Miscellaneous Policy (General) - Gbic.co.in

Miscellaneous Policy (General)Ahmedabad Ombudsman CentreCase No. 11 / 004 / 0090Mr. R. V. PatelVs.United India Insurance Co. Ltd.Award Dated 17.11.2004Complainant insured his Car under Private Car Package Policy. The Car was stolen on28.2.03. Respondent admitted the Claim and sent Discharge Voucher for Rs. 2,00,000/-based on the lowest of valuations which the Complainant refused to accept, I. E. V. beingRs. 3.80 lacs. Documents perused. It is observed that there are 3 Valuations out of whichtwo were obtained by the Respondent and the third one was obtained by the Complainant.Nothing found incredible in the valuation of Complainant’s Surveyor. The dispute being onlyon quantum of loss, the Golden Mean applied to resolve the complaint. Accordingly,awarded Rs. 2,32,000/- to the Complainant.Ahmedabad Ombudsman CentreCase No. 15 / 004 / 0021Dr. Shailesh S. ShahVs.United India Insurance Co. Ltd.Award Dated 3.12.2004Complainant and his wife deposited required Premium for Bhavishya Arogya Policy for theirlife. Except Receipt for the deposit Respondent did not issue Policy documents even afterlapse of around 4 years. It is observed from the record that the Complainant wascontinuously following up with the Responded, but none of his correspondences wereresponded by the Respondent. Respondent submitted that due to their system problem ingenerating the Policy Document, they could not prepare it. When asked why they did not tryfor alternative method in such an exigency, they could not explain satisfactorily.Respondent to issue the concerned Policy Documents within 7 days taking recourse to anyother alternative and the same should be confirmed to this Forum within 15 days.Ahmedabad Ombudsman CentreCase No. 11 / 010 / 0018Mr. Jitendrakumar ChandulalVs.IFFCO - TOKIO General Insurance Co. Ltd.Award Dated 03.12.2004Complainant held a Jewellers Block Protector Policy for his Jewellery Shop. He lost someornaments when a customer who visited his shop took away the same which was kept in abox down the counter. Claim repudiated. It is observed that the loss suffered by theComplainant was not by violent or forcible entry into the Premises or exit from it as perPolicy terms and conditions. It was not included in the coverage as per Exclusion Clause 7(c) of the Policy. Repudiation upheld.

Ahmedabad Ombudsman CentreCase No. GIC / OIC / 1 / 141Mr. Iqbal ParvezVs.Oriental Insurance Co. Ltd.Award Dated 13.12.2004Claim under Marine Transit Policy. There was a short delivery of 4 Packets of goodsdestined to Noida. Complainant sought for exemption from personal appearanceDocuments submitted by both the parties were enough to decide the case and hence, it isconsidered not necessary to call either of the parties of hearing. It is observed that thesubject Policy was for Marine Cargo - Inland Transit - Cover Type “B” As the Coverextended was Type - B, the liability for such loss does not vest on the Respondent, but if itwas Type - A, it will cover all Risks. The possibility of erroneous typing on the phase ofCover did not rule out. Therefore, the issue was examined on Rate of Premium charged. Itis observed that the Premium was charged @ 1 % on the declared value of the goods.Complainant quoted an identical case of Policy issued by the Respondent to one Mr. K. L.Jagatia, wherein the destination, Transporter, Premium charged @ 1 %, date of loadingwere all same and the said Policy was issued under Cover Type - A. Respondent could notindicate the reason for denial of Type - A Policy to the Complainant while Charging thesame Premium Rate. Further the Respondent had appointed Survey or and if the Cover wasType - B, why the survey was conducted as the Claim was not admissible because it beinga Type - B Cover. Opined that it may be a printing error and benefit of doubt casts in favourof the Complainant. Respondent to pay Rs. 12,200/- (not disputed by the Respondent)alongwith refund of Rs. 1,272/- paid to Surveyor by the Complainant.Ahmedabad Ombudsman CentreCase No. 11-005-0175Dr. Falguni MehtaVs.Oriental Insurance Co. Ltd.Award Dated 13.12.2004Complainant, while taking a House Holder’s Policy, submitted a list of 12 Items to becovered under the Policy, including her Mobile Phone. Her Mobile phone was stolen.Respondent while repudiating the Claim, stated that Mobile Phone being covered underSection 1-B & 2, the claim is not payable as it was stolen from outside the House. Thepoint taken for determination is that whether the Mobile Phone was covered under theaforesaid Sections. It is observed from the File of the Respondent presented duringHearing that there were so many infirmities. Even the Proposal Form was neither filled-upand signed by the Complainant - it was done by someone. The Proposal Form did notcontain any entry under Section-3. In the meantime Policy schedule issued by theRespondent contained columns filled up against Section-3. Complainant submitted that shewas not aware of any such bifurcation of risk. This Forum asked the Respondent duringHearing to segregate which particular item from the list of 12 items submitted by theComplainant at the Proposal stage is covered under Section-3 of the Policy Schedule, theycould not identify any of the items. Held that the Complainant’s contention that sheintended to include the Mobile Phone under Section- 3 is to be accepted. Respondent topay Rs. 4500/- net to the Complainant.Ahmedabad Ombudsman CentreCase No. GIC / NIA / 1 / 247Mr. J. B. ParmarVs.The New India Assurance Co. Ltd.

Complainant failed to submit the aforesaid documents and was it a genuine Claim and if so,can it be considered admissible. It is observed that Respondent had conducted aninvestigation though a Private Detective, who in turn submitted their Report stating that thedeath of LA was caused by an Accident. They further confirmed in their Report that neitherFIR was lodged nor Post-mortem was undertaken. Further, observed that the Claim Formsubmitted by the Complainant had been authenticated by Rural Labour Officer. As theScheme is desired and designed to benefit of underprivileged and unorganised segment ofrural population in conformity with the IRDA Regulations 2002, non-payment of Claimgiving priority to certain formal requirements will definitely defeat the sole prupose of theScheme. Genuineness of the Claim is established beyond doubt through investigation.Respondent to pay Rs. 20,000/- to the Complainant.Ahmedabad Ombudsman CentreCase No. NIA / 1 / 296Dr. Dashrathsinh B. DesaiVs.The New India Assurance Co. Ltd.Award Dated 23.2.2005A Scheme purporting to extend insurance protection in case of accidental death orpermanent disability to Farmers in the State of Gujrat was introduced by the Government ofGujrat and the Rules in this behalf were laid down by Agriculture & Rural DevelopementDepartment. Respondent extended Cover to Kheti Niyamak (Insured) and Complainant’sfather was an account Holder in the Scheme. He died in an accident As per the Provisionslaid down, the Taluk Executive Magistrate (Mamaladar) is the Designated Authority to lodgeClaim on behalf of the Account Holder. He is also designated in the Resolution as claimInquiry Settlement Officer under the Scheme. Examined the case in accordance with thePowers of Ombudsman conferred on him under RPG Rules. It is observed that the subjectinsurance is in the nature of Social Security Scheme and the present Scheme has onlyidentified class / category of persons which means that in Social Security Scheme, whethera person is an Insured Person is decided by stipulated criteria after the claim arises andthe same is governed by specific GR of the State Government. In view of this, it isconsidered that the subject Claim is beyond the jurisdiction of Ombudsman. Hence, anOrder is passed giving liberty to the Complainant to agitate his case at any appropriateForum.Ahmedabad Ombudsman CentreCase No. NIA / 1 / 279Mr. Ashok H. SutharVs.The New India Assurance Co. Ltd.Award Dated 10.03.2005Claim under Householders’ Insurance Policy. Complainant’s Tenament got damaged byEarthquake. The Building was 29 years old. Respondent appointed Surveyor & LossAssessor who in turn, submitted his Report assessing the gross loss at Rs. 21670/- andafter depreciation @, 50% and token deduction of salvage value of Rs.200/-, the net losswas assessed at Rs.11205/-. Complainant consented the valuation by countersigning theValuation Report. Accordingly, Respondent sent Discharge Voucher of Rs.11205/- to theComplainant which was not executed by him. Respondent submitted that Claim fordamages caused by Earthquake is only payable and pre-existed damages to the structureis not payable. Complainant admitted during Hearing that when he purchased the Building,it was damaged, but argued that the Surveyor did not take into account the actual damagessuffered to the Building. This forum did not interfere in the quantification of loss, as thesame was consented by the Complainant with his counter-signature. Directed the

Respondent to pay Rs.11205/-, with simple interest @ 7.5% per annum on the sum to becalculated from 14-9-2001.Ahmedabad Ombudsman CentreCase No. NIA / 1 / 166Mr. Dhiren C. ShahVs.The New India Assurance Co. Ltd.Award Dated 14.3.2005There were four Claims under 4 different Policies. Out of which Claims under three Policieswere settled by the Respondent in November 2003 and in July 2004. The Hearing was heldfor the unpaid Claim of Rs. 3,47,436/- It is observed from the documents that the Insured inthe subject Claim is a Public Limited Company. Held that under The RPG Rules, thesubject Claim is beyond the ambit of this Forum and hence, advised the Complainant toagitate his case in any other appropriate Forum.Ahmedabad Ombudsman CentreCase No. OIC / 1 / 153Mr. Harish N. GohelVs.Oriental Insurance Co. Ltd.Award Dated 15.3.2005Complainant lodged a Claim of Rs. 1,69,700/- towards loss sustained to his Fishing Boat.Respondent offered Rs. 37,305/- net and sent Discharge Voucher which was not executedby him. Respondent submitted that the Complainant made all payments in cash and he didnot submit any proof of cash withdrawals and due to lack of credible vouchers, theSurveyors assessed the loss what they considered fair and reasonable to the best of theirknowledge and experience. On perusal of documents, it is observed that the Surveyorslisted out 17 items and has indicated against each of it the Claimed amount and theallowed amount. Out of these 17 items, for two items aggregating to Rs. 58,000/-, noamount was allowed by the Surveyor because of the amount being very high and paid bycash. Conclusion arrived at is that the Surveyor has made substantial deduction from theclaimed amount and totally rejected the claim against two items as mentioned above whichis not convincing. Respondent to pay Rs. 52,965/- net to the Complainant.Ahmedabad Ombudsman CentreCase No. 002 / 0194Mr. Vijay G. ShahVs.The New India Assurance Co. Ltd.Award Dated 17.03.2005Complainant suffered loss of valuable items, insured under Householders’ Policies, by theftin two occasions. He lodged Claim for Rs.81675 under Policy No.230500 / 48 / 01 / 06108andRs.215000/- under Policy No.07762. Respondent admitted the Claim and offered Rs.21526/-and Rs.133030/- respectively. During Hearing, the items involved were compared with theSchedule of Articles attached to the Policy and observed that loss of Camera and Cashwere not included under Policy No.06108. Complainant agreed with it and consented to theoffer of Rs.21526/-. As regards the loss under Policy No.07762, it is observed that Golditems of 8 Tola which was covered under the Policy were not considered for settlement bythe Respondent, In addition to earlier offer of Rs.133030/-, the Respondent to payadditional Rs.32000/- towards loss of Gold Items.

