Insurance - Claim - Words "received claim" are not a disclaimer of any
further amount which may factually be true and correct with reference to assessment of actual loss of stocks - The insured, therefore, cannot be pinned down on this statement since he lodged
the protest on the same day - The company was not doing any favour to the insured of paying the insurance claim as assessed by them by circumventing the joint surveyor's report. (177)
Insurance - Hole in the heart - Claim is being rejected
on the ground that this disease is being related to the Caesarean operation which was conducted 3 days prior to her admission in the Fortis Hospital and as per the policy respondent No.3
could not claim any expenses incurred on disease traceable to pregnancy, child birth, miscarriage or Caesarean Section or Abortion etc. and it fell under Section 4.13 of the Exclusion Clauses
of the policy - There was no expert evidence led by the Insurance Company that this disease was related to the above said clause - Therefore, a direction was given to make the payment - Order
upheld - Legal Services Authorities Act, 1987 (39 of 1987) S. 2-C(8). (174) P.L.R.
Insurance - If insurer who wanted to contend that the
particular cover note issued by the agent was fabrication, it could have been best proved only by confronting the cover note with the same number that purported to cover the risk for another
vehicle - If he has not asked any question on the alleged valid cover note, then it should only be taken that the insurer had not availed to itself the best opportunity of proving what it was
contending for. (176) P.L.R.
Insurance - If there was any wrong dealing by an agent,
the insurer may have his remedy against his own agent and that cannot be set up against either the insured or a third party claimant - Motor Vehicles Act, 1988 (59 of 1988) S. 149. (176)
Insurance - Life Time Super Pension - ICICI Prudential -
Petitioner has paid Rs. 1,00,000/- as premium in two years - Surrender value paid as per the foreclosure clause amount which came to Rs. 53,485.08 Ps. - Upheld. (177)
Insurance - Medical Insurance - Terms of the insurance
policy have to be incorporated in the language and spirit with which, both the parties haveagreed - Applicant had suffered headache, giddiness andhypertension - Careful reading of these clauses shows that certain usual diseases like arthritis,
cataract, Piles, diabetes, gout and rheumatism, surgery of gallbladder etc. have been excluded for first two years - A perusal of these clauses further shows that heart disease does not find
mention - In normal course, a patient suffering from hypertension is not required to be admitted in a hospital - Investigation shows that the symptoms could lead to a heart disease - X-ray of
the chest and Echo test of the patient wasconducted - Prolonged treatment of four days could not be the result of simple hypertension - It
could be the symptoms of heart disease or heart attack - Hence, the claim of respondent for reimbursement of medical bills could not be rejected. Held, in normal course, a patient suffering
from hypertension is not required to be admitted in a hospital. Applicant-respondent was suffering from headache, giddiness and hypertension. As per the medical bills, the investigation shows
that the symptoms could lead to a heart disease. X-ray of the chest and Echo test of the patient was conducted on 04.01.2012. Hence, a prolonging treatment of four days could not be the
result of simple hypertension. It could be the symptoms of heart disease or heart attack. Hence, the claim of respondent No.1 for reimbursement of medical bills could not be rejected by
relying on exclusion clause 4.3 as mentioned in the insurance policy. The object of the insurance policy is to secure a patient when he is admitted in hospital in an emergent condition. The
exclusion clause has to be read to the benefit of the patient in genuine circumstances. (178) P.L.R.
Insurance - No doubt, the report of the surveyor is not sacrosanct and
not binding, but each and every case has to be examined independently as to whether the report of the of surveyor was based upon the spot inspection much less whether the fire had broken out
or not - Report of the surveyor clinches the issue vis-a-vis the cause of fire, much less the loss sustained as the site plans were taken into custody by the officers of the Insurance
Company, who after making the investigation, agreed to certain amounts, but resiled from the same - It is an act of truncation where Manager of the appellant company denied his signatures -
In fact, the Insurance Company was under legal obligation to pay the losses assessed by the surveyors - Appeal dismissed with costs of Rs.20,000/- to be recovered from the officer, who had
chosen to file the appeal, to be deducted from his salary in accordance with law. (183) P.L.R.
