1. The brief facts of the case of the complainant are that her husband Markand Jani was working under EHT (M) Gridco, Jeypore and died on 16.08.2012. During his life time Markanda had obtained 4 polices from the OP vide Policy No. (1) 573667747, (2) 572348782, (3) 590428233 & (4) 570647035. It is submitted that the OP settled claims in respect of Policy No. 590428233 & 570647035 and failed to settle claims under Policy No. 573667747 and 572348782. Thus alleging deficiency in service on the part of the OP she filed this case praying the Forum to direct the OP to settle the claims under said policies with interest @ 18% p.a. and to pay Rs.1.00 lac towards compensation to the complainant.
2. The OP filed counter denying the allegations of the complainant but admitted about the 4 polices taken by the husband of the complainant and the death of the Life Assured (LA) on 16.08.2012. It is contended that the LIC settled the death claim under 3 policies bearing No. 572348782, 590428233 & 570647035. Regarding the death claim under Policy No. 573667747 the OP submitted that the policy commenced from 27.03.2012 for a sum assured of Rs.50, 000/- under monthly Salary Saving Scheme (SSS) and only two initial monthly premiums have been paid under the policy with FUP w.e.f. 05/2012 and due to non payment of premiums from 05/2012 the policy was in lapsed condition and hence the complainant is not entitled for any benefit under the policy. Thus denying any deficiency in service, the OP prayed to dismiss the case of the complainant.
3. The complainant has filed certain documents along with affidavit in support of her case. The OP has filed certain documents in support of its case. Heard from both the parties through their respective A/Rs and perused the materials available on record. Both the parties have filed written arguments.
4. In this case, issue of 4 policies bearing No. (1) 573667747, (2) 572348782, (3) 590428233 & (4) 570647035 by the OP in favour of Markanda Jani and the death of Markanda on 16.08.2012 are all admitted facts. The complainant stated that the OP after the death of LA settled death claims under Policy No. 590428233 & 570647035 in favour of the nominee-complainant leaving other two policies bearing No. 573667747 and 572348782. It is seen that the above two policies were under SSS, the premiums being deducted from the salary of LA.
5. The OP stated that the claim under Policy No.572348782 has been settled on 30.11.2015 and a sum of Rs.52, 500/- has been credited to the bank account of the complainant. The A/R for the complainant through its written argument submitted that the OP has settled claim under Policy at Rs.52, 500/- with the reason that the premiums have not been paid regularly. The A/R for the OP also cited the reason that “Where at least 2 full years premiums have been paid but not more than 3 or more year’s premiums have been paid, if the death of the LA has occurred between 3 to 6 months of the due date of FUP, claim will be considered to the extent of half the SA. No bonus is payable. No deduction of premiums”. On perusal of record it is seen that the date of commencement of the policy was 28.07.2009. The OP stated in a statement which is available on record that the premiums were paid up to 07/2012 with 4 gap premiums (4 months 2/10. 3/10, 1/11 & 6/11). It is very much clear that the premiums were deducted from the salary up to 07/2012 and the LA died on 16.08.2012. The complainant has filed deduction particulars of premiums being obtained from the employer of the LA in case of policy in question from which it was ascertained that during 02/10 the LA was on EL and the premium for the said month could not be deducted from the salary since not drawn. However, after sanction of EL, the premium for the month of 02/10 has been deducted in the month of April salary and credited to the LIC (Rs.651 X 2) vide Cheque No.458348 dt.04.05.2010. Similarly, the premium for 03/10 has been deducted by the employer from the salary of LA and has deposited with the LIC-OP vide Cheque No.458323 dt.05.04.2010. Hence the contention of the OP that they have not received premiums for 02/10 & 03/10 is not true and they might not have adjusted the said 2 months premium by mistake at their level. Therefore, we find gaps for only two months i.e. 01/2011 & 06/2011 which is admitted by the PIO of the employer in his letter dt.17.02.2018, available on record.
