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  1. #1
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    CONSUMER COMPLAINT NO.24/2007.
    Friday, the 24th day of April, 2009.
    Between:
    1. Gottapu Uma Devi,
    W/o. (Late) G.Venkata Rao,
    Hindu, 42 years, Flat No.C-2,
    Jaya Residency, Jawaharlal Nehru Road,
    Rajahmundry.

    2. Gottapu Pravallika,
    18 years, Minor.

    3. Gottapu Praveen,
    15 years, Minor.
    (Being 2 and 3 minors Rep. by Mother
    Guardian Flat No.C-2, Jaya Residency,
    Jawaharlal Nehru Road, Rajahmundry.) ..Complainants.

    A N D

    1. Metlife India Insurance Co. Pvt. Ltd.,
    Rep. by its Branch Manager,
    Tilak Road, Rajahmundry.

    2. Metlife India Insurance Co. Pvt. Ltd.,
    Rep. by its Branch Manager,
    10-1-31, Ist Floor, Signature Towers,
    Waltair Uplands Road,
    Visakhapatnam – 530 003. … Opposite parties.



    This case is coming for hearing before this Forum and upon perusing the complaint, version of the opposite parties and other material papers on hand and upon hearing the arguments of Sri D.V.K.Ramesh, advocate for the complainants 1 to 3 and Sri P.Rajesh Babu, advocate for the Opposite parties 1 and 2 and having stood over for consideration till this day, this Forum has pronounced the following.

    ORDER


    (PER SRI K CH MOHANTHY, PRESIDENT)

    This is a complaint filed by the complainant under Section 12 of the consumer Protections Act to direct the opposite parties to pay the sum assured policy amount of Rs.3,30,000/- with interest at 12% p.a amounting to Rs.35,060/- , Rs.20,000/- towards compensation and to award Rs.10,000/- towards costs and other reliefs.

    2. The case of the complainant as set out in the complaint is that the 1st complainant’s deceased husband obtained Life Insurance Policy bearing No.1200600158255 under Met Smart Plan for Rs.3,30,000/- and paid an amount of Rs.51,730/- towards premium through the opposite parties agent having code No.11010857 at Rajahmundry. The policy was issued by the 2nd opposite party herein. The complainant’s late husband was an employee in the cadre of operations executive in HPCL, Rajahmundry and keeping good health. The policy from the opposite parties was obtained by the complainant’s late husband on 19.01.2006 after medically examined by their panel doctor of the opposite parties. The complainant’s husband was died on 31.01.2006. The complainants herein sent claim towards the death benefits of deceased life assured to the opposite parties during the month of February 2006, after considerable delay the opposite parties repudiated the claim of the complainants on 16.06.2006 alleging that the deceased life assured did not disclosed his health conditions before issuing the policy and treated the policy as void. The cause of the death of the DLA has no nexus with that of the three existing decease i.e Diabetes. The repudiation of the claim is not legally valid and purely invented by the opposite parties for the purpose of avoiding their genuine liability. The 1st complainant addressed a letter dt 08.07.2006 to the opposite parties and the same was replied. Than the complainant approached Parishkruthi and got issued a notice dt 20.08.2006 and received reply dt 07.09.2006 with false allegations. The repudiation of the claim was intentional and to avoid the liability, which amounts to deficiency of service on the part of the opposite parties. Hence, this complaint.


    3. The 1st and 2nd opposite parties filed their written version.

    The brief contention of the 1st and 2nd opposite parties are that the main and material allegation in the complaint are not true and correct and the complaint is not maintainable either in law or on facts. It is submitted that the policy was issued by the 2nd opposite party on an application submitted by the Deceased Life Assured on 23.11.2005 for a face value of Rs.4,76,000/-. The application for insurance cover clearly provided that after submission of the application and before the issue of policy if there is any change in general health, occupation, financial position the DLA would have to communicate the same in writing to Met Life. Upon analyzing the risk cover Met Life reverted to the DLA and requested to him to give a counter offer to which the DLA did on 10.01.2006. There upon, Met Life accepted the counter offer and issued Met Smart Policy bearing No.1200600158255 dt 20.01.2006 for a face value of Rs.3,30,000/-. It is true that the DLA paid a premium amount of Rs.51,730/-. Further, it is pertinent to note that in response to a specific query raised in the application for insurance as follows:

    “So far as you know, have you ever had or been told you had or been treated for any disorder, disease or disturbance of The Kidney, Bladder or genital organs such an inflammation, stone, tumor, sugar, albumin or blood/pus in the urine?”The DLA answered this in the negative.

    The DLA was referred to a medical examiner on 13.12.2005 who examined the DLA and medical questions were asked to DLA, whose answers were recorded by the medical examiner in the medical report. During the examination it was revealed that DLA suffered from Diabetes. In fact, during the medical examination to specific questions pertaining to the Gastro Intestinal System, the DLA once again answered in the negative. Unfortunately the DLA expired on 31.01.2006 and the cause of death reported as Upper GI Bleed and Hepatitis A. Upon receiving the claim intimation on 20.02.2006 this opposite parties communicated to the complainants on 23.03.2006 asking certain documents and the same were furnished by the 1st complainant. After examination of the said documents and investigation it was found that the DLA suffered from Ailments like Haematemesis, Cirrhosis of Liver and Upper Gastro Intestinal Tract Bleed before the issuance of the policy and the same was suppressed by the DLA while obtaining policy from this opposite parties. In fact, the DLA even under gone treatment for Cirrhosis of Liver and Upper GI Tract Bleed for one and half months before his death. Further, the symptoms suffered by the DLA at the time of his death clearly shows that the DLA was suffering from the symptoms even much before his 1st application of 23.11.2005, since the symptoms were a medical indication of an advance stage of lever decease and the material changes in the health were not disclosed by the DLA either at the time of counter offer or any time before issuance of the policy.
    It is true that the opposite parties herein received an appeal dt 08.07.2006 from the complainants and same was submitted before the appropriate committee which applied independent mind to the facts and circumstances of the case and decided to uphold the decision taken earlier and the decision was communicated to the claimants on 10.08.2006. It is further denied that the Met Life never responded to the legal notice got issued by the complainants. A contract of Insurance is a contract UBERIMA FIDES and there must be complete good faith on the part of the assured. The assured is under a solemn obligation to make full disclosure of all material facts relevant for the insurer to take into account while deciding whether the proposal should be accepted or not. The DLA in the instance case suppressed and misrepresented the vital facts about his health which would have influenced Met Life’s decision to grant insurance cover. The opposite parties therefore submit that the complaint be dismissed by granting them exemplary costs.


    4. Heard both sides. The opposite parties filed their written arguments.


    5. Points to be considered in this case are that;

    1. Whether there is any deficiency in service on the part of the opposite parties?
    2. Whether the complainants is entitled for the claim amounts and other
    reliefs asked for? If so, to what extent?


    6. Exs.A.1 to A.5 are marked on behalf of the complainant and Exs.B.1 to B.12 were

    marked for the 1st and 2nd opposite parties.



    7. Admitted facts in this case are that the complainant’s late husband by name G Venkata Rao obtained Ex.A.1 Life insurance policy with a coverage of Rs.3,30,000/- from the opposite parties on payment of Rs.51,688/- as installment premium which includes Rs.14,768/- towards extra premium and the date of commencement of the said policy is from 19.1.2006 to 13.5.2006/-. The deceased life assured was issued life insurance policy after medical examination by the panel doctor of the opposite parties. The complainant’s husband was died on 31.1.2006. The claim of the present complainants on the life of deceased life assured was repudiated under Ex.B.11 letter Dt.16.6.2006 by the opposite parties.


    8.POINT NO.1: The case of the complainant is that though her late husband obtained life insurance policy from the opposite party Met life insurance Company after medical examination, vide policy No.1200600158255 under Met Smart plan for Rs.3,30,000/- on payment of Rs.51,730/- as premium which included extra premium amount, but the opposite parties repudiated the complainants claim for the death benefits on deceased life assured with an allegation that the DLA did not disclosed his health condition, hence they treated it as the policy is void.
    Whereas, the opposite parties contended that the DLA applied for insurance coverage on 23.11.2005 and in the application itself it clearly provided that if after the submission of the application for coverage and before the issuance of policy, if there was any change in general health, occupation, financial position the DLA has to communicate the same to the insurance company. Upon analyzing the risk cover Met Life reverted to the DLA and requested to give a counter offer that the DLA did on 10.1.2006. Thereupon, this opposite parties issued policy on 20.1.2006 for face value of Rs.3,30,000/-. It is further submitted that in response to a specific query i.e “So far as you know, have you ever had or been told you had or been treated for any disorder, disease or disturbance of the Kidney, Bladder or genital organs such an inflammation, stone, tumor, sugar, albumin or blood/pus in the urine?” the DLA answered this in the negative. Further it is submitted that the DLA was referred to panel doctor for medical examination on 13.12.2005 and during examination the DLA’s answers were recorded by the doctor. At the time of this medical examination it was revealed that DLA suffered from diabetes and to specific questions pertaining to the Gastro Intestinal system the DLA answered in the negative. Unfortunately the DLA was expired on 31.1.2006 and the cause of the death was reported as Upper GI bleed and Hepatitis. The claim intimation was received on 20.2.2006 and on submission of documents by the complainant in reply to this opposite parties letter Dt.23.3.2006, upon examination of the said documents and investigation it was revealed that DLA suffered from ailments like Haematemesis, Cirrhosis of Liver and Upper Gastro Intestinal Tract Bleed which he suppressed at the time of obtaining policy. It is submitted that in fact the DLA undergone treatment for the above said ailments one and half months before his death. Further, the symptoms suffered by the DLA clearly shows that he was suffering from the ailments even much before his application i.e on 23.11.2005, since the symptoms were a medical indication of advanced stage of liver disease and suppression of this facts are material for the assessment of risk.

