State Consumer Disputes Redressal Commission
Bhupinder Singh vs Life Insurance Corporation Of India on 21 December, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH First Appeal No. : 340 of 2012 Date of Institution : 10.10.2012 Date of Decision : 21/12/2012 Bhupinder Singh, aged 53 years, s/o Sh. Mehma Singh, r/o House No.71, Village Buterla, UT, Chandigarh. Appellant/complainant V e r s u s Life Insurance Corporation of India, Unit-I Branch (163), Jeevan Deep Building, Sector 17-B, Chandigarh through Branch Manager. ....Respondent/Opposite Party Appeal under Section 15 of the Consumer Protection Act, 1986. BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT. MRS. NEENA SANDHU, MEMBER.
Argued by: Sh. C.L.Chaudhary, Advocate for the appellant.
Sh. Pawan Kumar Longia, Advocate for the respondent.
PER JUSTICE SHAM SUNDER (RETD.), PRESIDENT This appeal is directed against the order dated 23.08.2012, rendered by the District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (hereinafter to be called as the District Forum only) vide which, it dismissed the complaint, filed by the complainant (now appellant).
2. The facts, in brief, are that, on 28.11.2000, the complainant purchased one LIC Asha Deep Policy from the Opposite Party, for the sum assured of Rs.1,00,000/-. The premium for the said Policy was Rs.3,233/-, which was payable half yearly.
The complainant paid the premiums regularly upto 28.11.2011. According to the complainant, he was told that it was a Medical Insurance Policy, and, if, during its currency of the same, he suffered from any serious problems, like heart attack, cancer, kidney failure and paralysis, the Opposite Party was to pay him the sum assured of Rs.1,00,000/- plus accrued bonus, immediately, to meet the medical expenses. The complainant, developed some problem, in his kidney. He was put on dialysis, at IVY Hospital, Mohali. He was advised for kidney transplantation. After treatment, the complainant submitted his claim, alongwith the relevant documents, to the Opposite Party, on 13.10.2011. It was stated that the Opposite Party was many a time asked to settle the claim of the complainant, but all in vain. It was further stated that, on account of these reasons, the complainant suffered tremendous mental agony and physical harassment. It was further stated that the aforesaid act of the Opposite Party, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed, directing the Opposite Party to pay Rs.1,54,000/- to the complainant, immediately; compensation, in the sum of Rs.50,000/- for mental agony and physical harassment ; Rs.30,000/-, towards financial loss, on account of delay, in kidney transplantation and expenses on diagnosis; and cost of litigation, to the tune of Rs.11,000/- .
3. The Opposite Party, in its written version, admitted that the Policy, in question, was purchased by the complainant, for the sum assured of Rs.1 lac. However, it was denied that the sum assured of Rs.1,00,000/-, plus accrued bonus, was payable, immediately, to meet the medical expenses. It was stated that, as per the terms and conditions of the Policy, 50% of the sum assured was payable, immediately, and the balance 50% sum assured alongwith bonus, was payable on maturity of the Policy or on death of the insured, prior to the date of maturity. It was further stated that, 10% of sum assured was payable on each Policy anniversary, upto the date of maturity or death of the insured, prior to that date. It was further stated that the claim of the complainant was duly considered, as per the terms and conditions of the Policy, and 50% of the sum assured i.e. Rs.50,000/-, was released, in his favour vide cheque dated 22.3.2012, which was duly encashed by him, on 31.3.2012. It was further stated that 10% of the sum assured i.e. Rs.10,000/-, due on the Policy anniversary i.e. 28.11.2011, was also paid to the complainant, vide cheque dated 27.4.2012. It was further stated that the premiums were waived of, immediately, from the Policy anniversary, falling due after the date of eligibility of the claim. It was further stated that neither there was any deficiency, in rendering service, on the part of the Opposite Party, nor it indulged into unfair trade practice. The remaining averments, were denied, being wrong.
4. On 22.08.2012, when the complaint was fixed for final arguments, none appeared on behalf of the complainant. The District Forum, however, decided to proceed further and dispose of the complaint, on merits, as envisaged by Rule 4(8) of the Chandigarh Consumer Protection Rules, 1987, read with Section 13 (2) of the Consumer Protection Act, 1986 (as amended upto date), in the absence of the complainant.
