Ld. Advocate(s)
For Complainant: Patanjal Lahiri
For OP/OPs : Suvankar Bhattacharya
Date of filing of the case :01.09.2021
Date of Disposal of the case :31.05.2024
Final Order / Judgment dtd.31.05.2024
The concise fact of the case of the complainant is that the complainant
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Sankar Halder and his wife Gita Halder insured a Life Insurance Policy through SBI Life Insurance Company Limited being the OP No.1 under the Pradhan Mantri Suraksha Bima Yojona (PMSBY). The wife of the complainant made the insurance policy since 01.06.2015 @ Rs.330.00 per year through SBI Life Insurance Company, Krishnagar. OP No.1 paid premium from 01.06.2015, 01.06.2016, 01.06.2017, 01.06.2018, 01.06.2019 to 16.05.2020 and also paid the said premium of Rs.330.00 which the OP NO.1 Bank received. But from 16.05.2020 the insurance premium was deducted from the complainant’s wife SBI savings bank account bearing no.34799221632. After deduction the said amount was refunded to the complainant’s wife SBI bank account on 05.06.2020. The wife of the complainant died on 21.06.2020. Thereafter, the complainant demanded the insurance money of his deceased wife from the opposite party. But the Ops informed that the said premium money was refunded by the authority concerned and they are unable to arrange the insurance claim in the name of Gita Halder under the Pradhan Mantri Suraksha Bima Yojona. Thereafter, the complainant sent a registered letter on 19.10.2020 to the OP demanding the insurance money. The OP informed to the complainant that the said Gita Halder joined the insurance scheme on 13.06.2015 when the said Gita Halder was 49 years of age and as on the date of renewal that is on 01.05.2020 Gita Halder attended 55 years. So, the wife of the complainant is not eligible to be covered under the insurance scheme because the risk coverage on the life of the member was terminated on attaining 55 years of age. Then the complainant sent a registered letter to the head office of SBI Life Insurance at Mumbai Maharashtra as per the instruction of OP No.1. The wife of the complainant was born on 10.11.1965. She purchased the insurance scheme on 13.06.2015 at the age of 49 years 7 months 3 days. The said wife of the complainant died on 21.08.2020 when she was 54 years 9 months 11 days. So, the rejection of the policy on the ground of age is not acceptable and requested to the authority to take suitable action for the early settlement of PMJJBY insurance scheme but the said authority did not consider. The Op company advised the complainant to consult with the ombudsman. The complainant accordingly, consulted with the ombudsman but the ombudsmen did not give any scope to hear the complainant. Instead they arranged for audio/video hearing which was not acceptable to the complainant. The complainant sent the annexure-6A form to the ombudsman on 05.02.2021. Said authority did not consider the grievance of the complainant. Hence, the complainant has been deprived of the legal benefits. Due to Covid-19 and Lock Down the complainant could not met the Insurance Regulatory Development
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Authority of India (IRDAI). The cause of action for the present case arose on 12.05.2021. The OP has caused mental pain and agony to the complainant. So, the complainant prayed for an award with a direction to the OP No.1 to pay Rs.1,00,000/- to the complainant for mental agony and physical harassment , Rs.25,000/- towards litigation cost and Rs.2,00,000/- towards insurance benefit claim.
OP No.1&3 filed written version challenging the case as not maintainable. The ombudsman has already dismissed the complaint on merit. The positive defence case of the OP is that Mrs. Gita Halder life assured (LA) had a bank account no. 34799221632 with SBI and applied for insurance cover under the PMJJBY. The company had granted insurance cover for a basic sum assured Rs.2,00,000/- from 01.06.2015 to 31.05.2016 which was renewed every year till 31.05.2020. As per the terms and conditions the premium auto debited from deceased account in May, 2020 was refunded on 05.10.2020, so the insurance cover was terminated on 31.05.2020 as the deceased was 54 years 6 months 22 days as on date of renewal . The company has no role in debiting the premium. It is the responsibility of the insured member or the master policy holder. SBI and SBI Life are separate legal notice. In this case , the renewal premium was deducted by the bank as per the auto debit process and was remitted to the company. The company refunded the same on 05.10.2020 before receipt of any claim intimation. The company was not aware of the death of the deceased at the time of refund of premium. The company received claim intimation that on 27.10.2020 Mrs. Gita Halder died on 21.08.2020. Such deceased was not covered under the PMJJBY scheme. So the company repudiated the claim ,which was communicated to the complainant on 30.10.2020. The company received request letter on 19.11.2020 to reconsider the claim which was put before the claim review committee and it was decided to upheld the decision to repudiate the claim . It was communicated to the complainant on 12.12.2020. The OP has no contractual obligation to pay the death claim benefits. The OP claimed that the case is liable to be dismissed.
