MS. NIPUR CHANDNA, MEMBER

1. The complainant has filed the present complaint against the OP alleging deficiency in service and unfair trade practice on the part of OP.  The gist of the complaint is that the complainant is the policy holder of the OP Ins. Co. It is alleged by the complainant that OP has mismanaged her policy despite levying various charges of policy administration and fund management. It is further stated that she paid all the due premium before locking period to OP Ins. Co. but OP arbitrarily auto surrender the policy without her consent. It is further stated that complainant paid 5 year premium before locking period and as such her fund valued was more than one premium amount, hence, by moving the policy to auto surrender mode the OP company not only violates IRDA guidelines but also forcibly imposed loss to the complainant.
2. It is further alleged by the complainant that no clear information was provided by the officials of OP before auto surrender in fact the email and calls received from the officials of OP are contradictory one and vary from one officer to another. It is further alleged that instead of providing the redressal mechanism the service providers of the OP provides irritating options such as replacement of the existing policy using the sensitive details and documents of the customer available with the company and providing false information in respect to the fund value, benefits and surrender proceedings. It is further stated the  penalty be imposed on the OP company  for mismanaging the policy, lack of customer service, providing wrong information in respect to the fund valued, manipulating, misrepresenting and abusing the guidelines of IRDA, so that the OP will not dire in future to mis-sale  the policy with the available sensitive personal data, hence, this complaint.
3. Complaint has been contested by OP.  It has filed its written statement, wherein it denied any deficiency in services on its part and stated that the complainant for the first time approached Delhi government mediation and conciliation centre for redressal of her grievance and entered into a settlement wherein the complainant agreed to pay all due premiums within 15 days and the OP agreed to revive the policy without submission of medical certificate and evidence of insurability. Instead of  making the payment of premium to the opposite party for revival of the policy, the complainant thereafter approached insurance ombudsman against her grievance but the insurance ombudsman dismissed the her complaint  as it has already been settled before Delhi Government Mediation Centre. Thus the present complaint is hit by principle of res-judicata and is liable to be dismissed. It is further stated that due to failure on the part of the complainant in payment of the renewal premium, the policy moved to  auto surrendered and the surrender value of Rs. 1,45,875.70/- as per the policy terms and conditions was sent to complainant through cheque, however, the same was returned back undelivered.
4. It is further stated that the policy terms and conditions specifically provides for a Free Look Period of 15 days, during this period the policy owner is entitled to review the policy terms and conditions and request for a cancellation,  if dissatisfied with the terms and conditions of the policy.  The policy documents were delivered to the complainant and the same was duly received by her.  The complainant failed to approach OP for conversion/cancellation as well as for refund of the policy during free-looking period, it was presumed that the contract was legally concluded between the parties and as  such the claim of the complainant was rightly settled as per the policy terms and condition .
5. It is further submitted by OP that in past also complainant defaulted in paying the renewal premium for the year 2013-2014 due to which the policy moved to lapse status. On the request of complainant the policy was again revived after deposit of the required premium by complainant. Vide letter dated 31.08.2015 the complainant was duly informed about the payment of premium due on 27.10.2015 but the complainant failed to deposit the premium as such policy again moved to lapse status.
6. It is further submitted that the complainant has paid only 5 annual premium till 27.10.2015. Vide letter dated 27.09.2015, 10.12.2015 the complainant was duly informed about the payment of further premium but despite receiving the letters, the complainant failed to pay the premium and as such the policy move to auto surrender on 25.01.2016 and the surrender cheque of Rs. 145875/- was also sent to the complainant, however, received back undelivered.
7. Vide email dated 09.03.2016 and 11.03.2016 again  an opportunity was given to the complainant to again revive the policy in question but complainant failed to submit the reversal form and pay the renewal premium as such acting with utmost care and diligence and OP calculated  fund value of the policy in question as per the policy terms and conditions and also sent a cheque for a sum of Rs. 1,45,875/- which was returned undelivered as such the complainant is not entitled for any relief prayed. It is further prayed that the present complaint be dismissed with cost.
8. Rejoinder to the written statement of OP filed thereby denying the averments made in the written statement. Complainant filed her evidence by way of affidavit with the title proof of evidence. She has placed on record copy of intimation letter dated 10.12.2015, copy of emails exchanged between the parties, copy of call recording transcription, copy of policy payment receipts in support of her contention. She has also placed on record the copy of whatsapp message received by her on 28.01.2019 and 22.03.2019 where the OP company has agreed to pay Rs. 161486/- against the fund value of the policy in question to her.
9. Sh. Anmol Kishore Asstt. Manager Legal filed his evidence by way of affidavit on behalf of OP. OP has also placed on record the copy of order of Delhi Government Mediation and Conciliation Centre dated 18.07.2016, copy of ombudsman order dated 22.12.2016, copy of application form, copy of policy documents as well  as the terms and conditions and copies of emails exchanged between the parties.
10. We have heard argument advance at the Bar by AR for the complainant and have perused the record. Despite opportunity OP failed to address the arguments.
11. It is admitted by the parties that the OP has issued the policy which commence from the year 2010. The complainant has not denied that she has not received the policy documents as well as the terms and conditions. As per the complainant she has successfully paid five annual premium and as per the information given to him she is not required to pay further premium against the policy in question. Admittedly, the complainant has received the policy documents and has not raised any single query against the policy in question with OP company this means that the contract within the parties got concluded and she had completely understand the period of payment of premium and other terms and condition in respect to the same.
12. After the payment of five premium the complainant failed to pay further premium outstanding against the policy in question, hence, the policy moves to lapse status and the OP company after calculating the surrender value as per the policy terms and conditions sent a cheque of Rs. 1,45,815/- to the complainant returned back undelivered. Against the surrender value complainant knocked the door of Delhi Government Mediation and Conciliation Centre and as per the settlement order dated 18.07.2016 of mediation centre complainant agreed to pay total arrears of premium against the policy in question to the OP within 15 days from the date of order and OP agreed to revive the policy after receipt of the arrears of the premium, but the complainant backout from the settlement and approached this Commission.
13. As per policy terms and conditions, due to non-payment of further premium, policy in question was in  lapse status.  The complainant has failed to place on record any document which shows that she requested the OP to cancel the policy during free look period.  she further failed to place on record any documentary evidence which establish that the she approached OP to revive the lapse policy, In fact , despite entering into the settlement before Meditation Center she failed to pay the revival premium to OP, having no other option OP Insurance Company calculated the surrender value as per the policy terms and conditions and agreed to pay the same to the complainant.
14.  Insurance is a contract between the insured and insurer and both the parties are bound by the terms contained therein. The Hon’ble NCDRC in the matter of National Insurance Co. Ltd. vs. Vinod Puri as reported in I [2014] CPJ 341 (NC) is pleased to hold as under:

