State Consumer Disputes Redressal Commission
Pnb Metlife India Insurance Company ... vs Paramjit Singh on 7 January, 2015
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
Miscellaneous Application No. 2293 of 2014
in/and
First Appeal No. 1480 of 2014
Date of institution: 7.11.2014
Date of Decision: 7.1.2015
1. PNB MetLife India Insurance Company Ltd., Hazi Rattan Chowk,
Bhatinda, Through its Branch Head/Authorized Signatory.
2. PNB MetLife India Insurance Company Ltd., Brigade Seshamahal, 5,
Vani Vilas Road, Basavanagudi, Bangalore-560004.
.....Appellants/Opposite Parties
Versus
Paramjit Singh S/o Sukhdev Singh, R/o House No. 24958, Hazi Rattan
Chowk Road, Bhathinda.
.....Respondent/Complainant
First Appeal against the order dated 10.6.2014
passed by the District Consumer Disputes
Redressal Forum, Bathinda.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Jasbir Singh Gill, Member
Present:-
For the appellant : Sh. U.K. Kanwar, Advocate
Gurcharan Singh Saran, Presiding Judicial Member
ORDER
Applicant-appellants/opposite parties(hereinafter referred to as 'the OPs") have filed the present appeal against the order dated 10.6.2014 passed by the District Consumer Disputes Redressal Forum, Bathinda(hereinafter called "the District Forum") in consumer complaint No. 63 dated 10.1.2014 vide which the complaint filed by the complainant was accepted.
2FIRST APPEAL NO. 1480 OF 2014 Misc. Application No. 2293 of 2014 for delay
2. Alongwith the appeal, there is an application for condonation of delay of 84 days. In the application, it was submitted that the District Forum passed the order on 10.6.2014, which was received on 16.7.2014. It was discussed with their counsel at New Delhi and then Legal Department decided to file the appeal and instructed their counsel at Delhi to draft the appeal. Then the appeal was prepared and was sent to their Bangalore Corporate Office. Then certified copy of the order was missed in transit, which was traced after 15 days after clearance from their Corporate Office, Bangalore then the appeal was filed and in between there is delay of 84 days in filing the appeal. An additional application was also filed giving datewise development, therefore, keeping in view these averments, the delay of 84 days in filing the appeal is hereby condoned. ON MERITS
3. The complaint was filed by the complainant on the allegations that in the year 2011 Mr. Nohar Chand agent of the Op approached the complainant and allured him to purchase their insurance policy, which was purchased by him on 24.4.2012 after paying the premium of Rs. 11,924/-. After about 10 months of the issuance of the insurance policy, the complainant slipped in the bathroom and fell down resulting fracture in his right Pelvic (Choola). He got the treatment but ultimately, the Doctor advised for operation and on 24.4.2012 his operation was got conducted in Max Hospital, Bathinda for which they charged Rs. 1,25,000/-. On 16.5.2012 lodged the claim with the Ops alongwith relevant documents but the opposite 3 FIRST APPEAL NO. 1480 OF 2014 parties sent a letter dated 7.8.2012 stating that his policy of Rs. 2 lacs was for critical illness and rider was attached to the policy and no request for critical illness was received and the complainant protested his claim and brought to the notice of the opposite party that he was in critical condition. Then he was asked to submit a claim as a critical illness and accordingly, the complainant submitted his claim on 25.9.2012 but the same was rejected by the opposite party that the case does not fit into the terms and conditions of the critical illness and claim was rejected. Complainant approached the OP time and again and requested to settle the lawful claim of the complainant but opposite party did not pay any heed. Then he served a legal notice dated 12.8.2013 through his counsel Bansi Lal Sachdeva, Advocate. Accordingly, the complaint was filed for getting claim of Rs. 1,25,000/- alongwith interest @ 12% p.a. from the date of payment till realization, compensation of Rs. 50,000/- and Rs. 11,000/- as litigation expenses.
