The Complainant has filed this case alleging deficiency-in-service by the O.Ps, where O.P No.1 is the Branch Manager, Life Insurance Corporation of India, Balasore and O.P No.2 is the Divisional Manager, L.I.C of India, Cuttack Division.
1. Bereft of unnecessary details briefly stated, the case of the Petitioner is that the Complainant is a Policy holder under the O.Ps vide Policy No.586424263, dt.28.08.2005 for a term of 20 years with S.A Rs.50,000/- (Rupees Fifty thousand only). The Complainant got a severe injury on back side of his body, while he was lifting towards the first floor of his house. The Complainant had been to the doctor for his medical treatment at Nilagiri of Balalsore district. Despite very careful treatment treated by the doctor, the Complainant was not cured, rather he sustained permanent physical disability. Thereafter, the Complainant approached the O.P No.1 for getting permanent disability benefit, as prescribed in the Policy bond, but the O.P No.1 did not pay any heed to it. Thus, the Complainant had issued one legal notice to the O.P No.1 for the said relief/ benefit on 24.4.2015 through his Advocate. Prayer for award of disability benefit along with cost of litigation.
2. Written Version filed by the O.Ps through their Advocate, where they have denied about maintainability as well as its cause of action. The Pleader Notice dt.24.04.2015 issued on behalf of the Complainant did not mention about the nature of injuries sustained and disability cause to the Life Assured. However, on receipt of the Pleader notice, the O.P No.1 vide Regd. No.RO6762941IN dt.28.05.2015 have sent the claim form No.5279, 5280 and 5233 to the Policy holder Sumanta Pradhan with a request to submit the same along with the certificate of disability, which are necessary for determination of the genuineness of permanent disability as per the Policy conditions. The executed claim form referred above and the certificate of disability is not submitted by the Complainant/ Policy holder before this answering O.P till date. So, there is no question of deficiency of service on the part of this O.Ps. Moreover, the terms and condition for sanction of the disability benefit is mentioned in the policy bond as under:-
10(4) The disability above referred to must be disability, which is the result of an accident and must be total and permanent and such that there is neither then nor at any time thereafter any work, occupation or profession that the Life Assured can ever sufficiently do or follow to earn or obtain any wages, compensation or profit. Accidental injuries, which independently of all other causes and within 180 days from the happening of such accident result in the irrecoverable loss of the entire sight of both eyes or in the amputation of both hands at or above the wrists, or in the amputation of both feet at or above the ankles or in the amputation of one hand at or above the wrist and one foot at or above the ankle, shall also be deemed to constitute such disability.
10(5) Immediately after the happening of the disability, full particulars thereof must be given in writing to the Offices of the Corporation, where this Policy is serviced together with the then address and whereabouts of the Life Assured and within 180 days after the happening of the disability, there must be given to the servicing Branch Office of the Corporation in the manner required by it, proof of disability satisfactory to the Corporation and without any expense to the Corporation and thereafter, similar proof must be given, as and when required by the Corporation, of the continuance of such disability. Any medical Examiner nominated by the Corporation shall be allowed to examine the person of the Life Assured in respect of any disability claimed in such manner and at such times before and/or after the disability is accepted by the Corporation, as the Corporation may require.
3. On perusal of the documents available in the case record filed by both the contesting parties, it is noticed that:-
(i) The Complainant met an accident on 05.07.2012 and sustained permanent physical disability in spite of careful treatment by the doctor at Nlilagiri, but the Complainant has not filed any copy of document in support of his treatment/illness attended by the doctor at Nilagiri, which caused permanent disability to the Complainant.
(ii) Thereafter, the Complainant approached to the O.P No.1 for getting permanent disability benefit as per the Life Insurance policy issued by the O.Ps. But, the Complainant has neither disclosed the date of approach to the O.P No.1 nor has filed any copy of document in support of his claim that he approached to O.P No.1, for such action.
(iii) Lastly, the Complainant had sent a Lawyer notice to the O.P No.1 through his Advocate on 24.04.2015 to initiate necessary steps for award of such benefit. In reply to the above said Lawyer notice dt.24.04.2015, the O.P No.1 had dispatched a letter in connection with the claim of the Complainant to the Advocate of the Complainant under copy to the Complainant on 28.05.2015 vide their letter dt.21.05.2015, where they had also advised both to the Complainant and his Advocate to submit claim Form No.5279, 5280 and 5233 in order to verify the genuineness of the claim of the Complainant. But, the Complainant has not submitted the above said forms duly filled in by the Complainant to the O.Ps till date (Para-8 of W.V filed by the O.Ps on 06.06.2016). Hence, deficiency of service by the O.Ps to the Complainant is not noticed here.
(iv) It is ascertained that the Complainant was severely injured on 05.07.2012 and the Advocate on behalf of the Complainant served legal notice to O.P No.1 on 24.04.2015, in order to get permanent disability benefit from the O.Ps. Thus, the Complainant intimated to the O.Ps about the accident after 2 years and 8 months of incidence.
4. In view of the above materials available in the case record, it has been argued on behalf of the Complainant that when holding of Policy and Handicapped Certificate issued by the Doctors of District Head Quarter Hospital, Balasore is not disputed. The O.Ps only disputed regarding delay in informing O.Ps about such 100% disability of the Complainant. The Advocate for O.Ps also focused on the point. But after going through the documents like Handicapped Certificate filed in this Court, the 100% disability mentioned in the certificate in respect of the Complainant cannot be ruled out, which is updated on 05.06.2013. According to the O.Ps as the Complainant sustained injury on 05.07.2012 and the case is filed on 19.05.2015 and in spite of legal notice issued in view of the Authority reported in I (2015) CPJ 131 (NC) in the case of CHAMPABEN ATMARAM THAKRON (Vs.) REGIONAL PROVIDENT FUND COMMISSIONER & ANR. for serving legal notice or by making representation, period of limitation cannot be extended. But in the same case, the knowledge of 100% disability is came to the notice of Complainant on getting the Certificate on 05.06.2013. So in our considered view, the case is not barred by limitation as argued and is within the stipulated period as prescribed by the Law.
5. So, now on careful consideration of entire materials available in the case record and after hearing of both the sides, this Forum is of the opinion that the Complainant is entitled for the disability benefit from the O.Ps as per his Policy condition and also entitled for cost of litigation and mental agony sustained by him. Hence, Ordered:-
O R D E R
The Consumer case is allowed on contest against the O.Ps with cost. The O.Ps are directed to provide the disability benefit to the Complainant with respect to the Policy of the Complainant and a sum of Rs.1,000/- towards cost of litigation and Rs.1,000/- towards mental agony sustained by the Complainant. The O.Ps are also directed to comply the order within 60 days from the date of receiving of this Order, failing which it will carry interest @ 6% per annum till realization. The Complainant is at liberty to realize the same from the O.Ps under due process of Law.
Pronounced in the open Forum on this day i.e. the 27th day of March, 2017 given under my Signature & Seal of the Forum.
