PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA
(UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)
OMBUDSMAN – VIPIN ANAND
In the matter of Mr. Hareesh N Shetty Vs ICICI Lombard General Insurance Co. Ltd.
Complaint No: BNG-G-020-2122-0079
Award No.: IO/BNG/A/GI/0011/2021-22
• The complaint is submitted by Mr. Hareesh N Shetty against ICICI Lombard General
Insurance CO. Ltd. for the reimbursement of conveyance and compensation for the
dereliction of duty, harassment, mental agony and hardship caused to the complainant on
rejection of renewal of motor policy no. - 3005/A/204633907/00/00 by RI.
• According to the complaint, the complainant had a motor policy bearing no.-
3005/A/204633907/00/00 issued by RI on 01.09.2020. It was due for renewal on
04.09.2021. The complainant went to RI’s office for the renewal of his policy but the RI
refused to renew it. Thereby the RI asked him to renew his policy with some other insurer.
The complainant claims that he hired tourist car and spent Rs. 2000/- as hire charges for
about 60 kms to and fro journey to RI’s office. He had to undergo mental agony, distress and
hardship due to negligence and dereliction of duty by RI’s staff. So his complaint is for
compensation of Rs. 50 Lacs for mental agony and harassment plus Rs. 2000/- for car hire
charges by RI. He got his policy renewed from National Insurance Co. Ltd. after rejection by
RI vide policy no.-60230031210001272 dt. 12.08.2021.
• The Forum has gone through the documents and notes that the complainant has filed his
complaint for the compensation of Rs. 2000/- taxi hire charges plus Rs. 50 Lacs for mental
agony and harassment suffered by him due to rejection of renewal of his motor policy by RI.
The complainant has not suffered any direct monetary loss under an insurance policy since
he has not paid any premium to the RI for renewal of his policy.
• As per Rule 13(1) (h) of the Insurance Ombudsman Rules 2017 – The Ombudsman shall
receive and consider complaints or disputes relating to non-issuance of insurance policy
after receipt of premium in life insurance and general insurance including health insurance.
Despite the non receipt of premium by the RI, the complainant has sought a monetary relief
of Rs. 50 lacs. This Forum has no jurisdiction to consider this monetary relief.
• In view of the above, the Forum concludes that the complaint is NON-ENTERTAINABLE
under Rule No. 13 of Insurance Ombudsman Rules 2017 as amended upto date.
Dated at Bangalore on the 11
th
day of November 2021.
(VIPIN ANAND)
INSURANCE OMBUDSMAN
FOR THE STATE OF KARNATAKA
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. ARNAB PRADHAN Vrs. THE NEW INDIA ASSURANCE COMPANY LIMITED
COMPLAINT REF: NO: BHU-G-049-2122-0118
AWARD NO: IO/BHU/A/GI/ /2021-22
1.
Name & Address of the
Complainant
Mr Arnab Pradhan,
S/o Dr P.K.Pradhan, Mohanty Pada, Chandinichowk, Cuttack-
753002. Cell no.9776702510
2.
Policy No:
Type of Policy
Duration of policy/Policy
period
55040131190900017115 (Nil Depreciation Policy)
Bundled Motor Policy for Two-Wheeler, BMW/F 850 GS Two-
wheeler, IDV-Rs.14,63,000/-
12 months-23/03/2020 to 22/03/2021. DOA-08/07/2020
3.
Name of the insured
Name of the policyholder
Mr. Arnab Pradhan
Mr Arnab Pradhan
4.
Name of the insurer
The New India Assurance Company Limited
5.
Date of Repudiation
Settled for RS.163550/- on 23/10/2020
6.
Reason for repudiation
7.
Dt of receipt of the
Complaint
16/09/2021
8.
Nature of complaint
Partial settlement of claim
9.
Amount of Claim
Rs.1,05,237/- (balance amount)
10.
Date of Partial Settlement
11.
Amount of relief sought
Rs.1,05,237/- (balance amount)
12.
Complaint registered under
Rule no: of IO rules
13(1)b
13.
Date of hearing/place
08/11/2021, Bhubaneswar
14.
Representation at the
hearing
a) For the Complainant
Self through telephone (Mobile)
b) For the insurer
Mr. J R Mishra, Sr. BM through VC
15
Complaint how disposed
U/R 17 of the Insurance Ombudsman Rules, 2017
16
Date of Award/Order
08/11/2021
17. a. Brief Facts of the Case/ Cause of Complaint: -The complainant had insured his BMW/F
850 GS Two-wheeler with The New India Assurance Company Limited for the period 23/03/2020 to
22/03/2021 vide policy no. 55040131190900017115. The vehicle met with an accident on
08/07/2020. The Complainant submitted claim form and estimate for Rs.2,46,193/- obtained from
Prestige Motorrad on 16/07/20 after a delay of 9 days. On receipt of claim form on 16/07/2021,
surveyor was engaged who visited the garage on 17/07/2021. After repair Re-inspection was
conducted on 22/09/2021 and 23/09/2021. Surveyor submitted his report on 16/10/2021 where
he had assessed the loss for Rs.1,64,000/-. The insurer paid a sum of Rs.1,63,550/- after verifying
the bills. The Complainant had submitted bill for Rs.2,68.787/-. As he had received Rs.1,63,550/-
from Insurer, he has approached this forum for getting balance amount of 1,05,237/- (Rs.2,68,787/-
-Rs. 163,550/-)
b. The insurer, in its self-contained note, has admitted insurance and accident within policy
period. They stated that though estimate was for Rs.2,46,193/- he had submitted final bill for
Rs.2,68,787/-. They have submitted a detailed sheet mentioning reason for deduction for
Rs.1,05,237/-.
i)There was no estimate for clutch cover, control arm, heel guard, gasket ring, groved drive, wind
defeleet for Rs.37,275/-.
ii)No damage found for lateral trim for 41,474/-
iii) Tank cover for Rs.18,973/- not consistent to nature of accident and normal wear and tear
iv) Securing nut, body screw, gasket for Rs.1,289/- consumable items
v) Labour charges Rs.1345/-
v)Salvage Rs.4380/-
vi)Policy excess Rs.100/-
vii)PA premium Rs.450/- as PA cover not taken in policy
They had stated that the surveyor vide his letter 04/12/2020 had justified the assessment which
was also communicated to the complainant. Amount of Rs.1,63,550/- was paid to insured which
was just and proper.
18. a. Complainant’s Argument: - He had admitted for lodging claim for Rs.2,46,192/-. As he had
paid Rs,2,68,787/- to repairer and got reimbursement for Rs.1,63,550/- from insurer he is entitled
to get the balance amount
b. Insurer’s Argument: - They had rightly settled the claim as assessed by surveyor after
deducting Rs.450/- towards P.A. Premium as per audit guideline.
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 Policy, & policy wordings, survey report, estimate, final bill, photos,
detail calculation sheet submitted by insurer, b. Photocopies of estimate, bills
21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully
gone through all the documents relating the complaint and heard both the parties. When asked for
the details of the case, the complainant could not make his deposition correctly. He was also not
able to explain the Forum about the incident and about submission of documents properly. The
insurer informed that they have settled the claim as per surveyor’s assessment. The Forum
examined the documents and found that the insurer has settled the claim as per the surveyor’s
assessment after deduction of compulsory Personal Accident premium. The Forum found that the
surveyor is licensed by IRDAI.
AWARD
Taking into account the facts and circumstances of the case and submissions made by both
the parties during the course of hearing, it is observed that the complainant could not
substantiate his case for getting any additional amount. Since the insurer has settled the
claim as per surveyor’s assessment, the complainant is not entitled for any additional
amount on this claim.
Dated at Bhubaneswar on the 08
th
day of November, 2021
INSURANCE OMBUDSMAN
FOR THE STATE OF ODISHA
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Insurance Ombudsman- Shri Atul Jerath
Case of Sham Sunder v/s Universal Sompo General Insurance Co.
Ltd. Co
mplaint Ref no: CHD-G-052-2021-0041
Name & Address of the Complainant
Shri Sham Sunder
House No.1234, Sector 80,
S.A.S.Nagar (Mohali) -140308
Mobile No- 9417038734
Policy No:
Type of Policy
Duration of policy/Policy period
2367/62239139/SO/0000
Private Car Package Policy
14/12/2020 to 13/12/2021
Name of the insured
Name of the policyholder
Sham Sunder
Sham Sunder
Name of the insurer
Universal Sompo General Insurance Co. Ltd
Date of Repudiation
Not Applicable
Reason for repudiation
Not Applicable
Date of receipt of the Complaint
13-05-2021
Nature of complaint
Deduction of claim
Amount of Claim
Rs 39,800/-
Date of Partial Settlement
26-03-2021 for Rs 51,763/-
Amount of relief sought
Rs 39,800/-
Complaint registered under Rule no:
Insurance Ombudsman Rules, 2017
Rule 13 (1)(b) – any partial or total repudiation of
claims by an insurer
Date of hearing/place
29-10-2021, 16-11-2021/ Online hearing
Representation at the hearing
For the Complainant
Shri Sham Sunder, Complainant
For the insurer
Shri Prashant Shukla
Complaint how disposed
Award under rule 17
Date of Award/Order
25-11-2021
17) Brief Facts of the Case:
Shri Sham Sunder (hereinafter, the Complainant) has filed this complaint against Universal Sompo
General Insurance Co. Ltd (hereinafter, the Insurers), for wrongly doing deduction in his motor
claim.
18) Cause of Complaint:
a) Complainant’s argument: On 13-05-2021, Shri Sham Sunder had filed a complaint that his
Maruti Swift Car bearing Registration No.PB65-AU-1451insured on 05/12/2020 for the period
14/12/2020 to 13/12/2021 from Universal Sompo General Insurance Company Limited. His car
got damaged in a road accident on 30/01/2021 and same was got repaired from M/s Tricity Autos,
Zirakpur at total cost of Rs..85,763. His total claim amounted to Rs.91,563/- but the Insurance
Company passed only Rs.51,763 and deducted Rs.39,800/- on very irrelevant and false grounds. The
details of such calculations were given by complainant as under:-
S.No
Description
Amount
1
Total billed amount against repairs as per Invoice
no.5/BI/20001290 dated 10/03/2021 issued by M/s. Tricity Autos,
Zirakpur
85,763
2
Claim against burst tyre
4,800
3
Claim against deduction in towing charges bill
1000
Total Claim Amount
91,563
4
Amount paid by the Insurance Co to M/s.Tricity Autos, Zirakpur
against above said bill dated 10/03/2021
51,763
Amount illegally deducted by Insurance Co.
39,800
Insurance Company Limited deducted claim amount on the grounds that some alterations i.e.
replacement of normal rims and tyres with alloy wheel and wider tyres; were made in the vehicle
by the complainant and as such these parts are not covered under the present policy. It was also
informed by dealer that due to this, no claim has been considered for damage caused to front left
side suspension also. Accordingly, the tyre was not replaced by dealer and an amount of Rs.34,000/-
and for not paying anything against the damaged tyre costing Rs.4800. They also didn’t pay towing
charges of Rs 1000/-. He requested this forum to direct the Insurance Company to pay Rs.39,800/-
at the earliest in the interest of justice.
b) Insurers’ argument: In the SCN insurance company stated that the Complainant had availed
a Stand Alone OD Policy (Private Vehicle) for his motor vehicle bearing Registration No. PB 65- AU-
1451 bearing policy no. 2367/62239139/SO/0000, having policy validity period from 14/12/2020 to
13/12/2021. It is the case of the complainant that during the insurance period, on 30/01/2021
Insured Vehicle met with an accident and got damaged. Subsequently OD claim was intimated to
respondent company for which claim form was submitted and Claim No. CL20173046 was
generated. After the intimation of claim, as per terms and conditions of the Policy, insurance
company appointed the Surveyor “Shri Jitendra Singh” who conducted Survey and submitted its
report. The complainant had itself admitted in the complaint that an amount of Rs 51,763/- has
been paid against his claim. The said amount has been paid to the Tricity Autos, Maruti Suzuki on
26.03.2021 through NEFT vide UTR No. AXISCN0073923554. It is pertinent to mentioned here that
the loss as assessed by the appointed surveyor was Rs 52,306/-. The claim has been paid as assessed
by the Surveyor. The deductions which has made is because of Oversized Tyres, demanded twice in
the bill, the parts which are not relevant, consumables, and parts found safe in initial survey.
Further insurance company vide letter dated May 3, 2021 had responded to the insured and made
our stand crystal clear “that we have taken up the matter with the surveyor to understand the issue.
However, the surveyor explained that during conversation with you, he discussed about cause of
loss which you had mentioned in the claim form. Accordingly, the surveyor assessed loss which was
relevant to the cause of accident. The surveyor disallowed the damages which were not concurrent
with cause of loss which is mentioned in the claim form and also not forming a single sequence of
event, the same was explained to you.” Based on the facts stated above Insurance Company is
rightly justified to repudiate the claim of Insured on the aforesaid grounds.
19) Reason for Registration of Complaint: - Deduction of claim amount.
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)
Case called, both parties are present and recall their arguments as noted in Para 18 above.
Complainant stated that his total claim amounted to Rs.91,563/- but the Insurance Company passed
only Rs.51,763 and deducted Rs.39,800/- on very irrelevant and false grounds. Insurance Company
has deducted his claim amount on the ground of that some alterations i.e. replacement of normal
rims and tyres with alloy wheel and wider tyres; were made in the vehicle by the complainant and
as such these parts are not covered under the present policy. He requested for balance payment of
his claim.
During online hearing, the company was advised to explore the possibility of review of the claim so
as to arrive at an agreement. Insurance Company vide their email 29-10-2021 reiterated their stand
of SCN and stated that their deduction made is in order.
They stated that as per Owner’s Manual & Service Booklet of Maruti Suzuki India Limited (herein
after referred to as (“Maruti Suzuki’) it has been explicitly mentioned under (4) Limitation. Even
warranty in this booklet at “(f)” states that “Any vehicle which has been modified or altered,
including without limitation, the installation of performance accessories.” Further as per point “(g)”
this stipulates that, “Any vehicle on which parts or accessories not approved by Maruti Suzuki have
been used.” Insurance company also relied on “The Owner’s Manual & Service Booklet” under the
head of “Warning” clause. These sections have been used by the insurer to support their partial
rejection/ deduction from the claim. They also made a reference to the limitation clause of the
policy for supporting their decision.
On examination of various documents available in file including the copy of complaint, SCN filed by
insurance company, and submissions made by both complainant and insurance company at the
time of online hearing, it is observed that the payment of Rs. 51763/- was made to Tricity Autos,
Maruti Suzuki, empanelled workshop of insurance company on 26.03.2021 through NEFT vide UTR
No. AXISCN0073923554 for complainant’s claim which was assessed by insurance company
appointed independent Surveyor “Shri Jitendra Singh”.
The deduction of claim in the instant case has been done mainly due to the reason that some
alterations i.e. replacement of normal rims and tyres with alloy wheel and wider tyres; were made
in the vehicle by the complainant and as such it is contended by the insurer that these parts are not
covered under the present policy relying on Owner’s Manual & Service Booklet of Maruti Suzuki
India Limited , Motor Vehicle Act, 1988 and limitation as to use but making no reference to the
policy documents which is the basic contracts of insurance and form the basis for indemnification
of insured under the policy.
Examining all the above documents and facts presenting during the course of hearing as well as the
disclosures of the complainant in his complaint the following critical facts has emerged.
• The subject vehicle was insured by the company’s representatives after physical inspection
of the vehicle on 05.12.2020 after fully explaining the coverage under the policy as well add-
ons available.
• The alloy wheels in vehicle and the alleged over size tires were already installed in vehicle
at the time of its inspection of insurance on 05.12.2020 which infact were originally installed
in 2018 as contended by the complainant.
• No reference of this was either made in the proposal or the policy documents issued with
respect to its coverage or exclusion under the policy contracts.
In view of forgoing the deductions made by Mr. Jatinder Singh in house surveyor in his assessment
as regards items SR no. 1-11 on account of oversize tyre is arbitrary and not strictly in line with the
policy contracts. The contention of insurer on service booklets etc may be of concerns and
actionable by the manufacturer to handle warranty claims and cannot be the basis for settlement
for insurance claims. Deductions made by the surveyor at sr. no. 12- 18 appear to be in order and
requires no intervention at our level.
In view of the above facts the insurance company is directed to get the claim reassessed for the
deductions made by Mr. Jatinder Singh in house surveyor in his assessment for items SR no. 1-11
on account of oversize tyre and pay the balance amount to the complainant as per terms and
conditions of policy subject to compliance of claim related formalities within 30 days after 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 video conferencing, insurance company is directed to
pay the admissible claim amount subject to terms and condition of the policy after
completion of claim related formalities.
Hence, the complaint is treated as closed.
(Atul Jerath)
Insurance Ombudsman
November 25, 2021
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 16 of the Insurance Ombudsman Rules, 2017)
Insurance Ombudsman- Shri Atul Jerath
Case of Tarun v/s Go Digit General Insurance Co.
Ltd Co
mplaint Ref. No: CHD-G-059-2122-0009
Name & Address of the Complainant
Shri Tarun
72, Gandhi Dham, Jagdhri-135001
Mobile No.- 8295760500
Policy No:
Type of Policy
Duration of policy/Policy period
D009534049
Digit private car package policy
16-10-2019 to 15-10-2020
Name of the insured
Name of the policyholder
Tarun
Tarun
Name of the insurer
Go Digit General Insurance Co. Ltd.
Date of Repudiation
03-04-2021
Reason for repudiation
Non-fulfillment of requirement
Date of receipt of the Complaint
07-04-2021
Nature of complaint
Non-payment of claim
Amount of Claim
Rs 70,300/-
Date of Partial Settlement
Not Applicable
Amount of relief sought
Rs 70,300/- + interest
Complaint registered under Rule no:
Insurance Ombudsman Rules, 2017
Rule 13 (1)(b) – any partial or total
repudiation of claim by an insurer
Date of hearing/place
27-10-2021, 29-10-2021, 16-11-2021 /
Online hearing
Representation at the hearing
For the Complainant
Shri Tarun, Complainant
For the insurer
Shri Omkar Utture
Complaint how disposed
Recommendation under Rule 16
Date of Award/Order
16-11-2021
17. Brief Facts of the Case: Shri Tarun (hereinafter, the Complainant) has filed this complaint
against Go Digit General Insurance Co. Ltd (hereinafter, the Insurers), for non –payment of his
Motor accidental claim inspite of compliance of documents.
18. Cause of Complaint:
a) Complainants argument: On 07-04-2021, Shri Tarun filed a complaint to this office that his
vehicle no. HR-02T-4991 (Maruti Swift) met with an accident on 10/03/2020. He has done
compliance of every document but still his claim is not paid. He represented to customer cell but
no reply came to him till date. Complainant further vide his email dated 12-10-2021 pointed
that M/s Gupta Motor workshop has given cashless bill dated 11-07-2020 to insurance
company and later on insurance company in the month of August/ September 2021,
asked for re-inspection and final bill. He produced vehicle for re-inspection but it was
carried out by some other person who was not final surveyor. He attached photographs
of re-inspection which was carried out by person. He gave the bill which was generated
by workshop in his name to insurance company. He now came to know that insurance
company is taking plea that bills are different. He stated that bills were generated by
designated workshop of insurance company and he has no role in it. Nothing has been
muddled by him in the bill. He requested that forum to kindly instruct the insurance
company to pay his claim.
b) Insurers’ argument: Insurance Company stated that the vehicle of the complainant allegedly
met with an accident on 10th March 2020. However, the intimation regarding the same was
given to the Company on 12th March 2020 i.e after a delay of two days. In the meantime,
vehicle was shifted to “Gupta Motors”. As per the narration of loss, “on the way, a left side
passing truck dashed the IV, causing damages”. Accordingly, the surveyor visited the workshop
and physically examined the vehicle. On physical examination of the vehicle, it was observed
by him that, the damages noted do not tally with the cause of loss, he has made various
important observations and submitted his report along with his observations, the copy of
survey report and the color photographs of the accident vehicles were attached. Apart from
the above observations made by the surveyor, the Company also checked the previous claim
history of this vehicle and surprisingly it is revealed from the IIB that, the Complainant has taken
many claims on the vehicle. Based on the observations of surveyor and independent
verification of facts, the company officials suspected that, the alleged loss is not genuinely
described, there is suppression of material fact as to exact cause of loss, place of loss and the
driver who was driving the vehicle. Therefore, gave sufficient opportunity to the Complainant
to explain the correct details and sent clarification letter vide letter dated 27th March 2020.
This letter is also sent on the mail ID. It is submitted that, it is quite surprising that, the
Complainant instead of sending clarifications to our letter, he has approached this Hon’ble
court and failed to give his prompt response to the letter. They submitted that, Company has
given fair opportunity to the complainant, to explain correct cause of loss, place of loss and
driver at the time of loss, but there is willful misrepresentation of facts on the part of
complainant. The relevant facts which need to be taken into consideration in this claim. The
vehicle was removed from the spot and only after the vehicle reached at workshop intimation
was given to the company. The surveyor observed that, damages are not tallying with the cause
of loss. There is no explanation provided to the letter seeking explanation. The complainant has
failed to give the third-party vehicle details which caused this loss. Since, when a vehicle has
brushed the IV from left side, in a normal circumstance, one can note the vehicle number or
even description. No Police Complaint was lodged. The insured never met with the surveyor
nor participated anywhere during claim settlement. Further, insurance company vide email
dated 06-10-2021, stated after re-inspection and invoice that there are two different bills with
same date and invoice number, and they feel that complainant is trying to mislead this forum.
Thus, taking into consideration all these aspects, the Company has righty repudiated the claim.
Insurance Company requested that this complaint is liable to be dismissed since the
Complainant has made a willful breach of the policy terms and conditions and is not entitled
for any relief.
