The record is put up today for passing final order. This is a case u/s 12 of the C.P.Act 1986.
Complainant’s case in short is that as per request of O.P.2 the complainant opted for an insurance policy of O.P.1. The complainant accordingly took the policy from the O.P. and paid Rs.15185.03/- towards Insurance Premium of the said policy and policy certificate no.19463510 dated 25/11/2011 together with money receipt were issued to the complainant by O.P.1. The complainant asserts that in the first premium receipt the schemes of the policy deed including critical condition rider benefits were mentioned and that the complainant had tendered higher amount of premium to the tune of Rs.15,185.03/- to get other policy benefits including critical condition rider. The complainant became critically ill during subsistence of the said policy and she was checked up at Apollo Hospital at Chennai and the radiology department of Apollo Hospital on 29/10/2012 where it was detected that she was suffering from Mammogram on both her breasts and from the impression so given by the Apollo Hospital was nothing but she/was attacked with cancer. The complainant went to TATA Memorial Hospital at Mumbai and there she got her treatment of cancer as per advice of the doctors of TATA Memorial Hospital. On 04/12/2012 the complainant had to undergo breast conservation surgery and subsequently she was clinically treated and her treatment is still continuing under the care and guidance of TATA Memorial Hospital. She was released from TATA Memorial hospital on01/03/2013 and she also informed about her ailment and treatment to O.P.2 in writing and also submitted her partial claim of Rs.38,782/- as against critical illness Benefit Rider scheme and submitted copies of medical documents and vouchers to substantiate her claim. On 25/06/2013 she also send remainders to the O.Ps. to settle her claim but the O.Ps. haven’t bothered to settle her claim.
The complainant has prayed for an amount of Rs.68,782/- in total for her insurance claim, compensation for mental agony, damage etc.
Hence this case.
The O.Ps. have contested this case by filing a Written Version wherein the O.P. has denied and disputed the claim and the contention of the complainant.
Their specific stand is that the complainant opted only the basic plan and she has never opted for any rider in the policy and that the said policy was due for renewal premium for the term November 2012 and the complainant has failed to pay the renewal premium and for that reason the status of the policy was changed to early lapsed and the said policy is in lapse mode since November 2012. Under this background the O.Ps. have prayed for dismissal of this case with cost.
POINTS FOR CONSIDERATION.
1.Is the case maintainable both in law and facts?
- Is the complainant a consumer as per provision of Consumer Protection Act.1986?
- Are the O.Ps. guilty for deficiency in service as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All four points are taken up together for consideration and decision for the sake of convenience.
Seen and perused the pleadings of the parties, documents filed by the parties and the written arguments filed by the complainant.(O.Ps. have not filed written argument).
We find that admittedly the complainant Smt. Ruma Das purchased insurance policy number 19463510 dated 25/11/2011 from the O.P. Reliance Life Insurance Company Ltd. And she also paid Rs.15,185.03/- to O.P. Insurance Company towards her first Insurance premium on 25/11/2011 and that the term of the said policy was for 10 years . It is the case of the complainant that she had to undergo treatment for her breast cancer in the Apollo Hospital and TATA Memorial Hospital, Mumbai and for these she had to expend Rs. 38,782/- in total and she reported this matter to O.P.1 and O.P.2 on 01/03/2013 and on 25/06/2013 requesting them to settle her above claim but the O.Ps. took no step to settle her claim till date of filing of this case. The O).Ps. have also admitted the complainant as their consumer denying the claim of the complainant on the ground that she only opted the basic plan and not renewed the premium payable by November 2012, so the Reliance Life Insurance Corporation is not liable to pay any mediclaim to the complainant as prayed for. Therefore it is clear from the aforesaid discussion and the copy of the Reliance Life Insurance Policy, the first premium receipt and the policy schedule that the case is well maintainable and that the complainant is a consumer.
Now from the copy of the insurance policy(paragraph 10) we find that the complainant initially applied for cash flow plan and Rs.14,996/- was payable by the complainant towards installment premium for cash flow plan. But from the first premium receipt and the policy schedule we find that the complainant had paid a sum of Rs.15,185.03/- towards installment premium on 25/11/2011 and the benefit of critical condition rider was given to the insurer as additional benefits to this policy and most probably for this reason the complainant had to pay Rs.15,185.03/- in lieu of Rs.14,996/- towards 1st installment premium.
So the contention raised by the O.P. that the complainant never opted critical rider scheme has got no leg to stand upon. Furthermore, we find from the “policy conditions and privileges within referred to” Reliance Life Insurance Company under the heading, Terms and Conditions, premium (V) that in the event of unpaid premium is not received by the company, the company would adjust the said unpaid premium while settling such claim. In the view of this provision, if the premium was not paid by the complainant as alleged by the O.Ps. then the unpaid premium may be adjusted by the Reliance Life Insurance Corporation at the time of settlement of the claim of the complainant and that can’t be the ground of repudiation of the claim of the complainant.
In view of our discussion made here in before and after due consideration of the pleadings of the parties, documents filed by the parties and the written argument filed by the complainant and the arguments advanced by the Ld. Lawyer for the complainant (the O.Ps. neither filed written arguments nor advanced oral arguments)and the observation of the Hon’ble National Commission in an unreported decision in N. Muthuvet vs The Senior Branch Manager LICI and others in Revision Petition u/s 3842/2012 dt. 03/05/2013, we find sufficient reason to hold that the O.Ps. are guilty for deficiency in service for not taking step for settlement of the legitimate claim of the complainant despite complainant’s repeated requests. Accordingly the complainant is entitled to the reliefs specified below.
All points are disposed of .
In the result the case/application succeeds.
Hence, it is
O R D E R E D
that the case stands allowed on contest with cost of Rs.2000/-(Two Thousand) only.
The complainant do get the award of Rs.38,782/- against O.Ps.(Reliance Life Insurance Company Ltd.). The complainant do get further award of Rs. 5000/-( Five thousand) only in the head of mental agony and Rs. 5000/-( Five thousand) only in the head of deficiency in service against the O.Ps. The O.Ps.(Reliance Life Insurance Company Ltd.).are hereby directed to pay to the complainant the aforesaid cost and awards within 30 days from the date of this order failing which it will carry interest @9%p.a. till realization of entire amount and the complainant shall be at liberty to put this order into execution in accordance with law for realization.
Let copy of this final order be supplied to the parties free of cost forthwith in terms of Rule.5(10) of West Bengal Consumer Protection Rules 1987.
