Tripura

StateCommission

A/36/2016

Nitai Chandra Saha - Complainant(s)

Versus

The Life Insurance Corporation of India - Opp.Party(s)

Mr. S.Chakraborty

16 Mar 2017

ORDER

Tripura State Consumer Disputes Redressal Commission, Agartala.

 

Case No.A.36.2016

 

1. Nitai Chandra Saha,

S/o Late Brajabashi Saha,

Resident of Shibnagar, Masjid Road,

P.O. Agartala College, P.S. East Agartala,

West Tripura, Pin:799004.

… … … … Appellant/Complainant.

 

1. Life Insurance Corporation of India,

Represented by its Divisional Manager,

Divisional Office at Meherpur,

Silchar-15, Assam.

 

2. Branch Manager,

Life Insurance Corporation of India,

Branch Office at Thakur Palli Road,

Krishnanagar (TRTC), Agartala,

P.S. West Agartala,

District - West Tripura, Pin:799001.

… … … … … Respondents/Opposite parties.

 

Present

 

Mr. Justice U.B. Saha,

President,

State Commission, Tripura.

 

Mrs. Sobhana Datta,

Member,

State Commission, Tripura.

 

Mr. Narayan Chandra Sharma,

Member,

State Commission, Tripura.

 

 

 

 

For the Appellant:                       Mr. Shubhajit Chakraborty, Adv.

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

Date of Hearing and Delivery of Judgment: 16.03.2017.

J U D G M E N T [O R A L]

 

 

U.B. Saha, J,

The instant appeal is preferred by the appellant Sri Nitai Chandra Saha under Section 15 of the Consumer Protection Act, 1986 against the judgment dated 04.07.2016 passed by the Ld. District Consumers Disputes Redressal Forum, West Tripura, Agartala (hereinafter referred to as District Forum) in Case No. C.C. 20 of 2016 whereby and whereunder the claim petition of the appellant-complainant (hereinafter referred to as complainant) was dismissed by the District Forum.      

1. Heard Mr. Shubhajit Chakraborty, Ld. Counsel appearing for the complainant as well as Mr. Prahlad Kumar Debnath, Ld. Counsel appearing for the respondents-Life Insurance Corporation of India.
2. Admitted facts of the case are that, the complainant Nitai Chandra Saha, a driver by profession, obtained a policy from the respondent-opposite party Life Insurance Corporation of India (hereinafter referred to as Insurance Company/LICI/opposite party) under the scheme of Jeevan Anand (with profits) (with accident benefit) being Policy No.492378820 of which the date of commencement was 26.04.2008 and the sum assured was of Rs.1,70,000/-. On 30.12.2008, the complainant met with an accident under Madanriting Police Station, East Khasi Hill, Traffic Branch, Shillong and sustained grievous injuries on his person and he became senseless. Thereafter, he was taken to the Civil Hospital, Shillong, wherefrom he was brought to Agartala and ultimately he was admitted in AGMC & GBP Hospital at Agartala on 04.01.2009 morning. On 06.01.2009 considering the seriousness of injuries, the Medical Board of Agartala Government Medical College & Govind Ballabh Pant Hospital (in short AGMC & GBP Hospital) referred the complainant to SSKM Hospital, Kolkata, West Bengal. Then complainant was taken to Kolkata and was under continuous treatment there till September, 2009. Thereafter, he returned to Agartala, but he was required to get admitted in the AGMC & GBP Hospital on 22.11.2009 whereupon the Medical Board of the said hospital again referred him to CMC, Vellore. Accordingly, on 10.12.2009, he was taken to Vellore. On 12.12.2009, his right leg was amputated under knee at Sri Narayani Hospital & Research Centre, Thirumalaikodi, Vellore-55. He had to undergo treatment at CMC Vellore for a long period and after amputation, he became permanently disabled. Later, on 05.05.2010, the State Disability Board at the AGMC & GBP Hospital certified that he was 70% disabled after amputation of his right leg.

During the treatment of the complainant, the whole family of the complainant was with him and on their return to Agartala in the second week of December, 2010, the complainant sent his wife to the office of the respondent at Thakurpally Road, Krishnanagar near TRTC, Agartala with an application for getting the accidental benefit against the policy as at the time of accident, the insurance policy of the complainant was in force and was a valid one. The wife of the complainant though submitted application in writing, but she was advised by one office personnel of the LICI to submit the claim in prescribed form. Again, the wife of the complainant preferred an application in a whitepaper along with relevant documents claiming accidental benefit, but the respondents that time also neither provided any prescribed claim form nor took any interest for taking necessary step to settle the claim of the complainant. Thereafter on 29.12.2014, the complainant preferred another application for getting accidental benefit under the aforesaid policy along with relevant documents. In response to the above mentioned letter, the respondent no.1 LICI sent a letter dated 23.02.2014 by registered post wherein the complainant was requested to submit some requirements before the respondent no.2, the Branch Manager, LICI, Branch Office at Thakurpally Road with prescribed form No.5279 and 5280.

