Ombudsman: Shri Sudhir Krishna Case of Paul Durai J ...

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Paul Durai J IsaacversusICICI Prudential Life Insurance Company Ltd.

Complaint Ref. No.: DEL-L-021-2122-0034

1. Name & Address of the Complainant ShriPaul Durai J Isaac,

In policy- 9A, Pheleps Building, CP Delhi-110001

Presently-175, Taman Hijau 1, Jalan Kg Koh, Sitiawan,

32, 000 Perak, Malaysia

2. Policy No.

Type of Policy

Policy term/Premium Paying Term

19024406

Conventional

10/5 years

3. Name of the Insured

Name of the policy holder

Paul Durai J Isaac

Paul Durai J Isaac

4. Name of insurer ICICI Prudential Life Insurance Company Ltd.

5. Date of Repudiation/Rejection 24.06.2020; 03.07.2020

6. Reason for Grievance Missale

7. Date of receipt of the Complaint 15.03.2021

8. Nature of Complaint Delayed payment of foreclosure amount

9. Amount of Claim Rs. 7 lakh

10. Date of Partial Settlement N.A.

11. Amount of Partial Settlement N.A.

12. Amount of relief sought Rs.7 Lakh

13. Complaint registered under Rule no. of

the Insurance Ombudsman Rules, 2017

13(1) (f) –Policy Servicing related grievances

14. Date of hearing/ Place of hearing 21.04.2021/Refixed 18.05.2021/ Delhi, online, via WebEx

15. Representation at the hearing

a) For the Complainant Shri Paul Durai J Isaac, the Complainant

b) For the Insurer 1. Smt. Milan Panchal, Sr. Manager, Customer Service & Op.

2. Smt. Nitu Singh, Manager Customer Service & Relations

16. Date of Award/Order Award under Rule 17/ 18.05.2021

17. Brief Facts of the Case: ShriPaul Durai J Isaac(hereinafter referred to as the Complainant) has

filed this complaint against the ICICI Prudential Life Insurance Co. Ltd. (hereinafter referred

to as the Insurers) alleging delayed payment under the subject policy nos.19024406.

18. Cause of Complaint:

a) Complainant’s Argument:He took the subject policyunder MWP Act w.e.f. 17/12/2014, while

he was in India. Thereafter he shifted back to his native place, Malysia. As he did not pay full

premiums, his policy was discontinued and was due for foreclosure after 5 years. In April, 2019,

he completed formalities for taking foreclosure amount of the same, payable in December, 2019.

Since he was not residing at his Indian Address, he wanted the amount at Malysia. The Insurers

sent his amount of Rs. 4,82,052.94 vide Cheque sent at his India’s Address on 22-12-2019.After

his follow up he was asked to complete certain more requirements in January, 2020. Then he

visited India and followed up the matter on 28-1-2020. He was informed that the payment could

be made in his NRE and NRO Account only. He submitted cancelled cheque etc. of his relevant

account. After follow up with top executives of the insurers on 22-04-2020, he got payment on

26-05-2020 in his NRO Account. The insurers also offered him an interest of 2.75% at bankrates

amounting to Rs. 5,738.91, to which he refused as he wants compensation for his flights

expenses, hotel stay and other difficulties faced by him, apart from the delay and harassment.

b)Insurer's Argument: The Insurers have submitted vide their SCN dated 20.04.2021 thatthe

Policy was issued under MWP Act and benefits were payable to his wife. The premiums were

paid for 2 years and 2 months only. As such the policy got discontinued and the premiums were

transferred to discontinuance fund, which was payable after foreclosure w.e.f. 17-12-2019. He

was informed about the same 60 days in advance on 05-10-2019 and 15 days in advance on 02-

12-2019.In absence of requisite account details, the payment was sent through cheque on 17-12-

2019 and was reversed on 12-03-2020. The Complainant had approached the Insurers in

December 2019 and January 2020. Thereafter he approached their GRO in April 2020. His other

policy number 18760778 was foreclosed on 24-07-2019 and the amount was paid in his NRE

Account on 29-08-2019. As the subject policy was under MWP Act, the amount was payable to

his wife only. However in May 2020, he requested for removal of MWP Act and then his

foreclosure amount was paid to him in May 2020.The insurers have now evaluated the case and

are agreed to settle the case by paying Penal Interest @ 6.65% amounting to Rs. 43,210.43, for

delay calculated w.e.f. 17-12-2019, till 20-4-2021.

