Consumer Complaint No. 03 of 2016

Date of filing: 08.01.2016                                                               Date of disposal: 16 .8.2016

Complainant:               Smt. Anita Agarwal, W/o. Late Manoj Kumar Agarwal, 53, N.S. Road, Behind Jalan Bhaban, Near C.M.C. Club, Asansol – 713 301.

-V E R S U S-

Opposite Party:    1.     Branch Manager, L.I.C.I., Asansol Branch-2, G. T. Road, West End, Asansol – 713 304.

2.      Divisional Manager, L.I.C.I., Asansol Divisional Office, G. T. Road, West End, Asansol – 713 304.

Present:      Hon’ble President: Sri Asoke Kumar Mandal.

                        Hon’ble Member: Smt. Silpi Majumder.

           Hon’ble Member:  Sri Pankaj Kumar Sinha.

Appeared for the Complainant:            Mr. R.S. Ganguly, Authorized representative.

Appeared for the Opposite Party (s):  Ld. Advocate, Saurabh Dey.

J U D G E M E N T

This complaint is filed by the complainant u/S. 12 of the C.P. Act, 1986 against the Ops due to deficiency in service and unfair trade practice as the Ops have not settled the death claim of the life insurance policy of the life assured.

The complainant’s husband, since deceased, purchased two New Bima Kiran Policies (Premium Back Term Assurance with Loyalty Addition) one being No. 464236708 commencing from 18.3.2002, maturity on 19.3.2031 having death/maturity benefit of Rs. 3,70,000=00 and the other one being Policy No. 466332532 commencing on 14.8.2005, maturity on 24.8.2031 with death/maturity benefit of Rs. 5,80,000=00. Incidentally, the insured/policy holder died on 16.3.2010 in a traffic road accident. Death claim was submitted and the first policy being No.   464236708 had been properly settled and paid and there is no discrepancy and dispute in it. But the second policy being No. 466332532 has not been properly settled and paid. As per terms of the policy the complainant being the nominee and wife of the deceased policy holder is entitled to get the following benefit under the second policy being No. 466332532. Death benefit in the Policy No. 466332532 Rs. 5, 80,000=00 and additional sum equal to death benefit under this policy as per Clause 10 (b) in the policy condition printed in the policy Schedule Rs. 5, 80,000=00 i.e. total is being Rs. 11, 60,000=00 plus other benefits as Loyalty Addition along with the death benefit as per Clause 11 of the policy condition printed in the policy schedule. But the Ops paid only Rs. 5,80,000=00 + Rs. 1,30,000=00 = Rs. 7,10,000=00 instead of Rs. 11,60,000=00, being less amount of Rs. 4,50,000=00 and thus the nominee is entitled to get the balanced amount. The complainant repeatedly requested the Ops to make payment of the balance and due amount of Rs. 4, 50,000=00 in her various letters, the first on dated 28.6.2011 and the last on dated 10.02.2012. But no step on the matter has ever been taken on their part, which certainly amounts to negligence and deficiency in service on the part of the Ops. On behalf of the complainant Ld. Lawyer in his letter dated 13.5.2013 requested the Ops to look into the matter sympathetically and settle the claim. But the Ops replied in negative. The complainant then filed petition before the Insurance Ombudsman at Kolkata. Hearing of the petition as held on 21.11.2014 and decision as taken by the Ombudsman on 19.12.2014, wherein the Ombudsman principally admitted that “insurer displayed gross negligence in scrutinizing the printed document before it was approved for issue. However, the product along with the premium rate and benefit structure is approved by IRDA. The complainant cannot possibly demand better benefit after paying the identical premium for the same product latching on to a mistake in printing. There is no deficiency in service and the action on the insurer is correct. The complaint is dismissed as without any merit”. The decision of Ombudsman has been sent to the complainant vide Award No. O/KOL/A/LI/0147/2014-2015, dated 30.12.2014 wherein liberty has been given to the complainant to move a fresh application at any other Forum/Court which she may consider and deem fit and proper in the eventually of her disagreeing with the said award/decision of Ombudsman. Hence, being aggrieved and dissatisfied with the above award passed by the Ombudsman, the complainant files the instant petition before the district Consumer Forum for justice and compensation due to her sufferings in various ways due to non-receipt of actual and legitimate claim. Hence, the complainant files this complaint with a claim of Rs. 4, 50,000=00 towards non-paid and due amount, Rs. 1,00,000=00 for harassment and loss and Rs. 10,000=00 for litigation cost along with interest and other benefits.

