Jharkhand

Bokaro

CC/17/97

Jiveshwar Ashok Prasad - Complainant(s)

Versus

the Branch Manager, LIC, India - Opp.Party(s)

Amardeep Jha and Poonam

07 Jan 2022

ORDER

1. Complainant has filed this case with prayer for direction to O.Ps. to pay insurance claim of Rs. 25,000/- and for payment of Rs. 30,000/- and Rs. 10,000/- as compensation and litigation cost respectively to him.
2. Complainant’s case in brief is that Sharmila Devi was wife of the complainant who was working as Anganbadi Sevika vide code No. 48 at Ram Nagar Colony-3, Ward No. 14, Chas Sahari, Chas, Bokaro and as per Govt. policy she obtained Janashri Bima Yojna vide membership No. 1-10/2003-CD-1 on 16.08.2013. Further case is that wife of complainant faced an accident on 08.09.2013 during which she sustained fracture of her right leg and she was admitted at Bokaro General Hospital (in short BGH) on same day where she was oparated and iron rod was installed in her leg, who was discharged on 26.09.2013 for which total expense was about Rs. 35,000/-. As per insurance scheme she made claim for Rs. 25,000/- with the O.P. but it was not paid, mean while she died on 27.05.2014 for which claim was submitted but only death claim was settled and claim related to disability was not settled in spite of repeated requests, hence this case has been filed.
3. On notice both O.Ps. appeared and they have filed joint W.S. in which they have admitted the contents of para 5 and 6 of the complaint petition, however, except para 15 of the complaint petition there is no specific denial by these O.Ps. As per O.Ps. they have paid the death benefit to the complainant on account  of death of his wife. As per para 12 of the W.S. in spite of verbal and written advice the complainant  has not submitted required documents for disability benefit hence O.P. cannot be said negligent or deficient providing service.
4.      On perusal of the pleadings of the parties it is apparent that the fact related to opening of insurance policy by the wife of the complainant being Anganbadi Sevika is admitted fact. Another admitted fact is that till death of the wife of the complainant said insurance policy was operational or valid. Other admitted fact is that complainant has submitted claim before the O.Ps. for payment of disablement benefit which has not been settled. Other admitted fact is that wife of complainant died on  27.05.2014 whose death claim has been settled by the O.Ps.
5.      Main question for decision is whether denial of the claim are delay in settlement of the claim by the O.Ps. is justifiable or not ?
6.       Annexure 3 of the W.S. shows that it is photo copy of RTI reply dt. 31.03.2016 given by the office of the O.Ps. to the complainant in which it is mentioned that “The following requirement are required for further payment asked by you that (2) Disability Certificate from C.M.O., (4) Please, clarify whether the disability was due to the accident or it was congenital.” This reply itself shows that on supply of above mentioned information claim of the complainant would have been settled by the O.Ps.
7.      At this place it is important to mention that said reply was given on 31.03.2016 and prior to it wife of complainant died on 27.05.2014 , therefore, it was not possible to obtain and furnish the disability certificate of CMO.  So far, disability is concerned it can be safely said that prior to occurrence dt. 08.09.2013 related to accident there is no evidence of any side that said disability was congenital. Annexure B is related to photo copy of the treatment papers of the wife of complainant which is corroborative to the facts mentioned in the complaint petition. Annexure C is the claim form submitted by wife of complainant on 19.12.2013 before the O.Ps. for payment of claim related to her disability, about which it is said that it has not been received in the office of the O.Ps. If said claim would have been settled during life time of the wife of complainant then there would have been no dispute. Annexure E are the photo copies of application dt. 22.12.2015 and undated application in which it has been certified by the Medical experts  of the BGH that wife of complainant was suffering with fracture of right leg for which she was operated hence she was suffering with disability of the leg. Therefore, it is apparent that Medical Experts have established that wife of the complainant was suffering with disability.
8.       It is admitted fact that in case of disability of leg due to accident O.Ps. will pay Rs. 25,000/- to the Anganbadi Sevika.
9.       In light of above discussion we are of the opinion that in the peculiar facts of this case specially considering the fact related to death of the wife of complainant prior to the settlement of disablement claim the certificate submitted by Medical Experts cannot be ignored or discarded and mere on this hyper technical basis refusal or with holding of the claim is not justified. Hence there is deficiency in service by the O.Ps.
10.       Accordingly claim of the complainant is being allowed in the following manner :-

O.Ps. are directed to pay Rs. 25,000/- (Rs. twenty five thousand)as insurance claim amount to the complainant within 45 days from today, failing which they shall pay interest @ 10% P.A. on the above amount from filing of the case i.e. 23.06.2017.

O.Ps. are further directed to pay Rs. 10,000/- compensation and Rs. 5,000/- as litigation cost respectively to the complainant within 45 days from today.