    As per the insurance terms of the application the DLA was required to inform any changes in his health between the date of the application and issuance of policy. The DLA submitted his application on 23.11.2005 and accepted by the DLA on 6.1.2006 and the policy was issued on 19.1.2006. But the DLA undergone treatment for Cirrhosis of liver and GI Track bleed from 19.12.2005 to 26.12.2005 and the DLA suppressed this fact which gravely impacted the under writers decision. Hence, the claim was repudiated by this opposite parties and even the repudiation was upheld by the appropriate committee on 8.7.2006 which was communicated to the complainant on 10.8.2006. So, the present case on hand is a crystal clear case of MISREPRESENTATION, FRAUD AND SUPPRESSION OF MATERIAL FACTS and a deliberate non disclosure by the diseased life assured is nothing but with a mallifide intention.

    On perusal of the entire record it was found that the complainant obtained Life insurance policy from the opposite parties after undergoing medical examination by their panel doctor and was charged extra premium of Rs.14,768/- along with base policy premium of Rs.36,920/- and this extra premium was charged because the DLA was a diabetic. As per Ex.B.3 Medical certificate it was found that the deceased life assured maintained good health and he complained for the first time on 18.12.2005 of Hematemesis of sudden unrest and after initial treatment he was referred to Dr A Srinivasa Rao for further evaluation and treatment by the family doctor. It was found in Ex.B.2 discharge summery given by Dr A Srinivas Rao, Gastroenterologist who treated the DLA from 19.12.2005 to 26.12.2005 diagnosed cirrhosis of liver with GI Bleed – Non B, Non C stated and that the DLA underwent Sclerotheraphy for bleeding varices, bleeding was stopped and the general condition was improved. The doctor further certified that the DLA was discharged on 26.12.2005 after satisfactory improvement. So, it is evident that the DLA diagnosed for the ailments only on 19.12.2005 and was discharged on 26.12.2005 after treatment as his general condition was improved from the said ailments.

    As per Ex.B.6 death summery said to be issued by one Dr Sukanya, Registrar, without hospital name, the DLA was treated from 24.1.2006 to 31.1.2006 in their hospital and the illness was mentioned as Haepatitis-B, Decompensated Cirrhosis and the cause of death was upper GI bleed? Post EST Ulcer Bleed. As per this during the treatment as Post EVL bleeding subsided and sensorium also improved with colloids and albumin. Three days after admission he was shifted out of ICU where he remained stable, but started accumulating ascites, with oliguria. On 30.1.2006 the DLA had a sudden episode of transient hypotension from which he recovered, but again developed hypertension and was shifted to ICU where he developed 1 episodes of Bradycardia from which he was revived intubated, ventilated and put on ionotropes. Afterwards the deceased remained extremely unstable Hemodynamically and had another cardiac arrest from which he could not be revived despite prolonged CPR and declared dead on 31.1.2006.

    Further, we found from Ex.B.7 questionnaire regarding treatment details of DLA, that certificate was issued by an hospital administrator of Global Hospitals, Hyderabad that the DLA was admitted in their hospital with G I bleeding and he was under drowsiness and restless and the DLA suffering from Cirrhosis of liver from one and half months as per the statement of DLA at the time of admission. This questionnaire was not supported by any authenticated medical record and there is no affidavit filed by the administrator. The genuineness of this certificate is very much doubtful as this certificate was signed by the Hospital Administrator by name Dr S Sunil Kumar who did not treat the DLA and this certificate sans official seal of the hospital. Even, if we take this certificate into consideration the DLA suffered from the diseases prior to one and half months of his death i.e mid December, 2005, the DLA was might not aware of the symptoms during the time of his medical examination by the panel doctor on 13.12.2005. Further, it was also evident from Ex.B.2 and B.3 medical certificates that for the first time the DLA was treated for the diseases on 19.12.2005 only, so, the diseases were not preexisting diseases. It is further observed that the opposite parties alleged that the DLA did not inform them about his changed health condition, but as per Ex.B.2 certificate issued by the Gastroenterologist that after treatment the DLA’s general condition was improved and as such he was discharged. So, it is evident that the DLA’s health condition was normalized after treatment and there is no need to inform the same to the opposite parties. Even as per Ex.B.5 statement by S Sriram Naik, neighbour of DLA, the DLA used to maintain good health. It is further observed that the DLA paid the premium amount of Rs.51,688/- including extra premium of Rs.14,768/- along with his application dt.23.11.2005 vide Ex.A2 application and further there is no evidence with regard to Medical examination done on dt.13.12.2005 by panel doctor and found the DLA as Diabetic. But , by this date the DLA had already paid extra premium ,How could it possible ?

    Hence, we are in the considered opinion that the DLA suffered with the said diseases only after his medical examination and he was not known about the symptoms of the said diseases during the time of submission of application for life insurance policy to the opposite parties. “ As per the medical science the diagnosis of Cirrhosis is usually based on the presence of a risk factor for cirrhosis, such as alcohol use or obesity, and is confirmed by physical examination, blood tests, and imaging. The doctor will ask about the person’s medical history and symptoms and perform a thorough physical examination to observe for clinical signs of the disease. For example, on abdominal examination, the liver may feel hard or enlarged with signs of ascites. The doctor will order blood tests that may be helpful in evaluating the liver and increasing the suspicion of cirrhosis.

    It is further noted that cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Many people with cirrhosis have no symptoms in the early stages of the disease.

    As the disease progresses, symptoms may include weakness, fatigue, loss of appetite, nausea, vomiting, wait loss, abdominal pain and bloating, itching and spiderlite blood vessels on the skin. As the liver function deteriorates one or more complications may develop and in some people complications may be the first signs of the disease” (Source:Wikepedia)
    . Hence, it is clear that in the present case the DLA was not aware of the symptoms if any and further he was physically examined by the panel doctor of the opposite parties and even the doctor could not find any problem on abdominal examination of DLA and so, the doctor did not advise further tests.


    It is well settled that in case of suppression of material facts the insured must undergone treatment for a longer period as an in-patient or got operated within the period of 5 years prior to obtaining the policy and the insurer must prove this by adducing evidence through Medical records pertaining to the treatment given by the doctor to the insured. Further, as per the decision reported in AIR 2008 (NOC), 955 NCDRC, between National Insurance Company Vs Raj Narayan wherein it was held; “that every person suffers from symptoms of any disease without knowledge of the same – as insured unaware of disease at the time of making policy – Insurance Company liable to assured amount”.

    With the discussion held supra we are in the considered opinion that the DLA was treated for the above said diseases on 19.12.2005 to 26.12.2005 for the first time and recovered. Again after one month he was admitted for treatment of the said diseases and while undergoing treatment he had cardiac arrest from which he could not be revived despite prolonged CPR and died on 31.1.2006. So, it is evident that the claim for death benefits of the DLA was repudiated in a routine and mechanical manner by the opposite parties as the DLA was died within a short period after obtaining policy. The opposite parties herein completely failed to prove their case with any constructive proof that the DLA had the above said diseases prior to obtaining life insurance policy from Met life on his application Dt.23.11.2005 which is nothing but deficiency of service on the part of the opposite parties. Under these circumstances the opposite parties are certainly liable to pay the claim amount to the complainants herein. Further, it is observed that as per Ex.B.11 Dt.16.6.2006 the opposite parties herein refunded an amount of Rs.48,801/- to the complainants, but the same was not stated either in the complaint or in the version to the reasons best known to the opposite parties. If this amount of Rs.48,801/- was refunded to the complainant, the same may be deducted from the claim amount and the balance to be paid to the complainants.


