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					                            Group Personal
                            Accident Policy
                           Ahmedabad Ombudsman Centre
                               Case No. 12 / 002-0237
                                Mr. Yogesh Sampat
                                        Vs.
                          The New India Assurance Co. Ltd.
Aw ard Dated 24.02.2005
Complaint was against cancellation of GPA Policy effected for the period from 1999 to
2014. Respondent cancelled the Policy vide letter dated 27-2-04 ceasing the Risk effective
from 18-9-2002. Complainant through his written submission pleaded that the Respondent
did not follow the steps laid down under Condition No. 5 of the Policy and also voiced that
principle of natural / equal justice was not followed. The complaint is examined with
respect to Rule 12 of RPG Rules, 1998. It is observed that the subject complaint is not
covered under Section 12, Sub-section (b) to (1) of RPG Rules and hence, it is beyond the
purview of Insurance Ombudsman. Therefore, no Award is pronounced, but an Order is
passed giving liberty to the Complainant to agitate his complaint at any other appropriate
Forum.

                           Chandigarh Ombudsman Centre
                           Case No. GIC / 88 / UII / 11 / O5
                                  Smt. Seema Rani
                                         Vs.
                           United India Insurance Co. Itd.
Aw ard Dated 24.12.2004
Facts : The complainant’s husband late Sh. Sanjeev Kumar served as a constable in the
27th Battalion PAP Jalandhar Cantt. A Group Personal Accident Insurance Policy for the
employees of the said battalion was issued by the branch office, Jalandhar for the period
20.11.03 to 19.11.04. Shri Sanjeev Kumar was killed during the currency of the policy while
attempting to pacify two warring factions. His wife / nominee filed the claim through
Commandant PAP, which was repudiated on the grounds that as per the FIR report, the
death of the insured was not caused in an accident. It was a murder which is not covered
under the policy. Hence the claim was not payable.
Findings: The investigator concluded that the insured was murdered after having been
beaten and hit with a hammer on the head by four culprits. The dispute between the parties
started on some minor pretext in which Sh. Raj Kumar, brother of the insured was thrashed
by the accused. The insured happened to be there by chance. When he tried to rescue his
brother, he was hit on the head. He succumbed to injuries on way to hospital. The
investigation report confirmed that the insured came on the scene by chance. The legal
counsel, however, opined that the claim under personal accident policy is payable only if
there is bodily injury solely and directly from an accident. He expressed the view that an
accident would include such occurrences as death from fall or collision and there has to be
an element of negligence for accepting the liability under the policy. In the instant case,
murder was designed and therefore not covered under the policy.
Decison: Held that the insured’s death could not be considered as murder as it was not
designed; it was the result of an injury which was violent, external and grave and proved to
be fatal. The death was result of sheer accident. He got killed, but it was not a
premeditated or pre-planned murder. The insured had no scores to settle with the culprits.
As the deceased was not the object of wrath of the accused, it would be perverse to
conclude that it was a premeditated murder. He was hit accidentally and the resultant injury
proved fatal. Held that the insurer had erred in disowning liability and the claim was
payable.

