Tripura

StateCommission

A/36/2022

Sri Tarun Baran Roy - Complainant(s)

Versus

The Branch Manager, LICI. - Opp.Party(s)

27 Jan 2023

ORDER

Tripura State Consumer Disputes Redressal Commission AGARTALA: West Tripura

 

Case No. A. 33 of 2022

Case No. A. 34 of 2022

Case No. A. 35 of 2022

Case No. A. 36 of 2022

 

 

 

 

1. Sri Tarun Baran Roy,

S/o Late Jogesh Chandra Bhowmik,

T.G. Road, Ram Nagar,

Bankim Sarani, Akhaura Road,

Agartala, West Tripura, Pin: 799001.

.… … … … Appellant/Complainant

 

Vs

 

 

1. The Branch Manager, LICI

Udaipur Branch Office, Hospital Road,

P.O. Radhakishorepur, District - Gomati

Pin: 799120, Tripura.

 

2. Divisional Manager, LICI

Silchar Divisional Office, Meherpur,

Silchar – 788015.

 

3. Manager, HI – LICI

Silchar Divisional Office, Meherpur, Silchar – 788015.

 

4. Branch Manager, LICI, Branch No.2

Krishnanagar, Agartala as per judgment & order of the Ld. State Commission

Vide No.D/No.207-08 dt.28/06/2021.

                                                … … … … Respondent/Opposite Parties

 

 

 

Before

 

 

Hon’ble Mr. Justice Arindam Lodh

President

State Commission

 

Dr Chhanda Bhattacharyya

Member

State Commission

 

Mr. Kamalendu Bikash Das

Member

State Commission

 

 

 

Present:

For the Appellant:                                                In person.

For the Respondents:                                            Mr. Prahlad Kumar Debnath, Adv.

Date of Hearing &Delivery of Judgment:               27.01.2023.

Whether fit for reporting                                        yes

J U D G M E N T [ORAL]

 

1.        These appeals have been preferred by the appellant against the judgment and order dated 19.09.2022, passed by the learned District Consumer Disputes Redressal Commission, West Tripura, Agartala in connection with Case Nos.C.C.78 of 2019, C.C.66 of 2019, C.C.47 of 2020 and C.C.14 of 2021.

2.        In terms of the order dated 17.01.2023 passed by this Commission, Mr. Gautam Choudhury, the Branch Manager of LICI, Udaipur Branch has appeared today before this Commission.

3.        The grievance of the appellant is that, he filed complaint petitions before the learned District Commission alleging inter alia that he had purchased 4(four) policies under the name and style, ‘Health Plus Plan’ of the Life Insurance Corporation of India [for short, LICI] in year 2009, and accordingly, certificates against the respective policies were also issued to him. The appellant was a government employee. Though he purchased the said policies, but he never raised any claim till his retirement in the year 2015, as he used to claim medical reimbursement before the concerned government authority out of medical expenses. 

3.1.     During continuation of the policies, on different occasions, his wife got admitted and treated in the Christian Medical College (for short, CMC), Vellore, Chennai due to her illness and after recovery, the appellant, on behalf of his wife, submitted claim applications before the LICI for reimbursement of the expenditure he had incurred out of his wife’s treatment at CMC, Vellore, but the claim applications were repudiated by the authority concerned of the LICI.

3.2.     Being aggrieved, the appellant lodged a complaint before the learned District Commission and the learned District Commission directed the LICI to reimburse the claimed amount to the appellant, which he had incurred for treatment of his wife at CMC, Vellore.

3.3.     The LICI, then, preferred appeal before this Commission.

3.4.     The State Commission dismissed the appeal on the ground of delay and laches.

3.5.     The appellant has submitted that his wife was suffering from various ailments for which he had to visit the CMC, Vellore every year. It has also been submitted by the appellant that the wife of the appellant was treated in the CMC, Vellore in the year 2017, 2018, 2019 and 2020, and on all occasions, the appellant raised claims for reimbursement of the medical expenses out of his wife’s treatment at CMC, Vellore, but the claims of the appellant as raised by him for four consecutive years were rejected by the respondents-LICI on the ground that the policies do not have any coverage with such treatment.