Insurance - Petitioner did not give the claim within 48
hours - The specification of time is invariably to ensure that the claim is genuine and the person who lodges a complaint of theft does not create documents to make appear as though it is a
theft - If there are circumstances as to why he could not register complaint immediately and the Permanent Lok Adalat believed so - Has caused an abatement of 25% - Since the amount itself is
not very large for the insurance company, the benefit of 25% is an exercise of discretion that shall not be taken as any justifiable ground for intervention. (178) P.L.R.
Insurance - Question for examination would be "whether an
exclusion clause at all can be made in the Insurance Policy" - Exclusion of certain pre-existing diseases for a certain period - Condition has been accepted by the claimant-respondent No.1
and any payment with regard to hypertension can be disallowed by the insurance company, as the term `hypertension' does not require any further clarification. (178) P.L.R.
Insurance - Shopkeeper Insurance - Staff of the insured
was tapped on his back when he was carrying money of the insured by some unknown person and tricked to keep down the bag in hand to turn and remove the dirt which was stated to be sticking to
his shirt - The trickster ran away with the money contained in the bag - The amount in the hands of the employee in transit must include a situation of a person who keeps the article by his
side for attending to a person who was distracting him and ought not to be given a literal meaning of money being held in the hand - This would defeat the very purpose of insurance, for, it
was possible for an insurer to deny even the money held in the pocket, for, after all it was not a hand.(181) P.L.R.
Insurance - Standard fire and special Perils Policy -
Signed a detailed letters of subrogation which was on a stamp paper accepting in full and final settlement of the claim under the policy - There was no protest or demur raised around the time
or soon after the letter of subrogation was signed, that the notice itself was after three weeks and that the financial condition of the respondent was not so precarious that it was left with
no alternative but to accept the terms as suggested, we are of the firm view that the discharge in the present case and signing of letter of subrogation were not because of exercise of any
undue influence - There was full and final settlement of the claim.(S.C.) (177) P.L.R.
Insurance - Theft of car - Delay in lodging claim with
Insurance Company of 54 days - Instructions dated 20.09.2011, issued by Insurance Regulatory and Development Authority to all the insurance companies - As per the said instructions, this
condition should not prevent the settlement of genuine claims particularly when there is delay in giving intimation or in submission of documents due to unavoidable circumstances
-The companies were advised that they must not repudiate such claims on the ground of delay,
especially when the police has been promptly informed in thisregard. (176) P.L.R.
Insurance - Theft of motor cycle reported to the company
after 30 days - Where theft took place and police was informed the same day - However FIR was recorded after about one and half month - The delay of registration of the FIR cannot be
attributed to the claimant - IRDA instructions - Companies should not prevent settlement of genuine claims particularly when this delay in intimation or in submission of documents is due to
unavoidable circumstances - The companies were advised that they must not repudiate such claims on the ground of delay - Keeping in view the above instructions, the PLA has given a direction
to petitioner-Insurance Company to pay an amount. (175) P.L.R.Keeping in view the above instructions, the PLA has given a direction to petitioner-Insurance
Company to pay an amount. (175) P.L.R.
Insurance - Theft of vehicle - If the complainant was
explaining his relative delay in lodging a complaint to the fact that he had immediately informed the Insurance Company on the same day of the loss of the vehicle by lodging a complaint
through the toll free number to the Insurance company through its mobile on the date of the theft itself, then he was placing an important evidence of what he was contending - If this factual
detail was required to be repudiated, it could have been done through the phone call log that ought to have been maintained by the Insurance Company at that toll free call number - If there
are two views possible on a situation on whether such a complaint could have been accepted or not and if the Permanent Lok Adalat had decided to accept the same - If it had also punished the
Insurance Company for mental pain and suffering which the complainant had suffered by the Insurance Company dragging its feet and not setting the claim for theft ofvehicle Permanent Lok Adalat was still justified in passing award and if it had also punished the
Insurance Company for mental pain and suffering which the complainant had suffered by the Insurance Company dragging its feet and not setting the claim for theft of vehicle - Order upheld.
Insurance - Tractor was stolen - There no dispute with
regard to theft of the vehicle in question - The objection of the petitioner-company is that respondent No.1 had given intimation after a gap of 1/2 years - The fact that the FIR had
beenregistered the next day of the theft, clearly shows that there was no delay on the part
ofrespondent informing the police about the theft of vehicle - Award passed against the insurance
company - Award by the Permanent Lok Adalat - Upheld. (176) P.L.R.