Seeking Justice for Denied Group Insurance Claim: What Steps Can Be Taken Now?

This query is related to one of my friends. His father was employed in a Central PSU. The company had entered into an arrangement with a national insurer company to provide group insurance on payment of a premium of Rs. 525/-. The PSU management decided to deduct the amount in 3 installments of Rs. 176/- each. Whether this was agreed upon by the insurance company or not is not known. One installment was deducted, and his father met with an accident and expired. The matter relates to 1999-2000. The insurance company has denied paying the group insurance amount on the ground that the full premium has not been paid. PSU management has declined to take responsibility on the plea that group insurance was provided by the insurance company.

My friend filed a complaint with the local consumer forum but lost due to a lack of legal assistance. Now he wants to know whether something can be done in this matter at this point or not. If yes, what documents will be needed and where to go for justice?

I would suggest you approach the Insurance Ombudsman appointed by the IRDA. I hope you will get justice from there.

Regards,
Kamal

I think the PSU might not have deposited the premiums to the insurance company. The PSU is liable to pay the compensation. The case has to be filed against the employer. Better consult a good lawyer.

Regards,
Pon

The accident is whether on duty or a private accident. If it is an on-duty accident, the PSU has to pay compensation; it is their bounden duty. In case it is an outside private accident, the Motor Vehicles Act or personal accident policy will take care of the compensation. Whatever the case may be, please take further action by consulting a senior advocate.

Regards,
D. Gurumurthy

Query on Group Insurance Claim

Thank you for the concern. However, my query remains unanswered. It is clarified that the death occurred while the employee was away on official duty. The bus in which he was traveling got drowned. The only claim that has not been settled is that of group insurance. Mr. K. Prasoon has advised me to approach the IRDA Ombudsman. However, in the case of corporate group insurance schemes, individual employees are unaware of the terms and conditions of the agreement. What can they provide besides a copy of the payment slip, which certifies the deduction of the premium against the group insurance head? I kindly request only valid legal opinions so that I can assist the grieving family.

Regards,
AK Jain

I suggest you file a claim under the Employees' Compensation Act against the PSU since this is an accidental death that occurred during employment. If there is insurance, the employer can plead and involve the insurer in the process. Both the employer and insurer will present their positions. Please ensure that proper legal advice is sought, as any delays in this case need to be adequately explained.

Thanks,
V K Gupta

Insurance Policy Verification and Action Steps

Please ensure that the insurance company has issued the policy. If the policy was issued, review the terms and conditions carefully. Determine whether the insurance company or the PSU should pay the amount to the deceased.

Regards,
L. Kishore Kumar

I had the impression that you have all the policy details. Without policy details, you can't approach the Insurance Ombudsman. Employees have every right to know about the insurance policy if it is part of the employment contract or if the premium amount is being deducted from the employee's salary. Since the concerned person was working with the PSU, I believe the PSU will share the policy details if asked. Usually, PSUs don't play hide and seek games with employees. Still, if the PSU is not ready to share the details, you can obtain such information through the RTI Act.

As you have mentioned that your friend filed a complaint with the Consumer forum, on what basis did he file the complaint? If there are no details of the policy with the complainant, the Forum can't entertain such complaints. Also, the Forum can't entertain issues between the Employer and the Employee. I would advise you to please get the full details from your friend and then seek advice.

Regards,
Kamal

I appreciate your concerns. As advised by Mr. Kamal, an RTI application has already been filed to obtain as many details as possible. Regarding death compensation under the Employees Compensation Act, the compensation has been paid under the Motor Vehicle Act. This Group Insurance scheme serves as a form of accidental insurance in addition to compensation under the Act. I am also attempting to seek legal advice once the RTI application is responded to with the relevant documents. However, being in a remote location, obtaining legal advice poses a challenge. One would need to travel at least 300 kilometers to access legal assistance from a High Court-level Advocate.

Suggestions from all experts/professionals are welcome.

Regards,
AK Jain

Approaching Authorities for Insurance Grievance Resolution

Generally, it is advisable to approach different levels before reaching the highest authority. In your case, you should approach the zonal level office of the insurance company, as they have a grievance redressal authority who will assist you in resolving the issue. If you are still not satisfied, the insurance ombudsman can address the matter, and thereafter, the consumer forums will take up the issue. If these avenues fail, you can approach the judicial system to resolve the matter.

As your father was working in a PSU, you can approach the authorities there to request a copy of the policy for your review.

Regards

As far as I know, a person cannot claim benefits from different insurers for the same insured issue. If the deceased employee has already received death compensation under MACT, then I doubt any further compensation can be claimed under any other insurance policy.

Section 3(5) of the Employees' Compensation Act

Section 3(5) of the Employees' Compensation Act states that if a civil suit is filed by an employee claiming damages for any injury, then he loses the right to claim compensation under the Employees' Compensation Act.