Punjab

Ludhiana

CC/21/170

Indrawati Devi - Complainant(s)

Versus

ICICI Prudential Life Ins.Co.Ltd - Opp.Party(s)

Ramesh Kumar

05 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:170 dated 25.03.2021.                                                         Date of decision: 05.05.2023.

 

1. Smt. Indrawati Devi aged 43 years widow of Sh. Bias Muni,
2. Arun Kumar aged 22 years son of late Sh. Bias Muni and
3. Ajay Kumar aged 20 years son of Sh. Bias Muni (legal heirs of late Sh. Bias Muni), residents of House No.511, New Moti Nagar, Ludhiana.                                                                             ..…Complainants

                                                Versus

1. ICICI Prudential Life Insurance Limited, Unit No.1A & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad (East), Mumbai-400097 through its Manager.
2. The Manager, ICICI Prudential Life Insurance Limited, ICICI Bank Ltd. Rlg. ICICI Bank Tower Regional Office, Plot No.12, Gachibowli, Hyderabad-500032.
3. The Branch Manager, ICICI Prudential Life Insurance Limited, SCO 120, 7^th Floor, Feroze Gandhi Market, Ludhiana.

…..Opposite parties 

Complaint Under section the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Ramesh Kumar, Advocate.

For OPs                          :         Sh. V.S. Mand, Advocate.

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that Sh. Bias Muni was the husband of complainant No.1 and father of complainant No.2 and 3. During his life time, Sh. Bias Muni, purchased the policy No.31945314 dated 28.01.2019 of ICICI Pru iProtect Smart from the opposite parties by paying a premium of Rs.15,900/- on 03.01.2019 from his bank account No.057801519883 of ICIICI Bank Limited, Chandigarh Road, Jamalpur, Ludhiana. The opposite parties issued policy/cover note after accepting the premium and insured Sh. Bias Muni for a sum of Rs.50,00,000/- which include sum assured and accidental benefit. As per the policy terms and conditions, the sum assured of the policy was Rs.25,00,000/- and accidental death cover was Rs.25,00,000/-.

                   The complainants stated that on 18.08.2019, Sh. Bias Muni died in accident leaving behind them as his first class legal heirs. His post mortem was conducted on 20.08.2019 at Civil Hospital, Ludhiana. Police of P.S. GRP, Ludhiana initiated proceedings under Section 174 Cr.P.C. vide DDR No.217 dated 18.08.2019. In the post mortem, doctor made report that Sh. Bias Muni died due to the injuries received in the accident. The complainants further stated that after the death of Sh. Bias Muni, they lodged claim  with the opposite parties and submitted the documents as per their demand many times. The complainants approached the opposite parties many times to know about status of their claim but they did not listen to their genuine requests. The complainants further stated that they have submitted the documents before the opposite parties various times but they have not settled the claim. The documents are reproduced as under:-

1. Insurance policy/cover note.
2. Post mortem report of the deceased.
3. Police proceedings
4. Death certificate of the deceased.
5. Aadhar card & pan card of the complainants.
6. Bank passbook with cancelled cheques.
7. Income tax returns of the deceased.
8. Photographs of the complainants.
9. Other documents.

According to the complainants, they many times approached the opposite parties to pay the claim amount of Rs.50,00,000/- as per terms of the policy but they lingered on the matter on one pretext or the other. The opposite parties various times called the complainants to their office and put their signatures on various paper and took all the documents and also assured to pay the claim amount to them but till date the opposite parties have failed to pay the amount of claim to the complainants. The complainants further stated that on 18.02.2020, they were astonished to receive a letter from the opposite parties in which it was written that as yet the opposite parties are treating the case as a suicide and transferred the amount of Rs.10,779/- in the account of the complainant Indrawati. According to the complainants, Sh. Bias Muni died due to accident and they objected and visited the office of opposite parties but they assured that they will settle the claim and will pay the insured amount of Rs.50,00,000/- to the complainants after going through the documents. The complainant stated that the opposite parties without any rhyme and reason treated the accidental death as suicide just to wriggle out from their liabilities. The complainants again submitted the documents as demanded by the opposite parties but till date they have failed to pay the insurance amount of the claim to the complainants which amounts to deficiency in service on the parts of the opposite parties due to which the complainants have suffered stress, humiliation, mental agony as Sh. Bias Muni was the only bread earner of the family. The complainants sent a legal notices dated 07.08.2020 and 05.11.2020  to the opposite parties but no fruitful reply was given. Hence this complaint, whereby the complainants have prayed for issuing directions to the opposite parties to pay the insurance amount of Rs.50,00,000/- along with interest @18% per annum and also to pay compensation of Rs.10,00,000/- and litigation expenses of RS.25,000/- besides Rs.2000/- as typing charges etc.

