BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,FATEHABAD.
Complaint No.:195 of 2018. Date of Instt.: 18.07.2018.
Date of Order: 29.05.2019.
Kulvinder Singh @ Kulvinder Singh, age about 30 years, son of Gora Singh, resident of Ward No. 1, village Pirthala, Tehsil Tohana, District Fatehabad.
…Complainant.
Versus
1.Life Insurance Corporation of India, Branch Ratia Road, Tohana, District Fatehabad through its Branch Manager.
2. Life Insurance Corporation of India, SCO No. 3, 4 and 5, Sector-1, HUDA, Rohtak through its Divisional Manager.
…Respondents/OPs
Complaint U/s 12 of the Consumer Protection Act,1986.
Before: Sh.Raghbir Singh, President.
Sh.Jasvinder Singh, Member.
Present: Sh. Vinay Sharma, Advocate for the complainant.
Sh. S.K. Dharnia, Advocate for the Ops.
ORDER
The present complaint under Section 12 of the Consumer Protection Act, 1986 has been filed by the complainant against the Opposite Parties (hereinafter to be referred as OPs) with the averments that he got his life insured from Ops vide policy no. 179529292 commencing from 28.4.2014 and thereafter the complainant was paying its regular installments amounting to Rs.48,011/- each on half yearly basis and in this way the complainant had paid total seven installments to the Ops in the abovesaid policy. It is further submitted that at the time of purchase of the said policy Ops got conducted the medical examination of the complainant and he was declared fully fit as he was not suffering from any disease and thereafter the policy in question was issued. At the time of purchase of the policy in question it was agreed by the Ops that in case the complainant becomes permanent disable due to any disease or permanent loss of any part of body, in that eventuality the Ops will be liable to pay the sum assured of the policy.
2. It is further submitted that on 16.8.2017, the complainant was declared as 100% blind (disable from his both eyes) by Chairman, Handicapped Board-cum-Civil Surgeon, Fatehabad vide certificate no. 1187. It is further submitted that the complainant became permanent blind due to the reason that on 17.2.2017 at about 6 p.m. the complainant was going from his village Pirthala to Fatehabad on a motorcycle and when at about 6.30 p.m. the complainant reached in front of the bus stand, Bhuna then at that point a truck came from opposite side in a rash and negligent manner and on account of the speed of the truck a cloud of dust was being thrown. When the complainant was crossing the truck then a cloud of dust fell into the eyes of the complainant . On account of the same, the complainant felt pain in his eyes and as such he purchased eye drop from a medical store and put the drops in his eyes regularly .
3. It is furhter submitted that on 21.3.2017 an FIR No. 122 under Section 395 IPC was registered against the complainant in Police Station Sadar, Tohana and the complainant was arrested in that case and put into custody in Central Jail Hisar where he felt pain and swelling in his eyes. Therefore, the jail authroities produced the complainant in hospital of the Central Jail, Hisar on 21.4.2017 wherein the complainant was examined by the doctor and it was opined by the doctor that the complainant has completely lost vision in the left eye and the vision in the right eye has also decreased. Thereafter, on 25.4.2017 the complainant was once again examined by “Ophthalmic Surgeon” at Maharaja Aggarsain Medical College, Agroha and was diagnosed “Retinitis Tigmentosa”. Thereafter, the complainant was furhter referred to PGIMS Rohtak for further examination for 27.4.2018. It is further submitted that after sometime the complainant lost his vision of right eye also and he became completely blind. Due to cloud of dust the complainant has suffered complete loss of vision his both eyes and now complainant is 100% blind and unable to perform his casual as well as regular work and confined to bed.
4. It is further submitted that thereafter the complainant approached to OP no. 1 for getting insurance claim as per terms and conditions of the policy. On asking of OP no. 1, the complainant submitted his original policy bond with OP no. 1 and it was assured that the claim will be passed within a few days. Thereafter, the complainant visited the Ops many a times but no heed was paid on the request of the complainant by the Ops and ultimately Ops refused to give any claim to the complainant. It is further submitted that the abovesaid act on the part of Ops amounts to deficinecy in rendering service to the complainant and as such the complainant is also entitled for compensation. The complainant has further prayed that the Ops may be directed for making a payment of Rs.14 lakh i.e. the sum assured of policy alongwith interest with effect from 16.8.2017 till the date of actual payment. The complainant has also prayed that a compensation of Rs.2 lakh may be granted in his favour on account of mental agony and harassment suffered by him. Hence, the present complaint.
5. Ops appeared through counsel and filed a joint written statement wherein various preliminary objections with regard to cause of action, locus standi, maintainability and concealment of true and correct facts etc., have been raised.
6. In reply on merits, it is admitted that the Ops had issued an insurance policy on the life of the complainant with date of commencement as 28.4.2014 and the sum assured was Rs.14 lakh. It is further submitted that after submission of the claim the complainant was asked to submit the claim papers and other necessary documents. In this regard, the Ops have written many letters to the complainant to provide the abovesaid documents but the same has not been submitted till now and the complainant has straightway filed the present complaint on a premature stage because the claim of the climanant is under process and waiting for the abovesaid doucments and as such the present complaint of the complainant is liable to be dismissed.
7. In the written statement, it is denied by the Ops that the complainant had submitted original policy bond. It is further submitted that the Ops have only received disability certificate, aadhar card, voter card and ration card. It is further submitted that there is no deficiency on the part of Ops in rendering service to the complainant and as such the present complaint is liable to be dismissed.
