Haryana

Ambala

CC/383/2018

Darshan Lal - Complainant(s)

Versus

The Ombudsman Inss. - Opp.Party(s)

Kuldeep Singh

03 Feb 2020

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA.

 

                                                                        Complaint case no.         :    383 of 2018

                                                                        Date of Institution           :   21.11.2018

                                                                        Date of decision              :   03.02.2020.

 

 

Darshan Lal son of Late Shri Jeet Ram resident of village Sambhalwa, P.O.Laha, Tehsil Naraingarh, District Ambala.

    ……. Complainant.

          Vs.

 

1. The Ombudsman (Insurance), SCO No.101-103, Batra Building, 2^nd Floor Sector 17-D, Chandigarh through its Secretary.
2. Life Insurance Corporation of India, Naraingarh Branch Divisional Office, Jeevan Prakash, Sector 17-B, Chandigarh through its representative;
3. Life Insurance Corporation of India, Naraingarh Branch Office (Branch Code:17E), Anaj Mandi, Naraingarh-134203. 

                                                                   .…. Opposite Parties.

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986

 

 

Before:        Smt. Neena Sandhu, President,                                             

                   Smt. Ruby Sharma, Member,

Shri Vinod Kumar Sharma, Member.

                  

Present:       None for the complainant.

                   None for OP No.1.

                    Shri R.K.Jindal, Advocate, counsel for OPs No.2 and 3. 

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay accidental benefits of Rs.1,10,000/- along with interest on account of 100% disability of the complainant.
2. To pay compensation for the mental agony and physical harassment suffered by him.

 

                   In nutshell, brief facts of the present complaint are that on 16.04.2009, the complainant had purchased a policy bearing No.17652236 agent of LIC name “New Bima Gold” for the sum assured of Rs.1,10,000/- from OP No.3 i.e Life Insurance Corporation of India. The schedule of commencement of policy is being reproduced as under:-

Policy No. Date of Commencement of Policy date of commencement of Risk	Table & terms premium paying Term Extended Term	Sum assured under Basic Plan (Rs.) Extended Term cover Benefit (Rs.) Accident Benefit Rider Sum Assured (Rs.)	Instalment Premium for Basic Plan (Rs.) Instalment Accident Benefit Rider Premium (Rs.) Total Instalment Premium (Rs.) Mode of Payment of Premium	Due to Date of Premium Due date of Payment of Last Premium Date of Expiry of Policy Terms Date of Expiry of extended terms
176522336   16.04.2009 16.04.2009	179       20     20	110000 110000	2083.00 55.00 Hly	16th 16.10.2028 16.04.2029

 He was paying the premium regularly through his agent since the day of commencement of the policy i.e. 16.04.2009. On 03.07.2012, he met with a road accident, due to which he suffering injury in his backbone. He was referred to PGI, where he got treatment but he became 100% disabled as per the certificate issued by the Post-graduate Institute of Medical Education and Research, Chandigarh bearing Certificate No.5737 dated 26.04.2013.  He spent huge amount on his treatment, but unable to move freely due to injury suffered in the accident. Due to his 100% disabled he is not able to earning his livelihood. Vide policy bearing No. 176522336, he was duly insured with the OP/LIC and is thus entitled to get the accidental claim from the LIC. He approached the OP No.3 and requested to release the accidental claim, but after delaying the matter the OP No.3 refused to pay the accidental claim on the ground that the premium was paid after expiry of grace period. He was paying his premium regularly to the LIC through its agent. He used to give the premium. The OP No.1 decline the claim of the complainant vide award dated 21.05.2018 by giving weightage to the plea of the OP No.2 by observing that since the policy was lapsed as on date of accident and the premium was paid after expiry of grace period. Neither the agent intimated him regarding due premium nor the OP No.3 has ever issued notice to him with regard to the due date of premium against complainant. The action/inaction of the OPs in not fulfilling the policy New Bima Gold “zindgi Ke Saath Bhi, zindagi Ke Baad Bhi”, the OPs have committed deficiency in service. Hence, the present complaint.

2.                Upon notice, the OP No.1 did not appear, rather sent its written version by post, wherein, it is stated that offices of Insurance Ombudsman have been established under the provisions of Redressal of Public Grievances Rules, 1998 (R.P.G. Rules) notified by Ministry of Finance. Government of India in exercise of its powers under Insurance Act, 1938. Insurance Ombudsman Rules, 2017, notified by Ministry of Finance, Government of India in exercise of its powers under Insurance Regulatory and Development Authority of India Act, 1999 have replaced Redressal of Public Grievances Rules, 1998. Office of the Executive Council of Insurers formerly GBIC (Governing Body of Insurance Council) is an administrative body looking after the operations of Bima Lokpal (Insurance Ombudsman) which is a quasi-judicial Forum formed under the Insurance Ombudsman Rules, 2017 (earlier, RPG Rules). OP No.1 has carried out his duties as per the rules. The office of the Executive Council of Insurers or OP No.1 is not an interested party in the case. The High Court of Judicature for Rajasthan, Bench at Jaipur in the WP No.13053/2018 has passed the following order dated 05.02.2019:

“The matter comes up on the misc. application no.5/2018 filed by the OP No.1 for deleting the name of applicant/respondent No.1- the Insurance Ombudsman from the array of the OPs. Learned counsel for the OPs has submitted that the OP No.1- Ombudsman has passed order as per power conferred in such Insurance Ombudsman under the Rules of Government of India notification dated 25.04.2017 and as such the OP No.1 is not necessary party. For the reasons stated/mentioned therein, the said application is allowed. The OP No.1- Insurance Ombudsman is deleted from the array of the OP”.