19. Reason for Registration of Complaint: Non-payment of motor claim.
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):
Case called for hearing. Both parties are present and recall their arguments as noted in Para 18
above.
During the online hearing, it was enquired from the insurance company whether in the view of the
facts emerging they would like to re-look at the claim and arrive at an agreement. The insurer vide
their email dated 15-11-2021 stated that they are ready to pay the claim for Rs 22,500/- (Twenty
Two thousand Five Hundred) without any interest subject to terms and conditions of policy and
completion of claim related formalities. The same was agreed upon by the complainant at online
hearing.
Accordingly, an agreement by way of conciliation was arrived at between the insurer and
complainant, which I consider as fair and reasonable for both the parties.
In the light of the amicable settlement of complaint between the Parties, the complaint is disposed
off with a direction that the company shall comply with the agreement and shall send a compliance
report to this office within 30 days after the receipt of award copy for information and record.
AWARD
The complaint is resolved in terms of agreement of conciliation arrived at between the
complainant and insurers as stated above. Accordingly, both the parties should implement this
agreement within 30 days.
(Atul Jerath)
Insurance Ombudsman
November 16, 2021
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 16 of the Insurance Ombudsman Rules, 2017)
Insurance Ombudsman: Shri Atul Jerath
Case of Rajesh Kumar V/S HDFC ERGO General Insurance Co. Ltd.
Complaint Ref. NO: CHD-G-018-2122-0087
1.
Name & Address of the Complainant
Shri Rajesh Kumar
S/o Sh. Om Parkash, VPO- Mathana, Tehsil-
Thanesar, Distt.- Kurukshetra, Haryana-0
Mobile No.- 8199889003
2.
Policy No:
Type of Policy
Duration of policy/Policy period
2312201574902700000
Motor Policy
01-12-2016 To 30-11-2017
3.
Name of the insured
Name of the policyholder
Rajesh Kumar
Rajesh Kumar
4.
Name of the insurer
HDFC ERGO General Insurance Co. Ltd.
5.
Date of Repudiation
25.02.2019
6.
Reason for repudiation
Non submission of documents
7.
Date of receipt of the Complaint
17-06-2021
8.
Nature of complaint
Non-settlement of theft claim.
9.
Amount of Claim
Rs.30000/-
10.
Date of Partial Settlement
N.A
11.
Amount of relief sought
Rs.30000/-
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total
repudiation of claims by an insurer
13.
Date of hearing/place
17.11.2021
14.
Representation at the hearing
For the Complainant
Shri Rajesh Kumar, the complainant
For the insurer
Smt. Shweta Pokhriyal, Manager Legal
15
Complaint how disposed
Recommendations under Rule 16
16
Date of Award/Order
17.11.2021
17. Brief Facts of the Case: Shri Rajesh Kumar (hereinafter, the complainant) has filed this complaint
against HDFC ERGO General Insurance Co. Ltd. (hereinafter, the insurers) alleging non-
settlement of theft claim of motorcycle.
18. Cause of Complaint:
a) Complainant’s argument: His motor cycle was stolen from kurukshetra on 17.11.2017 for
which FIR No 1030 dated 24.11.2017 was registered. All the required documents sought by the
insurer were submitted by him. Police has already submitted the final report (Untraced) under
section 173 Cr.P.C along with in the court vide order dated 11.07.2019. Despite various visits
to office of insurer, claim has not been paid.
b) Insurer’s Argument: That the complaint of the complainant is liable to be dismissed on the
ground of claim being Pre-mature. The claim of the complainant has been closed by the respondent
on the ground of non-submissions of the requisite documents .The complainant even after various
repeated requests and reminders letters failed to submit the requisite documents. In absence of
the requisite documents the respondent was not able to decide the claim on merits and therefore
the same was closed and not repudiated. Therefore it is submitted that the complainant himself is
liable for the non -compliance of the present claim. On 18/11/2017 a claim was lodged by the
complainant alleging that his vehicle has been stolen. Soon after the claim intimation, the
respondent appointed an independent Investigator in order to verify the genuineness of the facts
and circumstances of the claim as reported. Thereafter, the respondent during claim process found
that certain relevant documents which were necessary for the settlement of claim have not been
provided by the applicant. Thus, the respondent issued a letter dated 13.08.2018 requesting the
complainant for the submission of documents like100 No. Call record, RTO forms 26, 28 , 29 & 30
duly signed by Insured, Previous Policy, Bank Account Statement, Un-traced Report U/S 173 CrPC
certified and accepted by Court, Letter of Indemnity cum subrogation duly notarized with copy of
witness ID proof. However, the complainant failed to provide the documents. The complainant even
after repeated requests dated 03.09.2018 and 08.11.2018 failed to submit the documents, and thus
the respondent was constrained to close the claim in want of documents. The respondent closed
the claim vide letter dated 25/02/2019, which was duly served upon the applicant. It is reiterated
that the claim of the applicant has never been rejected but has been closed due to Non-receipt of
documents from the complainant. That applicant has violated the terms and conditions of the
policy, therefore, he is not entitled for any claim as mentioned in the application.
19. Reason for Registration of Complaint: Incorrect denial of claims and cancellation of policy.
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):
Case called for hearing. Both parties are present and recall their arguments as noted in Para 18
above.
During the hearing, it was enquired from the insurance company whether in the view of the facts
emerging they would like to re-look at the claim and arrive at an agreement. The representative of
the insurer offered to settle the claim as per terms and conditions of the policy after receipt of
pending documents, details of which will be provided to insured through mail. The same was agreed
upon by the complainant during online hearing.
Accordingly, an agreement by way of conciliation was arrived at between the insurer and
complainant, which I consider as fair and reasonable for both the parties.
In the light of the amicable settlement of complaint between the Parties, the complaint is disposed-
off with a direction that the company shall comply with the agreement and shall send a compliance
report to this office within 30 days after the receipt of award copy for information and record.
Award
The complaint is resolved in terms of agreement of conciliation arrived at between the
complainant and insurers as stated above. Accordingly, both the parties should implement
this agreement within 30 days.
(Atul Jerath )
Insurance Ombudsman
17
th
November, 2021
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Insurance Ombudsman: Shri Atul Jerath
Case of Sadhoo Singh V/S Tata AIG General Insurance Co. Ltd.
Complaint Ref. NO: CHD-G-047-2122-0080
1.
Name & Address of the Complainant
Shri Sadhoo Singh
VPO- Bassi Gulam Hussain,
Hoshiarpur, Punjab-0
Mobile No.- 9417546746
2.
Policy No:
Type of Policy
Duration of policy/Policy period
0177771644
Motor Policy
20-02-2020 To 19-02-2021
3.
Name of the insured
Name of the policyholder
Sadhoo Singh
Sadhoo Singh
4.
Name of the insurer
Tata AIG General Insurance Co. Ltd.
5.
Date of Repudiation
N.A
6.
Reason for repudiation
N.A
7.
Date of receipt of the Complaint
17-06-2021
8.
Nature of complaint
Denial of full claim
9.
Amount of Claim
10.
Date of Partial Settlement
N.A
11.
Amount of relief sought
Full claim with cashless facility
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total
repudiation of claims by an insurer
13.
Date of hearing/place
17.11.2021/ Online hearing
14.
Representation at the hearing
For the Complainant
Shri Sadhoo Singh, the complainant
For the insurer
Shri Vikas Thakur
15
Complaint how disposed
Award under Rule 17
16
Date of Award/Order
17.11.2021
17. Brief Facts of the Case: Shri Sadhoo Singh (hereinafter, the complainant) has filed this complaint
against Tata AIG General Insurance Co. Ltd. (hereinafter, the insurers) alleging incorrect denial
of claim and termination of policy.
18. Cause of Complaint:
a) Complainant’s argument: His vehicle met with an accident at 10.30 A.M on 18
th
Feb 2021 in
which side mirror of driver side, Front bumper and rear bumper was damaged for which claim
was lodged with the insurers. The surveyor of the company has not approved the back bumper
being old damage. In an earlier accident back window and back bumper were damaged but as
the loss to bumper was minor so it was not claimed. The surveyor at that time advised
complainant to get it repair next time.
b) Insurer’s Argument: Complainant registered claim with the company on 19.02.2021 for loss
dated 19.02.2021. The company appointed an independent surveyor, Mr. Vishal Saini to inspect
the vehicle and assess the loss. The surveyor assessed the loss in respect of damages resulting
from present accident. However, few other damages were disallowed as the same did not
correlate to the cause of loss. A letter dated 05.03.2021 to the effect was sent by surveyor to
insured. After receipt of survey report, it was noted that the insured had taken the vehicle
without getting it repaired. Hence, a letter dated 22.03.2021 was sent to insured. But no
response received from him till date for reasons best known to him. It is specifically submitted
that damages to rear bumper were denied as the same were a result of aggravation of earlier
damages to the rear bumper.
19. Reason for Registration of Complaint: Incorrect denial of claims and cancellation of policy.
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):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The surveyor vide his letter dated 05.03.2021 to complainant explained therein as to why damage
to the rear portion was not approved. Moreover, the Complainant himself admitted in the
complaint that back bumper the car was damaged in an earlier accident and same was not claimed
at that time being minor loss. In these circumstances, the decision of non-consideration of claim for
damage to rear bumper by the insurer is justified and cannot be faulted. Therefore, the complainant
is dismissed being devoid of merits.
Award
Taking into account the facts, circumstances of the case, the submissions made by both
the parties during the course of hearing, the said complaint is rejected being devoid of
merits.
The complaint is rejected.
(Atul Jerath)
Insurance Ombudsman
17
th
November, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 16 of The Insurance Ombudsman Rules, 2017)
Insurance Ombudsman: Shri Atul Jerath
Case of Surinder Kumar V/S ICICI Lombard Gen. Insurance Co. Ltd.
Complaint Ref. No. : CHD-G-020-2122-0076
1.
Name & Address of the
Complainant
Shri Surinder Kumar
S/o Sh.Mohal Lal, # 3622, Shaastri Street
Amrik Singh Road, Bathinda, Punjab - 151001
Mobile No.- 8360107717
2.
Policy No:
Type of Policy
Duration of policy/Policy period
3005/2011895443/00/0000003735
Bundled – Two wheeler policy
05.02.2020 to 04.02.2021 (OD)
3.
Name of the insured
Name of the policyholder
Sh. Pavnish Kumar
Sh. Pavnish Kumar S/o Sh.Surinder Kumar
4.
Name of the insurer
ICICI Lombard Gen. Insurance Co. Ltd
5.
Date of Repudiation
01.02.2021
6.
Reason for repudiation
FIR delayed by 33 days, Intimation after 49 days
7.
Date of receipt of the Complaint
09.06.2021
8.
Nature of complaint
Repudiation of theft claim
9.
Amount of Claim
S.I. – Rs. 53032/-
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
17.11.2021 / Online hearing
14.
Representation at the hearing
For the Complainant
Sh.Surinder Kumar
For the insurer
Sh.Karan Bagdai
15.
Complaint how disposed
Recommendation under Rule 16
16.
Date of Award/Order
17.11.2021
17) Brief Facts of the Case: Shri Surinder Kumar (hereinafter, the Complainant), has filed this
complaint against the ICICI Lombard Gen. Insurance Co. Ltd (hereinafter, the Insurers) for non
settlement of motor (theft) claim.
18) Cause of Complaint:
a) Complainants argument: Theft claim of veh. no. PB03BD/3364 has been rejected by company,
without any consent. Reason given is delay of intimation but they have pull report of 100 number
police call details.
b) Insurers’ argument: The complainant had taken a Two Wheeler Package Policy under policy
number 3005/193129844/00/000 for the period from February 05, 2020 to February 04, 2021. The
complainant alleged that on September 02, 2020 at around 11:00am, the insured vehicle (IV) was
parked near binani printing press patta market, Bathinda. Thereafter he came back at around
11:15am & noticed that the IV was missing from the parked place. On perusal of the claim
documents and further enquiry of facts, it was established that the complainant had lodged FIR on
October 05, 2020. Hence, there is an unreasonable delay of 33 days for filing an FIR. Company had
asked the complainant to provide the GD entry/100 no. call/ PCR copy if the complainant had
intimated the police about loss of the subject vehicle on the date of theft. However, the
complainant has not submitted any reply about delay in intimation or any confirmation about
intimation of theft to Police on the day of theft. Complainant is trying to mislead/misguide with the
baseless allegations that he had approached the police and had informed the Police Authority about
the theft of IV. Company even filed an RTI with the concerned authority to confirm whether the
complainant’s allegations about the intimation to the police on the very same day has any merits
however unfortunately the Company did not get any revert on the same from the concerned
authority. Though the Company took the reasonable steps to get the facts/information however
the complainant was unable to prove his allegation with any concrete evidence. Further, as per
policy terms and conditions of the policy, a claim should be intimated to the Insurance Company
immediately. Due to delay in intimation of claim to the Company, they unable to verify the actual
cause of loss and were unable to take immediate steps to get the insured vehicle traced. Further,
the IV could have travelled a long distance or may have been dismantled by that time and sold to
scrap dealer. Hence, this did not allow them to carry out proper investigation at the time of theft
and the scope to get the vehicle traced becomes negligible. Complainant had failed to comply as
per policy terms and conditions and as it is seen, there is a violation of policy condition. The
intimation/claim should have been immediately intimated to the Insurance Company and the
intimation should have been given to Police immediately & FIR should have been filed. As the
Company did not receive any justification from the complainant and/or any confirmation about
intimation of theft to Police & to the Company on the day of theft. Hence, the said claim was
rejected and the same was informed to the complainant vide our letter dated February 01, 2021.
Further, in their support, Company also refers a case of Insurance Ombudsman, Ahmedabad centre
in the matter of Mr. Hiten Shah Vs. ICICI Lombard GIC Ltd. vide Award dated October 13, 2021.
19) Reason for Registration of Complaint: - Non settlement of claim.
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):
Case called for hearing. Both parties are present and recall their arguments as noted in Para 18
above.
At this stage, in view of the facts narrated by the insured during this personal hearing the insurer
representative offer to pay the said claim as per terms and conditions of the policy. The same was
agreed upon by the complainant. Accordingly, an agreement by way of conciliation was arrived at
between the insurer and complainant which I consider as fair and reasonable for both the parties
AWARD
The complaint is resolved in terms of agreement of conciliation arrived at between the
complainant and insurers as stated above. Accordingly, both the parties should implement this
agreement within 30 days of receipt of these orders.
(Atul Jerath)
Insurance Ombudsman
November 17, 2021
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 16/17 of the Insurance Ombudsman Rules, 2017)
Insurance Ombudsman: Shri Atul Jerath
Case of Narender Mann V/S The United India Insurance Co. Ltd.
Complaint Ref. NO: CHD-G-051-2122-0094
1.
Name & Address of the Complainant
Shri Narender Mann
House No.- 405, Sector-8, Part-II, Urban
Estate, Karnal, Haryana- 132001
Mobile No.- 9466341000
2.
Policy No:
Type of Policy
Duration of policy/Policy period
1120003119P102474880
Motor Policy
25-05-2019 To 24-05-2020
3.
Name of the insured
Name of the policyholder
Narender Mann
Narender Mann
4.
Name of the insurer
The United India Insurance Co. Ltd.
5.
Date of Repudiation
N.A
6.
Reason for repudiation
N.A
7.
Date of receipt of the Complaint
25-06-2021
8.
Nature of complaint
Payment of balance claim.
9.
Amount of Claim
Rs.4,05,000/-
10.
Date of Partial Settlement
N.A
11.
Amount of relief sought
Rs. 4,05,000/- plus interest
12.
Complaint registered under
Rule no: Insurance Ombudsman Rules,
2017
Rule 13 (1)(b) – any partial or total
repudiation of claims by an insurer
13.
Date of hearing/place
17.11.2021 and 24.11.2021
14.
Representation at the hearing
For the Complainant
Shri Narender Mann
For the insurer
Shri S.K Bhatia
15
Complaint how disposed
Award under rule 17
16
Date of Award/Order
29.11.2021
17. Brief Facts of the Case: Shri Narender Mann (hereinafter, the complainant) has filed this
complaint against The United India Insurance Co. Ltd. (hereinafter, the insurers) alleging
incorrect denial of claim.
18. Cause of Complaint:
a) Complainant’s argument: His vehicle got damaged on 06.02.2020 and is total loss because
the loss assessed by the surveyor is Rs.28,20,000/-. The IDV of the vehicle is Rs.21,15,000/-
and as per terms and conditions Rs.21,13,500/- should be payable whereas insurance
company paid Rs. 17,08,500/-. The insurance company issued a single policy with IDV of
Rs.21,15,000/- In case of total loss IDV less Policy clause is payable. The insurance company
has not paid the amount of Trailer which is insured for Rs. 4,05,000/- and hence this amount
is payable to him.
b) Insurer’s Argument: As per policy schedule of the insured vehicle, the vehicle was insured
with IDV of vehicle was Rs.17,10,000/- and IDV for the trailer was Rs.4,05,000/- for trailer
separately. As already informed to the insured that the claim has already been settled as per
final surveyor J K Sharma report. The Sum Insured as per policy schedule was Rs.17,10,000/-
+ Rs.4,05,000/-for trailer. As per cause of accident, the vehicle caught fire and it got
completely burnt. The trolley was almost safe and de attachable part of the vehicle, so the
sum insured for the vehicle (Horse) was taken and assessed the loss. Being here was only the
loss of vehicle (horse) which is valued at Rs.17,10,000/- as per insurance policy and trailer for
Rs.4,05,000/-is safe as per survey report. So in order to indemnify the loss item, loss has been
settled accordingly.
19. Reason for Registration of Complaint: Incorrect denial of claims and cancellation of policy.
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): Case called. Parties
are present and recall their arguments as noted in Para 18 above. The case was scheduled for
hearing on 17.11.2021 but could not be heard due to internet connectivity issue faced by the
complainant. Therefore, the complainant was rescheduled for hearing on 24.11.2021. The
grievance of the insured against the insurer is that they have not settled the total loss claim
of his vehicle as per policy terms and conditions. The complainant stated that Insurers issued
a single policy covering his vehicle with IDV of Rs.21,15,000/-. His vehicle is total loss and in
case of total loss IDV less policy clause is payable. The insurance company has not paid the
amount of trailer insured with Rs. 4,05,000/-. Hence this amount is payable to him. The
representative of insurance company stated that Sum Insured as per policy schedule was
Rs.17,10,000/- + Rs.4,05,000/-for trailer. As per cause of accident, the vehicle caught fire and
it got completely burnt. The trolley was safe and de attachable part of the vehicle, so the sum
insured for the vehicle (Horse) was taken for assessed the loss. The loss has been paid as per
the assessment of the surveyor and policy terms and conditions on net of salvage basis
without R.C for Rs.15,33,500/- considering the wreck value of Rs.1,75,000 with policy excess
clause Rs. 1500/- and released the payment as per satisfaction and discharge voucher duly
signed by the insured on 18.01.2021. The insurance company further released balance
amount of salvage amounting to Rs.25,000/- to complainant as wreck was sold for
Rs.1,50,000/-. As confirmed by the assessing surveyor to insurers, the estimate was issued by
the authorized dealer. No trailer loss was demanded for the trailer and no loss for the trailer
was discussed as the trailer was safe. Due non submission of estimates and demand for the
loss to the trolley, the assessment made by the surveyor cannot be faulted. Therefore,
assessment of loss for the horse is as per policy terms and conditions. The insurance company
paid the loss as per the assessment of IRDA accredited surveyor after proper discharge from
the complainant. The complainant did not raise any issue with the insurers for non -payment
of loss to trolley and gave clean discharge to them. As such, the claim settlement by the
insurers is in order as per policy terms & conditions and does not warrant any interference.
The complaint is rejected being devoid of merits.
Award
The claim settlement by the insurance company is as per policy terms and conditions and
does not warrant any interference. The complaint is rejected being devoid of merits
(Atul Jerath)
Insurance Ombudsman
29
th
November, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 16 of The Insurance Ombudsman Rules, 2017)
Insurance Ombudsman: Shri Atul Jerath
Case of Neelam Rani V/S ICICI Lombard General Insurance Co.
Ltd. CO
MPLAINT REF. NO: CHD-G-020-2122-0046
1.
Name & Address of the Complainant
Smt. Neelam Rani
Village- Chhajpur Khurd, Teh.- Bapoli,
Distt.- Panipat, Haryana- 132104
2.
Policy No:
Type of Policy
Duration of policy/Policy period
3001/180129132/00/B00
Motor Policy
13-09-2019 To 12-09-2020
3.
Name of the insured
Name of the policyholder
Neelam Rani
Neelam Rani
4.
Name of the insurer
ICICI Lombard General Insurance Co. Ltd.
5.
Date of Repudiation
Not provided
6.
Reason for repudiation
Non receipt of documents
7.
Date of receipt of the Complaint
14-05-2021
8.
Nature of complaint
Non settlement of motor OD claim
9.
Amount of Claim
Not provided (IDV is Rs. 1,40,000)
10.
Date of Partial Settlement
NA
11.
Amount of relief sought
Not provided
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
09.11.2021 / 24.11.2021/Online hearing
14.
Representation at the hearing
For the Complainant
Smt.Neelam Rani/Sh. Raja Ram
For the insurer
Sh.Karan Bagdai
15
Complaint how disposed
Recommendation under rule 16
16
Date of Award/Order
29.11.2021
17) Brief Facts of the Case:
Smt. Neelam Rani (hereinafter, the Complainant), has filed this complaint against the ICICI Lombard
General Insurance Co. Ltd. (hereinafter, the insurers) for non settlement of her motor claim.
