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2025 Supreme(Online)(NCDRC) 3312
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
A.P. Sahi, CJ, Bharatkumar Pandya, J
New India Assurance Company Limited – Appellant
Versus
Dinesh Gautam – Respondent
Revision Petition No. 301 of 2022 | Revision Petition No. 302 of 2022
For the Appellants/Petitioners: Dr. Sudhir Bisla
For the Respondents: Ms. Anubha Agrawal, Amicus Curiae
Insurance claims must adhere to policy conditions, including documentation and timely inspection; failure to comply warrants repudiation of claims.
Headnote:(A) Consumer Protection Act, 1986 - Section 19 - Insurance Claims - The Insurance Company repudiated insurance claims for permanent total disablement of buffaloes, citing lack of documentation and inspection opportunity as grounds for rejection. The State Commission initially allowed claims but the petitions were remanded for fresh hearing, addressing procedural errors in delay condonation and failure to adhere to policy conditions. (Paras 1, 36-48)
(B) Key Legal Principles - Insurers are bound by the policy terms, including timely inspection and documentation requirements for claims based on permanent total disabilities. (Paras 14, 44)
Facts of the case:
The complainant claimed insurance for buffaloes suffering from an ailment, but the insurance company denied the claim due to lack of physical inspection and documentation. The buffaloes were sold before the inspection could take place, leading to the initial rejection of the claims. (Paras 5, 12, 45)
Findings of Court:
The court found that the insurance company did not promptly investigate the claims and noted that the State Commission's ruling disregarded necessary policy terms regarding claim evaluation. (Paras 17, 36)
Issues: Whether the complainant's delay in filing appeals justified acceptance, and whether the claim repudiation was warranted based on policy terms. (Paras 16, 45)
Ratio Decidendi: The court emphasized that the insurance company failed to provide just opportunities for examination, and the procedural inadequacies in assessing claims were critical. Additionally, the necessity of adhering to policy conditions and documentation was stressed. (Paras 36, 48)
Result: Revision petitions allowed; matter remanded to the State Commission for a fresh decision.
| Table of Content |
|---|
| 1. claims were repudiated due to alleged non-compliance. (Para 1 , 2 , 3 , 4) |
| 2. treatment details and claim formation recounted. (Para 5 , 6 , 10 , 12) |
| 3. investigation and claim processes detailed. (Para 9 , 13 , 14 , 18) |
| 4. appeals allowed amidst substantial delay. (Para 15 , 17 , 19 , 26) |
| 5. re-examination of merits and procedural justice emphasized. (Para 27 , 34 , 35 , 36 , 46) |
| 6. matter remanded for fresh decision. (Para 49) |
ORDER
JUSTICE A.P. SAHL PRESIDENT
1. The petitioner Insurance Company repudiated the claims of the respondent/ complainant oh 15.07.2016 for permanent total disablement of two buffaloes A on identical grounds.
2. f Both claims were repudiated simultaneously but by two separate communications of the same date that became subject matter of challenge before the District Consumer Disputes Redressal Commission, Union Territory Chandigarh in consumer complaint nos. 643 and 644 of 2016. The District Commission rejected the complaints vide separate orders dated 17.10.2018, that were assailed by the complainant in two separate appeals FA/16/2021 and FA/17/2021. The complainant's appeals were allowed by two separate orders which are identical in nature on 25.11.2021.
3. The Insurance Company has filed these two revisions against decision of the . State Consumer Disputes Redressal Commission, UT Chandigarh on the same grounds as both cases are grounded on the same set of facts and documents. The evidence led in both the cases were same, the arguments advanced and the provisions relied on were identical, as such both the revision petitions are being heard simultaneously and are being disposed of by this common order.
4. In order to appreciate the controversy, the facts and the dates as occurring in CC/643/2016 giving rise to FA/16/2021 are being narrated and are not being repeated for the other revision, as the same documents and same dates form the narrative of both the cases.
5. The respondent/ complainant in his complaints has urged that the complainant setup a buffalo dairy farm and purchased 15 buffaloes with the financial aid from the Bank of' Baroda. After purchase and appropriate verification by the financing bank as also a veterinary doctor, who had inspected the stock, the insurance of the said buffaloes under the Permanent Total Disability Policy for all 15 buffaloes were acquired that was effective from 01.04.2016 to 31.03.2017.
6. The dispute regarding two of the buffaloes involved in these two revision petitions is in reference to the buffaloes that had been allocated microchip no. 95600003673461 and 95600003679821. These two buffaloes suffered from Mastitis during the subsistence of the policy. This disease results in the thickening of the teats and the choking of the veins in the udder as a result whereof they stop yielding milk. They were therefore subjected to treatment.
7. On account of this total disability of two of the buffaloes, a claim form was submitted along with the requisite, documents pertaining to the treatment and certificate of the empanelled doctor of the Insurance Company namely Dr. D. M. Singh.
8. Copies of the said medical prescriptions and the certificates have been filed with written submissions tendered by the learned amicus on behalf of the respondent through diary number 641 dated 06.01.2023.
9. There is no dispute that on receipt of this claim in May 2016, the Insurance Company deputed one Dr. Chauhan from Ropar, Punjab as an investigator, who according to the complainant visited the village but did not meet the complainant or come to the dairy farm of the complainant. The complainant admits that Dr. Chauhan had met with the brother of the complainant Ravi Gautam from whom he had allegedly demanded illegal gratification. It is also alleged that on a second occasion the complainant had telephonically requested Dr. Chauhan to visit the farm but he refused.
10. the complainant alleges to have sent a representation to the Insurance Company dated 30.05.2016 that has been rece
