint a second surveyor for second opinion, who did not allow this claim

for engine seizure.

b. The Insurer had no clause for add-on cover for engine protection when this policy was taken.

This add-on cover has been introduced in later policies and is not applicable for this case.

c. The insurance policy permits loss or damage due to flood and inundation vide Clause 1(v) of

Section I.

Insurer agrees to the statement (a) and (b). However, in respect of (c), the Insurer states that this

is a case of ‘consequential loss’ in terms of Clause 2(a) of Section I and hence not admissible.

I conclude that the damage to engine was caused by flood and inundation and therefore the claim

would be admissible vide Clause 1(v) of Section I of the Policy.

Award

The complaint is allowed and the partial repudiation of the claim by the Insurer is set-aside.

Accordingly, the Insurer is directed to settle the remaining amount of the claim within 30 days.

Dated : 31.10.2019 ( Sudhir Krishna)

INSURANCE OMBUDSMAN

(Delhi)



OMBUDSMAN- Shri Sudhir Krishna

CASE OF Shri. Ravi V/S The New India Assurance Company Ltd.


CASE NO: GI/NIA/01/19

1. Name & Address of the Complainant Shri Ravi r/o. D-832, Gali No. 3, Nathupura Badarpur Majra, Burari, New Delhi-110084


98000031180306786236 Motor Policy 24.07.2018 to 23.07.2019.


Shri Ravi Shri Ravi

Page 114 of 151

4. Name of insurer The New India Assurance Company Ltd.

5. Date of Repudiation 25.02.2019.

6. Reason For Grievance Repudiation












a) For the Complainant Shri Ravi- Self.

b) For the Insurer Smt. Dinesh Ahuja- AO



Shri. Ravi (herein after referred to as the complainant) had filed the complaint against the

decision of The New India Assurance Company Ltd. (herein after referred to as respondent

Insurance Company) alleging wrong Repudiation of claim.


a) Complainant's Argument: The complainant, vide his letter dated 18.03.2019, stated that he

purchased Car no. CH-01-BD-1417 from Mr. Gulshan Kumar, and submitted all car documents

to RTO Delhi on 27.08.2018. He got an e- Slip dated 01.11.2018 from RTO, which shows the

Tax details for Transfer of Ownership with New Number of Car as DL-1-CZ-9757. He also

approached the Insurance Company, where the Insurance executive Mr. Prakash informed him

that without RC, duly endorsed in his name by RTO, his request for the transfer of insurance

was not entertain-able. While enquiring about the transfer of R.C., the RTO officer informed

him that there was some rejection like Form- 27 and no signature on NOC slip, so vehicle was

not transferred in his name at RTO. Before completing the documents, required by RTO, his

aforesaid Car was stolen on 23.10.2018, for which he lodged FIR, no.037938 on 24.10.2018.

He submitted claim documents to the Company accordingly. His claim was repudiated by the

Company stating that the Complainant was not insured under the said policy on the date of

theft. He represented his case before the Insurance Company vide his letter dated 18.03.2019

for payment of his claim, but he got no relief. He has now approached this forum for relief.

: 2 :

b) Insurer's Argument: The Insurance Company, vide their letter dated 25.02.2019, had

rejected the claim stating that the Complainant was not insured under the said policy on the

date of theft. In their Self Contained Note, dated 10.10.2019, they stated that owing to various

reasons, stated by the complainant, the said vehicle, purchased by him, was not transferred in

his name, and the vehicle was stolen on 21.10.2018. On the day of theft on 21.10.2018, the said

vehicle was insured in the name of Shri. Gulshan Kumar. At the time of theft, the Complainant

Shri. Ravi was neither the owner as per R.C. of the vehicle, nor he was insured under the said

Page 115 of 151

policy in absence of Insurable Interest. Hence, the Insurer repudiated the said claim of an

uninsured vehicle.

19. Reason for registration of Complaint:- Repudiation of claim.


a) Copy of policy

b) Copy of Discharge Summary, Bill, Receipt, Report etc.

c) Copy of claim Settlement Advice.

d) Self Contained Note.


Parties present and heard.

Complainant says that he entered into agreement for purchase of this car from Shri Gulshan

Kumar on 14.12.2017 and submitted the documents to RTO for change of name in RC on

27.08.2018.

Insurance was renewed in July, 2018 in the name of Shri Gulshan Kumar. Vehicle was stolen in

October, 2018 and even at that point of time, the RC and the Insurance Policy had continued in

the name of Shri Gulshan Kumar.

It is surprising to note that the complainant has been claiming the vehicle to be its own but

without getting the RC changed since December, 2017. The reason for this delay given by him,

namely, objections raised by the RTO, are not adequate, and the Insurance Company cannot be

faulted in repudiating his claim.

Award


Dated: 04.11.2019. (Sudhir Krishna)

INSURANCE OMBUDSMAN

(Delhi)

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. HIREN KALITA VS UNITED INDIA INSURANCE CO. LTD.

COMPLAINT REF NO: GUW-G-051-1920- 0061: Award No

1. Name & Address of the Complainant MR.HIREN KALITA

2. Policy No:

Type of Policy


1302023118P111963851

MOTOR CLAIM

31/01/2019 TO 30/01/2020

3. Name of the insured MR.NAVA KUMAR BARUA(CLAIMANT NOT

Page 116 of 151

Name of the policyholder TRANSFERRED HIS NAME TO THE POLICY)

4. Name of the insurer UNITED INDIA INSURANCE COMPANY LIMITED

5. Date OF OCCURANCE OF LOSS/CLAIM 30/06/2019

6. DETAILS OF LOSS Rs.56728/-

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 THE MOTOR CLAIM

14/08/2019

9. Amount of Claim Rs.56728/

10. Date & Amount of Partial Settlement NIL

11 Amount of relief sought Rs.56728/-

12. Complaint registered under Rules of Insurance Ombudsman 2017

13(1)(b)

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

29/10/2019


For the Complainant Mr.Hiren Kalita

For the insurer Mr.A.Munin Choudhury

15 Complaint how disposed Through personal Hearing

16 Date of Award/Order 29/10/2019

17) Brief Facts of the Case: The complainant Mr Hiren Kalita purchased a car from Mr. Nava Kumar Barua in the month of

April 2019.In the Registration Certificate the complainant changed the name of the owner to his name on transfer of

ownership. Unfortunately on 30/06/2019, the car met with an accident at Jalukbari. The Insurance Co. repudiated the

claim stating that the RC had been transferred to the claimant’s name in March 2019.The accident took place on

30.06.2019.However till date the policy has not been transferred to claimant’s name and it still remains in the name of the

previous owner Mr. Nava Kumar Barua.

18a) Complainant’s argument: The complainant does not know the rules regarding transfer of the vehicle. As

per his knowledge, as per sec 157 of Motor Vehicle Act, policy automatically stands transferred in the name of

subsequent registered owner of the vehicle if it is in force. According to him he should get the claim as policy

is in force.

18 b) Insurers’ argument: a)The policy Covering Vehicle No.AS-01-AF-9724 was in the name of Sri Naba Kumar

Barua on the date of accident(on30.06.2019) which does not confirm insurable interest of the claimant Mr.

Hiren Kalita.

b) IMT specifies procedure to be followed in case of transfer of a policy one has to pay the prescribed

fee/premium within the specified period, which was not followed in this particular case.

c) In absence of consideration leading to nonexistence of insurable interest, non-admission of the claim on the

cited ground is as per the policy conditions and in conformity with MV Act/Rules.

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

approval from honorable ombudsman13 (1) (b).


Page 117 of 151

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 29/10/2019 .The complainant Mr. Hiren Kalita himself was present and the insurer was represented by Mr. A Munin Choudhury.

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. As per policy condition, in case of transfer of ownership of a vehicle the relevant

insurance policy also needs to be endorsed in the name of the new owner by making payment of

prescribed fee/premium within the specified period. But in this case as Mr. Hiren Kalita does not have

insurable interest on that particular vehicle as he did not follow the procedure of transfer. Moreover, his

contention about Sec 157 of Motor Vehicle Act also is not correct. The ownership of an existing policy is

not automatically transferred to the newly registered owner of a vehicle. During the course of hearing the

complainant submitted verbally that other than this particular vehicle he has another 4 Nos of

commercial vehicle & 1 private car which prove that he is not ignorant about the Insurance rules &

regulations. So the Forum upholds the insurer’s decision to repudiate the claim.