18) Cause of Complaint:
a. Complainants argument: Her tata indigo no. HR06T/3859 got accident on 06.02.2020. After
bringing vehicle to Panipat, survey and investigation is done. After 27 e-mails, company vide letter
dt. 25.09.2020 asked for some documents. She arranged all documents but could not contact
surveyor over phone. When company issued letter to surveyor Mr.Suresh Kumar, he resigned from
company. Neither company nor surveyor is listening to her.
b. Insurers’ argument: The complainant had taken a Private Car Package Policy under policy bearing
number 3001/180129132/00/B00 which was valid for the period from September 14, 2019 to
September 12, 2020. The insured (Neelam Rani) had filed an own damage claim with the Company
and as per the claim form, on February 06, 2020 at around 3am the insured vehicle (IV) met with
an accident due to heavy fog, due to fog the driver did not notice a sugarcane trolley & dashed the
front side of IV. The insured had reported the incident at Gagalheri police station and intimated to
the Company. Accordingly the Company duly allotted claim number MOT09724310 to the said claim
and appointed a surveyor to verify/assess the loss. In order to process the claim as per the terms &
conditions of the policy, the Company had asked the insured/complainant to submit the following
requisite documents;
Pan Card Purchase Invoice Indemnity Bond Vehicle Keys Form 28, 29 & 30 NOC /
Form 35 RC Cancellation / Letter to RTO Aadhar Card AML Documents
Despite repeated reminders the complainant did not submit the abovementioned requisite
documents to process the claim further. Therefore, the claim was closed by the Company on the
grounds of non-submission of the mandatory documents.
19) Reason for Registration of Complaint:- Non settlement of claim of travel insurance.
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):
Initially, case was called for hearing on 09.11.21. Both parties were present and recall their
arguments as noted in para 18 above. Insurance company stated that inspite of repeated requests
complainant has not submitted requisite documents to settle his total loss claim. Complainant
informed that insurance company is not providing duly signed certificate to be submitted in RTO.
In second hearing on 24.11.2021, insurance company informed that they have given relevant letter
for RTO to complainant who had to still comply with RC surrender, cancelled cheque/bank details,
indemnity bond. At this stage, insurance company offer to settle the said claim of complainant as
per terms and conditions of policy, subject to submission of above said documents and usual
formalities of claim. Complainant accepts this offer of insurance company during hearing and
assures to submit the requisite documents at the earliest. Thus an agreement of conciliation could
be arrived at between the Complainant and the Insurers, which I consider as fair and reasonable for
both the parties.
AWARD
The complaint is resolved in terms of the agreement of conciliation arrived at between the
Complainant and the Insurers. Accordingly, as mentioned above, the Complainant shall
submit the required documents to the Insurers at the earliest, and then Insurers will pay the
claim as per terms and conditions of the policy within 30 days of receipt of requisite
documents from insured.
(Atul Jerath)
Insurance Ombudsman
November 29, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, CHANDIGARH
(Under Rule 13 r/w 17 of The Insurance Ombudsman Rules, 2017)
Insurance Ombudsman: Shri Atul Jerath
Case of Suman Rani v/s Iffco-Tokio General Insurance Co.
Ltd. Co
mplaint Ref. No: CHD-G-023-2122-0089
Name & Address of the Complainant
Smt Suman Rani w/o late Shri Rohit Sharma
House No-99, Sector-13-17, Arya Nagar
Panipat- 132103
Mobile No.- 9812594661
Policy No:
Type of Policy
Duration of policy/Policy period
ITG/82741531
Private car Package Policy
21-03-2020 to 20-03-2021
Name of the insured
Name of the policyholder
Rohit Sharma
Rohit Sharma
Name of the insurer
Iffco-Tokio General Insurance Co. Ltd
Date of Repudiation
26-02-2021
Reason for repudiation
Breach of utmost good faith and violation of
policy conditions No- 1 and 8.
Date of receipt of the Complaint
25-06-2021
Nature of complaint
Repudiation of claim
Amount of Claim
Rs 3,03,135/-
Date of Partial Settlement
Not applicable
Amount of relief sought
Rs 3,03,351/- with interest.
Complaint registered under Rule no:
Insurance Ombudsman Rules, 2017
Rule 13 (1)(b) – any partial or total repudiation
of claim by an insurer
Date of hearing/place
24-11-2021/ Online hearing
Representation at the hearing
For the Complainant
Smt Suman Rani, Complainant
For the insurer
Shri Hitender Kumar, Senior Manager
Complaint how disposed
Award under rule 17
Date of Award/Order
30-11-2021
17. Brief Facts of the Case:
Smt Suman Rani (hereinafter, the Complainant), has filed this complaint against Iffco-Tokio General
Insurance Co. Ltd (hereinafter, the Insurers) for undue repudiation of her husband’s vehicle claim.
18. Cause of Complaint:
a) Complainant’s argument:
On 25-06-2021, Smt Suman Rani had filed a complaint that that her car no HR-06W-5654 was
insured with Iffco Tokio general insurance company Ltd. Policy no was ITG/82741531. Car was
registered in the name of her husband Shri Rohit Sharma. Car met with an accident on dated
26-07-2020 and she completed all claim papers but insurance company did not settle the
claim. Her husband expired on dated 26.10.2020. Insurance company rejected the claim vide
letter dated 26.02.2021. She requested this forum to reconsider her claim and instruct
company to pay her claim.
b) Insurers’ argument:
On scrutiny of the submitted claim/medical records it was observed that complainant
intimated a claim on 04/08/2020 regarding accidental damages to the aforesaid vehicle which
reportedly met with an accident on 26/07/2020. On receipt of the intimation of loss, an IRDAI
licensed & independent Surveyor Sh. Sanjeev Chhabra was deputed for survey of the loss and
M/s Expert Investigators for investigation. On perusal of the investigation report and
documents on record, the insurance Company made the following observation:
i) As mentioned in claim form, insured’s friend Mr. Vinod Kumar was driving the said vehicle
and met with an accident on 26/07/2020 near Harsingh Pura village when it collided with rear
of a tractor-trolly which applied sudden brake, as a result vehicle got damaged.
ii) The insured stated that Mr. Vinod Kumar borrowed his vehicle and he was alone in the said
vehicle at the time of accident and there was no third party loss and injury to anyone in the
said accident.
iii) However, during the investigation when the insured and Mr. Vinod Kumar were present with
the investigator at the alleged spot to verify loss particulars, Mr. Vinod Kumar was not able
to identify the spot but also could not corroborate the loss particulars provided by the
insured. This raises serious apprehension about veracity of the loss particulars provided by
the insured and also suggest that Mr. Vinod Kumar was seemingly not driving the vehicle at
the time of accident as submitted by the insured.
iv) The location of accident as identified by insured is not established as the local residents have
denied occurrence of any such accident at that location in the past. This raises further
apprehensions about veracity of loss particulars provided by the insured.
v) Towing / Crane receipt No. 965 dated 27/07/2020 was also provided by insured on record,
but after verification of said towing receipt from crane operator it is confirmed that no such
accident vehicle was towed by them. Thus it is concluded that the insured have
misrepresented the details of towing and produced fake towing receipt in support of his
claim.
vi) From technical examination it is found that seat belt in the damaged vehicle was unlocked
indicating it was not fastened at the time of accident. In such situation the collision would
have resulted in grievous injury to drive which is denied by insured. This further corroborate
that the reported driver was not driving the vehicle at the time of accident particularly in light
of the fact that the insured have not produced any MLC or medical report of driver in support
of driver details provided.
vii) Further, the registration number of the opposite vehicle not provided by the insured which
simply could not have fled away after the accident.
viii) The reported claim was intimated to insurance Company after 8 days from the date of alleged
accident which is violation of policy terms and conditions no.01. The said delay on the part
of insured has seriously prejudiced rights of insurer Company to verify compliance of terms
and conditions of the insurance policy at the time of accident particularly in the light of grave
misrepresentation observed as mentioned in above paras.
The claim reported under the policy is admissible only when the loss particulars provided by the
insured are established beyond reasonable doubts and policy terms and conditions are compiled
by the insured. From the above observations, it is concluded that the insured have not established
the loss particulars beyond doubts rather misrepresented facts in support of his reported claim.
The vehicle is damaged but not as per the loss particulars provided by the insured, the insured not
only misrepresented loss particulars, driver particulars and produced fake towing receipt in breach
of utmost good faith. Further by delayed intimation of claim to insurer, the insured seriously
prejudiced rights of insurer Company to verify compliance of policy terms & condition at the time
of accident. In the light of above observation, the claim lodged by the insured was rejected and
intimation of this effect duly given to the insured vide letter dated 26/02/2021. Thus, the
declaration given in the claim form and condition no.1 & 8 of the insurance policy are violated by
complainant. In the light of above submission, it is clear that there was no deficiency on the part
of insurer, as the claim was repudiated as per terms and condition of the insurance policy and
accordingly the claim is not tenable.
19. Reason for Registration of Complaint: - Repudiation of claim.
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):
Case called for hearing, both the parties are present and recall their arguments as noted in Para 18
above.
Complainant stated that her vehicle claim is still pending. Inspite of giving all clarification to
insurance company, her claim is not paid till date. He requested for payment of her claim.
During online hearing, the insurance company was advised to explore the possibility of review of
the claim to arrive at an agreement. Insurance company agreed to review the case. Insurance
Company vide their email dated 25-11021 reiterated their stand of SCN and stated that their
repudiation decision is in order.
On perusal of complaint, SCN (self -contained note), submission made by both the parties during
online hearing and review decision of the insurance company email, it is seen that in the instant
case, insurance company as repudiated the claim vide letter dated 26-02-2021 on the condition
No-8 of the policy terms and condition 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 the 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.” It
is pre-requisite for complainant to do compliance of condition of policy. Complainant plea that
everything was known to her husband and she can’t tell anything about accident can’t absolve her
completely from doing the claim formalities compliance. There are glaring discrepancies in the
statement given to the insurance company and it is pertinent for insurance company to get
clarification in order to decide admissibility of the claim under policy.
Keeping in view the above discussions, the denial of claim of complainant by insurance company is
in order and no relief is granted. Hence, the case is dismissed.
AWARD
Considering the facts & circumstances of the case and the submissions made by both the
parties during online hearing, the case is dismissed.
Hence, the complaint is treated as closed.
(Atul Jerath)
Insurance Ombudsman
November 30, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Subhash ChanderVersus The Shriram GeneralInsurance Company Ltd.
Complaint Ref. No.: DEL-G-042-2122-0163
17. Brief Facts of the Case: Subhash Chander (hereinafter referred to as the Complainant) has filed
this complaint against the decision of The Shriram General InsuranceCompany Ltd. (hereinafter
referred to as the Insurers) alleging wrongrepudiation of claim.
18. Cause of Complaint:
a) Complainant's Argument: His son Mohit Kharabwas returning to his home bythe Insured
Vehicle (IV) Car DL2CBA1304after attending a relative’s marriage on 15.03.2021night at 1.30
a.m. Near Nazabgarh, a truck hit the car from left side and damaged right side despite his son‘s
effort tosave the accident. The accidental car took round turn on its axis and after taking same
position, it stuck with tree. Mohit could not note truck No. as hebecameunconscious. A
1.
Name & Address of the Complainant
Shri Subhash Chander
Village: Mundhela Khurd, Post Office: Ujwa
New Delhi – 110073
2.
Master Policy No:/Certificate No.
Type of Policy
Duration of policy/Certificate period
102015/31/21/006411
Private Car Policy
26.07.2020 to 25.07.2021
3.
Name of Policy Holder
Name of Insured
Subhash Chander
Subhash Chander
4.
Name of the Insurer
Shriram General Insurance Co. Ltd.
5.
Date of repudiation
30.04.2021
6.
Reason for repudiation
Misrepresentationof facts in the claim
7.
Date of receipt of the complaint
03.09.2021
8.
Nature of complaint
Repudiation of Claim
9.
Amount of Claim
Rs. 491085/-
10.
Date of partial settlement
N.A.
11.
Amount of partial settlement
N.A.
12.
Amount of relief sought
Rs. 491085/--
13.
Complaint registered under Rule No.
of the Insurance Ombudsman Rules,
2017
Rule 13(1)(b) – any partial or total repudiation of
claims by an insurer
14.
Date of hearing/place
02.11.2021, Delhi, Online, Via WebEx
15.
Representation at the hearing
For the Complainant
1. Shri Subhash Chander, the Complainant
2. Kum. Lalita, D/o the Complainant
For the insurer
1. Shri Jayabrata Chakraborty, Regional Manager
((MC)
2. Shri Peeyush Jain, Asst. Manager (Legal)
16.
Date of Award/Order
Award under Rule 17/ 02.11.2021
passerby saw the said car and helped Mohit Kharab and informed Mohit Kharab’s cousin. His
cousin came around 3.00 a.m. and moved the car to nearby Gaushala with the help of his
friend’s tractor. On the same day, accident intimation was given to Insurance Company. As
there was no injury, complainant did not inform police. On 17.03.2021 surveyor Mr. Pradeep
Kumar came to the spot of accident and tookphotos and visited Gaushala to check and took
photos of accidental car and advised Mohit Kharab to take the car to workshop for repair. The
damaged car was taken at A & A Enterprises at Gurgaon and intimated the estimate of
damages to surveyor.On 19.04.2021, Investigator
Case of Subhash Chander Versus The Shriram General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-042-2122-0163
Lakshay Kumar visited complainant’s house and asked about accident and took statement of
Mohit Kharab and went to the spot of accident where he took some photographs. All
necessary information and documents were given to surveyor and investigator. But the
Insurers denied his claim stating that the damages of car did not match with the cause of
accident. Complainant wrote to GRO also but claim was denied for the same reason. Therefore
he has approached this forum for relief.
b) Insurer's Argument: The Insurers in their SCN dated nil have stated that they had issued a
policy no. 102015/31/21/006411 for the period 26.07.2020 to 25.07.2021 against vehicle no.
DL2CBA1304. After receiving the intimation of accident on 15.03.2021, Insurers deputed
Surveyor Mr. Sanjay Verma to survey and assess the loss and Mr. Lakshya Kumar to investigate
the matter.Surveyor submitted preliminary survey report of Rs. 284396/- in accordance with
policy terms, conditions and IMTs. Finally overall observation of investigation report and
documents submitted by the insured, Insurers found that cause of loss was not justified and
there was misrepresentation of the facts,for which complainant was intimated via letter dated
30.04.2021. The damages of the vehicle did not match with the cause of accident stated by
Mohit Kharab. Investigator visited the spot of accident where he did not find the sign of broken
tree and accident impact on the wall. The vehicle was so badly damagedin the accident, that
it could not be towed with tractor, therefore investigator also visited Mitro Gaushala for
confirmation but no one confirmed about it. Investigator asked about the contact no. of
passerby Mr. Jassu and details of tractor driver but Mohit Kharab stated that he did not have
their phone nos. In view of all, complainant tried to manipulate and hide the actual facts and
the narration of accident did not match with the spot and damages. Hence Insurers have
rightly repudiated the claim.
19. Reason for registration of Complaint:Repudiation of claim.
20. The following documents were placed for perusal:
a) Assessment Report& Investigation Report
b) Repudiation Letter
c) GRO
21. Result of hearing of the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The Insurers had got an investigation conducted into the accident. After examining the
evidence and making inquiries, the Investigator reported that the location of the accident did
not match with the statement of the Complainant, no police report was made available, no
medical report was filed even though the driver had fainted, local people did not corroborate
the accident, and no evidence of accident could be identified at theplace of the accident
reported by the Complainant. In these circumstances, the Insurers were justified in
repudiating the claim on the grounds of misrepresentation of facts by the Complainant.
Pursuantly, the complaint shall deserve to be rejected.
Award
The complaint is rejected.
(Sudhir Krishna)
Insurance Ombudsman
November 02, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Anil Kumar Rathi versus ICICI Lombard General InsuranceCo.Ltd.
Complaint Ref. No.: DEL-G-020-2122-0184
1.
Name & Address of the Complainant
Shri Anil Kumar Rathi
Plot No.330, IInd Floor, D-Block,Sec-15,Omaxe
City, Bahadurgarh – 124507 (Distt. Jhajjhar)
2.
Policy No.
Type of Policy
Policy term/policy period
3001/216243704/00/000
Private Car Package Policy
23.02.2021 to 22.02.2022
3.
Name of the insured
Name of the policy holder
Anil Kumar Rathi
Anil Kumar Rathi
4.
Name of insurer
ICICI Lombard General Insurance Co.Ltd.
5.
Date of repudiation
18.09.2021
6.
Reason for grievance
Rejection of Motor Claim
7.
Date of receipt of the complaint
28.09.2021
8.
Nature of complaint
Rejection of Motor Claim
9.
Amount of claim
Rs.8,00,000/- on Return to Invoice Basis
10.
Date of partial settlement
N.A.
11.
Amount of partial settlement
N.A.
12.
Amount of relief sought
Rs.15,19,174/- and Comprehensive Insurance
Cost
13.
Complaint registered under Rule
No.of the Insurance Ombudsman
Rules 2017
Rule 13(1)(b)- Partial or Total Repudiation of
Claims by the Insurer
14.
Date of hearing
17.11.2021
Place of hearing
Delhi, Online Video Conferencing via Cisco WebEx
15.
Representation at the hearing
For the Complainant
Shri Anil Kumar Rathi, the Complainant
For the Insurer
Shri Karan Bagdai, Legal Manager
16.
Date of Award/Order
Award under Rule 17/ 17.11.2021
17. Brief Facts of the Case: ShriAnil Kumar Rathi(hereinafter referred to as the complainant) has
filed this complaint against the decision of ICICI Lombard General Insurance Co.
Ltd.(hereinafter referred to as the Insurers) allegingwrong rejection of Motor Claim.
18. Cause of Complaint:
a) Complainant's Argument:He had taken the Comprehensive policy with Return to Invoice
and Zero Dep.Add On Cover from ICICI Lombard GIC for the period 23.02.2021 to 22.02.2022
for his Creta car Regn.No.DL-7CM-8145 It was driven by his friend alone, met with an accident
on 02.07.2021 and got totally damaged. He intimated and lodged the claim on 03.07.2021.
Surveyor completed the survey on 07.07.2021. Investigator was deputed after 20 days who
did not visit the spot of loss,only recorded his and driver’s statements and collected spot
photographs, which were captured after5 days of the accident on surveyor’s demand. Till 50
days from the claim intimation, he had not got any communication from the insurer and after
escalating the matter, got information that case
Case of Anil Kumar Rathi versus Cholamandalam MS General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-020-2122-0184
had been reassigned to the investigator for reinvestigation of the claim and wanted to see the
spot of loss. Surveyor alongwith him and driver,visited the accident spot,which was narrow
road and two car could not crossed simultaneously and these narrow roads used by local
traffic as the main roads were closed due to kisan protest. On 04.09.2021 Insurance Company
informed telephonicallythat claim was not payable as insurer had conducted forensic
(reconstruction) of the accident and as per forensic report, vehicle could not have met with
accident as per cause of loss briefed and spot of loss shown to investigator. Forensic person
neither visited the spot of loss nor spoke to the driver or him and based at Mumbai prepared
the report on imaginations without understanding the circumstances and situation of
accident hence reconstruction report was biased. Insurer rejected the claim on 18.09.2021
stating Misrepresentation of Facts (Cause of loss not justified with the existing damages on
vehicle and try to hide Material Facts about loss).He approached the GRO on 18.09.2021 but
his claim was not settled.
b) Insurer's Argument: The Insurance Company, vide Self Contained Note dated 12.11.2021
have stated that the Complainant had filed own damage claim stating that on 02.07.2021 his
vehicle met with accident when his friend Mr.Sombhir Sharma was driving the vehicle alone.
Surveyor was appointed after claim intimation,who observed discrepancies and opined for
further investigation. After perusal of available documents,observations and
findings,investigator stated that the case seems to be non-genuine and facts of the case were
misrepresented. Thereafter Bombay Forensic Services prepared the Accident Reconstruction
Reporton 30.08.2021 and on verification some crucial pointers were highlighted for
understanding of the case. After analyzing the accident scenario,it was noticed that IV steered
towards right side and dashed to tree, then the truck came from behind and dashed into the
IV. Apparently the truck coming from behind the IV would dash the rear RHS portion of the
IV, however,as per damage caused, rear RHS is found to be intact whereas LHS had been
impacted. This remark proved that the complainant had misrepresented the facts. After
analyzing accident spot,complainant took the investigator to two different spots in two
different investigations. The vehicle collided with the tree but there was no presence of any
bark material on the front of IV. No vertical damage was observed on front portion specifically
upper grill and bumper area as per scenario of IV dashing into the said tree. No uniform
crushing impact damages observed over rear area of IV as per scenario of the truck dashing
into the IV’s backside,as explained by complainant. The air bag panel seems to have been
deployed deliberately as there were multiple cut marks as per forensic report. Driver survived
without any injury. There was contradiction in driver’s statement regarding towing of vehicle.
There was no FIR/intimation given to the policy,though there was involvement of third party
vehicle i.e. truck no.HR63C7205. The alleged driver was also the proprietor of the Royal
Automobile Workshop,which had not been disclosed by the complainant. He tried to take
undue advantage of the policy by misrepresenting the facts of the case hence they had
repudiated the claim as per policy terms and conditions.
Case of Anil Kumar Rathi versus Cholamandalam MS General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-020-2122-0184
19. Reason for registration of Complaint: Rejection of Motor Claim.
20. The following documents were placed for perusal:
a) Copy of policy.
b) Copy of Repudiation letter, Mail Correspondence,Final Survey Report.
c) SCN of the Insurer along with enclosures.
21. Result of hearing with the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The subject vehicle met with an accident on 02.07.2021. The Complainant intimated and
lodged the claim on 03.07.2021.The Insurers appointed surveyor and investigator to examine
the claim. Their report disclosed several discrepancies in the claim. For instance, the claim
had proposed that the insured vehicle (IV) was hit on the right side, whereas the
survey/investigation found damages on the left side. Also, the claim had proposed that theIV
had collided with a tree but there was no presence of any bark material on the front of the
IV. There were many other discrepancies and misrepresentation of facts as well, as detailed
in Para 18b above. In view of these, the Insurers were justified in repudiating the claim.
