Punjab

Sangrur

CC/317/2015

Rajat Prasad - Complainant(s)

Versus

LIC Of India - Opp.Party(s)

Shri Harpreet Singh

08 Jan 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    317

                                                Instituted on:      18.05.2015

                                                Decided on:       08.01.2016

 

Rajat Prasad son of Hari Prasad, resident of H.No.135, Ajit Nagar, Sunam, Distt. Sangrur.

                                                        …Complainant

                                Versus

1.     L.I.C. of India, Divisional Office, “Jeevan Prakash”, Post Box No.42, Sector 17-B, Chandigarh through its D.M.

2.     L.I.C. Branch Office, Railway Road, Sangrur through its Manager.

3.     E-meditac, S.C.F. No.77, Sector 40-C, Chandigarh through its Manager.

                                                        ..Opposite parties

For the complainant    :       Shri Rajat Bansal, Adv.

For OPs No.1&2        :       Shri Amit Bedi, Adv.

For OP No.3              :       Shri Amit Goyal, Adv.

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Rajat Prasad, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant obtained the services of Ops by getting the insurance policy, namely, Jeevan Arogya having policy number 1656414107 with the date of commencement of the policy as 16.11.2013 with a premium of Rs.3122/-, but the OPs did not supply any terms and conditions of the policy along with the policy.  It is further averred that the next premium of the policy was due in May, 2014 and the complainant was in impression that his premium was to be deposited yearly, so the complainant did not deposit the premium, but when the complainant came to know about the policy premium was to be paid half yearly, then he went to the office of the OPs on 5.8.2014 and paid the premium along with interest and got revived the policy in question. 

 

2.             Further case of the complainant is that he undergone a major surgery on 16.09.2014 in which the kidney of the complainant was transplanted and the mother of the complainant donated the kidney, which was conducted in Shivalik Hospital and Trauma Centre, Mohali for the period from 5.8.2014 to 6.8.2014, Max Super Speciality Hospital, Mohali from 16.09.2014 to 28.09.2014 and further remained admitted in the PGI, Chandigarh from 28.09.2014 to 03.11.2014 and in Max Super Speciality Hospital, Mohali on 20.11.2014 and as such the complainant spent a huge amount of Rs.11,85,000/- including medicines.  It is further averred that thereafter the complainant submitted the claim to the OPs claiming an amount of Rs.6,84,000/-, but the Ops repudiated the claim of the complainant vide letter dated 15.02.2015, wherein the OPs mentioned repudiation code W04 and cause of repudiation mentioned that if the claimant was hospitalized within 45 days from the date of revival of the policy, then he is not entitled to claim.   It is further averred that the complainant thereafter also got served a legal notice upon the OPs to pay the claim, but all in vain.  Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant an amount of Rs.6,84,000/- along with interest @ 12% per annum w.e.f. and further claimed compensation for mental torture, agony and harassment and  litigation expenses.

 

3.             In the written reply filed by the Ops, preliminary objections are taken up on the grounds that the complainant has not come to the court with clean hands, as such is not entitled to get any relief.  It is stated further that the complainant is neither a consumer of the OP nor the dispute detailed in the complaint is a consumer dispute. It is further stated that this scheme is available to the employees and their family members only and under this scheme any employee/family member of any employee can purchase the LIC policy on concessional rates.  In the present case, the father of the complainant, Hari Prasad, who is working as Development Officer purchased the policy and he was well aware about the terms and conditions of the policy.  Moreover, the LIC is sending the booklet of terms and conditions along with the policy bond to each of policy holder.  It is stated that the claim has been declined as the claim had arisen within 45 days of the reinstatement of the policy.  On merits, the purchase of the insurance policy by the complainant has been admitted, however it is denied that the terms and conditions were not supplied to the complainant.  However, it is stated that the complainant was well aware about the terms and conditions of the policy.  It is stated further that though the OPs have fully sympathy with the complainant that he had to undergo medical treatment, but to say that he would have delayed the said treatment in case he had knowledge about the said clause of 45 days is totally wrong and an after thought or in other words, it can be safely construed that the complainant tried to play fraud upon the LIC, as he intentionally got the policy renewed on 5.8.2014, as he was aware about his medical condition that he will need a surgery in a month or so time, as need to replace kidney cannot arise in fortnight.  He renewed his policy on 5.8.2014 and he was operated on 16.09.2014 as per his own statement. The claim of the complainant is said to has been rightly repudiated. The other allegations levelled in the complaint have been denied in toto. 

 

4.             The learned counsel for OP number 3 also made a statement on 17.08.2015 that the written reply filed by Ops number 1 and 2 be also read as reply of OP number 3.

 

5.             The learned counsel for the complainant has produced Ex.C-1 copy of legal notice, Ex.C-2 and Ex.C-3 copies of postal receipts, Ex.C-4 copy of reply of legal notice, Ex.C-5 copy of policy, Ex.C-6 copy of repudiation letter, Ex.C-7 copy of proposal form, Ex.C-8 pamphlet of policy, Ex.C-9 brochure of the policy, Ex.C-10 copy of reply of RTI from New Delhi, Ex.C-11 copy of reply of RTI from Chandigarh, Ex.C-12 copy of reply of RTI from Bombay, Ex.C-13 copy of bill of Max Hospital, Mohali, Ex.C-14 copy of bill of PGI, Ex.C-15 copy of claim detail, Ex.C-16 copy of claim submitted from dated 1.5.2015,  and Ex.C-17 affidavit and closed evidence. On the other hand, the learned counsel for OPs has produced Ex.OP-1 affidavit, Ex.OP-2 copy of delegation of power, Ex.OP-3 copy of terms and conditions and closed evidence.