Dated at- Guwahati, The 29 th

day of October 2019

K.B.Saha

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM (Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. SURESH BABU IRS

Case between: Mrs.M.Bhagyalakshmi………………The Complainant

Vs

M/s Royal Sundaram General Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD) G -038-1920-0245

Award No.: I.O.(HYD)/A/GI/0299/2019-20

1. Name & address of the complainant

Mrs.M.Bhagya Lakshmi H.No.3-6-195/B, 401, IV Floor, Gowri Apartments, Himayatnagar, Hyderabad- 500 029.

2. Policy No./Collection No. VPC0794512000102

Page 118 of 151

Type of Policy Duration of Policy/Policy period

Private car package policy

04.01.2019 to 03.01.2020

3. Name of the insured Name of the Policyholder

Ms Bhagya Lakshmi Manikya

Ms Bhagya Lakshmi Manikya

4. Name of the insurer M/s Royal Sundaram General Insurance Co.

Ltd.


6. Reason for repudiation Premium Cheque dishonured

7. Date of receipt of the Complaint

17.06.2019

8. Nature of complaint Policy issuance pertaining to Motor insurance

9. Amount of Claim Non-Issuance policy issuance

10. Date of Partial Settlement ------

11. Amount of Relief sought Fresh policy issuance + Rs.30,000 as damages

12. Complaint registered under Rule No.13 (h) of Ins. Ombudsman Rules, 2017

Rule 13.1 (h) – Non-issue of any insurance document to customers after receipt of Premium.

13. Complaint how disposed Allowed ( Statistical Purpose)

14. Date of Order/Award 17.10.2019

15 )Brief Facts of the Case:

The complainant had renewed her private car with the respondent after paying the premium

amount by cheque. Subsequently, her policy was cancelled and the matter intimated to RTA

by the respondent on ground of non realization of the premium cheque amount. The

respondent had enquired from her banker and was given to understand that the cheque was

not presented to them. Despite the matter having been informed to respondent and a fresh

premium paid as per the link provided, the respondent had expressed to her that a fresh

policy could not be issued and instead offered to reinstate the policy that was previously

cancelled. She has also claimed Rs.30,000/- toward damages for the expenses she had

incurred to travel by an alternate means of transport in the absence a valid insurance policy

for her vehicle. Aggrieved by the foul play of respondent who had initially promised to issue a

Page 119 of 151

fresh policy and on receipt of a fresh premium amount had subsequently denied it, she has

therefore filed a complaint against the respondent in this forum.

16) Cause of Complaint: Non issuance of policy after receipt of

premium.

17) Reason for Registration of Complaint:

The claim preferred by the complainant was non issuance of policy after receipt of premium. As the complaint fell under Rule 13(h) of Insurance Ombudsman Rules, 2017, it was registered. After registration of complaint by this Forum and before hearing on 17/10/2019, the insurer further reviewed the complaint and issued Fresh policy to the insured. The Complainant also received the fresh policy but requested for payment of damages which are beyond the scope of Insurance Ombudsman rules 2017.

AWARD

The complaint is treated as resolved and closed.

Dated at Hyderabad on the 17th day of October 2019

(I.SURESH BABU)

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

Page 120 of 151

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM (Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. Suresh Babu

Case between: Sri B.Shankar ………………The Complainant

Vs

M/s National Insurance Co. Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD)-G- 048-1920-0239

Award No.: I.O.(HYD)/A/GI/ 0301/2019-20

1. Name & address of the complainant Mr B Shankar- AO LIC Of India, BO Bhongir, Yadadri District,Telengana state- 508 116. (Mobile No.94400 -94157)

2. Policy No./Collection No. Type of Policy Duration of Policy/Policy period

351010/31/16/6138950924 Package Policy (Private vehicle) 18.10.2016 to 17.10.2017

3. Name of the insured Name of the Policyholder

Mr. B .Shankar M/s LIC of India

4. Name of the insurer M/s National Insurance Company Limited


6. Reason for repudiation Meteorological certificate not produced

7. Date of receipt of the Complaint 06.06.2019 8. Nature of complaint Rejection of motor OD claim 9. Amount of Claim Rs .3,40,000/- 10. Date of Partial Settlement NA 11. Amount of Relief sought Rs. 7,00,000/- 12. Complaint registered under

Rule No.13.1 (b) of Ins. Ombudsman Rules, 2017

Rule 13(b)Any partial or total repudiation of claims by the Life Insurer/General insurer/ Health Insurer.

13. Date of hearing/place 11.10.2019 14. Representation at the hearing

a) For the complainant Self

b) For the insurer Mr.N.Naresh Kumar, AM

15. Complaint how disposed Allowed

16. Date of Order/Award 21.10.2019


The complainant was issued a motor package policy by the Maruti dealer M/s Aadarsha Automotives Limited., Karimnagar which is attached to the Divisional Office of LIC Of India

Page 121 of 151

represented by Mr B Shankar (complainant) to cover the risk of his vehicle. On 24.09.2017, he met with an accident when a lorry that was moving in front of his car had applied sudden brakes. In the ensuing impact, his car was damaged and he was injured. He was admitted in Yashoda Hospital for treatment of his head injury. His brother in law had shifted the car from the site of accident to a workshop where it was stated to have got burnt on 02-03.10.2017 due to lightning and thunder storms. A spot survey and final survey was conducted for the vehicle and the estimate given for the damage was Rs. 3,42,348/- on total loss basis. However, when the respondent insisted upon the complainant to furnish the meteorological report to confirm that there was lightning on that day which had burnt his car, he could not obtain the same. Aggrieved by non-settlement of both the claims he approached the forum for justice.

18) Cause of Complaint: Rejection of Motor OD claim a)Complainant’s argument:

The complainant states that the FIR and the car insurance papers were submitted to the respondent and the respondent’s official too had inspected the vehicle. The car was badly damaged later due to lightning when it was still under repairs in the workshop. After the spot and final survey was conducted, an amount of Rs. 3,40,000/- was offered to him as full and final settlement of the claim for which his consent was asked. In the meanwhile, at the insistence of the respondent, he tried to obtain the meteorological report from the authorities concerned but they refused to give so. The matter was communicated to the respondent but he received a letter from the respondent that the matter was closed as NO CLAIM. He had approached the Grievance department and as there was no favorable response, he has finally approached this office to resolve his issue.

b) Insurer’s argument:

The Insurer in their Self Contained Note has submitted that intimation was received on 31.10.2017. The complainant’s vehicle was damaged in the accident that took place on 24.09.2017. It was shifted to Sri Lalitha Maruti works, Nizamabad for repairs and while it was in the workshop, heavy rains and thunder sparks had occurred on 12-13/10/2017 which resulted in the vehicle getting burnt. A spot surveyor was appointed on 25.09.2017 and on 06.11.2017 the final survey was conducted. The DO of the respondent too had appointed another surveyor to obtain the meteorological certificate from the MRO. The insured was reminded several times to obtain the meteorological certificate but when approached by him, he was denied since there was no thunder and lightning on the said night. Hence, the claim was repudiated.

19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Rejection letter

Page 122 of 151

c. Correspondence with insurer d. SCN and its enclosures 21) Result of the personal hearing with both the parties:

Pursuant to the notices given by this Forum both parties attended the personal hearing at

Hyderabad on 11.10.2019. Both the parties reiterated their arguments for and against the complaint.

The insurer stated that he met with a vehicle accident when he hit a lorry that stopped

abruptly in front of his car. He was injured and admitted in hospital. It was his relative who took the car to Sri Lalitha Maruti works, Nizamabad for repairs and while it was in the workshop, heavy rains and thunder sparks had occurred on 12-13/10/2017 which resulted in the vehicle getting burnt. Though he was initially offered Rs.3.40 Lakhs for the first accident claim, the company denied the second claim caused due to thunder bolt. Now the insured expressed willingness to accept Rs.3.4 Lakhs initially agreed towards full and final claim settlement. However he expressed that out of Rs.3.4 Lacs agreed the salvage/wreck value was estimated as Rs.75,000/- which is on the higher side. He stated that the present wreck value will be very less .

The insurer assessed the loss as under and intimated to the insured who agreed to the

same. However, when there was a second claim, the insured did not accept the original sum agreed upon. The insurer stated that as per policy condition, the maximum liability under the policy is the Sum Insured/ Insured declared value at the time of taking the policy which is Rs.3,43,348/-. Therefore they agreed to settle the first claim as under:

Insured Declared Value of Vehicle: Rs.3,43,348 Less Salvage value on “ As is where is condition”: Rs. 75,000 Less policy excess: Rs. 1,000 Add Towing charges Rs. 1,500 Rs.2,65,848 The second claim was due to thunder bolt fire damage at the workshop. Any further

loss to the vehicle when it is in safe custody of the workshop, the insurer stated that, it is the responsibility of the workshop and not the insurance company as per contractual liability. The contended that their settlement was as per surveyor recommendation.