    9.POINT NO.2: In the result, the complaint is allowed directing the opposite parties to pay an amount of Rs.3,30,000/- (Rupees three lakhs thirty thousand only) with interest @9%P.A from the date of filing complaint i.e 24.1.2007 till realization. We further direct the opposite parties to pay Rs.2,000/- (Rupees two thousand only) towards costs of this complaint.

  2. #2
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    Default Met Life

    ORDER


    1.(a) This Complaint is filed on 10/12/2008 under section 12 of the Consumer Protection Act, 1986, alleging deficiency of service by the Opposite Party-Insurance Company (hereafter OP-Company) in respect of an Insurance Policy Coverage and seeking certain reliefs which according to the Complainant, are appropriate.

    The Complaint in brief, is as hereunder;


    (b) The Complainant had availed two Medical Insurance Policies bearing Nos.1200600182398 dt.25/11/2005 and 1200500138898 dt/09/04/2006 for Rs.2,50,000/- each. The Complainant was regular in paying the premiums. Those Policies had certain benefits including critical illness coverage of Rs.3,50,000/- and Rs.2,50,000/- respectively. The 1st Policy was for life and the 2nd Policy was for a period of 15 years. The Complainant became critically ill and approached Mallya Hospital, Bangalore. After checkup the hospital Authorities told him that he is suffering from Chronic Renal Failure. Then, the Complainant was admitted to Bangalore Hospital, Bangalore and he had spent huge amount.


    (c) The Complainant was advised by the Opposite Party-Insurance Company to submit the Claim Form for that critical illness. The Complainant accordingly submitted the same on 24/11/2006. That treatment had to be for a long time and the Complainant had to take the treatment since there was no other option for survival. However, the Opposite Party-Insurance Company did not honour that Claim. That resulted in a Legal Notice and ultimately, a Complaint before the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in Complaint No.CC.943/2007 on their file. That Complaint came to be allowed and the Opposite Party-Insurance Company was directed to pay a sum of Rs.2,00,000/- and the cost of the litigation at Rs.5,000/-, as per the Order dt.26/11/2007. As per the Medical advise, the Complainant had to expend Rs.15,000/- every month for medication regularly.
    As and when the Complainant had to so spend, he is required to lay a Claim on the basis of those Policies since there is Insurance Coverage for medication under those Policies. Accordingly, the Complainant laid a Claim for the subsequent period, but, the Opposite Party-Insurance Company repudiated the same on the ground that there was no such liability to honour the Claim regarding critical illness for the 2nd time. That repudiation of the Claim was unjust and improper since the Opposite Party-Insurance Company could not have repudiated the Claim on that ground. Hence, this Complaint is necessitated to direct the Opposite Party-Insurance Company to pay a sum of Rs.81,720-00/- to the Complainant being the Medical expenses and also to direct to pay cost and compensation.


    (d) Along with the Complaint, the Complainant has made available xerox copies of certain documents marking them at Annexures C-1 to C-81.


    2.(a) On admission of the Complaint, the Opposite Party-Insurance Company was called upon to produce their Version of the case. Accordingly, the same is made available on 12/02/2009. In brief, it is as hereunder.

    (b) This Complaint is neither maintainable at Law, nor on facts of the case. It is true, the Complainant is the Holder of two Medical Insurance Policies issued by the Opposite Party-Insurance Company. They are MET SURAKSHA-TROP with critical illness Rider and MET 100 GOLD with critical illness Rider respectively. The 1st Policy bears No.1200500138898. The date of proposal is 17/10/2005. The sum assured is Rs.5,00,000/-. The critical illness Rider is Rs.3,50,000/-. That Policy was issued on 25/11/2005. The premium is Rs.3,086-00/- payable half yearly. The 2nd Policy bears No.1200600182398. The date of proposal is 19/12/2005. It is for a sum of Rs.2,50,000/-. The critical illness Rider is Rs.2,50,000/-. The date of issue of the Policy is 09/04/2006. The premium payable is Rs.3,746-00/- half yearly. There was also a provision for the benefit of accidental death of the insured.

    (c) The Complainant preferred a Claim on 24/11/2006 with regard to the treatment connected with her Chronic Renal Failure. The Opposite Party-Insurance Company sought several clarifications from the Complainant including the details regarding the treatment taken at St.John’s Hospital, KIMS Hospital and Bangalore Hospital. Instead of providing those details, the Complainant filed a Complaint before the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in Complaint No.CC.943/2007, alleging deficiency of service by the Opposite Party-Insurance Company and for issuance of a direction to the Opposite Party-Insurance Company to make the payment claimed therein.
    That Complaint came to be allowed by the IVth Additional District Consumer Disputes Redressal Forum, as per the Order dt.26/11/2007 directing the Opposite Party to pay a sum of Rs.2,00,000/- along with the cost of Rs.5,000/-. In that Order, liberty is given to the Complainant to approach the proper Authorities for reimbursement of the amount spent by him for future treatment. Accordingly, the Opposite Party-Insurance Company has paid the sum of Rs.2,00,000/- with cost and treated the same as ex-gratia payment. Now the Complainant has chosen to file this Complaint claiming Rs.81,730-00/-claiming the alleged medical expenses up to 23/10/2008 on the basis of those Policies. Infact, the Complainant has suppressed the truth of the fact that he was suffering from Chronic Renal Failure before the issue of both the Policies. Towards proof of reappearance of the real failure, prior to the issuance of the Policies, the admission record of St.John’s Hospital is produced as Annexure-1 by this Opposite Party-Insurance Company. Further, regarding the 2nd Policy, after the submission of the Application and before the issuance of the Policy, the Complainant had visited Dr.K.S.Ramaprasad with regard to the Renal Failure and this fact has been stated in the critical illness Claim from 24/11/2006 duly signed by the Complainant showing that the “date of appearance of First symptom as 02/03/2006” in the column meant for “history of the case” in the said Claim Form.

    The date of the proposal of the 2nd Policy was 19/12/2005 and the Policy was issued on 09/04/2006. There is a declaration in that Application that the non- disclosure of facts or any un-true disclosure in the Application, the very contract becomes null and void and the premium paid till then would stand forfeited to the Opposite Party-Insurance Company. It is evident from the Admission Card and from the admission of the Complainant in the critical illness Claim Form that after filing the said Application and before the issuance of the Policy, there was a change in his general health and that he had to visit the Doctor on 02/03/2006 for Renal Failure. It was never intimated by the Complainant to the Opposite Party-Insurance Company while submitting that 2nd Application Form, nor, thereafter. Since, contract of Insurance is “uberamie fadie” the parties are bound to disclose the true acts while entering into such a contract. But, the Complainant had suppressed the fact of illness in the 2nd Application for Policy.

    (d) As per the exclusion Clause No.4 in the above Policies, no amount shall be payable under that benefit of critical illness condition unless it is so caused after the availment of the Policy and if it was existing very much there even previously, that benefit is lost. Further, in the above Policies, Clause-5 provides for termination under the situations stated therein.

    (e) It is true, the Complainant had caused a Legal Notice to the Opposite Party-Insurance Company on 31/07/2008. But, the allegations made therein are denied since false. In the circumstances, there is every reason to hold that this Complaint is intended to make profit unlawfully by misrepresenting the Terms and Conditions enshrined in those Policies. Wherefore, this very Complaint has to be dismissed with cost of the Opposite Party-Insurance Company.


    (f) Along with the Complaint, the Opposite Party-Insurance Company has made available certain documents marking them at Annexures-1 to 3.


    3. In this proceeding by way of evidence the Complainant has made available his affidavit on 03/03/2009. For the Opposite Party-Insurance Company their Associate Director-Legal namely Anil P.M. has sworn to an affidavit which is made available by way of evidence on 17/03/2009 along with the Affidavit. At the end, this Forum heard on merits.


    4. In the circumstances, the following points do arise for our consideration and decision in this Proceeding and they are;

    (i) Whether there was suppression of the material fact as to any illness of the Complainant at the time of submission of the Applications seeking Insurance Coverage as contended by the Opposite Party-Insurance Company ?

    (ii) Whether the Complainant is entitled for the benefit of Insurance Coverage touching critical illness under the Policies?

    (iii) Whether the Complainant is entitled for any relief in this case ?

    iv) What Order? 5. Our Findings to these points are as hereunder: i) No, ii) Yes, iii) Yes, iv) As per the operative portion of the Order here- below. 6. We shall strengthen our findings on the following:


    R E A S O N S


    POINT NO.1 (a):- Admittedly, the Complainant was provided with two Policies by the Opposite Party-Insurance Company. The 1st Policy was issued on 25/11/2005 and the next Policy was issued on 09/04/2006. In the 1st Policy, the sum assured was, Rs.5,00,000/-and the sum assured under the critical illness Rider is, Rs.3,50,000/-. In the 2nd Policy, the sum assured was, Rs.2,50,000/- and the sum under the critical illness Rider is, Rs.2,50,000/- It is significant that within a short period of four months, these two policies have come into effect.


