BRANCH MANAGER, LIFE INSURANCE CORPORATION OF INDIA v. RAMESHWAR SINGH NEGI
2008-12-02
C.C.PANT, IRSHAD HUSSAIN
body2008
DigiLaw.ai
ORDER (Per : Justice Irshad Hussain, President) : By order dated 04.05.1998 passed by the District Forum, Pauri Garhwal in consumer complaint No. 278 of 1995, appellant – Life Insurance Corporation of India, was directed to pay sum of Rs. 70,000/- to the complainant by way of double accident benefit of his insurance policy for sum of Rs. 35,000/- commencing from 27.09.1990 together with interest @ 18% p.a.; Rs. 500/- as litigation expenses and Rs. 2,000/- as damages, by observing that the complainant became disabled due to fracture of backbone, resulting from accidental slip on hill track, while the complainant was on his official duty as Forest Animals Guard on 27.04.1993. The District Forum has rejected the defence plea that the claim had been validly repudiated on account of the fact that the disability of the complainant was reported to be only 75%, whereas under the terms of the contract of insurance, the disability for getting double accident benefit, must be total and permanent and other pleas that the insurance policy was lying lapsed since 27.09.1993 and further that the information about the accident and alleged disability, was given as late as on 26.11.1993, despite the accident having taken place on 27.04.1993. The complainant still continues to be in the service of the Forest Department and is getting his salary/wages as usual. Regarding this, the District Forum observed that in case, the employer is not so heartless, as to deprive payment of salary/wages even on compassionate ground, the same would not be taken to suggest that despite the disability, the complainant has been able to earn his salary/wages and on that account, was not entitled to double accident benefit under the terms of the contract of insurance. Aggrieved by the order, appellant filed this appeal. 2. We have heard the learned counsel for the parties and have considered their submissions in the light of the facts, circumstances and legal aspects of the case. The main plea raised by the learned counsel for the appellant is that the accident benefit is available to the insured only if he is involved in an accident, resulting in total and permanent disability, as defined in Clause 10 of the policy. In this case, insured had suffered 75% disability and, as such, accident benefit was not available to the insured and the claim has been rightly repudiated.
In this case, insured had suffered 75% disability and, as such, accident benefit was not available to the insured and the claim has been rightly repudiated. According to the learned counsel, the District Forum fell in error in holding otherwise by making the aforesaid observations, which run counter to the terms and conditions of the policy of insurance. On the other hand, learned counsel for the complainant supported the order of the District Forum and urged that though the percentage of disability has been assessed to be 75% only per certificate of the doctor of the PGI, Chandigarh, the complainant became disabled totally and permanently on account of breaking of backbone in the accident and on account of paralytic condition, forcing him to take assistance of a helper in his day-to-day ordinary and usual way of life. 3. Having considered the respective submissions, we may state at the outset that the submissions of the learned counsel for the appellant have force and the appeal is fit to be allowed and the order of the District Forum is liable to be set aside, so as to dismiss the consumer complaint filed by the complainant. 4. Clause 10 of the policy of insurance in question read as under: “10. Accident Benefit : If at any time when this Policy is in force for the full Sum Assured, the Life Assured, before the expiry of the period for which the premium is payable or before the Policy anniversary on which the age nearer birthday of the Life Assured is 70 whichever is earlier, is involved in an accident resulting in either permanent disability as hereinafter defined or death and the same is proved to the satisfaction of the Corporation, the Corporation agrees in the case of : (a) Disability to the Life Assured : (i) to pay in monthly instalments spread over 10 years an additional sum equal to the Sum Assured under this Policy. If the Policy becomes a claim before the expiry of the said period of 10 years, the disability benefit instalments which have not fallen due will be paid alongwith the claim (ii) to waive the payment of future premiums. The maximum aggregate limit of assurance under all Policies on the same life to which benefits (i) and (ii) above apply shall not in any event exceed Rs. 5,00,000/-.