19. Reason for registration of Complaint: Same as 18(a) above.

20. The following documents were placed for perusal:

a) Copy of policy.

b) Copy of Correspondence between the Complainant and the Insurance Company.

c) Self Contained Note by the Insurance Company

21. Result of hearing with the parties (Observations and Conclusion):

Case called. Parties are present and recall their arguments as noted in Para 18 above.

The foreclosure amount of Rs. 4,82,052.93 was due on 17.12.2019 but the Insurers paidit into

the Complainant’s account on 22.05.2020. This would lead to the liability of payment of interest

by the Insurers for this period as per the provisions of the IRDAI (PPHI) Regulations 2017.

Accordingly, the interest is payable at 6.65%, which is 2% above the bank rate,for the period

from 17.12.2019 till 22.05.2020, which as per the Insurers works out to Rs. 13,876.52. As

Insurers did not pay the interest amount so far, they offer to pay interest on this interest amount

@6.65% till the interest is actually paid.

Insofar as the Complainant’s claim for reimbursement of his travel expenses from Malaysia to

India and other claims for compensation for the mental agony are concerned, it is clarified that

this forum has no jurisdiction to adjudicate on such items.

The complaint would deserve to be allowed partially as stated above.

Award

The complaint is allowed partially, as follows:

a. The Insurers are directed to pay interest on the foreclosure amount of Rs. 4,82,052.93 for

the period from 17.12.2019 till 22.05.2020 along with interest on that interest amount till

the date the interest is actually paid.

b. The interest amount mentioned above shall be computed at the bank rate plus two per cent,

as provided in the IRDAI (PPHI) Regulations 2017.

c. This interest amount should be paid by the Insurers into the bank account of the

Complainant by way of ECS.

d. The Insurers should provide details of computation of the interest amount paid, to the

Complainant.

e. The Insurers should comply with (a) to (d) above within 30 days of the receipt of this

award.

f. The complaint seeking reimbursement of the Complainant’s travel expenses from Malaysia

to India and other claims for compensation towards themental agony are rejected, being

outside the domain of this forum.

(Sudhir Krishna)

Insurance Ombudsman, Delhi

May 18, 2021

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 13 r/w 16 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Deepti Agarwalversus Life Insurance Corporation of India

Complaint Ref. No.: DEL-L-029-2022-0069

1. Name & Address of the Complainant Smt. Deepti Agarwal,

9A/69 W.E.A, Karol Bagh, New Delhi - 110005

2. Policy No.

Type of Policy

Policy Term/Premium Paying Term

330002294

Life Insurance

25 years/25 years


Name of the Policy Holder

Smt. Deepti Agarwal

Smt. Deepti Agarwal

4. Name of Insurer Life Insurance Corporation of India

5. Date of Rejection No satisfactory reply received

6. Reason for Grievance Non-receipt of maturity claim


8. Nature of Complaint Policy Servicing related

9. Amount of Claim Rs. 10000/- + bonus if any

10. Date of Partial Settlement N.A.

11. Amount of Partial Settlement N.A.

12. Amount of relief sought Rs. 10000/- + bonus if any + penal interest

13. Complaint registered under Rule no. of

the Insurance Ombudsman Rules,2017

13(f)-policy servicing related grievance against insurers and

their agents and intermediaries

14. Date of hearing 21.05.2021

Place of hearing Online Video Conferencing via Cisco WebEx App


For the Complainant 1. Smt. Deepti Agarwal, the Complainant

2. Shri Gianendra Kumar Agarwal, H/o the Complainant

For the Insurer Smt. Kala Sivaramakrishnan, Manager, CRM, Delhi DO-1

16. Date of Award/Order Recommendation under Rule 16/ 21.05.2021

17. Brief Facts of the Case:

Smt.Deepti Agarwal (hereinafter referred to as the Complainant) has filed this complaint against

the decision of the Life Insurance Corporation of India (hereinafter referred to as the Insurers or the