The Forum observed that over a period of two years from the date of loss, the salvage/wreck value due to thunderbolt fire has further brought down the value considerably. The insured has submitted an estimate in support of his contention from the Maruti workshop without a date showing the estimated salvage value to be around Rs. 15000/- . The insurer is directed to settle the claim as under to meet the ends of justice. There shall be no order as to interest since both the parties agreed for the claim settlement.

Insured Declared Value of Vehicle: Rs.3,43,348 Less policy excess: Rs. 1,000 Add Towing charges: Rs. 1,500 Rs.3,40,848 Less Salvage value on “ As is where is condition”: Rs. 40,000 Rs.3,00,848

Page 123 of 151

Award. Taking into account the facts & circumstances of the case, the documents on record and the submissions made by both the parties during the course of personal hearing, the insurer is directed to admit the claim for Rs.3,00,848/- towards full and final settlement of the claim. There shall be no order as to interest since both the parties agreed for the claim settlement

In the result, the complaint is Allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017:

a) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

b) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Hyderabad on the 21st day of October, 2019.

( I. SURESH BABU )

OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA

CASE OF G P GUPTA V/S TATA AIG GENERAL INSURANCE CO LTD

COMPLAINT REF: NO JPR-G-038-1920-0102

AWARD NO: IO/JPR/H/A/1920/00

1. Name & Address of the Complainant G P GUPTA , Jaipur

2. Policy No:

Type of Policy


SUM INSURED/IDV

0158968221 00

Pvt Car package Policy

01.11.2018 to 31.10.2019

Rs. 5 lakh



G P Gupta

G P Gupta

4. Name of the insurer TATA AIG GENERAL INSURANCE CO LTD


6. Reason for repudiation Non settlement- repair to steering assy denied


8. Nature of complaint Non settlement of claim



11. Amount of relief sought Rs 32320/-

12. Complaint registered under 13 i (b)

Page 124 of 151

Rule no: of IOB rules

13. Date of hearing/place 16.10.2019/ Jaipur


For the Complainant Sh. G P Gupta

For the insurer Sh. VInay Raina, Sr. Manager



17) Mr. G P Gupta (herein after referred to as the complainant) had filed a complaint against

the decision of TATA AIG GENERAL INSURANCE CO LTD(Jaipur) (herein after referred

to as the respondent Insurance Company) alleging non settlement of Motor claim .


Complainant’s argument: :- The complainant Sh G P Gupta had taken the package motor Policy

No. bearing No. 0158968221 00 for the period from 01.11.2018 to 31.10.2019 covering his

Hyundai Verna car registration no. RJ 14 CU 3761 for IDV Rs. 5 Lakh from TATA AIG

GENERAL INSURANCE CO LTD.(Jaipur). The Complainant stated in his complaint letter

that his vehicle logged in rain water on 15.08.2019. The loss to the vehicle was informed to the

Insurance Company and estimate along with all the required documents were submitted to the

insurer. The survey job was conducted. The complainant submitted that Sh Mukesh Saini

visited the workshop for survey, whereas Mr. Ajay Kumar Sharma was deputed as per version

of the respondent Insurance Company. The Insurance Company denied the claim for steering

assy loss due to water logging. Aggrieved, he requested the insurer, including its GRO to

reconsider the claim but failed to get any relief. Thereafter, he preferred a complaint to this forum

for resolution of his grievance.

Insurers’ argument:- The insurer stated in their SCN that the on review of the documents

submitted it was observed that as per claim form narration while passing through water logging

area, the captioned vehicle suddenly stopped and after some days steering got jammed. The

vehicle was inspected by the surveyor and he submitted that steering system was not

water/physical damaged and it was not working due to internal failure, hence not considered. As

per diagnostic trouble code system, there was no fault code of steering Assy. As per vehicle

service history the vehicle first came to workshop on 16.08.2019 and later it again came on

21.08.2019 with the said problem. The Surveyor concluded that steering Assy system was not

water logged neither physical damaged rather it occurred due to some internal mechnial fault. The

surveyor allowed drying and cleaning of the floor carpet for the insured vehicle and insurer’s

liability was Rs. 960/- after deducting excess for Rs. 2000/-. The Insurance Company is ready to

settle the claim as assessed.

Page 125 of 151

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


a) Complaint letter

b) Policy copy, repudiation letter

c) Jaipur

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

his vehicle was stranded in water log. He towed his vehicle and towing charges was claimed. The

complainant submitted that his vehicle was inspected by Mr. Mukesh Kumar Saini. He submitted a

copy of job card and other repairers documents which bore the name of Sh Muksh Kumar Saini. He

submitted that as informed by Insurance Company, Sh Ajay Kumar Sharma was appointed for

survey job but Mr Mukesh inspected the vehicle and assessed the loss. He submitted that hand

brake and headlights of the vehicle were also damaged which were not considered by the surveyor.

The Insurance Company submitted that as per the surveyor assessment, the company was ready to

settle the claim for Rs. 960/-. The loss as submitted by the complainant towards Steering Assy was

not caused due to water logging whereas it was a mechanical and internal breakdown. The same

was excluded as per policy exclusions.

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

During the hearing , Sh Mukesh Kumar Saini was called, he informed that he was a trainee under

the

surveyor Sh Ajay Kumar Sharma. He was a coordinator and was in communication with the

insured person for the claim. I find that the Insurance Company was ill prepared for the hearing in

respect of the instant case. I direct the Insurance Company to review the claim re assess the

damages as per the repairer’s job card and decide the claim on substandard basis, i.e. 75% of the

assessed loss.

Accordingly, an award is passed with the direction to the Insurance Company to settle

the claim as admissible on substandard basis i.e. 75% of the assessed loss.

AWARD


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

claim on substandard basis i.e. 75% of the assessed loss .

Page 126 of 151



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.

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: 16.10.2019 INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




CASE OF MAMTA GUPTA VS IFFCO TOKIO GENERAL INSURANCE CO. LTD.


AWARD NO: IO/JPR/G/A/19-20/0030

1. Name & Address of the Complainant Ms. Mamta Gupta, Jaipur

2. Policy No:

Type of Policy


IDV

M5453976

Private Car Motor Insurance

31.01.2019 TO 30.01.2020,

Rs. 7.20 lakh, date of Loss 11.03.2019



Ms. Mamta Gupta

Ms. Mamta Gupta

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


6. Reason for repudiation Wrong NCB declaration








13 i (b)

13. Date of hearing/place 10.10.2019Jaipur


For the Complainant Sh B K Gupta (father)

For the insurer Sh. Abhishekh Asstt Mgr., Sh Deepak Agnihotri Asstt

Mgr.



17) Mr. Ms. Mamta Gupta(herein after referred to as the complainant) had filed a complaint

against the decision of IFFCO TOKIO General Insurance Co. Ltd.(Jaipur) (herein after

Page 127 of 151

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

claim.


Complainant’s argument: Mr. Ms. Mamta Gupta, the Complainant had taken the package motor

Policy No.M5453976 for the period from 31.01.2019 TO 30.01.2020 covering car registration no.

RJ 14 VC 8367 for IDV Rs. 7.20 Lakh from IFFCO TOKIO General Insurance Co.

Ltd.(Jaipur). The Complainant stated in her complaint letter that her vehicle met with an accident

on 11.03.2019. The loss to the vehicle was informed to the Insurance Company and estimate of an

amount Rs. 27000/-approx along with all the required documents were submitted to the insurer.

The survey job was conducted and the Insurance Company denied the claim on account of

wrong NCB confirmation at the time of issuance of the policy stating ‘No Claim Bonus’

availed but not entitled. Aggrieved, he requested the insurer, including its GRO to reconsider the

claim but failed to get any relief. Thereafter, he preferred a complaint to their office for resolution

of her grievance.

Insurers’ argument:- The insurer stated in their SCN dated 10.09.2019 received on 25.09.2019

that the above loss was reported to the Insurance Company the vehicle was surveyed by Mr.

