PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,

STATE OF TAMIL NADU & PUDUCHERRY

(UNDER RULE NO: 17(1) of the INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri M Vasantha Krishna

CASE OF Mrs Jenifer Vs HDFC ERGO General Insurance Co. Limited

COMPLAINT REF: NO: CHN-G-018-1920-0203

Award No: IO/CHN/A/GI/0188/2019-2020

1. Name & Address of the Complainant Mrs Jenifer No. 7, Bishop Lane, Paruthipet, Avadi, Chennai 600071

2. Policy No. Type of Policy Duration of Policy/Policy Period Sum Insured (SI)

3317 1001 4535 4500 000 Personal Accident Insurance Policy 01/10/2016-30/09/2017 INR 10,00,000 (Accidental Death)

3. Name of the Insured Name of the Policyholder/Proposer

Mr Gnanaprakasam Appadurai Mr Gnanaprakasam Appadurai

4. Name of the Insurer HDFC ERGO General Insurance Co Ltd

5. Date of Repudiation 26/08/2019 (closure)

6. Reason for closure of claim Non- submission of documents

7. Date of receipt of the Complaint 05/12/2019

8. Nature of Complaint Non-settlement of Claim

9. Date of receipt of Consent (Annexure VI A)

10/01/2020

10. Amount of Claim Not furnished

11. Amount paid by Insurer, if any NIL

12. Amount of Monetary Loss (as per Annexure VI A)

Not furnished

13. Amount of Relief sought (as per Annexure VI A)

INR 10,00,000 and premium paid and interest

14. a. Date of request for Self-Contained Note (SCN)

18/12/2019

14. b. Date of receipt of SCN 06/02/2020

15. Complaint registered under Rule 13(1)(b) of the Insurance Ombudsman Rules, 2017

16. Date of Hearing/Place 19/02/2020, Chennai

17. Representation at the hearing

a) For the Complainant Mrs Jenifer

b) For the Insurer Mr V Karthikeyan

18. Complaint how disposed By Award

19. Date of Award/Order 12/03/2020

20.Brief Facts of the Case:

Complainant’s spouse Mr Gnanaprakasam Appadurai covered under respondent

insurer’s Personal Accident Insurance policy for the period from 01/10/2016 to

30/09/2017, with the sum insured of INR 10 lacs, met with a road accident on

15/02/2017 and succumbed to the injuries sustained, on 02/03/2017, inspite of

undergoing treatment at Gleneagles Global Health City, Chennai from the day he

sustained injuries. The nominee under the Policy was Baby Kenitta Blessy, the

minor daughter of the deceased insured and the complainant. Complainant preferred

the claim with respondent insurer in her capacity as natural guardian of the minor

nominee under the accidental death benefit section of the Policy for INR 10 lacs.

Insurer closed the claim due to non- submission of the KYC form, cancelled cheque

& bank pass book copy of the nominee (Kenitta Blessy). Aggrieved by the closure of

the claim, complainant took up the matter again with insurer stating that all the

documents requested were submitted. But there was no response from the insurer

and hence the complainant has approached this Forum for relief.

21) a) Complainant’s submission:

1. Complainant’s claim has been closed by the respondent insurer stating that

KYC form of her daughter and cancelled cheque leaf were not submitted, but

the same had already been submitted.

2. Since the nominee, her daughter G Kenitta Blessy is a minor aged 6 years,

KYC form was signed by the complainant after giving the details of her

daughter. Cancelled cheque leaf of the complainant was also submitted

3. Complainant also submitted a sworn affidavit duly notarised by an advocate

and solemnly affirming that there is no objection for disbursement of the policy

benefits to her daughter.

4. Insurer was informed of the total compliance of all the requirements of insurer

vide letter dated 05/09/2019. But there is no response from them. Hence

Forum’s intervention is requested for settlement of the claim.

b) Insurer’s contention:

1. There is no discrepancy as regards the cause of loss. Post review of the

documents furnished, complainant was requested to furnish necessary

documents for the admissibility of the claim.