                             Chennai Ombudsman Centre
                            Case No. 11.07.1173 / 2004-2005
                             Mr. Munnangi Bhaskara Rao
                                          Vs.
                          TATA AIG General Insurance Co Ltd.
Aw ard Dated 29.10.2004
Mr. Munnangi Bhaskara Rao of Vijayawada was covered under the Master Personal
Accident Policy issued by the Insurer to Road Safety Club Private Limited For loss of
hearing arising out of accident, the amount payable as per terms of policy was 25% of the
sum insured of Rs 30,000 / . It is reported that the insured met with an accident on
25.10.2003 at 10.00 PM on Deepawali day due to fall from a two wheeler when he was hit
by a Deepawali cracker blast on his ear, He was admitted in Usha Hospital immediately and
discharged on 28.10.2003 with an advice to contact an ENT Specialist. The insured
approached Government Hospital Guntur and hospital out patient records dated 23.12.2003
made a diagnosis “traumatic perforation left ear - exposure to crackers’. The insured
contacted Singari ENT Hospital who certified about the hearing loss in the left ear at 110
decibel.
The claim was rejected by the Insurer on 5.3.2004 on the ground that the claimant was
suffering from large central perforation in the left ear due to “chronic suppurative otitis
media” for a long time and hence not payable as it was pre-existing condition before the
policy was taken by the insured.
A joint hearing was held. The complainant was physically examined by the panel doctor of
the Insurer at Vijayawada on 3.2.2004 who opined that the perforation in the left ear was
due to “Chronic suppurative otitis media’: Based on this record, M / s. Paramount General
Hospital, Mumbai also opined that CSOM was a long standing condition and has no relation
with the alleged vehicular accident.
The case sheet summary issued by Usha Hospital, the out patient record given by Guntur
Government Hospital, the audiogram report of Singari ENT Hospital were perused The
suppurative (producing pus - discharging pus) otitis (inflamation of the ear) media (middle)
was not the pre-existing condition as the same was not recorded by the hospitals at
Vijayawada / Guntur / Singari ENT Hospital. The possibilities of formation of a pus and
inflamation after some time could not be ruled out. Further the general definition of the pre-
existing condition defined as a condition for which the insured was under treatment or
advice was recommended or received from physician before effective date of coverage, In
the absence of the same, the condition of pre-existing condition cannot be invoked by the
Insurer. Hence, direction was given to the Insurer to settle the claim.

                              Kochi Ombudsman Centre
                    Case No. IO / KCH / GI / 11 / OIC / 127 / 2003-04
                                    Mr. Rajendran
                                          Vs.
                              Oriental Insurance Co. Ltd.
Aw ard Dated 21.10.2004
Sri Rajendran has filed this complaint against the respondent on their repudiation of his
claim under Group Personal Accident Policy. According to the complaint he had an injury
due to an accident at his work place while lifting the tyres. He was under treatment at
Dhanya Hospital. The respondent rejected his claim for compensation for the reason that
the treatment was not for any accidental injury, but for some diseases which are explicitly
excluded from the scope of the policy. His appeal to the grievance cell was of no use.
Aggrieved with this he had approached this authority and prayed for an award of Rs. 6000/-
.
The Insured contented that the comlainant had not met with an accident while on duty. No
injury was visible extremely or through x-rays, And since the GPA policy issued to M / s
Apollo Tyres Ltd. excludes claim for Sprain, Lumbago and similar diseases, which are not
visible by the medical tests, the claim was repudiated. The order of repudiation is in order.
Taking into consideration all the records available in the file and also the contentions of the
parties concerned, the Ombudsman ruled that the complainant had not suffered an injury by
any accidental, external, violent or visible means. He may be under treatment for muscle
pain or sprain while he was lifting the tyre in course of his duties. The order of repudiation
is judiciously made and this Authority does not find any justifiable grounds to intervene.
Being devoid of merits, this complaint is dismissed.

                              Kochi Ombudsman Centre
                    Case No. IO / KCH / GI / 11 / OIC / 128 / 2003-04
                                   Sri T. O. Thomas
                                          Vs.
                              Oriental Insurance Co. Ltd.
Aw ard Dated 25.10.2004
Shri T O Thomas has filed this complaint against the respondent on their repudiation of his
claim under Group Personal Accident Policy. According to the complainant he had an
accidental fall in his house premises and had gone to Dhanya Hospital for treatment. The
respondent rejected his claim for compensation for the reason that the treatment was for a
disease and not for any accidental injury. His appeal to the grievance cell was of no use.
Aggrieved with this he had approached this Authority and prayed for an award of Rs.
45000/-.
The Insurer contented that the complainant was under treatment at Dhanya Hospital for
some ailments existing for the past 4 years and not for any illness arising out of an
accidental injury. The policy covers accidental Injuries only. As such the repudiation of the
claim is in order.
Taking into consideration all the records available in the file and also the contentions of the
parties coucerned, the Ombudsman ruled that the complainant was under treatment for
degenerative disc problems. The term “Degenerative” itself denotes that the disease was
not due to any accidental injury, but of a problem arose gradually by degeneration of disc.
The order of repudiation is judiciously made and this Authority does not find any justifiable
grounds to intervene.
Being devoid of merits, this complaint is dismissed.