3.6.     Being aggrieved by such repudiation, the appellant filed complaint petitions before the learned District Commission claiming the actual medical expenditure he had incurred and also claimed for a substantial amount for the alleged harassment caused by the respondents-LICI along with costs of litigation.

3.7.     On receipt of the complaint petitions, the learned District Commission issued notice upon the respondents-LICI. The respondents-LICI appeared and contested the claim petitions by filing written objection. Both the parties also adduced evidence on their behalf and after hearing the arguments of both sides, the learned District Commission dismissed the claim petitions of the appellant-petitioner on the ground of maintainability of the proceeding, particularly for the reason that Third-Party Administrator (TPA, in short), being a necessary party, was not impleaded in the complaint petitions, and consequently the learned District Commission did not enter into any other factual aspects of the complaint petitions.

            Hence these appeals before this Commission.

4.        Having receipt of notice, the respondents-LICI appeared before this Commission to represent the case through their learned counsel.

5.        Today, we have heard Shri Tarun Baran Roy, the appellant-in-person as well as Mr. P.K. Debnath, learned counsel appearing for the respondents-LICI. We have also hear Mr. Gautam Choudhury, the Branch Manager of LICI, Udaipur Branch at length and we have received substantial assistance from Shri Choudhury.

6.        At the very outset, according to us, the finding of the learned District Commission that the complaint petitions filed by the complainant-appellant are not maintainable due to non-impleadment of the TPA is unsustainable.

6.1.     We have posed questions to Mr. Debnath, learned counsel for the respondents-LICI to ascertain as to what is the role of TPA? Mr. Debnath in reply has fairly submitted that the LICI on receipt of a claim usually refers the issue to the TPA to consider the extent of entitlement as regards the claim of such purchaser of a policy.

 6.2.    We find there is no direct relation of the appellant with the TPA to purchase a policy under LICI. According to us, it is the internal arrangement of the LICI that they take the assistance of a Third Party Administrator (TPA) to settle the claim and to recommend. The LICI is the final adjudicator of the claim. It is not that the LICI is wholly bound upon the recommendation of the TPA. The LIC, being the seller of the policy, has every right to consider the claim and settle it up.

6.3.     As a corollary, the reasons assigned by the learned District Commission that the TPA is a necessary party and the complaints filed by the complainant-appellant is bad for non-joinder of TPA, is absolutely untenable in law.

            Hence, we reject this view of the learned District Commission.

7.        Now, coming to the principal issue as regards the extent of entitlement of the claims raised by the complainant-appellant, we have taken note of the policy certificates first. In the policy certificates, it is clearly written that the said ‘Health Plus Plan’ policy is subject to the ‘conditions and privileges’ attached to the certificates.

7.1.     We have made a query to the complainant-appellant whether he had received any copy of ‘conditions and privileges’ of the policies. Mr. Roy, the complainant in reply has informed that he had received the copy of the document for the first time when the respondents-LICI had adduced evidence before the learned District Commission, and at no point of time starting from the time of purchasing of the policies till that date, he did not receive any copy of the document, where the conditions and privileges of the policy are laid down.

7.2.     Mr. Debnath, learned counsel has strongly emphasised that the LICI can never go beyond the terms and conditions laid down in the said document. Mr. Debnath has tried to convince this Commission that from the certificate also it can be revealed that the document containing ‘conditions and privileges’ of the policy are attached with the certificate, and according to him, the learned Commission shall presume that the said document was attached with the certificates and the terms and conditions were written in the said document which were well within the knowledge of the complainant-appellant and he never raised objection to the terms and conditions and continued to pay the premiums of the policies till 2020.

7.3.     We have given our thoughtful consideration to the submissions advanced by Mr. Roy, the complainant-appellant herein as well as Mr. Debnath, learned counsel appearing on behalf of the respondents-LICI as a whole.