5. The Parties led evidence, in support of their case.
6. After hearing the Counsel for the Opposite Party/respondent, and, on going through the evidence, and record of the case, the District Forum, dismissed the complaint, on the ground, that the complainant was paid the amount of Rs.50,000/- plus Rs.10,000/-, which was due, as per the terms and conditions of the Policy, and, as such, there was no deficiency, in rendering service, or indulgence into unfair trade practice, on the part of the Opposite Party.
7. Feeling aggrieved, the instant appeal, has been filed by the appellant/complainant.
8. We have heard the Counsel for the parties, and, have gone through the evidence, and record of the case, carefully.
9. The Counsel for the appellant/complainant submitted that the claim was submitted by the complainant on 13.10.2011, alongwith all the relevant documents. He further submitted that, as per the terms and conditions of the Policy, the Opposite Party was required to make immediate payment of 50% of the sum assured, but, on the other hand, the amount of Rs.50,000/-, i.e. 50% of the sum assured, was sent to him, through cheque dated 22.03.2012, which was got encashed by him, on 31.03.2012, whereas, 10% of the sum assured, i.e. Rs.10,000/-, on account of the Policy Anniversary (i.e. on 28.11.2011), was paid on 27.04.2012. He further submitted that the claim of the complainant, was, thus, partly settled, by the Opposite Party, after inordinate delay, as a result whereof, he suffered tremendous mental agony and physical harassment. He further submitted that the District Forum, did not take into consideration, this aspect of the matter, and, thus, failed to award any compensation, to the complainant, on account of the aforesaid deficient act, on the part of the Opposite Party. He further submitted that the order of the District Forum, thus, being illegal and invalid, is liable to be set aside.
10. On the other hand, the Counsel for the respondent/Opposite Party, by placing reliance upon Regulation 9 of the Insurance Regulatory and Development Authority (IRDA) (Protection of Policyholders Interests) Regulations 2002, submitted that since the claim of the complainant was to be investigated by the Surveyor, to find out the genuineness thereof, it could be settled within 6 months, from the date of submission of the same. He further submitted that the amount of Rs.50,000/-, was, thus, paid within a period of 6 months, from the date of submission of the claim. He further submitted, that even a sum of Rs.10,000/-, was also paid promptly, to the complainant, by the Opposite Party. He further submitted that the question of any physical harassment and mental agony, having been caused to the complainant, on account of alleged act and conduct of the Opposite Party, did not at all arise. He further submitted that the District Forum, was, thus right, in holding that the Opposite Party, was neither deficient, in rendering service, nor indulged into unfair trade practice. He further submitted that the order of the District Forum, being legal and valid, is liable to be upheld.
11. Admittedly, the Policy, for the sum assured of Rs.1 lac, was purchased by the complainant, from the Opposite Party on 28.11.2000. There is also, no dispute, with regard to the factum, that the complainant had been paying the premiums, in time. The complainant took treatment, in the hospital, on account of kidney problem. There is also, no dispute, about the factum that he submitted the claim, alongwith all the relevant documents, on 13.10.2011. Clause 2 of the Policy, at pages 51 to 71, of the District Forum file, reads as under:-
2) RENAL DIALYSIS OR RENAL (KIDNEY) TRANSPLANTATION-
Life assured undergoes Renal Dialysis or Renal (kidney) transplantation as a result of an end stage renal failure presented as chronic irreversible failure of both kidneys. It must be well documented. Life assured must produce evidence of undergoing regular haematalysis and other relevant laboratory investigations and doctors certificate.
Clause 4 of the Policy, at pages 51 to 71, of the District Forum file, reads as under:-
4) QUANTUM OF PAYMENT OF SICKNESS BENEFIT CLAIM During the term of the policy provided policy in force, if the life assured is afflicted by any one of above listed major ailments and same is established as per rule then policyholder will be eligible for the following benefits:-
1) Immediate payment of 50% of the sum assured.
2) Waiver of subsequent premiums falling on or after the policy anniversary, immediately, after the date of eligibility on which conditions of aliments are fulfilled. However, unpaid premiums alongwith unpaid premiums, till the next anniversary up to eligible date will be recovered from the benefit claim amount.
3) Payment of an amount equal to 10% of the sum assured, every year commencing from the policy anniversary falling on or after date of eligibility and ending with the policy anniversary preceding the date of maturity or the date of death of the life assured, whichever is earlier.
4) Payment of balance 50% of the sum assured and vested bonus on the date of maturity or on death of the life assured, whichever is earlier. The bonus will be calculated on the full sum assured even though 50% of the sum assured would have been paid earlier.