                             Kochin Ombudsman Centre
                     Case No. IO / KCH / GI / 11-005-045 / 2004-05
                                Sri P. G. Unnikrishnan
                                          Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 01.12.2004
The complaint under Rule No. 12(1)(b) read with Rule 13 the RPG Rules, 1998 arose from
repudiation of a GPA claim preferred by the complainant before the Insurer. The
Complainant was employed in the GTN Textiles and reportedly while on duty in the factory
on 12.09.2003, he had sustained a pain on his back and was hospitalized. Subsequently he
had also availed of treatment from the ESI hospital.
The Insurer had rejected the claim stating that it was not a case of accident. It was, on the
other hand, a simple sprain on the back, due to a particular posture in which he was
positioned at his work place. The contention of the Insurer was also borne out of the
records in the file and the complainant was not able to prove that it was an accidental
injury.
Since there was nothing wrong in the interpretation of the Insurer, it was found that there
was no force or merit in the complaint and the same was dismissed.

                              Kochi Ombudsman Centre
                     Case No. IO / KCH / GI / 11-005-059 / 2004-05
                                   Sri P. Sivadasan
                                          Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 07.12.2004
The Complaint under Rule No 12(1)(b) read with Rule 13 the RPG Rules, 1998 is a
consequence of repudiation of a claim under Group Personal Accident Insurance floated by
the Insurer for the employees of M / s Appollo Tyres Ltd. The Complainant had sustained
contusion injury while working in the factory and the Insurer had rejected the claim stating
that “Contusion” as such was not covered under the policy. However, the Insurer had not
taken into account the nature of work required to be done by the complainant in the factory.
The nature of work of the insured was such that he had to pull a shaft for tightening the
grinder side and besides applying a lot of force in the process of his work, he also had to
stand at the same place for hours together. In the nature and circumstances of the case, it
was clear that the complainant had a real problem in as much as that he could no do his
work with a contusion on his leg.
Therefore, in all fairness, it was necessary to treat the period of his absence from duty and
spent on rest as advised by the Doctor to be eligible for the benefits and the Insurer having
been found to be in error of judgement, the complaint was allowed.

                              Kochi Ombudsman Centre
                     Case No. IO / KCH / GI / 11-005-058 / 2004-05
                                   Sri. C. L. Thomas
                                           Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 07.12.2004
The complaint under Rule No 12(1)(b) read with Rule 13 the RPG Rules, 1998 arose out of
repudiation of an accident benefit claim preferred by the complainant with the Respondent
Insurer under Group Accident Policy No. GPA - 2004 / 6 Covering the employees of M / s
Appollo Tyres Ltd. Perambra. The Complainant’s case is that on 01.02.2004, he had an
accidental fall in his bathroom and sustaining bodily injury in this process he was unable to
walk. The complainant reportedly had restorative physiotherapy for about 10 days and
could not attend to his work in the factory. The Insurer, on the other hand , resisted the
claim saying that the policy excludes any injury, which is not visible, even through medical
test, like sprain and similar injuries. They also disputed that the reported disability of the
Insured could not have been due to the said accident. However, the circumstances of the
case were strong enough to give credence to the version of the complainant and the
medical evidence in the file further fortified his case. The complainant was drawing a
monthly salary of Rs. 8305/- and the benefits calculated for 9 days of hospitalization
worked out to Rs. 9966/- The Insurer was asked to pay off the claim and thus the complaint
was allowed.

                             Kochi Ombudsman Centre
                     Case No. IO / KCH / GI / 11.005.069 / 2004-05
                                   Sri. K. P. Cherian
                                           Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 13.12.2004
The complaint under Rule 12(1}(b) read with Rule 13 of the RPG Rules, 1998 arose out of
repudiation of a GPA claim of the complainant by the insurer. It was a group personnel
accident cover for the benefit of the employees of M / s. Apollo Tyres. The complainant had
sustained an accidental injury at his work place on 29.5.2004 and the doctor had classed it
as “Group II sprain (L) Ankle”. The medical report also mentioned it as “Ankle sprain (L)”.
The insurer contended that sprain etc. which are not visible even though medical tests are
not covered under the policy. On a closer scrutiny of the case file, it was clear that the so-
called injury was only a minor sprain and the claim was made only because there was a
GPA facility available. There being no merits in the case, the repudiation of the claim by
the insurer was upheld and the complaint was dismissed.