 

6.             We have very carefully perused the complaint, version of the opposite parties, evidence produced on the file and written submissions and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

7.             In the present case, the complainant obtained the insurance policy, namely, Jeevan Arogya by paying a sum of Rs.3122/- as premium on 16.11.2013 from Ops number 1 and 2.  The premium was to be paid half yearly but the complainant mistook it to be a yearly premium and could not pay the premium due in May, 2014, but got the policy revived by paying the premium on 5.8.2014 along with interest on the delayed premium and till then no terms and conditions were supplied to the complainant by the OPs number 1 and 2.  On 16.09.2014 the complainant had undergone a major surgery of kidney transplant and as such submitted a claim of Rs.6,84,000/- to the OPs, but the same was declined by the Ops on the ground that the same was within 45 days of reinstatement of the policy,  as per clause number 6 of the terms and conditions of the policy no claim is payable.  But, then it is the specific case of the complainant that no terms and conditions were ever supplied by the Ops to the complainant.  

 

8.             After hearing the arguments of the learned counsel for the parties and on perusal of the documents placed on record, we find that the policy in question was launched by the Ops number 1 and 2 on 16.11.2013 as the same is evident from the document Ex.C-10 on record.   The complainant had obtained the policy on the same day i.e. 16.11.2013 as per document Ex.C-4 on record.  The learned counsel for the complainant has argued that as per the document Ex.C-9 the instructions material was printed on 12.6.2014 i.e. approximate 8 months after commencement of the policy and when the instructions have been printed only on 12.6.2014, then how the OPs number 1 and 2 could have supplied the copy of the terms and conditions along with the policy in question.  More over, OPs number 1 and 2 have not placed on record any cogent and reliable evidence on record in support of their version that the copy of the terms and conditions were ever supplied to the complainant along with the policy.

 

9.             The  complainant has also sent a legal notice on 1.7.2015, a copy of which is Ex.C-1 and in reply to the same, the Ops number 1 and 2 have stated in the document Ex.C-4 that “he himself filed mode of the payment of the policy in the proposal form as half yearly”, but from the perusal of the documents placed on record, we find that the OPs have not placed on record the copies of the proposal document though the same was sought by the complainant himself on 17.09.2015 and in the reply the OPs had submitted that the proposal form is not in the custody/possession of the Ops as on 09.10.2015.  So, in the light of this reply of the Ops, it could be assumed that the complainant was not aware whether the premium was to be paid half yearly or yearly.

 

10.            Further the main point of controversy in the present complaint is with regard to the terms and conditions of the policy because the OPs have repudiated the claim of the complainant on the ground that the surgery has been done within 45 days of the revival of the insurance policy in question.  Had the terms and conditions been in the knowledge of the complainant, then he could have been very well undertaken the operation only after 45 days, as there is no evidence on record to show that the operation was to be performed immediately and no such medical advice has been placed on record, so all this shows that the complainant was not aware of this fact, but has acted bonafide and in good faith. The learned counsel for the complainant has further argued vehemently that when the terms and conditions were not supplied by the Ops to the complainant, then the same are not binding upon the complainant and the claim of the complainant cannot be thrown by the Ops on that basis.  To support this contention, the learned counsel for the complainant has cited  Star Health and Allied Insurance Co. Ltd. versus Asha and others 2015(1) CLT 590, wherein it has been held that if the exclusion clause has not been explained to the insured when cover note was issued, then insurance company cannot derive any benefit from the exclusion clause.  The learned counsel for the complainant has further cited United India Insurance Co. Ltd. versus Milap Telecom 2012(2) CLT 690 (NC),  Oriental Insurance Company Ltd versus Brahmdeo Panjiyara 2012(3) CLT 682 (NC) and M/s. Modern Insulators Ltd. versus Oriental Insurance Co. Ltd. 2000(1) CLT 615 (Supreme Court).  On the other hand, the Ops have produced nothing on record to show that the terms and conditions of the insurance policy in question were ever supplied to the complainant.  As such, we find it to be a clear cut case of deficiency in service in repudiating the rightful claim of the complainant.  

 

11.            Now, coming to the point of quantum of compensation, we have very carefully perused the whole case file and find that the complainant has claimed an amount of Rs.6,84,000/-, but we failed to understand how he has claimed such an amount from the OPs number 1 and 2.  We have perused the document Ex.C-15, wherein complainant requested the OPs to pay him the claim amount of Rs.6,12,000/-, but in the complaint he has claimed an amount of Rs.6,84,000/-.  It is worth mentioning here that in the said document Ex.C-15 produced by the complainant himself he has demanded Rs.4,00,000/- on account of major surgery benefit (MSB 100 times of HCB) and Rs.2,12,000/- on account of remaining in the ICU/non iCU in the hospital i.e. total Rs.6,12,000/-, as such, we find that the complainant is entitled to get an amount of Rs.6,12,000/- from the OPs number 1 and 2.

 

 12.           So, in view of our above discussion, we find it to be a case of deficiency in service and accordingly, we allow the complaint and direct OPs number 1 and 2 to pay to the complainant an amount of Rs.6,12,000/-   along with 9% interest from the date of filing of the complaint i.e. 18.05.2015 till realisation in full. We further direct OPs number 1 and 2 to pay to the complainant a sum of Rs.10,000/- on account of mental tension, agony and harassment and a sum of Rs.11,000/- as litigation expenses. This order of ours shall be complied with by the OPs  within a period of thirty days of  receipt of a copy of this order. A copy of the order be issued to the parties free of cost. File be consigned to records.  

                Pronounced.

                January 8, 2016.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                       

                                                                (Sarita Garg)

                                                                    Member