Date of filing: 25-6-2016 Date of order : 4-1-2018
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM ::
KADAPA Y.S.R DISTRICT
PRESENT SRI V.C. GUNNAIAH, B.Com., M.L., PRESIDENT
SMT. K. SIREESHA, B.L., LADY MEMBER
Thursday, 4th day of January, 2018
CONSUMER COMPLAINT No. 58 / 2016
K. Kamal Bee,
W/o K. Khader, Dudekula Age 55 years, House Wife,
R/o D. No.5/121, Ramalayam Street,
Railway Yerraguntla Mandal,
Kadapa District. A.P. 516 309. … Complainant.
Vs.
- The Manager, Om Kotak Mahindra Life Insurance,
Regn. No.107, Regd. Office 6th Floor,
Peninsula Chambers,
Peninsula Corporate Park,
Ganpatrao Kadam Marg,
Lower Parel, MUMBAI-400 013.
Maharashtra State.
- The Business in-charge,
Om Kotak Mahindra Life Insurance,
C/o Kotak Mahindra Bank, Dwaraka Towers, 7 Roads,
Kadapa City-516 001. Kadapa District. ….. Opposite Parties.
This complaint coming for final hearing on 21-12-2017 in the presence of Sri K. Vijaya Krishna, Advocate, Kadapa for complainant and Sri G.S. Murthy, Advocate, Kadapa for opposite parties no.1 and 2, and upon perusing the material papers on record, the Forum made the following:-
O R D E R
(Per Sri V.C. Gunnaiah, President),
1) The complainant filed this complaint under section 12 of Consumer Protection Act, 1986 (for short herein after called as C.P. Act). Praying this Forum to direct the opposite parties jointly and severally to pay Rs.2,00,000/-towards term covered under policy with interest at 18% p.a. to pay Rs.1,00,000/- towards critical illness rider covered under the policy with interest at 18% p.a. to pay Rs.24,000/- towards permanent disability rider covered under the policy with interest 18% p.a. from 24-3-2009 till realization, to pay Rs.50,000/- for causing deficiency in service, to pay compensation of Rs.50,000/- for causing mental agony to the complainant and to award costs of the complaint.
2) The brief averments of the complaint which are as follows:- The complainant is the mother of one Kalamalla Dada Kalandhar who is the policy holder bearing No.00096204 taken by him on 20-10-2003 from the opposite parties, the complainant is also the nominee of the insured under the above policy. The term of the policy was 30 years. The sum assured under the policy is Rs.4,00,000/- (2,00,000 basic benefit+ 2,00,000/- term cover) for which he paid premium of Rs.5300/- +640/- total Rs.5,940/-. The policy holder in addition to the above basic benefit and term cover opted for 1)Rs.2,00,0000/- under accidental death benefit, 2)Rs.2,00,000/- under permanent disability benefit and 3)for Rs.1,00,000/- under critical illness benefit for which he paid annual premiums of Rs.160/-, 80/- and Rs.150/- respectively to the first O.P. Thus, he paid total premium of Rs.6400/- to cover all the benefits under the policy. While so, the policy of Dada Kalandar met with vehicle accident on 23-12-2008 while working in West Bengal State as Electrical Engineer in Indian Oil Corporation Ltd., and was succumbed injuries on 8-1-09 while undergoing treatment in A.M.R.I. hospital, Kolkata due to multi organ failure. After the death of the insured the complainant who is the mother and nominee made claim to the first opposite party and O.P.no.1 sent a letter on 24-3-09 that complainant shall entitled to the basic sum assured under the policy for Rs.2,00,0000/- only and enclosed cheque no.058650, dt.23-3-209 as full and final settlement of the said claim but on death of insured the amount payable is Rs.4,00,000/- O.P.no.1 failed to pay Rs.2,00,000/- for accidental death Rs.2,00,000/- for permanent disability and Rs.1,00,000/- for critical illness. The complainant after knowing the other benefit riders were in force on the date of death of the deceased approached the O.P.no.1 claiming above benefits. After reviewing the claim as a special case accidental benefit of Rs.2,00,000/-was paid but denied the other benefits Viz., permanent disability rider critical illness rider as not applicable as insured (deceased) died within 120 days from the date of accident after deducting Rs.160/- towards outstanding premium from the insured (deceased) for the accidental death benefit. As per the terms and conditions attached in the policy the complainant is entitled for all the benefits claimed and at least 12% of the total sum assured for the permanent disability benefit, thus he entitled for Rs.24,000/- out of sum of Rs.2,00,000/- for permanent disability rider with interest so also he is entitled for critical illness rider and the amounts for deficiency in service in causing mental agony to the complainant as claimed, but the Opposite Parties did not honour the claim of complainant for the above riders. The complainant approached Ombudsman but Ombudsman informed that the complainant that her complaint cannot be considered as the decision of insurance company is as per terms and conditions of the policy, and further adviced to approach any other court/forum to address her grievance. Therefore complainant filed this complaint for the above reliefs.