2.                Upon notice, the opposite parties filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint, suppression of material facts by the complainant; lack of jurisdiction and cause of action. The opposite parties stated that the Company had received a proposal form bearing number OS10524052 duly filled and signed by the Proposer/ Life Assured i.e. Muni Bias for ICICI Pru IProtect Smart T51 Plan on 7th January 2019 and on the basis of information provided in the Application form and believing the information and declarations furnished by the Life Assured to be true and correct, the Company had issued the policy bearing number 31945314 on 28.01.2019 on Bias Muni. The opposite parties further stated that on 22.10.2019, they received a Claimant statement form (death claims) intimation from the complainants under the disputed policy no: 31945314, stating that the DLA had passed away on 18.08.2019 at the railway track. According to the opposite parties, upon receipt of the said intimation, they had conducted an investigation through an independent Investigator under the statutory right provided under clause 14(2) of the Insurance Regulatory and Development Authority of India (Protection of Policyholder's Interest) Regulations, 2017 and Section 45 of the Insurance Act 1938, in order to verify the authenticity of the claim. During this investigation, it was confirmed that the Life Assured in fact committed Suicide. On the basis of the said findings, since the Life Assured had committed suicide on 18.08.2019 i.e. within just 8 months from date of inception of the disputed policy, the Suicide Clause (i.e. Clause 11 under Part F- the General conditions of the Terms and Conditions) of the subject policy became applicable, which is reproduced as under:-

 

“11. Suicide: If the Life Assured, whether sane or insane, commits suicide within 12 months from the date of inception of this Policy, We will refund 80% of the premium paid provided the policy is in force. In the case of a revived Policy, if the Life Assured, whether sane or insane, commits suicide within 12 months of the date of revival of the Policy, higher of 80% of the premiums paid till date of death or surrender value will be payable by Us. The Policy will terminate on making such a payment and all rights, benefits and interests under the Policy will stand extinguished.”

As per the said clause since the Life Assured had committed suicide on 18.08.2019 i.e. within just 8 months from date of inception of the disputed policy, on 19.02.2020, the Company duly accepted the claim and processed refund of 80% of the premium received under the policy i.e. Rs. 10,779/- was duly paid vide NEFT to the complainant Ms. Indrawati Devi, into her Oriental Bank of Commerce bank account bearing A/c. 51112191021284 and IFSC: ORBC0105111.

                   The opposite parties further stated that the Clause 11 of the Part F of the policy terms and conditions is in line with Chapter III- Minimum Death Benefit, Clause 9 (c) of IRDA (Non-Linked Insurance Products) Regulations, 2019, wherein it is clearly listed that the Company shall accept the claim and pay only 80% of the total premium received in case of death of the life assured due to suicide within 1 year from the policy issuance Hence, opposite party No.1 Company has duly acted in accordance to the governing body- IRDA's applicable regulation and has already duly paid the 80% of the premium amount as the member had committed suicide within one year of the issuance of the policy and settled the disputed claim. The relevant portion of the said regulation is reproduced as under:-

“c) In case of death due to suicide within 12 months from the date of commencement of risk under the policy or from the date of revival of the policy, as applicable, the nominee or beneficiary of the policyholder shall be entitled to at least 80% of the total premiums paid till the date of death or the surrender value available as on the date of death whichever is higher, provided the policy is in force.”

The opposite parties further stated that due compliance of the regulation and thus the same cannot be considered as service deficiency. Thus the present complaint is liable to be dismissed on these grounds alone. According to the opposite parties, the terms of an insurance policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substation. The courts while interpreting the cause of an insurance policy should ensure that no benefits are given outside the ambit of the meaning of the words and strict adherence is to be maintained with respect to the meaning of the contract.

                   The opposite parties further stated that the facts of the present case are highly complicated in nature and cannot be decided in summary proceedings under The Consumer Protection Act, 2019 and for adjudication of present complaint certain important aspects need to be considered like the cause of death of the Life Assured etc. Moreover, in order to adjudicate the exact cause of death, the present case needs to be adjudicated in an elaborate manner by examining:-

1. Various railway staff and authorities, locomotive Pilot Ashok Kumar and Guard Kalyan Kumar
2. Railway police force authorities
3. Doctor and medical staff who examined the dead body of the Deceased Life Assured and declared him dead,
4.  The police authorities, investigating police officer
5. The government body that issued the death certificate, etc.