Pursuantly, the complaint shall deserve to be rejected.
Award
The complaint is rejected.
(Sudhir Krishna)
Insurance Ombudsman
November 17, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Manjit Kumarversus National Insurance Company Ltd.
Complaint Ref. No.: DEL-G-048-2122-0186
1.
Name & Address of the Complainant
Shri Manjit Kumar
K-74, Vijay Vihar Phase-1, Sector-4, Rohini
New Delhi-110085
2.
Policy No.
Type of Policy
Policy term/policy period
360400/31/2019/10000784
Private Car Package Policy
01.06.2019 to 31.05.2020
3.
Name of the insured
Name of the policy holder
Manjit Kumar
Manjit Kumar
4.
Name of insurer
National Insurance Company Ltd.
5.
Date of repudiation
20.07.2020
6.
Reason for grievance
Rejection of Motor Claim
7.
Date of receipt of the complaint
12.10.2021
8.
Nature of complaint
Rejection of Motor Claim
9.
Amount of claim
Rs.2,75,000/-
10.
Date of partial settlement
N.A.
11.
Amount of partial settlement
N.A.
12.
Amount of relief sought
Rs.2,75,000/- as per Form VI
13.
Complaint registered under Rule
No.of the Insurance Ombudsman
Rules 2017
Rule 13(1)(b)- Partial or Total Repudiation of
Claims by the Insurer
14.
Date of hearing
17.11.2021
Place of hearing
Delhi, Online Video Conferencing via Cisco WebEx
15.
Representation at the hearing
For the Complainant
Shri Manjit Kumar, the Complainant
For the Insurer
Shri Khushi Ram Verma, Dy. Manager, DO-9, Rohini
Sec.3
16.
Date of Award/Order
Award under Rule 17/ 17.11.2021
19. Brief Facts of the Case: Shri Manjit Kumar (hereinafter referred to as the complainant) has filed this
complaint against the decision of National Insurance Co. Ltd.(hereinafter referred to as the Insurers)
alleging wrong rejection of Motor Claim.
20. Cause of Complaint:
a) Complainant's Argument:He had taken the Private Car Package policy from National Insurance Co.
for his car bearing Registration No.DL-6CQ-5744 for the period 01.06.2019 to 31.05.2020 for IDV of
Rs.2,75,000/-.On 10.01.2020 his car was stolen from Rohini when he went to meet his
friend,Mr.Deepak Kumar. FIR No.001139 dated 10.01.2020 was registered u/s 379 IPC. He intimated
the loss to the insurance company and claim was registered vide claim no.ODH-71707/360400 and
investigator was appointed. Insurance company sent pre-repudiation letter dt.19.3.2020 stating
that his claim was rejected as the vehicle was used for commercial purposes and finally rejected on
20.07.2020. He alleged that investigator had demanded bribe for positive claim settlement report
and when he turned down the said demand, he submitted the report with negative remarks and his
Case of Manjit Kumar versus National Insurance Company Ltd.
Complaint Ref. No.: DEL-G-048-2122-0186
claim was rejected. Mr. Deepak Kumar and Smt. Shakuntla Devi had given their statements
completely in contrast to what the investigator and insurance company had claimed. Insurance
company repudiated the claim solely on the ground that vehicle though registered and insured
asa private vehicle, at the time of theft, probably was being used as a taxi for carrying passengers
on payment but not denied the theft of vehicle. He gave reference of various judgements. He
approached the Insurer’s Grievance Cell and IRDAI but his claim was not settled and finally
approached to Ombudsman Office for justification of claim.
b) Insurer's Argument: The Insurance Company, vide Self Contained Note dated 10.11.2021 have
stated that the insured vehicle (IV) was covered under Private Car Package Policy and was
registered as Private Vehicle. Claim lodged against theft of vehicle on 10.01.2020 and intimated
to them on 10.01.2020 and investigator M/s D. Kapoor& Associates was deputed on the same day.
During claim processing they observed that as per statement of Sh. Deepak Kumar Raut, the IV
was being driven by Sh. Ranjit Kumar and used as Taxi, for hire by the travelers between different
regions/places, which was in contravention of the Rules and provisions of Motor Vehicles Act,1981
as well as violation of the Terms and Conditions of the Policy. Same fact was confirmed by another
neighbor/witness Ms.Shakuntala. Sh.Manjeet Kumar, in his statement categorically stated that he
went to meet Sh.Deepak Kumar on the day of theft whereas Sh.Deepak Kumar stated that he did
not know Sh.Manjeet Kumar. Therefore, statements of both those persons were
contradictory,which clearly proved that the Insured made false statement to extract claim from
the company. Whatever averted by the friends cum neighbor of insured was just afterthought to
convert the claim as a genuine claim,not submitted during pendency of claim. Due to concealment
and misrepresentation of material facts pertaining to the claim and violation of policy terms and
condition –Limitation as to Use and vague clarifications by insured for pre repudiation letter
dt.19.03.2020,claim was repudiated on 20.7.2020. As the complainant had mentioned crux of
judgment in his complaint which showed that insured was well aware about his fault and he
himself accepted that he was using his private vehicle for commercial uses without paying any
taxes or appropriate premium and the complaint lodged by him is rejected out rightly and as per
Condition No.7 regarding Disclaimer Clause as ‘Company shall disclaim liability to the insured for
any claim hereunder and such claim shall not within 12 months from the date of such disclaimer
have been made the insured subject matter of a suit in a court of law, then the claim shall be for
all purposes be deemed to have been abandoned and shall not thereafter be recoverable.
19.Reason for registration of Complaint: Rejection of Motor Claim.
20.The following documents were placed for perusal:
d) Copy of policy.
e) Copy of Pre-Repudiation letter, Repudiation letter,GRO Correspondence.
f) SCN of the Insurer along with enclosures.
Case of Manjit Kumar versus National Insurance Company Ltd.
Complaint Ref. No.: DEL-G-048-2122-0186
22. Result of hearing with the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The investigation conducted by the Insurers had determined that the insured vehicle was being
used for taxi/hire purposes. Therefore, the Insurers were justified in repudiating the claim, as per
the policy terms and conditions cited in Para 18b above. Pursuantly, the complaint shall deserve
to be rejected.
Award
The complaint is rejected.
(Sudhir Krishna)
Insurance Ombudsman
November 17, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Jitender Yadav Versus Bharti Axa General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-007-2122-0169
22. Brief Facts of the Case: Shri Jitender Yadav (hereinafter referred to as the Complainant) has filed
this complaint against the decision of the Bharti Axa General Insurance Company Ltd. (now, ICICI
Lombard GIC and hereinafter referred to as the Insurers or the Respondent Insurance Company)
alleging wrong rejection of his motor accident claim.
18. Cause of Complaint:
1.
Name & Address of the Complainant
Shri Jitender Yadav,
H. No. 62/63, Shivram Park Ext.2, Raholla,
New Delhi 110041
2.
Policy No:
Type of Policy
Duration of policy/Policy period
S6843786
Motor
17.11.2019-16.11.2020
3.
Name of the insured
Name of the policy holder
Jitender Yadav
Jitender Yadav
4.
Name of the insurer
Bharti Axa General Insurance Company Ltd.
5.
Date of repudiation
24.06.2020
6.
Reason for repudiation
Misrepresentation and suppression of material facts
7.
Date of receipt of the complaint
14.09.2021
8.
Nature of complaint
Rejection of claim
9.
Amount of claim
Rs 60000/-
10.
Date of partial settlement
NA
11.
Amount of partial settlement
NA
12.
Amount of relief sought
Rs 60000/-
13.
Complaint registered under Rule No.
of the Insurance Ombudsman Rules,
2017
Rule 13(1) (b) – any partial or total repudiation of
claim by insurer.
14.
Date of hearing/place
15.11.2021, Delhi, Online, Via WebEx
15.
Representation at the hearing
For the Complainant
Shri Jitender Yadav, the Complainant
For the insurer
Shri Ashay Mahajan, Chief Manager (Litigation)
16.
Date of Award/Order
Award under Rule 17/ 15.11.2021
a) Complainant's Argument: He had on 17.11.2019 purchased the vehicle bearing registration
number DL 8C AZ 1030 from the showroom and its insurance was done by the insurer from there
itself. The vehicle met with an accident on 23.04.2020 and an online intimation of the same was
given to the insurer. The vehicle was taken for repairs and the survey was also conducted at the
workshop. His claim was repudiated by the Respondent on 26.06.2020 stating that the accident
had occurred on a prior date. He represented against the rejection on 14.05.2021. As there is no
outcome of the same, he has approached this forum for relief.
b) Insurers Argument: The Insurers in their SCN of 10.11.2021 have stated that the insured had
complained that his vehicle met with an accident in Delhi on 23.04.2020. He had lodged the claim
Case of Jitender Yadav Versus Bharti Axa General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-007-2122-00169
against the same with the insurers by reporting online. However he had withdrawn the claim without
assigning any reason. He lodged another claim on 03.06.2020 reporting an accident, which occurred on
28.05.2021 at Nilothe More. He submitted a physical claim form for this loss and did not mention the
details of the previous accident. There is no police report or witness for the accidents. They state that
technically there is no liability for the accident reported on 23.04.2020 as it was withdrawn by the
complainant himself. The cause of the loss is not established. The complainant has misrepresented the
facts, thereby committing breach of the principle of Utmost Good Faith, which underlies every insurance
contract. They have therefore repudiated the claim.
19. Reason for registration of Complaint: Rejection of claim.
20. The following documents were placed for perusal:
a) SCN, Insurance policy, Claim Form.
b) SMS Chat.
c) Letter to GRO.
21. Result of hearing of the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The insured vehicle had met with accident on 23.04.2020, for which the Complainant had filed
online claim on 24.04.2020. The Insurers sought some details from the Complainant. But he
withdrew his claim on 09.05.2020. The Complainant states that the Insurers’ Surveyor Ashish
Sharma had advised him to withdraw the claim. The Insurers deny any such possibility and
state that they do not have any such surveyor by this name. The Insurers have stated that
Ashish Sharma was an erstwhile employee of the company and he was not deputed on the this
claim of the complainant or connected with the claim. The Complainant filed another claim on
03.06.2020 citing accident of for the same IV on 28.05.2020. This claim was filed in physical
mode. In both the claims, the place of accident was mentioned as the same. In both the claims,
no FIR and no witness have been cited by the Complainant. In these circumstances, the claim
becomes deeply doubtful and the Insurers’ action in repudiating the claim stands justified, on
the grounds of misrepresentation of facts by the insured. Pursuantly, the complaint would
deserve to be rejected.
Award
The complaint is rejected.
(Sudhir Krishna)
Insurance Ombudsman
November 15, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Shahnwaz SaifiVersus HDFC Ergo General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-018-2122-0171
23. Brief Facts of the Case:Shri Shahnwaz Saifi(hereinafter referred to as the complainant) had
filed the complaint against the decision of HDFC Ergo General Insurance Company Ltd.
(hereinafter referred to as the Insurers) alleging wrong rejection of the theft claim of his 2-
wheeler.
1.
Name & Address of the Complainant
Shri Shahnwaz Saifi,
B 28/7,United Apartments, Flat No. 502,4
th
Floor,
Block B, Shaheen Bagh, AFE Part II, Jamia Nagar,
Delhi-110025
2.
Policy No:
Type of Policy
Duration of policy/Policy period
2312910008262700001
Motor
09.11.2019-08.11.2020
3.
Name of the insured
Name of the policy holder
Shahnwaz Saifi
Shahnwaz Saifi
4.
Name of the insurer
HDFC Ergo General Insurance Company Ltd.
5.
Date of repudiation
11.09.2020
6.
Reason for repudiation
Non safeguard of the vehicle; Misrepresentation
7.
Date of receipt of the complaint
11.10.2021
8.
Nature of complaint
Theft of two-wheeler
9.
Amount of claim
Rs. 65183/-
10.
Date of partial settlement
NA
11.
Amount of partial settlement
NA
12.
Amount of relief sought
Rs.65183/-
13.
Complaint registered under Rule No. of
the Insurance Ombudsman Rules, 2017
Rule 13(1) (b) – any partial or total repudiation of
claim by insurer.
14.
Date of hearing/place
15.11.2021,Delhi, Online, Via WebEx
15.
Representation at the hearing
For the Complainant
Shri Shahnwaz Saifi, theComplainant
For the insurer
Shri Neeraj Kumar, Senior Manager (Legal)
16.
Date of Award/Order
Award under Rule 17/ 15.11.2021
24. Cause of Complaint:
a) Complainant's Argument:He had insured his vehicle, a two-wheelerHero Motocorp-Splendor
Plus bearing Registration no.DL 03 SEL 8768with the Insurers from 09.11.2019 to 08.11.2020
(for OD) under Bundled Two-Wheeler policy. The vehicle was stolen from C Block service road
Yamuna Vihar, Delhi on 18.03.2020. The FIR was registered in P.S. Bhajan Pura on the same
date.The insurer denied his claim after keeping it on-hold during the Covid 19 pandemic. He
was asked to handover the second key of the bike else the claim would be rejected. He had
represented to the insurer but there was no outcome of the same. He has now approached
this office to get his complaint redressed.
Case of Shahnwaz Saifi Versus HDFC Ergo General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-018-2122-0171
b) Insurer’s Argument: The Insurers in their SCN sent on 12.11.2021 have stated that the complainant
intimated the theft of the vehicle after a delay of one day. He had submitted one key of the
vehicle. He stated that the second key was misplaced and the former was the original key.
They sent the key for forensic examination. As per the forensic examination it was found to be
a duplicate key. It was unused and did not match with the mileage covered by the vehicle.
Scratch marks were intentionally created on it to falsely represent its usage. In their
repudiation, they invoked condition no. 8 of the policy whereby the insured must observe and
fulfill the terms and conditions of the policy and he must be true to the statements as per
declaration in proposal and claim form. They have also stated that insured had misrepresented
the facts. They also referred to condition no. 4 of the policy wherein the insured must take all
reasonable steps to safeguard the vehicle.
25. Reason for registration of Complaint:Rejection ofclaim.
26. The following documents were placed for perusal:
a) SCN, Policy, Proposal Form, Claim form.
b)Forensic Report.
c) Letter to GRO.
21. Result of hearing of the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The Complainant had submitted only one key of the insured vehicle (IV) to the Insurers, leads
to a reasonable conclusion that the other key was left in the IV, which could have led to the
loss of the vehicle. The Insurers got the submitted key subjected to forensic test, which had
concluded that this key too was not original and was a new key that was tampered with scratch
marks intentionally created on it to falsely represent its usage. In these circumstances, the
Insurers were justified in repudiating the claim in terms of the Policy Conditions No. 4 and 8 as
noted in Para 18b above. Pursuantly, the complaint would deserve to be rejected.
Award
The complaint is rejected.
(Sudhir Krishna)
Insurance Ombudsman
November 15, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Deepak Kumar versus United India Insurance Co. Ltd.
Complaint Ref. No.: DEL-G-051-2122-0181
1.
Name & Address of the Complainant
Shri Deepak Kumar s/o Ved Prakash
House No.A-1/26, Gali No.2, Prem Vihar,
Karawal Nagar, Delhi - 110094
2.
Policy No.
Type of Policy
Policy term/policy period
0417823120P105297821
PCV Package Policy
21.08.2020 to 20.08.2021
3.
Name of the insured
Name of the policy holder
Deepak Kumar
Deepak Kumar
4.
Name of insurer
United India Insurance Co. Ltd.
5.
Date of repudiation
16.07.2021
6.
Reason for grievance
Rejection of Motor Own Damage Claim
7.
Date of receipt of the complaint
24.09.2021
8.
Nature of complaint
Rejection of Motor Own Damage Claim
9.
Amount of claim
Rs.3,10,380/-
10.
Date of partial settlement
N.A.
11.
Amount of partial settlement
N.A.
12.
Amount of relief sought
Rs.3,10,380/-
13.
Complaint registered under Rule No.
of the Insurance Ombudsman Rules
2017
Rule 13(1)(b)- Partial or Total Repudiation of claim
by the Insurer
14.
Date of hearing
17.11.2021
Place of hearing
Delhi, Online Video Conferencing via Cisco WebEx
15.
Representation at the hearing
For the Complainant
Shri Deepak Kumar, the Complainant
For the Insurer
Smt. Usha Pal, Manager (Motor Service Hub)
16.
Date of Award/Order
Award under Rule 17/ 17.11.2021
21. Brief Facts of the Case: Shri Deepak Kumar (hereinafter referred to as the complainant) has filed
this complaint against the decision of United India Insurance Co. Ltd. (hereinafter referred to as
the Insurers) alleging wrong rejection of Motor Claim.
22. Cause of Complaint:
a) Complainant's Argument: The complainant stated that he was owner of Bus No.UP 17AT2421,
covered under policy no.0417823120P105297821. Vehicle met with accident on 27/28.09.2020
in the night at Arariya Vihar,Bihar. FIR No.800/20 was registered under Sections279,338 and
304A on 28.09.2020 at Police Station Arariya. Police personnel had intentionally registered the
FIR with remarks that accident occurred while driver was talking over phone whereas his driver
had not stated that he was talking over phone. That remarks were wrong as his driver was not
using the phone at that time.Insurance Company had rejected his claim on 16.07.2021 citing
negligence of Driver Ash Mohammad whereas there was no negligence of driver. He represented
to the Insurance Company on 03.08.2021 but his claim was not settled.
Case of Deepak Kumar versus United India Insurance Company Ltd.
Complaint Ref. No.: DEL-G-051-2122-0181
b) Insurer's Argument: The Insurance Company, vide Self Contained Note dated 01.11.2021 has
stated that Vehicle No. UP17AT2421, Tata LPT Bus was insured with them for the period
21.08.2020 to 20.08.2021 in the name of Deepak Kumar. Vehicle met with accident on 28.09.2020
in Araria,Bihar. Investigator was deputed as the spot survey revealed extensive damage to the
vehicle and death and severe injury to several others. Vehicle was surveyed and loss was assessed
for Rs.106379/-. Investigation revealed that insured bus hit a parked truck bearing registration
no.BR11S6823 near Arariya,Bihar and Mr.Aash Mohammad was driving the vehicle at the time of
accident. As per account of passengers/eye witnesses and charge sheet no.555/2020
u/s279,338,304 of IPC, it came to be known that the driver was driving the vehicle in a rash and
negligent manner and was busy in talking on his mobile phone, neglecting not just the safety of
passengers on board but also being hazard to the life of pedestrians and vehicles plying on the
road. Two passengers were died and a number of other passengers were injured severely due to
driver’s utter negligence. Claim was repudiated as it was clear that the driver at the time of
accident had shown extreme disregard for the safety of others when a reasonable duty of care
was owed,which resulted in the death of two passengers, injury to various other passengers and
damage to the third party.
19.Reason for registration of Complaint: Rejection of Motor Own Damage Claim.
20.The following documents were placed for perusal:
g) Copy of policy.
h) Copy of Claim Repudiation letter, FIR, Vehicle Documents.
i) SCN of the Insurer along with enclosures.
23. Result of hearing with the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The FIR and passengers in the bus had stated that the driver was talking on his mobile, which led
to the loss of his concentration, resulting in the accident for which this claim was filed.The conduct
of the driver amounts to gross negligence that was the root cause for the accident. In these
circumstances, the Insurers were justified in repudiating the claim. Pursuantly, the complaint shall
deserve to be rejected.
Award
The complaint is rejected.
(Sudhir Krishna)
Insurance Ombudsman
November 17, 2021
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI
(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)
Ombudsman: Shri Sudhir Krishna
Case of Ganga Sahai Meena Versus Bharati Axa General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-007-2122-0182
27. Brief Facts of the Case: Shri Ganga Sahai Meena (hereinafter referred to as the Complainant) has filed
this complaint against the decision of the Bharati Axa General Insurance Company Ltd. (hereinafter
referred to as the Insurers or the Respondent Insurance Company) alleging wrong rejection of his motor
accident claim.
28. 18. Cause of Complaint:
a) Complainant's Argument: He had insured his car, a Hyundai Grand i10 NiOS bearing registration
number DL 9C AT3503 for the period 24.07.2020-23.07.2021 with the insurer. The vehicle met with an
accident on 29.08.2020 on Jaigarh Road, Jaipur. The vehicle was driven by Gaurav Saini. The vehicle was
towed to the Hyundai service centre on the following day. An investigator was appointed by the insurer
who met the driver and asked him to provide his google location at the time of accident. He has
complained that investigator manipulated the facts and the claim was later denied by the insurer. He
has complained that the investigator has stated the location given by the driver was not the original
1.
Name & Address of the Complainant
Shri Ganga Sahai Meena, RZ 26P/A63, Gali no.37,
Indra Park, Palam Colony, New Delhi 110045
2.
Policy No:
Type of Policy
Duration of policy/Policy period
HAX/S6937552
Motor
24.07.2020-23.07.2021
3.
Name of the insured
Name of the policy holder
Ganga Sahai Meena
Ganga Sahai Meena
4.
Name of the insurer
Bharati Axa General Insurance Company Ltd.
5.
Date of repudiation
24.09.2020
6.
Reason for repudiation
Misrepresentation of material facts
7.
Date of receipt of the complaint
20.10.2021
8.
Nature of complaint
Rejection of claim
9.
Amount of claim
Rs.760000/-
10.
Date of partial settlement
NA
11.
Amount of partial settlement
NA
12.
Amount of relief sought
Rs.760000/-
13.
Complaint registered under Rule No.
of the Insurance Ombudsman Rules,
2017
Rule 13(1) (b) – any partial or total repudiation of
claim by insurer.
14.
Date of hearing/place
24.11.2021, Delhi, Online, Via WebEx
15.
Representation at the hearing
For the Complainant
1. Shri Ganga Sahai Meena, the Complainant
2. Shri Praveen Kumar, s/o the Complainant
For the insurer
Shri Ashay Mahajan, Chief Manager (Litigation)
16.