    (b) First of all, if really there was suppression if any material fact regarding the alleged illness of the Complainant while applying for the Policies at least in respect of the 2nd Policy, the Opposite Party –Insurance Company could have been more alert and would have thought twice whether to issue the Policy or not in the light of the already existing Policy which was obtained just four months prior to the 2nd Policy. The evidence is to the effect that the Opposite Party-Insurance Company had subjected the Complainant to medical check-up and that an increased premium was imposed by the Opposite Party-Insurance Company. That apart, this very same point was raised by the Opposite Party-Insurance Company in the previous proceeding between the parties, which was pending in Consumer Complaint No.943/2007 on the file of the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District. That Complaint came to be allowed, as per the Order dt.26/11/2007 a copy of which is, at Annexure C-17 made available by the Complainant along with the Complaint. Significantly, the said Authority had answered the said point against the Opposite Party-Insurance Company in that Order by holding that there was no suppression of material facts touching the alleged illness of the Complainant while submitting the Applications for Insurance Coverage. It is equally significant to note that the said Order of the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District has become final. It is submitted by the Learned Counsel representing by the Opposite Party-Insurance Company that there was no Appeal as against the said Order and that what was ordered there-under has been duly complied with by the Opposite Party-Insurance Company.



    (c) Wherefore in the above circumstances, we are of the opinion that further discussion may not be necessary as far as this point is answered and accordingly, this point is against the Opposite Party-Insurance Company.



    7. POINT NO.2(a):- It is an admitted fact that the above Policies provide certain benefits to the Insured including the benefit touching critical illness. As a matter of fact, in the previous Complaint, that benefit was availed, as revealed in the said Order. It is significant that in the said Order dt.26/11/2007 by the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District, it has been observed that Claim for future reimbursement under critical illness clause can be made by the Insured Complainant before the proper Authorities. Ofcourse, in that Complaint that Claim came to be rejected for the reason that there was no clear evidence in that regard. For better appreciation, we reproduce the relevant part of that Order which is found in page No.6. It reads like this: The Complainant has claimed Rs.15,000/- per month for medication regularly life long. When we peruse the documents at Annexure-D produced by the Complainant, it is an approximate cost estimated by the Doctor. The Complainant has not produced the Bills that how much amount will be required every month for the purpose of regular treatment and for future treatment. This Forum cannot award any cost or compensation, anticipating the cost on the approximate value given by the Doctors and without fixing the period. Hence, the said Claim of the Complainant is hereby rejected. However, the Complainant is at liberty to approach the proper authorities for reimbursement of the amount spent by him for future treatment.”


    (b) As already stated, since the above Order has become final, the above observation holds good. That apart, the learned Counsel representing the Opposite Party-Insurance Company has strenuously argued before us placing reliance upon the relevant Clauses of the Terms and Conditions touching the above Policies. The Complainant has made available copies of those Policies including the Terms and Conditions in evidence along with the Complaint itself marking them at Annexure C-1. The relevant part is, Rider – critical illness (CI). As revealed in Clause-2, that Rider will remain effective from the effective date as shown in the Schedule and shall remain valid unless terminated in accordance with the Terms and Conditions shown therein. Admittedly, the Complainant’s illness is, Kidney Failure. Kidney Failure is covered under the Policy as per Clause-3 among other deceases. Clause-5 is very much relevant and as already stated, it is interrelated to Clause-2 period of Coverage. For better appreciation, we reproduce that Clause-5 here. It reads like this: “Termination”: This Rider coverage will terminate on the earliest of any one of the four mentioned below: ‘On diagnosis of Critical Illness Condition within a period of 90-days from issue date or reinstatement of the policy; or, ‘Lapse, surrender of the Policy, conversion of the Policy into a paid-up Insurance; or, ‘The benefit expiry date shown in the Schedule under Rider Details; or, ‘The date of the first occurrence of the event on which, this benefit becomes payable. According to the Learned Counsel representing the Opposite Party-Insurance Company the last a Para that is, the date of the 1st occurrence of the event on which this benefit becomes payable would clearly probabilise that the Complainant as Insured is not entitled for the benefit of that Rider for the 2nd time, since that benefit was availed by him already.

    However, we do not think so. Admittedly, the ailment is, Kidney Failure. As revealed in evidence, that ailment is not cured and it is being treated. Further, admittedly the earlier Complaint through which the Complainant sought that benefit and got the same was far a definite period. It is not as if that ailment was cured completely and that the said payment was made, as per the said Order only after the cure of that illness. On the other hand, as already stated, the said illness is still continued and the Insured Complainant is suffering a lot on account of the same. Further, it is not as if that illness is changed and some other ailment has cropped-up.

    On the other hand, that critical illness is, Kidney Failure only. In this Complaint, the Complainant has claimed the medical expenses incurred by him touching that critical illness, till 23/10/2008 in a sum of Rs.81,720-00/-. Admittedly, this is the 2nd Claim. Admittedly, the 1st Claim made in the above Complaint before the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District is for the earlier period and that has been paid over by the Opposite Party-Insurance Company. Further, it is not as if the Insured Complainant is not paying the premiums touching the Policies. Admittedly, the premiums are being paid as and when they became payable. That means, the Opposite Party-Insurance Company is collecting the premium regularly from the Complainant. Further, as already stated, the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in the above case has clearly opined that the Insured Complainant is entitled for the future benefit touching critical illness under the said Insurance Coverage.

    Wherefore, in the light of the above aspects, we are of the clear opinion that the Insured Complainant is entitled for future reimbursement regarding the Medical expenses incurred by him touching the above critical illness. (c) When that is so, the non-reimbursement of the same by the Opposite Party-Insurance Company would clearly amount to deficiency of service within the purview of the Consumer Protection Act, 1986. Wherefore, this point is answered in favour of the Insured Complainant. 8.POINT NO.3:- It appears, no Claim Petition as such is made by the Insured Complainant before the Opposite Party-Insurance Company regarding the Claim made herein.

    On the other hand, according to the Complainant, a Legal Notice was caused on 31/07/2008 to the Opposite Party-Insurance Company requesting them to pay the Medical expenses for the period from 26/02/2008 till 19/07/2008 in a sum of Rs.55,515-00/- and also the Notice charges in a sum of Rs.1,000/-. Ofcourse, that Claim has not been conceded by the Opposite Party-Insurance Company and that made the Complainant to knock the doors of this Forum. However, the facts remains that there was no Claim Form as such by the Complainant for the period subsequent to the period covered under the Order of the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District dt.26/11/2007 which we have referred to above. Wherefore, the Complainant has to lay a Claim in the proper format in that regard and the Opposite Party-Insurance Company has to consider the same on merits and dispose-off the same in the light of the above observations of this Forum.

    As stated supra, there shall be interest on the amount payable at 9% p.a. at least from this date, till reimbursement. In the peculiar circumstances, we are not inclined to grant any compensation as such to the Complainant. However, cost of this litigation needy provided to the Complainant at a reasonable rate which according to us, would be Rs.1,000/-. Accordingly, this point is answered. 9. POINT NO.4:- In the result, we proceed to pass the following: O R D E R It is held that the Insured Complainant is entitled for the benefits conferred under the Policies in question in respect of critical illness for the period subsequent to the period referred to by the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in Complaint No.CC.943/2007 and the Complainant is at liberty to lay a Claim Petition before the Opposite Party-Insurance Company claiming the amount till the date of that Claim Petition and the Opposite Party-Insurance Company shall decide the same on merits and reimburse the amount which is required to be reimbursed on the merits of that Claim along with an interest at 9% p.a. from this date, till reimbursement.

    If desired, the Complainant shall lay the Claim positively within the period of 15 days from this date and on production of the same, the Opposite Party-Insurance Company shall dispose-off the said Claim within the period of 30 days from the date of submission of the Claim Application. In addition to the same, the Opposite Party-insurance Company shall pay a sum of Rs.1,000/- to the Complainant by way of cost of this litigation.

  3. #3
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    1,738

    Default Met Life Insurance

    Mr. Srinivas,

    S/o. Late Guruvappa,

    Aged about 50 years,

    R/A. KGP 9/425,

    @@@@hinagar, Mogral Post,

    Kasaragod District. …….. COMPLAINANT



    (Advocate: Sri.K.B. Arasa)



    VERSUS



    1. The Divisional Manager,

    Met Life Insurance Co. Ltd.,

    Brigade Sesh Mall,

    No.5, Vani Vilas Road,

    Bangalore – 560 004.



    (Advocate: Sri.K.S.N. Rajesh).