4. The claim was contested by the Ops, who in their written statement took the preliminary objections that the complaint was false, malicious, incorrect and malafide liable to be dismissed under Section 26 of the Act; no consumer dispute was made out from the complaint; the complainant after completely understanding the terms and conditions of their product "Met Health Care" had voluntarily filled the proposal form on 21.4.2011 and offered to pay Rs. 8,434/- annually for a period of three years and initial premium of Rs. 11,924/- was paid and policy was issued. Standard terms and conditions were sent to the complainant, he did not raise any 4 FIRST APPEAL NO. 1480 OF 2014 objection within the "Free Look Period" of 15 days. The opposite party had received the claim on 16.5.2012 in which it was alleged that the complainant was hospitalized for Hip replacement (Left) in Max Super Speciality Hospital, Bathinda and discharged on 28.4.2012 upon which a letter was sent on 30.5.2012 for additional details but the complainant did not respond then reminders were issued on 14.6.2012 and 26.6.2012 and after that the claim of the complainant was evaluated and paid a sum of Rs. 16,000/- vide cheque bearing No. 034768 dated 17.7.2012. The complainant was seeking settlement under Total Permanent Disability for a sum insured Rs. 2 lacs but his contention did not satisfy the terms and conditions of Clause 4.4 of the policy. The OP also received a reconsideration letter request and the complainant was again informed that the request was under consideration by the Appellate Authority. Vide letter dated 14.11.2012, the opposite party sent claim review letter to the complainant informed that the claim raised by the complainant outside the scope of the terms and conditions of the policy. Thereafter, the opposite party received a legal notice, same was duly replied on 15.3.2013. The claim raised by the complainant was beyond the scope of the terms and conditions of the policy, therefore, the claim was liable to be dismissed under Section 26 of the Act. There was no deficiency on the part of the Ops as defined under Section 2(i)(d) of the Act. Therefore, the complaint was liable to be dismissed. On merits also the same averments were reiterated and it was submitted that the complaint filed by the complainant is just to 5 FIRST APPEAL NO. 1480 OF 2014 extract the money from the Ops. It is devoid of merit and it be dismissed.
5. The parties lead their evidence in support of their pleadings.
6. After going through the allegations in the complaint, written statement filed by the OPs, evidence and documents brought on the record, it was held that even after one year of the incident the complainant was suffering from 40% of the locomotor disability, therefore, he was duly covered under the term total and permanent disability benefit, accordingly, the complaint was accepted with the direction to the Ops to pay the claim amount for which the complainant is entitled to as per policy in question on account of permanent disability within a period of 45 days, failing which they will have to pay interest @ 9% p.a. till realization.
7. In the grounds of appeal, it has been stated that the Hon'ble Forum wrongly presumed the terms and conditions as the respondent's claim does not fall under the clause of Critical illness. Moreover, the proceedings before the District Forum were in summary nature and these type of complicated questions cannot be decided in the summary procedure. The order passed by the learned District Forum is based upon surmises and conjectures and evidence has not been appreciated in a proper perspective, therefore, the impugned order is liable to be set-aside and consequently, the complaint is liable to be dismissed.
8. Firstly coming to the preposition whether these type of questions can be decided in summary proceedings? Both the parties 6 FIRST APPEAL NO. 1480 OF 2014 have tendered their evidence. Terms and conditions of the policy are to be appreciated to which both the parties are bound. The Presiding Officer of the District Forum and the Commission are the retired District Judges/High Court Judges having good experience at their back and in a position to interpret the terms and conditions of the policy. It was held by the Hon'ble National Commission that the District Fora are headed by senior official of the rank of the District Judges and they are fully competent to examine the complicated questions in "Shiv Kumar Agarwal versus Arun Tandon and another", 2007(2) CLT 287. In that case - plea that case involves complicated questions of act and law and will need expert evidence, which is not possible in the summary proceedings adopted by the Consumer Fora repelled - Consumer Forum which is headed by Senior Judicial Officers, are capable of dealing with even complex questions. When both the parties have complete their evidence then it is not proper to relegate the matter to the Civil Court and the District Forum should have decided the matter. Further a reference can be made to the judgment of the Hon'ble Supreme Court in the case of "Dr. J.J. Merchant and others Vs. Shrinath Chaturvedi", 2002(6) SCC 635 that:-
'the State Commission and District Forum are headed by retired High Court Judges and officers of District Judge level and in our view, this is not such a case which cannot be decided by the 'Consumer Fora' after obtaining evidence and if need be after getting an expert opinion'.
