Tripura

StateCommission

A/54/2023

BRANCH MANAGER, LICI, AGARTALA BRANCH 2 - Complainant(s)

Versus

NANI GOPAL BISWAS - Opp.Party(s)

NIRANJAN BAL

29 Jul 2024

ORDER

Tripura State Consumer Disputes Redressal Commission

Agartala: West Tripura

Case No. A.54 of 2023

 

 

1. The Divisional Manager,

Life Insurance Corporation of India Ltd. (LICI),

Silchar Division Office,

Meherpur, Silchar, P.O. Silchar,

Assam - 788001.

 

2. The Branch Manager,

Life Insurance Corporation of India Ltd. (LICI),

Branch No.2, Krishnanagar, Agartala,

P.O. Agartala, P.S. West Agartala,

District - West Tripura - 799001 & Ors.

 

.… … … … Appellants/Opposite Parties

 

-VS-

1. Sri Nani Gopal Biswas,

S/o Late Murari Mohan Biswas,

Vill: Nimbark, Bank Chowmohani, P.O. ONGC,

P.S. Amtali, District - West Tripura, Pin - 799014.

 

… … … … Respondent/Complainant

 

 

 

Before

Hon’ble Mr. Justice Arindam Lodh

President, State Commission

 

Smt. Daliya Saha

Member, State Commission

 

Shri Jhantu Debnath

Member, State Commission

 

 

 

 

Present:

For the Appellants:                                                         Mr. Niranjan Bal, Adv.

For the Respondent:                                                       Mr. Anjan Kanti Pal, Adv.

Date of Hearing & Delivery of Judgment:                        29.07.2024.

 

 

 

J U D G M E N T [ORAL]

Heard Mr. Niranjan Bal, learned counsel appearing for the appellants-opposite parties (here-in-after referred to as Insurance Company). Also heard Mr. Anjan Kanti Pal, learned counsel appearing on behalf of the respondent-complainant.

2. This is an appeal against the judgment and order dated 12.09.2023 passed by the learned District Consumer Disputes Redressal Commission, West Tripura, Agartala (for short, District Commission) in connection with Case No.C.C.39 of 2022.
3. The facts of the case as projected by the learned District Commission may be reproduced here-in-under for convenience:-

“1.1 The case of the complainant in short is that the son of the complainant Sri Tridip Biswas had taken a policy on 13.01.2016 under Jivan Arogya Scheme and the date of expiry of the said policy is on 13.01.2035. The said policy is under coverage name of the father of the policy holder, Sri Nani Gopal Biswas and Mother of the policy holder, Smt. Manju Biswas.

1.2 During the existence of the policy in the month of July, 2017 and July, 2018 the complainant was treated his disease at Medica Super Specialty Hospital, Kolkata. And in the month of July, 2019 the complainant was treated at Peerless Hospital and Research Centre Ltd., Kolkata for heart disease of spinal cord. 

1.3 All the relevant documents including the prescriptions, cash bills etc. were submitted before the O.P. No.3 for reimbursement of the treatment cost but the O.P. No.3 did not contact with the complainant.

On 18.11.2018 complainant submitted reimbursement bill for Rs.3,00,000/- and also for treatment cost of Rs.2,24,000/- to the O.P. No.1 and 2 through O.P. No.3 and 4 but the O.Ps did not settle the claim of the complainant.

1.5 Demand notice was also sent on 21.09.2020 claiming Rs.5,24,000/-. In reply to the demand notice the O.Ps No.1 and 2 sent a letter on 05.10.2020 that the bill is under examination.

1.6 By their letter dated 05.03.2021 and 09.03.2021 the O.P. repudiated the claim filed by the complainant.” 

4. Upon receipt of notice, the appellants-opposite parties, Insurance Company appeared and contested the case by submitting their written statement.
5. The learned District Commission after hearing the parties allowed the claim of the complainant, i.e. the respondent herein. The relevant portion of the order may be reproduced herein below for convenience, in extenso:-

“5.1 It is argued that at the time of taking the policy of insurance Nani Gopal Biswas did not divulge his pre-existing disease and meaning thereby the Insurance company had failed to exercise the option of choosing whether to enter into an agreement with Nani Gopal Biswas i.e., whether to issue such policy or not. It is no more Res-intigra that the policy of insurance is a contract of utmost good faith wherein the insured is liable to divulge the material facts with in his knowledge.

5.2 But the alleged forwarding letter although was written in the name of the complainant but it does not bear signature of the complainant. Similarly, the Medical Certificate allegedly issued by Dr. Saha in the name of the complainant also does not bear signature of the complainant. Hence, these papers are summarily rejected. As such, we do not find reason to reject the claim.

6. Both the points are decided accordingly against the O.P.

7. In the result, it is directed that the O.P. shall reimburse Rs.5,24,000/- to the complainant with a further sum of Rs.30,000/- as compensation including litigation cost within 30 days from today, otherwise this amount shall carry interest @ 7.5% P.A. from today till the date of actual payment.”

6. Being aggrieved by and dissatisfied with the said judgment dated 12.09.2023 passed by the learned District Commission, the appellants, Insurance Company have preferred the instant appeal before this Commission.
7. Mr. Bal, learned counsel appearing for the appellants-opposite parties, Insurance Company submits that the learned District Commission while deciding the case failed to consider the evidence on record in its true perspective. The Major Surgical Benefit sum assured is equal to 100 times which is applicable daily benefit in any policy year for each insured and the said benefit shall be payable by the Insurance Company regardless of the actual costs incurred and there is no direct relation of the amount spent with the payable claim amount. However, he has agreed that the complainant is entitled to get the actual benefit of the insurance policy. He has further argued that the award made by the learned District Commission was on the higher side and urged for reducing the awarded amount.
8. Mr. Pal, learned counsel appearing for the respondent-complainant while supporting the impugned judgment would contend that the learned District Commission rightly passed the impugned judgment while holding that “………..the policy of insurance is a contract of utmost good faith wherein the insured is liable to divulge the material facts with in his knowledge.”
9. We have given our thoughtful considerations to the facts and circumstances of the case as well as the submissions advanced by the learned counsel appearing for the parties. Having gone through the records, it transpires that the appellants-Insurance Company was deficient in providing appropriate and adequate services to the respondent-complainant. More so, on perusal of the policy document, we find that there is no transparency in the policy conditions mentioned in the policy documents. The policy conditions mentioned in the policy documents must be transparent so that people can understand the terms and conditions of the policy easily.
10. Here, we have constrained to hold that the opposite party, the appellants herein, was in clear deficiency in service towards the respondent-complainant.
11. However, we are of the opinion that the award passed by the learned District Commission appears to be on the higher side and the said amount of award and compensation under the aforesaid two heads should be reduced and accordingly, it is reduced.
12. In view of the above, the appellants, Insurance Company is directed to pay Rs.2,00,000/-(Rupees two lakhs) as policy benefit/Insurance claim, Rs.1,00,000/- (Rupees one lakh) as compensation out of their negligence and deficient in service towards the respondent-complainant and Rs.50,000/- (Rupees fifty thousand) as costs of litigation to the respondent-complainant. We also find there is lack of transparency in the policy document and for this reason, we impose a cost of Rs.25,000/- (Rupees twenty thousand) upon the appellants-opposite parties. The award of compensation shall be paid to the respondent-complainant within 30 days from today, otherwise it shall carry interest @7% per annum.
13. Accordingly, the order of the learned District Commission is modified to the extent as indicated here-in-above.

With the aforesaid directions, the instant appeal stands partly allowed and disposed.