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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Ram Surat Ram Maurya, Presiding Member
Rushali Pankaj Palesha —Appellant
versus
United Insurance Co. Ltd. and Anr. —Respondents
First Appeal No.161 of 2014
(Against the Order dated 16/01/2014 in Complaint No. 256/2012 of the State Commission Maharashtra)
Decided on 21.9.2022
Counsel for the Parties:
For the Appellant:Mr. Angad Singh Gill, Advocate
For the Respondent No.1:Mr. Abhishek Gola, Advocate
For the Respondent No.2: Deleted
IMPORTANT POINT
Claim Amount - The Insurance Regulatory and Development Authority (Protection of Policyholder’s Interest) Regulations, 2002.
Headnote:
Consumer Protection Act, 1986 —S.19 [Consumer Protection Act, 2019 —S.51] – The Insurance Regulatory and Development Authority (Protection of Policyholder’s Interest) Regulations, 2002 - Rg. 9 - Appeal against order of State Commission - Services – Insurance – Uni Home Care Policy - Repudiation of Claim – Delay in settlement of Claim – Interest payable - Lower Fora has misread and misinterpreted the terms of the policy - The Insurer stated that death had occurred on 02.07.2010 while the Insurer was intimated on 29.04.2011, although under the Policy, claim ought to have been lodged within one month from the death. Therefore, the Insurer vide letter dated 18.01.2012, informed the complainant as “No claim” - On the death of one borrower, the Insurer paid half of the sum insured as full and final settlement on 13.12.2012 – The sum insured of Rs.41/- lacs, for Personal Accident was not jointly for two borrowers rather on the death of any of the insured, the capital sum insured in the policy was payable. The Insurer and State Commission has misread and misinterpreted the terms of the policy. The Insurer has illegally reduced 50% of the claim - State Commission has also misinterpreted the Clause “No sum payable under this policy shall carry interest”. On reading the entire paragraphs under this head, it is nowhere provided that interest payable on account of delay is not payable. Regulation 9 of The Insurance Regulatory and Development Authority (Protection of Policyholder’s Interest) Regulations, 2002 directs the Insurer to settle the claim maximum within six months. In case, it is not settled within six months, then the Insurer is held liable to pay interest 2% above on market rate of interest. In the present case, the claim was intimated on 29.04.2011 and 50% of the claim was paid on 13.02.2012. Delay of about three and half month, after six month has occurred -Therefore, the appeal is allowed. [Paras 5 to 9].
Result: Appeal allowed.
ORDER
Heard Mr. Angad Singh Gill, Advocate, for the appellant and Mr. Abhishek Gola, Advocate, for respondent-1.
2. Mrs. Rushali Pankaj Palesha (the complainant) has filed above appeal from order dated 16.01.2014 of State Consumer Disputes Redressal Commission, Maharashtra, partly allowing CC/256/2012.
3. Mrs. Rushali Pankaj Palesha (the appellant) filed CC/256/2012, for directing United India Insurance Company Limited (respondent-1) to pay (i) Rs.41/- lacs with interest @15% per annum from 01.07.2011 till actual payment, as the insurance claim, (ii) Rs.10000/- as compensation for mental agony and harassment, (iii) cost of the litigation; and (iv) any other relief, which is deemed fit and proper in the facts and circumstances of the case.
4. The complainant stated that she and her husband late Pankaj Palesha (the Insured) took housing loan from Bank of Maharashtra (opposite party-2). By way of additional security, the bank obtained “Uni Home Care Policy” from United India Insurance Company Limited (opposite party-1), paying premium of Rs.37775/- from the loan account of the complainant and her husband, for the period of 27.03.2008 to 26.03.2028, for sum insured of Rs.41/- lacs, for fire and Rs.41/- lacs, for Personal Accident. Pankaj Palesha fell down from terrace of the building on 02.07.2010 and died. The complainant intimated the death of Pankaj Palesha to the Insurer, vide letter dated 26.04.2011. As required by the Insurer, the complainant submitted claim form on printed proforma on 02.05.2011 and the police papers relating to the death of Pankaj Palesha, including post mortem report. The Insurer appointed Mr. Shyam Maheshwari, Advocate, as an Investigator, who also made inquiry from the locality of the complainant and collected all the relevant papers from the complainant. The Insurer wrote a letter dated 18.01.2012, informing the complainant as “No claim”. The complainant protested the matter by letter dated 17.02.2012. The complainant also informed that she had received the claim from Life Insurance Corporation of India under other policy on 22.02.2012. The Insurer then verbally demanded newspapers report relating to incident, which was submitted on 23.02.2012. When for a long period, the complainant did not receive any information, then she gave a legal notice dated 01.06.2012, which was replied by the Insurer vide letter dated 16.06.2012 that some investigating agency has been appointed and its report has not been received. When nothing was heard further, then this complaint was filed.
5. United India Insurance Company Limited (opposite party-1) filed its written reply on 28.01.2013, in which, the material facts have not been denied. The Insurer stated that death had occurred on 02.07.2010 while the Insurer was intimated on 29.04.2011, although under the Policy, claim ought to have been lodged within one month from the death. Therefore, the Insurer vide letter dated 18.01.2012, informed the complainant as “No claim”. However, on humanitarian ground, an Investigator has been appointed. On receipt of report of the Investigator, The Insurer approved the claim for Rs.2050000/-, vide letter dated 12.12.2012 and transferred the amount in the loan account of the complainant in Bank of Maharashtra through RTGS on 13.12.2012. The loan was sanctioned to two borrowers as such sum insured of Rs.41/- lacs for Personal Accident was jointly for two borrowers. On the death of one borrower, the Insurer paid half of the sum insured as full and final settlement on 13.12.2012. There was no deficiency in service on the part of the Insurer.
6. The appellant filed Affidavit of Evidence of Mrs. Rushali Pankaj Palesha and various documents. The Insurer filed Affidavit of Evidence D.H. Pawar and various documents. State Commission, by impugned judgment dated 16.01.2014, held that an interpretation of policy terms and condition shows that sum insured on account of personal accident was in respect of both the borrowers i.e. husband and wife. In