Shankar Lal Saini, Surveyor and loss assessor, immediately for the verification of facts and

assessment of the said loss. On perusal of the report and other documents on record, it was

observed that the aforesaid claim was repudiated vide letter dated 09.05.2019 on the ground that

the insured has wrongly claimed/manipulated the NCB as the insured had taken the benefits of the

facts of NCB from the previous policy. It was observed that NCB was allowed based on the

declaration from the insured that there was no claim in the previous policy. On scrutiny of the

documents it was observed that NCB under the present policy was not correct and subsequently

request for depositing the premium within 10 days was made. It was confirmed from the website of

the Insurance Information Bureau portal of India that OD claim has already been availed from Tata

AIG hence NCB slab should be 0% instead of 25% availed by the insured in current policy. Hence

gross misrepresentation and withholding of information on the part of the insured. Therefore the

company opted to forfeit benefit under the policy.



f) Complaint letter

g) Policy copy, estimate, invoice,survey report

h) Form VI A duly signed by the complainant.

i) SCN and consent for mediation and conciliation incorporated on SCN

Page 128 of 151

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


the Insurance Company had not responded to his queries and had not settled the claim. The

Insurance Company submitted that the Complainant had wrongly declared his entitled NCB. The

complainant has taken a claim from the previous insurer Tata AIG. The facts were observed from

IIB portal of India after the claim arose. The Insurance Company agreed that it had not confirmed

the NCB from previous insurer as per IRDA guidelines within the period of 21 days from the date

of renewal of the policy.

I have perused the documents placed on the record and submission made during the personal

hearing. I find that the Insurance Company has accepted the premium for an amount Rs.7100/-

on 05.04.2019 and the policy was regularized. In a judgment reported in 2017 (2) CPR 553

(NC) "United India Insurance Company Ltd. versus M/s Jindal Poly Buttons Limited" it was

observed by the Hon'ble National Commission that where the insured took the benefit of wrong

NCB, his insurance claim would be reduced proportionately. Relying on the judgement, it was

held that the complainant is entitled to payment of the amount assessed by the Surveyor after

making deduction of 25% (entitled 0% NCB but availed 25% NCB) from the said amount. In

view of the above, I direct the Insurance Company to settle the claim as admissible after

deducting 25% of the claim amount (entitled 0% NCB but availed 25% NCB), I direct the

Insurance Company to settle the claim as admissible.

Accordingly, an Award is passed with the direction to the Insurance Company to settle the

claim as admissible under the policy.



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


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




AWARD


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

as admissible.

Page 129 of 151

PROCEEDINGS BEFORE




CASE NAND BIHARI NAGAR V/S THE UNITED INDIA. INS. CO. LTD.

COMPLAINT REF: NO JPR- G- 051- 1920-0067

AWARD NO: IO/JPR/GI/A/1920/0028

1. Name & Address of the Complainant Nand Bihari Nagar, Kota

2. Policy No:

Type of Policy


IDV

1406003117P110728784

Motor Insurance 4W PACKAGE vehicle

29.10.2017 to 28.10.2018

Rs.3.90 lakh, DOA 25.05.2018



Nand Bihari Nagar

Nand Bihari Nagar

4. Name of the insurer THE UNITED INDIA. INS. CO. LTD






10. Date of Partial Settlement NIL




13 i (b)

13. Date of hearing/place 01.10.2019 / Jaipur


For the Complainant Sh. Nand Bihari nagar

For the insurer Sh. Shankar Sharma, Dy. Mgr

15 Complaint how disposed Award in favour of the Complainant


17) Mr. Nand Bihari Nagar (herein after referred to as the complainant) had filed a complaint

against the decision of The United India Insurance Co. Ltd.(Jaipur) (herein after referred to as the

respondent Insurance Company) alleging Non settlement of vehicle accident claim.


Complainants argument: Mr. Nand Bihari Nagar, the Complainant had purchased a Vehicle bearing

No. RJ20 CD 3361, Volkswagon Polo 2014 which was covered under a Policy No.

14096003117P110728784 favouring Sh Pardeep Makhija for the period from 29.10.2017 to 28.10.2018

for the IDV of Rs 3.90 lakh from The United India Insurance Co. Ltd.. The complainant stated that

his above mentioned vehicle met with an accident on 28.05.2018. The complainant submitted an

estimate for repair of Rs.3.24 lakh. The Insurance Company denied the claim stating that there was no

insurable interest of the complainant on the policy because on the date of the loss as the policy was not

transferred on the name of the transferee i.e. Sh Nand Bihari Nagar. Aggrieved, he requested the

Page 130 of 151

insurer, including its GRO 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 Sh Nand Bihari had lodged a claim under

the policy on 05.06.2018. On processing the claim it was observed that the policy was insured in the

name of Sh Pradeep Makhija and the RC book of the vehicle was in the name of Sh Nand Bihari Nagar.

The complainant had not applied for the transfer of the policy as on 26.10.2018. The new owner of the

vehicle has not applied for transfer of ownership of the vehicle in the policy by issue of endorsement.

No NOC from the previous owner, sales letter and new transferred RC along with prescribed fee was

submitted which was a violation of GR 17 of the India Motor tariff. As per principle of insurance the

complainant did not have insurable interest in the said policy and the claim does not come under the

terms and conditions of the policy and the claim was repudiated.


20) ) The following documents were placed for perusal.

j) Complaint letter

k) Policy copy, repudiation letter, RC copy

l) GR 17 of the IMT

m) Form VI A duly signed by the complainant.

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

o)

22) Result of hearing with both parties (Observations & Conclusion) :- Both the parties

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

insured vehicle met with an accident on 28.05.2018 and he applied for RC transfer on 25.05.2018.

He purchased the vehicle on 22.05.2018. The insurance of the same was not transferred in favour

the registered owner. The Insurance Company submitted that the complainant had not applied for

the transfer of the vehicle till date along with all the documents as required for transfer of the

vehicle and no transfer fee was paid. The Complainant had no insurable interest in the policy at the

time of the accident and the claim was repudiated.

I have perused the documents placed on record and the submission made during the personal

hearing. I find that the complainant had not applied for transfer of the policy to the Insurance

Company as transferred RC was not received till date of loss, although he had not applied for

transfer of the RC.

I find that under the provision of the GR 17, it was the duty of the complainant to apply for

insurance transfer to the insurer within 14 days of transfer of ownership, failing which he was not

eligible to get the claim of the vehicle. General Regulation 17 of the Indian Motor Tariff Act

provides :- GR.17. “On transfer of ownership, a Package policy, is deemed to have been transferred

in favour of the person to whom the motor vehicle is transferred with effect from the date of

Page 131 of 151

transfer. The transferee shall apply within fourteen days from the date of transfer in writing under

recorded delivery to the insurer who has insured the vehicle, with the details of the registration of

the vehicle, the date of transfer of the vehicle, the previous owner of the vehicle and the number

and date of the insurance policy so that the insurer may make the necessary changes in their record

and issue fresh Certificate of Insurance.”

As such the accident occurred on 28.05.2018 within the grace period for getting the vehicle insurance

transferred, as per the GR 17 provision, but he had not applied for transfer of the policy to the Insurance

Company and no NOC from the previous owner for transfer of policy was submitted alongwith the requisite

fee. I direct the Insurance Company to settle the claim on substandard basis i.e. 75% of the admissible

claim..

Accordingly, an award is passed with the direction to the Insurance Company to settle the

claim on substandard basis i.e. 75% of the admissible claim.



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


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


Place: Jaipur SANDHYA BALIGA

Dated:.01.10.2019 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 on substandard basis.

Page 132 of 151

PROCEEDINGS BEFORE




CASE OF SHYO CHAND BHARIA V/S BAJAJ ALLIANZ GENERAL INSURANCE CO LTD



1. Name & Address of the Complainant SHYO CHAND BHARIA, Jaipur

2. Policy No:

Type of Policy


SUM INSURED/IDV

OG-18-1401-1801-00010970

Pvt Car package Policy

18.12.2017 to 17.12.2018

Rs. 8 lakh



Shyo Chand Bharia

Shyo Chand Bharia

4. Name of the insurer BAJAJ ALLIANZ GENERAL INSURANCE CO

LTD


6. Reason for repudiation Non submission of documents








13 i (b)

13. Date of hearing/place 16.10.2019/ Jaipur


For the Complainant Sh. Shyo Chand Bhadia

For the insurer Sh. Mukesh Sharma, Asstt Manager legal claims



17) Mr. Shyo Chand Bharia (herein after referred to as the complainant) had filed a complaint

against the decision of BAJAJ ALLIANZGENERAL INSURANCE CO LTD(Jaipur) (herein

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

Accident claim.


