Life Insurance Corporation of India vs KAMLA DEVI

THIS appeal is directed against the order dated 7.3.2001 passed by the District Consumer Disputes Redressal Forum, Rewari whereby the complaint filed by the respondent-complainant against the appellant-opposite parties was accepted.

IN order to focus the controversy involved in the present appeal essential facts need to be noticed briefly. Tek Chand husband of Kamla Devi had taken two polices, Nos. 111617729 and 33023508, with double accident benefit for Rs. 50,000 and Rs. 25,000 on 28.2.1993 and 28.2.1996 respectively from the opposite parties. Said Tek Chand met with an accident on 14.9.1997. At the time of accident he was employed with State Bank of INdia and was posted at Rewari Branch. On that day at about 8.30 p.m. a Tata Sumo vehicle dashed against scooter bearing registration No. HR-36A-2120 driven by Tek Chand. He fell down from the scooter and suffered grievous as well as simple injuries. A report bearing FIR No. 705 dated 15.9.1997 was lodged with the Police Station, Rewari. He was admitted in the Civil Hospital, Rewari from where he was referred to Safdarjung Hospital, New Delhi on 16.9.1997. He was shifted to Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi in the state of coma for further treatment. He was treated there with the diagnosis of severe head injury, temporal contusion and haemotoma, etc. He remained under treatment in the said hospital from 16.9.1997 to 21.4.1998 continuously for a period of seven months as indoor patient as per medical certificate dated 7.1.1999 issued by the Hospital Authorities in which it is stated that "he is unconscious and is likely to remain so far many years and he will not be able to join his duties for ever. His thumb impression may be accepted as his identity." Another medical certificate of Quadriplera paralysis of all the four limbs, with 100% disability/handicap was also issued by the hospital authorities on 15.12.1998. On 6.5.1999 the condition of Tek Chand was deteriorated and for that reason he was again taken to ''Sir Ganga Ram Hospital, New Delhi'' and his diagnosis were still the same as was about 1 years ago. He was in state of coma, but since no bed was available in ICU ward of the said hospital, Tek Chand was referred to ''Ram Manohar Lohia Hospital, New Delhi'' where he died on 7.5.1999. The complainant being nominee of both the policies submitted her claim with the opposite parties for the sum assured. The opposite parties repudiated the claim in respect of policy No. 330235088 for Rs. 25,000 while in respect of claim under policy No. 111617729 for Rs. 50,000 the opposite parties made only single payment. Under both the policies double accident benefit was denied to her. She claimed that at the time of accident the policy No. 330235088 was enforced upto 27.9.1998 and premium due thereafter was paid on 25.7.1998 and on the other policy No. 111617729 the premium due on 22.2.1999 was also paid. Therefore, at the time of death both the policies were in force. Aggrieved by the non-payment of the claim made as stated above, the complainant invoked the jurisdiction of the District Forum wherein she made the following claims: "(a) The respondents may kindly be directed to pay the claim of Rs. 50,000 under policy No. 11617729, as of double accident benefits and under Policy No. 330235088, as a basic sum assured Rs. 25,000 plus Rs. 25,000 as of double accident benefits with accrued bonus and interest thereon and with costs of the complaint. (b) It is further prayed that the respondents may kindly be directed to pay interest on the delayed claim amount at the rate of 24 per cent per annum from the date of due date i.e., from the date of death i.e., 7.5.1999 till the realisation of the amount. (c) It is further prayed that a sum of Rs. 25,000 may kindly be awarded in lieu of financial loss and mental agony suffered and other expenses spent thereupon. (d) Any other relief, which this Hon''ble Forum may deem just and proper, may kindly be awarded."

The complaint was contested by the opposite parties. IN the written statement filed they averred that the policy No. 330235088 commenced from 28.3.1996 and not from 28.2.1996. The premium under this policy was payable quarterly which was due on 28.9.1998 but was not paid and for that reason the policy lapsed due to non-payment of further premium and for that reason it was lying in lapse condition on the date of death of the assured and under the terms and conditions of the policy nothing was payable on the death of the life assured. It was further averred that it had taken lenient view of the death cases and as per policy, if the premiums are paid for two years and death occurs after six months but within one year from the unpaid premium due, notional paid-up value is paid as on ex gratia basis. Accordingly, it was prayed that in this case as the premium had remained unpaid on 28.9.1998 under the aforesaid policy, a sum of Rs. 4,375 was sent to the complainant as ex gratia payment. At the same time they denied its liability to pay further amount to the complainant and double benefit under this policy as per terms and conditions of this policy. IN respect of policy No. 111617729 it was averred that death had occurred after the expiry of 120 day from the date of accident. So to say, 590 days after the policy was issued, they are liable to pay the benefit to the complainant as per terms and conditions of the policy. It was further stated that premium under this policy was due on 28.9.1999 which was not paid. But still the sum assured was paid to the complainant as it attracted claim concession clause. But at the same time the complainant was not entitled to get double accident benefit under the terms and conditions of the policy. Accordingly, it was prayed that the complaint merited dismissal. On appraisal of the pleadings of the parties and evidence adduced on record, the District Forum concluded as under: "IN Forum''s opinion respondents were deficient in service in repudiating the claim on the basis of non-payment of premium on 28.9.1998. IN Forum''s opinion death beyond 120 days is not applicable to injury of brain. As per condition No. 10(2)(b) it is the injury on body which prescribed the limit of 120 days and not head injury. Forum holds that respondents have illegally repudiated the claim under this policy and directs them to honour the same in terms of policy. As regards policy No. 111617729 for Rs. 50,000 which was in subsistence up to 21.2.2000 respondents have only honoured the policy for Rs. 50,000 and have not given double benefit of the amount of policy as per terms and conditions of policy. Whereas basic sum assured stands paid under this policy, double benefit was denied to complainant without any reason. Forum directs respondents to honour this policy in terms and conditions of policy as well and complainant is entitled to double benefit under this policy. Complainant is also awarded interest at the rate of 9% p.a. on the sums given as per order from 30.10.1999 till realisation. INterest is to be counted as compensation."