Date of Award/Order
Award under Rule 17/ 24.11.2021
one. He has further stated that the repudiation letter received by him bears a different vehicle number
and another date of accident. He represented against the rejection on
Case of Ganga Sahai Meena Versus Bharati Axa General Insurance Company Ltd.
Complaint Ref. No.: DEL-G-007-2122-0182
14.11.2020. But insurer maintained the stand taken earlier. He then approached this forum for relief.
b) Insurers Argument: The Insurers in their SCN have stated that the insured had taken Smart Drive Pvt.
Car Bundled policy covering the vehicle. The complainant had provided misleading information about
the driver. The vehicle was driven by an unknown person who was not in possession of a valid driving
licence at the time and place of accident. The reported driver, namely, Gaurav Saini was not there at the
accident spot as checked from the Google timeline by the investigator. They have also refuted the
baseless allegations made against the investigator by the complainant. The complainant has
misrepresented the facts, thereby committing breach of the principle of Utmost Good Faith, which
underlies every insurance contract. They have admitted the error committed while writing the last digit
of the vehicle no. as 2 instead of 3 in the repudiation letter. They have indicated the date of accident as
29.08.2021 in the repudiation letter. The claim has been rejected owing to misrepresentation and false
statements made by the complainant
19. Reason for registration of Complaint: Rejection of claim.
20. The following documents were placed for perusal:
a) SCN, Insurance policy, Claim Form.
b) SMS Chat, Investigation Report.
c) Letter to GRO.
21. Result of hearing of the parties (Observations and Conclusion):
Case called. Parties are present and recall their arguments as noted in Para 18 above.
The Complainant states that the vehicle No. and the date of the accident stated in the repudiation
letter are incorrect. The Insurers state that there was some clerical error and they would inform the
Complainant about the corrections within 2 days.
The investigation conducted by the Insurers had found that the driver of the insured vehicle (IV) as
informed by the Complainant was not actually driving the vehicle. Therefore, the Insurers were
justified in concluding that the IV was driven by an unknown person who was not in possession of a
valid driving licence at the time and place of accident. The investigation had also found other
discrepancies in the claim, as noted in Para 18b above. All these facts lead to the conclusion that the
complainant has misrepresented the facts, which would make the claim liable for repudiation.
Pursuantly, the complaint would be liable for rejection.
Award
The complaint is rejected.
(Sudhir Krishna)
Insurance Ombudsman
November 24, 2021
Proceedings of
THE INSURANCE OMBUDSMAN
KERALA, LAKSHADWEEP & MAHE
[Under Rule No.13 1(b) Read with Rule 14 of the Insurance Ombudsman Rules, 2017]
Present: MrGirishRadhakrishnan
Insurance Ombudsman
Complaint No.KOC-G-005-2122-0098
Complainant :Mr. Albert C Mathew
Respondent Insurer : Bajaj Allianz General Insurance Company Limited
AWARD
Award No.IO/KOC/A/HI/0434/2021-22
1.
Address of the complainant
:
Choorackal House,
Koratty,
Nalukettu PO
Thrissur
2.
Policy Number
:
OG-22-9992-1843-00000191
3.
Type of Policy
:
Motor
4.
Date of receipt of Complaint
:
08.09.2021
5.
Nature of complaint
:
Premium refund not received
6.
Date of hearing
:
16.11.2021
7.
Party present for the
Complainant
:
Mr. Albert C Mathew (Online)
8
Party present for the Insurer
:
Ms. Reshma (Online)
This is a complaint filed under Rule 13 (1) b read along with Rule 14 of the Insurance Ombudsman
Rules, 2017. The complaint is regarding refund of motor insurance premium. The Complainant Mr
Albert C Mathew is the policy holder who had availed of a policy bearing number OG-22-9992-1843-
00000191 from the Respondent Insurer Bajaj Allianz General Insurance Co Ltd and the said policy
and the refund of the premium thereof is the subject of dispute in this matter.
1. Complainants’Averments
The averments in the complaint are as follows:
(1) The Complainant stated that he sought renewal of his Motor insurance policy covering his
2-wheeler issued by the Respondent Insurer.
(2) He was intimated an Insured Declared Value (IDV) of the vehicle initially, but when he
received the renewed policy document, he found that the IDV was shown as a much lower
amount, only Rs. 22,623/-.
(3) He disputed the fixing of the IDV as above and sought cancellation of the policy and refund
of the entire premium of Rs.2930/-. However the Insurer has not refunded the premium in
spite of several emails sent to them.
2. Respondent Insurer’s Contentions
The Respondent Insurer entered appearance and filed a Self Contained Note (SCN). The averments
and submissions in the SCN are summarized as under: -
(a) The Policy number: OG-22-9992-1843-00000191, a LONG TERM TWO WHEELER PACKAGE
POLICY in favour of the Complainant was issued under certain terms, conditions and
limitation thereof. There is no deficiency of service or unfair trade practice on the part of the
Insurance Company.
(b) The complainant availed a LONG TERM TWO WHEELER PACKAGE POLICY SCHEDULE No OG-
22-9992-1843-00000191 having policy validity period from 30-JUN-2021 To 29-JUN-2023
which is subjected to its terms, conditions and exclusions thereof.
The allegation in the complaint that the IDV was shown as a bigger amount but after renewal
it was shown as only 22623 is false and baseless. The Respondent Insurer had issued a Long
Term Policy for 2 years covering the period and with the below IDV which is clearly mentioned
in the policy-
Sl.
no
Start Date
End date
IDV
1
30-jun-21
29-jun-22
22,623/-
2
30-jun-22
29-jun-23
21,492/-
(c) As per provisions of Indian Motor Tariff Regulations GR 24 B, a policy can be cancelled only
after ensuring that the vehicle is insured elsewhere, at least for Liability Only cover and after
surrender of the original Certificate of Insurance for cancellation. In compliance of these
regulation, the Respondent Insurer had sought a copy of the alternate policy for the same
period from the Insured (Complainant) vide mail dated 29-6-21 which has not been
submitted by the Complainant. Instead only a copy of a policy issued for the first one year
has been submitted.
(d) The Respondent Insurer required the Complainant to submit the alternate policy copy for the
2
nd
year also to ensure that no manipulation is made with the policy schedule which was
already issued to him for 2 years. Even if the policy for the 1
st
year is cancelled on the basis
of alternate policy copy for that year, the possibility of obtaining a certified copy or notarised
copy of the policy issued by the Respondent Insurer for the 2
nd
year on the basis of the original
policy may also be not ruled out. The Respondent Insurer has sought alternate policy copy
for 2
nd
year in utmost good faith as a measure of precaution to save itself from any Third
Party liability which may arise in case notarised or certified copy of the original policy issued
by it is submitted before any authority, in spite of cancellation of the policy for the 2
nd
year.
(e) The Complainant produced alternate policy copy only for the 1
st
year. On that basis, the
Respondent cannot cancel the policy for the 2
nd
year. Even if policy for the first year is taken
from another insurance company, liability will lie upon the Respondent for the 2
nd
year unless
the policy for the 2
nd
year is also cancelled. However to cancel the policy for the 2
nd
year, as
per the IRDAI regulation, alternate policy copy is mandated. It is only for the said reason the
Respondent had sought the alternate policy copy for both the period.
(f) The Respondent Insurer had acted in bonafide and without any malafide and thereforeis not
guilty of any deficiency in service as alleged in the complaint. The complaint may therefore
be dismissed with cost to the Respondent Insurer.
3. I heard the Complainant and the Respondent Insurer at an online Hearing on 16.11.2020.
The Complainant iterated the points he had made in his original complainant. He submitted that
he attempted many times to get the refund due to him, but in vain. He could not furnish a two-
year policy for his vehicle simply because his current insurer issues only annual policies. In fact,
he did ask the new insurer to issue him a policy for the next year also, citing the reason thereof.
However he was told by the new insurer that the policy for the subsequent period cannot be
issued before three months behind the expiry of the current annual policy. He has submitted copy
of the current policy to the Respondent Insurer; he can submit the copy of the next policy (2022-
23) as soon as it is issued to him by the current insurer. This is a factor beyond his control.
Refusing the refund of his premium on this ground is unreasonable.
The Respondent Insurer submitted that they had issued a single long term policy for two years
for the vehicle in question, with two different IDVs for each year. Premium of Rs. 2,930/- was
collected as a one-time payment for both the years together. They would have it that as per
provisions of GR 24, they can cancel the policy only if the Complainant furnishes an alternate
insurance policy for the two years. They also contended that by cancelling for the first year alone,
the Respondent Insurer would be drawn into unnecessary legal issues, as the Complainant can
potentially make use of the policy document without actually insuring his vehicle for the second
year by means of using a certified/attested copy.
4. Having heard both the sides and having perused all the documents submitted in detail, I find as
under: -
(1) The Complainant had insured his two wheeler, GJ 16 CE 5217, with the Respondent Insurer
for two years from 30/6/2021 to 29/6/2023, paying a premium of Rs. 2,930/-. He had a
dispute with the Respondent Insurer on the subject of the Insured’s Declared Value of the
vehicle, wherein he felt that the Insurer had reduced the IDV without his consent and to an
unreasonably low amount.
(2) The Complainant took out a policy for the same vehicle, commencing 30/6/2021 with another
insurer for an IDV acceptable to him. He then sought cancellation of the policy issued by the
Respondent Insurer and refund of the premium of Rs. 2,930/-. The Respondent Insurer
contends that they cannot cancel and refund at this time because (a) as per GR 24, they can
cancel and refund only if another policy exists for the same vehicle for the same period and
in this case the alternative policy exists only for the first of the two years they have originally
insured; and (b) there are chances of misuse of the policy’s second year coverage (as
described earlier above).
(3) Since the provisions of GR 24 B of The India Motor Tariff General Regulations’ (duly
subsumed into the IRDAI’s rules and regulations governing motor insurance) on the issue of
‘double insurance’ has been invoked by the Respondent Insurer, the same bears a closer
scrutiny here. GR 24 B states as under:
“B. Double Insurance
When two policies are in existence on the same vehicle with identical cover, one of
the policies may be cancelled. Where one of the policies commences at a date later
than the other policy, the policy commencing later is to be cancelled by the insurer
concerned. If a vehicle is insured at any time with two different offices of the same
insurer 100% refund of premium of one policy may be allowed by canceling the later
of the two policies. However, if the two policies are issued by two different insurers,
the policy commencing later is to be cancelled by the insurer concerned and pro-rata
refund of the premium thereon is to be allowed.
If however, due to requirements of Banks/Financial Institutions, intimated to the
insurer in writing, the earlier dated policy is required to be cancelled, the refund of
premium is to be allowed after retaining premium at short period scale for the period
the policy was in force prior to cancellation.
In all such eventualities, the minimum premium as specified in the tariff is to be
retained. In either case, no refund of premium can be allowed for such cancellation if
any claim has arisen on either of the policies during the period when both the policies
were in operation, but prior to cancellation of one of the policies.”
While the Condition makes no specific reference to a situation like what has occurred in the
instant case – and it is certainly not reasonable to assume that a rule or proviso must take
into account every single scenario – a careful reading does guide one into what is the
essential intent of 24 B. I consider it indicative in a fundamental sense that the Condition
makes mention of policy cover and policy period separately. By any reasonable reading, it
would strike at the root of the Respondent Insurer’s avowed position that the two policy
periods should be identical to enable cancelling their policy and refunding the premium. This
position is based on conflating both these factors, policy cover and policy period and such
conflation is clearly not in consonance with the intent and spirit of 24 B. There is no
reasonable ground to dispute the existence of a “double insurance”situation in the instant
case, as envisaged under 24 B.
(4) The second related argument made by the Respondent Insurer is not only incorrect, it is also
betrays a serious attitudinal issue that the Respondent Insurer’s management may well see
fit to recognize and address. The Respondent Insurer is effectively telling the Ombudsman
that they apprehend that the Complainant could avoid insuring his vehicle in 2022-23 and
instead use a fraudulent copy of the same policy document now sought to be cancelled and
thus foist any future liability arising during that period on to the Respondent Insurer. Apart
from a regrettable (and entirely gratuitous and baseless) presumption of immorality on the
part of the Complainant, the Respondent Insurer is discounting the fact that they will now
be in possession of the knowledge and record of the cancellation of the policy at the express
request of the Complainant (vehicle owner), that they can easily mount an effective defence
if (at all) a liability is sought to be foisted on them fraudulently as they profess to fear, and
that this cancellation goes into even the RTO records by means of the normal SOP in such
cases whereby the insurance company formally informs the RTO that their policy on the
particular vehicle has been cancelled.
(5) It is clear enough to a reasonable mind that the Insured is entirely justified in his case that a
full refund of the premium he has paid under policy no.OG-22-9992-1843-00000191 is now
due to him by reason of his having obtained another policy from another insurer. The
alternative policy which he professes to have been issued to his satisfaction (on the matter
of IDV) commences from 30
th
June 2021, ie, the same commencement date as the
Respondent Insurer’s policy that is sought to be cancelled. That this alternative policy does
not run for two years is the only difference but is one that does not erode the strength of
his case. An annual policy is de rigueur and standard practice in motor insurance. I therefore
have no hesitation is holding that the Complainant is is entitled to refund of his premium
paid to the Respondent Insured for the above cited policy.
5. Award
In the result, I hereby order as under:
Respondent Insurer will refund to the Complainant, and amount of Rs.2,830/- (Rupees Two
thousand Eight hundred and Thirty) being the premium amount paid by him under the policy no.
OG-22-9992-1843-00000191 less Rs.100/- the “minimum premium” the Respondent Insurer can
retain per policy as per norms. No award as to costs. Insurer shall comply with the Award within 30
days of receipt of the copy of the Award and submit a confirmation thereof to this Office.
Dated this the 23
rd
day of November 2021.
Sd/-
Girish Radhakrishnan
INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OFWESTERN U.P AND UTTARAKHAND
UNDER THE INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – SH. C.S. PRASAD
CASE OF SH. BHARAT V/S. ICICI LOMBARD GEN. INS. CO.
COMPLAINT REF. NO.: NOI- G- 020- 2122 - 0093
AWARD NO:
Name & Address of the Complainant
Sh. Bharat
S/O Sh. Arjun Singh,
Nayal, Aligarh,
Uttar Pradesh-202138.
Ph. No. 9548826408
Policy No:
Type of Policy
Duration of policy/Policy period
S.I.
3005/182253626/00/000
Bundled Two Wheeler Policy
03.10.2019 to 02.10.2020
Rs.51,172/-
Name of the insured
Name of the policyholder
Sh. Bharat
Sh. Bharat
Name of the insurer
ICICI Lombard Gen. Insurance
Date of Repudiation
02.03.2020
Reason for repudiation
Claim closed due to non submission of
required documents
Date of receipt of the Complaint
29.07.2021
Nature of complaint
Private Vehicle
Amount of Claim
N.A.
Date of Partial Settlement
N.A.
Amount of relief sought
Rs.53,000/- as per Annexure VI A
Complaint registered under
IOB Rules, 2017
13 (1) B
Date of hearing/place
09.11.2021 /Noida
Representation at the hearing
a) For the Complainant
Sh. Bharat
b) For the insurer
Mr. Karan Bagdai-Legal manger
Complaint how disposed
Award
Date of Award/Order
15.11.2021
17) Brief Facts of the Case:- Sh. Bharat, the Complainant had taken Bundled Two Wheeler Policy
No. 3005/182253626/00/000 from ICICI Lombard Gen. Insurance covering his Hero Honda
Splendor 2019, vehicle No. UP 16 CJ 3182 for the period from 03.10.2019 to 02.10.2020 for the
S.I. of Rs.51,172/-. The claim was closed by the Insurance Company due to non submission of
required documents. Aggrieved, he requested the insurer including its GRO to reconsider the
settlement of his claim but failed to get any relief. Thereafter, he has preferred a complaint to
this office for resolution of his grievance.
18) Cause of Complaint:
a) Complainants argument : The Complainant Sh. Bharat stated in his complaint that his
motorcycle was stolen on 15.11.2019, and he had immediately intimated to the Police
Authority and the Insurer. The Police registered the case vide FIR No.0615 dated 15.11.2019
and issued the Court closure report on 15.10.2020. His claim was closed by the Insurer on
account of One Day delay in submission of post theft papers like Final Court Report etc.
b) Insurers’ argument: The Insurer stated in their SCN that Mr. Bharat had taken a Two wheeler
Package Policy under policy no. 3005/182253626/00/000 for the period from October 3, 2019
to October 2, 2020 wherein the Insured had opted for the IDV amount of Rs. 51,172/-.
The Insured had filed theft claim stating that on dated November 15, 2020, he had parked the
Insured Vehicle near Steller IT Park at 3.15 pm he went to deliver the food and when he came
back the insured vehicle was missing from the parking area.
After receipt of the Claim intimation, the company hired the investigator wherein the
Compnay’s Investigator met with the Insured and try to procure the mandatory documents
from the Insured with this regard, he provided with the basic documents but there were more
documents which were required to review the claim as per the policy terms and conditions.
Therefore, Company had sent the reminder letter on December 22, 2020 and January 18, 2021.
After the reminder letter, their CSM was trying to reach him via call but the Insured said that
he is at his native place and they tried to reach him in the month of February, 2021. As per the
IRDAI guidelines, the claim should be closed within the prescribed timeline. Despite repeated
reminders the Insured had not submitted the requisite documents to process the claim further.
Therefore, the claim was closed by the Company on the grounds of non-submission of the
necessary documents.
In order to review the claim as per the terms of the policy, the following documents were
requested by the Company from the Insured namely;
1- Passbook copy/Cancelled cheque
2- RTO Intimation
3- Indemnity Bond
4- Bank NOC/Loan account statement ( Vehicle hypothecated with Hero Fincorp Ltd )
The Company would like to state that after receipt of the complaint copy from the Insurance
Ombudsman, they have tried contacting the Insured and informed him to submit the
mandatory documents. On receipt of the above mandatory documents the company will
review the claim and update the status of the claim to Ombudsman office and the Insured. The
mail communication has already sent to the Insured on 01.10.2021.
In view of the above, they request the insured through Ombudsman office to submit the
required documents to review and assess the claim as per the terms and conditions of the
policy.
19) Reason for Registration of Complaint:- Theft of Motor Claim closed due to non submission of
required documents.
20) The following documents were placed for perusal:-
a) Complaint copy
b) Policy with terms and conditions.
c) Annexure VI A
d) SCN
21. Observations and Conclusion :- Both the parties appeared for personal hearing through video
call and reiterated their submissions. The Complainant Sh. Bharat stated in his complaint that
his motorcycle was stolen on 15.11.2019 and he had immediately intimated the Police
Authority and the Insurer. The Police registered the case vide FIR No.0615 dated 15.11.2019
and issued the Court closure report on 15.10.2020. But, his claim was not paid by the Insurer.
The Insurance Company reiterated that the insured did not provide the required documents.
Two reminders dated December 22, 2020 and January 18, 2021 were sent to the complainant,
but as no reply was received, so the claim was closed due to non- submission of required
documents. Furthermore, after receiving the complaint copy, they again sent mail to the
complainant for submission of required document on 01.10.2021 but the complainant again
did not revert back to them. However, during the course of hearing, the Insurer agreed to
settle the claim if the complainant submits the required documents as below:-
● Passbook copy/cancelled cheque
● RTO Intimation
● Indemnity Bond
● Bank NOC/Loan account statement (vehicle hypothecated with Hero Fincorp Ltd.)
During the course of hearing, the complainant was directed to submit the above mentioned
requisite documents to the Insurer within 14 days from the date of hearing for settlement of
his claim. The Complainant was ready to do the same.
The complainant has not submitted the required documents to the Insurer. The complainant
was directed to submit the above mentioned required documents to the Insurer within 14 days
from the hearing date, and the Insurance Company is directed to pay the admissible claim
amount to the complainant within 15 days after receiving the above mentioned documents
under intimation to this forum.
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 complainant was directed
to submit the above mentioned required documents to the Insurer within 14 days
from the hearing date and the Insurance Company is directed to pay the admissible
claim amount to the complainant within 15 after receiving the above mentioned
documents under intimation to the undersigned.
The complaint is treated as disposed off accordingly.
22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty to
approach any other Forum/Court as per laws of the land against the respondent Insurer.
23. 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 thirty days of the receipt of the award and intimate compliance of the same
to the Ombudsman.
Place: Noida. C.S. PRASAD
Dated: 15.11.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND
UNDER INSURANCE OMBUDSMAN RULES 2017
OMBUDSMAN – SHRI C.S. PRASAD
CASE OF MOHD. SALMAN V/S THE ROYAL SUNDARAM GENERAL INSURANCE COMPANY LTD.
COMPLAINT REF: NO: NOI-G-038-2021-0103
AWARD NO:
Name & Address of the Complainant
Mohd. Salman,
C-116, S-1, DLF Colony, Bhopura,
Sahibabad, Ghaziabad, UP 201006.
Policy No:
Type of Policy
Duration of policy/Policy period
VPCD01074000101
Private Car Package Policy
27.11.2020 to 26.11.2021
Name of the insured
Name of the policyholder
Mohd. Salman
Mohd. Salman
Name of the insurer
Royal Sundaram General Insurance Co.
Ltd.
Date of Repudiation
07.07.2021
Reason for repudiation
Condition No. 1 : Notice & Condition No. 5:
Misrepresentation of facts, fraud, non-
disclosure of material facts
Date of receipt of the Complaint
05.08.2021
Nature of complaint
Motor
Amount of Claim
Rs.8,60,000/- (IDV of the vehicle)
Date of Partial Settlement
n.a.