Complainant’s argument: :- The complainant Sh Shyo Chand Bhariahad taken the package

motor Policy No. bearing No. OG-18-1401-1801-00010970 for the period from 18.12.2017 to

17.12.2018 covering his Skoda car registration no. RJ 19 CB 0004 for IDV Rs. 8 Lakh from

BAJAJ ALLIANZ GENERAL INSURANCE CO LTD.(Jaipur). The Complainant stated in his

complaint letter that his vehicle met with an accident on 14.12.2018 at Manali. The loss to the

vehicle was informed by the driver and thereafter driver proceeded to Chandigarh for bringing

repairer. When returned, the vehicle was into 20-25 feet a deep valley dashed by some unknown

Page 133 of 151

vehicle . The matter was reported by some unknown person. The matter was to the Insurance

Company and along with all the required documents were submitted to the insurer. A total loss

claim was lodged which was not settled by the Insurance Company. Aggrieved, he requested the

insurer, including its GRO to reconsider the claim but failed to get any relief. Thereafter, he

preferred a complaint to this forum for resolution of his grievance.

Insurers’ argument:- The insurer stated in their SCN that the on review of the documents

submitted it was observed that the office has wrote registered letters dated 11.03.2019 and

18.03.2019 but no reply received from the complainant. It was submitted that the insured was

having prior knowledge that the engine of his vehicle was getting heated and not in a condition to

drive. Despite that the driver drove the vehicle in damaged condition upto 180 kms which resulted

in consequential damage and RS axle broke due to the negligence of the driver. The insured

admitted that he allowed the driver to leave the vehicle in unattended condition, hence there was

breach of condition. Therefore, the Insurance Company had no other option except to repudiate the

claim. In view of the above, the claim stand repudiated.



p) Complaint letter

q) Policy copy, repudiation letter

r) Jaipur

s) Form VI A duly signed by the complainant.

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

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


he was informed by the driver that Right axle of the vehicle was broken and he was proceeding to

Chandigarh for getting the repairer. After 5-6 hrs when he returned, the vehicle was found to have

fallen down into the 20-25 feet deep valley. The driver rushed to Jaipur to inform the insured. The

matter was informed to the Insurance Company. The damaged vehicle was lifted by the crane and

the bill also raised. The Insurance Company did not settle the claim. The Insurance Company

submitted that the driver was aware that the engine of the vehicle was heated and even though he

drove the vehicle. He left the damaged vehicle unattended on the road side and when he returned

the vehicle was found in the valley extensively damaged. The insured had violated the policy

condition that the damaged vehicle was not to be left unattended. The surveyor had also submitted

that the damages did not correlate with the cause of the accident and the complainant had informed

the Insurance Company about the incident after a delay of 3 days. Hence the claim was repudiated.

Page 134 of 151

I have perused the documents placed on the record and submission made during the hearing, I find

that Insurance Company has not disputed the accident and damages to the vehicle. The complainant

admitted that the vehicle was left unattended by the driver and on his return the vehicle was

extensively damaged as it had fallen in the valley. It was submitted by the Insurance Company that

the vehicle had no impact on the windshield though the vehicle had fallen into the 20-25 feet deep

valley. During the hearing, the Insurance Company showed the photographs of the damaged

vehicle. After examining the photographs which were also shown to the complainant. It is seen that

the windshield and the vehicle as a whole did not show the signs of extensive damages correlating

to the cause. There was inconsistency with respect to the cause of loss and damages to the vehicle.

In view of the violation of the policy condition and inconsistency of damages with regard to cause

of loss, I see no reason to interfere with the decision of the Insurance Company.

Accordingly, the complaint is hereby dismissed.



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




PROCEEDINGS BEFORE




CASE SURESH CHAND MEENA V/S LIBERTY GENERAL INSURANCE CO. LTD.

COMPLAINT REF: NO JPR- G- 051- 1920-0067


1. Name & Address of the Complainant Suresh Chand Meena, Jaipur

2. Policy No:

Type of Policy


201110000018701164800000

Motor Insurance 4W PACKAGE vehicle

10.02.2019 to 09.02.2020

AWARD


both the parties during the course of hearing, the complaint is hereby dismissed.

Page 135 of 151

IDV Rs. 7 lakh, DOA 19.05.2019



Suresh Chand Meena

Suresh Chand Meena

4. Name of the insurer LIBERTY GENEARL INS. CO. LTD






10. Date of Partial Settlement NIL




13 i (b)

13. Date of hearing/place 01.10.2019 / Jaipur


For the Complainant Sh. Suresh Chand Meena

For the insurer Sh. Gajraj jat Claims Service Mgr and Akshay Tanwar

15 Complaint how disposed Award in favour of the Complainant


18) Mr. Suresh Chand Meena (herein after referred to as the complainant) had filed a

complaint against the decision of Liberty General Insurance Co. Ltd.(herein after referred to

as the respondent Insurance Company) alleging Non settlement of vehicle accident claim.


Complainant’s argument: Mr. Suresh Chand Meena, the Complainant, had taken the

package policy for private car Hyundai Creta vide Policy No. 201110000018701164800000 for

the period from 10.02.2019 to 09.02.2020 for the IDV of Rs 7 lakh/- for his Vehicle No. RJ14

LC 9607 from Liberty General Insurance Co. Ltd. The insured vehicle met with an accident

on 19.05.2019 and the claim was informed to the Insurance Company. The survey job was

conducted and the Insurance Company denied the claim on account of wrong NCB

confirmation at the time of issuance of the policy stating ‘No Claim Bonus’ availed but not

entitled. The complainant submitted that his previous policy and the policy in question were

got issued by the respondent Insurance Company. Aggrieved, he requested the insurer,

including its GRO 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 respondent had issued a private car

package policy covering vehicle RJ 14LC 9607 based on the declaration by the complainant

that he was entitled to 50% NCB based on his previous insurance policy with Royal Sundaram

General Insurance Co Ltd. expiring on 09.02.2019. The policy as purchased online through the

portal of policybazar. Thereafter, on verification from the previous insurer, it was observed that

Page 136 of 151

the complainant was granted 25% NCB in the expiring policy and since he had no claim under

the expiring policy his entitlement was 35% and not 50% as granted to him on declaration.

Subsequently, the complainant was sent a letter dated 25.02.2019 with the request to pay the

difference amount of Rs. 1907/- on account of lesser entitlement of NCB within 10 days. The

complainant made payment of the difference amount on 10.07.2019 following which an

endorsement wef 10.07.2019 correcting NCB entitlement to 35% was made for the remaining

period. The insured reported a claim for damage to the insured vehicle on 18.05.2019. The

vehicle was surveyed by an in-house surveyor who assessed the loss for an amount of Rs.

17506/- however, in view of wrong declaration of NCB benefits under own damage section of

the policy stand forfeited and the claim was repudiated vide letter dated 28.05.2019.


20) ) The following documents were placed for perusal.

u) Complaint letter

v) Policy copy, repudiation letter, RC copy

w) Form VI A duly signed by the complainant.

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

23) Result of hearing with both parties (Observations & Conclusion) :- Both the parties

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

submitted that the Insurance Company sent a letter dated 25.02.2019 at his Jaipur address,

but he was transferred to Kapurthala hence he could not deposit the requisite NCB recovery

premium. However, he deposited the NCB recovery premium for an amount of Rs. 1907/-

on 08.07.2019. The complainant submitted that he had not lodged any claim in his previous

policy and there was no wrong information by him regarding NCB entitlement. The

Insurance Company submitted that NCB recovery letter to the complainant at his residence

was sent through registerd post which was not adhered to. The complainant availed NCB

@50%, whereas he was entitled for 35% NCB at the renewal of the policy. Hence, as a

policy condition wrong NCB declaration makes the claim repudiated.

I have perused the documents placed on the record and submission made during the

personal hearing. I find that the Insurance Company has accepted the premium for an

amount Rs.1908/- on 08.07.2019 and the policy was regularized. In case NCB was wrongly

taken by the insured, whether the claim is required to be repudiated in toto. In a judgment

reported in 2017 (2) CPR 553 (NC) "United India Insurance Company Ltd. versus M/s

Page 137 of 151

Jindal Poly Buttons Limited" it was observed by the Hon'ble National Commission that

NCB was taken by the complainant wrongly and the claim was repudiated on that ground.

It was observed by the Hon'ble National Commission that where the insured took the

benefit of wrong NCB, his insurance claim would be reduced proportionately. Relying on

the judgement, it was held that the complainant is entitled to payment of the amount

assessed by the Surveyor after making deduction of 15% (entitled 35% NCB but availed

50% NCB) from the said amount. In view of the above, I direct the Insurance Company to

settle the claim as admissible after deducting 15% of the claim amount (entitled 35% NCB

but availed 50% NCB).



k. 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.

l. 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:.01.10.2019 INSURANCE OMBUDSMAN

AWARD


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

the claim.