Bhubaneswar Ombudsman CentreCase No. I.O.O. / BBSR / 11 - 449Shri Kulamani BiswalVs.The New India Assurance Company Ltd.Award Dated 06.10.2004Insured complainant, owner of Tarini General Store had taken a Shop Keeper’s InsurancePolicy from New India Assurance which covers the Money in Transit Risk. On 8th July2002, Insured complainant collected Rs. 20,643 from three retailers out of which hedeposited Rs. 10,000/- in S.B.I Jaipur Road Branch & carried balance amount in his pocket.He also withdraw sum of Rs. 25000/- from SBI & subsequently collected a sum of Rs.15000/- from another retailer. He kept Rs. 40,000/- cash in his motor cycle basket. Hestarted his journey to Canara Bank, Jaipur Road for deposition of that money. On the wayhe parked his motor cycle in front of Sandhu Petrol pump & spent some time with owner.When he returned found the cash was stolen. F.I.R. was lodged u / s 379 of I.P.C & finalreport stated the fact true but no clue, Surveyor found the case is genuine. Insurerrepudiated the claim on the ground that Money in transit coverage was granted onlybetween two places not so many transactions. Insurance Ombudsman set aside therepudiation on the ground that the correct interpretation is that Money in transit policyprovides cover for loss of money in transit between any two places but not the second perilbetween subsequent two places. It never restricts the cover in between insured premises &bank & vice versa. Insurer is directed to pay Rs. 40,000/-Bhubaneswar Ombudsman CentreCase No. I. O. O. / BBSR / 11 - 441Shri Debasis PadhiVs.Oriental Insurance Co. Ltd.Award Dated 18.11.2004Insured complainant insured his diagnostic equipments under Office Umbrella Policy ofOriental Insurance Co. Ltd. on 25-02-2001 on XOMAT - 1000 Kodak Auto Processor gotdamaged. Insurer repudiated the claim on the ground that damage machine was notcovered under the policy. As per the policy schedule and proposal XOMAT - 1000 did notfind its Place in the list of equipments. Insured complainant exhibited the list of equimentssubmitted to insurer for insurance included that damaged machine which bears the seal &signature of insurer. More over sum insured mentioned in the policy corroborates the priceof damaged machine which is an integral part of X-Ray machine. Hon’ble Ombudsmandirected the insurer to pay Rs.89,074/- to the complainant within 15 days of consent of insured complainant.Bhubaneswar Ombudsman CentreCase No. I.O.O. / BBSR / 11 - 465Shri Dipti Ranjan MohapatraVs.United India Insurance Co. Ltd.Award Dated 03.01.2005Insured complainant had taken a Shop Keeper’s’s Insurance policy for the stocks (homeappliances) of his shop from above insurer. Due to torrential rain the water accumulated onthe roof of the shop and roof collapsed due to its weight on 25-7-2003 damaging the stockskept therein by the impact of the falling debris and water. Insured complainant lodged aclaim for the compensation. The surveyor has assessed the loss for Rs. 35,000/-. Insurerrepudiated the claim on the ground that the proximate cause of loss was not due to

operation. of any insured peril. During the hearing the complainant contended that impactdamage is one of the perils covered under Sec-I of the policy and damages having beencaused due to impact of collapsing roof. Insurer contended that impact damage does notinclude destruction caused to insured property by hitting of debris of a collapsing roof. Asper lexical meaning of the term “Impact Damage” means the damage caused by force withwhich one object hit another. In this case the debris of collapsed roof and wateraccumulated on the roof hit the insured properties kept in shop. The definition of impactdamage given in All India Fire Tariff can not be imported to the contract of Shop Keeper’sInsurance. Insurer is directed to pay Rs. 25,000/- within fifteen days of consent given byinsured complainant.Bhubaneswar Ombudsman CentreCase No. I.O.O. / BBSR / 11 - 460Shri Sitaram PandaVs.The Oriental Insurance Co. Ltd.Award Dated 16.02.2005Insured complainant has filed this complaint under Rule 12(1)(b) for partial repudiation ofhis claim by Oriental Insurance Co. Ltd. Insured complainant insured his cloth shop underShop Keeper’s policy for sum insured of Rs. 10,00,000/- On 8-4-2002 fire broke out due toelectrical short circuit and damaged the stocks worth Rs. 12,79,480/- as claimed bycomplainant. The surveyor has assessed the loss for Rs. 477095/- where as the insurer hassettled the loss forRs. 3,52,998/-. Though the complaint had received the amount due to financial constraintsbut preferred the complaint in this forum.During the Hearing the complainant has stated that surveyor ignored the documents shownby him in order to reduce the assessment which was further reduced by the insurer andpointed out the lacunae in the loss assessment.In presence of surveyor, complainant and Insurer the loss has been worked for Rs.4,63,072/- On negotiation both the parties confirmed their satisfaction regardingassessment. Hon’ble Ombudsman directed the Insurer to pay balance of Rs. 1,10,000/-within 15 days of receipt of consent letter from the complainant.Chandigarh Ombudsman CentreCase No. GIC/63/OIC/11/05Shri Suraj BhanVs.Oriental Insurance Co. ltd.Award dated: 3.12.2004FACTS : The complainant purchased two buffalos for Rs. 16000 each on 28.10.02 byraising loan from PNB branch Jalbera, and were insured from DO Ambala w.e.f. 29.11.02.One of the buffalos died in the night intervening between 16/17th Dec., 2002 afterswallowing a sharp edged nail. The complainant immediately informed the Branch Managerof the bank and pursued the matter with the insurer regarding settlement of claim but it wasof no avail. The claim was repudiated on the ground that the buffalo had died due to a preexistingdisease. The complainant contended that the buffalo was not sick at the time itwas purchased and was duly medically examined.FINDINGS : M/s Royal Associates (Investigators) deputed to ascertain the cause of deathreported that as the buffalo was sick for 20-25 days prior to its death, the buffalo may havebeen sick at the time the insurance cover was taken. It was contended that the claim wasrightly repudiated under exclusion clause 7-B which reads “death or loss due to accidentor disease contracted prior to risk is not covered under the policy”. It was noted that the

insurance cover was given on the basis of health certificate dated 28.10.02. The animalwas examined by the veterinary doctor on 4.12.02 and again on 13.12.02, soon after thedate of commencement of risk. The complainant contended that he would not purchase asick animal by raising loan from the bank, as his livelihood depended on sale of milk. Theinvestigator had only suggested that post mortem report be checked to ascertain the causeof death.DECISION : Held that the investigator had left the issue open ended and a decision wasrequired to be taken after examining the PMR. As the insurer could not establish that thecause of death as indicated in the PMR was an ailment which pre-dated the inception of thepolicy, the repudiation was not on sufficient and valid grounds and hence not in order.Therefore, the claim was ordered to be paid.Chandigarh Ombudsman CentreCase No. GIC/58/UII/11/05Shri Gulshan Rai MunjalVs.United India Insurance Co. ltd.Award dated: 3.12.2004FACTS : The complainant purchased on 21.5.03 a mobile phone for Rs. 5200 on SBI creditcard no. 40006661037972481. The State Bank of India entered into a tie up with the UII,New Delhi to offer some insurance benefits to the card holders, including coverage of lossof any item purchased on credit card within 90 days from the date of purchase. Thecomplainant lost the mobile while returning from office on 3.6.2004. An FIR was lodged on5.6.2004. The complainant approached UII to make good the loss suffered by him. Theclaim was, however, repudiated on the ground that it was not tenable under the policyconditions, as only loss of item within the residential premises was covered.FINDINGS : The complainant felt that he should have been informed at the preliminarystage that the claim was not tenable as he had intimated that the loss occurred while hewas returning from office. He should not have been asked to submit various documents.Besides limiting the coverage of risk only to loss within the residential premises wasunreasonable in the case of mobile phones, as these are meant to be carried on person bythe owner.DECISION : Held that the repudiation of claim was in order in terms of policy conditions.However, the decision should have been conveyed without seeking any documents as thecomplainant had intimated that the mobile was lost outside residential premises. It wouldhave saved the complainant considerable botheration. The expectations of the complainantwere unnecessarily raised by sending the claim form and requiring him to furnish otherdocuments, which proved to be an exercise in futility. Since the complainant was made toundergo avoidable inconvenience and also felt harassed, token compensation of Rs. 500on ex-gratia basis was ordered to be paid to the complainant.Chandigarh Ombudsman CentreCase No. GIC/78/NIA/11/05Major Gen. Kuldeep Singh BajwaVs.New India Assurance Co.Award dated: 30.12.2004FACTS : Major General Kuldeep Singh Bajwa secured a Good Health policy for his son anddaughter-in law from BO Chennai through CITI Bank. The policy was effective from1.12.2001. His daughter-in-law was taken ill and hospitalized in Ram Saran Das Kishori Lal

Charitable Trust Hospital for renal allografting from 26.2.2002 to 15.3.2002. He submitted amediclaim for Rs 1,47,323. It was repudiated on 23.6.2003 on the ground that the treatmentpertained to a pre existing disease, since hers was a known case of hypertension.Aggrieved by the decision, he filed a complaint contending that his daughter-in-law did nothave any symptoms of the disease earlier, nor was she aware of it.FINDINGS : The perusal of the discharge summary revealed that the insured had a historyof hypertension since November, 2001 and was a known case of polycystic kidney.Besides, claims relating to congenital internal diseases are not entertainable during firstyear of the policy under exclusion clause 4.3 which stipulates that “ during the first year ofthe operation of insurance cover, the expenses on treatment of diseases such as cataract,benign prosthetic hypertrophy, hysterectomy for menorrhagia or fibromyoma, hernia,hydrocele, congenital internal disease, fistula in anus, piles, and sinusitis and relateddisorders are not payable.”DECISION : It was established on the basis of documentary evidence that the claimant wasa patient of H.T since November, 2001, which is a direct complication of polycystic kidney.The discharge summary and the medical certificate issued by the Consultant Nephrologistalso confirmed that it was a pre-existing disease. Held that the claim was, therefore,rightly repudiated under the terms and conditions of the policy. The claim was otherwisealso not admissible under the exclusion clause 4.3 of the policy as it pertained to acongenital disease during the first year of the policy.Chandigarh Ombudsman CentreCase No. GIC/73/NIA/11/05Salil AggarwalVs.New India Assurance Co.Award dated: 31.1.2005FACTS : Shri Salil Aggarwal had taken a Adhikari Suraksha Kavach policy from BO,Gurgaon for the period from 18.1.2002 to 17.1.2003, which inter alia, covered a laptop. Thelaptop was stolen from his car on 9.1.2003. He lodged an FIR and informed the insurer. Asurveyor was deputed who assessed the loss at Rs. 31,500 net of excess clause. Aninvestigator appointed to ascertain the genuineness of claim concluded that the claim wasnot payable as the complainant had no insurable interest. The laptop was purchased byMrs. Vinita Aggarwal, complainant’s wife from Oxshott Consulting India Private Ltd. on22.4.2002, while the insurance cover was, however, in the name of Shri Salil Aggarwal.The claim was, therefore, repudiated vide letter dated 12.12.2003.FINDINGS : The laptop originally belonged to M/S Oxshott Consulting Private Ltd. wherethe complainant was employed as a Director. The company was wound up and the laptopwas sold to his wife Smt. Vinita Aggarwal. The laptop did not belong to him, but he was itsuser. He clarified this to the Development Officer who issued the covernote. He wasassured that the risk against loss or damage was covered for the user of the laptop. Hewas not aware of the policy limitations as the policy document was not issued to himdespite request. The insurer was advised by the legal counsel that mere possession oflaptop did not create an insurable interest for the claimant. As per terms and conditions ofAdhikari Suraksha Kavach Policy, the damage is indemnified only in respect of a laptopbelonging to insured and in his personal custody while anywhere in the world for purpose ofhis business or profession.DECISION : Held that having regard to the understanding given by the Development Officerin the matter of appropriateness of the policy, the fact that the policy was issued withoutverifying the question of ownership and insurable interest and that the terms and

