Complaint No. 11-G8-059/12-13
Mrs. Jaya Deka
Vs
The Reliance General Insurance Co. Ltd.
Complainant: The Complainant stated that her husband Mr. Kashab Deka was an insured member under Personal Accident Insurance Policy (Group) bearing Policy No. 1503302914000026 procured from the above Insurer by the Employer GTFS Multi Services Limited covering the period from 29.05.2010 to 28.05.2011. While the policy was in force, the Insured met with a motor accident on 03.02.2011 and succumbed to his injuries on 09.02.2011. Thereafter, she lodged a death claim before the Insurer along with all supporting documents. But, the Insurer has repudiated the claim without any justified ground. Feeling aggrieved, the Complainant has lodged this complaint.
Insurer : The Insurer has stated in their “Self Contained Note” that the death claim covered under Personal Accident was intimated to them on 23.07.2010. As per the intimation the deceased met with a motor accident on 03.02.2011 and later succumbed to his injuries and breathed his last breath on 09.02.2011. The Complainant has intimated the claim after a delay of 162 days from the day of death which grossly violates policy condition No.1 which hereby states that “In case of death, written notice of the death must, unless reasonable cause is shown, be so given before interment / cremation, and in any case, within one calendar month after the death”. Therefore, the Insurer has repudiated the claim.
Decision : It is apparent from the policy terms and condition that the claimant must submit written notice of the death within one calendar month after the death. In the instant case, it is apparent that the Complainant did not submit the written notice directly to the Insurer within one month from the date of death. It appears from the copy of letter written by the Complainant addressing to the Employer of the Insured (GTFS Multi Services Limited) that she intimated them about the death of her husband on 09.02.2011 due to accident which was received by the Employer on 15.02.2011. The copy of letter dated 18.07.2011 written by the GTFS Multi Services Limited to the Manager, Reliance General Insurance Co. Ltd. goes to show that they had forwarded the 09 Nos. of claim papers to the Insurer.
It is clear from the above that the Employer (GTFS Multi Service Ltd.) of the Insured did not send the written claim intimation letter to the Insurer within the stipulated period of time. It is an admitted fact that in case of Group Policy, the Insured person does not have the copy of the policy document with them and any claim “arises, it is to be submitted to the Employer first by the claimant. The Master Policy is kept by the Employer. In the instant case also the Complainant is not exceptional from that. It is also ample clear that there was no lapse on the part of the Complainant in intimating the death claim through proper channels. It is proved that there is a huge fault on the part of the Employer for which the genuine party has suffered. For the fault of the Employer the claimant should not be allowed to suffer. It is against the principle of natural justice. Considering the entire facts and circumstances of the case, the Insurer is asked to reconsider the claim of the Complainant and arrange to settle the claim by condoning the delay. Hence, the decision of repudiation of the claim by the Insurer is set aside.
Insurer is accordingly directed to settle the claim within 15 days allowing penal interest @ 8% P.A. on the premium amount.