6. It is seen that the policy commenced from 07/2009 and the premiums deposited till 07/2012 i.e. for 3 years and 01 month with gap premiums on 01.11 & 06/11 and thus the premiums for 2 years and 11 months have been received by the OP. The OP cited the conditions of Claims Manual where it has been stated at Clause 4b that “Where at least 2 full years premiums have been paid but not more than 3 or more year’s premiums have been paid, if the death of the LA has occurred between 3 to 6 months of the due dat3e of FUP, claim will be considered to the extent of half the SA. No bonus is payable. No deduction of premiums”. It is found in this case that premiums for 3 years and 01 month except 2 months gap premiums have been paid and thus premiums have been paid for more than 2 years. Secondly, the said clause further shows that if the death of the LA were to occur between 3 to 6 months of the due date of the 1st unpaid premium. The FUP was 01/2011. The premium was paid till 07/2012 and the LA died on 16.08.2012. If the OP found 2 gap premiums in the policy in question, it is the duty of the OP either to pursue with the DDO of the LA or to contact LA directly but no evidence is adduced by the OP regarding any intimation either to the LA or to his DDO for deposit of gap premiums. Further the LA is not literate enough to know about the rules of insurance policies. It was the duty of the OP to let the LA know about gap premiums but in this case the OP has shown grave injustice by not informing about the gap premiums. Further after the gap premiums, the LIC has received near about 12 premiums and hence the principle under Clause-4b of Claim Manual is not necessarily applicable to this case of the complainant. Thus the complainant is entitled for full death claim from the OP minus the amount already paid to the complainant.
7. Regarding policy No.573667747 it is seen that the policy commenced from 27.03.2012 and the LA has deposited 2 initial premiums while opening the policy i.e. 03 & 04 of 2012. This is a SSS and the OP has received the signed LASSS Authorisation Letter from the LA for onward transmission to the DDO of the LA. The OP stated that they have sent the A/L to the DDO but failed to file any document to that respect. There is nothing mentioned in the counter or written argument of OP about mode of dispatch of that A/L to the DDO. The employer of the LA stated in his letter dt.177 dt.17.02.2018 that their office has no knowledge about policy No.573667747. This is a policy under Salary Saving Scheme and the OP should sent the A/L in safety mode and keep the acknowledgement but the OP stated that their dispatch register during the relevant period as per rule has been destroyed within 3 years and they have no such record with them. In our opinion, this not a right answer. Now-a-days everything is being recorded in the computer. The OP must have recorded the dispatch details of the A/L of the LA in its computer but simply denied stating that the dispatch register is not available since destroyed. The OP is solely responsible for sending the A/L to the DDO of the LA for prompt deduction of premiums from the salary of the LA but the OP has taken the matter as casual for which the present problem arose. For this problem, in our opinion the OP is only liable and for the mistake of the OP the poor complainant should not suffer any more. From the above facts and circumstances it was clearly ascertained that the OP has not sent the A/L to the DDO of the LA and now taking different pleas. Thus the complainant is entitled for death benefits under policy No.573667747 and the LIC is to settle the claim accordingly.
8. Further due to such inaction of the OP, the complainant has been suffering since long and has come up with this case incurring some expenditure for which she is entitled for interest @ 6% p.a. from the date of filing of this case on the awarded sum besides Rs.5000/- towards cost of litigation. In the peculiar circumstances of the case, we are not inclined to grant any compensation in favour of the complainant.
9. Hence ordered that the complaint petition is allowed in part and the OP is directed to settle the claim under two policies in favour of the complainant accordingly.
The OP is to settle the death claim under Policy No. 572348782 afresh with assured bonus and pay in favour of the complainant minus the amount already paid. The amount to be paid bears interest @ 6% p.a. from the date of filing of this case.
The OP is to settle the death claim in full in respect of Policy No. 573667747 with accrued bonus and pay the same to the complainant with 6% interest from the date of filing of this case.
The OP is to pay Rs.5000/- towards cost of litigation to the complainant.
We are not inclined to pay any compensation in favour of the complainant.
The above directions are to be complied by the OP within 30 days from the date of communication of this order.