As per advice of the respondent no.1, the complainant on 10.04.2015 submitted duly filled up prescribed form along with all relevant documents, but unfortunately the respondents did not take any heed towards the claim of the complainant.

Thereafter, the complainant again issued a letter dated 10.09.2015 as reminder to the respondents, but the respondents did not come forward to settle the claim of the complainant. Thus finding no other alternative, the complainant for getting redress and ends of fair justice approached the Ld. District Consumer Disputes Redressal Forum by way of filing a complaint which was dismissed by the Ld. District Forum on the ground that the complainant did not fulfil the Clause-10 A of the Policy Certificate and the complaint petition filed by the complainant was time barred. Hence the appeal.     

3. The respondent Insurance Company appeared before the Ld. District Forum by way of filing written statement, wherein it is admitted that the petitioner was the policyholder under LICI accidental benefit and the policy covered the period from 2008. It is also stated that the petitioner was under treatment up to 2010 and thereafter, the relative of the complainant visited the office of the Insurance Company, but there is no evidence to support it. In the written statement, the respondents have also contended that the petitioner produced the claim petition form and on perusal of that form, it was found that the claim petition form was actually submitted in prescribed format on 29.12.2014. By letter dated 23.02.2015, Manager, Claims of LICI asked the complainant to produce FIR, Driving Licence and other particulars and those were submitted by the complainant on 08.04.2015 and a reminder letter was sent on 10.09.2015. Finally, the respondents repudiated the claim of the petitioner on 31.03.2016 on the ground that after recovery in the year 2010, the complainant failed to inform the Insurance Company. He informed the LICI after long time in the year 2014 and thus he violated the terms and conditions of the policy. More so, disablement is not total and the claim is time barred.
4. Mr. Chakraborty, Ld. Counsel appearing on behalf of the appellant-complainant while urging for setting aside the impugned judgment would contend that the insured was a driver and admittedly his one leg below the knee has been amputated. Resultantly, he is sufficiently disabled for pursuing his livelihood by way of driving any vehicle or any other work. He further submits that the Ld. District Forum failed to interpret the condition of Clause-10 A of the Policy Certificate in true sense. According to him, when there is any ambiguity, or a term is capable of two possible interpretations, the one beneficial to the insured should be accepted consistent with the purpose for which the policy is taken, namely, to cover the risk on the happening of certain event. In support of his aforesaid contention, he has referred to a decision of the Hon’ble National Consumer Disputes Redressal Commission (hereinafter referred to as National Commission) dated 28^th November, 2006 in Life Insurance Corporation of India Vs Ram Singh Tanwar in Revision Petition No.3446 of 2006 wherein, the National Commission decided a similar case in hand and in that case also, the complainant was employed as a driver and when he was driving a truck from Pali to Jaipur, he met with an accident and sustained injury on his right leg and thereafter, his right leg was required to be amputated so that he may survive. The LIC repudiated the claim on 12.03.2001 by contending that amputation of one leg was not sufficient for paying the sum assured, but the National Commission dismissed the Revision Petition upholding the judgment of the State Commission.
5. He has also pointed out that in the case of Ram Singh Tanwar (supra), the National Commission also considered the Clause-10 of the insurance policy i.e. accident benefit like the Clause-10 A of the Policy in question in this case.
6. He has also relied upon the decision of the Hon’ble Apex Court in United India Assurance Company Ltd. Vs Pushpalaya Printers - 2004 (3) SCC 694 which was considered by the National Commission in Ram Singh Tanwar (supra) and the National Commission noted that “The State Commission referred to the decision of the Apex Court in United India Assurance Company Ltd. V/s. Puspalaya Printers 2004 (3) SCC 649 and observed that if there is any ambiguity, or a term is capable of two possible interpretations, the one beneficial to the insured should be accepted consistent with the purpose for which the policy is taken, namely, to cover the risk on the happening of certain event. The State Commission thereafter referred to the fact that a Medical Board was set up by the Government of Rajasthan at SMS Hospital, Jaipur and that Board has certified that the right leg of the complainant below knee was amputated on 25.12.2000. The State Commission also noted that complainant was not educated and cannot be gainfully employed because he is not a normal person. On the said basis, the State Commission confirmed the order passed by the District Forum directing the LIC to pay the sum assured.” He has also contended that in the instant case also, the District Forum ought to have held that the complainant is entitled to the benefit of the policy even on the face of Clause-10 A of the Policy Certificate as the disability of the complainant is the result of an accident and also permanent in nature as right leg below the knee was amputated.
7. He has also relied upon the judgment of Chhattisgarh State Commission in The Oriental Insurance Company Ltd. Vs Smt. Reeta Devi in Appeal No.FA/12/782, wherein, the Chhattisgarh State Commission dismissed the appeal preferred by the Insurance Company in which, the Insurance Company repudiated the claim of the complainant therein on the ground of delayed in intimation. He has also taken us on Paragraph-15 of the aforesaid judgment which is as follows:-