                            Kochin Ombudsman Centre
                     Case No. IO / KCH / GI / 11.003.070 / 2004-05
                                Sri. P. K. Vasudevan
                                          Vs.
                            National Insurance Co. Ltd.
Aw ard Dated 14.12.2004
The complaint under Rule No. 12(1)(b) read with Rule 13 of the RPG Rules 1998 is
consequent to the repudiation of a mediclaim by the insurer under Pol. No.570700 / 47 /
2001 / 3801054. The complainant was the beneficiary under GPA policy issued in favour of
Anugraha Welfare Service, Thrissur.
It is said that the complainant had met with a bike accident on 15.4.2002 and his claim for
the medical expenses was refused by the insurer citing that there was no evidence to the
alleged accident: As per the claim, the complainant’s treatment was for a damaged nasal
septum. The insurer had also found out that the hospital records produced by the claimant
emanated from a Maternity Hospital although the Doctor was an ENT Surgeon. The insurer
also found out a number of other doubtful inconsistencies in the records and it was more
probable that the nasal septum defect was an existing deformity for which a surgical
intervention was done. There was nothing on record to prove the accident and hence the
claim was rejected. The contentions of the insurer were found to be on reliable grounds
and the complainant not being able to prove the alleged motor accident, the repudiation of
the claim was upheld by the insurance Ombudsman.

                             Kochin Ombudsman Centre
                     Case No. IO / KCH / GI / 11-005-073 / 2004-05
                                   Shri. T. V. Binse
                                          Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 15.12.2004
The complaint under Rule 12 (1) (b) read with rule 13 of the RPG Rules, 1998 is as
consequence of repudiation of a GPA claim by the insurer. The complainant being an
employee of M / s. Apollo Tyres was covered under the GPA scheme. The complainant had
allegedly skipped from his Motor bike on 27.5.2004 and the description of the wound was
“Lacerated Wound (Rt) 4th web”. However, the medical certificate did not mention anything
about the accidental fall; the description was only about the nature of wound. Unless it was
confirmed that the injury was due to an accident as claimed by the complainant, the insurer
could not settle the claim. The complainant was not able to lead any evidence to grove his
version of the Motor bike accident on 27.5.2004 and hence the action of the insurer in
repudiating the claim was upheld by this Forum.

                              Kochi Ombudsman Centre
                     Case No. IO / KCH / GI / 11-005-077 / 2004-05
                                    Shri. T. V. Joy
                                          Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 17.12.2004
The complaint under Rule No.12 (1) (b) read with Rule 13 of the RPG Rules 1998 is an
offshoot from repudiation of a GPA claim by the insurer. The complainant who is an
employee of M / s. Apollo Tyres (covered under GPA policy) had reportedly sustained an
injury “contusion (L) thigh” which was not externally Visible. The insurer rejected the claim
stating that sprain, Iumbago etc. which are not externally visible or detectable even though
medical tests are excluded under the policy. On a close scrutiny of the records and based
on the oral testimony of the complainant himself, there was nothing serious about the case
and it appeared to be a sprain due to a fall for which the doctor had advised rest for 2
days. Under the circumstances the complaint having been found to be of no substance was
dismissed and the repudiation of the claim by the insurer was upheld.

                              Kochi Ombudsman Centre
                     Case No. IO / KCH / GI / 11-005-080 / 2004-05
                                   Shri. C. Ramesan
                                          Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 22.12.2004
The complaint under Rule No. 12 (1) (b) read with Rule 13 of the RPG Rules, 1998 was as
a consequence of partial repudiation under the GPA policy issued by the insurer covering
employees of M / s. Apollo Tyres. As per the complainant, a Fabric Roll had accidentally
fallen on his left leg and he was admitted in the hospital. After a few days, the treatment
continued at his native place - Thalassery and he was on leave for 63 days. The insurer
had settled the benefits for 42 days of Temporary total disablement. It was found that the
Doctor at Thalassery had recommended for 56 days of confinement to the bed / rest for the
patient. The insurer had limited the period to 42 days depending on the opinion of an
Ortho-consultant who had neither seen nor treated the patient and therefore could not give
a reliable opinion. Besides the work of the complainant in the factory required brisk
movement of the body left and right over and over again for nearly 8 hours of work every
day. Considering the circumstances of the case, it was found that the opinion of the Doctor
at Thalassery was more stable and acceptable. The insurer was therefore directed to settle
the benefits to the complainant for 2 more weeks taking the total to 56 days of total
temporary disablement.