    2. The Registrar,

    Manipal University,

    Madhava Nagar,

    Manipal – 576 104. ……. OPPOSITE PARTIES


    The Complainant’s brother Sundara M was joined as a security guard under 2nd Opposite Party’s college at Mangalore and he died on 21.4.2006.

    It is submitted that, the 2nd Opposite Party as per its circular dated 20.10.2005 informed the group life insurance policy is active from 1.10.2005 for all the regular employees of the institutions. The brother of the Complainant Sundara was the regular employee of the 2nd Opposite Party as on 1.10.2005. The 2nd Opposite Party as per the above said circular recovered insurance premium from the salary of Sunadra and remitted the same to the 1st Opposite Party.

    It is submitted that the Complainant’s brother M.Sundara died during the course of his employment under the 2nd Opposite Party on 21.4.2006. It is submitted that the circular dated 20.10.2005 the Group Life Insurance Policy is obtained for a sum of Rs.10,00,000/- for each employee for the financial assistance to the family members of the employee in case of the death of the employee during the tenure of his service with the 2nd Opposite Party. It is submitted that Sundara M was unmarried and his parents are pre-deceased, the Complainant alone is the surviving family member of the deceased Sundara and also the nominee.

    After the death of his brother Sundara M filed a claim form before the Opposite Parties but the Opposite Parties failed to honour the claim. Thereafter the Complainant issued a legal notice on 25.10.2007 to the Opposite Parties but the Opposite Parties issued a frivolous reply and not honoured the claim of the Complainant which amounts to deficiency in service and hence the above complaint is filed by the Complainant before this Hon'ble Forum under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Hon'ble Forum to the Opposite Parties to pay Rs.10,00,000/- with 12% interest from 21.4.2006 to the Complainant and also claimed for compensation and cost of the proceedings.

    2. Version notice served to the Opposite Parties by RPAD. Opposite Party appeared through their counsel filed separate version.

    Opposite Party No.1 contended that they had issued a group policy bearing No.3200500000266 in favour of the Manipal Education and Medical Group International Private Limited which was effective from September 30th 2005. It is submitted that all members are actively at work on the day the coverage commences. All employees who are either performing in the usual way all their regular duties of their work or are absent from work for reasons other than sickness, injury or medical leave will be considered as actively at work. For employees who are not actively at work on the commencement date of coverage, their coverage will commence on the day they join full time active duty and have given a good health certificate from their physician.

    The terms and conditions of the Group Life Insurance Policy also provides that only those persons who met the eligibility criteria as stated in the policy schedule were eligible to be covered. It is contended that the deceased was not actively at work within the definition of the policy as on the commencement date of the policy i.e., 30.9.2005, since he was absent on account of sickness. He resumed work only on 17.11.2005 and he also failed to produce good health certificate from a doctor in order to be covered under the policy as per the eligibility criteria and further contended that deceased did not attend work at all after 1.12.2005 and was on continuous leave thereafter. He expired on 21.4.2006 and it is prayed that the Complainant is not entitled for any claim and prayed for dismissal of the complaint.

    Opposite Party No.2 submitted that Opposite Party No.2 introduced the Group Life Term Insurance Policy of Opposite Party No.1 for the benefit of its over 8,000 employees as a staff welfare measure. The insurance premium payable was Rs.1,200/- per annum for each employee for sum insured of Rs.10.00 lakhs. The management decided to collect only the partial premium from the employees by way of deduction from salary as shown in the circular dated 20.10.2005. The said circular was based on the representations of Opposite Party No.1 as to the premium payable and the benefits of the policy. It is submitted that the terms of the policy were not given to Opposite Party No.2 to Opposite Party No.1 at the time when the circular was issued. A total sum of Rs.93,72,300/- was paid as premium to Opposite Party No.1 for the said policy which was valid for the period from 30.9.2005 to 29.9.2006.

    It is submitted that late Mr. Sundara M was a regular employee of Kasturba Medical College, Mangalore i.e., Opposite Party No.2 and he was working as a Security Guard. His name was covered in the group policy No.3200500000266 had with Opposite Party No.1. The Company has accepted the premium paid by the management on behalf of late Mr.Sundara M. It is submitted that the proportionate amount of premium have been refunded by Opposite Party No.1 to Opposite Party No.2 in respect of employees who had left from the institution. The name of late Sundara M., was not included in the bill of proportionate premium refunded in respect of employees left/died.

    It is submitted that the Opposite Party No.1 has covered the name of late Mr.Sundara and accepted the full premium and it had released the list of members covered by allotting Company’s identification number i.e., man/BHU/150680 to Mr. Sundara M. The date of the commencement of the policy is 30.9.2005. At that time all the members are actively at work on the day the coverage commences. It is submitted that the condition came to the knowledge of the Opposite Party No.2 only on 10.10.2005 and his last date of working was 10.8.2005 and he had availed leave from 11.8.2005 to 20.4.2006 and died on 21.4.2006 and the production of good health certificate did not arise. Opposite Party No.2 had submitted that partial premium of Rs.80/- from his salary had collected from his salary in the month of November 2005 and submitted the claim of the Complainant is maintainable only against the Opposite Party No.1 and not against the Opposite Party No.2 and contended that there is no deficiency whatsoever on the part of the Opposite Party No.2 and prayed for dismissal of the complaint.

    3. In view of the above said facts, the points now that arise for our consideration in this case are as under:

    (i) Whether the Complainant proves that the Opposite Parties committed deficiency in service?


    (ii) If so, whether the Complainant is entitled for the reliefs claimed?

    (iii) What order?

    4. In support of the complaint, Sri.Srinivas (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him. Ex C1 to C9 were marked for the Complainant as listed in the annexure. One Sri.Anil P.M. (RW1), Associate-Legal and Duly Constituted Attorney of Opposite Party No.1 and one Sri.H.S. Bhat (RW2) – working as Management Executive of the Opposite Party No.2 filed counter affidavits and answered the interrogatories served on them. Ex R1 to R4 were marked for the Opposite Parties as listed in the annexure. The Complainant produced notes of arguments.

    We have considered the notes/oral arguments submitted by the learned counsels and we have also considered the materials that was placed before the Hon'ble Forum and answer the points are as follows: Point No.(i): Affirmative.

    Point No.(ii) & (iii): As per the final order.
    Reasons

    5. Point No. (i) to (iii):

    The facts which are not in dispute that the Opposite Party No.1 had issued a group policy bearing No. 3200500000266 in favour of the Manipal Education and Medical Group International Private Limited which was effective from September 30th 2005 (i.e., Ex R1). It is also admitted that the Opposite Party No.2 introduced the Group Life Term Insurance Policy of Opposite Party No.1 for the benefit of its over 8,000 employees as a staff welfare measure. The insurance premium payable of Rs.1,200/- per annum for each employee for sum insured of Rs.10,00,000/-. It is also admitted that the management i.e., Opposite Party No.2 collected partial premium from the employees by way of deduction from salary as shown in the circular dated 20.10.2005 (i.e., Ex C1). And it is also admitted that a total sum of Rs.93,72,300/- was paid as premium to Opposite Party No.1 for the said policy which was valid for the period from 30.9.2005 to 29.9.2006 and it covered 8,926 employees of Opposite Party No.2.

    It is further admitted that the premium was collected by the Opposite Party No.2 from the salary of the Sundara M and paid premium. And further it is not in dispute that late Mr.Sundara M was a regular employee of Kasturba Medical College, he was working as a Security Guard - II, his name was covered in the group policy No.3200500000266 had with the Opposite Party No.1 and the company accepted the premium paid by the management on behalf of Mr.Sundara M.

    It is also not in dispute that the proportionate amount of premium has been refunded by Opposite Party No.1 to the Opposite Party No.2 in respect of employees who had left from the institution and the name of late Sundara was not included in the bill of proportionate premium refunded in respect of employees left/died. The Opposite Party No.1 has covered the name of late Mr.Sundara M and accepted the full premium and the company i.e., Opposite Party No.1 released the list of members covered by allotting Companies identification number for every employee. Accordingly the Company has allotted No.Man/BHU/150680 to Mr. Sundara M at the time of commencement of the policy all the members are actively at work on the day the coverage commences.

    Now the point in dispute is that the Opposite Party No.1 specifically contended that the deceased Sundara M did not fulfill the eligibility criteria as laid down in clause No.2 of the policy and therefore he was not eligible to be covered under the policy at the time of his demise. However, we have perused the clause No.2 of the policy, the policy schedule contained interalia the following provision with regard to eligibility criteria which reads thus:

    Eligibility criteria:-

    1) Coverage is provided to all full time and permanent employees of Manipal Group Companies comprising of Manipal Education and Medical Group International India Private Limited.

    2) All members are actively work on the day the coverage commences. All employees who are either performing in the usual way or regular duties of their work or are absent from work for reasons other than sickness, injury or medical leave will be considered as actively at work. For employees who are not actively at work on the commencement date of coverage, their coverage will commence on the day they join full time active duty and have given a good health certificate from their physician.