The complaint is treated as disposed off accordingly.

Page 138 of 151

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

Mrs. Priyanka Krishna Srivastava…………..……....………………. Complainant V/S

SBI General Insurance Co. Limited…………..………..…………Respondent COMPLAINT NO:LCK-G-040-1718-0225 Order No. IO/LCK/A/GI/0034/2019-20

1. Name & Address of the Complainant Mrs. Priyanka Krishna Srivastava, 382., Hariharganj, Rajendra Nagar Colony, Fatehpur City - 212601

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

0000000006264575 Motor Own Damage Policy 16.04.2017 to 15.04.2018

3. Name of the life insured Name of the policyholder

Mrs. Priyanka Krishna Srivastava Mrs. Priyanka Krishna Srivastava

4. Name of the insurer SBI General Insurance Co.Ltd.

5. Date of Repudiation/Rejection N.A.

6. Reason for repudiation/Rejection N.A.



9. Amount of Claim ---

10. Date of Partial Settlement ---

11. Amount of relief sought ---

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

13. Date of hearing/place On 04.10.2019 at 10.15 am at Lucknow



For the insurer Ms Chynikca Modie



17. Mrs. Priyanka Krishna (Complainant) has filed a complaint SBI General Insurance Company Limited (Respondent) alleging repudiation of her motor claim.

18. Brief Facts Of the Case:- Complainant has stated that the vehicle was met with an accident on 26.06.2017

and accidental vehicle was sent to workshop for repair. Claimant has submitted all claims related documents

to RIC for settlement of her claim but her claim was repudiated by the respondent whereas she has already

paid the NCB recovery amount to respondent on 29.06.2017 as per demand letter of the respondent dated

01.09.2017. Aggrieved with the unjustified settlement of the claim, the complainant had approached this

forum.

In their SCN/reply, RIC has stated that on receipt of the claim intimation from the insured on 27.06.2017. RIC

has deputed IRDA licensed surveyor Mr. Syed Amir Raza Rizwi to inspect the vehicle and assess the

loss/damage. The said policy was issued by the respondent with a no claim bonus of 25% on the basis of

complainant declaration. Pursuant to NCB confirmation request, complainant’s previous insure M/s Tata AIG

confirmed that complainant have had preferred a claim under his previous policy with them. Respondent has

submitted that an insurance contract is the most common type of uberrimae fidei contract. Which inflexibly

Page 139 of 151

sets that an insurance agreement requires the highest standard of good faith. On the contrary, the

complainant herein tried to avail an unearned NCB bonus by false declaration and misrepresentation of facts.

It is worthwhile to mention that the benefits payable and premium charged under Section 1 of the policy

remains forfeited unless the amount towards reinstatement is received by the company and entitlement of

claim under Section 1 of the policy is available only if it arises on or after the payment of NCB receovery

premium. Looking to the above, RIC had repudiated the claim and informed the complainant vide their letter

dated 31.07.2017.

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly

filled/signed not submitted by the complainant till the date of hearing while respondent filed SCN along with

enclosures.

20. During hearing complainant remained absent. I have heard the representative of respondent at length and

perused paper filed on behalf of the complainant as well as the Insurance Company.

21. Notices were sent to the complainant for hearing today which were duly served but none is present.

Respondent representative is present. It is a case of non disclosure by the complainant regarding No Claim

Bonus from earlier Insurer. As per proposal form and policy document, insured did not mention the fact that

he had received a claim from the earlier insurer i.e. Tata AIG General Ins.Co.Ltd. After the issue of the policy

by the respondent when the matter was enquired from the earlier insurer it was informed by them that the

complainant had earlier received a claim for the same vehicle. Thereafter a letter was sent to the complainant

for depositing an amount of Rs.3060/- towards reinstatement of benefit under Section-1 of the policy but no

response was given by the complainant. Thereafter on 21.06.2017, the respondent cancelled/withdrawn

covers available under Section-1 [own damage] of the policy. However, the coverage under Section II/III/IV as

applicable remained unchanged.

Thereafter a claim for Rs.27755/- was made by the complainant on 27.06.2017. Admittedly NCB amount was

subsequently deposited by the insured. The claim was repudiated on the ground of wrong disclosure by the

insured.

I have gone through the records and heard the respondent representative. it is clear that the claimant has not

mentioned the fact of receiving the claim from the earlier insurer i.e. Tata AIG General Ins.Co.Ltd. in the

proposal form. Even he did not care to deposit the amount for reinstatement of benefit despite the letter of

the respondent dated 25.05.2017. Very interestingly after moving the claim on 27.06.2017 claimant

deposited the aforesaid amount thereafter but it could not be effective retrospectively. Once a wrong

information is given by the claimant and even after providing an opportunity to correct the same, claimant did

not do so by depositing the amount then he cannot take benefit of depositing the amount after submission of

the claim. Accordingly, respondent has rightly repudiated the claim of the complainant which did not require

any interference.

Accordingly, complaint is devoid of any merit and is liable to be dismissed.

22. Complaint filed by Mrs. Priyanka Krishna Srivastava stands dismissed.

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

Dated : October 04, 2019 (Justice Anil Kumar Srivastava)

Place : Lucknow Insurance Ombudsman

Page 140 of 151


Mr. Pallav Shukla …………..……....………………. Complainant

V/s National Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-G-048-1718-0190 Order No. IO/LCK/A/GI/0039/2019-20

1. Name & Address of the Complainant Mr. Pallav Shukla, Flat No :402, Raj Tower, Arya Nagar, Kanpur


45160031166160000738 Private Car Package Policy 21.10.2016 to 20.10.2017


Mr. Pallav Shukla Mr. Pallav Shukla

4. Name of the insurer National Insurance Company Limited 5. Date of Repudiation/Rejection N.A. 6. Reason for repudiation/Rejection N.A. 7. Date of receipt of the Complaint 29.06.2017 8. Nature of complaint Delay in settlement of claim 9. Amount of Claim Rs.78,505/-

10. Date of Partial Settlement --- 11. Amount of relief sought --- 12. Complaint registered under Rule Rule No. 13(1)(a) of Ins. Ombudsman Rule 2017 13. Date of hearing/place On 15.10.2019 at 11.00 am at Lucknow 14. Representation at the hearing

For the Complainant Mr. Pallav Shukla

For the insurer Mr. Kalendra Dixit

15. Complaint how disposed Dismissed 16. Date of Award/Order 15.10.2019

17. Mr. Pallav Shukla (Complainant) has filed a complaint against National Insurance Company Limited (Respondent) alleging delay in settlement of his motor claim.

18. Brief Facts Of the Case: The complainant had stated that his vehicle was insured under the aforesaid

policy. The said car met with an accident on 23.12.2016 & the claim was intimated to the RIC. All the claim

documents were also provided on 11.01.2017.After that three registered letters were also sent to

respondent but no reply was received by him. He himself repaired his vehicle and paid Rs.78,505/- as final bill

to the repairer. Aggrieved with the unjustified settlement/payment of his claim, the complainant had

approached this forum.

In their SCN/reply, RIC has stated that the impugned policy for aforesaid vehicle without engine protection.

The said vehicle was met with accident on 23.12.2016 and estimate was prepared by the workshop on

24.12.2016. On intimation the surveyor was deputed on 06.01.2017nad vehicle was surveyed on 07.01.2017.

The survey was done as per cause of accident and It was a case of engine seizer. As add on coverage to

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secure engine was not taken by the complainant, hence claim of engine damaged is not covered under this

policy. The complainant took the vehicle from the garage without informing the surveyor for re-inspection of

the said vehicle. Surveyor assessed the loss on the initial photographs and submitted the report. The claim

was approved by the competent authority as per surveyor report and photographs.

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 both the parties at length and perused paper filed on behalf of the complainant as well as

the Insurance Company.

21. The vehicle was damaged on the way from District Fatehpur to Kanpur on 23.12.2016 at about 10.00 pm.

The accident was not a result of direct impact rather the accident took place due to dense fog and to save a

vehicle from the front side, insured vehicle got out of control and landed down in road side ditch and damage

occurred on lower portion. Initial survey was conducted wherein it was found that the engine assembly was

not working and was diagnosed seized. Such type of seizer only occurs when the engine is kept running in the

absence of oil. Such type of losses to the engine internal parts were not having any relationship with the

proximate cause of the loss. Dismantling of the engine assembly was not allowed by the surveyor.