The maximum aggregate limit of assurance under all Policies on the same life to which benefits (i) and (ii) above apply shall not in any event exceed Rs. 5,00,000/-. If there be more Policies than one and if the total assurance exceeds Rs. 5,00,000/- the benefits shall apply to the first Rs. 5,00,000/- assured in order of date of the Policies issued. The waiver of premiums shall extinguish all options under this Policy except as to such assurance, if any, as exceeds maximum aggregate limit of Rs. 5,00,000/- and which may have been kept in force by continued payment of the premiums and the benefits covered by (b) of this clause. The disability above referred to must be a disability which is the result of an accident and must be total and permanent and such that there is neither then nor at any time thereafter any work, occupation or profession that the Life Assured can ever sufficiently do or follow to earn or obtain any wages. Compensation or profit. Accidental injuries which independently of all other causes and within 120 days from the 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 wrists, or in the amputation of both feet at or above the ankles, or in the amputation of one hand at or above the writ and one foot at or above the ankles, shall also be deemed to constitute such disability...........” 5. From above, it would, thus, appear that unless and until, the disability is 100%, the double accident benefit to the insured, can not be made available by the insurer. Certificate of disability (Paper Nos. 24 to 25) on record, admittedly certify that the insured’s disability was assessed to be 75% only and it was further mentioned that it was uncertain as to how much time will be required for the complainant to recover fully from the disability. Certificate nowhere indicate that the disability of the insured was certified to be total and permanent. The complainant was brought before the Commission in wheel chair, though appear to be a disabled person, but does not fall in the category of “100% disability”, as defined in the contract of insurance, as reproduced above.
Certificate nowhere indicate that the disability of the insured was certified to be total and permanent. The complainant was brought before the Commission in wheel chair, though appear to be a disabled person, but does not fall in the category of “100% disability”, as defined in the contract of insurance, as reproduced above. Under these circumstances, the insurer was justified in repudiating the claim on the ground that the insured had not suffered total and permanent disability, as envisaged by the condition of the policy of insurance. 6. We may advantageously refer to a latest decision of the Hon’ble National Commission in the matter of Life Insurance Corporation of India Vs. Prakash Chandra; III (2008) CPJ 208 (NC) and wherein, under similar facts and circumstances, the insured has not been held entitled to accident benefit of the policy of insurance and the repudiation of the claim was held to be justified. In the case before the Hon’ble National Commission, the insured was certified disability to the extent of 58% and under similar condition of the contract of insurance, it was held that the insured does not fall in the definition of “100% disability”, mentioned in the contract, i.e., the policy condition. It is also of significance that in the said case, the insured was brought before the Hon’ble National Commission in the wheel chair and despite that due to the percentage of disability, he was not found to be totally and permanently disabled and the accident benefit of the policy was denied. The earlier decision of the Hon’ble National Commission in the case of Ajay Kumar Vs. Life Insurance Corporation of India; I (2007) CPJ 230 (NC), pressed into service by the learned counsel for the appellant, had been followed in the decision given in the case of Prakash Chandra (supra). On behalf of the appellant, an earlier decision of the Hon’ble National Commission rendered by a Bench of President four other Members, in the case of L.I.C. of India Vs. Ramesh Chandra; 1997 (2) CPR 8 (NC), was referred, wherein similar principle had been laid down and on account of the assured not being totally and permanently disabled, as defined in Clause 10 of the contract of insurance, the accident benefit to the assured was denied. 7.
Ramesh Chandra; 1997 (2) CPR 8 (NC), was referred, wherein similar principle had been laid down and on account of the assured not being totally and permanently disabled, as defined in Clause 10 of the contract of insurance, the accident benefit to the assured was denied. 7. Having regard to the above facts and discussion, we are forced to hold that the appellant made no deficiency in service in repudiating the claim and the District Forum fell in error in allowing the complaint and awarding the accident benefit under the policy of insurance to the complainant. 8. Appeal is allowed. Order dated 04.05.1998 of the District Forum is set aside and consumer complaint No. 278/1995 is dismissed. No order as to cost.