12. The case of the complainant, admittedly, fell within the ambit of the Clauses extracted above. According to Clauses 2 and 4 extracted above, if during the term of the Policy provided the same, is in force, the life assured was afflicted by any one of the major ailments including Renal Dialysis or Renal (Kidney) transplantation, and the same was established, as per Rule, then the Policyholder, shall be eligible for immediate payment of 50% of the sum assured. The Parties are bound by the terms and conditions of the Policy. Once the claim, alongwith the relevant documents, was submitted to the Opposite Party, on 13.10.2011, it was its duty to pay 50% of the sum assured, immediately. The word immediately can be construed, in such a manner, as may not defeat the very purpose of the afore-extracted Clause 4. The Opposite Party was, thus, required to settle the claim of the complainant, as per the afore-extracted Clause 4 of the Policy, within 2 to 3 days. On the other hand, as stated above, 50% of the assured amount, as per Regulation 9(2) of the Insurance Regulatory and Development Authority (IRDA), (IRDA) (Protection of Policyholders Interests) Regulations 2002, was sent to the complainant on 22.03.2012, vide cheque, which was got encashed by him, on 31.03.2012, i.e. after 5 months of the submission of the claim. On account of non-settlement of the claim of the complainant, immediately, after the submission of the same, alongwith all the relevant documents, the Opposite Party was certainly deficient, in rendering service. On account of this act and conduct of the Opposite Party, the complainant suffered tremendous mental agony and physical harassment. The complainant was, thus, required to be compensated. The District Forum did not take into consideration, this aspect of the matter, and, as such, fell into a grave error, in dismissing the complaint, as a whole. In our considered opinion, for mental agony and physical harassment, caused to the complainant, and for the deficient act and conduct of the Opposite Party, compensation, in the sum of Rs.20,000/-, if awarded, that would be just, fair, reasonable and adequate. The complainant, is, thus, entitled to compensation, in the sum of Rs.20,000/-.
13. No doubt, reliance was placed by the Counsel for the respondent, on Regulation 9(2) of the Insurance Regulatory and Development Authority (IRDA) (IRDA) (Protection of Policyholders Interests) Regulations 2002. There is nothing, on the record, that the claim submitted by the complainant, alongwith the relevant documents, required investigation by the Surveyor. Even, there is also nothing, on record, that any Surveyor was appointed for investigating the claim, by the Opposite Party. There is nothing, on record, that any report was submitted by the Surveyor, after the alleged investigation, into claim of the complainant. There is nothing, on record, to establish that the Surveyor allegedly visited the hospital, where the complainant took treatment, and made inquiries from the Doctors, but they failed to satisfy him. As such, the Opposite Party, could not take benefit of Regulation 9(2) aforesaid, on the ground, that the claim of the complainant was settled, within a period of 6 months, from the date of submission of the same. As stated above, the Parties were bound by the terms and conditions of the Policy, and by not settling the claim of the complainant, immediately, after the submission of the claim, as per the terms and conditions, the Opposite Party, was certainly deficient, in rendering service. The submission of the Counsel for the respondent/Opposite Party, therefore, being devoid of merit, must fail, and the same stands rejected.
14. No other point, was urged, by the Counsel for the parties.
15. In view of the above discussion, it is held that the order passed by the District Forum, being not based on the correct appreciation of evidence, and law, on the point, suffers from illegality and perversity, warranting the interference of this Commission.
16. For the reasons recorded above, the appeal is partly accepted, with costs. The order of the District Forum is set aside. The respondent/Opposite Party is directed as under:-
i. to pay a sum of Rs.20,000/-, as compensation, on account of mental agony and physical harassment, caused to the complainant and for the deficient act of the Opposite Party, in rendering proper service.
ii. to pay a sum of Rs.7,000/-, as cost of litigation.
iii. The amount mentioned, in clause no.(i) of paragraph number 16 above, shall be paid by the Opposite Party, within 40 days, from the date of receipt of a copy of the order, failing which it (Opposite Party), shall be liable to pay interest @9% P.A., on this amount, from the date of filing of the complaint, besides payment of litigation costs of Rs.7,000/-.
17. Certified copies of this order, be sent to the parties, free of charge.
18. The file be consigned to Record Room, after completion Pronounced.
21.12.2012 Sd/-
[JUSTICE SHAM SUNDER (RETD.)] PRESIDENT Sd/-
[NEENA SANDHU] MEMBER Rg