DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.571 of 14-12-2010 Decided on 21-04-2011
Jeet Ram, aged about 56 years s/o Sh. Sohan Lal, r/o G.E.Air Force, Q/No.P-607/2, Silver Jublee Colony, Bhisiana, Distt. Bathinda. .......Complainant
Versus Life Insurance Corporation of India (LIC of India), Bibi Wala Road, Bathinda, through its Branch Manager. ......Opposite party
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM
Smt. Vikramjit Kaur Soni, President. Dr.Phulinder Preet, Member. Sh.Amarjeet Paul, Member. Present:- For the Complainant: Sh.Naresh Garg, counsel for the complainant. For Opposite parties: Sh.Inderjit Singh, counsel for opposite party. ORDER
VIKRAMJIT KAUR SONI, PRESIDENT:-
1. The present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended up-to-date (Here-in-after referred to as 'Act'). The brief facts of the complaint are that the complainant had purchased one Insurance Policy No.300538175 from the opposite party under Table 014 11 11 w.e.f. 11.01.2007 for a Sum Assured of Rs.One Lac alongwith Accident Benefit i.e. AB and Disability Benefit under clause 10 and charged Rs.2,641/- quarterly premium. The opposite party issued the Policy documents which contains one page with Four folds only. Neither the terms and conditions were supplied to the complainant till date by the opposite party nor the same was the part of the Insurance Policy. For this, the complainant has taken the support of the precedent laid down by the Hon'ble State Commission in case titled O.I.C. Vs. Puneet Pasricha, FAO No.1579/2004, decided on 05.03.2010. The complainant further alleged that at the time of issuance the said Policy, the officials of the opposite party took signatures of the complainant on blank Proposal Form. No copy of Proposal Form was ever sent to the complainant whereas the same is mandatory as per Regulations 2002 of Insurance Regulatory and Development Authority. The complainant was working as Electrician with GE Air Force at Bhisiana, Air Force Station, Bathinda and on 29.07.2009 at about 5.00 p.m., he met with an accident with 11 KV wires. Due to this accident, his left arm upto Elbow i.e. left hand and forearm alongwith half right foot amputated by the doctors at Bathinda. After the accident, the complainant was taken to the Air Force Hospital and then shifted to Nagpal Hospital, Bathinda due to serious burnt injuries and then shifted to Chabra Hospital, Bathinda where his above said body parts were amputated by the doctors. The team of the doctors of the office of Civil Surgeon, Bathinda i.e. Civil Hospital, Bathinda after examining the complainant, issued the Permanent Disability Certificate No.1390 to the complainant to the extent of 80% on 28.10.2009. The complainant lodged the claim after obtaining the Permanent Disability Certificate with the opposite party in December 2009 alongwith all the above said documents i.e. duly signed claim Form, copies of the Treatment Record of the above said Doctors and copy of Disability Certificate etc. As per Policy terms, on the permanent disability to the insured, the claim is payable i.e. monthly installments equal to the Sum Assured and the quarterly premium waived to the insured and has taken the support of the precedent laid down by the Hon'ble State Commission in case tilted L.I.C. of India Vs. Om Parkash and Amarjit Singh Vs. National Insurance Co. Ltd., FAO No.937/2003 dated 31.08.2009. Thereafter, the complainant approached the opposite party but they did not listen to him and claim is still pending with them till date and has also charged the payment of quarterly renewal premium against the policy terms from the complainant and the complainant now paid 5 installments of Rs.2,641/- per quarter i.e. total Rs.13,205/- after accident against the terms and conditions of the policy till date. The opposite party neither release the monthly installments to the complainant as per disability benefits under the said Policy till date nor waive the quarterly premium to the insured and more then 1-1/2 years lapsed, the claim is still pending with them and no intimation with this regard, has been received by the complainant. As per settled law by the Hon'ble Supreme Court in case titled U.I.I.C. Vs. MKJ Corporation, 1996 (3) CPJ 8 SC wherein, the Hon'ble Supreme Court held that the claim should be settled with in 2 months and our own Hon'ble State Commission (Punjab) in case titled Universal Processors Vs. O.I.C 1998, (1) CLT 478 held that the Insurance companies should settle the claim within 3-4 months of the claim filed. In the present case, the opposite parties have not settled the claim from almost 17 months. The complainant has also taken the support of the law laid down by the Hon'ble Supreme Court in case titled Lucknow Development Authority Vs. M.K.Gupta, 1994 AIR 787 (SC) wherein it has been held that the erring official must be penalized who was sitting on the claims with the malafide intention. The