Accordingly, claim was partially allowed for Rs.3406/-.

Although it is true that the engine is also covered under the policy but the loss in the engine was not

proximate cause of damage. Further re-inspection was not got done by the claimant hence claim was partially

allowed. It is admitted by the claimant that after the accident, he drove the vehicle for about more than 30

km resulting in seizer of the engine.

Under such circumstances, the respondent has rightly partially allowed the claim which did not require any

interference. Accordingly, complaint is devoid of merit and is liable to be dismissed.

22. Complaint filed by Mr.Pallav Shukla stands dismissed.

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



PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017) Mr. Atul Seth …………..……....………………. Complainant

V/S National Insurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Atul Seth C/o Impala Agencies, 6, Narang Building, Ashok Marg, Lucknow-226001.


450100/31/14/00003518 Private Car Package Policy 13.06.2014 to 12.06.2015

Page 142 of 151


Mr. Atul Seth Mr. Atul Seth

4. Name of the insurer National Insurance Company Limited

5. Date of Repudiation/Rejection ---

6. Reason for repudiation/Rejection ---






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



For the Complainant Mr. Atul Seth

For the insurer Mr. Tarun Kumar Agnihotri



17. Mr. Atul Seth (Complainant) has filed a complaint against National Insurance Company Limited (Respondent) alleging non settlement of his motor claim.

18. Brief Facts Of the Case: The complainant has stated that the aforesaid vehicle was continuously

insured from 2012 till 2015. The aforesaid policy was issued by the respondent office Lucknow DO-I. The

said vehicle was met with an accident on 02.01.2015 and a claim was raised. The complainant

further stated that the total cost incurred by him towards the repair of the vehicle was Rs.1,53,348/- but

no surveyor was appointed for said claim. Aggrieved with the non settlement of his claim, the complainant

had approached this forum.

In their SCN/reply, RIC has stated that the said policy was issued by the respondent with No Claim Bonus of

20% on the basis of complainant declaration on the duly filled/signed proposal form. On processing of

claim intimation dated 04.09.2014, it was noted that two claims were also taken on the previous policy.

That claim of accident dated 02.09.2014 was repudiated due to wrong declaration of NCB. For that

repudiation of claim, complainant had approached the District Consumer Forum, Lucknow. It was further

stated that another claim was also intimated on same policy. As the previous claim was not paid due to

wrong NCB therefore no surveyor was deputed on aforesaid claim.


of policy document while respondent not filed SCN with enclosures.

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

complainant as well as the Insurance Company.

21. Admittedly the insurance policy was initially issued in favour of the claimant on the basis of the

proposal form submitted by him. It is stated in the proposal form that the claimant has not taken any claim

against the existing policy. Claim is repudiated by the respondent on the ground that the insured has

furnished false information regarding no claim with respect to the vehicle in question, although earlier he

had received claim amount on 29-06-2013 and 07-12-2013. Such type of concealment of material fact is

Page 143 of 151

sufficient ground for repudiation of the claim. Accordingly I do not find any infirmity in the order

repudiating the claimant’s claim. Hence, complaint is liable to be dismissed.

Accordingly, complaint is dismissed.

22. Complaint filed by Mr. Atul Seth stands dismissed.

23. Let copies of this award be given to both the parties.





Mr. Ajay Singh …………..……....………………. Complainant V/S

New India Assurance Company Limited…………..………..…………Respondent


1. Name & Address of the Complainant Mr. Ajai Singh, Life Insurance Corporation of India, DO Taramandal Road, Gorakhpur


42050131150300009180 Private Car Package Policy 17.02.2016 to 16.02.2017


Mr. Ajai Singh Mr. Ajai Singh

4. Name of the insurer New India Assurance Company Limited




8. Nature of complaint Partial repudiation of claim

9. Amount of Claim Rs. 65,104/-


11. Amount of relief sought Rs. 22,798/- + interest

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




For the insurer Mr. Ashwini Kumar



Page 144 of 151

17. Mr. Ajai Singh (Complainant) has filed a complaint against New India Assurance Company Limited

(Respondent) alleging partial repudiation of his motor claim.

18. Brief Facts Of the Case: The complainant had stated that his vehicle was insured under the aforesaid

policy. The said car was met with an accident on 03.03.2016 from the front, back and the right side. The claim

was intimated and vehicle was sent to the workshop on 07.03.2016. An estimate for Rs.1,04,844/- was raised

by the workshop and final bill of Rs. 65,104/- was prepared. But the surveyor had only allowed right side of

damages and only approved Rs. 42,306/- due to which rest of amount of Rs. 22,798/- was paid by him

whereas his car was insured with NIL dep. cover. Aggrieved with the partial repudiation of his claim, the

complainant had approached this forum.

In their SCN/reply, RIC has stated that the said vehicle was insured with their policy and reported it met with

an accident on 03.03.2016. And present resulting damages only inspected, examined and assessed by an

independent IRDA authorized surveyor whose assessment specially relating to the cause of accident narrated

in the claim document minus salvage value if any, were reimbursed by the company under the NIL Dep Policy

without making any deduction on account of any depreciation (excluding tyres).


of policy document while respondent filed SCN with enclosures.

20. During hearing complainant remained absent. I have heard the representative of respondent at length

pursued paper filed on behalf of the complainant as well as the insurance company.

21. Claim form submitted by the claimant with the respondent, wherein it is stated that the car met with an

accident from the front side. Respondent representative produced the original record before me. Although

complainant has filed different details of the accident which could not be believed because it does not bear

any signature of the receipt. Claim of Rs.65104/- was submitted and an amount of Rs.42284/- was paid. The

amount was paid on the basis of report of the surveyor hence there is no merit in the complaint. Assessed

amount has already been paid to the claimant. Accordingly, complaint is liable to be dismissed.

22. Complaint filed by Mr. Ajay Singh stands dismissed.

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




Mr. Virendra Dutta…………..……....………………. Complainant

V/s The Oriental Insurance Company Limited…………..………..…………Respondent


Page 145 of 151

1. Name & Address of the Complainant Mr. Virendra Dutt, 108, Hydil Colony, Chopan, Sonbhadra.


222599/31/2016/4712 Motor Own Damage Policy 28.03.2016 to 27.03.2017


Mr. Virendra Dutt

4. Name of the insurer The Oriental Insurance Company Limited




8. Nature of complaint Delay in settlement of claim

9. Amount of Claim --



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




For the insurer Mr.Anand Kand Chauhan

15. Complaint how disposed Dismissed as settled


17. Mr. Virendra Dutt (Complainant) has filed a complaint against Oriental Insurance Company Limited

(Respondent) alleging delay in settlement of his motor (PA) claim.

18. Brief Facts Of the Case:- The complainant has stated that he had met with an accident on 16.05.2016

while driving his vehicle and severely injured. He was admitted in hospital and later on his right leg was

amputated by the doctor of BHU, Varanasi. Complainant has submitted all claim related documents to RIC for

settlement of his claim but his claim was not settled. Aggrieved with the non-settlement of the claim, he

approached this forum for redressal of his grievance.

In their reply/SCN, the respondent has submitted the details vide their mail dated 03.10.2019 in which it has

been stated that the claim (PA owner Driver Claim) has been settled for Rs.50000.00 on 07.05.2018 as per

policy terms and conditions.

19. The complainant has filed a complaint, correspondence with the respondent. Annexure-VIA duly

filled/signed not submitted by the complainant till the date of hearing while respondent filed SCN along with

enclosures.

20. During the hearing complainant remained absent. I have heard the representative of respondent in length

and perused papers filed on behalf of the complainant as well as the respondent.

21. Notices for hearing was sent to the complainant but she is not present. Respondent representative is

present.

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Respondent representative submits that it is a case of loss of limb wherein an amount of Rs.50000/- has been

paid to the complainant. No further action is required in the matter. Accordingly complaint is dropped.