conditions of the policy were not furnished to the complainant, repudiation of claim on thegrounds of absence of insurable interest was not justified.Ordered that the claim be processed on merits without raising the question of insurableinterest at a belated stage.Chandigarh Ombudsman CentreCase No. GIC/186/NIC/11/05Shri Kailash ChanderVs.National Insurance Co.Award dated: 10.2.2005FACTS : Shri Kailash Chander took a Shopkeepers Policy for the period 25.3.2004 to24.3.2005 which inter-alia covered stocks of his kiryana shop for sum insured of Rs. 3 lacs.He suffered loss on account of fire on 15.4.2004. He informed the insurer and a surveyorwas deputed who assessed the loss for Rs. 91,477. However, he was paid only Rs.66,825. He complained that he had submitted relevant documents such as bank statement,inventory list for six months and the balance sheet for 12 months in confirmation of thestock level of over three lac rupees. His representation for reconsidering his claim to theextent of Rs.3 lac since on the day preceding the fire the stock value exceeded Rs. 3 lac,was rejected.FINDINGS : The loss was assessed at Rs. 91,477 and after mandatory deductions andapplying average clause and deducting Rs. 211 on account of reinstatement premium andRs. 1000 for the value of sound stock, the claim was settled for Rs. 66,825. Thecomplainant failed to produce any reliable documentary evidence with regard to the stockof goods at the time of fire, as he did not maintain stock register, cash book, ledger etc.He only furnished a copy of trading account statement for availing bank limit, which showedthe goods stock to be of the value of Rs. 3,92,500/-, whereas he had taken cover for Rs. 3lacs. Therefore, average clause was applied by the insurer and loss was reducedproportionally. However, in the absence of any reliable evidence with regard to the stock ofgoods in the shop, the surveyor made his own assessment of the possible value of goodsdestroyed in fire keeping in view the location, quantity of goods stored and the shop areaetc. The average clause was not invoked by the surveyor.DECISION : Held that in the absence of reliable evidence with regard to value of the goodsin the shop at the time of fire, the average clause could not be applied on the basis oftrading account statement. In the given circumstances, only acceptable estimate of losswas the assessment by the surveyor who inspected the premises soon after the occurrenceof the incident. Since the same was accepted, any other fragile evidence cannot be reliedupon to reduce the assessed loss further. In the given circumstances, physical verificationby the surveyor was the most reliable alternative for assessing the actual loss. Therefore,the claim was ordered to be settled as per the loss assessed by the surveyor lessreinstatement premium Rs. 211 and salvage value Rs. 1,000. The insurer was held to beliable to pay the balance amount.Chandigarh Ombudsman CentreCase No. GIC/85/OIC/11/05Dr. Yoginder PaulVs.Oriental Insurance Co. Ltd.Award dated: 11.3.2005FACTS : Dr. Yoginder Paul took a house holder’s policy for the period 14.8.2002 to13.8.2003. His house was burgled on the night intervening between 6/7 July 2003. Heinformed local police authorities on 7.7.03 and requested for spot survey and registration of

Chennai Ombudsman CentreCase No. 11.03.1166 / 2004 - 2005Mr. C. Saji DavidVs.National Insurance Co. Ltd.Award Dated 29.10.2004Mr. Saji David insured his household articles since 1993 onwards. The Insurer sent arenewal notice for the premium amount of Rs. 2,483/- towards of the policy for the period25.01.2003 to 24.1.2004. Accordingly the premium was paid. The Insurer sent the policyaltering the sum insured under different sections and sent a refund voucher for Rs. 407/-.The Insurers also gave the cheque towards refund.On 31.5.2003, when the insured was abroad, some culprits had broken the door and stolenthe jewellery, dresses, cash, etc. The matter was reported to Police by the neighbours.After returning to India, the insured made a supplementary complaint to the Police on6.6.2003 as per which the value of jewels lost was Rs. 74,400/-. The surveyor released hisreport on 3.3.2004 recommending settlement of the jewellery claim for Rs. 17,000/-, as thesum insured for jewellery was Rs. 17,000/- under the policy.A joint hearing was conducted. The insured said that the reduction of sum insured underjewellery section to different sections under the policy was done without his knowledge. Hefurther stated that in the year 1995 - 1996, when the sum insured was increased from Rs.80,000/- to Rs. 1,12,000/-, item wise valuation was done by the valuer. To the question bythis Forum as to why he did not study the policy on receipt, he stated that he did not noticethe same till the claim arose. He alleged that some items covered under Section I havebeen changed to Section V and VI without his consent and premium was adjusted. Sincethe refund cheque did not contain any covering letter, he presumed that the Insurer isrefunding the premium under the provision of no claim bonus.The Insurer said that they have decided to restrict the sum insured to Rs. 17,000/- as therewas no valuation report in the underwriting file. To the question as to whether the Companycalled for the valuation certificate from the insured in writing, the Insurer had answered innegative. At the time of sending the refund cheque also, the Insurer did not send anycovering letter. When the Insurer added new items like plate glass, etc., under the policy,the Insurer could not give any answer under whose advice these were included. They alsoclarfied that no separate proposal was taken for inclusion of new items. When asked aboutthe calculation sheet, the Insurer stated that they did not have it in file.The series of events showed how the events would have taken place. The basisresponsibility lied with the Insurance Company to directly write to the insured calling forrequirements and communication in writing would be the correct and acceptable practice. Itis not clear how the Insurer distributed the sum insured under one section to other sectionsBy all the above actions, the Company had acted in a unilateral manner. This case wasreferred to the Vigilance Department of the Insurer for further investigation. As the policy inquestion was issued for Rs. 17,000/- for jewellery value, it is not appropriate to pass anaward more than the sum insured under the policy by this Forum and accordingly the casewas dismissed.Chennai Ombudsman CentreCase No. 11.02.1193 / 2004 - 2005M/s. Ambika JewellersVs.The New India Assurance Co. Ltd.Award Dated 16.11.2004Shri R. Mohanlal, the sole proprietor of M/s. Ambika Jewellers insured his jewellery shopwith The New India Assurance Company Limited for the period 12.08.2002 to 11.08.2003

Chennai Ombudsman CentreCase No. IO (CHN) / 11.8.1158 / 2004 - 05Shri C. S. MuralidharanVs.Royal Sundaram Alliance Insurance Co. Ltd.Award Dated 26.11.2004The complainant, Shri C. S. Muralidharan had availed a Health Shield Policy for the period20.8.2003 to 19.8.2003. He was hospitalised on 8.2.2004 for Colevesical Fistula. His claimfor reimbursement of medical expenses was repudiated by the insurer on the ground thattheir medical specialist had opined that the diagnosed ailment was a complication of thepre-existing diverticular disease of the colon, which should have existed prior to 20.8.2003.From a perusal of the documents submitted in the case, it emerged that diverticulosis(diverticular disease), which was stated to be forerunner of colevesical Fistula, could notbe found on routine examination and there was no palpable evidence of the same in theinsured prior to November 2003. The insured was asymptomatic till November 2003 and thediagnosis of the disease of Colevesical Fistula was made subseqent to November 2003only. Since pre-exisitence of neither the disease of Diverticulosis Coli nor ColevesicalFistula stood established either by way of symptoms or diagnosis through investigativetests as on the date of inception of the policy, i. e. 20.8.2003, it was held that the insurerwas not justified in repudiating the claim on the ground of pre-existence of the disease.Hence, the insurer was directed to entertain the claim and pay the admissible medicalexpenses. The complaint was allowed.Chennai Ombudsman CentreCase No. IO (CHN) / 11.2.1072 / 2004 - 05Shri Bhagwanji K. MistryVs.The New India Assurance Co. Ltd.Award Dated 15.12.2004The complainant Shri Bhagwanji K. Mistry was covered from 1.12.2000 onwards under theGood Health Policy to City Bank Card Holders. Shri B. K. Mistry was hospitalized ondifferent occasions in the month of February, April and May 2002 for DilatedCardiomyopathy and Coronary Artery Disease. His Claim for reimbursement of the medicalexpenses was repudiated by the insurer on the grounds that the ECG taken in February2002 revealed two old infarcts and the ECHO also showed extensive damage of the hearttissues and hence it was concluded that the insured had heart attack earlier and thereforethe disease was pre-existing.It was observed from the records submitted before the Forum that the insured was recentlydiagnosed for dilated cardiomyopathy and admitted for CAG and subsequently for CABG.The ECG taken in Februry showed ST - T changes in anterolateral leads. Echo suggesteddilated left ventrical mildly dilated left atrium, extensive anteroinferior wall scar.There was also a letter from the examining doctor of Belle - Vue Nursing Home whichstated that the ECG taken on 12.2.2002 was indicative of LAHB with Ant-Int-Ischaemia -the duration of ischaemia cannot be determined by any cardiologist. Further, In the medicalcertificate attached to the claim form, the attending doctor in response to the questionwhether the present ailment was a result of any pre-existing disease, had answered “No”.The insured was covered under the mediclaim policy for more than a year prior to the ECGand ECHO taken in February 2002 which were the basis for concluding that infarction anddamage to the heart tissues / vessel had taken place earlier. The fact remains that theradiological reports only reveal that the damage had taken place at an earlier point of timeand as per the medical opinion of the insurer’s own doctor as well as the attending