2. Nominee is a minor girl and the late insured is survived by the following

persons

Name Age Relationship

Kenitta Blessy 06 Daughter (Minor)

Ms. Jenifer 27 Wife of insured

Ms Padmavathi 67 Mother of insured

3. Though complainant has submitted an affidavit stating that there is no

objection to pay the claim amount to her daughter, complainant didn’t furnish

similar affidavit from Ms Padmavathi, mother of the deceased and the same

was furnished subsequently after the complainant was requested to do so.

4. Complainant was also requested to furnish the salary details of her late

spouse, the insured. But the same was not furnished. As per policy terms,

income proof is mandatory for availing the claim compensation under the

policy.

5. All other documents except income proof are received by insurer. Hence the

complainant’s claim was closed for want of documents.

6. Once the income proof is submitted, insurer is ready to process the payment

after calculating the final amount payable.

7. Even after approaching the Forum, complainant was requested to give her

voluntary consent to withdraw this complaint, post-remittance of the claim

amount. But there is no cooperation from her. Hence Forum is requested to

direct the complainant to furnish the details requested, to process the claim, in

the name of the nominee.

22)Reason for Registration of Complaint: - Rule13 (1) (b) of the Insurance

Ombudsman Rules, 2017, which deals with “Any partial or total repudiation of claims

by the life insurer, General insurer or the health insurer”.

23)The following documents were placed for perusal.

Written Complaint dated 02/12/2019 to the Insurance Ombudsman

Claim closure letter of the Insurer dated 26/08/2019

Complainant’s representation dated 05/09/2019 to the Insurer

Consent (Annexure VI A) submitted by the Complainant

Self-Contained Note (SCN) of the Insurer dated 05/02/2020

Personal Accident policy with terms and conditions

Claim form dated 24/08/2019

KYC of Mrs G Jeniffer & Baby G Kenitta Blessy

Accident Register of Global Health City

Death Summary of Gleneagles Global Health City, Chennai

Death Certificate issued by Global Health City, Chennai

Legalheirship certificate dated 30/06/2017

Sworn Affidavit by complainant dated 14/08/2019

First Information Report (FIR) no. 106/2017 dated 16/02/2017 of Police

Station TIW Chrompet

Post Mortem (PM) Report and Final Police Report

Birth certificate of the nominee

24) Result of hearing with both parties (Observations & Conclusion)

1. The Forum records its displeasure over the delay in submission of SCN by the

insurer.

2. Complainant’s claim is in respect of the accidental death benefit of INR 10

lacs under Personal Accident policy availed by her spouse.

3. Death of the insured person was due to accident and has been confirmed

through PM report &death summary issued by Gleneagles Global Health City,

Chennai and FIR.

4. Insurer have also not disputed the cause of death.

5. Insurer, while closing the claim stated that they didn’t receive the KYC and

bank details of nominee Ms Kenitta Blessy. But in the SCN they have stated

that the income proof of the late insured is necessary to calculate the

compensation and non-receipt of the same is cited as the reason for closing

the claim.

6. The policy schedule states that the maximum compensation in respect of an

insured person under the policy shall not exceed 5 times the annual income.

Income proof for availing the compensation at the time of claim is mandatory.

Income proof shall mean the previous year’s returns filed with the Income Tax

Department.

7. During hearing, insurer informed that they are willing to settle the claim,

waiving the requirement of income proof.

8. While closing the claim on 26/08/2019, insurer stated that KYC and bank

details of the nominee were not received. When complainant represented to

the insurer on 05/09/2019 stating that she has already submitted all the

requirements, insurer didn’t raise any objection. They are now willing to settle

the claim without seeking any other documents. Therefore, Forum concludes

that the complainant complied with all the requirements on 26/08/2019.

9. As per Regulation 15.8 of Protection of Policyholders’ Interests Regulations,

2017 dated 22/06/2017, insurer shall offer settlement within 30 days from the

date of receipt of last relevant and necessary document from the insured.

Hence insurer should have offered settlement on or before 25/09/2019. Since

they failed to do so, they are liable to pay interest from 25/09/2019 till the date

of settlement.