    3) All members are within the age band of 18 to 59 years age last birthday at the time of entry to the scheme.

    From the above clause it has stated that all employees who are either performing in the usual way or regular duties of their work or are absent from work for reasons other than sickness, injury or medical leave will be considered as actively at work.

    Now the point for consideration is that the Opposite Party No.2 in their version Para No.4 it is stated that the Opposite Party No.1 has covered the name of late Mr.Sundara M and accepted the full premium. The company had released the list of members covered by allotting company’s identification number for every employee. Accordingly the company has allotted identification number to Mr.Sundara M. The date of commencement of the policy was 30.9.2005. At that time the clause No.2 of the policy condition was not made known to the Opposite Party No.2 and the name of late Mr.Sundara M was already covered under the policy. The condition came to the knowledge of the Opposite Party No.2 only on 10.10.2005. The above said evidence of the Opposite Party No.2 was not contradicted by the Opposite Party No.1.

    From the above evidence of the Opposite Party No.2 it clearly shows that the Opposite Party No.1 ought to have furnished the condition before commencement of the policy or the Opposite Party No.1 should not have collected the premium paid by the Opposite Party No.2. And further it is pertinent to note that the Opposite Party No.1 ought to have cross verified the employees who are benefited under the above policy before acceptance of the premium. In the present case, the Opposite Party No.2 had collected the premium from the salary of Mr.Sundara M and paid to Opposite Party No.1 and the policy is commenced from 30.9.2005 now Opposite Party No.1 cannot contend that the Complainant is not actively at work on the day the coverage commences.

    It is clearly shows that the conditions of the policy issued by the Opposite Party No.1 only after the commencement of the policy not before. And it is significant to note that it is an internal arrangement between the Opposite Party No.1 and the Opposite Party No.2 for the welfare of the staffs of the Opposite Party No.2. The deceased Mr.Sundara M is innocent as far as the condition of the policy is concerned. The premium of the policy was recovered from the salary of the beneficiary i.e., Mr.Sundara M and the policy was issued and the identification number was also issued. And further we have noted that the proportionate amount of the premium has been refunded by Opposite Party No.1 to Opposite Party No.2 in respect of employees who have left from the institution. If at all the Mr.Sundara M is not covered under the policy the Opposite Party No.1 could have refunded the premium paid by the Opposite Party No.2. The same was not done by the Opposite Party No.1.

    From the above discussion as well as the admitted facts on record before the FORA it is proved beyond doubt that the policy was in force at the time of death of the Mr.Sundara M and the sum assured under the policy was of Rs.10,00,000/- and the entire premium was paid by the deceased Mr.Sundara M till his death and hence the repudiation of the claim is not justifiable which amounts to deficiency in service.

    In view of the above discussions, we are of the considered opinion that the Complainant is only legal heir of the deceased Sundara M and the Complainant produced legal heir certificate issued by the concerned department as per Ex C3 before the FORA. Therefore, by considering the above we hereby direct the Opposite Party No.1 i.e., Met Life Insurance Co. Limited to pay Rs.10,00,000/- to the Complainant along with interest at 10% p.a. from the date of death i.e., 21.04.2006 till the date of payment. And further Rs.1,000/- awarded as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.

    Since there is no deficiency on the part of the Opposite Party No.2 the complaint against Opposite Party No.2 is hereby dismissed.

    6. In the result, we pass the following:


    ORDER

    The complaint is allowed. Opposite Party No.1 i.e., Met Life Insurance Co. Limited is hereby directed to pay Rs.10,00,000/- (Rupees ten lakhs only) to the Complainant along with interest at 10% p.a. from the date of death i.e., 21.04.2006 till the date of payment. And further Rs.1,000/- awarded as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.

  4. #4
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    Default Met Life

    M.C. Annaiah,

    S/o. Late Chengappa,

    Aged 55 years,

    Byrambada Village,

    Votiangadi Via Ammathi,

    Virajpet Taluk,

    Kodagu District.





    OPPOSITE PARTY:



    Met Life India Insurance Limited,

    ‘Brigade Sheshamahal, 5,

    Vani Vilas Road,

    Basavanagudi, Bangalore

    By its officer in-charge.



    O R D E R


    The case of the complainant briefly stated is as follows;



    1. That the complainant is an agriculturist and the opposite party is a private Life Insurance Company, believing the representation of the agent of opposite party obtained “insurance under the plan met smart plus” of an assured sum of Rs.1,50,000/- by paying initial amount of Rs.15,000/- through DD Drawn on Karnataka Bank, Madikeri.



    2. That the opposite party wrote a letter dated 3-6-2008 assuring to dispatch the policy, but the complainant has not received the policy despite repeated request and reminders including a legal notice dated 9-6-2009 and the opposite party having taken the legal notice has not responded positively which act of O.P amounts to deficiency in service.



    3. The complainant being a consumer has prayed for following relief;



    a) Direct the opposite party to deliver the policy to the complainant;

    b) Or return Rs.15,000/- which is paid by the complainant to opposite party with 18% interest per annum till payment.

    c) Direct the opposite party to pay a sum of Rs.2,000/- as a damages.

    d) Order costs of Rs.1,500/- and such other relief deemed fit.



    4. The complainant has enclosed along with the complaint the following documents;



    1. Copy of the letter dated 3-6-2008

    2. Copy of the savings Bank a/c details & transaction of complainant dated 7-5-2008.

    3. Copy of the legal notice dated 9-6-2009

    4. Receipt dated 9-6-2009

    5. Acknowledgement card dated 11-6-2009



    5. Upon admitting the complaint notice was ordered to be sent to the opposite party namely Officer in charge ‘Met Life India Insurance Ltd., Brigage Sheshamahal 5, Vanivilas Road, Basavanagudi , Bangalore.



    6. The opposite party having taken the notice has remained absent on the date fixed for his appearance, without sufficient cause and therefore he was placed exparte on 16-7-2009. Thereafter the opposite party took time to file his affidavit in lieu of examination in chief and later the same was filed re-iterating what is already stated in the complaint.



    7. As stated above the important documents to establish the case of the complainant have been placed before the Forum. The following issues arise for determination.





    1. Whether the opposite party has committed any deficiency in service on their part in not sending the policy to the complainant for which the complainant is entitled ?



    2. To what order ?









    R E A S O N S



    8. The documents submitted by the complainant unequivocally establish that the opposite party has failed to send the policy for which the complainant is entitled for. The material placed before the Forum reveal that the complainant has deposited Rs.15,000/- with the opposite party and the opposite party has also written a letter stating that the policy would be dispatched soon, but the same has not been dispatched hither to.


    The opposite party on receipt of the notice from the Forum has not appeared before the Forum and taken any kind of defence despite opportunity given to the opposite party and therefore by filing the affidavit of the complainant in lieu of examination in chief has alleged that the opposite party has committed deficiency in service in not dispatching the policy to him and no concrete reasons have been given for not sending the policy to the complainant and there is no reason what so ever to reject the case of the complainant because the complainant has placed every material to prove the allegation made against the opposite party.


    Hence we answer point no.1 positively holding that the opposite party has committed deficiency in service and therefore, the opposite party has to be directed to send the policy or alternatively pay a sum of Rs.15,000/- along with interest of 10% per annum from the date of receipt till payment and the complainant for being put to mental agony and hardship is to be suitably compensated and for complainant being driven to the Forum by incurring expenditure. The opposite party having committed deficiency in service has to reimburse the cost incurred by the complainant inpursuing his case in the Forum.



    9. With the above observation we proceed to pass the following order.



    O R D E R



    Complaint is allowed. The opposite party is hereby directed to send the policy immediately to the complainant or alternatively to pay a sum of Rs.15,000/- to the complainant and 10% interest thereon from the date of receipt of the said amount till its payment.



    The opposite party is also hereby directed to pay the damages of Rs.1,000/- for complainant being put to mental agony and hardship and further the opposite party is directed to pay the cost of Rs.1,000/- to the complainant towards the cost of this proceedings.



    The above order shall be complied within sixty days from the date of receipt of this order by the opposite party.



    Communicate the order to the parties.

  5. #5
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    Default Met Life India Insurance

    Hanush Jindal s/o Sh. Diwan Chand Jindal r/o Gulmohar Nagar, Baba Balk Nath Mandir, Gali No.10, Khanna, Ludhiana..



    …..Complainant.

    Versus



    1- Met Life India Insurance Co. Ltd., at Feroze @@@@hi Market, Ludhiana, through its General Manager/Authorized Signatory.

    2- Met Life India Insurance Co. Ltd. Head Office, Brigade Seshamahal, 5, Vanivilas Road, Basavan Gudi, Bangalore-560004 through its Manager.

