Wednesday, August 4, 2010

Application for complaning for not receiving of claim

Consumer Disputes Redressal Forum _____.

In the matter of :

_____ alias _____
… Complainant.

_____ Insurance Company.
…… Respondents.

Complaint U/S of the Consumer Protection Act as Amended upto date.


I, _____ alias ___ S/o,D/o late ____ R/o _____, do hereby solemnly affirm and declare as under :-
1- That the ____ of the deponent namely ____ was employed in ____, _____ and he got insured his life and took a Insurance Policy from the respondent NO.1 through the respondent No.2, who is the agent of the respondent No.1 company. The respondents No.1 and 2 insured ____ vide their Insurance Policy bearing its No. ____, for the insured amount of Rs. ____/-.
2- That while getting the said insurance Policy from the opposite party, it was made clear that the life of the ___ of the deponent was insured by the respondents. During the lifetime _____ fulfilled all the required terms and conditions of the respondent and deposited the installments of the Insurance policy with the respondents.
3- That the ____ of the deponent had appointed the deponent as his nominee in the above mentioned policy. However, said ____ met with a accident at _____ and he expired on ____. Copy of the death Certificate is enclosed herewith. The Medical Officer/Station house officer, ____, conducted the post mortem of the deceased. The photocopy of the PMR is enclosed. The said accident case was registered vide Cr. No.____ Under Section ____ IPC in P.S. ____. The copies of the FIR/inquest reports etc. are enclosed herewith the complaint.
4- That just after the accident the deponent contacted with the respondents No.1 and 2. The respondents demanded the relevant documents regarding the said accident and as per the requirement of the respondents No.1 and 2 the deponent sent all the documents i.e. copy of the FIR, police inquest report, photos of the accident place, identity card of late ____ photocopy of the Ration Card, photocopy of the affidavit, driving licence of deceased, the publication of the News Paper dated ____, copy of Local S.L. No. ____ etc. on ____ from ____ Post Office vide Receipt No. ____. Copies of the same are enclosed.
5- That the ____ of the deponent ___ delivered the relevant documents of late ____ as per the requirement of the respondents. Due to non-availability of the death certificate the same was again sent to the respondent on ____. Thereafter the police file report of ____ was demanded and the same was sent on ____. The deponent has sent the copies of nomination for obtaining the claim to the respondent from time to time.
6- That the deponent sent the income proof of ____ on ____ after obtaining it from the employer of the deceased Shri ____. The copy of same is enclosed. Several letters were written by the respondents to the deponent and vide their letter dated ____ the respondent told the deponent that ___ claim case has been taken on top priority. The photocopies of the letters sent by the respondents to the claimant are enclosed herewith.
7- That the deponent visited the office of the respondent No.3 and contacted the respondents No.1 and 2 through various letters and requested them to pay the insured amount of Rs. _____/- to ____ but the respondents firstly were assuring the deponent to make the payment but later on refused to do so. The deponent sent her last letter dated ____ to the respondents but all in vain.
8- That due to the delay tactics and thereafter intentionally not making the payment of the insured amount the respondents have caused mental agony, harassment, tension to the deponent for which the deponent is entitled to receive the amount of Rs. ____/- from the respondents and thus total amount of Rs. ____/- from the respondents jointly and severally. Thus the opposite party has not rendered the satisfactory services to the deponent and not performed their part of contract.
9- That the cause of action to file the present complaint has arose on ____ when the deponent sent the last letter and it finally arose on ____ when the respondents finally repudiated the claim of the complainant. Hence this complaint.
10- That the deponent is a consumer of the respondent as defined under the Consumer Protection Act, and the aforesaid act of the opposite parties amounts to deficiency of service, indulgence in unfair trade practice and malpractice and further this hon’ble court has jurisdiction to entertain, try and decide this complaint.
11- THAT photocopy of the insurance policy is___. The photocopy of the death Certificate of ____ is ___. The photocopy Of the FIR is ___. The photocopy of the Post Mortem is____.


Verified that the contents of my above affidavit are true to best of my knowledge and belief and nothing has been concealed therein.
Verified at ____ on ___________