physician, the exact date and time of the infarction cannot be determined. It thereforefollowed that the damage could also have taken place any time between the inception ofthe policy on 1.12.2000 and the date of ECG i. e. 12.2.2002 which covered a span of 14months and hence the disease need not be pre-existing. Under the circumstances, it wasconcluded that the damage to the heart vesels, though having taken place initially prior toFebruary 2002 has not been established on evidence to be pre-existing, as per theavailable medical records. It was therefore held that the insurer was not justified ininvoking exclusion clause 4.1.of the policy and the Insurer was directed to settle the claim.The complaint was allowed.Chennai Ombudsman CentreCase No. IO (CHN) / 11.8.1237 / 2004 - 05Shri V. L. VijayaraghavanVs.Royal Sundaram Alliance Insurance Co. Ltd.Award Dated 15.12.2004The complainant, Shri V. L. Vijayaraghavan was covered under Health Shield Policy for theperiod 24.3.2003 to 23.3.2004. He was hospitalised in December 2003 on two occasionsand was diagnosed to have Coronary Artery Disease and Acute IWMI for which a CoronaryBypass Graft was done on him. His claim was repudiated by the insurer on the ground thatthe insured was suffering from Diabetes and Hypertension and the ailment of CAD was acomplication of pre-existing Diabetes and Hypertension prior to the inception of the policyand such severe disease as Triple Vessel Disease warranting CABG could not haveoccurred in just a year’s time and was definitely pre-existing.It was observed from the discharge summary of the present hospitalisation that the patientwas a borderline diabetic - not on treatment and not a hypertensive. There was bio -chemistry report of the Institute of Naturopathy dated 14.2.2003, produced by the insured,which revealed the blood sugar level to be within the normal range and this report wasmade available to the insurer at the time of proposal. The insurer could not submit anyproof to establish that these ailments were pre-existing. Hence, it was concluded that atthe time of proposing for insurance, the insured was not suffering from DM and BP and thecontention of the insurer that CAD was a complication of pre-existing BP and DM was foundnot tenable. As regards the conclusion of the insurer that Triple Vessel disease was alsopre-existing, it was observed that the only noting regarding the history of the presentillness was ‘history of class II Angina since 10 to 15 days. None of the medical recordssubmitted conclusively established that the insured was suffering from caridac problem oreven showed any symptom of the same prior to March 2003.Under the circumstances, pre-existence of neither Diabetes / Hypertension nor any cardiacproblem having been conclusively established to be pre-existing to March 2003, it was heldthat the insurer was not justified in repudiating the claim. The complaint was allowed andthe insurer was directed to pay the admissible medical expenses.Chennai Ombudsman CentreCase No. IO (CHN) / 11.02.1156 / 2004 - 05Mr. Maria SelvarajVs.The New India Assurance Co. Ltd.Award Dated 16.12.2004Mr. Maria Selvaraj the sole proprietor of M/s. Apma Leathers insured his leather processingunit with The New India Assurance Company Limited for the period from 13.7.2001 to12.7.2002 for the stock of raw skin, wet blue, hides, finished leather, semifinished leatherfor a sum insured of Rs. 55 lakhs. On 23.7.2001, some culprits entered the premisesforcibly and stolen 662 number of pieces. The surveyor appointed by the Insurer assessed

the loss at Rs. 5,03,120/- which includes the commission paid by the insured to the sellerto the tune of 300 % on the invoice cost. The Insurer rstricted their liability on the basis ofinvoice cost plus freight (deleting the commission portion) and sent the voucher for Rs.1,57,568/-. The insured objected for releasing the claim voucher for a reduced amount andrequested the Insurer to settle the full amount. He also pointed out that the surveyorapplied an uniform rate of Rs. 760/- per piece whereas the items stolen was finishedleather also and its cost was around Rs. 1,320/- per piece.The insured approached this Forum with a request to consider his claim. A joint hearingwas conducted. With regard to the value of finished leather and the quantity lost it wasnoticed that there was a prima - facie evidence that the insured lost finished leather alsoapart from hide leather. Hence a direction was given to the Insurer to get an expert opinionon this matter and decide the case accordingly.With regard to the commission of 300 % said to have been paid, it was noticed that thesame sum insured was taken under fire and burglary policy. The sum insured of Rs. 55lakhs was not the value at risk on all the days and the value will vary from 0 to 55 lakhs.Just because there was a balance sum insured available, it could not be argued that otherexpenditure relating to procurement of stock were included in the value. The proposal formsubmitted by the insured at the time of inception of the policy did not mention anythingabout the same. It is noted that the purchaser have procured the leather at a lesser invoicecost facilitate the seller to pay a reduced sales tax and the balance was paid by way of acommission by the purchaser. This kind of clandestine transaction should not be basis onwhich the insured raised his demand for the balance amount. Therefore the insurer’s actionof restricting their liability, omitting the commission portion cannot be faulted.Chennai Ombudsman CentreCase No. 11.03.1275 / 2004 - 2005Mr. M. Harichandra RajuVs.The New India Assurance Co. Ltd.Award Dated 4.2.2005Mr. M. Harichandra Raju took a Rasta Aaptti Kavach Policy for the period 27.1.2003 to26.1.2004. The sum insured under Section I (PA cover) was Rs. 1 lakh and under Section II(Medical expenses for bodily injury caused by and arising out of road accident) was Rs. 1lakh. It was reported that when the insured was travelling a pillion rider in his motor cycle,the rear tyre of the motor cycle said to have been burst as a result of which the motor cycleskidded and both the rider and the insured fell on the road. The insured preferred a claimfor the hospitalisation expenses with the Insurer and the same was rejected by them on theground that the medical expenses resulting solely and directly from road accident whichwould normally give rise of third party claim under motor policies / Motor Vehicles Act onlywill be covered.The insured approached this Forum with a plea that the injuries suffered was directly andsolely due to the road accident and the Investigator appointed by the Insurance Companyalso verified and confirmed that the injury sustained was due to accident.The provision under the policy makes the position clear that an individual can be coveredand skidding of vehicle resulting in bodily injury to such an individual will also come withinthe cover offered under the policy. If the policy covers the above risks specifically, then theargument of the Insurer that the insured cannot claim for his own negligence under theRasta Aaptti Kavach policy lost its sanctity. Road accident, which would normally give riseto a third party claim, does not mean that the accident should essentially given rise to athird party claim. The medical records produced by the complainant to the InsuranceCompany and the Investigation Report proved beyond doubt that the accident resulted tothe injury and the the complaint was allowed for a sum insured of Rs. 1 lakh.

Chennai Ombudsman CentreCase No. IO (CHN) / 11.2.1343 / 2004 - 05Mr. RavikumarVs.The New India Assurance Co. Ltd.Award Dated 10.3.2005Mr. Ravikumar insured his personal computer under Electronic Equipment Policy with TheNew India Assurance Company Limited, Coonoor Branch Office for the period from17.6.2003 to 16.6.2004. It is reported that on 2.10.2003, his personal computer (Pentium 2)went out of order. The insured produced an estimate from the repairer for Rs. 16,725/- andinsisted that he is entitled for total replacement of computer. The hard disc, CPU and RAMwere in working condition. The surveyor appointed by the Insurance Company assessed theliability of the Insurer at Rs. 11,925/-. The insured did not agree with the recommendationof the surveyor who demanded replacement of computer with the improved version ofPentium 4. The insured argued that Pentium 2 model and its accessories become obsoleteand hence there is no other go for him than to going for replacing the damage computerwith Pentium 4. The Insurer appointed a second surveyor who assessed the loss at Rs.6,677/-, keeping in mind the replacement of the computer by a better model. A joint hearingwas conducted.The second surveyor, after considering the betterment involved, has applied 50 %deduction for processor and the mother board. This kind of deduction, as worked out by thesecond surveyor, is not envisaged under the policy - because the surveyor assessed onlyfor the loss of some individual parts and not treating the loss as total loss for the unit as awhole The insurer’s explanation for sending the second surveyor is totally unacceptable.Section I of the policy makes the position clear that the Insurer has the option for paymentof loss in cash. In other words, the insured will have no option to insists the Insurer thatthey must adopt only a particular method of loss assessment. The insured decided to go infor a new model as the old model became obsolete and parts were not available in themarket. Further, the processor, mother board and modem only were damaged and not otherparts. Hence, this forum come to the conclusion that this loss will not fall under “total lossof the unit category” - but to be treated as partial loss only. Hence direction was given tothe Insurer to process the claim as per the recommendation of the first surveyor along withthe service charges of Rs. 900/- paid for monitor, which was documentarily proved by theinsured.The surveyor applied the excess provision of Rs. 2,500/- treating the claim as total loss.This was also questioned by the insured. As the claim is considered under the partial losscategory, the correct excess to be deducted would be only Rs. 1,000/- as per policycondition. Accordingly, the claim payable was calculated.Chennai Ombudsman CentreCase No. IO(CHN) 11.4.1362 / 2004 - 05Mrs. Savithri VasudevanVs.United India Insurance Co. Ltd.Award Dated 15.03.2005Shri Vasudevan has availed House Holders insurance Policy for the period from 17.11.2002 to 16.11.2003 with United India Insurance Company Limited. Under Section III ofthe policy (All Risk), the insured covered jewellery and valuables for a sum insured of Rs.2,23,600/- and one of the items covered was Navarathinam ring for Rs.13,000/-During the month of June 2003, the insured preferred a claim for the loss of one diamondstone, which was red in the ring. The claim form signed by the party confirmed that thediamond stone in the ring was lost due to theft. The Insurer vide their various lettersrequested the insured of produce a copy of the FIR and missing certificate. The insured

expressed his inability to produce the same from the police authorities. The Insurer finallyrepudiated the claim on the ground that the loss of diamond stone was due to normal wearand tear.A joint hearing was conducted. Indian Penal Code defines the theft as whoever intending totake dishonestly any movable property out of the possession of any person without thatperson’s consent, moves that property in order to such taking, is said to commit theft.During the time of hearing, a specific question was put forth to the complainant about whenand where the diamond stone was lost for which the reply given was that he did not knowabout the same when it happened exactly. Even though there is no direct evidence to provethat the stone was lost due to wear and tear as alleged by the Insurer, it is also to be notedthat it has been proved that the loss had occurred due of operation of an insured peril. Thepolicy conditions stipulate that the insured must produce documents / explanation andevidence to substantiate the claim as the Company may reasonably require. Under thesecircumstances, this Forum could not find fault with the Insurer.Delhi Ombudsman CentreCase No. GI / 309 / UII / 04Shri. Ravinder Kumar AggarwalVs.United India Insurance Company LimitedAward Dated 17.12.2004The complainant was aggrieved by the inadequate settlement of his claim.It was held that after already receiving payment of his claim from the Insurance Companyand discharging the insurance company form any further liability by signing the dischargevoucher (clean), he cannot now rake up old issues. If he thought that the compensationoffered by the insurance Company was inadequate or that the Insurance Company hadbeen unfair to him by not allowing certain expenses legitimately incurred by him, then heought not to have accepted the payment of his claim. He should have come straight to thisForum with his grievance.Delhi Ombudsman CentreCase No. GI / 280 / UII / 04Smt. Shilpa VigVs.United India Insurance Company LimitedAward Dated 09.11.2004Mobile phone set was insured for Rs. 13,300/-. The mobile was stolen. The InsuranceCompany settled the claim for Rs. 6,750/-, whereas, the complainant wanted the full suminsured, namely Rs. 13,300/-. The Insurance Company had settled the claim on the basis ofreport of the loss assessor.The stand of the Insurance Company was upheld. The contact of the insurance is contractof the indemnity and the insured is entitled to compensation only to the extent of financialloss. The financial loss has to be assured on the basis of the market price of the same typeof mobile at the time of theft. If the same type is no longer available in the market on thebasis of more or less comparable model which is available. The complainant cannotdemand the full sum insured as compensation. The full sum insured is only a maximum limitto the indemnity to be provided. The Insurance Company is justified to pay the claim paidas per the report of the loss assessor.Guwahati Ombudsman CentreCase No. NL / NIC / 11 / 126 / 03 - 04 / 2004Mrs. Manju Rajkhowa