    ….Opposite party.






    O R D E R









    1- Complainant in January, 2008, took life insurance policy from opposite party no.1, vide policy no.1200 8004 74212. Premium of Rs.6000/- was payable after every six months. First premium was paid by paying R.1450/- in cash and Rs.4550/- vide cheque no.3167, drawn on Axis Bank, Khanna. Opposite party encashed the cheque on 28.1.2008 and thereafter, sent policy detail on 3.2.2008. Opposite party under the policy, also deducted amount of Rs.600.15 as premium allocation charges, administration charges and cost of insurance. But after 15 days of receipt of the policy, opposite party sent letter of cancellation to the complainant, intimating that they were unable to continue the policy and refunded cash amount of Rs.1450/- through cheque dated 20.3.2008.


    They intimated that they are not in a position to consider his application for life insurance coverage, as initial deposit of Rs.4550/- has not been made available by the complainant. He claimed in this complaint under section 12 of the Consumer Protection Act, 1986, that such plea on part of the opposite party, is false. Because the cheque of Rs.4550/- was drawn and encashed by opposite party.


    So, full amount of premium was paid and thereafter, had issued policy in his favour. Hence, he never encashed refund of Rs.1450/- sent by opposite party through cheque. Thereafter, opposite party were approached repeatedly, requesting to continue his policy to which they paid no heed. Such act on part of opposite party, claimed amounting to deficiency in service and sought direction against opposite party, to continue his policy, to pay Rs.50,000/- for mental tension and agony and Rs.5500/- as litigation costs besides Rs.10,000/- as counsel fee, with 12% interest.

    2- Opposite party vide their reply, have virtually conceded claim of the complainant to be correct. Though, they have taken objection that complaint is false, malicious, filed with malafide intention and deserves to be dismissed. However, they admitted that complainant submitted application on 21.1.2008 for insurance policy and on receipt of Rs.6000/-, policy no.1200 8004 74212 was issued to complainant on 3.2.2008. But thereafter, due to technical error, opposite party inadvertently sent letter dated 20.3.2008 to the complainant, intimating rejection of his application, on account of non payment of whole insurance premium amount.


    They also issued cheque of Rs.1450/- to the complainant under their letter dated 20.3.2008. Thereafter, lapse letter on 25.9.2008 was issued, stating therein lapse of the policy, on account of non payment of payment of premium amount, due for the month of 3.8.2008. So, denied that policy of the complainant was cancelled and that the policy has not been cancelled till date. But it is kept in the lapse status. The policy can be re-instated on receipt of premium of Rs.6000/- of 3rd August, 2008. It is denied that complainant ever approached them for reinstatement of the policy and such allegations are false.

    3- Both parties in support of their versions, led evidence in the shape of affidavits and documents and stood heard through their respective counsels.

    4- In view of defence of the opposite party, it is evident that policy had been issued to the complainant by opposite party, after receipt of premium of Rs.6000/-. Premium of the policy was payable on 3rd February and 3rd August, 2008, every year. So, it means that first premium of Rs.6000/- was already paid by the complainant and then policy in his favour, was issued and policy number conveyed to him under letter Ex.C1/A dated 1.3.2008 of the opposite party. But subsequently, opposite party sent cancellation letter Ex.C3 dated 20.3.2008, intimating complainant that his application for insurance was not considered, due to non payment of premium of Rs.4550/- and refunded Rs.1450/- by way of cheque in his favour. Ex.C4 is copy of that cheque, which complainant claimed in this complaint and sworn by affidavit Ex.CW1/A, that he has no encashed the same.

    5- In these circumstances, it is apparent that harassment stood caused by opposite party to the complainant, by intimating him vide letter Ex.C3 dated 20.3.2008, not to consider his application for insurance coverage. Though, first premium of Rs.6000/- was realized by opposite party from the complainant. They wrongly may be on account of mistake, issued letter Ex.C3 to the complainant. This such error on part of opposite party, must have caused harassment, agony and sufferance to the complainant.

    6- For such deficiency in service or negligence on part of opposite party, consequently, complainant deserves to be compensated, for lapse committed by the opposite party. Hence, complaint allowed. Opposite party directed to treat policy of the complainant, in force since the date of inception, but complainant would be liable to pay premium of Rs.6000/- due thereon i.e. on 3rd August, 2008 and 3rd February, 2009. However, opposite party shall not claim any penalty by way of interest on payment of such premium if deposited by the complainant within 45 days of receipt of copy of this order by him.


    In case, complainant fails to deposit two installments as aforesaid, opposite party may treat insurance policy of the complainant, as per their rules and regulations pertaining to lapsed policy. For causing harassment to the complainant, opposite party ordered to pay compensation and litigation costs compositely assessed at Rs.5000/- to the complainant, within 45 days of receipt of copy of order. Copy of order be supplied to the parties free of costs. File be consigned to record room.

  6. #6
    Join Date
    Sep 2009
    Posts
    1,356

    Default Met Life

    Hanush Jindal s/o Sh. Diwan Chand Jindal r/o Gulmohar Nagar, Baba Balk Nath Mandir, Gali No.10, Khanna, Ludhiana..



    …..Complainant.

    Versus



    1- Met Life India Insurance Co. Ltd., at Feroze @@@@hi Market, Ludhiana, through its General Manager/Authorized Signatory.

    2- Met Life India Insurance Co. Ltd. Head Office, Brigade Seshamahal, 5, Vanivilas Road, Basavan Gudi, Bangalore-560004 through its Manager.

    ….Opposite party.








    O R D E R








    1- Complainant in January, 2008, took life insurance policy from opposite party no.1, vide policy no.1200 8004 74212. Premium of Rs.6000/- was payable after every six months. First premium was paid by paying R.1450/- in cash and Rs.4550/- vide cheque no.3167, drawn on Axis Bank, Khanna. Opposite party encashed the cheque on 28.1.2008 and thereafter, sent policy detail on 3.2.2008. Opposite party under the policy, also deducted amount of Rs.600.15 as premium allocation charges, administration charges and cost of insurance. But after 15 days of receipt of the policy, opposite party sent letter of cancellation to the complainant, intimating that they were unable to continue the policy and refunded cash amount of Rs.1450/- through cheque dated 20.3.2008. They intimated that they are not in a position to consider his application for life insurance coverage, as initial deposit of Rs.4550/- has not been made available by the complainant. He claimed in this complaint under section 12 of the Consumer Protection Act, 1986, that such plea on part of the opposite party, is false.


    Because the cheque of Rs.4550/- was drawn and encashed by opposite party. So, full amount of premium was paid and thereafter, had issued policy in his favour. Hence, he never encashed refund of Rs.1450/- sent by opposite party through cheque. Thereafter, opposite party were approached repeatedly, requesting to continue his policy to which they paid no heed. Such act on part of opposite party, claimed amounting to deficiency in service and sought direction against opposite party, to continue his policy, to pay Rs.50,000/- for mental tension and agony and Rs.5500/- as litigation costs besides Rs.10,000/- as counsel fee, with 12% interest.

    2- Opposite party vide their reply, have virtually conceded claim of the complainant to be correct. Though, they have taken objection that complaint is false, malicious, filed with malafide intention and deserves to be dismissed. However, they admitted that complainant submitted application on 21.1.2008 for insurance policy and on receipt of Rs.6000/-, policy no.1200 8004 74212 was issued to complainant on 3.2.2008. But thereafter, due to technical error, opposite party inadvertently sent letter dated 20.3.2008 to the complainant, intimating rejection of his application, on account of non payment of whole insurance premium amount.


    They also issued cheque of Rs.1450/- to the complainant under their letter dated 20.3.2008. Thereafter, lapse letter on 25.9.2008 was issued, stating therein lapse of the policy, on account of non payment of payment of premium amount, due for the month of 3.8.2008. So, denied that policy of the complainant was cancelled and that the policy has not been cancelled till date. But it is kept in the lapse status. The policy can be re-instated on receipt of premium of Rs.6000/- of 3rd August, 2008. It is denied that complainant ever approached them for reinstatement of the policy and such allegations are false.

    3- Both parties in support of their versions, led evidence in the shape of affidavits and documents and stood heard through their respective counsels.

    4- In view of defence of the opposite party, it is evident that policy had been issued to the complainant by opposite party, after receipt of premium of Rs.6000/-. Premium of the policy was payable on 3rd February and 3rd August, 2008, every year. So, it means that first premium of Rs.6000/- was already paid by the complainant and then policy in his favour, was issued and policy number conveyed to him under letter Ex.C1/A dated 1.3.2008 of the opposite party. But subsequently, opposite party sent cancellation letter Ex.C3 dated 20.3.2008, intimating complainant that his application for insurance was not considered, due to non payment of premium of Rs.4550/- and refunded Rs.1450/- by way of cheque in his favour. Ex.C4 is copy of that cheque, which complainant claimed in this complaint and sworn by affidavit Ex.CW1/A, that he has no encashed the same.

