Delhi

East Delhi

CC/52/2014

HEMANT - Complainant(s)

Versus

LIC OF INDIA - Opp.Party(s)

18 Oct 2016

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.-        52/2014

                                                                                                   Date of Institution              15/01/2014

                                                                                                   Order reserved on               18/10/2016        

                                                                                                   Date of Order                       20/10/2016                                                                                     

 

In matter of

Mr Hemant Sharma, adult   

S/o Sh Biseshwar Dayal Sharma    

R/o- HN 329, Gali no 2

Sunder Puri, Ghaziabad UP……….…………………...…………….Complainant

                                                                    Vs

The Manager , LIC of India  

Branch Unit no 12D,

29-31, Aditya Mega Mall,

Nr Karkarduma Courts, Delhi 110032 ……………….…………..Respondents

 

Complainant’s Advocate        Prashant Sisodia & Rahul Kr Verma   

Opponent  Advocate               Madan Sagar

 

Quorum   Sh Sukhdev  Singh       President

                  Dr P N Tiwari                Member

                  Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief

This complainant has been filed u/s 12 of C P Act, 1986 against OP for alleged deficiency in their services for rejecting accidental claim under Disability clause. Facts of the case                                                                                                

Complainant aged about 23 years, had accidental injuries due to train accident Delhi Ghaziabad line on 07/04/2011, where he lost his both legs were injured.

 

He was taken to Govt Hospital, Ghaziabad by his friends and after treatment, he was shifted to GTBH hospital, Delhi for further treatment where his both legs were amputated. At MMH Hospital, Ghaziabad, MLC and Railway Memo by Railway police was prepared.

He stated that he had a LIC policy with OP vide Policy no. 124166404 for a sum assured one lakh. The commencement of this policy was 10/01/20108. He was paying his LIC premium and had enclosed his receipt with policy bond copy.

Complainant filed his accidental claim application with OP on dated 12/07/2011. Complainant received OP message on 04/06/2013 that his policy was lapsed at the time of accident; hence claim could not be processed.

Aggrieved by the rejection of accidental claim, filed this complaint and claim accidental damages as per policy conditions stating that OP had received his premium till Jan 2013. He also state that OP had full knowledge of accident and policy condition as waiving of premium after the time of accident where he suffered damages, still OP received his premium till Jan 2013. So, OP were liable to pay the accident benefits to him. Even after sending OP legal notice, no reply was received. Thus, claimed accidental bene3fits as per the policy conditions with 18% interest with Rs 30,000/- damages and Rs 10,000/- litigation charges,

Notice was served and OP submitted their written statement denying all the allegations of the complainant and prayed for dismissal of complaint. OP submitted that complainant accident had when his policy was not in force and was lapsed due to nonpayment of premiums regularly and had no locus standi to file complaint.

 

 

It was admitted that complainant had paid his premium after the accident on 15/04/2011 for sum Rs 5352/, whereas his policy was lapsed on 07/04/2011. OP had submitted Annexure A & B.

Complainant filed his rejoinder and evidences on affidavit which were on record and not controverted. OP did not file their evidences. Arguments were heard and order was reserved.

After scrutinizing all the facts and evidences on record, it is to be seen whether complainant was entitled for accident benefit under policy conditions by considering the following points as under –

1-Whether accident benefits claimed were genuine by complainant,

2- Whether policy conditions were fulfilled by both the parties,

3-Disability  percentage and future of Employment of complainant.   

 

1-Whether accident benefits claimed were genuine by complainant

As per the facts of the complaint and evidences on record, it was seen that complainant met an accident on railway tract and was recorded by Railway police by making Railway police Memo, MLC and referring complainant to another higher centre for further management which resulted in both legs amputation, falls under category of a genuine claim as per accidental benefit clause of the said policy.

2- Whether policy conditions were fulfilled by both the parties

It was seen that the complainant took LIC policy from OP which was effective from 10/01/2008 and it was a quarterly paying premium schedule.

 

 

By seeing the evidence of premium paid by complainant, it was clear that quarterly premium from Jan 2011 was not by the complainant in time, but OP had received the premium with late surcharge on 15/04/2011 as per annexure A and B submitted by OP. Hence, the gap period occurred in paying premium was waived off by OP.  By this, it was clear that there was no lapse of policy when OP had accepted quarterly premium with late fee. Thereby, no violation of policy condition by complainant but, rejection of accident benefit claim was a violation of their own policy condition.

3-Disability percentage and future of Employment of complainant

By going through the nature of accident occurred and the outcome of treatment resulting in the amputation of both legs of complainant, proves that injury was serious and complainant became orthopedically handicapped throughout his earning life. Also by considering   

“The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995
No. 1 of 1996, (1st January, 1996)

Sec 2 (b) “disability' means –

                        blindness;

                      ii-    low vision;

                      iii-   Leprosy cured

                      iv-   hearing impairment

                      v-    loco motor impairment

                      iv-   mental retardation

                      vi-mental illness  

w-"rehabilitation" refers to a process aimed at enabling persons with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychiatric or social functional levels;

 

x-"Special Employment Exchange" means any office or place established and maintained by the Government for the collection and furnishing of information, either by keeping of registers or otherwise, respecting –

a)-persons who seek to engage employees from amongst the persons suffering from disabilities;

b) persons with disability who seek employment;

vacancies to which person with disability seeking employment may be appointed;

i-"State Coordination Committee" means the State Coordination Committee constituted under sub-section (1) of section 13;

ii-"State Coordination Committee" means the State Executive Committee constituted under sub-section (1) of section 19.