3)Opposite parties filed common written version/counter denying the allegations in the complaint regarding deficiency in service on the part of Opposite Parties and entitlement of claims by complainant.
4)It is further averred that the complaint is barred by limitation as under Section 24 A of C.P. Act, 1986. The terms and conditions of the policy is binding on the parties on submission of claim by complainant and after proper assessment the claim was admitted and paid on 23-3-2009 and communication was sent on 24-3-2009 to the complainant. After receiving the sum assured the complainant in the year, 2015 claimed for payment of riders i.e., for accidental death benefit and critical illness benefits and permanent disability rider. The claim of complainant was reviewed and considered by the opposite parties and paid Rs.2,00,000/- deducting Rs.160/- premium due and an amount of Rs.1,11,369-05 ps. towards interest and credited to her State Bank account towards accidental death benefit and the same was intimated to her on 17-3-2015.
5) As regards to other riders claimed by the complainant i.e., critical illness rider is concerned, they are only survival benefits and not payable in addition to the death benefits/basic benefits. Hence, complainant is not entitled for the said benefits as death benefit was already paid with regard to permanent disability benefit rider is concerned the life assured i..e, (deceased here) should have survived at least 120 days from the date of accident, as per terms and conditions of the said rider in the policy, but the deceased died on 8-1-2009, from 23-12-2008 on which day he met with an accident and the same shall be informed to company within 30 days from the date of accident. But the claims were made only after the death of deceased. hence, the claim was not payable and not entitled for the permanent disability rider and critical illness as claimed. The sum assured was not Rs.4,00,000/- but it is only 2,00,000/- as per the proposal form. Further the complainant is not entitled for any critical illness rider as he is not covered under any of the 12 ailments mentioned in the terms and conditions. The Opposite Parties have rightly acted and paid claim and settled. Hence, there is no deficiency in service for not paying the amount for permanent disability rider, critical illness rider, term cover as per the policy terms and conditions. Therefore the complaint is not tenable and the complainant is not entitled for any reliefs and complaint is liable to be dismissed with heavy costs.
6) On the above pleadings the following points are settled for determination :-
- Whether is there any deficiency in service on the part of Opposite parties as pleaded by complainant ?
- Whether the complainant is entitled for reliefs claimed from the Opposite parties as prayed for ?
- To what relief
7)No oral evidence has been let in by the parties, but on behalf of the complainant her affidavit is filed and got marked Ex.A1 to Ex.A10 and on behalf of the Opposite parties no affidavit is filed, but got marked as Ex.B1 to Ex.B7.
8)After closure of evidence, the complainant not filed written arguments. But opposite parties filed written submissions. Heard arguments on both sides and considered the written submissions filed by the opposite parties.