Respondent Insurance Company) alleging non- payment of maturity claim under the subject policy

number 330002294.

18. Cause of Complaint:

a) Complainant's Argument: The subject policy matured on 28.06.2020. The Complainant at the

time of maturity was in U.S.A, so as per LIC’s Claims Relaxation Ordersubmitted claim documents

via email on 03.07.2020, but the Insurer instead of processing maturity claim kept asking for

requirements such as NEFT etc. and violated its own guidelines. Further, she even agreed for

collection of documents by Insurer from her daughter’s residence in Gurugram but after

confirmation of authenticity of the personnel collecting the documents. However, the Insurer is

neither implementing its own guidelines nor providing credential of person deputed for collection

of documents. Moreover, she is unable to travel to India due to Covid-19 pandemic and has had

requested Insurer on several occasion through several levels for processing of maturity

claim but her request remains unheard. Hence, she has approach this forum for relief.

b) Insurer’s Argument:The Insurers vide SCN dated 19.05.2021have submitted that the Claim

Relaxation Order dated 03.07.2020 is applicable only on those policies, which are issued by

servicing branch. However, in the instant case, policy issuing office and servicing branch office are

different. Hence, claims relaxation order is not applicable. Also, their Branch Office had even

offered to collect documents from complainant’s daughter but this arrangement did not work out as

she insisted on LIC stamp acknowledgment which could not be given as LIC stamp cannot be taken

out of Office. Further, now as per LIC’s latest relaxation for facilitating claims settlement, they

have sent a mail to the complainant on 11.05.2021, suggesting submission of maturity claim

requirement at their Gurugram Branch in Sector– 44. They have also assured immediate settlement

of maturity claim on receipt of the claim documents.

19. Reason for registration of Complaint: Policy servicing related grievance.

20. The following documents were placed for perusal:

a) Copy of complaint and Correspondence between Insurer and complainant.

b) Self Contained Note of the Insurers.

c) Policy document& Claim relaxation order.

21. Result of hearing with the parties (Observations and Conclusion):

Case called. Parties are present and recall their arguments as noted in Para 18 above.

At this stage, the Insurers offer to make the maturity payment along with interest at Bank Rate plus

2 per cent from the date the policy had matured and till the date the Insurers make the payment,

subject to the Complainant delivering the policy bond in original at the nearest branch of the Insurers

through personal visit or by courier. The Complainant agrees to do so within one week. Thus an

agreement of conciliation could be arrived at between the Complainant and the Insurers, which I

consider as fair and reasonable for both the parties.

Award

The complaint is resolved in terms of the agreement of conciliation arrived at between the

Complainant and the Insurers. Accordingly, the Complainant shall deliver the policy bond in

original at the nearest branch of the Insurers through personal visit or by courier and the Insurers

shall thereafter make the maturity payment along with interest at Bank Rate plus 2 per cent from

the date the policy had matured and till the date the Insurers make the payment.

Parties should implement this agreement within 30 days.

(Sudhir Krishna)

Insurance Ombudsman, Delhi

May 21, 2021

AWARD NO. IO/KOC/A/LI/0005/2021-2022

PROCEEDINGS OF

THE INSURANCE OMBUDSMAN, KOCHI

(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF

THE INSURANCE OMBUDSMAN RULES, 2017)

Complaint No. KOC-L-006-2021-0426

PRESENT: Ms. POONAM BODRA

INSURANCE OMBUDSMAN, KOCHI.

