BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.184 of 2016

Date of Instt. 25.04.2016

Date of Decision: 24.07.2018

Bachan Singh son of Sh. Arjan Singh, house No.1579, Ward No.8, Near Akali Gurudwara, Village and Post Office, Begowal, District Kapurthala.

..........Complainant

Versus

1. Life Insurance Corporation of India, Divisional Office, Jeevan Parkash, Model Town Road, Jalandhar through its Senior Divisional Manager.

2. Manager (Claims) Life Insurance Corporation of India, Divisional Office, Jeevan Parkash, Model Town Road, Jalandhar.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. KC Malhotra, Adv Counsel for the Complainant.

Sh. SC Sood, Adv Counsel for the OP No.1 and 2.

Order

Karnail Singh (President)

1. This complaint is presented by the complainant, wherein alleged that the complainant is a senior citizen. A life insurance policy was obtained by Inderjit Singh son of the complainant, vide life insurance policy bearing No.132063073 for Rs.8,00,000/- under plan Jeevan Anand with accident benefits Table No.147 for term 16 years through its authorized agent with OP No.1 through Branch Office, Kartarpur under the Supervisory and Administrative Control of OP No.1. That due to misfortune and ill-luck of the complainant Inderjit Singh died in car road side accident in Bemsheim (Germany) in foreign country on 11.03.2015. Deceased Life Assured succumbed to serious injuries sustained in road side accident in prime his youth at the age of 39 years. Due to untimely and unfortunate death of Deceased Life Assured, who is the only bread earner of the complainant and as such, the complainant and his family had gone under shock and grief, distress and trauma. Subsequent to the death by accident of life insured, his corpse (dead body) was brought to India for last religious ceremonies at his native village Begowal, District Kapurthala.

2. That subsequent to the cremation of deceased life assured, the complainant being nominee submitted an insurance claim for paying the claim i.e. sum assured and benefits and double accident benefit claim, as additional amount of sum assured covered under accident benefit because cause of death was road side accident. The death claim was registered by the OP along with that claim. The complainant also submitted prescribed claim form, death certificate and all the requisite necessary and relevant papers and documents relatable to death by accident of deceased life assured. In response to that claim, a claim for basic sum assured for Rs.11,76,000/- was paid on 07.05.2015. However, OPs have arbitrarily withheld double accident benefit claim for Rs.5,00,000/- unreasonable and inexcusable despotic and autocratic approach and functioning of OPs, till date. The complainant was awe struck, shocked and surprised to receive letter as reminder, reference claim/D/1061 dated 06.02.2016 from OP No.2, asking to submit attested copy of Post Mortem Report concerning death of deceased life assured for considering claim for double accident benefit under the policy subject matter of the complaint. The complainant had not received any such letter from OP No.2. Obviously, OP No.2 to cover up its inaction laxity and delaying tactics to sit over double accident benefit claim settlement to save itself from gallows of non-adherence of IRDAI statutory binding mandate and the executive instructions of its Central Office made up this poly to shift the blame on the complainant. The absence of Postmortem Report is purely technical objection and fallacy, which cannot be hurdle in any way of a valid claim. Moreover, PMR is not the only document to prove the death of DLA has taken place by accident and is not essential and necessary document in itself. The fact that no postmortem was conducted on dead body does not mean that no accident took place, which ultimately turned fatal for the insured. It is laid down clearly in instructions/guidelines of OPs that double accident benefit claim cannot be denied to the complainant and postmortem report and FIR not obligatory in every case. If the postmortem report and other medical treatment documents not produced, then duty casted upon the insurance company to call for alternative to such as statement of the eye witness to the accident, the result of our inquiries, investigation, attending physician or hospital certificate, which would be sufficient to establish that the death of the life assured was by way of accident not of other cause .

3. All such extenuating and extra ordinary circumstances and factors have not been considered and deliberately dilly-dallied DAB claim settlement unnecessarily and unwarranted, which tantamount to deficiency in rendering service and unfair trade practice and accordingly, a legal notice was served to the OP, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to settle and pay double accident benefit claim of life insurance policy No.132063073 for Rs.5,00,000/- additional sum assured for accident benefit claim and further interest thereon be also awarded @ 12% per annum from the date of lodgment of claim, till actual payment. OPs be further directed to pay compensation to the tune of Rs.2,00,000/- and litigation expenses of Rs.10,000/-.

4. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed its joint written reply and contested the complaint by taking preliminary objections that the complainant is estopped by his own act and conduct from filing the present complaint and further averred that the present complaint is pre-matured. It is further alleged that the OP has already been requested to the complainant and also sent letters to the complainant that the complainant should provide hospital treatment record, postmortem report and other documents relating to the alleged accident, but the complainant failed to provide the requisite documents and the OP could decide the matter only if the above said documents are provided in order to make a payment under double accident benefit claim. As per terms of the policy, the corporation shall not be liable to pay the additional sum referred in Section 10 (a) or (b), if the disability or death of the life assured shall;

i). Be caused by intentional self injury, attempted suicide, insanity and immorality or whilst the life assured is under the influence of intoxicating liquor, drug or narcotic

ii). Take place as a result of accident while the life assured is engaged in aviation or aeronautics in any capacity other than that of a fare paying, part paying, non paying passenger in any aircraft which is authorized by the relevant regulations to carry such passenger and flying between established aerodromes, the life assured having at that times no duties on board the aircraft or requiring descent therefrom; or

iii). Be caused by injuries resulting from riots, civil commotion, rebellion, war (whether war be declared or not), invasion, hunting, mountaineering, steeplechasing or racing or any kind or

iv). Result from the life assured committing any breach of law; or

v). arise from employment of the life assured in the armed forces or military service of any country at war (whether was be declared or not) and further submitted that the OP is a public undertaking and posses a public money and is to make the payment after considering the genuine claim. On merits, the claim of the complainant to the extent that the complainant is nominee of the insured Inderjit Singh and Inderjit Singh died and basic claim of the insurance i.e. Rs.11,76,000/- have been admittedly paid, but the remaining amount is not paid for want of some necessary documents. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merit and the same may be dismissed.

5. In order to prove the case of the complainant, the counsel for the complainant Sh. KC Malhotra, Adv tendered into evidence affidavits of the complainant Ex.CA and Ex.CB along with other documents Ex.C-1 Claimants Statement Form No.3783 (A), Ex.C-2 Legal Notice, Ex.C-3 to Ex.C-5 Postal Receipts, Ex.C-6 Letter dated 07.03.2016, Ex.C-7 to Ex.C-9 Postal Receipts, EX.C-10 OP Manager Claims Letter dated 03.03.2016, Ex.C-11 Letter dated 11.02.2016, EX.C-12 RTI Application dated 10.02.2016, Ex.C-13 Letter of Authority, Ex.C-14 ID Proof Driving License of complainant, Ex.C-15 Reply to RTI Application of the complainant and then tendered some other documents i.e. Ex.C-16 Letter dated 16.11.2016, Ex.C-17 Postal Receipt, Ex.C-18 and Ex.C-19 English Translation of Ex.C-20 and Ex.C-21, Ex.C-22 of documents received in Dutch Language from the Germany, Ex.C-23 Envelope, Ex.C-24 Death Information, Ex.C-25 No Objection Certificate, Ex.C-26 Dead Body Clearance Certificate, Ex.C-27 Copy of the Passport, Ex.C-28 Confirmation regarding death, Ex.C-29 Map of Place of accident, Ex.C-30 to Ex.C-37 Photographs of accident, Ex.C-38 Letter dated 19.06.2015, Ex.C-39 Letter dated 07.03.2016, Ex.C-40 to Ex.C-42 Postal Receipts, Ex.C-43 IRDAI Regulations 2015 and then closed the evidence.

6. Similarly, counsel for the OP No.1 and 2 tendered into evidence affidavit of Hari Shankar Gupta, Manager as Ex.OP/A and some documents Ex.OP/1 to Ex.OP/3 and then closed the evidence.

7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely and also perused the brief written arguments submitted by the counsel for the complainant.