Vs.National Insurance Co. Ltd.Award Dated 29.11.2004FACTS : The contention of the complainant that the insured computer and the printer alongwith all accessories and continues to pay the renewal premium which was charged on theoriginal value of the computer. That the computer being damaged she, on advice of thecompany, got it repaired on 6.6.03 at an expense of Rs. 19,250.00 through the dealer. Thatthere was delay in settlement of the claim and finally they offered an amount of Rs. 6,000/-which she refused to accept.Contention of the Opposite party on the other hand is that the claimant is a trained agent ofthe company and she insured her computer at Rs. 1 lakh w. e. f. 27.11.98 to 26.11.99. Thatshe continued to renew the policy sometime at short and some times at long intervals andthe insured / complainant, at her own choice, kept the sum insured at Rs. 1 lakh. That onthe alleged report of the loss, in - house verifier was deputed who assessed the loss at Rs.6,525.00 after application of 50 % depreciation and deduction of compulsory policy excessof Rs. 2,500.00.DISCUSSIONS : It is undisputed that the damage was due to voltage fluctuation as perinspection report of the in-house verifier confirmed by the engineer of the repairer M/sModular peripherals (India) Pvt. Ltd. Notwithstanding, the fact that all the parts replacedwere parts with limited lives, it has not been mentioned anywhere when these parts werepurchased or what was the life of the damaged parts at the time of damage. But factsremain that the cause of damage was voltage fluctuation not the age of the parts. It wasalso not stated in the statement of the opposite party whether at the time of damage of thecomputer the parts with limited life were repaired only or replaced by suprerior one.Therefore, I find the application of 50 % depreciation is not logical and appropriate.Therefore, in my opinion 10 % depreciation will meet the ends of justice instead of 50 %depreciation, on the particular circumstances of the case.DECISION : It is therefore directed that the opposite party will settle the claim by deductionof 10 % depreciation and pay interest as ordered.Guwahati Ombudsman CentreCase No. 11 / 002 / 0026Shri Apurba BarmanVs.New India Assurance Co. Ltd.Award Dated 01.03.2005FACTS : An employee of Oriental Insurance Co. Ltd. namely, Shri Apurba Barman lodgedthis complaint against New India Assurance Co. Ltd. stating that on 01.06.2001 rain - waterinundated / flooded the dwelling house of the complainant and he lodged a claim of Rs.29,150/- on the basis of report of the surveyor. An amount of Rs. 6,678/- was paid on01.08.03 which he received under protest.The insurer / opposite party would submit that on getting the report of the damage, Mr.Pranjal Bhagawati was appointed as surveyor to assess the loss. The surveyor submittedhis report assessing the loss at Rs. 6,678/- and discharge voucher was signed by theinsured as full and final settlement and accordingly cheque no 2685 was issued on31.07.03.There is no dispute regarding the flood, insurance cover and about the receipt of the sumassessed by the surveyor. The only objection is that the quantum assesed was not proper(Evidence discussed)It is difficult under the facts and circumstances of the particular claim to assess the actualamount of loss. But then, in view of the fact that goods / articles remained under the water

only for a day or two and the extent of damage may not be serious and claiming Rs. 29,150may not have justification.It is directed that the opposite party will pay further a sum of Rs.1,200/- (inclusive of interest) to the claimant and on payment of which it will be treated asfull and final settlement of the entire claim provided the claimant sends his letter ofacceptance.Kolkata Ombudsman CentreCase No. 205/2/NL/2003-2004Smt. Uma Banerjee &Shri Amarendra Kr. BanerjeVs.United India Insurance Co. Ltd.Award Dated 25.02.2005Facts & Submisstion The Complainant’s Nokia 3310 Mobile phone was insured under aSpecial Contingency insurance Policy. The Said phone was stolen from the purse of Smt.Banerjee and a claim was filed. The insurance company repudiated the claim on the groundthat the perils covered under the policy were ‘Burglary/Fire and allied Perills’ and, so theftwas not covered. Accordingly, the claim was repudiated stating that the cause of loss i.e.‘theft’ was not falling within the purview of the policy. The Complainants contested thedecision stating that in the proposal form he included the word ‘misfortune’ but the samewas omitted from the policy due to error of the typing clerk.,Held : In the Proposal from against “perils to policy was insured covering “Burglary Cover,Fire and allied perils”. Therefore, going by the policy coverage, theft claim would fallbeyond the purview of the same. Since a copy of the policy was available with thecomplainants, they must have been aware of the scope of cover. It is not mandatory thatthe insurance company would accept every request in the proposal form and, therefore, itwas not automatic that the terms “misfortune” was agreed to be covered. In thecircumstances, repudiation was upheld.Kolkata Ombudsman CentreCase No. 457/21/008/L / 11/2004-2005Shri Buddhadeb SahaVs.OM Kotak Mahindra Life Insurance Co. Ltd.Award Dated 18.03.2005Facts / Submissions Shri Buddhadev Saha had a policy no. 58338 with Om KotakMahindra (L). Shri Saha paid his 5th Qly. Premium (due 28.03.04) by cheque dt 10.03.04drawn on SBI. The Cheque was presented by City Bank, Chowringhee Branch, throughclearing system and paid by SBI on 24.03.2004. But Om Kotak Mahindra Life Insurance Co.Ltd did not issue any receipt against this premium. Moreover, informed the L.A. vide letterdt 18.05.04 that the policy had lapsed on account of non-payment of premium due on28.03.04. On enquiry, Shri Saha was informed that the Pol. No. was written worngly on thecheque so the amount was not adjusted. However after 26th July 2004, OKMLICL issuedthe premium receipt for the said qly. Premium (28.03.04) giving the credit from 10.06.04though the premium was paid well in advance of the due date of premium. Shri Sahaimmediately objected this vide letter dated 02.08.04. He also furnished the Xerox copy ofthe said cheque which clearly showed that there was no mistake in writing the Pol. No. andthe date of the payment of cheque.Since Shri Saha lost faith and confidence on OMKMLICL and sought relief for :i) Full refund of five premiums i.e. Rs. 13,146.75 paid by him;

ii) Income Tax benefit under Sec. 88 CCC since he could not produce the premiumdeduction receipt (28.03.04);iii) Interest on Rs. 2630/- from 24.03.04 to 10.06.04 and relief for the mental torture thatthe he suffered on account of the attitude of OMKMLICL.The Insurer (OMKMLICL) stated that due to punching error the premium of Rs. 2630/- (due28.03.04) was credited against the Pol. No. 55338 instead of the complainant’s Pol. No.58338 and so the lapsed letter was generated and issued to Shri Saha on 18.05.04.However, When the error came to the light of the Insurer, rectified the same afterdiscussing the matter with Shri Saha over phone and vide letter dt. 03.09.2004. The Policywas continued to be in force.But later on due to non payment of the Qly. Premium due 28.06.04 the policy was lapsed.So it was clear that the policy was lapsed due to non-payment of Qty premium 28.06.04and not for premium due 28.03.04. They also admitted the deficiency in service on theirpart but it was more a fault in the “System” rather than any deliberate human negligence.In course of hearing arranged on 18.03.05, Shri Shah expressed his total lack ofconfidence and faith in the Insurer and rejected the proposal of the Insurer or continue withthe policy. On the other hand the Insurer expressed the circumstances under which thethings happened. The Insurer admitted their deficiency in rendering service to the P.H. butat the same time explained that it was more a fault in the system rather than any deliberatehuman negligence.Held The Facts stated by the complainant and the clarifications cited by the Insurerwere considered carefully. The explanation give by the insurer was not convincing enough.It was a clear of a deficiency in rendering service on the part of the insurer for which thecomplaint must be compensated.The Insurer (OMKMLICL) was directed to make the following payments within 15 days fromthe receipt of consent letter from the complainant.i) Refund of 5 premium amount amounting to Rs. 13, 146.75.ii) Interest for the delay in giving credit to the premium of Rs.2630/- for the period from24.03.04 to 10.06.04. Interest is to be calculated at a rate 2% above the bank rateduring the period of default;iii) Loss of benefit on account of rebate under Section 88 and 80 CCC of the IT Act, 1961subject to actual calculations;iv) For mental torture and harassment, a token relief of Rs. 2,500/-.Kochi Ombudsman CentreCase No. IO / KCH / GI / 11 - 002 - 018 / 2004 - 05Shri A. P. SreejithVs.New India Assurance Co. Ltd.Award Dated 03.11.2004The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules 1998 arose fromrepudiation of Death claim under Pravasi Suraksha Social Welfare Scheme - Certificate No.47 / 760901 / 80041 issued by the respondent. The complainant’s brother, the policyholder,had an accidental fall and he succumbed to his injuries while he was in Lebanon. Thecomplainant was the nominee under this policy. The respondent despite Lawyer Noticedeclined his claim for death benefit. His appeal to consider his claim in full to theGrievance Cell of the Insurer was of no use. Aggrieved by the decision of the respondenthe had approached this Authority to reopen the case and award the amount in full.The Insurer contested that the actual cause of death could not be ascertained from thedocuments submitted by the claimant. It can be due to an accidental fall or an intentionalsuicide. The father of the deceased gave contradictory versions to the insurer. Thecomplainant did not co-operate with the insurer by submitting the required documents toprove that death was due to an accident. As such they were unable to settle the claim.

Taking into consideration all the records available in the file and also the contentions of theparties concerned, the Ombudsman ruled that the Insurer could not take a decision forwant of satisfactory proof as to the cause of death. In the absence of any concreteevidence to prove otherwise, the cause of death can be attributed to accident. Thecomplainant is entitled for the amount as per the policy conditions. Setting aside thedecision of the respondent, this Authority directs the Insurer to release the sum insuredwithin 15 days from the date of receipt of this order.As for his claim for interest, this Authority does not find any justification to allow hisprayer, as he was also equally responsible for the delay in taking a decision on his claim.In the above premises the complaint is disposed of as above.Kochi Ombudsman CentreCase No. IO / KCH / 11 / NIC / 22 / 2004 - 05M/s Kerala StateCo-op Rubber Marketing Federation LtdVs.National Insurance Co.Ltd.Award Dated 16.11.2004Consequence of partial repudiation and adjustment of claim amounts for alleged short fallin insurance premia by the Insurer under two separate claim – one relating to a flood in thegodown of the insured and the other in relation to a burglary in a separate godown. Theinsured had claimed Rs. 7.74 lakhs for both the claims together. However, the surveyors ofthe Insurer had assessed the claim at Rs. 2,15,964/- only. Even this amount of Rs.2,15,964/- was not paid to the complainant by the Insurer stating that there was a short fallin the premium collected by them earlier and so the amount was adjusted towards the saidshort fall. On a perusal of the records, it was found that the Insurer had originally underquoted the rate so as to secure the business, which resulted in a complaint by anotherInsurer before the Tariff Advisory Committee, and the TAC had asked the respondentcompany to set right the mistake. Obviously, the complainant was not responsible for themess created by the Insurer and there was no meaning in asking the complainant to makegood the short fall in an as much the Insurer had done it intentionally as proved by thecircumstances. Consequently, the Insurer was asked to settle the claim to the complainantas computed by the surveyors and suffer the shortage of premium themselves as thecomplainant was not responsible for the muddle created by the Insurer.Kochi Ombudsman CentreCase No. IO / KCH / GI / 11-002-037 / 2004 - 05Shri K. V. SebastianVs.New India Assurance Co.Ltd.Award Dated 19.11.2004The Complaint under Rule No. 12(1)(b) read with Rule 13 the RPG Rules, 1998 relates tothe repudiation of a Marine – Hull claim by the Respondent Insurer. The Vessel MFVKUNNEL was insured with the respondent and during the period of insurance coverage, itwas capsized in the rough sea near Chellanam on 03.04.2002. The Insurer repudiated theclaim invoking a number of technical points like (1) the rules regarding regulation andlicencing was violated (2) the vessel was altered and fitted with an engine after insurance(3) the fitting of the engine after the insurance was not registered with the Fishingauthorities etc. However, on verification of the records, it was clear that the Complainanthad informed the Insurer about fitting of an engine and the Insurer’s surveyor hadinspected the vessel and certified it as sea worthy with the Engine No. etc. duly quoted inthe report. The surveyor had also given a valuation of Rs. 6,00,000/- for the vessel (Rs.3,00,000/- for the Engine + Rs. 3,00,000/- for the other accessories). Now when a claim

