Punjab

Rupnagar

CC/18/29

Sham Lal - Complainant(s)

Versus

Life Insurance Corporation of India - Opp.Party(s)

Sh. Nikhil Badhwa, Adv

01 Aug 2018

ORDER

BEFORE THE DISTT. CONSUMER DISPUTES REDRESSAL FORUM, ROPAR

                                 Consumer Complaint No. :  29 of 24.04.2018

                                 Date of decision                    :     01.08.2018

 

Sham Lal, aged about 24 years, son of Dev Raj, resident of Village Barari, PO Basali, Tehsil Anandpur Sahib, District Rupnagar 

                                                                 ......Complainant

                                             Versus

  Life Insurance Corporation of India, Jeevan Jyoti Building Giani Zail       Singh Nagar, Rupnagar, through its Branch Manager. 

                                                                         ....Opposite Party

                                   Complaint under Section 12 of the                                                      Consumer Protection Act, 1986

QUORUM

 

                        SH. KARNAIL SINGH AHHI, PRESIDENT

                        SMT. SHAVINDER KAUR, MEMBER

 

ARGUED BY

 

Sh. Nikhil Badhwar, Adv. counsel for complainant  

Sh. H.C. Verma, Adv. counsel for O.P. 

 

                                           ORDER

 

              SH. KARNAIL SINGH AHHI, PRESIDENT

 

1.         Complainant has filed the present complaint seeking directions to the opposite party to pay the accident benefit under the insurance policy vide which the complainant was entitled for the monthly payment in installments spread over 10 years i.e. Rs.1250 per month an additional sum equal to the accident benefit sum assured under this policy and the future payment of premium was also to be waived off and to refund the preimiums paid by the complainant; to pay Rs.50,000/- on account of deficiency in consumer services may also be awarded in favour of the complainant and against the O.P.

 2.   Brief facts made out from the complaint are that complainant is having a insurance policy with O.P. No.1 vide policy No.165004878 have date of commencement 15.3.2012 thereafter he was regularly paying the premium. On 06.07.2017, the complainant met with an accident in the revenue limits of Village Ajampur on Nurpurbedi-Kangar road, at about 8.40 PM thereafter he was referred to the PGI Chandigarh where he was treated upon the right leg was amputated above knee and he remained admitted in PGI from 7.7.2017 to 21.7.2017 and he is still under treatment. Thereafter, the complainant approached the O.P. for the accident benefit under the insurance policy and submitted all the documents along with disability certificate vide which the he was entitled for monthly payment in installments spread over 10 years i.e. Rs.1250/- per month an additional sum equal to the accident benefit sum assured under this policy and the future payment of premium was also to be waived off. The complainant approached the office of OP  many times but of no use. The complainant was utterly shocked when OP vide letter dated 26.3.2018, has informed the complainant that the disability benefit is not payment as per 11 A terms and condition of the policy. Hence, this complaint. 

  3.  On notice, O.P. appears through counsel and filed written reply taking preliminary objections; that the present complaint is not maintainable; that the complainant has no locus standi to file the present complaint against the answering O.P.; that the complainant has no cause of action to file the present complaint. On merits, it is stated that a policy bearing No. 165004878 was issued to the complainant by O.P. on 15.3.2012 for a sum assured of Rs.1,25,000/- under T & T 165/15/15 and a quarterly premium of Rs.1531/-. The complainant has paid the premium till March, 2018 and the policy is inforce condition. As per the terms and condition of the policy under clause 11(a), the Disability Benefit is to be paid if the disability is the result of an accident, which must be total (100%) and permanent and such that the life assured thereafter can never ever sufficiently do any work, occupation or profession or follows to earn or obtain any wages, compensation or profit. The disability certificate issued by the PGI clearly mentions the percentage of disability as 85% and not 100%. Rest of the allegations made in the complaint have been denied and prayer has been made dismissal thereof.   

4.    On being called upon to do so, the complainant has tendered his duly sworn affidavit Ex.CW1/A along with documents Ex.C2 & Ex.C4 and closed the evidence. The learned counsel for the O.P. has tendered sworn affidavit of Sh. JPK Minhas, Manager Legal Ex.OP1 along with documents Ex.OP2 to Ex.OP6 and closed the evidence.    