8. The learned counsel for the complainant tendered in evidence affidavit of the complainant as Annexure CW1/A alognwith the documents as Annexure C-1 to Annexre C-6 and closed the evidence of the complainant. On the other hand, the learned counsel for the Ops tendered in evidence affidavit of Rajendra Singh Manager (Legal) as Annexure R-1 on bhalf of the Ops alongwith the documents as Annexure R-2 to Annexure R-23 and closed the evidence of the Ops.
9. In the present case, the arguments was previously heard. During arguments the Ops had taken a plea that the requisite documents have not been furnished by the complainant and as such the decision regarding the insurance claim of the complainant has not been taken till date and the matter is pending. Therefore, vide order dated 9.1.2019 the complainant was directed to submit copy of the FIR and Form no. 5279 and 5280 or any other relevant document which the complainant considers it appropriate for the proper deicison of the insruance claim to the Ops within a period of 15 days. The Ops were further directed to take decision regarding the insurance claim of the complainant within a period of 21 days from the date of receipt of the abovesaid document from the complainant. The case was further adjourned for submitting decision regarding the insurance claim of the complainant by the Ops.
10. In compliance of the order dated 9.1.2019, the relevant documents were submitted by the complainant before the Ops for taking decision regarding his insurance claim. After receiving the documents the Ops considered the insurance claim of the complainant and repudiated the same vide letter dated 25.3.2019 on the ground that as per terms and conditions of the insurance policy disability claim is payable if disability is due to accident and would be occurred within 180 days from the date of accident. In the present case, the cause of disability is Retinitis Pigmentosa and the abovesaid disease is congential i.e. since birth and as such the insruance claim of the complainant does not fall within the purview of the insurance policy. The repudiation letter dated 25.3.2019 is placed on record as Annexure R-22.
11. We have duly heard the arguments advanced by learned counsel for both the parties and have also perused the documents placed on record. It is not disputed that the complainant had purchased an insurance policy of Rs.14lakh from the OP commencing from 28.4.2014. It is also not disputed that 7 installments of Rs.48011/- each were deposited by the complainant with the Ops as premium. It is also not disputed that as per the insurance policy in the event of accidental death or permanent disability the insurance benefits are payable to the life assured. It is also not disputed that the complainant was declared 100% permanent physical impairment/blindness. The same is also evident from the certificate dated 16.8.2017 (Annexure R-3) issued by Chairman Handicapped Board- cum-Civil Surgeon Fatehabad. It is the case of the complainant that at the time of purchase of the insurance policy in question it was agreed by the Ops that in case the complainant becomes permanent disable due to any disease in that eventuality insurance claim will be paid to him. It is also further the case of the complainant that on 17.2.2017 when he was going to Fatehabad from his village and when he reached near bus stand Bhuna a truck came from opposite side in a very rash and negligent manner throwing the cloud of dust and the dust fell into the eyes of the complainant. On account of the abovesiad incident an infection got in his eyes and he became disabled. Therefore, the case of the complainant for grant of insurance claim falls within the purveiw of the terms and conditions of the insurance policy.
12. On the other hand, it is the case of the Ops that the complainant suffered disability on account of a disease namely, Retinitis Pigmentosa which is an inhereted disorder. Therefore, the disability in the case of the complainant is not on account of an accident and as such the complainant is not entitled for insurance claim for disability as per terms and conditions of the policy.
13. From perusl of the insurance policy, it is evident that in the event of permanent and total disability of the life assured the insurance benefits are payable. It has been further clarified in the insurance policy placed on record that the permanent disability of the life assured must be a result of an accident. Therefore, the core issue to be decided by this Forum in the present case is as to whether the complainant has suffered disability in the present case on account of an accident or not. From perusal of the documents placed on record as Annexure C1, Annexure C-2 and Annexure C-6, it is evident that the permanent disability to the complainant is on account of a disease namely Retinitis Pigmentosa. From perusal of the medical literature placed on record by the Ops, it is revealed that the Retinitis Pigmentosa is an inherted disorder and therefore not caused by injury/infection or any other external or environmental factors and people suffering from Retinitis Pigmentosa are born with the disorder already programmed into their cells. Moreover, the Senior Medical Officert Civil Hospital, Fatehabad vide his report Annexure R-14 has opined that the disability to the complainant/life assured has been caused by the disease namely, Retinitis Pigmentosa and the same is congenital which means the disease by birth.
14. In view of the aforesaid discussion, we have no hesitation to conclude that in the present case the permanent disability to the complainant has not occurred on account of an accident and the same is a result of a disease which is an inhereted disorder. In the terms and conditons of the insurance policy placed on reocrd, it is clarified that the disability referred in the insurane policy must be a disability which is the result of an accident and the same must be permanent. In the present case, since the disability is not a result of the accident and as such the repudiation of the insurance claim by the Ops of the complainant is justified. We are, therefore, of the considered opinion that there is no deficiency on the part of Ops in rendering service to the complainant in repudiating the insurance claim of the complainant. So, the complainant is not entitled for insurance claim.
15. From documents i.e. the reciept issued by life insurance company placed on record, it is revealed that the last installment of the premium was paid by the complainant on 22.7.2017. The learned counsel for the complainant during arguments submitted that since the complainant has become permanent disable and as such he is not in a position to make payment of the installments of premium. In view of all the facts and circumstances of the case and by taking a sympethetic view, we direct the Ops to refund of the amount of all the installments of premium paid by the complainant to the Ops alongwith interest at the rate of 8% per annum from the date of payment till realization. The abovesaid order be complied with within a period of 45 days, otherwise the abovesaid amount shall carry an interest at the rate of 9% per annum during the period of default. With these directions, the present complaint is disposed of accordingly. Copy of this order be supplied to both the parties free of cost. File be consigned to the record after due compliance.
Announced in open Forum. Dated:29.05.2019
(Raghbir Singh) President
(Jasvinder Singh) Member