AWARD PASSED ON 17.05.2021

1. Name and Address of the complainant

: Ms. Anju P

Anjali, Edavanassery, Mynagappally P O, Kollam, Kerala - 690519

2. Policy Number

: 194700180


: Ms. Anju P

4. Name of the Insurer

: Bajaj Allianz Life Insurance Co. Ltd.

5. Date of receipt of Complaint

: 22.02.2021

6. Nature of complaint

: Shortfall in surrender amount

7. Amount of relief sought

: --

8. Date of hearing

: 20.04.2021

9. Parties present at the hearing

a) For the Complainant : Ms. Anju P (Online)

b) For the Insurer : Mr. Nikhil (Online)

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is regarding shortfall in surrender amount. The complainant, Ms. Anju P is the policyholder.

1. Averments in the complaint are as follows:

The Complainant stated that she had deposited 3 premiums @12291/- under the Policy No.0194700180.. The agent told to remit 3 premiums and close the policy after the policy term and will get surrender amount and bonus. Hence the complainant requested for the surrender of the policy in 2020 and the amount quoted was Rs.19100/-. The complainant was shocked and raised the issue with Grievance redressal cell but the reply was not satisfactory.

The Complainant’s brother took similar policy and invested 75000/- and after 3 years on closing, got Rs.78000/- and faced similar issues. The is about the servicing of the respondent company.

The complainant’s multiple concerns are as mentioned below.

No proper communication with the customers.

Grievance redressal cell is not effective

No consideration for the customer during the pandemic.

Surrender value very less unlike it was promised.

The complainant requests the Forum to intervene and resolve the concerns raised in the complaint.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the Complainant has not placed the true and correct facts in the matter before this Hon’ble Form. The complainant has suppressed certain material facts in the matter while at the same time skewing the facts in order to claim monetary benefit in contravention and in clear breach of the terms and conditions of the said policy. It is submitted that the complainants have alleged that there has been an incorrect calculation contrary to the terms and conditions in respect of Surrender Value of the said Policy. It has been further alleged that the amount of Rs.19,100/- would be paid under the said Policy. However, the Company has calculated the surrender value on the said Policy, and the same is amounting to a sum of Rs.30,735.75/- as on 14th April 2021

It is further submitted that the said Policy has been issued on the basis of the Proposal forms submitted to the Company and on the terms and conditions contained therein. In respect of the aforesaid Policy, we have to draw your attention to the terms and conditions which in Clause 14(b) provide as under:

“14. Non-Forfeiture

a) ….. b) If at least three full years Regular Premium has been paid and subsequent Regular Premiums are not paid in full, the Policy will be converted to a Cover Continuance Policy on the expiry of the Grace Period, any Additional Rider Benefit under the policy will immediately lapse but the Life Insurance Cover under the base Policy alone will continue and:

i. The Life Insurance Cover available under the base Policy will continue by deduction of the due Life Insurance Risk Premium (including applicable service tax) at each premium frequency from the AMV, provided the AMV less amount of PDP less any outstanding loan including the interest accrued thereon (per Section 17 below), all as on the date of deduction, is sufficient to deduct the due Life Insurance Risk Premiums (including applicable service tax). The remaining AMV and the AAMV, if any, shall continue to be enhanced by the Guaranteed Investment Return (GIR).

ii. If at any time during the Policy Term, the AMV less amount of PDP less any outstanding loan including the interest accrued thereon (per Section 17 below), all as on the date of deduction, is insufficient to deduct the due Life Insurance Risk Premium (including applicable service tax), the Policy will be terminated immediately and any Surrender Value (per Section 3 d)) as on the date of termination shall be payable.

iii. The AMV and the AAMV, if any, shall continue to be enhanced by the Guaranteed Investment Return as per Section 4 above until the Maturity Date or prior termination.

iv. Under a Cover Continuance Policy, no Additional Rider Benefit shall be payable” It is submitted that the Complainant failed to pay the premium due on 17th December 2013, resulting in a premium payment of only three years under the said Policy, as a result whereof, the aforesaid Clause 14(b) was applied. Further, on perusal of the aforesaid Surrender Value Statement (Annexure A hereto) the Company has applied the GIR Addition Monthly and duly deducted the Cover Continuance Charges as per the terms and conditions.