                   On merits, the opposite parties admitted the issuance of iProtect Smart (T51) policy No. 31945314 on the basis of proposal form on 28.01.2019, detail of which is reproduced as under:-

Policy No.	31945314
Application No.	OS10524052
Product	ICICI Pru iProtect Smart T51
Life Assured	Muni Bias
Nominee	Indrawati Devi
Agent	ICICI Bank Ltd.
Sum assured	Rs.25,00,000
Premium amount	Rs.13,474
Total premium paid	Rs.15,900
Frequency for premium	Annul
Proposal date	Jan 07, 2019
Proposal received date	Jan 07, 2019
Risk commencement date	Jan 28, 2019
Policy issuance date	Jan 28, 2019
Paid to date	Jan 28, 2020
Policy dispatch details	01/02/2019 vide Speed post AWB No.ED303441889IN

In accordance to Clause 10(1) & 8(1) of the Insurance Regulatory and Development Authority (Protection of Policyholder’s Interests) Regulations, 2017, an insurance company is required to send a welcome kit consisting of policy terms and conditions and in the present case too, company had sent the policy documents on 01.02.2019 through speed post which was duly received by the life assured. After receipt of the policy documents, the deceased life assured did not approach the insurance company with any grievance or concerns to cancel/withdraw the policy within the free look period and instead remained the same with him, implying that he was satisfied with the terms of the same and therefore, the deceased life assured waived off his right to cancel the policy. The opposite parties further stated that on 22.10.2019, they received a death claim intimation from the complainants stating that the DLA has passed away on 18.08.2019. According to the opposite parties the DLA has died within just 8 months of the issuance of the policy which amounts to an early claim i.e. death within 3 years and they conducted due investigation as per Section 45 of the Insurance Act, 1938 to determine the bonafides of the claim and cause of death. During the investigation, it was informed to the opposite party company that:  

1. That the DLA committed suicide by laying on Railway track.
2. That on 18-08-2019 at around 07:30 AM, DLA went to duty and till late night did not return from the job. That next day at around 08:00 AM, a Police Constable came to DLA's house who was sent by ASI Manjit Singh and informed the family that a dead body is found on Railway Track and family has to go to Civil Hospital mortuary to take the dead body of DLA Bias Muni.
3. That on the same day, DLA family members went to Civil Hospital mortuary and confirmed that dead body is of DLA Bias Muni
4. That as per Police Officials, DLA's dead body was found on Dhandari Railway Station Ludhiana DLA was laying on Railway Track. The dead body was divided into 2 parts. DLA's head was severed from torso. There was no any scratch on body of LA only his neck was cut. Spot pics enclosed herewith.
5. That the DLA was seen by a locomotive Pilot Ashok Kumar (9760539132) and Guard Kalyan Kumar (9729532848). That the Pilot and Guard informed Station Master and Station Master came with Railway Police Force (RPF).

The opposite parties further stated that as per Clause 11 of Part F under General conditions of the policy terms and conditions clearly state that the in case of death of the Life assured occurs due to suicide within 1 year from the policy issuance or revival only 80% of total premium paid by the Policyholder shall be paid on acceptance of the claim. The relevant clause of the policy Terms & Conditions is reproduced as under:

“11. Suicide: If the Life Assured, whether sane or insane, commits suicide within 12 months from the date of inception of this Policy. We will refund 80% of the premium paid provided the policy is in force. In the case of a revived Policy, if the Life Assured, whether sane or insane, commits suicide within 12 months of the date of revival of the Policy, higher of 80% of the premiums paid till date of death or surrender value will be payable by Us. The Policy will terminate on making such a payment and all rights, benefits and interests under the Policy will stand extinguished.”

 

The said clause 11 of the policy terms and conditions is as per IRDAI Non Linked Regulations, 2019 which lists down the requirements and procedure for a non linked policy. The said mandate is mentioned in Chapter III- Minimum Death Benefit, Regulation 9(c) as reproduced as under:-

“c) In case of death due to suicide within 12 months from the date of commencement of risk under the policy or from the date of revival of the policy, as applicable, the nominee or beneficiary of the policyholder shall be entitled to at least 80% of the total premiums paid till the date of death or the surrender value available as on the date of death whichever is higher, provided the policy is in force.”