9)Point No.1 and 2 :- These two points are connected each other. Hence they are taken up for discussion together for the sake of convenience. Learned counsel for complainant contended that the complainant is entitled for term cover of Rs.2,00,000/-, Rs.1,00,000/- towards critical illness rider, Rs.24,000/- towards 12% of the permanent disability rider cover under the policy issued by the O.P.no.1. But complainant failed to pay the same. Therefore, there is deficiency in service on the part of opposite parties and the same is proved by filing Exhibits A1,A2,A7,A8,A9 and A10. Hence, complainant is entitled for all the claims against opposite parties including costs of the complaint. He further contended that the claim is not barred by limitation as opposite parties honoured the claim of accidental death benefit rider claim on 25-2-2015 as per Ex.A8. So, denying the other claims attracts deficiency in service. Hence, complainant is entitled for all the claims.
10)On the other hand learned counsel for opposite parties vehemently contended that there is no deficiency in service on the part of opposite parties, as they initially paid the basic benefit of Rs.2,00,000/- to the complainant on intimation of death claim and also paid accidental death benefit of Rs.2,00,000/- after deducting Rs.160/- premium duly reviewing the claim of complainant on sympathetic ground, though refused to pay the critical illness claim and disability claim rightly as per the terms and conditions of the policy, as they are survival benefits of the deceased (insured). Therefore under any stretch of imagination no deficiency of service can be attributed to the opposite parties and complainant is not entitled for any reliefs in this case. He further argued that the claim by the complainant is barred by limitation as she made the claim after 7 years of the death of insured.
11)There is no dispute in this case that Kalamalla Dada Kalandar is the insured under Ex.B2 policy document and his policy No. is 00096204 under description of complaint Kotak Endowment assurance. He made the first payment premium on 25-11-2003 as per Ex.A2 receipt, Ex.A1 and B1 are the proposal form filled up by the insured. There is also no dispute that complainant is the mother and nominee of the insured Dada Kalandar under Ex.B2 policy. It is further admitted fact that complainant met with accident on 23-12-2008 and died on 8-1-2009 while undergoing treatment at A.M.R.I. Hospital, Calcutta. Ex.A3 FIR, Ex.A4 medical certificate issued by A.M.R.I. hospital, Calcutta shows the deceased insured met with accident on 23-12-2008 and died on 8-1-2009, Ex.A5 is the death certificate issued by the Registrar Births and Deaths Calcutta Municipal Corporation. Ex.A6 is the Cremation Certificate issued by Police station, Yerraguntla, Kadapa District. The above documents shows the deceased Kalamalla Dada Kalandar died in the accident after undergoing treatment and was cremated.
12) It is the case of complainant that when she made claims under the policy obtained by his deceased son Dada Kalandar the opposite parties allowed the claims of basic benefit of Rs.2,00,000/- and accidental death benefit of Rs.2,00,000/-, but repudiated to pay the claims of term cover of Rs.2,00,000/-, critical illness rider of Rs.1,00,000/- and permanent disability rider cover of Rs.24,000/- of his deceased son. Hence, there is deficiency in service on the part of opposite parties.
13) It is the case of opposite parties that they have rightly rejected the claims of critical illness benefit rider and permanent disability rider claim as they are survival benefits of the deceased. The cover term benefit includes basic benefit of the policy which is sum assured and that was already paid. Therefore no deficiency of service on their part and the above claims were rejected by the opposite parties as per terms and conditions of the policy under Ex.B2 and the same was intimated to complainant under Ex.A8 and Ex.B5. hence, complainant is not entitled for the claims.
14)Though a contention was raised that the complaint was barred by limitation as complainant claimed the rider benefits after 7 years of the death of deceased but the same cannot be accepted as opposite parties paid accidental death benefit claim of complainant at Rs.2,00,0000/- on 25-2-2015. Therefore the claim now cannot be said barred by limitation in this complaint as it is filed within 2 years from 25-2-2015.
15)As regards to repudiation of critical illness rider benefit cover under the policy as seen from Ex.A8 and Ex.B5 documents the opposite parties clearly mentioned the reason how the complainant is not entitled for critical illness benefit rider as per the terms and conditions of the policy. As seen from the terms and conditions of the policy the critical illness benefit rider is only accelerated payment of the death benefit of happening of contingencies as specified in the contract. In this case the insured/deceased met with an accident on 23-12-2008 and died on 8-1-09. He is not alive to claim the benefit of critical illness. He died due to the injuries caused in the accident. So, the opposite parties paid the death benefits of the insured under basic benefit of the policy sum assured and accidental death benefit of Rs.2,00,000/-. Therefore, the payment for critical illness does not arise in this case as it is only an accelerated payment of death benefit of the deceased (insured).