The Ops have contested the case by filing written version jointly. In their written version the Ops have admitted that the husband of the complainant purchased two New Bima Kiran Policies (Premium Back Term Assurance with Loyalty Addition) one being No. 464236708 commencing from 18.3.2002, under Table 150, maturity on 19.3.2031 having sum assured of Rs. 3, 70,000=00 with accidental benefit of Rs. 3,70,000 and the other one being Policy No. 466332532 commencing on 24.8.2005, under Table & Term: 15-25, maturity on 24.8.2031 having sum assured of Rs. 5, 80,000=00 with accidental benefit of Rs. 1,30,000=00. Both claim was submitted when the first policy being No. 464236708 have been properly settled. The deceased purchased thee policy being No. 464236708 with accidental benefit of Rs. 3, 70,000=00 under Table No. 150 and the life assured stated his above policy number in his last proposal form dated 30.7.2005, these Ops accepted the last policy being No. 466332532 under Table No. 150 having sum assured of Rs. 5,80,000=00 with accidental benefit of Rs. 1,30,000=00 and the said accidental benefit of Rs. 1,30,000=00 was accepted as per terms and condition of the policy in Table No. 150 under Head ACCIDENT BENEFIT AND DISABILITY BENEFIT as well as Clause 10 of the policy Bonds where total accident benefit is limited to Rs. 5,00,000=00. Before accepting the last policy being No. 466332532 annual premium of Rs, 7,799=00 was calculated for sum assured of Rs. 5,80,000=00 with admissible accident benefit of Rs. 1,30,000=00 and subsequently the policy was issued with yearly premium of Rs, 7,799=00.  After accepting the said policy bond the life assured tendered his annual premium of Rs, 7,799=00 from 24.8.2005 to till death on 16.3.2010 for covering of sum assured for Rs. 5,80,000=00 with admissible accident benefit of Rs. 1,30,000=00 and during currency of the aforesaid policy, the life assured did not raise any question regarding accident benefit of Rs. 1,30,000=00 for policy No. 466332532 before these Ops which clearly indicates that the life assured was fully satisfied with sum assured for Rs. 5,80,000=00 having accident benefit of Rs. 1,30,000=00 for yearly premium of Rs. 7,799=00 under policy No. 466332532. The Ops also calculated annual premium i.e. Rs. 7,799=00 by giving rebate under Table No. 150 with term of 25 years. Since as per terms and conditions of the policies, maximum accident benefit for the aforesaid two policies in question under Table No. 150 was limited to Rs. 5,00,000=00 and yearly premium of the policy being No. 466332532 was fixed by these Ops for Rs. 7,799=00 for covering sum, assured of Rs. 5,80,000=00 with admissible accident benefit of Rs. 1,30,000=00 which is also supported by the premium calculation and as such the deceased life assured tendered the said premium of Rs. 7,799=00 throughout the currency of the policy for keeping his policy in force status for the sum assured Rs. 5,80,000=00 with admissible accident benefit of Rs. 1,30,000=00 and as such there is no deficiency of service for settlement of the claim in question.  As the maximum limit for accident benefit under Table No. 150 if Rs. 5,00,000=00, therefore, the complainant is not at all entitled to get the additional payment of Rs. 4,50,000=00 along with harassment, loss and litigation cost.

Decision with reasons:

            The complainant and the Ops filed written notes of argument by adducing evidence on affidavit. The ld. Advocate on behalf of the complainant argued on several points. Firstly, the ld. Advocate on behalf of the complainant submitted concerned two policies on which it was written on the back of the first policy being No. 464236708 commencing from 18.03.2002 under heading Accident Benefit under Clause 10(b): Death of the life assured: to pay additional sum equal to the death benefit under this policy, if the Life Assured shall sustain any bodily injury resulting solely and directly from the accident caused by outward, violent and visible means and such injury shall within 180 days of its occurrence solely, directly and independently if all other causes result in the death of the Life Assured. “However such additional sum payable in respect of all the policies taken under this plan and under Bima Kiran Plan (T. No. III) on the same life to which this benefit will apply, shall not exceed Rs. 5, 00,000=00.” But in case of policy No. 466332532 in which death benefit/maturity benefit was assigned to the tune of Rs. 5, 80,000=00 and in this policy under heading Accident Benefit under Clause 10(b): it has been categorically mentioned in the following words. “to pay additional sum equal to the death benefit under this policy, if the Life Assured shall sustain any bodily injury resulting solely and directly from the accident caused by outward, violent and visible means and such injury shall within 180 days of its occurrence solely, directly and independently if all other causes result in the death of the Life Assured.” In this policy taken in the year 2005 the commencement on 24.8.2005 “however such additional sum payable in respect of all the policies taken under this Plan and under Bima Kiran Plan, (T. No. III) on the same life to which this benefit will apply shall not exceed Rs. 5,00,000=00” has been omitted as it was written in the policy of the 2002 and that is why the insured had taken another policy in the year 2005. In view of the policy conditions it is absolutely wrong interpretation that only Rs. 5,00,000=00 is payable as accidental benefit in both the policies. Therefore, the complainant claimed to get the accidental benefit under the policy being No. 464236708 of the year 2002 to the tune of Rs. 3,70,000=00 + Rs. 3,70,000=00 i.e. Rs. 7,40,000=00 and under the policy No. 466332532 of the year 2005 to the tune of Rs. 5,80,000=00 + Rs. 5,80,000=00 i.e. total of Rs. 11,60,000=00.