22. Complaint filed by Mr. Virendra Dutt stands dismissed as settled.





Mr. Mukesh Chandra Gupta…………..……....………………. Complainant V/s

United India Insurance Company Limited…………..………..…………Respondent COMPLAINT NO:LCK-G-051-1718-0160 Order No. IO/LCK/A/GI/0023/2019-20

1. Name & Address of the Complainant Mr. Mukesh Chandra Gupta, 319/8, Churiwali Gali, Kothi Jagdishpur, Chowk, Lucknow-226003


08010031110100003435 Motor Own Damage Policy ---


Mr. Mukesh Chandra Gupta Mr. Mukesh Chandra Gupta

4. Name of the insurer United India Insurance Company Limited 5. Date of Repudiation/Rejection --- 6. Reason for repudiation/Rejection --- 7. Date of receipt of the Complaint 12.10.2017 8. Nature of complaint Delay in settlement of claim 9. Amount of Claim Rs.15000 to Rs.20000.00

10. Date of Partial Settlement N.A. 11. Amount of relief sought Reasonable 12. Complaint registered under Rule Rule No. 13(1)(a) of Ins. Ombudsman Rule 2017 13. Date of hearing/place On 01.10.2019 at 10.15 am at Lucknow 14. Representation at the hearing

For the Complainant Mr. Mukesh Chandra Gupta

For the insurer Mrs. Shashi Bala

15. Complaint how disposed Allowed 16. Date of Award/Order 01.10.2019

17. Mr. Mukesh Chandra Gupta (Complainant) has filed a complaint against United India Insurance Company Limited (Respondent) alleging delay in settlement of his motor claim. 18. Brief Facts Of the Case:- The complainant has stated that he had intimated his motor vehicle accidental

claim in 2013-14. The respondent had asked to provide NCB confirmation vide their letter dated LRP: MSH:

250: 2013-14 dated 03.01.2014. He raised question about this letter relevance and did not reply this letter. He

further stated that he visited the respondent office many times for settlement of impugned claim. He also

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raised his grievance vide his letter dated 16.06.2017 with respondent but no action was taken by them.

Aggrieved with the repudiation of the claim, she approached this forum for redressal of her grievance.

In their reply/SCN, the respondent has stated that the aforesaid claim was closed due to non submission of

documents. Said claim was intimated and IRDA approved surveyor was deputed for the survey of the claim.

Surveyor had submitted the assessment report for Rs. 12,279/- without check in the pre-inspection report of

the vehicle. As per the PI report some parts were already broken/scratched. Therefore the claim was

approved for rs. 4,420/- and a letter dated 06.06.2017 was sent to the insured for submission of bank details

for claim disbursement but the same was not given by him. In the absence of the documents, the claim was

closed.

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 both the parities at length and perused papers filed on behalf of complainant as well as

respondent.

21. The Vehicle in question was ensured with the respondent for a period from 15-12-2011 to 14-12-2012.

Vehicle met with an accident on 15-04-2012. Vehicle was damaged. On the information given by the insured,

survey was done by IRDA licensed surveyor Mr. R.P Awasthi and report was submitted on 30-05-2012 wherein

an amount of Rs. 12279.14/- was assessed to be payable by the insurer. It appears that the matter was not

settled. Complainant made a complaint to the respondent on 16-06-2017. A fresh survey report was

submitted by the same surveyor on 22-05-2017 where in it was mentioned that the assessment was done

without P.I report. Supplementary report was submitted on the basis of P.I report and the amount assessed

was Rs. 4420/- only. Complainant submits that he had suffered losses of about Rs. 16000/-. Respondent

representative submits that the initial survey was conducted without P.I report. Hence the supplementary

survey was required with P.I report where in amount assessed was decreased.

22.Initial survey was done in 2012. Second survey report is of 2017. Why initial survey was not done with P.I

report? Why and how the amount initially assessed by the same surveyor has been decreased by him in

supplementary survey report which was given after about five years. No ground has been shown for

decreasing the amount except that some parts were shown as scratched and real view mirror LH and RH were

found broken. While in the initial survey report the amount was assessed as cost of parts labour charges and

painting charges. No rule is mentioned either in the SCN or shown by the respondent representative under

which second survey was done after a lapse of a period of about 5 years. There is nothing on record to show

that any intimation was given to the insured for second survey. Such type of second survey decreasing the

amount can not be accepted as genuine. In such circumstances amount decreased on the basis of report of

the same surveyor could not held to be in accordance laws and rules.

Complainant’s contention has force. Accordingly the respondent is directed to pay the complainant Rs.

12279/- as losses.

23. Let the copy of award be sent to the complainant and the respondent for compliance within 30 days.

Dated : October 1, 2019 (Justice Anil Kumar Shrivastava)


Page 148 of 151



Mr. Paras Nath Yadav…………..……....………………. Complainant V/S

TATA AIG General Insurance Company Limited…………..………..…………Respondent

COMPLAINT NO:LCK-G-047-1718-0224 ORDER NO. IO/LCK/A/GI/0033/2019-20

1. Name & Address of the Complainant Mr. Paras Nath Yadav, H.N- C-88/A-1 Sainik Housing Society Colony, Sarojani Nagar, Lucknow


0156840082 Private Car Package Policy 16/12/2016 to 15/12/2017


Mr. Paras Nath Yadav Mr. Paras Nath Yadav

4. Name of the insurer TATA AIG General Insurance Company Limited




8. Nature of complaint Partial repudiation of claim & service related complaint

9. Amount of Claim ---


11. Amount of relief sought ---

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



For the Complainant Mr. Paras Nath Yadav

For the insurer Mr. Mridul Mishra



17. Mr. Paras Nath Yadav (Complainant) has filed a complaint against TATA AIG General Insurance Company

Limited (Respondent) alleging not allowing the replacement of damaged part in his vehicle claim.

18. Brief Facts Of the Case:- Complainant has stated that he had purchased the policy with respondent for his

vehicle. The policy was issued with agent name and the same was removed from the policy after his objection.

Even the respondent had not shared the proposal form and detailed policy documents. Still the fresh policy

issued had contained the name of the agent. So he doubted the genuinely of the received insurance policy. He

further stated that he made a claim on 29.11.2017 and without his approval for repair work , the assessment

was done in between workshop and the surveyor of respondent insurance company. In the aforesaid claim

one part tray assey was also damaged but not allowed for replacement by the insurance company. Even after

intimation of claim, a survey was conducted on 06.12.2017 and vehicle was unattended for 07 days. He also

asked for the brokerage on the issued policy. Aggrieved with the service parameters & partial claim settlement

of insurance company, now the complainant approached this forum.

Page 149 of 151

In their SCN/reply, RIC has stated that the insured had taken a policy from an agent. On his objection the

name of the agent was removed from the insurance policy. The revised policy was issued in the direct code of

the company and the same was also shared with the insured on 18/12/2017 with a remark that “ Insured

should ignore the previous policy papers”. The respondent had further stated that a claim of aforesaid vehicle

dated 27.11.2017 was intimated to them on 06.12.2017. A surveyor was deputed to assess the loss and the

assessment of Rs. 42,014/- was made and only Rs. 1,000/- was deducted towards the excess clause in the final

bill. It was also submitted that policy does not provide any coverage with respect to reimbursement of

expenses for picking/ dropping vehicle or any kind of convenience charge.

19. The complainant has filed a complaint letter, correspondence with respondent and not submitted

Annexure VI-A duly filled/signed while respondent filed SCN with enclosures.

20. During hearing complainant remained absent. I have heard the representative of respondent at length and

perused paper filed on behalf of the complainant as well as the Insurance Company.

21. Main grievance of the complainant appears to be the harassment made out on him by the officer/official

of the respondent. So far as pecuniary damages are concerned admittedly as per the survey report,

assessment was made at Rs. 42014/- and the amount of Rs.41014/- was paid after deduction of Rs. 1000/-

towards excess clause. A grievance is made that towing charges have not been paid although claimant himself

admits that the vehicle was in running condition and he himself drove the same to the garage. Hence there is

no question of payment of towing charges.

As far as damages for harassment are concerned, it is not within the jurisdiction of this forum. Complainant

may if he so like approach the appropriate forum for redressal of his grievance. Accordingly I am of the view

that the complaint of the complainant is devoid of merit and is liable to be dismissed.

Accordingly complaint is dismissed.

22. Complaint filed by Mr. Paras Nath Yadav stands dismissed.




Page 150 of 151

COMPLAINT NO:LCK-G-040-1718-0225 Order No. IO/LCK/A/GI/ /2019-20

22. In view of above facts and circumstances, I come to conclusion that the respondent has rightly repudiated

the claim and acted in accordance with the terms and conditions of the policy. Therefore, I am of the opinion

that there is no reason to interfere the decision of respondent company and hence, complaint is liable to be

dismissed.

23, The complaint filed by Mrs. Priyanka Krishna Srivastava stands dismissed herewith.




Page 151 of 151

PROCEEDINGS BEFORETHE INSURANCE OMBUDSMAN, STATE …

Documents