“15. The appellant/Insurance Company repudiated the claim of the respondent/complainant on the ground of delay in intimation. The Insurance Regulatory & Development Authority vide CIRCULAR NO.IRDA /HLTH /MISC /CIR /216 /09 /2011, DATED 20/09/2011 has directed all the Insurance Company not to disallow the entire claim of the claimants only on the ground of delay in intimation if the claim is otherwise payable. So, we cannot appreciate the action of the appellant/Insurance Company of repudiating the claim only on the ground of delay in intimation. In the instant case, regarding delay in giving intimation regarding the incident, sufficient explanation was given by the respondent/complainant. Looking to the law laid down in Nitin Khandelwal's case (supra), it is not proper on the part of the Insurance Company to repudiate whole claim of the respondent/complainant only on the ground of delay in intimation.”

He has also taken us to the judgment of the Punjab-Haryana High Court in Life Insurance Corporation of India Vs Permanent Lok Adalat & Another [LPA No.404 of 2016 (O&M)] wherein, the Punjab-Haryana High Court observed, inter alia, that “We have heard the learned counsel for the appellant and find that the argument raised before this Court is absurd to say the least. The insured was a labourer and if his one leg has been amputated he would resultantly have been sufficiently disabled from pursuing even his livelihood. The argument is hollow and even otherwise no such interpretation can be placed on clause 10(4) that an insured would be entitled to get the compensation if he suffered only 100% disability and not otherwise. The opening words of clause 10(4) reveal that a disability referred to must be disability which is the result of an accident and must be 'total' and 'permanent' which have to be read and assigned a separate meaning and not to be construed conjunctively.

It would certainly entitle the claimant to a claim in terms of the policy since undisputedly, amputation of a leg falls in the category of a permanent disability.

We are further of the opinion that the entire litigation initiated by the insurance company to thwart a valid claim smacks of a deliberate attempt to frustrate the legitimate claim of a person who took out the policy with a firm hope that his interest would be taken care of in the eventuality of an unfortunate accident or death. The insurance companies cannot be permitted to defeat such valid claims by raising frivolous objections which apart from defeating the claim and the purpose of the insurance altogether always result in wastage of time of the courts unnecessarily and heap further misery on persons already in distress.”      

8. Mr. Debnath, Ld. Counsel while supporting the impugned judgment of the Ld. District Forum submits that the disability of the complainant is not in total, but only 70%. He further submits that mere amputation of one leg does not disentitle the complainant from doing any other job. He further submits that the complainant did not adduce any evidence that just after amputation of his one leg, his family members approached the respondent-Insurance Company. He has also relied upon the Clause-10 A of the Policy Certificate, the relevant portion of which is as follows:-

“The disability above referred to must be disability which is the result of an accident and must be total and permanent and such that there is neither then, nor at any time thereafter any work, occupation or profession that the Life Assured can ever sufficiently do or follow to earn or obtain any wages, compensation or profit. Accidental injuries which independently of all other causes and within 180 days from the happening of such accident, result in the irrecoverable loss off the entire of both eyes or in the amputation of both hands at or above the wrists, or in the amputation of both feet or at above ankles, or in the amputation of one hand at or above the wrist and one foot at or above the ankle, shall also be deemed to constitute such disability.”  

In support of his aforesaid contention, he has relied upon the judgment of National Consumer Disputes Redressal Commission in Sonu Rathee Vs Life Insurance Corporation of India (Revision Petition No.483 of 2013), particularly Paragraph-9 of the aforesaid judgment which is as follows:-

“9. On reading of the latter part of the above term of the insurance contract it is clear that the insurance benefit in case of 100% permanent disability on account of accident would be available to the insured only if the disability is of such a nature that it has rendered the insured unable to follow his work, occupation or profession to earn or obtain any wages, compensation or profit. Undisputedly, in the instant case after having suffered the permanent disability the petitioner continued to works as LDC in UHBVNL and was paid salary, which he was getting prior to the accident. Thus, the impugned order of the State Commission allowing the appeal dismissing the consumer complaint in view of above condition of insurance contract cannot be faulted.”