Guidelines for Evaluation of Permanent Physical Impairment in Amputees  

Basic Guidelines …

1. In case of multiple amputees, if the total sum of percentage permanent physical impairment is above 100%, it should be taken as 100%.

2. Amputation at any level with uncorrectable inability to wear and use prosthesis, should be given 100% permanent physical impairment.

3. In case of amputation in more than one limb percentage of each limb is counted and - 15 - another 10% will be added, but when only toes or fingers are involved only another 5% will be added.

4. Any complication in form of stiffness, neuroma, infection etc. has to be given a total of 10% additional weightage.

Above knee up to lower 1/3 of thigh 80%.

Through knee 75%

B.K. upto 8 cm 70%

 

B.K. up to lower 1/3 of leg 60%

Through Ankle 55%

Syme’s 50%

Upto mid-foot 40%

Upto fore-foot 30%

All toes 20%

Loss of first toe 10%

Loss of second toe 5%

Loss of third toe 4%

Loss of fourth toe 3%

Loss of fifth toe 2%

By following these standard criteria, evaluate of percentage of disability in the person is calculated by the board of concerned specialties. But present disability certificate issued by the orthopedic board from MMG Hospital, Ghaziabad, does not fixes the correct disability percentage in the complainant.  It is clear from the disability certificate that complainant is totally permanent disable and unable to earn for his life as he may be earning before accident.

Also, when OP had accepted lapsed policy premium with late fee means that the policy continuity was there and OPs mere issue of rejecting the accident claim stand unjustified.   

 

As OP submitted that that the policy was lapsed from 07/04/2011 and later on accepted premium on 15/04/2011, was within the given condition of the policy condition 2 under head PAYMENT OF PREMIUM which reads as “A grace period of one month but not less than then 30 days will be allowed for payment of yearly, half yearly and 15 days for monthly premiums. In this case, it was paid and accepted by OP on 8rth day of lapse period. Hence again it was justified for payment.  

Further seeing the condition 3 under head as REVIVAL OF DISCONTINUED POLICIES which reads as “ If the policy has lapsed, it may be revived during the life time of the life insured but, within a period of 5 years from the date of 1^st unpaid premium and before the date of maturity”. In this, the policy was revived on the 8rth day of lapsed.

By seeing condition 10.1 under the head as “DISABILITY BENEFIT, which reads as   “if, while this policy is in force for the full sum assured, the life assured, prior to the policy anniversary on which the age nearer birth day of the life insured is 70 years becomes the subject to disability as hereinafter defined, and the same to the satisfaction of the Corporation as assurance herein after provided, the Corporation  agrees  to waive the payment of future premiums up to as assurance of Rs 20,000/-as per the case”. Here, in this case is below the specified amount.

By seeing condition 10.2 under the head as a) Disability of Life insured which read as i) to pay in monthly installments spread over 10 years an additional sum equal to the sum assured under this policy.  

 

If the policy becomes a claim before the expiry the said 10 years the disability benefits installments which have not fallen due will be paid along with the claim.    

ii) to waive off the payment of future premiums.  

OP had also taken its own view that the complainant would have taken damages from the Railway tribunal and not from OP. It is pertinent to mention here that OP had accepted the accident claim as per policy conditions, but, despite of being recommended by their own agent/surveyor’s report for giving genuine claim, did not accept the report dated 12/07/2011.  

So, rejection of accidental claim by OP was unjustified on two reasons as

i)- Admitted fact of accident by all the related evidences,

ii) Refusal of accident claim by OP in reference to policy conditions.

OP has also violated the Sec 45 of Insurance Act.

In addition to this, we have also considered citations as under—

1. LIC of India vs Kaushilya – IV (2012) CPJ 841(NC)

RP 3433/2006 decided on 04/10/2012. It was held that OP to pay full premium with accidental claim as benefit under the policy conditions.

1. Maya Devi vs LIC of India-RP 2824/2007 decided on 21/05/2008, III(2008) CPJ 120(NC).

It was decided Insurer liable under policy condition to pay benefits.

 

1. LIC of India vs Usha Jain, FA 696/2002, decided on 08/08/2002, I(2002)CPJ100(MPSCDRC). Held that accidental benefits to be paid by Insurer/OP.

Hence, we are of the opinion that complainant had proved the deficiency of OP for denying to pay the accidental claim as per the policy in question. Thus, we allow this complaint and pass the following order as under

• OP is directed to process the accidental claim as per the condition of the said policy and pay the accidental benefit to the sum assured to the complainant within 30 days from the receiving of this order.
• We also award for payment of additional sum assured as per condition 10 of the Disability Benefit in the time essence.
• If order is not complied within time period, OP shall incur the interest of 9% from the date of rejection of accidental claim till realization.
• Compensation of a sum of Rs 10,000/- with litigation charges Rs 5000/- shall be paid accordingly.

Copy of this order be sent to the parties as per the act and file be consigned to Record Room.

 Mrs Harpreet Kaur  Member                                    (Dr) P N Tiwari   Member                                                          

                                      

                                           Shri  Sukhdev Singh - President