10. Complainant is also eligible for claim under Medical Insurance Premium

Indemnity and Dependent Child Education Benefit covers, subject to the

relevant terms and conditions of the Policy.

The attention of the Insurer is hereby invited to the following provisions of the

Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of the 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

b) According to Rule 17(7) of the Insurance Ombudsman Rules, 2017, the

complainant shall be entitled to such interest at a rate per annum as specified in the

regulations, framed under the Insurance Regulatory and Development Authority of

India Act, 1999, from the date the claim ought to have been settled under the

regulations, till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17(8) of the Insurance Ombudsman Rules, 2017, the award of

Insurance Ombudsman shall be binding on the insurers.

Dated at Chennai on this12th day of March 2020

(M Vasantha Krishna)

INSURANCE OMBUDSMAN

FOR THE STATE OF TAMIL NADU AND PUDUCHERRY

AWARD

Taking into account the facts & circumstances of the case and the submissions made during the course of hearing, by both the parties, Forum concludes that the closure of the claim by insurer was not in order. Insurer is therefore directed to settle the claim of the complainant for INR 10,00,000 along with interest as defined under Rule 17 (7) of Insurance Ombudsman Rules, 2017, from 25/09/2019 till the date of payment.

Insurer is also directed to settle the claim under Medical Insurance Premium Indemnity and Dependent Child Education Benefit sections of the Policy upon receipt of necessary documents and subject to applicable policy terms and conditions.

Thus the complaint is Allowed.

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. Suresh Babu

Case between: SRI P. SAI BABU………………The Complainant Vs M/s The New India Assurance Co. Ltd…………The Respondent Complaint Ref. No. I.O.(HYD).G-049-1920-0391

Award No.: I.O.(HYD)/A/GI/ 0392 /2019-20 1 Name & address of the complainant Mr. P. Sai Babu

Flat #408, Apex Sai Srinivasam,

Near Ramalayam, Bharat Petrol Bunk,

Madinaguda,Hyderabad, - 500 050.

(Cell No. 70936-02200)

2. Policy No./Collection No.

Type of Policy

Duration of Policy/Policy period

Policy no:99000046191300000001

Card No.: 4691980033724377

Debit Card holders’ policy

15.04.2019 to 14.04.2020

3. Name of the insured

Name of the Policyholder

Miss Ponugupati Dhruthi

M/s Axis Bank

4. Name of the insurer M/s The New India Assurance Co. Ltd.

5. Date of Repudiation 18.10.2019

6. Reason for repudiation Delay in submission of claim papers

7. Date of receipt of the Complaint 08.01.2020

8. Nature of complaint Claim pertaining to Personal accident Insurance

9. Amount of Claim Rs. 5,00,000/-

10. Date of Partial Settlement -----

11. Amount of Relief sought Rs. 5,00,000/-

12. Complaint registered under Rule No.13.1 (b) of Ins. Ombudsman Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of claims by the Life insurer, General Insurer or the Health insurer

13. Date of hearing/place 03.03.2020

14. Representation at the hearing

a) For the complainant Self

b) For the insurer Mr.P.Sesha Sai Kumar.

15. Complaint how disposed Allowed

16. Date of Order/Award 03.03.2020

17) Brief Facts of the Case: The complainant is the father of Miss Ponugupati Dhruthi who had a salary account in M/s Axis Bank

and was a holder of debit card provided by the bank. The card carried certain features of which

there was a personal accident cover for an amount of Rs. 5 Lakhs. She met with a road accident on

17.07.2019 and died on 18.07.2019 while undergoing treatment for the injuries sustained by her in a

hospital. An FIR was filed on the day of her death by her brother. When the complainant had

approached her daughter’s bank to file a claim under the Personal accident cover against her debit

card, he was asked to submit the claim along with certain documents. Despite his submission of

papers within the stipulated time, the claim was denied by the respondent company which covered

the card holders under personal accident insurance. He had therefore approached this Forum to

seek a favorable solution in this matter.