The LIC(I) is functioning for protection of policy holders’ interest strongly as per the Regulations of IRDA, Govt. of India and other laws of the country. The complainant also submitted a letter from LIC reference No. CRM/EZO/TB in reply to the complainant’s letter dated 01.02.2015 “that the maturity benefits, death benefits and accidental benefits along with all other benefits are payable as per the laid down terms and conditions of the respective policies which are clearly defined and printed in the policy bonds”. So the complainant claimed Rs. 5, 80,000=00 + Rs. 5, 80,000=00 for the second policy No. 466332532of year 2005.

            Ops took the plea that additional sum payable in respect of all the policies taken under this Plan and under Bima Kiran Plan (T. No. III) on the same life to which this benefit will apply shall not exceed Rs. 5,00,000=00. So the complainant is entitled to get Rs. 5, 00,000=00 as additional sum for both the policies i.e. policy No.  464236708 of the year 2002 and policy No. 466332532 of the year 2005. Accordingly, they have paid Rs. 3, 70,000=00 as additional sum and Rs. 5,00,000=00 – Rs. 3,70,000=00 = Rs. 1,30,000=00. Yearly premium has been accordingly calculated under Table No. 150 with term of 25 years having sum assured for Rs. 5,80,000=00 with admissible accidental benefit of Rs. 1,30,000=00 at age 35 by fixing annual premium as Rs. 7,799=00. By giving rebate for the said premium taking into account of the first policy being No. 464236708 of the year 2002 i.e. they have depended their support on the aggregate additional benefit payable under the same table as Rs. 5, 00,000=00 as mentioned in the first policy which they have admitted that this clause has been omitted in the second policy as terms and conditions as mistake of printing. So the complainant has been paid Rs. 3, 70,000=00 for the first policy and Rs. 1, 30,000=00 for the second policy. Therefore, the complainant cannot claim Rs. 5, 80,000=00 for the second policy taken by the complainant, as additional benefit.  

            Perused all the documents adduced by the complainant and the Ops. It is observed that the Ops have omitted to include the terms and conditions of total aggregate for accident benefit of Rs. 5, 00,000=00 has been omitted incidentally. But this plea i.e. omission of including any vital point on the policy in question, by the Ops cannot be entertained as it has been decided by the Hon’ble National Commission reported in 2012 (4) CPR 677 (NC) in the case of SBI Life Insurance Company Limited Vs. Smt. Khursheed Jahan Begum & Anr. wherein it has been mentioned that  ‘insured cannot be penalized for fault of Insurance Company’. However, the first policy has commenced in the year 2002 and the second policy has commenced in the year 2005 i.e. the Ops have got enough opportunity to rectify the terms and condition as mentioned in the second policy. Lastly, the letter from Assistant Secretary, CRM/EZO/LIC vide their letter No. CRM/EZO/TB that the maturity benefits and accidental benefits along with all other benefits are payable as per terms and conditions laid down in the respective policies which are clearly defined and printed in the policy bonds. As in the second policy it has been clearly defined and printed in the policy that the additional benefit will be equal to the sum assured. As the sum assured for second policy is Rs. 5, 80,000=00, therefore, the accidental benefits will be equal to Rs. 5, 80,000=00. As there has been no mentioning of the clause of total aggregate, accident benefit under the same table shall not exceed Rs. 5, 00,000=00,  hence, the complainant is entitled to get Rs. 5, 80,000=00 as accident benefit for the second policy. As the complainant has been already paid Rs. 1, 30,000=00 as accident benefit for the second policy being No.  466332532, so the complainant is entitled to get further amount of Rs. 4, 50,000=00 (Rs. 5, 80,000 – Rs. 1, 30,000) for the second policy. Accordingly, the complaint of the complainant succeeds.

            Fees paid is correct.

            Hence, it is

O r d e r e d

that the complaint is allowed on contest with cost agaisnt the Ops. That the complainant does get an award and the Ops are directed to pay either jointly or severally Rs. 4,50,000=00 (Rs. Four lakh fifty thousand) only to the complainant as balance amount of accidental benefit within 45 (forty five) days from the date of passing of this award, in default, it will carry penal interest @8% (eight per cent) per annum till realization and the Ops are further directed to pay either jointly or severally Rs. 5,000=00 (Rs. Five thousand) only as compensation for harassment, mental pain and agony and Rs. 2,000=00 (Rs. Two thousand) only as litigation cost within 45 (forty five) days from the date of passing of this award, failing which, the complainant will be at liberty to put the entire award in execution as per provisions of law.

            Let plain copies of this final order be supplied to the parties free of cost as per provisions of law.

                   (Asoke Kumar Mandal)        

             Dictated and corrected by me.                                                  President      

                                                                                                          DCDRF, Burdwan

                    (Pankaj Kumar Sinha)

                            Member

                     DCDRF, Burdwan

                                                      (Silpi Majumder)                        (Pankaj Kumar Sinha)

                                                             Member                                             Member

                                                     DCDRF, Burdwan                            DCDRF, Burdwan