had arisen, the, Insurer was troubling a semi-literate person with all technical requirementsabout which they could have enlightened him when the vessel was inspected by theInsurance Surveyor after the engine was installed. However, ignorance being no excuse inlaw and some contributing negligence having been found on the complainant also, theclaim was allowed as Ex-gratia (non-standard) to the extent of Rs. 2,00,000/-.Kochi Ombudsman CentreCase No. IO/KCH/GI/11/NIA/51/2004 - 05Ms. Zareena Akbar AliVs.New India Assurance Co.Ltd.Award Dated 02.12.2004The Complaint under Rule No. 12(1)(b) read with Rule 13 the RPG Rules, 1998 relates to aGroup Policy Covering member of Asianet Satellite Communications Ltd, which promiseda sum of Rs. 50,000/- on the death of a member during the currency of the policy. Theinsurance was arranged through the Respondent Company. The Insured Shri Akbar Ali diedin a road traffic accident on 21.01.2003. The claim was rejected by the Insurer for thereason that the subscription of late Akber Ali was in arrears for about 8 months as on thedate of his death. As per the enrolment form received by the Insurer on 20.9.2003, theSubscription covering a period of 8 months up to August 2003 was sent to the Insurer inone lot. The accident being on 21.01.2003, the enrolment form as well as the remittance ofsubscription was received only the date of death of Shri Akbar Ali and the Insurer has noliability under the Policy. Thus the complaint having been found devoid of merits wasdismissed.Kochi Ombudsman CentreCase No. IO/KCH/GI/11-005-054/2004 - 05M/s Popular Vehicles & Service LtdVs.Oriental Insurance Co.Ltd.Award Dated 06.12.2004The complaint under Rule No. 12(1)(b)read with Rule 13 the RPG Rules, 1998 was inconsequence of partial repudiation of claim by the Insurer. The insured had claimed Rs.145565.69 as compensation for the damage he had sustained. However, the Respondenthad allowed only Rs. 1,00,755/- disallowing Rs. 11195/- being the profit margin. Thecomplainant approached this Forum praying to reopen the case and allow the towingcharges and other expenses incurred by them in full.The Insurer contented that as per the policy conditions the maximum amount allowable astowing charges is Rs. 2500/- and they have allowed it in full. As the popular Automobiles,Trichur is sister concern of the complainant, they have deducted Rs. 11,195/- from thegross amount payable as the profit margin.Taking into consideration all the records available in the file and also the contentions of theparties concerned, the Ombudsman ruled that the Popular Automobiles and PopularVehicles & Service belong to the same person, the accounts are kept separately and theirassets and liabilities are not interchangeable. As such the Respondent’s action indisallowing profit margin of Rs. 11195/- is untenable. Therefore, partially setting aside thedecision of the Insurer this Authority directs the respondent to pay Rs. 11,195/- inadditional to Rs. 1000/- already agreed to by them.Kochi Ombudsman CentreCase No. IO/KCH/GI/11-005-068/2004 - 05Shri A. George

Vs.Oriental Insurance Co.Ltd.Award Dated 13.12.2004The complainant under Rule no. 12(1)(b)read with Rule 13 of the RPG Rules, 1998 is as aconsequence of repudiation of a marine Insurance claim by the respondent insurer. Thecomplainant had insured his fishing vessel MFV RANISHMON with the insurer and on18.11.2002 at about 4.30 a.m. an unknown vessel is said to have collided with the insuredvessel and it sank into the sea. The insurer had conducted two investigations into the caseand the investigators were unable to agree with the contentions of the complainant.Moreover, it is said that the crew members who were trapped in the sea water were in thesame condition for 13 long hours. But, as per the medical certificate, none of them hadsustained any disorder except minor aches and pains which again unacceptable to theDoctors whose opinions were called for . Most probably, if it all the collision had takenplace, the Serang and crew members were presumably asleep at the material time andtherefore they had violated the Watch and warranty clause of the policy. The Serang of thevessel also presumably had no certificate of competency. Apart from everything else therewere ever –so may contradictions in the statements furnished by the complainant and thecase was very suspicious. In these circumstances, the action of the insurer in repudiatingthe claim was upheld by this Forum.Kochi Ombudsman CentreCase No. IO / KCH / 81 / 11-02-072 / 2004-05Shri G. R. NairVs.The New India Assurance Co. Ltd.Award Dated 14.12.2004The complaint under Rule No. 12 (1) (b) read with Rule No. 13 of the RPG Rules 1998 wasin relation to partial repudiation of a claim House Holder’s Insurance Policy No.487607020564 held by the complainant. The Insurer had agreed to settle the claim (arisingout of a Burglary) to the extent of Rs. 12,382/- only. On mediation by the InsuranceOmbudsman, the insurer had agreed to settle the claim at Rs. 17,500/- and the dispute wascompromised between the parties.Kochi Ombudsman CentreCase No. IO/KCH/GI/11/NIA/39/2004 - 05Shri K. AsokanVs.New India Assurance Co.Ltd.Award Dated 16.12.2004The complaint under Rule No. 12(1)(b)read with Rule 13 of the RPG Rules, 1998repudiation of a Marine-Hull claim by the insurer. The complainant had insured his fishingboat MFV Shivasakthi with the respondent company for a sum insured of Rs. 3.75 lakhs.According to the complainant, while conducting fishing operations near Chettuva on12.6.2001, the sea became rough with wind and rain. Huge waves engulfed the vessel andthrashed it against sand-heap resulting in the total loss of the Vessel. The insurerrepudiated the claim on the plea that the complainant had committed breach of the tradingwarranty attached to the policy which stated that “Warranted vessels were laid up between1st of June and 15th August”. There was also a dispute in relation to belated payment of aninstallment premium. The mishap had occurred on 12.6.2001 i.e., during trawling banperiod warranted in the policy. The complainant pleaded that he was unaware of thetreading warranty and even the policy bond was not delivered to him by the insureralthough the premium was collected. The insurer contended that the policy was released

through the Agent of which there was proof available with them. In the copy policy, it wasfound that the monsoon lay up period was not very specific and the general warranty wasoperative between 1st of June and 15th of August. Besides, it was also seen that the stormsignal issued by the Port authorities was not applicable to mechanized boats. In thecircumstances, although technically there was a breach of the trading warranty, the boat ofthe complainant was a mechanized one and he had lost it entirely which was not disputedby the insurer. In the circumstances, although the repudiation was upheld, the insurer wasasked to pay sum of Rs. 1.5 lakhs to the complainant as ex-gratia treating the claim asNon- standard.Kochi Ombudsman CentreCase No. IO / KCH / GI / 11.005.088 / 2004 - 05M/s Abad Group of HotelsVs.Oriental Insurance Co.Ltd.Award Dated 05.01.2005The complainant under Rule no. 12(1)(b)read with Rule 13 of the RPG Rules, 1998 was inrelation to the refund of excess premium collected by the Respondent Insurer. Thecomplainant was the owner of a Group of hotels at Kochi and Nedumbassery. The Insurercovered the hotels. Though the total Insured amount was Rs. 17,71,50,000/- the Insurerhad insured the policies for a total amount of Rs. 6,68,00,000/- only. The Complainantclaims that they are eligible for the difference in premium as the insurer had charged thepremium for the total amount of Rs. 17,71,50,000/- The Insurer clarified that it was by atechnical error in the computer and the insurance coverage was for the correct amount ofRs. 17,71,50,000/- and as such no amount is refundable. Aggrieved by the decision of theInsurer, the complainant had approached this Authority for redressal of their grievances.Taking into consideration the contentions of the parties and the records available in the filethe Ombudsman ruled that the complainant had preferred the complaint only on31.01.2004, after the period of the So-called policies. Both the parties are equallyresponsible for the mistake as they had not detected it during the currency of the policiesand continued to renew the policies on time. Since neither party has suffered any detrimentdue to the mistakes in the policies issued in January 2003 no damages to be awarded ascompensation. The decision of the Insurer stands and being devoid of merits this complaintstand dismissed.Kochi Ombudsman CentreCase No. IO/KCH/GI/11-005-026/2004 - 05Shri P. SureshVs.Oriental Insurance Co.Ltd.Award Dated 11.01.2005The complainant under Rule no. 12(1)(b)read with Rule 13 of the RPG Rules, 1998 is aresult of repudiation of a claim by the insurer in respect of a Householder’s InsurancePolicy no. 1311/2001 issued by the respond insurer. The complainant had preferred a claimfor Rs. 4885/- as he had already incurred an expenditure of that amount to restore hisrefrigerator insured under this policy. Against this amount the respondent had sanctionedonly a sum of Rs. 1060/-. Aggrieved by the decision of the insurer, the complainant hadapproached this Authority. During personal hearing the dispute was compromised asbetween the parties at the instances of the Insurance Ombudsman and the Insurer agreedto pay an amount of Rs. 1800/- to the Complainant in full and final settlement of the claims.The compromise was duly recorded and thus the dispute was amicably resolved.