9. Therefore, we does not agree with the preposition raised by the counsel for the appellants that these type of claims cannot be adjudicated by the Consumer Fora in a summary proceedings. 7 FIRST APPEAL NO. 1480 OF 2014
10. It is further argued that the case of the respondent/complainant does not fall within the clause of critical illness. Whereas the Ops have taken the plea that the complainant pressed to take his case under Total Permanent Disability for which insurance cover is upto Rs. 2 lacs and the Ops had taken the plea that it is not covered under Clause 4.4 whereas the learned District Forum has given the opinion that the case of the complainant is covered under Clause 4.4, therefore, the learned District Forum has not allowed the complaint that it is covered under the critical illness, rather it has been allowed under Clause 4.4 of the policy for total permanent disability.
11. In case we go through the coverage for which the premium was paid by the complainant, his coverage for accidental total and permanent disability is upto Rs. 2 lacs as per the policy issued by the Ops, which has not been denied by the counsel for the appellant. His coverage for critical illness benefit was also for Rs. 2 lacs, therefore, in case the claim of the complainant is not covered under critical illness benefit then we have to see whether claim of the complainant is covered under accidental total permanent disability benefit. It is not denied by the counsel for the appellants that injury received by the complainant was accidental, whether it is total and permanent? The order so passed by the learned District Forum will reveal that the complainant had placed on the record disability certificate Ex. C-6, which shows that even after about one year of the operation, the complainant was suffering from 40% locomotor disability whereas Clause 4.4 of the policy reads as under:- 8
FIRST APPEAL NO. 1480 OF 2014 "4.4 Total and Permanent Disability Benefit:
Upon the establishment of Total and Permanent Disability (as defined hereinafter) of the Person insured, and acceptance of the claim by the Company, the Company shall pay the Sum Assured thereunder.
"Total and Permanent Disability" or "TPD" means disablement of the Person Insured which satisfies the provisions of any of Parts 1, 2 or 3 below.
Part 1. Unable to work The Person Insured suffers an Accidental Bodily Injury which renders him/her unable to engage in any occupation or employment or business for remuneration or profit for an uninterrupted period of at least six months immediately following the Accident;
xxxxx xxxxxx xxxxx xxxx"
12. Total permanent disability includes in case any person is unable to engage in any occupation or employment or business for an uninterrupted period of atleast six months immediately following the accident. It has been so pleaded by the complainant in case a complainant has disability of locomotor of after 40% then it is difficult to engage himself in any occupation or employment or business for remuneration. The impugned order does not disclose that any evidence was led by the Ops that after their operation the complainant engaged himself in any profession after the operation within a period of six months as per the clause referred above. Therefore, the claim of the complainant is totally covered under this clause. It was wrongly repudiated by the Ops. The learned District Forum was justified to allow the claim. We affirm the findings so recorded by the learned District Forum.
9FIRST APPEAL NO. 1480 OF 2014
13. The counsel for the appellants was unable to make out any point for admission of the appeal, therefore, the appeal so filed by the appellants/Ops is dismissed in limine.
14. The appellants had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal. This amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to the respondent by way of a crossed cheque/demand draft after the expiry of 45 days, subject to stay, if any, by the higher Fora/Court.
15. Remaining amount shall be paid by the appellants to the respondent within 30 days from the receipt of the copy of the order.
16. The arguments in this appeal were heard on 5.1.2015 and the order was reserved. Now the order be communicated to the parties as per rules.
17. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Gurcharan Singh Saran)
Presiding Judicial Member
January 7, 2015. (Jasbir Singh Gill)
as Member