complainant further alleged that due to the non-payment of the claim amount i.e. monthly installments of the Sum Assured of Rs.One Lac and waiver of quarterly installments i.e. Rs.2,641/- per quarter and the complainant has been suffering mental harassment. The complainant already spent the Medical charges from his own pocket and the quarterly installments paid to the opposite parties, as such, the complainant is also entitled for interest on the above said amount from 30.07.2009 as per Regulations, 2002 Insurance Regulatory and Development Authority 9, (6) and further alleged that in case of delay in the payment, the insurer shall be liable to pay interest at a rate which is 2% above the Bank rate prevalent at the beginning of the financial year in which the claim is reviewed and further put the Reliance on law laid down by the Hon'ble Supreme Court in case titled Lok Shanker Pandey Vs. U.O.I., 2002(2)RCR (Civil) 783 (SC) that Interest is not a penalty or punishment at all but is normal assertion on capital and our own State Commission in case titled United India Insurance Vs. Payal Gupta, 2007(III) CPJ 403 – Interest and compensation – Liability to pay interest for depriving complainants from user of money. Hence, the complainant has filed this complaint to seek directions to the opposite parties to waive the quarterly premium of Rs.2,641/- as per Policy Condition on account of Disability, refund the amount of Rs.13,205/- (5 Quarterly Renewal receipts) already paid to the opposite parties till date and the complainant is also entitled for the refund of the quarterly premium @ Rs.2,641/- per quarter and the opposite parties be also liable to pay the monthly installments equal to the Sum Assured i.e. Rs.One Lac alongwith interest and Rs.20,000/- on account of mental harassment alongwith litigation expenses. 2. The opposite party has filed its written statement and pleaded that on the receipt of intimation and claim from the complainant, the Doctor has issued Disability Certificate to the complainant only to the extent of 80% disability which does not fall within the ambit of Total & Permanent Disability as per terms and conditions of the Policy. Since the disability of the complainant is partial and the permanent disability, claim is not payable as per terms and conditions of the Policy and the complainant was advised to continue depositing the premium and thereafter, he has been continuously depositing the premium. Thereafter, the complainant with 2/3 persons, visited the opposite party at Bathinda office. The officials of the opposite party explained the complainant that his accident benefit has been disallowed as the disability is partial and permanent. According to the terms and conditions of the Policy, the Life Assured has not obtained any wages, compensation or profit and the complainant is a Govt. employee and is serving at Air Force, Bhisiana as Electrician and he is working as such even after the accident and has been withdrawing his salary. On receipt of letter dated 24.01.2011, the repudiation letter has been sent to the complainant. The opposite party has relied upon the precedent laid down by the Hon'ble National Commission in case titled in Ajay Kumar Vs. LIC of India, 2007(1) CPJ 230 (NC) that Insurance-Accident Benefits-Award of-Legality-As per Policy, only total and permanent disability resulting from accident covered-clear, in instant case, disability is upto the extent of 81% and partial-Accident benefit is not payable. The opposite party further pleaded that this Hon'ble Forum has got no jurisdiction to try and entertain the present complaint, as the claim of the complainant has been thoroughly investigated and after throughly investigation, it was found that the claim is not payable. The Policy bond which includes the terms and conditions of the Policy have duly been sent to the complainant and the complainant himself has admitted the receipt of the Policy. The opposite party has denied that it has obtained the signatures of the complainant on blank Proposal Form rather the Proposal Form has been fully filled, signed and submitted by the complainant himself. After the receipt of Proposal Form from the complainant, the Policy has been issued as per rules and guidelines of IRDA. As per documents and record produced by the complainant, he has suffered amputation of left forearm above elbow and amputation of two toe (Rt.) foot which does not fall within the ambit of Total and Permanent Disability as per terms and conditions of the Policy. 3. Parties have led their evidence in support of their respective pleadings. 4. Arguments heard. Record alongwith written submissions submitted by the parties perused. 