After considering the pleadings of both the parties the Commission considers it necessary to ascertain the following points for proper adjudication of this case.
Points for Determination
Point No.1.
Whether the case is maintainable in its present form and prayer.
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Point No.2.
Whether the complainant is entitled to get the relief as prayed for.
Point No.3.
To what other relief if any the complainant is entitled to get.
Decision with Reasons
Point No.1.
The present point relates to question as to maintainability of the case.
Although, the OPs pleaded that the case is not maintainable yet in course of argument Ld. Defence Counsel did not advance any argument as to the question relating to maintainability of the case.
However, having perused the pleadings of the parties and the materials in the case record the Commission is of the view that the present case is not barred under any provisions of law. The complainant specifically pleaded and argued that the wife of the complainant had a life insurance policy through the OP No.1 which is admitted case. The said wife of the complainant namely Gita Halder died on 21.08.2020 and after her death specific claim was raised with the OP. The present case is filed under the provision of the C.P Act.
The OP could not assign specific reason as to why the case is not maintainable . So, having considered all the facts and circumstances of the case and the provision of law the Commission holds that the case is maintainable in its present form and prayer.
Accordingly, point no.1 is answered in affirmative in favour of the complainant.
Point No.2&3.
Both the points are closely interlinked with each other and as such these are taken up together for brevity and convenience of discussion.
It is the admitted case of the parties that the complainant and his wife Gita Halder made a life insurance policy through OP No.1 on 01.06.2015 under the scheme of Pradhan Mantri Jeevan Joyoti Bima Yojona (PMJJBY) scheme of Central Government of India on 01.06.2015 @ Rs.330.00 per year and the complainant continued the
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said policy upto 16.05.2020. The premium was deducted from 16.05.2020 from the savings bank account no. 34799221632. The said Gita Halder, insured died on 21.08.2020. After her death the complainant lodged a claim to the proper authority. It appears that the OP claimed that the insurance premium was refunded by the authority concerned and as such the OP is unable to arrange the insurance claim.
The OP further claimed that the said Gita Halder joined the insurance scheme on 13.06.2015 and as on the date of joining the age of the LA Gita Halder was 49 years. On the premium due date that is 01.06.2020 his wife attended 55 years , so she was not eligible to cover under the insurance scheme. As per the scheme rules the risk coverage on the life of the member shall terminate on attaining 55 years of age.
But from the documents it transpires that the date of birth of the LA Gita Halder is 10.11.1965 and she joined the insurance scheme on 13.06.2015 at the age of 49 years 7 months 3 days. As per the pleadings of the parties the age of the deceased Gita Halder on 21.08.2020 that is date of her death is 54 years 9 months 11 days.
The complainant filed original death certificate of the deceased Gita Halder . As per the death certificate date of death is 21.08.2020.
The complainant seems to have stated that the petitioner died on 21.06.2020 but as per the death certificate the date of death is 21.08.2020.
Be that as it may , the said Gita Halder appears to have died at the age of 54 years 9 months 11 days when the policy was active.
It is the specific the case of the OP that the insurance cover was granted to the LA for one year and the same was further renewed every year till the cover age date that is 31.05.2020. On receipt of annual premium of Rs.330.00 every year. The said Gita Halder died at the age of 54 years 9 months 11 days. At that time the policy was active. So, she was below the 55 years of age at that time.
The OP repudiated the claim of the complainant on the ground that the deceased member was age of 54 years 6 months and 22 days as on the date of renewal which was near upto 55 years. Hence , she was not eligible for renewal of insurance coverage.
The OP could not establish that the complainant’s wife LA Gita Halder attended the age of 55 years at the time of her death. So,
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the ground stated by OP against for rejection of the claim is not valid and proper. As per the project feature PMJJBY scheme of the Central Government the member shall automatically seize on the earliest grievance of any one of the following funds the dead members attendance 55 years of age .
The said clause is not applicable here since the deceased LA has not attended the age of 55 years on the date of her age.
The Ld. Advocate for the complainant rightly argued that the premium was deducted from the deceased account in May, 2020.
It is not denied by the OP but Ld. Defence Counsel argued that the said premium was refunded on 05.10.2020.
