J U D G M E N T :-
This is an order for petition filed on behalf of Aparna Dey (Agent code 1248/519) W/o Shantanu Sarkar for directing LIC to pay Rs 140,000/- being claim amount of Medi claim Insurance Scheme for Club Member Agents Group policy and for compensation amount 100,000/- towards mental agony and physical harassment with Rs 40,000/- separately as litigation cost along with interest @ 18 % till the payment of claim amount against LIC of India and Others being opposite parties.
The petitioner and opposite parties contended that Aparna Dey agent code 1248/519 is employed as agent with opposite party and accordingly procures business for LIC of India since 1996. Also contended by petitioner and opposition that complainant is member of Club Member Agents Group. Also contended that opposite party being LIC of India provides Mediclaim Insurance Scheme to the Club Members Agent Group.
Contended by both parties that opposite party has provision of deducting applicable premium from the payable commission to the agent for the said policy coverage named Mediclaim Insurance Scheme for Club Member Agents Contended that the complainant underwent severe surgeries that were billed for under 150,000/- cap of insurance cover for Mediclaim Insurance Scheme for Club Member Agent Group.It is further contended that the complainant claimed for the amount through application dated 06/01/2016 submitting the requisite documents to Manager Sales of opposite party no 1. It is also further contended that the complainant Aparna Dey also made later correspondences to the opposite parties in context of reimbursement of her claim. Also contended, that the opposite parties were sent a legal notice accordingly for the disposal of claim by complainant through her learned counsel.
That the opposite parties were unable to dispose off the claims of complainant and therefore the cause of action arose to file the case at District Consumer Dispute Redressal Forum Ramgarh, having sufficient jurisdiction to hear the case. The case was filed at Ramgarh on 13/04/2018 and since then the case has been pending hearing and disposal at this forum.
F i n d i n g s
Undersigned member of District Consumer Dispute Redressal Forum Ramgarh has made complete perusal of the case file and available records. That there are several documents filed by the complainant in support of her claim of policy. That the documents are marked exhibits listed exhibits as:
- Copy of letter Mktg./A/ZD/37/2016 dated 14.09.2016 with salient features of Group Medi claim Insurance Scheme Policy year 2016-17
- Copies of medical records of complainant.
- Copy of complainant’s certificate for Divisional Manager’s Club Membership dated 25/11/2016.
- Correspondence records dated 05/07/2016, 18/10/2016, and 23/01/2017 and copy of legal notice and dispatch proof as one document.
That the opposite party too files written statement to stat:
That, “there is no deduction of any amount under the head of ‘Club Membership Group Mediclaim Insurance Scheme is provided to the club member agents by New India Assurance Company Limited.”; and “The scheme is OPTIONAL i.e. it is the wish of any club member agent whether to opt for this scheme or not.
”That, opposite party have also contended that the premium for the scheme is deducted from the every eligible club member agent by December of that year subject to the commission payable to that agent. . Further adding that the premium was not deducted from the commission of complainant in this case as also the agent did not pay her premium for the insurance cover and therefore not entitled for the claim as per the petition.
That the written statement of opposite parties mentions of annexure stating the reasons for non deduction of premium from commission of complainant but the same are not filed along with in the written statement.
In the light of all the documents available including the written complain, written statement of opposition parties and hearing the learned counsel
of complainant the question before the District Consumer Dispute Redressal Forum arises:
i). Whether the complainant is entitled for relief as consumer as claimed in petition?
ii). Whether the liability of paying the premium lied with the complainant as consumer of service to avail the benefits of insurance cover?
iii) If the deficiency of service took place on part of opposition parties as per the petition?
CONCLUSION
It is admitted fact of the parties that the complainant is a member of Club Member Group of LIC of India at Divisional Manager level membership. It is also admitted fact that the complainant is entitled to insurance cover as group member as per rules. The complainant has filed in support of claim petition, copy of letter of LIC of India Mktg./A/ZD/37/2016 dated 14.09.2016 with salient features of Group Medi claim Insurance Scheme Policy year 2016-17.Undersigned member has observed from perusal of same and consideration of available documents; the insurance cover for the Club Members is mandatory for the Club Member Agents till age of 85 years as in no. 12 of the document annexure.
The document also shows that the ‘Nodal Officer in Division (mgr sales) is responsible for keeping beneficiaries informed of the policy details’ in no 11.At the same place it also clearly mentions Nodal Officer responsible for collection of insurance premium after deducting the
same from there commission earned by the agent as per module in the document and at the latest by December of the year.
That the premium has to be deducted in lump sum amount and not in installments. It implies that the complainant is not responsible for nonpayment of premium nor has available options to opt out of the Mandatory scheme for the club member agents.
R E S U L T
Upon final perusal of available materials and the findings, hearing the complainant and from regular absence of counsel of opposition, the not filing of documents mentioned in written statement, the consideration of all exhibits and documents by the complainant, this member concludes that there is no ground for the claims contradicted by opposition parties in their written statement. The opposite parties also tried to misleads the forum by stating the complainant was responsible to update her premium as well as had option available to opt out of insurance scheme.The member also found deficiency of service on part of Opposite party and hence believes the complainant entitled to the Mediclaim Insurance claim as per her petition..
ACCORDINGLY
The undersigned member District Consumer Dispute Redressal Forum Ramgarh hereby directs the opposite parties liable to pay full claim amount being 140, 000/- as per the petitioner’s claims within 90 days from the date of this order. This member also directs the opposite parties to pay, as compensation for mental agony, harassment and litigation cost a total sum of 28,000/- to complainant. Failing to comply with this order, the opposite party shall have to pay an interest of @ 9% per annum from the date of order to till final realization of amount.
That in case of opposite party failing to pay the amount to complainant, the complainant shall be entitled to get order executed through the process of court. Supply free copy of order to both the parties.
Supply free copy this order to the complainant and the opposite party.