    5- In these circumstances, it is apparent that harassment stood caused by opposite party to the complainant, by intimating him vide letter Ex.C3 dated 20.3.2008, not to consider his application for insurance coverage. Though, first premium of Rs.6000/- was realized by opposite party from the complainant. They wrongly may be on account of mistake, issued letter Ex.C3 to the complainant. This such error on part of opposite party, must have caused harassment, agony and sufferance to the complainant.

    6- For such deficiency in service or negligence on part of opposite party, consequently, complainant deserves to be compensated, for lapse committed by the opposite party. Hence, complaint allowed. Opposite party directed to treat policy of the complainant, in force since the date of inception, but complainant would be liable to pay premium of Rs.6000/- due thereon i.e. on 3rd August, 2008 and 3rd February, 2009. However, opposite party shall not claim any penalty by way of interest on payment of such premium if deposited by the complainant within 45 days of receipt of copy of this order by him. In case, complainant fails to deposit two installments as aforesaid, opposite party may treat insurance policy of the complainant, as per their rules and regulations pertaining to lapsed policy.

  7. #7
    zameersiddique@gmail.com Guest

    Default Harashment of Employees by Metlife India

    On Tue, Aug 17, 2010 at 3:45 PM, zameersiddique <zameersiddique@gmail.com> wrote:

    Hi Everyone,

    Followup No : 115.

    Any updates for me....as i sent the last mail to you people on 30th of July.

    Total no of follow ups 114 ( Via mails, Phone calls etc.)
    Total no of trail mails 37 (As reflecting on my screen as well in continuation of the same)
    PF Status Claim not received by the office.(Pls find the attched screenshot)
    Incentive Status As per Metlife's record, its paid (here attached all the payment slips,settlement doc where no as such payout reflecting)
    Time duration Since last working day that is 12 june 09 (more than 13 months)
    Current Status After few initiatives of Zenia(HR), people open there eyes but dont know whom to liase.
    Revert on PF On asking for the acknowledgement of PF submission, I was produced by the blank form as attached) with the note of the contact information of PF department, Now the monkey of their shoulder is on mine.
    Best Part of Story While discussing the same with ex-collegues got suggestion that not to ask about incentive part as even several number of existing employees havn't received any....So question arises where the hell incentives
    of the poor employees has gone.
    My Intiative for Integrity : Even i tried to explain the values(Pls follw the trail mail where 1's explain & emphasised on same) Metlife's as brand to its own brand representatives , but useless.


    On Sat, Jul 31, 2010 at 2:31 PM, <srane@metlife.com> wrote:

    Hard work spotlights the character of people: some turn up their sleeves, some turn up their noses, and some don't turn up at all.

    Hi Everyone,

    I Trust all of you are doing well.

    Well i would like to remind all of you respective peoples that my last years accelarated issues are still open and no one is ready to take the responsibility. So this time i would like take an another effort from my end, By keeping some more people, PF officials into the loop.

    REQUEST : I would really appreciate if you mark m CC too while forwarding the same to the concern departments.

    1.Incentives amount of Rs: 5,069,Payout for JFM ’09.
    Calculation of Incentive are as below:

    Interim Incentive Statement for JFM’ 09

    Emp Code : 1047308

    Productivity Incentive - Quarterly:
    Target : 801,504
    Met Growth (New Business) : 82,500
    Weighted Premium : 239,500

    % of GS Achievement : 30%
    Incentive Rate : 0.00%

    Met Growth Incentive (A) : 1,444
    Other Product Incentive (B) : -
    Incentive Payout (C=A+B) : 1,444
    Licensing Incentive – Monthly (Mar’ 09) :
    No. of Licensed : 2

    Incentive Payout (D) : 1,500

    Activation & No. of Cases Incentive – Monthly (Mar’ 09):
    FTM Active : 3

    Incentive Payout (E) : 3,000

    Quarter Incentive :
    Incentive Payout (F=C+D+E) : 5,944

    Mothly Productivity Incentive – Jan’ 09 & Feb’ 09 :
    Jan’ 09 : -
    Feb’ 09 : 875
    Total (G) : 875

    Plz find my details are as follows:-

    Name : Zameer H.Siddique
    Employees : 1047308
    Channel : Tide Agency
    Location : Millennium Plaza Pune
    Immediate Manager : Mr.Nitin Baviskar
    Area Manager : Mr.Sanjay Bhogade
    Date of Joining : 30/10/2008
    Date of Resignation : 12/05/2009
    Last working Day : 12/06/2009
    Notice Period : 30 Days
    Date: Mon, Oct 26, 2009 at 5:43 PM
    Subject: Re: Request for the Settlement
    To: nbaviskar@metlife.com


    Gentle Reminder - 3,

    Its a humble request,Pls do the needful & mark me CC too.

    On Tue, Sep 29, 2009 at 12:52 PM, zameer siddiqui <zameersiddique@gmail.com> wrote:


    Gentle Reminder,
    Pls do the needful as another month is about to end.
    Dear Sir,

    As discussed earlier i am forwarding you the details of pending doc's & unsettled fund.
    Pls forward my query to the concern person or departments.

    --
    Regard's
    Zameer H Siddique
    Director | Marketing
    International Pay Solutions LLP
    Pune - 411045
    Mail:zameersiddique@gmail.com
    Yesterday I Dared to Dream,
    Today I Dare to Win...

  8. #8
    Unregistered Guest

    Default MD

    Met life with the help Axis Bank folks who get commission sells products that are cumsumer unfriendly. The product I brought was mislead by axis staff .I have a policy that I pay several lacks x in 6 yearly(annual premium) with poor and unfaire option to surrender , if we cannot pay and I am at default and loose entire money .there is no options to surrender in first 3 years.
    The bigest fraud come that the guarranteed return is not in lumsump , but paid after the term ie 7 years, and in instalment on monthly basis that is less than equal to the total premium you paid .
    Any one who has dealt with AXIS bank and metlife to come forward for a fight .
    Other should not pay attantion to AXis emplyee or agents and Metlife to sell any product until seen your friend and get qutation / review of fine print.
    People who bought such policy to pl come forward and fight this unjust.

  9. #9
    Join Date
    Sep 2010
    Posts
    3

    Default

    Hi, Full story of Hitachi AC'S: Call no. 1508180905 & 15081802923 2nos AC Split Zunih 200i (1.5 & 1.2 ton) Payment given thru ICICI net banking to hitachi Dealer (Electromart Vaisahali) after discussed with Mr Dinesh Grover : 15.04.2015 Recvd AC after 6days from dealer on: 21.04.2015 but bill date is 20.04.2015. Installation team came and installed the AC but at that time after discussion with Dinesh Grover, zero amount pay to service team and service team has closed the call in system. 1.5ton split AC was stopped after 1week, call logged in system on 01.05.2015. I have recvd call from Puneet CSO Hitachi on 05.05.2015 on the update on my logged call. Every days (from 06.05.2015 to 26.05.2015) I called to service team, dinesh grover, sms to them but no one give update from Sevice side, sales side & Mr TPS rawat too was not solve the ac problem and not replace the AC. I spoken to customer service Thomas & Anshul for this delay but they are helpless. i got a call on 15.05.2015 from Htachi Ahemdabad they told me replacement under process and same will replace within 2days but ac replace after 25.05.2015. After 25days, my AC will replace but my family was suffered due to this bad service and not used the AC in these 25days. Again last week, drain pipe fitting ok, water came from pipe but water came from indoor unit sensor unit. But as per Service team , no issue in this, sometime happened in hitachi AC and this ac is new and no training given to Engg for this new model. ((((got mail from hitachi service head: Wed, Jul 1, 2015 at 3:30 PM, wrote: Dear Mr. Gagan Gupta, I acknowledge the receipt of your e-mail. As per your earlier telephonic discussion with our Area Service Manager regarding refund. Sir, we would like to inform you that your refund of the machine has been approved and it is in process for refund. I am marking this mail to Mr. Kuldeep Kumar, who is the Branch Service Incharge for us in this region. He will take further action. If you need any further assistance, please do call us on our Helpline Number 35324848 (prefix your STD code) or send an email to us. With Best regards, Head Service Hitachi Home & Life Solutions (India) Ltd. )))) From July01st to till date no one from Hitachi will give the update/status, customer service Anshul on hitachi chat room,they r not authorise to answer my refund query, give number of CRO hitachi 9711620936/938 no one pick my calls. I have ready the Print out of every discussion with hitachi, video of water dripping, video of replaced ac damage part. Pls help... Rgds Gagan Gupta 9899486669

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