Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 492.
Instituted on : 11.10.2018.
Decided on : 30.11.2023.
Joginder (in coma) age 30 year s/o Sh. Randhir Singh s/o Sh. Deep Chand through his wife Smt. Poonam w/o Joginder being next friend and natural guardian of the Joginder R/o VPO Jassia, Distt. Rohtak.
..............Complainant.
Vs.
- The Life Insurance Corporation of India, Through its Sr. Divisional Manager/incharge, having its Office at Subhash Road, Opp. Radio Station, Rohtak.
- Dr. Karmvir Singh, RCI-A17877, Psychologist, Civil Hospital Rohtak.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh.Anurag Malik, Advocate for the complainant.
Sh.V.K.Groha, Advocate for the opposite party No.1
Opposite party No.2 given up.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per the complainant are that he had purchased a life insurance policy from the opposite party No.1 in his name vide policy No.1799-1263-7 dated 28.01.2015 for a term of 21 years. The agent of opposite party No.1 told the complainant that in case of disability or unableto earn his livelihood due to disability, remaining premium of above said policy will be paid by the LIC and the insurance policy will continue and provide all benefits without payment of further premium. On 29/04/2016 complainant met with road accident and sustained serious and grievous head injuries and remained in coma since date of accident. The complainant was firstly admitted in P.G.I.M.S., Rohtak and on the same day he was shifted to Maharaja Aggarsain, Hospital, New Delhi and thereafter he was admitted at Mansarovar Hospital, Rohtak and was discharged on 23/06/2016. The family members of complainant has spent Rs.12 lacs on the treatment, medicine etc.. The permanent disability of complainant was assessed by the board of Doctors of Civil Hospital, Rohtak and his permanent disability was assessed 90%. After accident complainant is mentally and physically challenged person and unfit to join any kind of job due to permanent disability. As such complainant is total permanent disabled and unable to earn anything through his life and required all time attendant for rest of his life. The board of doctors had confirmed that complainant is total permanent disabled and unable to earn anything throughout his life and required full time attendant. As per life insurance plan, complainant is entitled for waiver of premium in case of disability/unable to earn anything. The opposite party No.1 again and again asked for premium payments whereas, complainant is not liable to pay further installments. Thefamily members of complainant have deposited one half yearly installments of Rs.5613/- under protest on repeated requests of O.P. No.1 and O.P. No.1 is liable to refund the same. Hence there is deficiency in service on the part of opposite party No.1and it is prayed that opposite party may kindly be directed to refund the amount of Rs.5,613/- alongwith interest @ 15% p.a. from the date of payment till its actualto the complainant. Opposite party no.1 be further directed to waive further premium installment which are due after the day of accident i.e. 29/04/2016 and to give all the benefits of life Insurance policy, to pay an amount of Rs.50,000/- towards compensation for causing mental & physical harassment and Rs.25000/- as litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite parties. Opposite partyno.1 filed its reply and has admitted that the respondent has issued a Policy no.179912637 on the life of Sh. Joginder S/o Sh. Randhir Singh with Date of commencement 28-01-2015 for Sum assured of Rs.2.00Lacs under Plan & Term: 815-21-21 and nominee is Smt. Poonam (Wife) and the said policy was issued subject to terms and conditions printed on the policy bond which resulted into contract. It is further submitted that required disability claims forms & other required documents are not submitted by the life assured to the respondent till date. After receipt of the requirements i.e Form No. 5279, Form No. 5280, Form No.5133, treatment details, cause of disability, FIR & MLC claim will be considered by respondent as per terms and conditions of the policies. It is submitted that on the receipt of all relevant documents and others forms regarding settlement of disability claim of LA will be considered. It is further submitted that there is no deficiency in service on the part of the respondent and dismissal of complaint has been sought. However, opposite party No.2 was given up by ld. counsel for the complainant vide his separate statement dated 04.02.2019.
3. Learned counsel for the complainant in his evidence has tendered affidavits Ex.CW1, documents Ex.C1 to Ex.C6 and has closed his evidence on dated 26.04.2019. Ld. Counsel for the complainant has also tendered documents Ex.C7 & Ex.C8 in additional evidence and closed his additional evidence on dated 20.11.2023. Learned counsel for the opposite party No.1 has tendered affidavit Ex. RW1/A, documents Ex.R1 to Ex.R4 and closed his evidence on dated 16.08.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case, the claim of the complainant has not been settled by the opposite party no.1 on the ground that required disability claims forms & other required documents are not submitted by the life assured to the respondent till date. Claim will be considered by respondent after receipt of the requirements i.e Form No. 5279, Form No. 5280, Form No.5133, treatment details, cause of disability, FIR & MLC. We have observed the documents placed on record by both the parties. As per disability certificate Ex.CW2 issued by office of Civil Surgeon, Rohtak on dated 21.06.2017, the complainant is 90% disable and was diagnosed for “Head injury 
severe hemiparesis and apheresis and severe level of intellectual IQ 30, Disabilities/functioning” . As per respondent no.1, complainant has not submitted the required documents for settlement of the claim, but on the other hand as per the letter Ex.C8 complainant has submitted form no.5280 but the opposite party has demanded form 5280-A. The other documents i.e. form no.5279 and form no.5233 are placed on record as Ex.C7 and also submitted to the opposite party. Hence it is proved that all the other documents have been submitted by the complainant. We have also observed the statement of Dr. Karamvir Singh dated 04.02.2019, as per which he has stated that: “he has seen the disability certificate of complainant issued by the office of Civil surgeon in which, he has signed in the capacity of Specialist and issued by the Civil Surgeon. In this certificate the disability is 90% and IQ level is 30. On that basis, complainant is unable to earn and complete any taskindependently”. Hence from the disability certificate and the alleged statement, it is proved that complainant was having 90% disability and was not able to do any task independently. On the other hand, Ld., counsel for the opposite party has placed reliance upon the law of Hon’ble Bombay High Court titled as LIC of India Vs. Ramesh Chandra on 11 April 1997, as per which it is submitted that : “The accidental injuries which independently of all other causes and within 120 days from 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 feet at or above ankles, or in the amputation of one hand at or above the wrist and one foot at or above the wrist ankles only constitute such disability. The case of the complainant is not of the amputation of both hands at or above the wrists or in the amputation of feet at or above ankles. The case of the complainant is the amputation of one hand at or above the wrist but that is not independently deemed to be a disability as is covered since thecoverage in the clause is only in cases of amputation of one hand at or above the wrist and one foot at or above ankle”. The above said authority is not fully applicable on the facts and circumstances of the case as in the present case, complainant is having 90% disability and he was suffering from Hemiplegia/hemiparesis and as per the definition given on the web, the meaning of Hemiplegia/hemiparesis is that : “Two of the most common secondary effects of TBI(Traumatic brain injury) are hemiplegia and hemiparesis. Hemiplegia describes paralysis on one side (left or right) of the body while hemiparesis describes weakness on one side of the body.Hence the injury of the complainant is more severe and he is unable to move. As such the repudiation of claim by the opposite party No.1 is illegal and amounts to deficiency in service.
6. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party No.1 to pay the claim amount as per terms and conditions of the policy and also pay Rs.20000/-(Rupees twenty thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
30.11.2023
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Nagender Singh Kadian, President
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TriptiPannu, Member.
……………………………….
Vijender Singh, Member