Insurance contract has to be construed like any other contract on basis of its terms and conditions and outside aid for construction of insurance policy is impermissible.

15. The Hon’ble Apex Court in the case of Oriental Insurance Co. Ltd. versus Sony Cheryan reported in (1999) 6 SCC 451 is pleased to hold as under:

The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy.

16. Similarly in the case of General Assurance Society Ltd. vs. Chandumull Jain and Anr., reported in (1996) 3 SCR, 500, the Constitution Bench has observed that the policy document being a contract and it has to be read strictly. It was observed:

In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however, reasonable, if the parties have not made it themselves. Looking at the proposal, the letter of acceptance and the cover notes, it is clear that a contract of insurance under the standard policy for fire and extended to cover floor, cyclone etc. had come into being.

17. The Hon’ble NCDRC in the matter of Ind Swift Ltd. versus New India Assurance Co. Ltd. reported in IV[2012] CPJ 148 (NC) is pleased to rule as under:

Construction of the policy is to be construed strictly as per the terms and conditions of the policy document which is binding contract between the parties and nothing can be added or subtracted by different meaning.

18. Similarly in LIC versus Banwarilal Yadav reported in IV[2013] CPJ 38 (NC) the Hon’ble NCDRC observed as under:

“Forum has no jurisdiction to go beyond terms and conditions of the Policy.”

19. The NCDRC in yet another matter in the matter of Morien Chemicals Ltd. versus UCO Bank reported in III [2013] CPJ 261 (NC) is pleased to hold as under:

“Insurance Company is not liable to pay damages which are not covered under the policy.”

20. Having regard to the facts and circumstances of the present case, we are of the considered view that since the complainant had deposited a sum of Rs.1,50,000/- against the premiums, she is entitled for refund of the surrender value of the policy in question, although she failed to exercise his right of cancellation of policy in free look  period. The complainant has placed on record the copy of text messages received from OP dated 28.01.2019 and 22.03.2019 thereby offering the complainant a sum of Rs. 1,61,486/- against the policy in question. Since the OP has itself admitted the liability of Rs. 1,61,486/-  to be payable to the complainant against the policy in question. We direct the OP to pay Rs. 1,61,486/- to the complainant as surrender value. The present complaint is disposed off in above terms.
21. OP is directed to comply the order within 30 days from the date of receipt of this order failing which OP is liable to pay to the complainant interest @9% per annum from the date of non-compliance till realization.
22. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving the application from the parties in the registry. Order be uploaded on www.confonet.nic.in.

Announced in open Commission on30.04.2024.

SANJAY KUMAR                                    NIPUR CHANDNA                         RAJESH            

       PRESIDENT                                                MEMBER                             MEMBER