8. The case of the complainant to the effect that the son of the complainant namely Inderjit Singh procured life insurance policy from the OPs bearing Policy No.132063073 for assured amount of Rs.8,00,000/- under plan Jeevan Anand and it is also not in dispute that the said policy having additional benefit of double accident benefit, but according to rule and regulation as incorporated on the insurance policy. Death of the insured Inderjit Singh and thereafter, dead body was cremated in his native village and then claim was filed by nominee i.e. complainant Bachan Singh and in response to that insurance claim, a basic insurance claim of Rs.11,76,000/- have been admittedly paid to the complainant being a nominee.

9. As the most of the case of the complainant is admitted, therefore, the documents, which are not necessary for the issue in dispute, is avoid to discuss just for repetition.

10. In this case, the dispute in issue is only whether the complainant is also entitled, in addition to basic insurance claim, for double accident benefit of Rs.5,00,000/- as claimed by the complainant and the said claim is not denied by the OP rather the plea taken by the OP is only that the said additional benefit can only be awarded to the insured if the requirement of the insurance policy, as enumerated itself in the insurance policy, is fulfilled and on this aspect, the OP alleged that the complainant miserably failed to supply the required document i.e. postmortem report and medical treatment document and regarding that so many letters were sent to the complainant, which are dated 06.02.2016 Ex.OP-2 and dated 11.02.2016 Ex.OP-1 and similarly, the complainant also produced on the file two letters concerning to this matter, which are dated 03.03.2016 Ex.C-10 and dated 11.02.2016 Ex.C-11. In response to aforesaid letters, the complainant has not given any specifical reply that why he is not producing the postmortem report, where from the cause of death is to be ascertained by the OP for settlement of the double accident benefit. The counsel for the complainant alleged that the said documents are not necessary for the settlement of the double accident claim and if the documents are not available, then it is the duty of the OP to get an alternative evidence/proof and got investigation from its own official, but this version of the complainant is not acceptable because it is not the case of the complainant that the said terms and conditions were not supplied to the insured at the time of supplying the copy of insurance. It is pertinent to mention here that the complainant has not intentionally and willfully produced on the file copy of the insurance policy just to conceal the factum that a Clause 10 (a) and (b) as referred by the OP, is to be concealed from the Consumer Forum, but at the time of argument, for assistance sake, we asked both the parties to produce the copy of insurance policy, so that this Forum should reach to the conclusion whether the terms and conditions were incorporated upon the insurance policy or not, if not incorporated/described on the insurance policy, then it means the said terms and conditions are separately retained by the insurance company and the same liable to supply and explain to the insured at the time of inception of the policy. But when the counsel for the OP produced the original insurance policy, which has been ordered to retain on the file (un-exhibited) and thereafter, we have gone through the said insurance policy and find that Section 10 and a and b are very well elaborated on the reverse side of the insurance policy. So, it means the said terms and conditions were well in the knowledge of the assured person at the time of purchasing the policy, therefore, these instructions are binding upon the insured person as well as upon the nominee i.e. Complainant.

11. From the perusal of the said terms and conditions, it is clearly established that the additional double accident benefit is not a legally claim of the complainant rather the said claim is to be paid on establishment of the some facts, which are required in the said terms and conditions and similarly has been incorporated by the OP in its written reply. It is very much necessary for the OP to get it assured whether the death of the insured was caused due to accident only or it is attempted to involve himself in accident or due to some insanity and whether he is under influence of intoxicant liquor, drug or narcotic. These factum can only be assessed from the postmortem report, wherein the cause of death have been very well explained by the doctor and viscera of the dead body was removed and sent to the chemical laboratory for test, where from the real cause of death or in regard to consuming of intoxicant or narcotic can be detected, but in the absence of the postmortem report, the insurance company cannot investigate the case of the insured, whether it is fall under the said Section 10/ a and b of the terms and conditions and if the case is not covered, then the complainant is not entitled for the said double accident benefit insurance claim. So, in this case, the complainant has not only supplied the postmortem report rather the complainant also did not cooperate the insurance company, therefore, we do not find any deficiency in service on the part of the OP and thus, we reach to the conclusion that there is no solid substances in the argument of the learned counsel for the complainant, therefore, the complaint of the complainant is dismissed with no order of cost. Parties will bear their own cost. The complaint could not be decided within stipulated time frame due to rush of work.

12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Harvimal Dogra Karnail Singh

24.07.2018 Member President