It is submitted that the Complainant is attempting to unjustly enrich themselves against the terms and conditions of the said Policy that were duly agreed upon by way of the Proposal forms and the non-challenge of the terms of the said Policy during the free-look period. It is submitted that a Contract of Insurance is an agreement between the proposer and the Insurance Company, wherein both parties agree to be bound by and are expected to strictly adhere to the terms and conditions of the Contract of Insurance. Further, it is incumbent upon both parties to the contract to discharge their respective obligations, in performance of the contract.

It is therefore submitted that any alleged promises or vague allegations which are not the part of the express terms and conditions of the said Policy as received by the Complainant, are neither binding on the Company nor enforceable as law as per the provisions of the Indian Contract Act, 1872. Since the company has acted strictly in accordance with the terms and conditions of the said Policy, the present Complaint is nothing but an abuse of the provisions of the Insurance Act on the part of the Complainant, purely for his/her own malafide intentions. In view of the submissions made above, it is evident that the Complainant has leveled false accusations without an iota of evidence just to derive illegal financial gains contrary to the Contract of Insurance under the said Policy. It is therefore, humbly requested that this Complaint under reply, be dismissed in the interest of justice and equity.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that the surrender value was less than the amount promised. The Respondent Insurer submitted the points mentioned in the averments.

4. The Company has calculated the surrender value on the said Policy, and the same is amounting to a sum of Rs.30,735.75/- as on 14th April 2021 .Forum directs to pay the surrender value as on the date of settlement but not less than Rs30736 immediately.

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs. 30736 , within the period mentioned hereunder. No cost.

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.

Dated this the 17th day of May 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF


(UNDER RULE NO. 13 1(i) READ WITH RULE 14 OF







: Mr. RAMESH OTHAYOTH

SREYAS, MATHUKKOTH; POST VARAM,

2. Policy Number

: 797205491


: Mr. RAMESH OTHAYOTH


: LIC of India


: 25.02.2021


: ULIP - Pension policy


: --

8. Date of hearing : 20.04.2021


a) For the Complainant

: Mr. Ramesh Othayoth (online)

b) For the Insurer : Smt. Subha (Online)

AWARD

This is a complaint filed under Rule 13 1(i) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding ULIP - Pension policy. The complainant, Mr. RAMESH OTHAYOTH is the policyholder.


The Complainant stated that he was an ex service man retired from service on 31.12.2006.The retirement benefits was

invested in LIC Market plus policy for a term of 10 years. The purpose of the investment was for his son’s further studies.

The policy got matured in July 2020.Intimation for the same was received on MAY.Due to covid restrictions the

complainant could not visit the branch. In July his son returned from Uttarakand and hence the complainant had to go

on quarantine for 28 days. The complainant approached the respondent insurer in August by then the maturity proceeds

were converted to pension plan. A request was given to refund the maturity amount but it was rejected by the company.

The complainant mentions that he had availed loan for son’s marriage and further expenses for his second son who is

pursuing MBBS. Hence requests the forum to refund the maturity amount.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the captioned policy,

Market plus 1, Unit linked deferred pension plan, is taken by the life assured from our branch 11 Kannur.

This is a unit linked deferred compulsory pension plan which provides pension to annuitant as per the option and mode

of payment, given by the life assured, mentioned in policy conditions, page no.1 of policy bond, item (a) of benefits

payable on vesting. This states that an amount equal to the policy holder’s fund value at the time of vesting date, after

allowing for an option to commute a maximum of one-third of the policy holder’s fund value , shall be compulsorily

utilized to provide a pension bases on the then prevailing immediate annuity rates and other items and conditions either

from the corporation or from any other Life Insurance Company registered with IRDA.