6.    We have heard the learned counsel for the parties and have gone through the record of the file, carefully.

7.    Complainant counsel Sh. Nikhil Badhwar, argued that Sham Lal (Complainant) was having an insurance policy issued by the O.P. with commencement 15.3.2012 and it was a long term policy against accident etc. On 06.07.2017,  the complainant when met with an accident at about 8.40 PM then remain admitted in PGI, Chandigarh from 07.07.2017 to 21.7.2017 and right lower limb was amputated. The doctor declared disability 85%. Thereafter, complainant approached to the OP for the payment of compensation, waiving off subsequent installments and payment of Rs.1250/- per month spread over 10 years. O.P. declined the relief, hence, this complaint. Learned counsel argued that qua the occurrence FIR was registered, policy is Ex.C4 and disability certificate is OP6 with speaks 85%, under these circumstances, non extending the benefits to the complainant amounts to deficiency in service. Lastly prayed to allow the complaint with cost.

8.    OP counsel Sh. HC Verma, argued that so far the accident dated 06.07.2017, issuance of policy, deposit of premium by the complainant and disability 85% are the admitted facts. The OP has rightly declined the relief because the terms and condition of the policy speaks if the disability is 100% then the policy holder (complainant) is entitled to the relief claimed. OP has rightly refused. No deficiency in service and complaint deserves to be dismissed.

9.    Complainant purchased the policy and deposited the premium till the date of accident regularly. After the accident, complainant informed the O.P., the doctor issued the disability 85%, the claim was lodged and it was rejected. So, it is a consumer dispute and complaint is maintainable.

10.  Coming to the controversial point whether complainant has been able to prove deficiency in service or not. Further whether OP has rightly rejected the claim. Admitted documents need not to be discussed. The only controversial point is the disability as well as the policy. After amputation of right limb, doctor issued disability certificate, copy of which is Ex.OP6 and it speaks disability 85%, whereas other parts of the body mentioned OK. OP has taken the plea that between the parties policy copy of which OP3 is the terms and condition as well as constitution. If at any time ambiguity arises between the complainant and OP that is to be decided in the light of policy Ex.OP3. Complainant pleaded that he was drive the vehicle when accident took place, OP counsel during the course of arguments placed on file, proposal form for insurance filled up by the complainant and has taken the plea that in the proposal form no where mentioned the profession of the complainant as driver. But the Forum after considering the evidence as well as the dispute has come to the conclusion that on the basis of proposal form neither the relief is to be declined or to be granted as the result of the complaint is based upon the policy which is the star document.

11.  Ex.OP3 is photocopy of the policy issued by the OP in the name of complainant with commencement 15.3.2012. The accident occurred on 6.7.2017 i.e. why the complainant approached to this Forum. Section 11 of the policy deals with accident benefit then 11(a) deals with disability to the life assured. It is mentioned that how to pay monthly installments spread over 10 years by the insured and in its 4^th para deals with how to pay the disability benefits. Relevant portion of the said para is reproduced as under:-

       "The disability above referred to must be disability whichy 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 Asured can ever sufficiently do or follow to earn or obtain any wages. Compensation or profit. Accidental injures 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 at or above the ankle, shall also be deemed to constitute such disability.

12.  Complainant counsel during the course of arguments relied upon the law laid down by the Hon'ble Calcutta High Court, W.P. No.14347 of 2000, decided on 17.2.2003, titled as Prabir Kumar Nath Vs Life Insurance Corporation of India and Others. The Hon'ble Calcutta High Court has laid down the law that the amputation of one leg, certificate of 60% disability issued by the competent authority of insured bust driver held entitled as total disability mentioned in the policy. The benefit was extended to Prabir Kumar Nath by the Hon'ble High Court that it was mentioned in the policy if the disability 60% then it will be considered total disability. But the star document in this complaint is the policy Ex.C4 and its relevant portion is reproduced as above and in the policy it is mentioned if amputation of both feet or both hands amounts to total disability, whereas, if amputation above the wrist and one foot or above the ankle that amounts to total disability. If there is amputation of one foot or above the ankle or one hand then that is not total disability. So the forum cannot travel beyond the policy Ex.C4, which is the star document relied upon by both the parties. Rejection of claim does not mean deficiency in service.

13.  In the light of above discussion, the complaint stand dismissed, leaving the parties to bear their own cost. 

14.   The certified copies of this order be supplied to the parties forthwith, free of costs, as permissible under the rules and the file be indexed and consigned to Record Room.

 

                     ANNOUNCED                                                    (KARNAIL SINGH AHHI)

                     Dated.01.08.2018                                     PRESIDENT
 

 

 

                                                          (SHAVINDER KAUR)

                                                                             MEMBER