16)So for as permanent disability rider is concerned as per the terms and conditions of the contract of policy if the life insured survives for atleast 120 days from the date of accident, he is entitled for the above said benefit. But in this case as already stated above the life insured met with accident on 23-12-008 and expired on 8-1-2009. Hence, the deceased was not entitled to claim the permanent disability rider. So the complainant is not entitled for that benefit.
17)The opposite parties clearly intimated the same why the rejected the claims of critical illness benefit and permanent disability rider benefit has not applicable to the deceased as per Ex.B5 and Ex.A8. As seen from Ex.B2 policy document and also as per Ex.A2 first premium receipt they clearly goes to show that the sum assured under the policy was Rs.2,00,000/- only.
So, that amount has already been paid to the complainant by the opposite parties and also paid the accidental death benefit of Rs.2,00,000/-. The repudiation of other claims by opposite parties are only in terms and conditions of the policy obtained by the deceased from them which is binding on both the parties. Therefore we hold there is no deficiency in service on the part of the opposite parties in repudiating the claim of complainant in respect of critical illness, permanent disability and term cover to the deceased and the complainant is not entitled for any reliefs as claimed against the opposite parties and complaint is liable to be dismissed. Accordingly points 1 and 2 are answered against the complainant.
18) In the result, the complaint is dismissed but in the circumstances without costs.
Dictated to the Typist, transcribed by him, corrected and pronounced by us in the open forum, this the 4th day of January, 2018
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant: nil For Opposite party : nil
Exhibits marked on behalf of the Complainant :-
Ex: A1:- Proposal form dated 20-10-2003 issued by Om Kotak Mahindra Life
Insurance.
Ex: A2:- First Premium Receipt, dt. 25-11-2003.
Ex: A3:- F.I.R. in Crime No.158/2008, Dt. 28-12-2008 of Haldia P.S.
Ex: A4:- Medical Certificate of cause of death issued by AMRI hospital, Kolkata,
Dt. 8-1-2009.
Ex: A5:- Death Certificate dated 27-1-2009 issued by the Registrar, Births and
Deaths, Kolkata Municipal Corporation.
Ex: A6:- Cremation Certificate issued by Panchayat secretary, Yerraguntla, Kadapa
District, Dt. 16-1-2009.
Ex: A7:- Letter Dt. 24-3-2009 issued by Chief Manager, Claims Department, Kotak
Life Insurance.
Ex:A8:- Reply letter Dt. 25-2-15 issued by the Kotak Mahindra Life Ins.Ltd.
Ex: A9:- Letter Dt. 17-3-2015 issued by the Kotak Mahindra Life Insurance regarding
payment of accident rider benefit.
Ex: A10:- Annexure-II of the Office of the Insurance Ombudsman, Hyd, Dt. 29-9-15.
Exhibits marked on behalf of the Opposite parties: -
Ex: B1:- Proposal form issued by the respondent company.
Ex: B2:- P/c of document issued by the respondent Dt. 11-2-2014.
Ex: B3:- Copy of claim intimation dt. 28-2-2009.
Ex: B4:- Copy of letter issued by the respondent company to the complainant,
Dt. 24-3-2009.
Ex: B5:- Copy of letter issued by the respondent company to the complainant,
Dt. 25-2-2015 and Dt. 17-3-2015.
Ex: B6:- Copy of reply letter to the Secretary O/o The Insurance Ombudsman,
Hyderabad, Dt. 16-7-2015 along with E-mail copy.
Ex: B7:- P/c of First Premium Receipt, dt. 25-11-2003.
MEMBER PRESIDENT
Copy to :-
1) Sri K. Vijaya Krishna, Advocate, kadapa
2) Sri G.S. Murthy, Advocate, kadapa, for O.P.no.1 and 2
P.R.
