Page 46 - Insurance Times March 2016 Sample

noted that considering his pay package, a daily benefit of
Rs. 10,500/- per day was not compatible.
CASE NO. GIC/ 156/OIC/11/14
Anju Gupta
Vs
Oriental Insurance Company Ltd.
Facts: Personal Accident insurance was obtained by the
complainant's husband for a period from 09.10.2012 to
08.10.2013. Unfortunately, he died in a road accident and
a claim for a payment of Rs. 22,25,000/- was settled for
Rs. 19,25,000/- by the Company. Hence, feeling aggrieved,
she had approached this office for a release of the addi-
tional payment amounting to Rs. 3,00,000/-.
Findings: The Complainant informed that during process-
ing of the claim, Company had demanded old policies from
her, whereas she was not aware and the requisitioned docu-
ments couldn't be traced at home. The representative of
the company explained that Personal Accident policy record
of insured was available in the office from 2006 onwards.
Thus, a claim settlement was made on the basis of avail-
able record for the confirmed amount of Rs. 19,25,000/-
only. Therefore, the complainant was requested to provide
policies prior to 2006 to verify admissibility of additional
amount towards cumulative bonus, earned if any. However,
in the absence of the requisite documents, additional
amount of Rs. 3,00,000/- was not considered for payment
by the Company.
Decision: It was held that company's decision to with-hold
release of an additional payment of Rs. 3,00,000/-, pend-
ing production of old policy record by the widow of the
insured was unjustified. Since coverage for an accidental
death for Rs. 22,25,000/- was clearly mentioned on the face
of the policy, onus for ascertaining the correct coverage lied Therefore, Clause 1 of the policy conditions is attracted. The
on the Company. Therefore, demand for old policies and
consequent denial of additional amount owing to failure to
provide the same, was undesirable. Accordingly, directions
were given for the release of an additional payment of
Rs.3,00,000/-.
!! Hearty Congratulations !!
Thanks readers for excellent response for our Insurance Quiz published in our February 2016 issue. We announce
Deepa Soni as the winner of the lucky draw for our Insurance Quiz February 2016 issue.
Who will be the next?????
46 The Insurance Times, March 2016
Complaint No: IO/KCH/GI/11-004-223/2012-13
Jose J Ponnezath
Vs
United India Insurance Co. Ltd
Facts: The complainant had taken Individual Personal Ac-
cident policy from the Respondent Insurer. On 04.10.2010,
while removing some packets from his car, he slipped and
suffered injury to his vertebrae. He underwent treatment
and on the advice of the doctor he took bed-rest till
01.11.2010.His claim for compensation for Temporary To-
tal Disablement was repudiated by the Insurer on the
ground that the injury was not the result of an accident.
Findings: The complainant submitted that while lifting
weight from the car, he slipped and as a result, he suffered
severe low back pain. Prior to the accident on 03.10.2010,
he had not suffered low back pain and was not having any
disc problem. The repudiation of the claim is without any
justification.
The claim is to be allowed. The insurer submitted that MRI
taken on the advice of the treating Doctor would reveal
annular bulges and degenerative changes. Disc prolapsed was
due to degenerative changes on account of disease and not
on account of any accident. Therefore, the claim was rightly
repudiated by them based on the policy conditions.
Decision: The content of this Medical Report was not
taken into consideration by the Insurer while repudiating
the claim. The contents of the Medical Report over shad-
ows the contents of the MRI Report relied on by the in-
surer which showed that there is sufficient medical evi-
dence in this case that the complainant suffered disc pro-
lapsed as a result of an accident.
complainant was bed-ridden and was not in a position to
engage in any work and earn income. So, the disablement
was total but temporary in nature. Therefore, Clause 1(f)
is attracted in this case. As a result, an award is passed di-
recting the Insurer to pay compensation of Rs.20,000/- to
the complainant within the prescribed period, failing which,
the amount payable shall carry interest at 9% per annum
from the date of filing of the complaint till payment is ef-
fected. No cost.