According to the opposite parties after due evaluation and assessment of the claim, it was clear that the DLA committed suicide which was on 18.08.2019 i.e. within 12 months from the date of inception of the policy and as such, since the Life Assured had committed suicide on 18.08.2019 i.e. within just 8 months from date of inception of the disputed policy, on 19.02.2020, the Company duly accepted the claim and processed refund of 80% of the premium received under the policy i.e. Rs. 10,779/- was duly paid vide NEFT to the complainant Ms. Indrawati Devi, into her Oriental Bank of Commerce bank account bearing A/c. 51112191021284 and IFSC: ORBC0105111. The claim has already been accepted and honoured as per the terms and conditions of the policy. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                The complainants filed rejoinder to the written statement of the opposite parties reiterating the facts mentioned in the complaint and controverting those mentioned in the written statement.

4.                In support of their claim, the complainants tendered their joint affidavit Ex. CA in which they reiterated the allegations and the claim of compensation as stated in the complaint. The complainants also tendered documents Ex. C1 to Ex. C3 are the copies of Aadhar cards of the complainants, Ex. C4 to Ex. C6 are the copies of PAN cards of the complainants, Ex. C7 is the copy of insurance policy, Ex. C8 and Ex. C9 are the copies of income tax returns of Sh. Bias Muni, Ex. C10 is the copy of post mortem of Bias Muni, Ex. C11 is the copy of police proceedings, Ex. C12 is the copy of death certificate of Sh. Bias Muni, Ex. C13 is the copy of claim settlement letter dated 18.02.2020, Ex. C14 is the copy of legal notice dated 07.08.2020, Ex. C15 to Ex. C17 are the copies postal receipts, Ex. C18 is the legal notice dated 05.11.2020, Ex. C19 to Ex. C21 are the copies  postal receipts, Ex. C22 is the copy of DDR No.217 dated 18.08.2019 and closed the evidence.

5.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Thejus Joseph, Senior Manager of the opposite parties along with documents Ex. R1 is copy of customer declaration, Ex. R2 is the copy of claim settlement form (death claims), Ex. R3 is the copy of affidavit of Suresh Kumar, Investigator, Ex. R4 is the copy of photograph of identity card and dead body of Bias Muni, Ex. R5 is the copy of policy documents, Ex. R6 is the copy of claim settlement letter dated 18.02.2020 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, rejoinder, affidavit and annexed documents and written reply along with affidavits and documents produced on record by both the parties. We have also gone through the written arguments submitted by the opposite parties.

7.                Admittedly, on the basis of proposal form submitted by Mr. Bias Muni now deceased, the opposite parties issued a policy on 28.01.2019 known as ICICI Pru iProtect Smart having life and accidental cover of Rs.25,00,000/- each. On 18.08.2019 i.e. within 8 months of inception of the policy, deceased Bias Muni was run over by a goods train in the area of Line No.6, Platform No.2, Railway Station Dhandari Kalan, Ludhiana resulting in severance of his head from the rest of his body. . Inquest proceedings under Section 174 Cr.P.C. were initiated vide DDR No.217 dated 18.08.2019 Ex. C11 by the officials of Police Station GRP, Ludhiana. ASI Manjit Singh while conducting inquest proceedings concluded that the apparent cause of death was railway accident with a train and also ruled out receipt of any information with regard to commission of suicide. The concerned SHO vide his report Ex. C22 endorsed the cause of death due to railway accident and none to be blamed. Post mortem of dead body was conducted on 20.08.2019 vide post mortem report Ex. C10 and cause of death was declared to be due to hemorrhage and shock as a result of injury which are sufficient to cause death in ordinary cause of nature by a railway accident. All the injuries are ante mortem in nature.

8.                Complainant No.2 being widow and nominee of the deceased Bias Muni and Arun Kumar and Ajay Kumar complainants No.2 and 3 being sons of deceased Bias Muni submitted a claim settlement form (death claims) Ex. R2 on 22.10.2019, upon which an independent investigator Suresh Kumar was appointed whose affidavit Ex. R3 was tendered by the opposite parties. He made the following observations as detailed in para no.5 of his affidavit Ex. R3 which reads as under:-

          “5.     During the course of investigation, the following facts came to my               knowledge:

