1. This is a complaint filed by Smt.S.Meenakshi - Insurance ...

DELHICase No. GI/223/NIA/09In the matter of Smt. S. MeenakshiVsNew India Assurance Company LimitedAWARD dated 05.08.2010 - Accidental fire claim1. This is a complaint filed by Smt.S.Meenakshi (herein after referred to as the complainant)against the New India Assurance Company Limited (herein after referred to asrespondent insurance company) in respect of partial repudiation of accidental fire claim.2. The complainant submitted that there was a fire in her kitchen situated in her residenceand due to fire considerable damage was done in the kitchen. The complainant hadhousehold policy. She filed a claim for Rs.24715/- which was examined by a surveyorwho assessed the loss at Rs.8250/- which has been paid to the complainant but thecomplainant was not satisfied with this amount. She desired that she be compensatedmore as her claim was much more than the loss assessed and been paid by the insurancecompany.3. It has been stated on behalf of the company that the policy holder has been compensatedthe loss adequately which occurred due to fire in the kitchen. The surveyor assessed theloss at Rs.8250/- after adjustment of depreciation and other deductions as per the policyconditions.4. I have considered the submissions of the complainant and also seen the writtensubmissions as placed on record on behalf of the company. After due consideration ofthe matter, I hold that the policy holder was not compensated for the loss occurred onaccount of fire in the kitchen as ought to have been done. The assessed loss was

considerably less than the loss occurred due to fire. While assessing the loss, surveyorhas committed a mistake by allowing 50% instead of 15% on building portion. He alsocommitted mistake by deducting policy excess of Rs.1000/- instead of nothing. Thus inmy considered view, it would be fair and reasonable if the assessed loss is taken atRs.10500/- instead of Rs.8250/-. Since the complainant had already been paidRs.8250/-, she will be further entitled to a sum of Rs.2250/-. Accordingly, theinsurance company is directed to make a further payment of Rs.2250/- to thecomplainant.5. The Award shall be implemented within 30 days of receipt of the same. Thecompliance of the Award shall be intimated to my office for information and record.6. Copies of the Award to both the parties.HYDERABADHYDERABAD OMBUDSMAN CENTRECOMPLAINT No. I.O.(HYD) G -11. 011.342. 2009-10Sri Gottipati Bala Subba Naidu V/s Bajaj Allianz Gen. Ins. Co. Ltd.Award No:G-034/28.05.2010Sri Bala Subba Naidu insured two tobacco barns under a Group Master Policy issued to theTobacco Board by M/s Bajaj Allianz General. Both the barns were gutted in a fire accident on16.3.09. Sri Bala Subba Naidu preferred a claim for loss to the tune of Rs.2,11,300 but theinsurer offered to settle the claim at Rs.47,868. The complainant rejected the offer andrequested for reconsideration of the offer. Since the insurance company did not respond tohim, Sri Naidu lodged a complaint with this office.The complainant stated that both his barns damaged by fire on 16.3.09. The insurancecompany arranged survey and finally offered to settle an amount of Rs.47,868 which he refusedto accept as the loss he suffered was much higher.

The insurer explained that the policy issued to the Tobacco Board covering the barns ofits members has different sections, each having different sums insured. The policy also issubject to policy excess of Rs.10,000 on each barn. The insurer submitted that they haddeputed an IRDA licenced surveyor to inspect the damage and assess the loss. The surveyorassessed the net loss at Rs.47,910 for one barn and the loss in respect of the second barn wasmuch less than policy excess of Rs.10,000. Hence the complainant was offered payment ofRs.47,910 as full and final settlement of the claim.O R D E RThe complainant claimed that two barns of the complainant were destroyed by fire. Thesurveyor deputed by the insurer assessed the loss on only one barn with. The complainant hasfiled evidence in the form of certificates from the fire brigade and the MRO to show that thefire accident occurred in both the barns. The insurer did not rebut this claim with any evidence.Consequently, the claim of the complainant that both the barns suffered damage has to beaccepted. The question is the extent of the damage and the claim that can be admitted. Thecomplainant has filed a statement that he incurred expenditure of Rs. 1,58,300 towards repairsto the barns while claiming that the value of stocks lost was Rs. 81,000 in the claim ofRs.2,11,300. After reducing the value of stocks, the damage to the structure, as per the claimworked out to Rs.1,30,300. The claim in respect of damage to the barns has to be reckoned asRs.1,30,300. The complainant is directed to furnish to the insurer supporting bills for thisexpenditure and the insurer is directed to examine the claim in this behalf afresh and allowexpenditure that has been incurred by the complainant towards the barns. It is made clear thatthe insurer is precluded from raising the issue that only one barn was gutted in fire. On thebasis of evidence adduced, it was holded that both the barns of the complainant were damagedin the fire accident and that claim is exigible equally in respect of both the barns.The insurer’s surveyor assessed loss of tobacco in respect of one barn at Rs.35,285 for 5quintals @ Rs. 7057 per quintal. This is accepted as reasonable in respect of one barn. Theinsurer’s surveyor did not accept the claim of loss in the other barn. It was holded that thecomplainant had lost the stock in the second barn also and that claim is exigible in respect of