He has also emphasized a line from the judgment of National Consumer Disputes Redressal Commission in LIC of India Vs Neeraj Kumar (Revision Petition No.613 of 2009) wherein the National Commission set aside the order dated 11.12.2008 passed by the State Consumer Disputes Redressal Commission, Delhi in Appeal No. FA-08/999, considering the Clause-10 and Clause-10 A of the policy involved in the said case. He has finally relied upon a decision of the National Consumer Disputes Redressal Commission in Life Insurance Corporation of India Vs Surendra Kumar Tripathi decided on December 04, 2002 [LAWS (NCD)-2002-12-43] wherein the National Commission had considered the Clause-10 and Clause-10 (a) of the Policy in question in that case, wherein, the National Commission had observed that the District Forum as well as the State Commission has no jurisdiction to go beyond the terms and conditions of the policy bond and could only order the payment of the disability benefit if it was specified event covered by Clause-10.  

9. We have gone through the policy in question as well as the prescriptions issued by the various hospitals and also the disability certificate issued by the State Medical Board, from which it appears that the complainant was continuously under treatment up to 2010 and disability certificate was issued on 05.05.2010 showing 70% permanent disablement. In his evidence, the complainant has specifically stated in his Affidavit-in-Chief that after amputation of right leg he cannot move anywhere without any assistant and his wife and daughter were all along with him at the time of his treatment outside the State and in the second week of December, 2010 after returning to Agartala, his wife was sent to the office of the opposite parties at Thakur Palli Road, Krishnanagar near TRTC, Agartala with an application for taking necessary steps for getting accidental benefit against his policy as at the time of accident, the insurance policy was in force and valid one. It is also stated that his wife submitted an application in black & white, but one office staff of the opposite parties who was engaged in Receive Section advised her to submit the claim in prescribed format including necessary documents instead of submission of the said application on a white paper. In cross, the said contention of the complainant was not denied, rather a suggestion was made that he had not claimed the amount in respect of policy, which he denied.
10. We have also gone through the impugned judgment, wherein the Ld. District Forum dismissed the complaint petition relying upon the decision of the National Commission in Neeraj Kumar (supra) as well as Sonu Rathee (supra). Upon perusal of the aforesaid two judgments of the National Commission, we are of the opinion that both the judgments are distinguishable as the facts of those cases are totally different than the case in hand. In case of Neeraj Kumar (supra), though the doctors assessed 69% permanent disability, but the fact remains, Neeraj Kumar, the complainant of that case, even after amputation of his right arm was working as constable in Delhi Police and earning salary. But the case in hand, the complainant is a driver whose right leg is amputated below the knee and disability is to the extent of 70% and admittedly, he is not in a position to drive any vehicle for maintaining his livelihood. In Sonu Rathee (supra), the petitioner even after having suffered disability continued in service to earn salary and on that ground though his claim was allowed in District Forum, but disallowed by the Haryana State Consumer Disputes Redressal Commission and ultimately, the National Commission upheld the decision of the Haryana State Commission. Both the aforesaid cases were decided by the National Commission considering the fact that the complainants of those cases even after the disablement, continued in service to earn their salary, therefore, those cases has no application so far the case in hand is concerned. In Surendra Kumar Tripathi (supra), the National Commission very rightly said that neither the District Forum nor the State Commission had any jurisdiction to go beyond the terms and conditions of the policy bond and could only order the payment of the disability benefit if it was specified event covered by the Clause-10. In Ram Singh Tanwar (supra), the complainant-respondent was a driver like the present complainant and when he was driving a truck, he met with an accident and sustained injury on his right leg and thereafter, his right leg was required to be amputated so that he may survive. The LIC repudiated the claim contending that amputation of one leg was not sufficient for paying the sum assured, as contended by the respondent-Insurance Company in the instant case, but the National Commission noted, inter alia, that “The State Commission referred to the decision of the Apex Court in United India Assurance Company Ltd. V/s. Puspalaya Printers 2004 (3) SCC 649 and observed that if there is any ambiguity, or a term is capable of two possible interpretations, the one beneficial to the insured should be accepted consistent with the purpose for which the policy is taken, namely, to cover the risk on the happening of certain event. The State Commission thereafter referred to the fact that a Medical Board was set up by the Government of Rajasthan at SMS Hospital, Jaipur and that Board has certified that the right leg of the complainant below knee was amputated on 25.12.2000. The State Commission also noted that the complainant was not educated and cannot be gainfully employed because he is not a normal person. On the said basis, the State Commission confirmed the order passed by the District Forum directing the LIC to pay the sum assured.” In the instant case also admittedly, the right leg of the complainant below the knee was amputated and the same was certified by the State Disability Board issuing the certificate on 05.05.2010. Clause-10 A would attract in case of the amputation of both feet or at above the ankles, but in the instant case, the amputation is below the knee. In Ram Singh Tanwar (supra) the National Commission while considering the Clause-10 relating to accidental benefit stated that “No doubt the aforesaid condition as per the policy term, is not in divided form as stated above. But, for the purpose of understanding and interpretation the condition is divided into two parts without any addition. First part of the condition, inter alia, provides that in the accident there must be total and permanent disability so that assured can never sufficiently do or follow to earn or obtain any wages, compensation or profit. This part is different from the second part narrated above.

