Orissa

Jharsuguda

CC/57/2018

Surnamoye Bohi / Swarnamayee Bhoi W/O- Late Prem Sagar Bhoi - Complainant(s)

Versus

The Branch Manager Life Insurance Corporation Of India, - Opp.Party(s)

Self

15 Dec 2021

ORDER

IN THE COURT OF THE DISTRICT   CONSUMER DISPUTES REDRESSAL COMMISSION, JHARSUGUDA.

                                                           C.C.NO-57/2018

Surnamoye Bhoi@ Swarnamayee Bhoi, aged about 52 yrs.

W/O-Late Prem Sagar Bhoi,

       Ro: Pipilimal, Po/Ps: Belpahar,

       Dist : Jharsuguda………………………………………………………..……Complainants.

     

Versus

 

1.  The Branch Manager,

Life Insurqance Corporation of India, Jharsuguda Branch

Po/Ps/Dist: Jharsuguda.…………………………………..……………Opp. Parties.

 

            Counsel for the Parties:-

For the Complainant                       :-         Self.               

For the Opp. Party No-1                 :-         Sri Anup Mishra,Adv. & Associates.

             Present:-     1. Shri  Dipak Kumar Mahapatra, President.

                                     2. Smt. Anamika Nanda, Member (W).

Date of Hearing:- 09.12.2021, Date of Order: 15.12.2021

 

SRI DIPAK KUMAR MAHAPATRA, PRESIDENT:- Brief facts of the case is that, the Complainant is the legally married wife of Late Prem Sagar Bhoi who had obtained four LIC policies in his life time vide policy serial nos- 590288509 commenced on dtd.28.11.1991, for sum assured Rs.50,000/-, serial no-591253960  commend on dtd. 27.10.1999, for a sum assured Rs. 1,00,000/-, serial no-593069411 commenced ondtd.22.05.2006 for sum assured Rs.50,000/- and serial no-593279521  commenced on dtd.29.03.2007 for a sum assured Rs.1,00,000/-. The Complainant is the nominee in all the policies.  The Policy holder died on dt. 02.12.2009 and the Complainant being the nominee filed claim before the O.P with observing necessary formalities after obtaining Medical Report from one Jahangir Gandhi  Hospital, Belpahar. After verification the O.P settled only one policy vide serial no- 593069411 favouring the Complainant. The agent of the O.P initiated the policy bearing no- 593279521 by motivating the policy holder and making him agree, when the children were minor. AS per the assurance of the Agent of the O.P the policy was initiated on dtd. 29.03.2007. The O.P again sought for medical report to settle the claim but the Hospital authority has denied providing the same again and again. The O.P did not settle the claim even after several requests but knowingly harassing the Complainants which amounts to Deficiency in Services.

As per the O.P the policies were issued in the name of Prem Sagar Bhoi, who had named Surnamoye Bhoi, wife as nominee in three out of four mentioned policies in this Para. In policy number 593069411, the nominee was Rajesh Kumar Bhoi, son of the policy holder, who was a minor at the time of commencement of policy and Surnomoyee Bhoi's name was entered in the appointee's field. He admitted that intimation for death claims were received for three policies- 590288509, 591253960 and 593069411 and claim of all these policies were settled by our office. But he denied that the medical report from any hospital were called for by LIC office or submitted by the claimant at that time. Because for settlement of non-early death claim (Claim arising after 3 years from date of risk of any policy), LIC do not require medical reports (Claim form B). The Policy no.593279521 was issued for LIC's Money Plus Plan-table No.180, and it is a unit linked endowment plan which offers investment cum insurance during the term of the policy. On the face of the policy bond it is clearly written under point-b under the heading "Benefits payable and events, on the happening of which, they are payable" and is being reproduced as (b)- Amount payable on death: In the event of death of Life Assured prior to the date of maturity, when the cover is in full force, an amount equal to the higher of sum assured under the basic plan or the Funds value of the units held in the Policyholders Fund Value shall become payable.......". So it is clearly written that claim is to be settled at the time of death and not at the time of maturity. The claimant in this policy is not submitting the required documents, which are necessary for settlement of Early Claims (Where Death is within three years of the commencement of Risk under a policy). In this case the policy has commenced on 29.03.2007 and death of the policy holder is 02.12.2009. So our office had called for required documents, i.e-Claim Form B & B1 along with Form A, C, original policy bond, treatment particulars and affidavit. The complainant has submitted the death claim after a long period of eight years after death of the policy holder and not submitting the required documents for processing of the claim. That there is no deficiency on the part of the Opposite Party as the Corporation has set certain rules and regulations for

every aspect of servicing and for processing of early death claims certain requirements are necessarily called for. The complainant's plea that the claim be settled as per old records of insurance policies are bad as per the rules of the Corporation and illogical as well because,earlier claims were settled as per Non-early Claims procedure where the documents

required for Early claim were not submitted. The O.P states that as soon as he receives the required documents as sought for he will take decision for settlement of the death claim on policy no-593279521.

POINTS OF DETERMINATION:-

1. Whether the Complainant is comes under the purview of Consumer Protection Act-2019?
2. Whether the O.Ps has committed any Deficiency in Service to the Complainant?

 

From the above discussion and materials available on records we inferred that the Complainant comes under the purview of Consumers as her deceased husband had availed four LIC policies during his life time where the complainant is the nominee in three policies and being the married wife of the policy older she claimed for the death claim settlement before the O.P. The O.P repudiated the death claim of her husband for the only reason that the claim documents were reached to the O.P with a delay of 8 years from the stipulated time period fixed by the Authority. According to the circular dated September 20th, 2011 (Annexure-A) issued by INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY Ref:-IRDA/HLTH/MISC/CIR/216/09/2011 Date: 20.09.2011 CIRCULAR To: All life insurers and non-life insurers -Delay in claim intimation/documents submission with respect to (i).     All life insurance contracts and (ii).  All Non-life individual and group insurance contracts The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents. The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances. The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation. Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time. The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurers stand to condone delay on merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured. This matter has been well settled in the case of  “Shriram General Insurance ... vs Rajesh Kumar Son Of Sh. Murari Lal”, on 10 March, 2014 by State Consumer Disputes Redressal Commission,Haryana, Panchkula.  Hence the Insurance Company is held liable for any deficiency in services to the complainant and we order as under.

ORDER

The Complaint petition is allowed. The O.P is directed to release the appropriate Compensation amount in favour of the Complainant, specified under the LIC policy with 9% interest  per annum from the date of filling of this case i.e dtd. 18.02.2021 till its realization." The O.P is further directed to pay Rs. 20,000/-(Rupees Twenty Thousand) as compensation towards harassment, mental pain and agony, and Rs. 5,000/- (Rupees Five Thousand) towards the cost of litigation. All the above orders are to be carried out within 30 (Thirty)

days of receiving of this order, failing which, the complainant is at liberty to proceed in due process of law.    

Order pronounced in the open court today i.e, on 15^th  day of December-2021 under my hand and seal of this Commission.

Office is directed to supply copies of the Order to the parties free of costs receiving acknowledgement of the delivery thereof.

               I agree,

                                                                                               

                   MEMBER.                                                                             PRESIDENT.

                                                      Dictated and Corrected

                                                                      By me.

 

                    President