Amount of relief sought
Rs. 8,60,000/-
Complaint registered under IOB rules
13 (1) (b)
Date of hearing/place
16.11.2021 at Noida – Online hearing
Representation at the hearing
For the Complainant
Mohd. Salman, Self
For the insurer
Mr. Sachin Rastogi
Complaint how disposed
Award
Date of Award/Order
24.11.2021
17) Brief Facts of the Case: This complaint is filed by Mohd. Salman against M/s Royal Sundaram
General Insurance for repudiation of his car’s accidental claim.
18) Cause of Complaint:
Complainant’s argument: The complainant had taken private car package policy no.
VPCD01074000101 from Royal Sundaram, for his vehicle Cruze LT, Regn. No. UP 16 BL 6612, Year
of Mfg. 2016, for the IDV of Rs. 8,59,011/-. The above car met with an accident on 13.02.2021. The
insurance company repudiated his claim for the reason of misrepresentation, fraud, non-disclosure
of material facts or non cooperation, whereas, he had sent all documents to the surveyor.
Insurers’ argument: The insurance company submitted their SCN dated 22.09.2021 wherein they
stated that the complainant lodged a claim on 16.2.2021 and accordingly they deputed a surveyor.
The surveyor submitted in his report that the cause and nature of the accident was narrated in the
claim form that “Near Moradabad, an ahead moving crane suddenly applied brake and the vehicle
hit the crane and the following vehicle hit from behind”. He assessed the net loss for Rs. 2,92,000/-
on CTL basis as the repair cost exceeds 75% of the IDV. The surveyor mentioned that “the damages
are not relevant with regard to the engine. Further, the damage sustained by the vehicle is not
relevant to the cause of accident as per the below observations: a) front impact is not possible with
any crane, as mentioned in claim form. It appears to hit with a pole or tree”. As per the surveyor’s
report the damages were not correlating to be caused by hitting behind the crane for the reasons:
Horizontal line of impact is not present along the contact area of the crane, Both headlight and the
fenders are intact, Vertical line impact on the front portion found, from lower portion of the bumper
up to the height of the bonnet.
The complainant did not disclose the material facts at the time of taking insurance that he had
already taken a claim on CTL basis from ICICI Lombard and further sold the wreck to his brother and
again purchased the same for a lesser value and after getting it repaired on sub-standard by hiding
all such facts and got the insurance for a very high IDV which the actual market value was 3 lakhs.
19) Reason for Registration of Complaint: - Repudiation of claim
20) The following documents were placed for perusal.
a) Complaint letter
b) Insurance Policy
c) SCN
d) Survey Report
21) Observations and Conclusion: - The complainant and the representative of the insurance
company were present for an online hearing on 16.11.2021. The complainant stated that the
insurance company repudiated the claim for his vehicle. The insurance company reiterated that as
per the survey report the damages were not relevant with regard to the engine and were not
consistent with the cause of the accident. The surveyor also mentioned that the damages were
not correlated to be caused by hitting behind the crane for these reasons. Further, the complainant
did not disclose the material facts that he had already taken a claim on CTL basis from the previous
insurer; he sold the wreck to his brother and again purchased the same for a lesser value and after
getting it repaired. He hid these important facts and got the insurance for a very high IDV from the
actual market value was 3 lakhs. During the course of hearing, the complainant accepted the fact
that the said vehicle was not in the name of his brother hence he was unaware of any previous
claim for the said vehicle.
On going through the documents exhibited and the oral submissions made by both the parties
during the hearing, it has been noted that the complainant wilfully did not disclose the facts that
the insured vehicle was involved in accident previously and there was a total damage claim for the
same. During the course of hearing, he accepted the fact that the insured vehicle was not in the
name of his brother. After going through the survey report of Mr. Pushkar Kumar Sinha, it has been
found that the complainant was the third owner and the vehicle was an obsolete model, he
purchased the same from his brother for Rs. 5 lakhs but the market value was Rs. 3.25 lakhs. And
the wreck value is Rs.2,06,000/-. He also mentioned that as per previous claim records from IIB
report, a CTL claim for Rs. 13 lakhs was paid to the first owner by ICICI Lombard on 21.2.2019, the
complainant then purchased the wreck, repaired and transferred the same to his brother and then
again transferred the same to his name on 16.1.2020. This material information was not disclosed
by him to the insurance company in the proposal form. Furthermore, the damages sustained by the
vehicle were not relevant to the cause of the accident, the surveyor mentioned in his report. The
investigation report of M/s Scrutiny Professionals dated 14.4.2021 stated that they had noticed
some discrepancies in said matter. As per insured cum driver timeline, they came to know that he
didn’t visit Meerut on the day of accident, he didn’t disclose purpose of travelling, the IDV of the
subject vehicle was on higher side and damages were not correlating with the scenario told by the
insured. Looking into the facts and circumstances, there are many discrepancies regarding the
genuineness of the accident of the vehicle. The complainant had breached the principle of
insurance contract of 'utmost good faith' which states that both the parties have to be transparent
with each other and material facts have to be disclosed both before the policy is issued and after. I
see no reason to interfere with the decision of the insurance company to repudiate the claim.
The complaint is closed.
AWARD
Taking into account the facts and circumstances of the case and the submissions made by
both the parties, I see no reason to interfere with the decision of the insurance company
to repudiate the claim.
The complaint is closed.
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 thirty days of the receipt of the award and intimate compliance of the same to the
Ombudsman.
Place: Noida. C.S. PRASAD
Dated: 24.11.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. & UTTARAKHAND
UNDER INSURANCE OMBUDSMAN RULES, 2017
OMBUDSMAN – SH. C.S. PRASAD
CASE OF SH. AVI SHARMA V/S. UNITED INDIA INS. CO. LTD.
COMPLAIN REF. NO.: NOI-G-051-2122-0100
AWARD NO:
Name & Address of the Complainant
Sh. Avi Sharma
R/O 1/399, New Subhash Nagar,
Saharanpur,Uttar Pradesh-247001.
Ph. No. 7017875068
Policy No:
Type of Policy
Policy period
Sum Insured
22300031200160204340
Private Car Package Policy
21.05.2020 to 20.05.2021
Rs.5,70,996/-
Name of the Insured
Name of the policyholder
Ms. Neha
Ms. Neha
Name of the insurer
United India Insurance Company Limited
Date of Repudiation
--
Reason for repudiation
--
Date of receipt of the Complaint
03.08.2021
Nature of complaint
Deduction in claim amount under Motor
claim
Amount of Claim
--
Date of Partial Settlement
--
Amount of relief sought
Remaining amount + Compensation as
per Annex VI A
Complaint registered under
IOB rules, 2017
13 (1)(b)
Date of hearing/place
18.11.2021 / NOIDA
Representation at the hearing
a) For the Complainant
Sh. Avi Sharma
b) For the insurer
Mrs Anita Raheja, Asstt Manager
Complaint how disposed
Award
Date of Award/Order
25.11.2021
17. Brief Facts of the Case:- Sh. Avi Sharma, the Complainant had taken Private Car Package Policy
for his vehicle no.HR 02 AS 8055, Skoda Rapid 2018 in his wife’s name Ms. Neha bearing No.
22300031200160204340 for the period from 21.05.2020 to 20.05.2021 for the S.I. of
Rs.5,70,996/-. His motor claim was partially 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 has preferred a complaint to this office for resolution of his grievance.
18. Cause of Complaint:-
a) Complainant’s argument:- Sh. Avi Sharma, the Complainant stated in his complaint that he
has a Zero Dep Policy. He has lodged a claim for Rs.25,818/- which has been settled by the
Insurer for Rs.20,000/- without providing him the reason for deductions.
b) Insurers’ argument:-The Insurer in their SCN stated that the above said vehicle has been
insured vide Policy No. 22300031200160204340 for the period 21/05/2020 TO 20/05/2021.
The policy was taken by the insured through Policy Bazaar Web Aggregator. Unfortunately,
the insured vehicle met with an accident on 21/06/2020 and the claim was intimated to them
on 23/06/2020 through online portal and accordingly the surveyor Sh. Farukh Khan had been
appointed by them to assess the loss.
The surveyor had submitted his report to their office on 13/07/2020 and assessment had been
done for Rs.20,000/- and accordingly the claim had been approved for Rs.20,000/- by the
concerned authority.
The details of assessment had been done as:
● RH Fender for Rs. 1809/-
● RH Front Door for Rs. 6248/-
● Mirror Housing for Rs 2389 /-
Total of parts (including GST of Rs. 2686) is Rs. 13132/-
Total Labour amount (inclusive of GST of Rs.1260) is Rs. 8260/-
Total assessment Rs. 21392/-
Less Excess of Rs. 1000/-
Less salvage of Rs. 392/-
Total Claim amount: Rs. 20000/-
As per the surveyor's details description, he has assessed the loss based on Pre-assessment
report and the same has been conveyed to the customer and bill provided by him of Rs.25818/-
was inclusive of consummable of Rs. 1312/- and labour of Rs. 11375/-. So as per the surveyor's
detailed description, he has done the assessment as per the pre assessment report which had
already been conveyed to the insured. And they have done the payment to the insured
according to the survey report.
19) Reason for Registration of Complaint: - Deduction in claim amount under Motor claim
20) The following documents were placed for perusal.
a)Customer complaint
b) Annexure vi and vi (a)
c) Policy Copy
d) SCN
21) Observations & Conclusion :- Both the parties appeared for personal hearing through video
call. The complainant Sh. Avi Sharma reiterated that he has a Zero Dep Policy. He has lodged
a claim for Rs.25,818/- which has been settled by the Insurer for Rs.20,000/- without providing
him the reason for deductions which is unjustified.
The Insurance Company clarified that the claim was settled as per survey report. The
complainant claimed for Rs.25,818/- and they have paid the claim for Rs.20,000/- with the
deductions of Rs.1312 for consumables, Rs.1,000/- for Excess Clause, Rs.392/- as Salvage Value.
The rest amount of Rs.3,115/- is deducted as the workshop has charged the extra labour
charges from the Insured.
During the course of hearing, it was directed to the Insurer to review the deducted amount of
Rs.3,115/- as excess labour charge. The Insurer has asked the surveyor to review the difference
in labour amount. After reviewing the labour amount by the surveyor and as a gesture of
goodwill, the Company is ready to pay the claim amount of Rs.3,115/- on the basis of revised
survey report.
Ongoing through the documents exhibited and the oral submissions made by both the parties,
it is observed that the company is ready to pay the deducted labour amount of Rs.3,115/- to
the Complainant as a customer centric gesture. Hence, the Insurance Company’s decision to
pay the claim does not warrant any interference by way of Award at present. The Complaint
is dismissed.
Award
Taking into account the facts and the submissions made by both the parties during the
course of hearing, the Insurance Company’s decision to pay the claim but not issue the
policy does not warrant any interference by way of Award at present.
The Complaint is dismissed.
22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty to
approach any other Forum/Court as per laws of the land against the respondent Insurer.
Place: Noida. C.S. PRASAD
Dated: 25.11.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND
UNDER INSURANCE OMBUDSMAN RULES 2017
OMBUDSMAN – SH. C.S. PRASAD
CASE OF SH. DEVESH SINHA V/S. LIBERTY GENERAL INSURANCE
COMPLAINT REF. NO. : NOI-G-028-2122-0102
AWARD NO:
Name & Address of the Complainant
Sh. Devesh Sinha
E-1101, Neelpadam-1,
Sector-5, Vaishali,
Ghaziabad, Uttar Pradesh- 201301.
Ph. No. 9681460512
Policy No:
Type of Policy
Duration of policy/Policy period
IDV
2011-400403-20-1000175-02-000
Private Car Package Policy
15-12-2020 to 14-12-2021
Rs.3,56,400/-
Name of the insured
Name of the policyholder
Sh. Devesh Sinha
Sh. Devesh Sinha
Name of the insurer
Liberty General Insurance
Date of Repudiation
--
Reason for repudiation
--
Date of receipt of the Complaint
10.08.2021
Nature of complaint
Partial settlement of claim
Amount of Claim
--
Date of Partial Settlement
--
Amount of relief sought
Annex VI A not submitted
Complaint registered under
IOB rules
13 (1) (b)
Date of hearing/place
18.11.2021 / NOIDA
Representation at the hearing
a) For the Complainant
Sh. Devesh Sinha
b) For the insurer
Ms. Shraddha Kinare, Corporate Legal
Manager
Complaint how disposed
Award
Date of Award/Order
25.11.2021
17) Brief Facts of the Case:- Sh. Devesh Sinha, the Complainant had taken Private Car Package
Policy No. 2011-400403-20-1000175-02-000 from Liberty General Insurance covering his Maruti
Swift Dzire 2016, vehicle No. DL 02 CAW 1708 for the period from 15-12-2020 to 14-12-2021 for
the S.I. of Rs.3,56,400/-. His claim was not fully paid by the Insurance Company. Aggrieved, he
has lodged the complaint with the insurer including its GRO but failed to get any relief.
Thereafter, he has preferred a complaint to this office for resolution of his grievance.
18) Cause of Complaint:
a) Complainant’s argument : The Complainant Sh. Devesh Sinha stated in his complaint that his
car got damaged from front side, right and left of the engine but his claim was not fully settled
by the Insurer.
b) Insurers’ argument: The Insurer stated in their SCN that
1. That, this Respondent Liberty General Insurance Ltd. issued Liberty Private Car Package
Policy bearing number 201140040320100017502000 for the period from 15/12/2020 to
15/12/2021 subject to terms, conditions and exclusions enumerated under the policy.
2. That, claim was reported for damage to the insured vehicle in an accident dated 08.07.2021.
The cause of accident as mentioned in the claim form is “My car is moving 5 km speed, at
corner it hit by Auto (Commercial) from opposite side. Traffic was very heavy. Left & right
also got damaged due to imbalance”.
3. That, on intimation of the claim, immediately the in-house surveyor inspected the vehicle
and assessed the loss. The surveyor observed that the cause of loss and the nature of the
damage were not correlating with the description of accident in the claim form.
4. That, the reasons cited for the observations of damage not correlating to the cause of loss
are as under:
● 5kmph is a traffic Jam like situation, and in that heavy of a traffic, coming of an auto from
opposite side, chances are very less.
● Even if agreed, that opposite side coming auto hit from front side, by looking at the
damages and angle & line of impact, the auto was in left front side of the insured vehicle.
● The severity of the impact is that it crushed the Hood and broken the front grill into
pieces.
● In that heavy impact, no damage to Number Plate, Front Bumper and Bumper re-
enforcement found, whereas the first point of impact would be front bumper and
number plate itself.
● In such a heavy impact, in a head on collision, where the lighter object (Auto) hit the
heavier object (Car with 5 people sitting), speed was only 5kmph.
● The object can either stop moving or can drag back. No chance of the vehicle
misbalancing and hitting the side vehicles at left and right side at once.
● Further, on inspecting the damages to the vehicle, Front bumper is multiple damage,
even broken from the LH corner and the lower side portion before this accident.
● Right side damage is a soft dent on the RH Rear Door, if the vehicle would have rubbed
off against a moving/standing side vehicle, there would have been horizontal scratched
and dents on the body parts, which in this case are not present.
● And on the left side of the vehicle, the running board is old damaged, it is rusted and not
matching the other damages as per date of loss.
● Rear Bumper is multiple damage at the left side corner and there is a clear disconnect in
the damages on the left side, between LH Front Door & Rear Bumper and LH Qtr. Panel.
5. That, in view of the above observations, vide letter dated 23.07.2021, the complainant was
informed about the inability to consider the damage not found consistent with the cause of
loss whilst requesting him to produce the vehicle for re-inspection and submission of the
final invoice in order to conclude the survey report and assess the final loss amount without
prejudice.
6. That, it is submitted that it is the duty of the complainant to prove the manner & the extent
of loss in order to successfully claim under the Policy. The complainant has failed to provide
clarifications/justification for claiming the said damage if at all the same had happened in
the accident. Communication with the complainant is already filed on record by the
complainant himself.
7. That, finally, the claim was processed for an amount of Rs.11,650/- in favor of the workshop
as per the terms and conditions of the policy and as per the loss assessed by the surveyor,
for the parts that were found consistent with the cause of loss, on receipt of the final
invoices.
That, the claim stands paid towards full and final settlement of the claim and there is no
further amount due and payable to the complainant.
19) Reason for Registration of Complaint:- Claim not fully settled
20) The following documents were placed for perusal:-
a) Complaint Copy
b) Policy with terms and conditions.
c) SCN
21. Observations & Conclusion :- Both the parties appeared for personal hearing through video call
and reiterated their submissions. The Complainant, Sh. Devesh Sinha reiterated that his car got
damaged from front side, right and left of the engine but his claim was not fully settled by the
Insurer. However, he has written the complaints to CEO of the Insurance Company and IRDAI
about poor service of the Insurance.
The Insurance Company reiterated that after the intimation of the claim, they appointed an
IRDA approved independent surveyor in the case who inspected the vehicle and found glaring
discrepancies in the cause of loss mentioned in the claim form and as explained by the
complainant and the actual damages caused in the vehicle. During inspection, it was observed
by the Surveyor that damages demanded for repairs were rusted, old and multiple and did not
correlate with cause of loss mentioned in the claim form. As per the description mentioned in
the claim form “My car is moving 5 km speed, at corner it hit by Auto (Commercial) from
opposite side. Traffic was very heavy. Left & right also got damaged due to imbalance”. After
inspecting the damages to the vehicle by the surveyor, it was observed by him that Front
bumper had multiple damage, even broken from the LH corner and the lower side portion
before this accident. Right side damage was a soft dent on the RH Rear Door, if the vehicle
would have rubbed off against a moving/standing side vehicle, there would have been
horizontal scratched and dents on the body parts, which in this case were not present. The
cause of loss mentioned in the claim form and claimed damages in the vehicle do not correlate,
therefore, same are not admissible in claim and thus it was advised to treat the claim
accordingly.
I have examined the documents exhibited and the oral submissions made by both the parties.
It is a well settled law that a Surveyor’s report has significant evidentiary value unless it is proved
otherwise. The complainant must supply legitimate reasons for departing from such report. In
Sikka Papers Ltd. Vs. National Insurance Co. Ltd. & Ors., Hon’ble Supreme Court held that:“It is
true that surveyor’s report is not the last word but then there must be legitimate reasons for
departing from such report”. Similarly, in Oriental Insurance Co. Vs. Mehta Wool Store, Hon’ble
NCDRC while deciding the dispute observed that: “The Surveyors are independent assessors and
their report has to be given due importance and weightage unless there is overwhelming
evidence to the contrary”.
Furthermore, it is observed in the present case that as per Survey Report of the IRDA approved
independent surveyor, the damages to the vehicle are not correlating with cause of loss. As the
discrepancies could not be explained by the complainant and he did not provide any satisfactory
and reliable explanation, the company has settled the claim on the basis of Survey Report. As
the complainant could not successfully contest the objections raised in the Survey Report, I see
no reason to interfere with the decision of the Insurance Company.
AWARD
Taking into account the facts and the submissions made by both the parties during the
course of hearing, I see no reason to interfere with the decision of the Insurance
Company.
Hence, the complaint is dismissed.
22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty to
approach any other Forum/Court as per laws of the land against the respondent Insurer.
Place: Noida. C.S. PRASAD
Dated: 25.11.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE
THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND
UNDER INSURANCE OMBUDSMAN RULES 2017
OMBUDSMAN – SHRI C.S. PRASAD
CASE OF MR. PRAKASH SINGH V/S. HDFC ERGO GEN. INS. CO. LTD.
COMPLAINT REF. NO.: NOI-G-018-2122-0099
AWARD NO:
Name & Address of the Complainant
Mr. Prakash Singh
S/O Sh. Pritam Singh,
77, Tulsi Vihar, 24 Foota Road,
Dadri, Gautam Budh Nagar,
Uttar Pradesh-201308.
Ph. No. 9312181818
Policy No:
Type of Policy
Duration of policy/Policy period
IDV
2311 1008 3577 4500 000
Private Car Package Policy
14.08.2020 to 13.08.2021
Rs.4,05,432/-
Name of the insured
Name of the policyholder
Mr. Prakash Singh
Mr. Prakash Singh
Name of the insurer
HDFC ERGO General Insurance Co.
Date of Repudiation
--
Reason for repudiation
--
Date of receipt of the Complaint
03.08.2021
Nature of complaint
Private Vehicle
Amount of Claim
--
Date of Partial Settlement
N.A.
Amount of relief sought
Approx. Rs.26,500/- as per Annex VI A
Complaint registered under
IOB rules
13 (1) (b)
Date of hearing/place
29.11.2021 / NOIDA
Representation at the hearing
a) For the Complainant
Mr. Prakash Singh
b) For the insurer
Ms. Shweta Pokhriyal, Asstt. Manager
Complaint how disposed
Award
Date of Award/Order
29.11.2021
17) Brief Facts of the Case: Mr. Prakash Singh, the Complainant had taken Private Car Package
Policy No. 2311 1008 3577 4500 000 from HDFC Ergo for the period from 14.08.2020 to
13.08.2021 for an IDV of Rs.4,05,432/-. The Complainant had lodged the claim for his Maruti
Swift 2017, Vehicle No.UP-16-BP-4547 which was rejected by the Insurance Company.
Aggrieved, he requested the Insurer including its GRO to reconsider the claim but failed to get
any relief. Thereafter, he has preferred a complaint to this office for resolution of his grievance.
18) Cause of Complaint:
a) Complainant’s argument: The complainant Mr. Prakash Singh stated in his complaint that
his vehicle met with an accident on 10.06.2021. He lodged the claim with the Insurance
Company which was rejected by the Insurer.
b) Insurers’ argument: The Insurer stated in their SCN that :
1. That the present complaint pertains to claim under the Private Car Package Policy bearing
policy number 2311 1008 3577 4500 000 valid from 14/08/2020 to 13/08/2021. It is
submitted that the policy was issued in Good Faith to the complainant subject to the terms
and conditions and that in case if any liability arises under the policy the same shall be
subjected to and restricted by the terms and conditions of the policy.