5. The learned counsel for the complainant has submitted that the complainant had purchased one Insurance Policy No.300538175 under Table 014 11 11 w.e.f. 11.01.2007 with Sum Assured of Rs.One Lac alongwith Accident Benefit i.e. AB and Disability Benefit under clause 10 and the opposite party charged Rs.2,641/- quarterly premium. The opposite party issued the Policy documents which contains one page with Four folds only. Neither the terms and conditions were supplied to the complainant till date by the opposite party nor the same was the part of the Insurance Policy. The officials of the opposite party at the time of issuing the said policy, took signatures of the complainant on blank Proposal Form. On 29.07.2009, the complainant who was working as Electrician with GE Air Force at Bhisiana, Air Force Station, Bathinda, at about 5.00 p.m., met with an accident with 11 KV wires. Due to this accident, his left arm upto elbow i.e. left hand and forearm alongwith half right foot amputated by the doctors at Bathinda. Firstly, he was taken to the Air Force Hospital and then shifted to Nagpal Hospital, Bathinda due to serious burnt injuries and then shifted to Chabra Hospital, Bathinda where his above said body parts were amputated by the Doctors. After examining the complainant, the team of the Doctors of the office of Civil Surgeon, Bathinda, issued the Permanent Disability Certificate No.1390 to the complainant to the extent of 80% on 28.10.2009. The complainant lodged the claim with the opposite party in December 2009 after obtaining the Permanent Disability Certificate alongwith all requisite documents. As per Policy terms on the Permanent Disability to the insured, the claim is payable i.e. monthly installments equal to the Sum Assured and the quarterly premium waived to the insured. The complainant approached several times to the opposite party but they did not listen to him and claim is still pending with them and has also charged the payment of quarterly renewal premium against the policy terms from the complainant and the complainant now paid 5 installments of Rs.2,641/- per quarter i.e. total Rs.13,205/- against the terms and conditions of the Policy. The opposite party neither released the monthly installments to the complainant as per Disability benefits under the said Policy nor waived the quarterly premium to the complainant and more then 1-1/2 years lapsed, the claim is still pending with them and no intimation with this regard, has been received by the complainant. 6. The learned counsel for the opposite party has submitted that after receiving the intimation regarding the claim of the complainant, it has been observed that the Doctor has issued Disability Certificate to the complainant only to the extent of 80% disability which does not fall within the ambit of Total & Permanent Disability as per terms and conditions of the Policy. For this, the opposite party has relied upon the Condition No.10-4 of the terms and conditions of the policy which is reproduced as under :- “The disability 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 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 liability.” After perusing the documents and claim Form, the complainant was informed that since the disability of the complainant is partial and the permanent disability claim is not payable as per terms and conditions of the Policy and he was advised to deposit the premium continuously. Thereafter, the complainant with 2/3 persons, visited the opposite party at Bathinda office. The officials of the opposite party explained the complainant that his accident benefit has been disallowed as the disability is partial and permanent. It is clearly mentioned in the terms and conditions of the Policy that after the accident and disability, Life Assured has not obtained any wages, compensation or profit. The complainant being Govt. employee and is serving Air Force, Bhisiana as Electrician and is working even after the accident and has been withdrawing his salary. On receipt of letter dated 24.01.2011, the repudiation letter has been sent to the complainant. The learned counsel for the opposite party has further submitted that if the complainant is disagree with the decision of the opposite party, he may appeal to the Zonal Manager of the opposite party for reconsideration of the claim as the complainant himself admitted the receipt of the Policy. The officials of the opposite party has not obtained the signatures of the complainant on blank Proposal Form. After the receipt of Proposal Form from the complainant, the policy has been issued as per rules and guidelines of IRDA. As per documents and record produced by the complainant, he has suffered amputation of left forearm above elbow and amputation of two toe (Rt.) foot which does not fall within the ambit of Total and Permanent Disability as per terms and conditions of the Policy. The opposite party has refused to pay the claim of the complainant. 