Page 49 - Insurance Times January 2018 Sample

Note” that the death claim covered under Personal Acci- Office of The Insurance Ombudsman, Kochi
dent was intimated to them on 23.07.2010. As per the in-
timation the deceased met with a motor accident on Complaint No. IO/KCH/GI/11-003-030/2012-13
03.02.2011 and latter succumbed to his injuries and Subhadra
breathed his last breathe on 09.02.2011. The Complainant
has intimated the claim after a delay of 162 days from the Vs
day of death which grossly violates policy condition No.1
National Insurance Co. Ltd
which hereby states that “In case of death, written notice
of the death must, unless reasonable cause is shown, be so
given before internment / cremation, and in any case, The complainant’s deceased son was covered under Group
within one calendar month after the death”. Therefore, the PA policy taken by PNYS Chit Fund. He was covered for Rs.
Insurer has repudiated the claim. 1 Lac under two policies. He died in a road traffic accident
while riding a motor cycle. The claim for the same was
Decision : It is apparent from the policy terms and condi- repudiated by the insurer on account of non-production of
tion that the claimant must submit written notice of the driving licence of the deceased and also contended that the
death within one calendar month after the death. In the insured committed breach of law with criminal intent.
instant case, it is apparent that the Complainant did not Therefore, the complaint.
submit the written notice directly to the Insurer within one
month from the date of death. It appears from the copy of The complainant submitted that the driving licence was lost
letter written by the Complainant addressing to the Em- in the accident and hence could not submit the same. The
ployer of the Insured (GTFS Multi Services Limited) that she deceased had not contravened any of the provisions of the
intimated them about the death of her husband on MV Act or any other law. The repudiation of the claim is
09.02.2011 due to accident which was received by the against policy conditions.
Employer on 15.02.2011. The copy of letter dated The insurer submitted that the deceased was not holding
18.07.2011 written by the GTFS Multi Services Limited to valid driving licence and thereby, he had contravened the
the Manager, Reliance General Insurance Co. Ltd. goes to provision contained in the MV Act regarding driving licence.
show that they had forwarded the 09 Nos. of claim papers He rode the motor cycle with criminal intent. Thereby, he
to the Insurer. had violated exception Clause 5 of the policy conditions. The
It is clear from the above that the Employer (GTFS Multi repudiation is legal and proper.
Service Ltd.) of the Insured did not send the written claim Decision:- A perusal of the terms and conditions of the
intimation letter to the Insurer within the stipulated period Group policy would reveal that there is no stipulation that
of time. It is an admitted fact that in case of Group Policy, the policy conditions relating to PA Insurance (Individual)
the Insured person do not have the copy of policy document “policy are made applicable as far as the impugned policies
with them and any claim “arises, it is to be submitted to are concerned. There is no specific provision in the terms
the Employer first by the claimant. The Master Policy is kept and conditions of the disputed policy that in case of road
by the Employer. In the instant case also the Complainant traffic accident while the insured is driving a motor vehicle,
is not exceptional from that. It is also ample clear that there the claimants must produce the driving licence of the in-
was no lapse on the part of the Complainant in intimating sured. So, the closure of the claims on that ground can not
the death claim through proper channel. It is proved that be sustained based on the terms and conditions of the dis-
there is huge fault on the part of the Employer for which puted policies.
genuine party has suffered. For the fault of the Employer
In other words, there is no evidence that the accident took
the claimant should not be allowed to suffer. It is against place on account of breach of law. Even while the insurer
the principle of natural justice. Considering the entire facts alleges breach of law with criminal intent, the criminal
and circumstances of the case, the Insurer is asked to re- intent in riding the motor cycle in violation of MV Act is
consider the claim of the Complainant and arrange to settle not revealed by the insurer. In an almost identical situation,
the claim by condoning the delay. Hence, the decision of Hon. HC of Kerala in Binoma Vs State of Kerala, 2013(3) KLT
repudiation of the claim by the Insurer is set aside. 172, after considering the policy conditions and other rel-
Insurer is accordingly directed to settle the claim within 15 evant documents, held that what has to be considered is
days allowing penal interest @ 8% P.A. on the premium not the cause for drowning but the cause for the death.
amount. So, cause of accident is irrelevant and cause of death is
material. T

The Insurance Times, January 2018 49

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