1. That the DA committed suicide by laying on Railway track.
2. That on 18.08.2019 at around 07.30 AM, DLA went on duty and till ate night did not return from the job. That next day at around 08.00 AM, a Police Constable came to DA’s house who was sent by ASI Manjit Singh and informed the family that a dead body is found on Railway Track and family has to go to Civil Hospital mortuary to take the dead body of DA Bias Muni.
3. That on the same day, DA family members went to Civil Hospital mortuary and confirmed that dead body is of DA Bias Muni.
4. That as per Police officials, DLA’s dead body was found on Dhandari Railway Station, Ludhiana. DLA was lying on Railway Track. The dead body was divided into 2 parts. DLA’s head was severed from torso. There was no any scratch on body of LA only his neck was cut. Spot pics enclosed herewith.
5. That the DLA was seen by a locomotive Piot Ashok Kumar (9760539132) and Guard Kalyan Kumar (9729532848). That the Pilot and Guard informed Station Master and Station Master came with Railway Police Force (RPF).”

9.                Based upon the observations of the investigator, the opposite parties invoked the clause 11 of Part F under General conditions of the policy terms and conditions and rejected the claim by observing that the cause of death has been considered as suicide and as per the terms of the policy, the premium is payable in case of death due to suicide in the first year of the policy terms. The opposite parties transferred an amount of  Rs.10,779/-  to the bank account of complainant No.1 Indravati Devi vide letter Ex. C13=R6 dated 18.02.2020. During the process of settlement of the claim on 07.08.2020 a legal notice Ex. C14 was issued and another legal notice dated 05.11.2020 Ex. C18 was issued after the rejection of the claim.

10.              The point of issue which arises for consideration is whether Bias Muni died due to railway accident or he committed suicide.

                   Suicide and railway accident both are unfortunate incidents but both differ in several important aspects. Suicide is a deliberate, intentional act of taking one’s own life while railway accident is an unintentional inadvertent incident involving a train such as a collusion, derailment or a person struck by train. Also in case of a suicide, the individual usually experiencing intense emotional pain or mental distress and he may feel that by ending his life is the only way to escape from their sufferings. It is a person’s choice and is a result of complex personal and societal factors. Railway accidents occur as a  the result of variety of reasons such as human error, mechanical failure or inadequate safety measure. No doubt, some accidents may involve intentional act by offender such as vandalism or sabotage but by any stretch of imagination this cannot be considered as suicide. The inquest proceedings conducted by the police officials, the injuries sustained, cause of death and other attending circumstances are of paramount importance which can help in distinguishing between a railway accident and a suicide committed on railway tracks.

                   In the present case, the investigator enlisted certain circumstances and opined the incident to be a case of suicide. The officials of GRP Dhandari Kalan, Ludhiana immediately went to the spot, took the dead body into possession and analyzed circumstantial evidence available at the site. No independent public witness came forward to disclose that he had seen the deceased committing suicide. No suicide note was also recovered during the inquest proceedings. The police did not come across any evidence of premeditation or indications of previous suicidal behavior. ASI Manjit Singh as well as SHO of Police Station were of the considered opinion that it is a railway accident. Further the doctor conducting post mortem also formed same opinion with regard to cause of death. The affidavit of investigator Suresh Kumar does not reflect whether he has considered the specific opinions of these officials while observing that Bias Muni committed suicide by lying on railway track. He has referred to the names of Locomotive Pilot Ashok Kumar and Guard Kalyan Kumar but did not record their statements to substantiate the factum of suicide. No independent report was prepared by the investigator. Non consideration of findings of the inquest proceedings, the opinions of ASI, SHO and concerned doctor has resulted in forming of an erroneous opinion by the investigator. So such opinion cannot be made basis of rejection of the claim by the opposite parties by invoking Clause 11 under Part F- the General conditions of the Terms and conditions. So the rejection of claim by the opposite parties is totally unjustified. In the given circumstances, it would be just and appropriate if the opposite parties are directed to consider and reimburse the claim of the complainants in terms of policy terms and conditions. The opposite parties are also burdened with composite costs of Rs.10,000/-.

11.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to consider and reimburse the claim to the complainants as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainants within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

                  (Jaswinder Singh)                                         (Sanjeev Batra)                             Member                                                        President 

 

Announced in Open Commission.

Dated:05.05.2023.

Gobind Ram.

 

 

Indrawati Devi Vs ICICI Prudential                                CC/21/170

Present:       Sh. Ramesh Kumar, Advocate for the complainant.

                   Sh. V.S. Mand, Advocate for the OPs.                 

 

                   Arguments, heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite parties to consider and reimburse the claim to the complainants as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainants within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                              (Sanjeev Batra)

                             Member                                             President   

 

Announced in Open Commission.

Dated:05.05.2023.

Gobind Ram.