2. That the on 10/06/2021, a claim was lodged by the complainant alleging that the insured
vehicle had sustained damages in an accident that had happened on 06/06/2021. It is
pertinent to mention here that intimation regarding the loss has been given to the
answering respondent on 10/06/2021 i.e. after un-explained delay of 5 days. That as per the
terms and conditions of the policy, under condition 1, it is mentioned that the insured shall
give immediate intimation to the insurer in case of any loss or damage. The policy wording
is reproduced herewith:-
Condition no.1 of the Insurance policy reads as under:-
“Notice shall be given in writing to the company immediately upon the occurrence of any
loss or damage and in the event of any claim and thereafter the insured shall give all such
information and assistance to the company shall require…….”
Further, it is submitted that delay in intimation of claim is a fundamental breach of the terms
and conditions of the policy and the same has been upheld by the Hon’ble Apex Court in the
case titled Sonell Clocks And Gifts Ltd. (S) v. The New India Assurance Co. Ltd. however,
the answering respondent being a customer centric organization decided to further process
the claim on merits.
3. That as alleged in the Claim form, on 06/06/2021; the insured vehicle sustained damages
when the vehicle in the front suddenly applied break which led to the insured vehicle hitting
the vehicle and subsequently the vehicle coming from the rear also hit the insured vehicle.
4. That after the alleged accident was reported to the respondent, the respondent appointed
Surveyor, Dines, as mandated under the Insurance Act, 1938 in order to assess and verify
the damages. That during the survey, following observations were made by the Surveyor:
a) Damages are not co-relating with the cause of loss as mentioned in the Claim Form.
b) It was also observed that there was some residue of a tree’s bark present on the
bumper and the LH Fender which proves that the vehicle had hit a tree from the
front.
c) Damages on rear side are also not relevant to the cause of loss as the line of impact
on the boot and the rear bumper are completely different.
5. That it is a well settled law that a Surveyor’s report has significant evidentiary value unless
it is proved otherwise. The complainant must supply legitimate reasons for departing from
such report. In Sikka Papers Ltd. V. National Insurance Co. Ltd. And Ors., Hon’ble Supreme
Court held that:
“It is true that surveyor's report is not the last word but then there must be legitimate reasons
for departing from such report.”
Similarly, in Oriental Insurance Co. v. Mehta Wool Store, Hon’ble NCDRC while deciding the
dispute observed that:
“The Surveyors are independent assessors and their report has to be given due importance
and weightage unless there is overwhelming evidence to the contrary.”
6. It is clear from the photographs taken at the time of survey that the complainant has
misrepresented the details of loss in order to claim indemnification for all the accumulated
damages.
7. That the complainant has manipulated the loss details in order to extract money from the
respondent. That misrepresentation of material facts goes against the declaration on the
reverse side of the claim form, which is quoted for your reference:
“I/We the above named do hereby to best of my /our knowledge and belief warrant the
truth of the forging statements in every respect and I/we agree if I/ We have made or in
any further declaration the company may require in respect of the said accident shall make
any false or fraudulent statements or suppression or any suppression concealment, the
policy shall be void and all rights to recover thereunder in respect of past or future accidents
shall be forfeited.”
8. In view of the above, the claim of the complainant was rightly repudiated as No Claim by
the respondent as the complainant had misrepresented the material facts to the
respondent.
9. Without prejudice to the aforementioned submissions it is submitted that in case of own
damage insurance claim the liability of the insurance company is limited to the extent of
loss assessed by the surveyor and hence without prejudice to other contention, it is
submitted that the liability of the respondent cannot exceed the liability as assed by the
surveyor and also subject to the terms and conditions of the insurance policy.
10. That complicated questions of law and facts are involved in the present complaint, which
requires lengthy procedure of law of evidence by way of examination in chief and cross
examination. Thus the matter is required to be relegated to the civil court.
The Apex Court has held in “Oriental Insurance Company Ltd versus unimahesh Patel
reported in 2006(4) CivCC 203” Page 1 that proceedings before Commission are essentially
summary in nature and issue which involve dispute factual questions should not be
adjudicated by the Commission.
The larger bench of National Commission has held in “Reliance Industries Ltd. Versus
United India Insurance Co. Ltd.,” reported in 1998(1) CPJ 13 that question of ownership of
goods, conspiracy and fraud were raised, which required elaborate inquiry for disposal. The
matter can be properly decided by civil court and not under Consumer Protection Act.
Hon’ble National Commission has also held in “M/s Singhal Swaroop Ispat Ltd versus
United Commercial Bank” reported in 1992(3) CPJ 50 that where the allegations of fraud,
forgery have been raised by the parties against one another requiring elaborate oral or
documentary evidence, the matter be relegated to civil court for adjudication.
11. That in view of the aforementioned submissions, there is no deficiency in service on the
part of the respondent and the complaint deserves to be dismissed.
19) Reason for Registration of Complaint: - Motor Claim rejected
20) The following documents were placed for perusal.
a) Complaint letter
b) Policy copy
c) SCN
d) Annexure VI A
21. Observations and Conclusion :-
Both the parties appeared for personal hearing through video call and reiterated their
submissions. The Complainant Mr. Prakash Singh reiterated that his vehicle sustained damages
when the vehicle in the front suddenly applied sudden break which led to his vehicle hitting
the vehicle, and then the vehicle coming from the rear also hit the insured vehicle. He lodged
the claim with the Insurance Company which was rejected by the Insurer.
The Insurance Company clarified that there is 5 days delay in intimation to the Insurer.
Furthermore, as per the report of the deputed surveyor, the following observations were made
by the Surveyor:
● Damages are not co-relating with the cause of loss as mentioned in the Claim Form.
● It was also observed that there was some residue of a tree’s bark was present on the
bumper and the LH Fender which proves that the vehicle had hit a tree from the
front.
● Damages on rear side are also not relevant to the cause of loss as the line of impact
on the boot and the rear bumper are completely different.
I have examined the documents exhibited and the oral submissions made by both the parties.
It is a well settled law that a Surveyor’s report has significant evidentiary value unless it is
proved otherwise. The complainant must supply legitimate reasons for departing from such
report. In Sikka Papers Ltd. Vs. National Insurance Co. Ltd. & Ors., Hon’ble Supreme Court held
that:“It is true that surveyor’s report is not the last word but then there must be legitimate
reasons for departing from such report”. Similarly, in Oriental Insurance Co. Vs. Mehta Wool
Store, Hon’ble NCDRC while deciding the dispute observed that: “The Surveyors are
independent assessors and their report has to be given due importance and weightage unless
there is overwhelming evidence to the contrary”.
Furthermore, it is observed in the present case that as per Survey Report of the IRDA approved
independent surveyor, damages are not co-relating with the cause of loss as mentioned in the
Claim Form. The Insurer has submitted the photographs also. The Hon’ble Supreme Court in
its decision dated 08.12.2020 under Civil Appeal No.4010-4011 of 2020, has held that in Motor
claims, the principle of preponderance of probability is to given preference rather than proof
beyond reasonable doubt.
As the discrepancies could not be explained by the complainant and he did not provide any
satisfactory and reliable explanation to the Insurer, and in the light of Hon’ble Supreme Court’s
decision as discussed above, I find no reason to interfere with the decision of the Insurance
Company.
AWARD
Taking into account the facts and the submissions made by both the parties during the
course of hearing, I see no reason to interfere with the decision of the Insurance
Company.
Hence, the complaint is dismissed.
22. If the decision of the Forum is not acceptable to the Complainant, he/she is at liberty to
approach any other Forum/Court as per laws of the land against the respondent Insurer.
Place: Noida. C.S. PRASAD
Dated: 29.11.2021 INSURANCE OMBUDSMAN
(WESTERN U.P. & UTTARAKHAND)
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 16/17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN– VINAY SAH
CASE OF Mrs.Padma Madhav Dalvi v/s Bajaj Allianz General Insurance Company Ltd
COMPLAINT NO: PUN-H-005-1920-0716
Award No IO/PUN/A/HI/ /2021-22
1.
Name & Address of the
Complainant:
Mrs. Padma M.Dalvi, Kolhapur
2.
Policy No:
Type of Policy:
OG-19-2005-1801-00000873
Private Car Package Policy
3.
Policy period:
4/9/2018 to 3/9/2019
4.
Insured Declared Value:
Rs. 503000/-
5.
Date of inception of first policy:
4/9/2018
6.
Name of the Policyholder:
Mrs.Padma Mahesh Dalavi
7.
Name of the Insurer:
Bajaj Allianz General Insurance Company
Ltd
8.
Reason for Partial Settlement:
Complainant is not ready to accept the
amount of claim offered by RI.
9.
Date of receipt of the Complaint:
17/2/2019
10.
Nature of complaint:
Lower amount of claim offered by RI
11.
Amount of Claim:
Rs. 417077/-
12.
Insurance Ombudsman Rule (IOR)2017
under which the Complaint was registered:
13 (1)(b)
13.
Date of hearing/Place:
23/08/2021, Online Hearing, Pune.
14.
Representation at the hearing
a) For the Complainant:
Herself
b) For the insurer:
Mr. Irfan Shaikh, Atul Khare
15.
Complaint how disposed:
Allowed
Contentions of the Complainant:
The complainant was having Private Car Package Policy for her Maruti ErtigaCar bearing Registration
no MH-12-NE-4833 (2016 manufacturing) with Respondent Insurer (hereinafter referred to as RI)
for one yearstarting from 04.09.2018. Due to unprecedented flood at Kolhapur on 5/8/2019, her
vehicle was completely submerged under flood water and suffered severe internal and external
damages. RI offered to settle the claim for Rs. 2 lacs on Cash Loss basis against the estimate of
repairs, of Yashodhan Automobiles, Kolhapur for Rs.4,17,077/-. Complainant rejected the offer as
the offer amount is less than 40% of the IDV (Rs. 5,03,000/-) and it was computed without any
justification. Complainant requested RI to increase the offer amount at least 60 to 70 percent of
IDV as the same RI has already settled flood affected cars of the same city on Cash Loss Basis which
is equivalent to 60 to 70 percent of IDV and damaged vehicles were 5 years old. She feels that as
her claim was computed under Constructive Loss (as per definition) and shown as Cash Loss. She
raised the issue to Grievance Cell of RI with the request to make her understand the formula applied
under Constructive Loss and Cash loss.
She did regular correspondence with RI for increase in claim settlement amount on cash loss basis,
she escalated grievances to CEO of RI and IRDAI for redressal. On 15/01/2020 RI repudiated the
claim on the ground of non-initiation of repairing of damaged vehicle. If fact, she shifted the
damaged vehicle to Bombay Auto Works, Pune and repairing works started in December 2019.
However, complainant was waiting for the enhancement of assessed amount by the surveyor and
after continuous follow up RI consented to enhance claim amount from Rs.2lakhs to Rs.2.13lakhs.
This enhanced amount by RI is also not acceptable to the complainant. RI has taken depreciation
for electrical items in 50% category where as her car is in higher demand in market with higher
value. The repudiation of her claim was sudden, unilateral and without any prior intimation and it
happened when she approached to IRDAI.
Aggrieved with this decision, the complainant has approached the forum for redressal of his
grievance.
Contentions of the Respondent Insurer (RI):
The Self Contained note states that Complainant had preferred a claim on 14
th
August 2019 in
respect of damages to her car due to flood loss occurred on 6
th
August 2019. There was delay in
intimation by eight days as complainant intimated the alleged loss on 14
th
August 2019 which had
occurred on 6
th
August 2019, i.e. after a delay of 8 days leading to violation of Policy condition no.1.
RI has received estimate in the claim on 22
nd
Nov.2019. Survey was conducted on 27
th
Nov2019 in
presence of the complainant. After physical inspection surveyor has worked out liability for
Rs.213731/- Entire detail was explained to the complainant and shared on mail also.
Respondent had called the complainant time and again to submit the consent to workshop to carry
out the repairs and to complete few formalities for claim processing as per various reminder letters,
to which the complainant did not agree and proceed. Unless the compliances were made by the
complainant, the RI was not in a position to decide on the claim admissibility. After due scrutiny of
the claim of the complainant, the claim was closed vide letter dated 15/01/2020 due to no response
and no co-operation and delayed intimation, and violation of duties of utmost good faith by the
complainant.
Result of personal hearing with both the parties (Observations & Conclusions):
During the personal hearing on 23/08/2021 (through video-conferencing) both the parties
reiterated their respective stand.
Complainant contended that the amount offered by RI on cash loss settlement for Rs. 2 lakhs is not
acceptable. Surveyor has considered software items and high value electronic items under plastic
parts with 50% depreciation to reduce the claim amount. The damaged vehicle was lying in the
repairer’s workshop for 4 months and she was waiting for clearance from RI to start repairing works.
All of a sudden she received repudiation letter from the RI informing that for non co-operation and
non-initiating repairing works on her part the claim is rejected. The vehicle has already been
repaired and she has incurred more than Rs. 2 lakhs to put the car in road worthy condition. All bills
for purchasing the new parts from authorized dealer and labor bills have been produced to RI for
verification and assessment of claim.
Respondent Insurer contended that depreciation was applied as per policy terms and conditions.
Complainant was provided reminders after reminders to start repairing work of the damaged
vehicle and there was no positive response from her side and due to non co-operation the claim
was rejected. Thereafter, considering the circumstances of flood loss and damages suffered by the
vehicle the surveyor finally submitted report in consultation with the complainant for settlement
of claim on repair basis for Rs. 1,54,274/-.
Having listened to the contentions made by both the parties, forum instructed RI to submit final
assessment (bill check report) directly to the forum for examination.
Respondent Insurer submitted Bill Check Report showing loss assessment of Rs.1,54,274/-,
Provisional survey report and estimate of Yashodhan Automobiles of Kolhapur through mail on
27/09/2021. Forum shared all three documents to the Complainant for her observations.
Complainant sent her observations vide mail dated 4
th
October 2021.
Taking into account the facts and circumstances of the case, submissions made by both the parties
and the documents available on the file, the forum has the following observations:
• Due to flood the vehicle was completely submerged and suffered internal and external
damages. RI’s insistence on complainant to accept cash loss basis settlement without properly
explaining her the system of arriving at ‘Constructive Total Loss’, in view of the queries raised
by her, was that, as her repairing cost was Rs.3,19,150/- was not crossing 75% of the IDV
(Rs.5,03,000/-).
• In view of no justification received from the RI and after waiting for the enhancement of the
settlement offer, complainant repaired her vehicle on her own. This action of repairs by the
complainant is justifiable, under these circumstances. In view of this, forum allows the
settlement of the claim on repair basis and during the hearing asked the RI to submit the bill
check report.
• Now coming to the quantum:
Part of the repairing work was done by Yashodhan Automobiles at Kolhapur and afterwards
the vehicle was shifted to Bombay Auto Garage, Pune for specialized job of Auto transmission
system of the vehicle as Kolhapur workshop did not have expert mechanics to carry out this
specialized job.
Forum has not observed any anomaly regarding depreciation imposed on software items and
high value electronic items. The depreciation had been calculated as per terms and conditions
of the policy.
• Surveyor Sardar A Patil while assessing the Labor Charges of the claim has not considered the
labor charges incurred by Complainant at Yashodhan Automobiles, Kolhapur. Further, he has
not provided break-up of Labor Charges allowed of Bombay Auto Garage, Pune, which is gross
violation of guidelines provided by IRDAI. A consolidated amount of Rs, 30,000/- has been
sanctioned towards labor charges of Bombay Auto Garage of Pune without providing item
wise break up. Forum has examined the Labor Bill of Bombay Auto Garage and out of total bill
amount of Rs. 77500/- the following amounts are not to be considered:
Serial no.
Description
Amount
claimed (INR)
Approved by RI
Remarks
1
Gear box oil
4,800
No break-up
provided
Not related to
labor charges.
2
Engine oil & filter
2,200
No break-up
provided
Not related to
labor charges.
3
Scanning &
diagnostic
2,000
No break-up
provided
Not related to
labor charges.
4
Spares
2,800
No break-up
provided
Not related to
labor charges.
Total
11,800
RI had considered Rs.30,000/- towards labour; whereas Forum finds that the actual labour
expenses paid by the complainant is of Rs. 65,700/- (excluding non payable items of
Rs.11,800/- as described above). Hence, balance amount of Rs. 35,700/- also should be
included in the total offer amount of Rs. 1,54,274/- (Rs. 1,54,274/- + Rs. 35,700/-=
Rs.1,89,974/-).
In view of the above observations the Respondent Insurer is directed tosettle the claim on
repair basis for Rs. 1,89,974/-. In addition to that, the labor charges of Yashodhan
Automobiles should be considered separately as per terms and conditions of the policy.
Award follows:
AWARD
Under the facts and circumstances of the case, the Respondent is directed to settle the
claim on repair basis for Rs.1,89,974/- plus admissible labor charges of Yashodhan
Automobiles, if the bill of the same is already produced, towards full and final settlement
of his complaint.
The award is to be complied with within one month from the date of receipt of this award
failing which it will attract interest at the bank rate plus 2% extra from the date of rejection
of claim till the date of payment of this award.
The attention of the Complainant and the Insurer is hereby invited to the following provisions of
Insurance Ombudsman Rules 2017:
17(6) the insurer shall comply with the award within thirty days of the receipt of the award and
intimate compliance of the same to the Ombudsman.
17(8) the award of Insurance Ombudsman shall be binding on the insure
Dated: 11/11/2021, Pune
VINAY SAH
INSURANCE OMBUDSMAN, PUNE
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE
(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)
UNDER SECTION 17 OF THE INSURANCE OMBUDSMAN RULES-2017
OMBUDSMAN– VINAY SAH
CASE OF Mr.Tanveer Ismail Bagwanv/s HDFC ERGO General Insurance Company Ltd
COMPLAINT NO: PUN-G-0018-2021-0019
Award No IO/PUN/A/GI/ /2021-22
1.
Name & Address of the
Complainant:
Lt Col Bagwan Tanveer, Khadki
2.
Policy No:
Type of Policy:
2311202845317100000
Private Car Standalone OD Only
3.
Policy period:
27/6/2019 to 26/6/2020
4.
Insured Declared Value:
Rs. 1087370/-
5.
Date of inception of first policy:
NA
6.
Name of the Policyholder:
Mr. Tanveer Ismail Bagwan
7.
Name of the Insurer:
HDFC ERGO General Insurance Company
Ltd
8.
Reason for repudiation/Partial Settlement:
For less payment due to non-concurrent
damages
9.
Date of receipt of the Complaint:
3/7/2020
10.
Nature of complaint:
RI should consider the entire amount of
claim.
11.
Amount of Claim:
37450/-
12.
Insurance Ombudsman Rule (IOR)2017
under which the Complaint was registered:
13 (1)(b)
13.
Date of hearing/Place:
22/09/2021, Online hearing. Pune
14.
Representation at the hearing
c) For the Complainant:
Himself
d) For the insurer:
Mr. Neeraj Shivangikar.
15.
Complaint how disposed:
Dismissed
Contentions of the complainant:
Complainant took Motor package policy for his New vehicle Honda City purchased in 2019 from
Respondent Insurer (hereinafter is called RI) for the period 27/6/2019 to 26/6/2020. On 26
th
May
2020, while parking the vehicle at parking lot, at Southern Command, Pune, bonnet of the vehicle
dashed to protruding part of the wall and so he reversed his vehicle and there was a small height
protruding divider bar which could not been seen due to its height much lower than eye level which
accidentally hit car’s right side doors and part above the right wheel were damaged.
RI had appointed surveyor, Mr. Jayant Patil. As per survey report, the damages of the Bonnet and
Front Bumper was considered and damages to Right Hand Side Fender, RHS Front door, RHS Rear
Door and RHS Quarter Panel of the vehicle were disallowed, as the damages do not correlate with
the cause of accident. These damages do not commensurate with the loss details.
Out of total claimed amount of Rs.52870/- RI has sanctioned only Rs.15420/- and remaining amount
of Rs. 37450/- has been rejected.
Respondent Insurer has deputed an inexperienced surveyor (0.4 yrs experience as mentioned by
HDFC Ergo) Mr. Jayant Patil and also demanded 10% of the claim amount to recommend the claim
for sanction. Surveyor waited for favor from him till 9
th
Jun, 2020 and non-receipt of bribe, he
mentioned in his report that the damages do not correlate to the cause of accident.
Aggrieved with the partial payment of claim, complainant has approached this forum for redressal
and resolution of his grievance.
Contentions of the Respondent Insurer (RI):
RI has submitted its Self-contained note (SCN). As per SCN, on 31/5/2020, RI has received an
information of damages to the vehicle from complainant that occurred on 26/5/2020.
Accordingly, Claim Assessor was appointed for physical verification and assessment of the loss.
It is submitted that, on inspection of the vehicle, Claim Assessor found only following damages as
correlating with the nature of accident and hence the same were allowed: -
Bonnet
Front Bumper
The Claim Assessor after analysing the damages and comparing the same with theStatement of loss
as mentioned in claim form observed that the damages to RHSFender, RHS Front Door, RHS Rear
Door and RHS Quarter Panel of the vehicle werenot co-related with description of accident
mentioned in the claim form for the reasons mentioned below:
• If the metal comes in contact with any hard object like stone/brick/cement the paint on
metal gets peeled off also it creates an impression which is not found on fender.
• There is a dent on RH Side Fender which appears to be caused by hitting and not by
rubbing/scratching of two parts i.e. fender and divider.
• There is a scratch on upper side near mirror which is also not possible to be damaged by
divider.
• The scratches on front RH door are also not in line and are not damaged due to divider.
• The scratches on Rear Door and Quarter Panel appear to be in line but they do not match
with the cause of loss as mentioned in the claim form. Also, if it is considered that these
specified parts would have hit the divider than there should have been continuity in damage
but there was a gap between the two damages.
The net assessment of Rs. 14620/- was approved and paid as Cashless to workshop. The assessed
amount was paid as per the detailed observation and terms and conditions of the policy, hence
there is no question of further payment.