Kochi Ombudsman CentreCase No. IO/KCH/GI/11-008-096/2004 - 05Smt. & Shri Ramchandra MenonVs.M/s Royal Sundaram Alliance Insurance Co.Ltd.Award Dated 02.02.2005The complaint under Rule no. 12(1)(b)read with Rule 13 of the RPG Rules, 1998 stems outof repudiation of a mediclaim under the Health shield Plan of the Insurer. The period ofinsurance was from 22.04.2003 to 21.04.2004 and the complainant and family were thebeneficiaries of the scheme. Smt Sreekumari, one of the beneficiaries had undergone asurgery for removal of gall bladder stones at Sudheendra Mission Hospital from27.07.2003 to 02.08.2003 and the insurer citing condition D1 of the policy refused thereimbursement of the expenses i.e. Pre-existing nature of the disease. From the records itwas borne out that the disease was pre-existing although the complainant was not aware ofthe same. This however, did not help the complainant as much as that the exclusion ClauseD1 Excluded all pre-existing health condition whether or not the patient was aware of it.The Apex Courts have also ruled time and again the Insurance contract should beinterpreted in terms of the terms used in the contract and a judicial forum could notattribute expensive meanings to them. However reasonable such interpretation may appearto be. In the circumstances, the Exclusion Clause being very clear, the Insurer was right ininvoking the same for repudiation of the claim although the complainant might not havebeen aware of the problem as it existed all the while in her body. Therefore the Insurer’saction in repudiating the claim was upheld and the complaint was dismissed.Kochi Ombudsman CentreCase No. IO/KCH/GI/11-003-105/2004 - 05Dr. K. RamakrishnanVs.National Insurance Co.Ltd.Award Dated 09.02.2005The complaint before the Insurance Ombudsman arose against the repudiation of a claimpreferred by the complainant before the Insurer against a Traffic Accident Policy. TheComplainant and his wife were covered under the Policy. It was reported that while theywere traveling on the scooter on 24.04.2004, the complainant’s wife fell down from thescooter unconscious and she was taken to the Medical College, Kozikode. Subsequentlyshe was also treated at Jantha Hospital Tanur. The Insurance Company was intimatedabout alleged accident only on 28.07.2004, 3 months after the so-called incident. Therewas no police report also about the alleged accident. Therefore, the Insurer did not believethe contention of accident . From the Hospital records from the Medical Collage, it wasfound out that the diagnosis was “Intra Cerebral Haemorrhage with CVA” with a history ofhypertension and diabetes and Ischaemic Heart Disease. No where in the Medical Collagerecords, there was any mention of the alleged accident. Only in the Tanur Hospital letter anuncorroborated statement existed as “fall”. Moreover, the complainant had also informedthe Insurer that his wife felt giddiness while traveling on the scooter and fell down from thescooter. From the circumstances of the case, it was amply evidenced that thecomplainant’s wife had a variety of diseases and the story of alleged accident could behardly believable. There was no records to substantiate the accident and it appeared to bea make believe story so as to suit the requirements of Traffic Accident Policy. In the abovecircumstances, the complaint being devoid of merits was dismissed.Kochi Ombudsman CentreCase No. IO/KCH/GI/11-004-104/2004 - 05M/s Keltron Elector Ceramics Ltd.

Vs.United India Insurance Co.Ltd.Award Dated 23.02.2005The complainant under Rule No. 12(1)(b) read with Rule 13 of RPG Rule 1998 arose as aconsequences of repudiation of a claim preferred by the Complainant against transit-lossceramic capacitors on the way from Kuttipuram (Kerala) to Allahabad. The insurance Co.had rejected the claim on the plea that the consignments were received by the consigneeintact and the shortage was found only in two cartons out of a total of 5 cartons dispatched.However, the Postal department had issued receipts and for the registered parcels and thecharges collected per carton was Rs. 368/- each corresponding to the declared weight of11 to 11.5 Kgs. Besides, the consignee had called. The Insurance Company at Allahabadas two cartons weighed less and they were opened only in the presence of the insuranceSurveyor. Since the Consignor was able to produce proof to the point that they had sentthe cartons by registered post and as the consignee had disputed parcels only in thepresence of the insurance surveyor, the possibility was that there was some skillful midwaypilferage, which was covered by insurance. Considering the circumstances of the case, thecomplainant was allowed and the insurer was directed to make good the loss of Rs.48,588/- to the consignor.Kochi Ombudsman CentreCase No. IO/KCH/GI/11-011-128/2004 - 05Ms. Helni VargheseVs.Bajaj Allianz Gen.Ins.Co.Ltd.Award Dated 15.03.2005The complainant under Rule No. 12(1)(b) read with Rule 13 of RPG Rule 1998 is in relationto repudiation of an accident claim by the insurer under a policy styled “Pravasi BharathiyaBima Yojana”. The insured as per the complainant had taken out the policy and left forSaudi Arabia, where, at his work place, he met with an accident and died on 13.6.2004.The policy was a special privilege policy issued by the insurer only for the benefit of thosewho needed Emigration check as per the passport and did not cover those who were notrequired to undergo the Emigration clearance. In the case of the insured in the presentcase, although he was required to comply with the emigration formalities earlier,subsequently from 1994 he was in the ECNR category because of confirmed VISA statues.However, in the proposal, he had declared that emigration check was require in his caseand the policy was caused to be issued. The complainant pointed out that the travel agenthad not spelt out the conditions and that her husband had only signed the form. However,in view of the wrong declaration, while the repudiation was upheld, considering theimpecunious situation of the complainant, an ex-gratia of Rs.20,000/- (10% of the sum assured) was allowed and the complaint was disposed of.Mumbai Ombudsman CentreCase No. GI-149 of 2003-2004Shri Nandan V. PatilVs.The Oriental Insurance Company Ltd.Award Dated 05.10.2004M / s Prathmesh Medical & General Stores which was covered under the Shopkeeper’sInsurance policy of Oriental Insurance Company, Vasai Branch Office under Borivali D.O.against the policy No.124302 / 48 / 2003 / 00021 for the period from 5.4.2002 to 4.4.2003had lodged a claim with ‘Oriental’ after some delay for reimbursement of their losses and

the Company repudiated the claim on the ground that the intimation of loss was given tothem after a lapse of more than 4 months giving the Company no chance to survey,investigate and assess the loss amount actually to be considered by them. Aggrieved atthis decision the Insured / Complainant approached Insurance Ombudsman seeking hisintervention in the matter. Both the parties were called at the hearing and the recordsperused.From the records it is evident that the claimant put up his claim to Oriental in an undatedletter in November, 2002 which was received at Oriental’s Branch Office on 11.11.2002 thatis, clearly after almost 5 months from date of loss suffered by Prathmesh Medical &General Stores and even after one month of settlement of claims due to the same cause ofloss i.e. floods by United India. This is a clear violation of condition 5 1 (b) of the policyissued by the ‘ Oriental’ and strongly suggests that they were prompted only after the claimpaid by United India. In the facts and circumstances, Oriental’s stand that they got verylate intimation without any evidence of loss and damaged property which was subjectmatter of insurance being not in existence and thereby they were deprived from surveyingand assessing the same, cannot be faulted and thus upheld. There is no valid reasontherefore, for this Forum to interfere with their decision.Mumbai Ombudsman CentreCase No. GI - 39 of 2003-2004M/s Nitin PlasticsVs.Royal Sundaram Alliance Insurance Company Ltd.Award Dated 08.10.2004Shri Nitin Agarwal, the proprietor of M/s Nitin Plastics, had taken a Marine Cargo Policy no.ME 00000500000100 from Royal Sundaram Alliance Insurance Company Limited, issued on12.6.2002 for a sum insured of US$ 14,560/- (Indian Rs. 7,85,905/-) covering aconsignment of 8 porcelain “Idols of Krishnaji” for transit from Thane to Singapore by Flightthrough Kuala Lumpur. The policy had been issued subject to Institute Cargo Clauses (Air),and other applicable clauses.The company vide their dated 2.9.2002 repudiated the claim on the ground that the cargowas collected from the airport against a clean receipt on 9.7.2002 and was subsequentlystored at the clearing agent’s warehouse. It was only on 22.7.2002 (a delay of 13 days)when the cargo was to be delivered it was found to be damaged. The company regrettedtheir inability to consider the claim under Exclusion 4.5 Institute cargo Clause (A). Notsatisfied with the decision of the Company, the complainant , M/s Nitin Plastics,approached the Ombudsman stating that the company’s rejection is unlawful and unjust. Inhis letter of 15.9.2003, he mentioned that the company is twisting the ground of rejectionfrom Clause 4.5 initially on 2.9.2002 to Clause 5.1.2 in there repudiation letter dated14.8.2003. Parties to the dispute were called for hearing on 14.7.2003 and 25th July 2003.As regards the Delay and storing the consignment at the warehouses, the proprietor of M/sNitin Plastics had deposed before the Ombudsman to submit that the consignment wasstored in the bonded warehouse before payment of customs duty but the letter of BechtransInternational dated 5.7.2003 which was forwarded after the hearing says clearly that as thewarehouse is in Free Trade Zone/Changi Airport, no duty is payable.Without going into detailed analysis of actual import of all the provisions of the TransitClause quoted above and its applicability under different situations, this Forum beingessentially of a summary trial nature can give its views based on documents madeavailable to it, without calling fresh evidences, witnesses or by examining them etc. Strictlyon that basis, it would like to observe that the provisions of 5.1.2 read in conjunction withall other provisions, under Clause 5, would determine the course of transit once the

delivery has been taken under clean receipt without any qualification and then stored inthe warehouse for merely procedural formalities. In the case of a transit insurance ongoods, transit ends and cover ends when custody and control of the goods pass from thecarrier or his agent to the consignee or his agent. This is a time-honoured principle inMarine Transit Insurance and therefore, the contention of the Company that the interesthas passed to the Agents on their receiving delivery of consignment in sound condition aseffectively the holder thereby concluding the transit which was insured, cannot be called inquestion.In the facts and circumstances, the claim of Shri Nitin Agarwal of M/s Nitin Plastics, underMarine Cargo Policy No. ME 00000500000100 for damage to the consignment of 8 “idols ofKrishnaji” is not sustainable. Case is disposed of accordingly.Mumbai Ombudsman CentreCase No. GI - 516 of 2003-2004Shri D. JanardhananVs.The New India Assurance Company LimitedAward Dated 14.10.2004The New India Assurance Company Limited, D.O. 142000 had issued a Loss of Licensepolicy bearing No. 142000/43/00/00026 to Shri D. Janardhanan for the period from29.9.2000 to 28.9.2001 with sum insured of Rs. 20 lacs. Shri Janardhanan Lodged acomplaint before the office of the Insurance Ombudsman on 16th June, 2003 asking forrelief of Rs. 20 lac alongwith commercial lending rate of interest plus appropriatecompensation for mental harassment and agony and torture apart from prayer for any otherdirection of relief. As per Rule 16(1) of the Redressal of Public Grievance Rules, 1998 thisOffice covered to Shri D. Janardhanan in regard to inability to register his complaint. Laterthe Complainant filed a Writ Petition before the High Court of judicature at Bombay in itsCivil Appellate Jurisdiction making the Insurance Ombudsman as Respondent no. 1 videwrit Petition No. 30947 of 2003. A copy of Writ Petition was served to this Office on 8thOctober 2003. Accordingly, the Office of the Insurance Ombudsman registered theComplaint of Shri D. Janardhanan under Complaint No. OMB/MUM/GI-516/03/04 based onhis complaint dated 14th july, 2003 wherein the amount was restricted to Rs. 20 lacs Asper directive of Hon’ble High Court, Mumbai dated 5th December, 2003 this Office hasacted immediately. Parties were heard and records perused. Finally, in view of the clearguidelines under 13(3) (C) of RPG Rule, 1998 and the desire of the Complainant to lodgeda complaint of Rs. 20 lacs plus Interest and other costs before MSCDRC vide his complaintdated 14th July, 2003 the case was dismissed from this Forum.Mumbai Ombudsman CentreCase No. GI-37 OF 2003-2004Shri S. V. PatelVs.The National Insurance Company Ltd.Award Dated 18.10.2004The Proprietor of M / s Kirti Electric & Hardware Stores, had taken a Shopkeeper’s Policyfrom National Insurance Company Limited, Bhiwandi DAB, under Policy No.2002 / 9801471for the period 28.6.2002 to 27.6.2003 for a Sum Insured of Rs. 7,00,000/-.The Insured lodged a claim with the Company due to civil commotion on 29.6.2002. TheCompany appointed their Investigator, Shri Avinash More, to look into the incidence andsubmit their report for suitable action.