7. The Policy purchased by the complainant was Endowment Assurance Policy with Profits + A.B. vide Ex.C-2. According to this Policy, the condition and privileges within referred to 10-1 (a) & (b) and 10-4 which is read as under :- “10-1. Disability Benefit : If while this policy is in force for the full Sum Assured, the Life Assured, prior to the policy anniversary which the age nearer birthday of the Life Assured is 70 years becomes subject to a disability as herein after defined and proves the same to the satisfaction of the Corporation as herein after provided, the Corporation agrees to waive the payment of future premiums upto an assurance of Rs.20,000/- on the following conditions. (a) The maximum aggregate limit of assurance under all Policies issued by the Corporation upon the same life to which the benefit of the waiver will apply, shall not in any event exceed Rs.20,000/-. If there be more policies than one and if the total assurance exceeds Rs.20,000/- the waiver shall apply to the first Rs.20,000/- assured in order of the date of Policies issued. The premiums paid after satisfied proof of such disability is furnished to the Corporation, shall be only for the assurance, if any, exceedings the maximum aggregate limit. (b) The waiver of the premiums shall extinguish all options under this policy except as to such assurance, if any, as exceeds the maximum aggregate limit of Rs.20,000/- and which may have been kept in force by continued payment of premiums. 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 as or above the ankle, shall also be deemed to constitute such disability.” 8. A perusal of Ex.C-3 shows that Electrical burn injury - left hand and right foot – Amputation done. Patient advised left hand amputation but refused by patient discharged on request. The Ex.C-4 shows that the complainant approached Chabra Hospital. In Operative Notes, it has been mentioned that :- “Amputation of left upper limb through mid forearm level, BB and debridement of infected raw areas LA on 20.08.2009. Amputation of 4th toe right foot and part of right forefoot and secondary closure of raw area SA on 25.08.2009.” The operative note clearly shows that the complainant has been operated for left arm above wrist and toe of right foot. The hand alongwith half right foot toe amputed in circular shape as shown in photograph. The clause 10-4 of the Policy which has been clearly interpreted by Hon'ble H.P. State Consumer Disputes Redressal Commission, Shimla in case titled Life Insurance Corporation of India & Another Vs. Om Prakash , F.A.No.306 of 2008, decided on 18.12.2009, the Hon'ble State Commission has followed the law laid down by the Hon'ble Supreme Court in case titled Vikram Greentech India Limited and Another Vs. New India Assurance Company Ltd., (2009) 5 Supreme Court Cases 599. 9. In the present case, the opinion taken by Sehgal Health Care Clinic is read as under :- “In the present case, the disability is not 100% and only one limb (upper limb amputation above wrist) is involved. The amputation of toe of right foot can not be taken into consideration as per policy para 10-4. So, the claim is disallowed. (Not payable).” 10. Again the opposite party vide letter dated 11.05.2010 closed the file of the complainant and the Manager requested the complainant to get the opinion of their DMR whether the claim for disability is payable or not. 11. A perusal of documents and photographs placed on file shows that the amputation of left arm upto Elbow i.e. left hand and forearm alongwith half right foot, 80% disability certificate has been issued to the complainant by the office of Civil Surgeon, Bathinda whereas according to condition No.10-4, disability 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 as or above the ankle, shall also be deemed to constitute such disability. 12. In the present case, the complainant has suffered 80% disability and he is an Electrician earning his livelihood by doing electrical work which means he is technical person. No technical person can work with one arm and his toe has also been amputed in the circular form which makes him difficult to work. Hence, the complainant is within ambit of condition No.10-4. A perusal of documents shows that he has filed claim vide Ex.C-16 on 12.12.2009. As per settled law by the Hon'ble Supreme Court in case titled U.I.I.C. Vs. MKJ Corporation, 1996 (3) CPJ 8 SC wherein, the Hon'ble Supreme Court held that the claim should be settled with in 2 months. Thereafter, the opposite party has been charging quarterly installment of Rs.2,641/- per quarter and has charged in total Rs.13,205/-. 13. Therefore, in view of what has been discussed above, this complaint is accepted with Rs.10,000/- as cost and compensation and the opposite party is directed to pay all the benefits applicable under the Table 014 11 11 of the Policy. Compliance of this order be done within 45 days from the date of receipt of copy of this order. 14. A copy of this order be sent to the parties concerned free of cost and file be consigned for record. '
Pronounced in open Forum 21-04-2011 (Vikramjit Kaur Soni) President
(Dr.Phulinder Preet) Member
(Amarjeet Paul) Member |