The OP further defended the case that as per the clause 4(i)(iv) it is the responsibility of the insured to remit the premium in full before the annual renewal date.
Thus if there is any mis-communication about the information as to the date of death in between the opposite parties the complainant cannot be held responsible. So, it cannot be considered that the deceased was not covered under the PMJJBY on the date of her death.
The complainant proved all the relevant documents in support of her claim.
No.1 is the acknowledgement - subscriber registration in (PMJJBY) having account no. 34799221632.
No.2 is the SBI Life e-Sampark receipt.
No.3 is the copy of pass book renewal of policy.
No.4 is the Aadhar Card of the complainant.
No.5 is the Death Certificate of Gita Halder.
The OP filed certain documents wherefrom it is revealed that the Secretary of the Insurance Ombudsman sent a letter to this Commission wherein it is held that the petitioner can seek relief in the court/forum on the merits of his case and that court/forum can always take a view different to that of the insurance ombudsman if it finds any merit in the case.
The attention of this Commission has been drawn in this regard.
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Accordingly, this court differs from the decision of the ombudsman.
The documents filed by the OP also taken into consideration. As per the proceedings before the insurance ombudsman the claim of the complainant was repudiated.
The said decision of the ombudsman appears to have mechanically considered the submission of the parties but it is reflected that the said Gita Halder attended the age of 55 years .
In the instant case the as per the death certificate and the pleadings of the parties the age of the deceased Gita Halder has been calculated as 54 years 9 months 11 days. So, the deceased LA died before attentaining the age of 55 years .
The policy document filed by the complainant suggests that the deceased was eligible for the said insurance benefit under this scheme.
The OP also has relied upon the subscriber registration certificate filed by the complainant and the e-sampark receipt showing the said insurance scheme was active till the date of death of the Gita Halder. The bank account also shows that premiums were deposited in the name of the deceased.
From the document of the complainant it further appears that she lodged the complaint to the OP SBI life insurance company for payment of the insurance claim money .
The letter filed by the OP dated 30.10.2020 also discloses that the risk infrastructure will terminate attaining the age of 55 years but the deceased did not attentainig that age.
The complainant also filed representation against the decision of the OP.
Ld. Advocate for the complainant relied upon a decision reported in WP (c) 6304 by 2019 between Pavan Sachdeva Vs. Office of the insurance ombudsman wherein it was held that the ombudsman clearly to apply the correct test to the dispute before it. The impugned order of the ombudsman by ignoring the relevant consideration, was set aside.
The said case law is relied on.
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The complainant further referred to one decision reported in 2023 Live Law (SC) 509 wherein it was held that once there is a valid insurance policy in favour of a person the claim of reimbursement of the expenses incurred must be paid.
The said case law is also relied on .
The OP could not refer any counter case law against the ruling submitted by the complainant.
In the backdrop of the aforesaid discussion vis-a-vis the observation made hereinabove the Commission comes to the finding that the complainant proved the case upto the hilt. The OP has acted in a manner which tantamounts to deficiency in service which should be compensated in terms of money.
Accordingly, point no.2&3 are answered in affirmative and decided in favour of the complainant.
Consequently, the complaint case succeeds on contest against OP No.1&3 and ex-parte against OP No.2,4&5.
Hence,
It is
Ordered
that the complaint case no.CC/70/2021 be and the same is allowed on contest against OP No.1&3 and ex-parte against OP No.2,4 &5 with cost of Rs.5,000/- (Rupees five thousand). The complainant do get an award for a sum of Rs.2,00,000/- (Rupees two lakhs) from the opposite parties jointly and severally towards PMJJBY insurance benefit for deceased Gita Halder , Rs.10,000/- (Rupees ten thousand) towards deficiency in service and harassment and mental pain and agony and Rs.5,000/- (Rupees five thousand) towards litigation cost. The OPs are jointly and severally directed to pay to the complainant Rs.2,15,000/- (Rupees two lakh fifteen thousand) within 30 days from the date of
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passing the final order failing which the entire award money shall carry an interest @8% p.a from the date of passing the final award till the date of its realisation.
All Interim Applications (I.A) stand disposed of accordingly.
D.A to note in the trial register.
The case is accordingly disposed of.
Let a copy of this final order be supplied to both the parties at free of costs.
Dictated & corrected by me
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PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,) ................ ..........................................
PRESIDENT
(Shri HARADHAN MUKHOPADHYAY,)
I concur,
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MEMBER
(SHRI NIROD BARAN ROY CHOWDHURY)