Second part deals with accidental injuries which independent of all other causes, result in loss of limbs as mentioned therein. Such loss of limb is also deemed to constitute permanent disability. It is a deeming provision where capacity to earn is not required to be considered. It makes it clear that independent of the injuries which may be total and permanent for any other cause, the loss of limbs, as stated therein, would by itself be deemed to be permanent disability.”

The National Commission in Ram Singh Tanwar (supra) has also given an example “that a businessman can do his work even if there is amputation of one hand and/or above the wrist and one foot and/or above the ankle.” But in the instant case, the complainant being a driver after the amputation of his right leg below the knee cannot do his work of driving to maintain his livelihood and there is no allegation that he is doing any job for maintaining his livelihood.  

11. We want to give another example, suppose a carpenter lost his all fingers due to an accident then the said carpenter would not be in a position to do his work of carpentry for maintaining his livelihood. Losing of all fingers are though in according to the Medical Science not permanently disabled, but for the purpose of interpretation of Clause-10 A, losing of all fingers has to be considered as permanent disablement.
12. In Ram Singh Tanwar (supra), the National Commission finally observed, “It is necessary for the officers of the LIC to change their negative approach in dealing with such claim and the insurance coverage should not be nullified by backward looking interpretation of the Act and in some cases litigation could be avoided. The Apex Court, in this context, held in Skandia Insurance Co. Ltd. Vs Kokilaben Chandravadan, (1987) 2 SCC 654 at 665, that: It is the statutory provision defining the conditions of exemption which is being interpreted. These must, therefore, be interpreted in the spirit in which the same have been enacted accompanied by an anxiety to ensure that the protection is not nullified by the backward looking interpretation, which serves to defeat the provision rather than to fulfill its life-aim. To do otherwise would amount to nullifying the benevolent provision by reading it with a non-benevolent eye and with a mind not turned to the purpose and philosophy of the legislation without being informed of the true goals sought to be achieved. What the Legislature has given, the Court cannot deprive of by way of an exercise in interpretation when the view which renders the provision potent is equally plausible as the one which renders the provision impotent.”
13. In the instant case, except the contention regarding delay in preferring the claim, there is no other valid ground raised by the Insurance Company. According to us, when the petitioner was not in a position to move just after amputation of his leg below the knee in the year 2010, how he himself can approach the Insurance Company for his legitimate claim benefit of insurance policy. In the instant case, the complainant specifically stated that his wife went to the Branch Office of Insurance Company and also filed an application, but the said application was not received by the officer of the Insurance Company, rather suggested to file an application in prescribed form. Even educated persons are not in a position to easily fill-up the form in certain cases, then how a driver or his family member would fill-up the form by themselves. The Insurance Company should have helped them to fill-up the form when they visited their office so that they could get the benefit of the insurance policy for which the insured made payment of premium in time.
14. In the instant case, admittedly, the accident was occurred when the policy was in force. Therefore, the so-called delay as contended by the LICI should not be a ground for repudiating the claim of the complainant in view of the Circular No. IRDA /HLTH /MISC /CIR /216 /09 /2011, dated 20.09.2011 as referred in Para-15 of Reeta Devi (supra).
15. In view of the discussion made herein above, the impugned judgment is set aside and the respondent-LICI is directed to make payment of the accident benefit as assured in the policy and non-payment of assured benefit in time is obviously a deficiency in service and for such deficiency, the respondent-Insurance Company shall pay Rs.15,000/- and towards the costs of litigation an amount of Rs.10,000/- shall be paid to the complainant. The respondents Insurance Company are also directed to pay the total amount to the complainant within six weeks from today.
16. In the result, the appeal is allowed.                            

Send down the records to the Ld. District Forum, West Tripura, Agartala.

 

 

MEMBER State Commission Tripura MEMBER State Commission Tripura PRESIDENT State Commission Tripura