It is prayed that the name of Insurance Ombudsman may kindly be deleted from the list of OPs and their offices/authorized officials may kindly be exempted from the proceedings.

                   Upon notice, OPs No.2 & 3 appeared through counsel and tendered written version, raising preliminary objections regarding maintainability, not coming before this Forum with clean hands and suppressed the true and material facts, time barred and bad for non joinder and mis joinder. On merits, it is stated that policy No.176522336 was taken by Shri Darshan Lal for sum assured of Rs.1,10,000/- with date of commencement of 16.04.2009 under Plan & Term 179-20(LIC’s New Bima Gold) in which Half-yearly premium of Rs.2083/- was to be paid till date of maturity. The premium due for April, 2012 was paid by the complainant on 25.07.2012, after the lapse of grace period of 30 days and at the time of alleged accident the policy was in lapsed condition. The complainant is not entitled to the Disability benefits under the policy in question as the policy was lying in lapsed condition at the time of accident (which occurred on 03 July 2012) on account of non-payment of premium due on 16.04.2012 as per the policy condition 4 the disability claim is not payable. The Accident Benefit Rider will cease to apply if the policy in lapsed condition, during the auto cover period the accident benefit rider shall not be available, as such the OPs have rightly regretted claim of Disability Benefit under the policy in question vide its letter dated 17.06.2014, which was also appreciated by the Ombudsman while its passing the award in favour of OP dated 21.05.2018. There is no deficiency in service on the part of the OPs No.2 and 3 and the present complaint may be dismissed with heavy costs.

3.                The counsel for the complainant tendered affidavit of complainant as Annexure CA alongwith documents as Annexure C-1 to C-5 and closed the evidence. On the other hand, OP No.1 failed to produce any evidence despite availing various opportunities, so its evidence was closed by Court order vide order dated 05.12.2019. On the other hand, learned counsel for the OPs No. 2 & 3 tendered affidavit of Shri Ravi Mohan, Manager(L&HPF), LIC of India, Divisional Office Karnal as Annexure OP-2/A alongwith documents as Annexure OP-2A to OP-2D and closed the evidence.

4.                We have heard the learned counsel of the parties and carefully gone through the case.

5.                At the outset, the Ld. counsel for the OPs No.2 and 3 argued that the present complaint is not maintainable before this Forum, because the matter involved in the present case has already been adjudicated by the Ombusdman vide order dated 21.05.2018. We do not find any merit in this contention of the Ld. Counsel for OPs No.2 and 3, because in the case of Kamleshwar Prasad Singh Versus National Insurance Co. Ltd. decided on 14.10.2004, the Hon’ble National Commission has held that the decision of the Ombusdman is not binding on the complainant and the decision of the Insurance company to repudiate the claim is subject to adjudication by the Fora constituted under the Consumer Protection Act.

6.                On merits, complainant has pleaded that due to accident he became 100% disabled and is unable to earn his livelihood in spite of that the OPs refused to pay him the accidental claim, which amounts to deficiency in service.

                   On the contrary, the Ld. counsel for the OP No.2 and 3 argued that the OPs No.2 and 3 have rightly refused to pay the claim amount because at the time of accident i.e. 03.07.2012, the policy of the complainant was in lapsed condition, thus as per term No.4 of the terms and conditions of the policy, accidental benefits are not payable to him.   

6.                Admittedly, complainant purchased the policy in question from the LIC of India, for Sum Assured of Rs.1,10,000/- with half yearly premium @ Rs.2083/- with 55 installments. The date of commencement of the policy was 16.04.2009. Due date to pay last premium was 16.10.2028 and date of expiry of policy/date of extended term was 16.04.2029. As per the complainant on 03.07.2012, he met with an accident due to which his backbone got injured and he took treatment from the PGI, it issued him a 100% disability certificate. Complainant lodged the claim with the OPs No.2 and 3, but they refused to pay the claim amount. He filed a complaint before the Ombudsman i.e. OP No.1, who vide award dated 21.05.2018, had dismissed the complaint on the ground that as per Term No.4 of the Term and Conditions of the Policy, the disability benefits due to the accident are not payable to him because the policy was in lapsed condition as on the date of accident and the premium was paid after expiry of grace period. From the policy document Annexure C-1, it is evident that the life insured was under obligation to deposit half yearly premium due on 16^th of April and 16^th of October of every year till the date of maturity. Grace period of 30 days was given to Life Assured to deposit the due amount of the premium as is evident from the term No.2, ‘payment of premium’ of the terms and conditions of the policy. The Ld. Counsel for the OPs No.2 and 3 submitted that the premium due on 16.04.2012, was not paid by the complainant within the grace period of 30 days as a result whereof, policy got lapsed on 16.05.2012. Complainant paid the premium amount on 25.07.2012, which was actually due on 16.04.2012. Complainant met with an accident on 03.07.2012, and at that time the policy was in lapsed condition, as such as per term No.4 of the terms and conditions of the policy, which reads as under:-

“The accident Benefit Rider will cease to apply if the policy is in lapsed condition. During the auto cover period Accident Benefit Rider shall not be available.”

The complainant is thus not entitled to get the accidental benefits. Therefore, the present complaint filed by the complainant against OPs No.2 and 3 is liable to be dismissed. Even, the complaint filed against OP No.1 is also liable to be dismissed because complainant is not the consumer qua the OP No.1.

7.                In view of the aforesaid discussion, we hereby dismiss the present complaint, being devoid of merit. The parties are left to bear their own cost. Certified copy of this order be supplied to the complainant, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :03.02.2020.

          (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

                  Member                      Member                        President