The Complainant has blatantly lied and tried to malign the image of the Surveyor by pleading a false
accusation that the Surveyor demanded 10% of the claimed amount. Complainant is trying to
misuse his respectable position and alleging the claim assessor with baseless allegations out of
frustration.
The loss caused and co-relating on account of cause of loss as mentioned in claim form has been
considered and paid to the repairer. Rest of the damages which complainant is claiming have not
been caused by the nature of accident as Complainant is claiming. It seems that Complainant is
claiming older damages in present claim which is not permissible.
Result of personal hearing with both the parties (Observations & Conclusions):
A personal hearing was conducted on 22/09/2021 (through video-conferencing), which was
attended by both the parties.
To consider the complaint for payment, the forum asked the complainant to produce the repair bills
of the damaged vehicle, if he had repaired it at that time. Forum called him on different dates and
lastly on 12/11/21 also for the bills, but till this date, same is not received. In view of this, forum is
unable to decide the liability of the RI and hence complaint stands closed.
The Award follows:
AWARD
Under the facts and circumstances of the case as complainant failed to submit the bill of
repairs carried after the accident of the damaged vehicle, complaint is declared as ‘Closed’
Dated: On 15
th
day of November, 2021 at Pune
VINAY SAH
INSURANCE OMBUDSMAN, PUNE
CASE of Mr. Nibash Kumar Vs ICICI Lombard General Insurance Co. Ltd.
COMPLAINT REF: NO: PAT-G-020-2122-0060
AWARD NO: IO/PAT/A/GI/0009/2021-2022
1
Name & Address of the Complainant
Mr. Nibash Kumar
Vill-Katri Dih ,PO-Katrisarai, Nalanda,Bihar
2
Policy No:
Type of Policy
Duration of policy/Policy period
3001/MI-08931225/00/B00
Package Policy (Private Vehicle)
29.05.2020 to 28.05.2021
3
Name of the insured
Name of the policyholder
Mr. Nibash Kumar
Mr. Nibash Kumar
4
Name of the insurer
ICICI Lombard General Insurance Co. Ltd.
5
Date of Repudiation
23.09.2020
6
Reason for repudiation
Misrepresentation of facts
7
Date of receipt of the Complaint
18.05.2021
8
Nature of complaint
Rejection of claim
9
Amount of Claim
As per ICICI Lombard General Insurance Policy (As per
point 8 of form VI-A, submitted by the complainant)
10
Date of Partial Settlement
NA-
11
Amount of relief sought
Not specified by the Complainant in form VI-A.
12
Complaint registered under Rule no:
16/17 of Insurance Ombudsman Rule 2017
13
Date of hearing/place
-Not applicable-
14
Representation at the hearing
a) For the Complainant
-Not applicable-
b) For the Insurer
-Not applicable-
15
Complaint how disposed
Award
16
Date of Award/Order
25 .11.2021
Brief Facts of the Case:
The claimant availed Private car Package policy from the Respondent Insurer (ICICI Lombard General
Insurance Company Limited). As per the complaint letter, the insured vehicle met with an accident on 24
June, 2020 for which a claim was lodged under this policy. The insurer has rejected the claim lodged by the
Insured. Aggrieved with the decision of the Respondent Insurer, the Complainant has approached this forum
for payment of claim.
Cause of Complaint:
Complainant’s argument: The Complainant has mentioned as follows (Reproduced from his complaint letter
addressed to OIO,Patna) “My vehicle has crashed into unknown vehicle at Sataua village near Giriyak Bazar
at around 7 pm on 24 June,2020. I informed the insurance company via mobile on 25
th
June. I was told to go
to the place where the car is to be built. The Engine no., Chassis no. and the colour of my car is same, yet the
insurance amount was not given to me, incorrectly.
It is requested that, the mental, financial and time loss caused by the insurance company be replenished by
them.”
The Complainant has approached this Forum for payment of his claim.
Insurers’ argument: In the email dated 22.11.2021 sent to OIO, Patna; the Respondent Insurance
Company has stated as follows-
“The Company has reviewed the grievance of the complainant and has decided to process the claim as per
terms and conditions of the policy. On receipt of the final invoice & the requisite CKYC
(Observations & Conclusion):- It is noted from the submissions made by the Insurer that they have reviewed
the grievance of the complainant and now decided to process the claim as per terms and conditions of the
policy after receipt of the final invoice & the KYC information/documents from the complainant. In view of
the same, the complainant is advised to submit the self attested copy of final invoice & the KYC information
for processing of claim and the Respondent Insurer is directed to settle the claim within a month of receipt
of these documents.
AWARD
Taking into account the facts & circumstances of the case and the submissions made by both the
parties, the complainant is advised to submit the copy of final invoice & the KYC information for
processing of claim and the Respondent Insurer is directed to settle the claim within a month of
receipt of the documents failing which they shall have to pay interest as per IRDA guidelines.
The complaint is accordingly disposed off.
SHREE NAGENDRA KUMAR SINGH
INSURANCE OMBUDSMAN
FOR THE STATE OF BIHAR & JHARKHAND
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. SUBHADEEP CHAKRABORTY Vrs. HDFC IRGO GENERAL INSURANCE CO. LTD
COMPLAINT REF: NO: BHU-G-018-2122-0126
AWARD NO: IO/BHU/A/GI/ /2021-22
1.
Name & Address of the
Complainant
Mr. Subhadeep Chakraborty,
Flat no. C-204, Jyothsna Enclave,
Jayadev Vihar, Next to May Fare Hotel,
Bhubaneswar Pin-751013. Cell-7002131893
2.
Policy No:
Type of Policy
Duration of policy/Policy
period
2311100958514000000
Private car Standalone OD Policy, IDV Rs.7,05,351/-
12 months-10/01/2021 to 09/01/2022, DOL-29/07/2021
Maruti Ciaz-2018 Model-AS-06-X-8628
3.
Name of the insured
Name of the policyholder
Mr. Subhadeep Chakraborty,
Mr. Subhadeep Chakraborty,
4.
Name of the insurer
HDFC IRGO General Insurance Co. Ltd.,
5.
Date of Repudiation
Partially settled
Not applicable
6.
Reason for repudiation
7.
Dt of receipt of the
Complaint
15/09/2021
8.
Nature of complaint
Partial settlement of claim
9.
Amount of Claim
Rs.12,000/-
10.
Date of Partial Settlement
Not intimated by complainant and Insurer
11.
Amount of relief sought
Rs.12,000/-
12.
Complaint registered under
13(1)b
Rule no: of IO rules
13.
Date of hearing/place
26/11/2021, Bhubaneswar
14.
Representation at the
hearing
c) For the Complainant
Self through VC
d) For the insurer
Ms Saswata Banerjee and Mr. Dipankar Ghosh through VC
15
Complaint how disposed
U/R 17 of the Insurance Ombudsman Rules, 2017
16
Date of Award/Order
26/11/2021
17. a. Brief Facts of the Case/ Cause of Complaint: -The complainant had insured his Maruti Ciaz
2018 model car bearing registration no. AS-06-X-8628 under Private car Standalone OD Policy with
HDFC IRGO General Insurance Co. Ltd., for the period 10/01/2021 to 09/01/2022 vide policy no.
2311100958514000000. The vehicle was parked on parking spot as usual. On 26/07/21 at 6.00am
the vehicle was found in waterlogged condition after which he towed the vehicle to nearest Maruti
service centre. On being intimated by complainant Insurer utilised services of Er Anindya Dey for
assessment of loss. Surveyor had assessed the loss for Rs.44,141.53 which was paid to the
complainant. Being dissatisfied on amount of claim paid to him he has approached this forum to
get balance amount.
b. The insurer, in its self-contained note, has admitted insurance and loss within policy period.
On getting intimation they had deputed IRDA approved surveyor who had assessed the loss for
Rs.44,141.53 which was paid to complainant. They have mentioned that other than consumable
items like element, clip rear seat mounting, cable fuel lid opener and self-requested body polishing
and underbody coating all damaged items were allowed. Zero depreciation cover policy is issued as
per IRDANI25RP0001V01201920/A0014V01201920 filed before IRDA which excludes Tyres and
Batteries. They had settled the claim as assessed by surveyor based upon policy condition on valid
and legal grounds and there was no deficiency on their part.
18. a. Complainant’s Argument: - Initially he was reimbursed Rs.37,000/- and subsequently GST
amount of Rs.7155/- was also paid to him. Wiring harness and control assy are electrical set but
Insurer had considered as plastic part which is wrong. He further mentioned that Control other
company are considering battery under zero depreciation and his insurer has applied depreciation
on battery is wrong. Policy conditions were not supplied with the policy. Had he aware of the policy
condition he could have changed the insurer within 15 days of issuance of policy.
c. Insurer’s Argument: - They had settled the claim as per policy condition and the same was
filed before IRDA which was approved. It is further mentioned in the policy that “For detailed
policy terms and conditions please visit our website https//www, hdfcirgo.com/download
policy wordings”. As claim settlement was just and proper complaint is not admissible and
be dismissed.
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 Policy, & policy wordings, survey report, claim form submitted by
Insurer
b. Photocopies of policy conditions of another general insurer
21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully
gone through all the documents relating the complaint and heard both the parties. The complainant
stated that his vehicle was insured with zero-depreciation cover through Coverfox Broker, in whose
broacher, it is clearly mentioned that nothing is deducted for depreciation. The insurer advised him
to repair the vehicle in their net-work garage, but they did not make any cash-less settlement,
therefore, he was forced to pay the garage bills and then submitted documents to the insurer for
reimbursement. However, the insurer settled the claim by deducting normal depreciation without
considering Zero-depreciation cover. He further stated that he was not paid the GST amount initially
but on various requests they have now paid the GST. The complainant further stated that the
insurer has so far not sent him the policy wordings. The insurer stated that the policy wordings are
available in their website and they have paid the GST. The insurer informed that they have paid as
per assessment made by the IRDAI approved surveyor.
AWARD
Taking into account the facts and circumstances and submissions made by both the parties during
the course of hearing, it is found that the complainant had purchased the insurance from the
respondent insurer through Coverfox Broker. The Forum observed that the insurer failed to fulfil
its duty to make the tied-up-garage settlement even though he was asked by them to repair the
vehicle in their net-work garage. The forum examined the wordings of the Broker which specifies
“….. with this add-on (of Zero-depreciation cover) there is no deduction for depreciation even on
the car’s parts, other than tyres(s) and tube(s).” The broacher does not exclude battery for
payment. The Forum further examined the policy wordings of the insurer and found that this add-
on does not cover tyres and batteries. Since the complainant was not provided with the policy-
wordings and purchased the policy based on the broacher given to him by the broker, it is natural
on his part to believe that Battery is not excluded under the add-on cover. The Forum finds that
the wordings in the broacher of the broker and the wordings in the insurer’s policy are different
from each other. The Forum finds that in absence of policy wordings the policyholder goes by the
wordings given by the broker selling the insurer’s products and under no circumstances the
wordings can completely be different from each other. Under the above circumstances, the
insurer is bound to compensate the complainant in line with the provision given in broacher of
the broker. Further, it is the duty of the insurer to provide a copy of the policy-wordings along
with the certificate of insurance, which is not done in this case. Under the above circumstances,
the complainant is entitled for the battery cost in full as per the broacher of the broker and
therefore, the insurer is directed to pay the complainant the balance amount of Rs.29,096/-
(Rupees twenty-nine thousand and ninety-six only) including proportionate GST.
Accordingly, the complaint is allowed.
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.
b. 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 26
th
day of November 2021
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 SARAT CHANDRA BISOI Vrs. NATIONAL INSURANCE COMPANY LIMITED
COMPLAINT REF: NO: BHU-G-048-2122-0125
AWARD NO: IO/BHU/A/GI/ /2021-22
1.
Name & Address of the
Complainant
Mr. Sarat Chandra Bisoi,
Near P.G.Hostel, Plot no.346, Unit-6,
Ganga Nagar, Bhubaneswar, Khorda
Cell no.9438295352
2.
Policy No:
Type of Policy
Duration of policy/Policy
period
1637003119630006243
Package Policy
12 month-28/03/2020 to 27/03/2021
Maruti Swift Dzire-2016 model-OD-02-AB-6630
DOL-11/05/2020
3.
Name of the insured
Name of the policyholder
Mr. Sarat Chandra Bisoi,
Mr. Sarat Chandra Bisoi,
4.
Name of the insurer
National Insurance Company Limited
5.
Date of Repudiation
11/08/2021
No valid permit at the time of accident
6.
Reason for repudiation
7.
Dt of receipt of the
Complaint
27/08/2021
8.
Nature of complaint
Non settlement of claim
9.
Amount of Claim
Rs.2,48,165/-
10.
Date of Partial Settlement
Not applicable as claim repudiated
11.
Amount of relief sought
Rs.2,48,165/-
12.
Complaint registered under
Rule no: of IO rules
13(1)b
13.
Date of hearing/place
26/11/2021, Bhubaneswar
14.
Representation at the
hearing
a) For the Complainant
Self through phone
b) For the insurer
Mr. K N Behera, Officer through VC
15
Complaint how disposed
U/R 17 of the Insurance Ombudsman Rules, 2017
16
Date of Award/Order
26/11/2021
17. a. Brief Facts of the Case/ Cause of Complaint: - The complainant had insured his Maruti
Swift Dzire-2016 model bearing Registration no. OD-02-AB-6630 with National Insurance Company
Limited for the period 28/03/2020 to 27/03/2021. On 08/05/2020 the vehicle had been to Chennai
to bring Mr Sathak Shovan Tripathy who was a covid+ patient. Dy commissioner of police (HQ) vide
letter no. 72 dated 07/05/2020 had allowed vehicle to ply from Bhuabnswar to Chennai for bringing
Mr Sarthak Shovan Tripathy who was sick and stranded at Chennai subject to adhering rules and
regulations of Govt of Odisha/Govt of India. While returning the vehicle met with an accident on
11/05/2021 near Kasimokata in Andhra Pradesh for which he lodged claim with insurer. The vehicle
was repaired at Indo Japan Service, Bhubaneswar. Complainant had submitted tax invoice dated
26/11/2020 before this forum for Rs.2,48,165/-. Insurer had intimated complainant vide their letter
dated 21/07/2021 to submit permit authorization and tax deposit receipt within 7 days from receipt
of the said letter on which the complainant could not submit the same. On verification of permit
no.1685/2016 it was found that authorisation valid from 18/01/2016 to 17/06/2021 was not issued
by STA, Cuttack. As tourist permit was not valid at the material time of accident, Insurer had
repudiated the claim against which complainant has approached this forum for redressal of his
grievance.
b. The insurer, in its self-contained note, has admitted insurance of the vehicle and loss within
the policy period. There was no authorisation for tourist permit or National permit at the time of
accident. They have verified authorised permit no.1685/2016 in respect of vehicle no. OD-02-AB-
6630 from STA Cuttack which was not valid on date of accident i.e. 11/05/2021. As the permit was
not valid they had repudiated the claim which was just and proper.
18. a. Complainant’s Argument: - His vehicle had been to Chennai to bring Mr Sarthak Shovan
Tripathy who was a covid+ with all legal permission from concerned authority on humanitarian
ground. He had admitted that his national permit expired in 2017 and not renewed the same as his
vehicle was plying inside the state of Odisha. As National Insurance company had repaired the
vehicle in their authorised garage, he is entitled to be reimbursed entire amount incurred by him
towards repair of the vehicle.
b.Insurer’s Argument: - On verification of permit from STA Cuttack it was observed that the same
was not valid at the material time of accident for which they had repudiated the claim as per policy
terms.
19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017.
20. The following documents are placed in the file: - Photocopies of Policy, & policy wordings, all
vehicular documents.
21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully
gone through all the documents relating the complaint and heard both the parties. The complainant
admitted that the vehicle was without valid permit as on the date of accident, as he could not renew
it due to Covid-19 situation. The insurer stated that they have verified the RTO records and found
that the National Permit to ply in other states has expired on 17.06.2017 and since the vehicle was
without valid Permit as at the time of accident the claim is not payable.
AWARD
Taking into account the facts and circumstances of the case and submissions made by both the
parties, it is observed that the Permit, to ply on the road of other states at the time of accident,
had expired. The reason given by the complainant is not acceptable as Covid-19 situation
happened in India in 2020, but the Permit was not valid since 2017. The complainant’s response
during hearing was negative to the query, if the complainant has made any official deposit with
the RTO for Permit. Therefore, the complainant is not entitled for his claim under this complaint.
Accordingly, the complaint stands dismissed.
Dated at Bhubaneswar on the 26th day of November 2021
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. RAJANI KANTA SAHOO Vrs. BHARATI AXA GENERAL INSURANCE COMPANY LIMITED
COMPLAINT REF: NO: BHU-G-007-2122-0112
AWARD NO: IO/BHU/A/GI/ /2021-22
1.
Name & Address of the
Complainant
Mr Rajani Kanta Sahoo, Ex District Panchyat Officer,
Gothapatana, Bhubaneswar Pin-751029
Near Hotel Barbie. Cell no.9437119215
2.
Policy No:
Type of Policy
Duration of policy/Policy
period
FPV/SM826649/23/10/006386. Smart Drive Private Car
Policy
12 months-21/10/2020 to 20/10/2021
Maruti Swift-2017 model- OD-05-AD-9511-IDV Rs.4,53,481/-
DOL-06/06/2021
3.
Name of the insured
Name of the policyholder
Mr Rajani Kanta Sahoo
Mr Rajani Kanta Sahoo
4.
Name of the insurer
Bharati Axa General Insurance company Limited
5.
Date of Repudiation
Date of repudiation neither intimated by complainant nor
Insurer
Not admissible as per policy condition
6.
Reason for repudiation
7.
Dt of receipt of the
Complaint
24/08/2021
8.
Nature of complaint
Non settlement of claim
9.
Amount of Claim
Rs.62,980/-
10.
Date of Partial Settlement
Not applicable as claim repudiated
11.
Amount of relief sought
Full damage claim of motor vehicle
12.
Complaint registered under
Rule no: of IO rules
13(1)b
13.
Date of hearing/place
22.11.2021 and 29/11/2021, Bhubaneswar
14.
Representation at the
hearing
e) For the Complainant
Self through VC
f) For the insurer
Mr. Souvik Chakraborty, Executive through phone
15
Complaint how disposed
U/R 17 of the Insurance Ombudsman Rules, 2017
16
Date of Award/Order
22.11.2021 and 29/11/2021
17. a. Brief Facts of the Case/ Cause of Complaint: -Complainant had insured his Maruti Swift-
2017 model Private Car bearing Registration no. OD-05-AD-9511 for an IDV of Rs.4,53,481/- vide
policy no. FPV/SM826649/23/10/006386 with Bharati Axa General Insurance company Limited. On
26/05/2021 the complainant while going in Gramya Panchyat area for collecting damage report
occurred due to Yash cyclone claim, vehicle was waterlogged, and engine got stopped. With the
help of village people vehicle was pulled up from water and he returned to office in the same car
and kept the vehicle in garage of his residence at Gothapatna. On 06/06/2021 complainant was
going from Koraput from Bhubaneswar with his family. After driving around 50 km engine stopped
functioning on the road. Complainant then contacted workshop of Jyoti Motors, Nayapalli,
Bhubaneswar who toughed the vehicle to the workshop on 07/06/2021. After inspection it was
observed that engine got damaged due to water contact. Complainant then intimated insured and
submitted claim form with detail narration of the incident. After being intimated Mr Deepak Kumar
executive of insurance asked complaint regarding cause of incidence of damage. Subsequently
another executive of insurance company Mr Firoz Nayak again asked the same question which was
replied by complainant. On 07/07/2021 insurance executive Mr Nayak advised complainant to go
the place of occurrence with him to apprise about the cause and location of incidence spot.
Complainant had to hire a vehicle by spending Rs.2000/- for going to the spot with Mr Nayak. After
reaching the spot of incidence Mr Nayak enquired the fact from villagers who also gave photo of
water logging period. Complainant had spent Rs.62,980/- towards repair of engine work. After
series of follow up for settlement of claim insurer repudiated the claim as the claim was not payable
as per policy condition. Being dissatisfied on the repudiation, complainant approached this forum
for redressal of his grievance.
b. The insurer has not submitted self-contained note.
18. a. Complainant’s Argument: - As the claim occurred within policy period, he is entitled to be
reimbursed Rs.62,980/- which was incurred by him towards repair of his vehicle.
b. Insurer’s Argument: - The insurer has not submitted self-contained note.
19. Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules, 2017.
20. The following documents are placed in the file: - Photocopies of Policy, claim form, statement
on cause of loss submitted by complainant
21. Result of hearing with both parties (Observations & Conclusion): - This Forum has carefully
gone through all the documents relating the complaint and heard both the parties. During the
previous hearing on 22.11.2021, the complainant stated that he has taken Engine Protection cover,
but the insurer could not confirm, therefore, the Forum granted time to convey their decision
during to-day’s hearing. During the hearing to-day, the insurer was not sure if Engine Protection
cover was granted or not.
AWARD
Taking into account the facts and circumstances of the case and submissions made by both the
parties during the course of hearing, The insurer has failed to submit their Self-contained note in
spite of two hearings are conducted, which is not correct. The insurer could not confirm coverage
of Engine protection. The Forum examined the Certificate of insurance and found that the insured
is granted additional cover of Engine Protection on payment of additional premium. Therefore,
the claim is admissible. The complainant has submitted bills for Rs.62,980/- which is subject to
25% depreciation plus 10% salvage and applicable policy Excess. Therefore, the insurer is directed
to pay the complainant Rs.45,300/- (Rupees forty-five thousand three hundred only) towards full
and final settlement of the claim under this complaint.
Accordingly, the complaint is allowed.
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.
b. 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 29
th
day of November, 2021 INSURANCE OMBUDSMAN
FOR THE STATE OF ODISHA