                              Kochi Ombudsman Centre
                     Case No. IO / KCH / GI / 11-005-086 / 2004-05
                                Shri. S. Vikraman Nair
                                          Vs.
                             Oriental Insurance Co. Ltd.
Aw ard Dated 23.12.2004
The complaint under Rule No.12 (1) (b) read with .Rule 13 of the RPG Rules 1998 arose
out of partial repudiation of a GPA claim by the respondent insurer. The complainant – an
employee of M / s.A,pollo Tyres - had sustained a blunt injury on his shoulder (L) although
there was no fracture. The accident was on 8.4.2002 and there being no records for
treatment beyond 26.4.2002, the insurer had restricted the benefit to 18 days only
(8.4.2002 to 26.4.2002), The complainant stated that he was on physiotherapy upto
8.5.2002. In the claim form itself, Dr. Jacob, Ortho Surgeon had mentioned that the patient
was on physiotherapy and was to use a sling from 18.4.2002 to 8.5.2002. It was therefore
clear that the complainant was under treatment for 30 days upto 8.5 2002 and the insurer
was wrong in restricting the benefits to 18 days only. The complainant had proved his case
beyond doubt and hence the insurer was asked to settle the benefits io the complainant for
the remaining period of 12 days thus taking the total of Temporary total disablement to 30
days.

                                   Kochi Ombudsman Centre
                          Case No. IO / KCH / GI / 11-005-085 / 2004-05
                                        Shri. V. I. George
                                                Vs.
                                  Oriental Insurance Co. Ltd.
Aw ard Dated 23.12.2004
The complaint under Rule 12(1) (b) read with Rule 13 of the RPG Rules 1998 is related to
rejection of a G.P.A. claim by the insurer. The complainant-an employee of M / s. Apollo
Tyres - is covered under the GPA policy. It is said that, on 13.4.2004, the complainant
sustained an accidental fall - a road accident-and that he was under treatment for 45 days
since his leg was in plaster. According to the Doctor, it was a ligament sprain ® ankle and
Iumbago and there was no fracture. There was no visible injury either. Interestingly from
the claim form, it was revealed that the treating Doctor was known to the complainant for
about 20 years and the case history was such that the long treatment for a minor sprain /
Iumbago was unbelievable. In any case, sprain / Iumbago, ligament, filling etc. are
exclusions as per the policy and therefore the repudiation of the claim by the insurer was
found proper and justifiable. The complaint was therefore dismissed.
premises were cleaned regularly and that someone or other of the family member visited
the premises regulary and stayed for 1-2 days 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 is unimaginable that the users would
not be there. A house or a flat is there for habitation and the contents and household goods are to be used and
consumed for which the inhabitants have to stay. In fact this ensures stay of the users and the two are linked.
The moment it is not habitable or kept unused or locked, and if that is for long period, it should be intimated as
it may become uninsurable. The Operative Clause of this Policy under “Reasonable Care 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 which was not done while proposing the insurance or renewing the
same or anytime during the currency of the policy. In this regard, the reference to 120 days can only be taken to
mean that upto 120 days period may be accepted not only in temporary removal case alone but the spirit of the
clause can be stretched further as a pervading one binding the entire contract but for which it is meaningless to
issue a Householders’ policy without the householder residing therein. In the facts and circumstances, the
contention of the Company, New India, that the claim is not payable is sustainable and the complaint of the
Insured to pay for loss / damage to the contents under Policy No.142000 / 48 / 01 / 05555 for the period
19.12.2001 to 18.12.2002 is not tenable.

				
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