such stock as well. It was estimate the value of stock destroyed in the second barn at Rs.30,000and direct the insurer to pay this amount.In fine, the claim of the complainant insofar as the loss/damage to the structure isrestored for fresh examination and assessment of the claims in accordance with the terms ofthe policy. The claim in respect to loss of stocks in the barns is allowed at Rs.65,285 (Rs.35,285plus Rs. 30,000).In the result, the complaint is treated as allowed in part.HYDERABAD OMBUDSMAN CENTRECOMPLAINT No. I.O.(HYD) G -11.04.144.2010-11Sri Bhupendra Sharma V/s United India Insurance Co. Ltd.Award No:G-108/14.09.2010Sri Bhupendra Sharma along with his family and dependent parents was covered under hisemployer’s corporate group Health Insurance Policy for a sum insured of Rs.5.00 lakhs. He preferreda claim on the insurer for in-patient prostate cancer treatment of his father. His father underwentHigh Intensity Focused Ultra Sound [HIFU] ablation for prostate cancer. The insurer/TPA denied theclaim stating that the treatment was an experimental and unproven treatment / therapy. Aggrievedby the rejection of insurer, Sri Bhupendra Sharma filed this complaint for redressal.The complainant stated that his 72 year old father was suffering from Prostate Cancer andit was first detected on 18.4.2009. They preferred to undergo treatment at Rajiv Gandhi Instituteand Research Centre at Delhi. He further stated that keeping in view his father‟s age and physicalcondition, they chose HIFU treatment instead of surgery and radiation. The complainant statedthat HIFU treatment was yielding better results than surgery and radiation especially for seniorcitizens without any complications and so they opted for that treatment. He stated that therejection of claim by the TPA / Insurer was unjustified and added that the insurer‟s reason for

epudiation that “HIFU or radical surgery or chemotherapy or radiotherapy can be construed tobe „Experimental / Unproven treatment‟ since the success of treatment and the prognosis of thedisease is unpredictable” was incorrect. He stated that he submitted to the insurer certificatesissued by hospitals of various other countries where it was accepted as a specific treatment for„cancer prostate‟.The insurer stated that HIFU for cancer prostate was still under trial for safety andeffectiveness. They further stated that it was not recommended as specific treatment for „cancerprostate‟ as per NICE clinical guidelines [33] and American Cancer Society [7]. The insurercontended that this treatment was outside the scope of the policy as per exclusion No. 4.13.O R D E RThe insurer denied the claim on ground that HIFU ablation is still an experimental orunproven treatment. That HIFU treatment is widely recognized in Europe, Canada andelsewhere in the world is not in dispute. US FDA is yet o accord recognition to the method. It iscommon knowledge that there is no proven treatment for complete cure of carcinoma. There isenough outcry against use of chemotherapy for treatment of cancer. Its success rate as a curefor cancer is still in doubt. Yet, it is widely used for treating carcinoma. If there is one suremethod recognised for treating cancer, the insurer would be justified in rejecting claim on HIFUablation treatment. The policy does not state that the treatment has to be recognized by anyspecific authority. It only excludes treatment which is undergoing clinical trials. The reason forsuch exclusion is that costs associated with such treatments are high and the outcome isuncertain. HIFU ablation treatment is not under clinical trials. It is being employed in Europeand Canada as also in the other parts of the world for treatment of prostrate cancer. It isacknowledged to be as effective as or more effective than any other IMA certified treatment forthe problem.In view of the above, it was held that the insurer rejected the claim unreasonably. Theexpenses towards hospitalisation incurred amounted to Rs.2,74,771 against which theadmissible claim works out to Rs.2,39,442 as per the information furnished by the TPA. Theinsurer is directed to settle the claim at Rs.2,39,442.

In the result, the complaint is allowed in part at Rs.2,39,442.