18) Cause of Complaint: Rejection of claim pertaining to Personal Accident Insurance policy. a) Complainant’s argument:

The complainant had stated that he had come to learn from some source that the debit card which his daughter was holding covered the risk of accident and therefore he had approached her banker on 06.09.2019 and fulfilled all the requirements asked for by the bank on 20.09.2019. Surprisingly, his claim was rejected by respondent citing reason that there was a delay in submission of the claim documents to them. He had stated that her daughter died on 18.07.2019 after which he had approached the banker on 06.09.2019 and submitted all the required documents to them on 20.09.2019 and the reason given by respondent puzzled him and he had therefore questioned as to where he was late in submitting all the requirements. b) Insurer’s argument: The respondent submitted their self contained on 27.02.2020. It is informed that Late Ponugupati Dhruthi daughter of the complainant Sri P.Sai Babu was covered under a policy issued to Axis Bank covering Axis Bank Debit card holders for a Personal Accident cover of Rs.5 Lakhs. They had initially rejected the claim due to delay in submission of documents as per agreed terms and conditions with axis bank. Now, they have reviewed the claim and agreed to condone the delay and to process the claim on receipt of required documents as per terms and conditions of the policy. 19) Reason for Registration of Complaint:

The insurer rejected the claim preferred by the complainant. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered. 20) The following copies of documents were placed for perusal: a. Policy copy b. Apollo hospital report dated 18/07/2019 c. Rejection letter d. Correspondence with insurer e. Axis Bank statement, FIR, Death certificate, PM report, Final Charge Sheet,

21) Result of the personal hearing with both the parties: Pursuant to the notices given by this Forum both parties attended the personal hearing at Hyderabad on 03.03.2020. The complainant stated his daughter met with a road accident on 17/07/2019 and succumbed to head injuries in Apollo hospital on 18/07/2019. He has come to know that as a debit card holder of Axis bank, she was covered for Personal Accident insurance of Rs.4 Lakhs. His son as informed the police on the same day. He has obtained death certificate and PM report. When he approached the bank on 6.9.2019 and intimated the claim. On 09.09.2019 he received a mail from the Bank Manager to submit documents like claim form, Fir, Assignee Verification, PM report, death certificate and bank statement. He submitted the same on 20.09.2019. After a month’s time, he received a letter from the bank on 02.11.2019 to which rejection letter addressed to the bank was attached. It was written in the letter, date of repudiation as 18.10.2019 and reason for rejection of the claim as “claim is rejected on grounds of delay in submission of claim documents as per SLA”. The insurer has stated that a group policy was issued by their Mumbai Office covering card holders of Axis bank. Ms.Ponugupati Dhruthi was a debit card holder bearing no.4691980033724377 for a sum insured of Rs.5 Lakhs, met with a Road accident on 17.7.2019. The claim was denied due to delay in submission of documents. However, they have reviewed and agreed to condone the delay. They have asked the insured / nominee to submit the documents required to process the claim to their Mumbai Office directly. The Forum has gone through the documents submitted:

FIR: No.481 dated 18.07.2019 at Jubilee Hills- Ms P.Dhruthi was a pillion rider on a two wheeler along with her colleague Mr. Abhinav Kavuru. The vehicle accidently hit a road divider near jubilee hills both fell on the road with grievous injuries and shifted to Apollo hospital. The brother of Ms.P.Dhruthi gave the police complaint and sought for action to be taken on the bike rider for negligent/rash driving.

Apollo Hospital has certified admission with alleged h/o RTA at 12.30 PM on 17/07/2019. They have issued a death certificate with cause of death as “ cardiopulmonary arrest secondary to polytrauma”.

After all revival protocol, she was declared dead on 18/07/2019 at 1.17 PM.

Final Charge Sheet under section 173 CR.PC shows the cause of death was accidental. Mr.Abhinav Kavuru survived with grievous injuries and that there was no mistake on his part. The complaint on the rider was withdrawn and the case is treated as action abated.

The PM report shows cause of death as “head Injury”.

Mail dated 2.11.2019 , 9.16 am from insured addressed to axis bank operationshead, it is clear the insured has submitted the required claim documents on 20.09.2019 and sought for status of the claim.