Aggrieved by the above said order, the present appeal has been filed by the opposite parties. Learned Counsel representing the appellant has been heard at length. None has chosen to appear to argue the matter on behalf of the respondents.

Learned Counsel representing the appellant while assailing the order dated 7.3.2001 of the District Forum has supported the stand taken by the opposite parties in the written statement which according to him is in accordance with the terms and conditions of both the policies and the District Forum had acted illegally and unauthorisedly ignoring the terms of the policies. He has vehemently urged before us that both the policies were lying in lapsed condition as noticed above and the District Forum did not take into consideration that ex gratia payment of Rs. 4,375 was made in respect of policy No. 330235088 and Rs. 50,000 has been paid in respect of policy No. 111617729 to the complainant. In support of the stand taken he has referred to the observations made in case LIC of India v. Ramesh Chandra, II (1997) CPJ 45 (NC)=1997 (2) CON.LT 474, which reads as under: "The question is whether the amputation of right hand suffered by the complainant is a specified event and constitute disability entitled to an accident benefit under Clause 10(a) of the policy bond. The accident benefit is available to the assured only if he is involved in an accident resulting in total and permanent disability as defined in Clause 10. The disability referred in the said clause must be disability which is the result of accident and must be total and permanent. The accident injuries which independently of all other causes and within 120 days from happening of such accident result in the irrecoverable loss of the entire sight of both eyes or in the amputation of both hands at or above the wrist or in the amputation of feet at or above ankles, or in the amputation of one hand at or above the wrist and one foot at or above the wrist only constitute such disability. The case of the complainant is not of the amputation of feet at or above ankles. The case of the complainant is the amputation of one hand at or above the wrist but that is not independently deemed to be a disability as is covered since the coverage in the clause is only in cases of amputation of one hand at or above the wrist and one foot at or above ankle. It bears repetition that the deeming clause constituting the disability will get attracted only if there was the amputation of one hand at or above the wrist and one foot at or above the ankle. If it is the amputation of one hand at or above wrist or the amputation of one foot at or above the ankle, then it does not by the fiction of the Clause 10(a) constitute disability. The construction of the policy bond which is the basis of the contract of insurance, is a question of law and its true and correct interpretation would give jurisdiction to the Fora to pronounce upon the deficiency in service, if any. The District Forum as well as the State Commission had no jurisdiction to go beyond the terms and conditions of the policy bond and could only order the payment of the disability benefit if it was specified event covered under Clause 10 of the conditions of policy. The amputation of only one hand does not fall within the deeming definition constituting disability in terms of Clause 10(a) of the policy bond and thus the impugned orders suffer from serious illegalities."

In order to decide the controversy raised notice has to be taken of Clause 10 of the Insurance policy which has been issued to the assured. It deals with accident benefit. Clause 10(b) states that the opposite party shall be liable to pay an additional sum equal to the sum assured under a policy if the life assured shall sustain any bodily injury directly from the accident caused by outward, violent and visible means within a period of 120 days of its occurrence solely, directly and independently causes result in death of the life assured. However, such additional benefit in respect of the policy together with such additional sum payable under the policy of the life assured shall not exceed five lacs. In this case undisputedly, the accident had taken place on 14.9.1997 in which Tek Chand suffered grievous and multiple injuries on his body and ultimately died on 7.5.1999. So to say, more than 120 days after the death of accident in which he had suffered severe head injury, temporal contusion and haemotoma, etc. He was admitted at Civil Hospital, Rewari from where he was referred to the Safdarjung Hospital, New Delhi and on 16.9.1997, he was taken to Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi in the state of coma. It is also stated in its report dated 7.1.1999 that the patient was unconscious and was likely to remain so for many years and he would not be able to join his duties forever. Another medical certificate of Quadriplera paralysis of all the four limbs, with 100% disability/handicap issued on 15.12.1998 has been placed on record. The District Forum observed that the clause of 120 days is not applicable to the injury of brain. It is not explainable as to how such an interpretation has been made when Clause 10(b) of the policy speaks of bodily injury not with regard to any particular portion of the body as sought to be concluded by the District Forum. The District Forum has not kept in view the well settled principle that the Court or Tribunal cannot rewrite the contract of insurance and direct the insurer to act in violation of the terms of the policy. Therefore, the conclusion drawn by the District Forum, as such, has no sanction of medical authorities or under the law. In this case one cannot ignore that policy 330235088 had lapsed on account of non-payment of premium due on 28.9.1998. Thus, the opposite parties were fully justified in paying the ex gratia amount of Rs. 4,375 under this policy. As regards to policy No. 111617729, the complainant has already received Rs. 50,000 in terms of condition of the policy referred to above and the double benefit is not available to the claim under both the policies. The District Forum has gone wrong in granting the relief beyond the terms and conditions of the policy issued to the assured. Under the circumstances of the case, the findings of the District Forum, as such, cannot be sustained and are set aside.

FOR the aforesaid reasons, while accepting the appeal the impugned order is set aside and the complaint is dismissed. Appeal allowed