            It is true, that in the certificate it is written that the document containing ‘conditions and privileges’ is attached with the certificate. The said sentence reads as under:-

            “………..and it is hereby declared that the policy of assurance shall be subject to the ‘conditions and privileges’ attached herewith……….”

7.4.     Now, the question is whether the said document was actually attached with the certificate or not?

 7.5.    According to us, whether the said document was attached or not, some responsibilities also lies upon the purchaser of the policy to go through the certificate, and if he does not find any document containing the terms and conditions of the policy, then, he should ask the company to furnish the copy of the same. At the same time, we also should not close our eyes to the practical scenario of the marketing policy of the LICI, who runs the business through their agents, and there is no dearth of instances where the agents not only mislead an ordinary purchaser but also many literate purchasers are misled by their marketing acumenship.

7.6.     In the above scenario, we would have no option but to believe the statement of the complainant/appellant that the document containing the ‘conditions and privileges’ was not attached with the certificate.

7.7.     In course of hearing of the appeals today, a copy of the policy certificate is also placed before us, wherein, we do not find that the said document containing ‘conditions and privileges’ is attached with the said certificate and there is no mark or indication to suggest that even at any point of time such document was attached with the certificate.

7.8.     In view of the above presumption that the said document containing ‘conditions and privileges’ was attached with the certificate goes in favour of the complainant/consumer. However, at the same time, we are unable to discard the submission of learned counsel appearing on behalf of the respondents-LICI that the policy lays down by certain terms and conditions and the Corporation cannot travel beyond the terms of the policy. In furtherance thereof, when it was clearly written that the said document is attached with the policy certificate, then, we find some laches also on the part of the complainant-appellant, since he did not pursue with the respondents-LICI to supply the copy of the document containing the conditions and privileges before purchasing the said policy. 

7.9.     As such, we are of the view that the respondents-LICI has to follow and comply the terms and conditions laid down therein. However, the respondents-LICI through their agent, undoubtedly, misled the complainant-appellant, which amounts to deficiency in service. As a renowned Insurance Company of the country, the respondents-LICI must be fair and transparent in all of their actions and transactions. It is a settled proposition of law that for the fault of the agents, the master will be liable to pay compensation.

8.        In view of the above analysis, we are constrained to direct the respondents-LICI to pay compensation at the rate of Rs.25,000/- each for the four policies for causing deficiency in service and the harassment the complainant/consumer has suffered due to misleading acts of the agent of the LICI.

9.        As we have already held that the complainant-appellant is also negligent not to go through the certificates issued to him, he will not be entitled to reimbursement of the medical expenses he had incurred for the treatment of his wife at CMC, Vellore.

10.      Accordingly, we direct the respondents-LICI to pay a sum of Rs.1,00,000/- (Rupees one lakh) only to the complainant-appellant against the four policies within a period of 3(three) weeks from today.

11.      However, out of context, we would like to suggest the respondents-LICI to take into account the socio-economic as well as literacy status of the people of our country and to incorporate the regional languages in each and every policy document apart from Hindi and English languages so that the unwary class of public of this nation are not defrauded or misled by some unscrupulous agents of the respondents-LICI. We also reiterate that the respondent-LICI must be fair and transparent in all its actions and transactions and it must be shown and found in all of its certificates and documents. The citizens of this country have the right to know all the essential terms and conditions laid down in the policies before purchasing any policy. It should be kept in mind that fairness and fair-play are the integral components of public policy and constitutional requirements as well. The executives of the LICI are directed to formulate specific guidelines for their officers and agents so that the citizens are not misled or defrauded by any members related to the Corporation who are working in the field and marketing their products.

12.      A copy of this order may be forwarded to the Chairman of Life Insurance Corporation of India (LICI) by the Registry of this Commission within 7(seven) days from today. The Branch Manager, LICI present here is also requested to forward a copy of this order to the Chairman of LICI for perusal of the observations as made here-in-above and do the needful as early as possible. A copy of this order may also be forwarded to the Secretary, Ministry of Consumer Affairs Department, Government of India, New Delhi for necessary action.  

13.      The appeals accordingly stand disposed in terms of the above observations and directions.