On 2.11.2019, 11.27 AM the Bank informs him of rejection, enclosing rejection letter dated Nil addressed to the Banker by the respondents per their agreement.

The complainant’s daughter died in a Road accident on 18/07/2019, necessary documents have been submitted on 20.09.2019 to the bank. It is the duty of the bank to submit the same to the insurer. Delay is condoned by the insurance company. The Forum therefore directs the insurer to settle the claim for Rs.5 Lakhs along with interest without insisting on resubmission of documents to avoid further delay, to the nominee of the deceased.

A W A R D Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the personal hearing and the information/documents placed on record, the insurer is directed to settle the claim for Rs.5,00,000/- with interest to the nominee without insisting on resubmission of documents already submitted to the Axis Bank . The complaint is Allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017:

a) According to Rule 17(6), the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

b) According to Rule 17(7), the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17 (8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 3rd day of March , 2020.

( I. SURESH BABU )

OMBUDSMAN

FOR THE STATES OF A.P.,

TELANGANA AND YANAM CITY

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman - Shri I. Suresh Babu, IRS

Case between: Mr.K.Uma Mahesh………………The Complainant Vs

M/s HDFC ERGO General Insurance Co.Ltd…………The Respondent

Complaint Ref. No. I.O.(HYD).G-018-1920-0400

Award No.: I.O.(HYD)/A/GI/0394/2019-20

1. Name & address of the complainant Mr. K. Uma Mahesh c/o Mr. M. Srinivas

16-8-2/2, Official Colony 3 Line, Premier III,

Visakhapatnam,Andhra Pradesh State- 530 002.

2. Policy No./Collection No.

Type of Policy

Duration of Policy/Policy period

52361869/00001

Individual Personal Accident Plan 1

20.01.2017 to 19.01.2019

3. Name of the insured

Name of the Policyholder

Mr. Kotcherla Uma Mahesh

Mr. Kotcherla Uma Mahesh

4. Name of the insurer M/s HDFC ERGO General insurance Co. Ltd.

5. Date of Repudiation 30.05.2018

6. Reason for repudiation Disability certificate from Government Hospital not

submitted

7. Date of receipt of the Complaint 27.01.2020

8. Nature of complaint Claim pertaining to personal accident insurance

9. Amount of Claim Rs. 15,00,000/-

10. Date of Partial Settlement ----

11. Amount of Relief sought Rs. 15,00,000/-

12. Complaint registered under Rule No.13.1 (b) of Ins. Ombudsman Rules, 2017

Rule 13.1 (b) – any partial or total repudiation of claims by the Life insurer, General Insurer or the Health insurer

13. Complaint how disposed Allowed (Statistical Purpose)

14. Date of Order/Award 11.03.2020

15) Brief Facts of the Case:

The complainant had purchased an individual Personal Accident (PA) insurance Policy from

respondent whose validity was for a period of 2 years with effect from 20.01.2017. On 12.01.2018,

he met with an accident due to which he was stated to have suffered from 90% impairment of his

trunk and all his 4 limbs. Despite filing a PA claim against the insurance policy, the respondent

company had closed his claim file on account of non submission of requirements asked for in order

to process his claim. Aggrieved by the closure of his claim, he had approached this Forum to seek

justice.

16) Cause of Complaint: Rejection of Personal Accident claim. 17) Reason for Registration of Complaint:-

The claim preferred by the complainant was not settled by the insurer. As the complaint falls under Rule 13.1(b) of Insurance Ombudsman Rules, 2017, it was registered.

After filing the complaint by the complainant and before hearing scheduled on 17.03.2020,

the insurer further reviewed the complaint and settled the claim for Rs.15,00,000/- by way of NEFT

on 10.03.2020. The insurer has informed the same over mail dated 11.03.2020. The complainant

has also confirmed receipt of amount over phone and requested this Forum to close the complaint.

A W A R D

The complaint is treated as resolved and closed.

Dated at Hyderabad on the 11 th day of March, 2020

(I.SURESH BABU)

INSURNACE OMBUDSMAN

FOR THE STATES OF A.P., TELANGANA AND YANAM CITY