Not getting any response from the Company, the Insured approached the Ombudsman on19.4.2003. The Company and Complainant were heard on 7.11.2003 and 21.8.2003respectively.Pursuant to the hearing the company vide letter dated 9.1.2004 intimated to the Insuredthat the claim had been surveyed and investigated by their surveyor and investigators. Theinvestigators had observed that no such incidence (RIOT) took place on 29.6.2002, in theBhiwandi, Khadipur area in which the risk is situated. The Bhiwandi Police Authorities havenot registered any such case during the said period. Hence the Company, regretted theirinability to admit liability under the Shopkeeper’s Policy.From the records submitted by the Company, it is noted that the Company had investigatedthe matter through Investigator, Shri Avinash More and as per his report dated 23.9.2003,there was a quarrel of two persons in Ekta Chowk which is 500 meters from the Insured’sshop hence, riot was not in the location of the Insured. The Insured’s immediateneighbouring shops have given a written statement that there was no robbery, rioting intheir area. The police confirmed that there was a quarrel between two persons and norobbery had taken place. The Insured had registered FIR in the Bhiwandi Police Stationand the police had not allotted any C.R No. under which the loss was reported in the policestation nor was the incidence reported in the Bhiwandi Magistrate Court. The Company hasalso stated that the Surveyors, M / s Atul Shah & Co. had visited the insured’s premisesseveral times including June 29 & 30, 2002 to assess the loss due to flood, but no mentionhad been made in his report about the alleged loss by civil commotion.In the facts and circumstances, this Forum does not find any valid reason to interfere withthe decision of the Company in repudiating the claim.Mumbai Ombudsman CentreCase No. GI - 454 of 2002-2003Ambika Grain StoresVs.National Insurance Company LimitedAward Dated 27.10.2004M/s Ambika Grain Stores applied for Fire Insurance with Flood cover to National Insurance,Bhiwandi Branch in June 2002 and while the policy was effected from 25.6.2002, heavy rainfloods took place on 26.6.2002, in which there was large scale loss/damage to his property.Apparently, Surveyor M/s J.B. Boda and Company was appointed by the Company And m/sAmbika Grain Stores approached the Ombudsman’s Office 3.2.2003 only because ofdelayed response from National Insurance and Subsequently non-settlement of claim.Parties to the dispute were heard on 30.5.2003 and 18.6.2003 and the records wereperused.This Forum can adjudicate on issues when they are Fully determined by the company oneway or the other. Under the present case, this Forum has not been provided with a singledocument or paper by the Company. It does not have in possession the policy copy, theterms of insurance, the company of the survey report, the observation and comments of theSurveyors on the loss etc., the insurer’s comments on the same and so on.It also appears that while at the time of deposition made to the ombudsman, Shir P.K. Jain,represented as the Proprietor of Ambika Grain Stores and there was a letter to that effectto this Forum, the recent letter addressed to this Forum has been sent by one Shri PramodL. Kabra, claiming to be the Proprietor of Ambika Grain Stores, which is quite confusing. Itcan also suggest that there is no sole proprietorship in which case the complaint would falloutside the scope of this Forum.In the facts and circumstances this forum does not have any view emerging from insuranceCompany as regards the claim lodged with them. The question of deciding upon the

complaint is, therefore, not possible in absence of any decision. Moreover, as there havebeen number of cross references without any response from the Insurance Company, andthe complainant also refers to approaching alternative forum, I hereby decide not to passany Award on this complaint.Mumbai Ombudsman CentreCase No. GI-266 OF 2003 - 2004Shri Prem Prakash KhannaVs.The New India Assurance Co. Ltd.Award Dated 17.11.2004Shri Prem Prakash Khanna, had taken a House Holders’ Insurance Policy to cover contentsunder Policy No.142000 / 48 / 0l / 05555 from ‘The New India Assurance CompanyLimited., Code 142000, Jeevan Seva, 2nd Floor, Santacruz, Mumbai, for the period19.12.2001 to 18.12.2002 for a Sum Insured of Rs. 2,17,000/-. Shri Prem Prakash Khanna,reported to The New India Assurance Company, by fax dated 24.6.2002 that on 23.6.2002 aburglary took place at the premises at Villa No.l, Row No.3, Vallabh Nagar, Borivli, and thematter had been reported at MHB Police Station Borivli, vide FIR No.121 dated 23.6.2002.The Company vide their letter dated 11th March, 2003 informed Shri Prem PrakashKhanna, that on scrutiny of the papers, it was observed that his house was locked andunoccupied for more than 120 days during the policy period, which is excluded from thescope of the policy, hence the claim cannot be admitted. Further by letter dated 24.4.2003,they drew his attention to the House Holders Insurance Clause as applicable to Section II,under the head Extension.Not satisfied with the response, Shri Pravin Khanna approached the Insurance Ombudsmanon 28.6.2003.. He further informed that the premises were cleaned regularly and thatsomeone or other of the family member visited the premises regulary and stayed for 1-2days during week end. This can be substantiated by Electricity bills, telephone bills etc.Parties to the dispute were called for oral deposition an October 17, 2003.The subject matter of Insurance being the household goods and contents, it isunimaginable that the users would not be there. A house or a flat is there for habitation andthe contents and household goods are to be used and consumed for which the inhabitantshave to stay. In fact this ensures stay of the users and the two are linked. The moment it isnot habitable or kept unused or locked, and if that is for long period, it should be intimatedas it may become uninsurable. The Operative Clause of this Policy under “ReasonableCare implicitly mentions this. Moreover, the most natural thing in a flat is to stay and use it,not staying in a flat is ‘uncommon’ and, therefore; has to be specifically mentioned whichwas not done while proposing the insurance or renewing the same or anytime during thecurrency of the policy. In this regard, the reference to 120 days can only be taken to meanthat upto 120 days period may be accepted not only in temporary removal case alone butthe spirit of the clause can be stretched further as a pervading one binding the entirecontract but for which it is meaningless to issue a Householders’ policy without thehouseholder residing therein. In the facts and circumstances, the contention of theCompany, New India, that the claim is not payable is sustainable and the complaint of theInsured to pay for loss / damage to the contents under Policy No.142000 / 48 / 01 / 05555for the period 19.12.2001 to 18.12.2002 is not tenable.Mumbai Ombudsman CentreCase No. GI-630 OF 2003 - 2004Shri Bahadur B. Dangor(House Holder Policy)Vs.The National Insurance Company Limited.

Award Dated 14.12.2004Shri Bahadur B Dangor lodged a claim with National Insurance Company Limited, PuneD.O. III for theft of jewellery and belongings under his Householder’s Policy No. 271500 /48 / 32 / 3601049 / 99 during journey by train 2859 Mumbai Howrah Geetanjali Express on23 / 24.3.2000 between 11.30 p.m. and 7.15 a.m. The complaint was lodged with HowrahGovernment Railway Police and some follow up was done by National Insurance CompanyLimited through correspondence with GRP Howrah, their own Divisional Office in Kolkata.While this Forum is not aware of the final outcome, it appears from the Complainant’s letterdated 15. 1.2004 issued to this Forum, that the case may have been closed by National asclaim not documented or the matter not responded by the Railway Police or so. As per Rule13(3)(b) of the Redressal of Public Grievances Rules,1998 “ No complaint to theOmbudsman shall lie unless the Complaint is made not later than one year after the insurerhad rejected the representation or sent his final reply on the representation of theComplainant “. Hence this Forum cannot entertain cases beyond one year from the date ofrejection by the Company and this matter pertain to the year 2000. In the facts andcircumstances the complaint of Shri Bahadur B Dangor for claim under Policy No.271500 /48 / 32 / 3601049 / 99 for alleged loss of Jewellery is dismissed from this Forum withoutgoing into the merit of the same and as per provisions of the Redressal of Public GrievanceRules, 1998Mumbai Ombudsman CentreCase No. GI - 555 of 2003-2004Shri Visanji Khetshi ShahVs.Tata AIG General Insurance Co. Ltd.Award Dated 23.12.2004Shri Visanji Khetshi Shah, had taken a Travel Global Protection Policy from Tata AIGGeneral Insurance Company Ltd., Mumbai under Schedule on WA-3A279747 for a durationof 60 days from July 9,2003 to September 6,2003. Shri Visanji, intimated to the call centreof Company on 8th September, 2003 informing that few articles were found missing fromhis baggage delivered to the him by the British Airways during his journey on 6.9.2003 fromLondon to India.The company vide letter dated 11.9.2003 informed Shri Visanji Khetshi Shah, that theTravel Insurance policy provides Coverage for total loss of baggage whilst in custody ofcommon carrier only and not damaged to the luggage or partial loss of its contents. Hence,they regretted their liability to pay the claim subject to the terms and conditions it thepolicy schedule. Aggrieved by the decision of the company, the Insured represented to theCompany vide letter dated 17.9.2003 stating that the Airport Authorities do not allow thepassengers to lock the baggage for checking explosive articles contained in the baggage,and the airport authorities break the lock if the baggage is locked for checking thebaggage. Not satisfied with the response he approached the Insurance Ombudsman on 5thDecember, 2003 seeking intervention in the matter of settlement of his claim. A hearingwas held on 14th December, 2004 and Shri Visanji Khetshi Shah, Complainant, appearedand deposed before the ombudsmen. The Company was unrepresented and whencontacted over phone, they submitted that the concerned person was not available forwhich they wanted postponement of the hearing which was rejected. However, thecompany’s submission dated 13.2.2004 with the self contained note, copies of proposalform and the Travel Guard policy have been received, which are taken on record at thishearing. All these provided good for issuing this Award to avoid further delay.The Insured was carrying valuable items including jewellery in a ladies bag which was keptunlocked. In the defence, he mentioned that because of frequent checkings at variousairports, which totally disrupts the baggages, he considered it proper not to lock thebaggage until those were checked. Moreover, the Airport authorities often get wild if there

was delay in opening bags for checking. This argument is unacceptable in the light ofpractical situation. The Insured is supposed to take care of the goods covered under theInsurance Policy with due care for their safety and security. The cardinal Principle ofInsurance is to behave ‘as if uninsured’. The other important point, is that any policyoperates within certain terms and conditions and violating those would make the claimsubstantiated and non-payable. Accordingly on the basis of the Documents producedbefore this forum, it is apparent that the loss is not sustainable under the scope of thepolicy and the terms of the particular clause incorporated under the policy documents.