The company’s Divisional office claims dept. is sending IPP intimation letters to all ULIP compulsory IPP policies before 6

months of vesting by registered post. In this case The dept. has sent IPP intimation letter regarding the vesting of the

policy and its proceedings on 10/02/2020 by registered post No. RL83305185 0IN. Copy of the journal of the registered

post is enclosed.

Life assured has approached our Kannur branch office in Sept 2020 ( ie, after the vesting date of the policy) with letter

dated 06/08/2020 to get the lump sum amount as on the date of vesting (15/07/2020) of the policy. Branch office has

clearly informed him that the payment of amount on vesting date is not possible after vesting, as per policy conditions

mentioned in first page, benefits of policy (a). The procedure for surrender after vesting date was explained in detail. But

life assured wants to get the value at maturity of the policy. The copy of the letter sent by branch office to the life assured

dt. 23/11/2020, explaining the procedure to get surrender value after vesting of the policy, is enclosed.

As the vesting date is over at the time of getting his request for lump sum amount , the payment of total amt. as on date

of vesting is not possible under this case, according to policy conditions. Life assured can commute a maximum of one

third of the policy holder’s fund value ie, Rs. 1,27,734/- (3,83,203 *1/3) and the balance amt in the policy holder’s fund

value will be utilized to provide pension on the prevailing immediate annuity rate, as per the option and mode of payment

given by the policy holder.

In this policy, the Bid value of the units in the policy holder’s account as on the vesting date is getting by multiplying the

units as on date of vesting by the Net Asset Value (NAV) of that date.

Here the o/s units in this policy holder’s account as on date of vesting is 17234.382.

NAV as on that date for growth fund is- 22.2348

So bid value is 17234.382*22.2348= 3,83,203/-

The circulars CO/CRM/1173/23 dt. 10/10/2019, 2 nd para of first page and CO/CRM/1188/23 dt. 29/01/2020, page no.

3, D(4) clearly state that if the policy under plan 191, is vested on or after 24/08/2019, with option F or J, the surrender

after vesting conditions shall be governed by circular CO/PD/123 dt. 23/08/2019. Ie, as per Jeevan Shanthi plan. Copy of

circulars are enclosed.

The surrender condition after vesting of Jeevan Santhi plan is that the policy with annuity option F& J can be surrendered

at any time after 3 months of vesting for any reason. So this policy holder will get surrender value after 3 months from

15/07/2020, if he submits the option F or J, for escalating the data to our SZ IPP cell as the surrender admission of vested

policy can be done by IPP cell only. This condition is clearly informed the policy holder vide branch letter dt. 23/11/2020.

But till date the policy holder did not submit any requirements for surrender of the policy after vesting date.

The surrender quotation can be generated through module only after escalating the data to IPP Cell. For that the annuity

option and mode of annuity are to be submitted by the life assured, which is not yet received.

The IPP intimation by registered post was sent well before the date of vesting, ie, on10/02/2020. Our claims dept. has

confirmed that the option letter sent on 10/02/2020 was not received as undelivered. The payment details after the

vesting date is clearly mentioned in both the policy bond as well as in the intimation letter. The maturity discharge form

which is enclosed along with option letter clearly states that the maturity discharge form to be submitted if the fund

value as on date of vesting is below Rs. 1,00,000/-. Life assured can send a letter or can contact our office over phone,

by mail or through any agent before vesting date regarding surrender before vesting/lump sum payment of the policy.

The nonpayment of surrender request after vesting date, for the lump sum payment of bid value as on date of vesting,

is purely based on policy conditions and the circulars issued by LIC in this regard. So we would pray before Honororable

Ombudsman to uphold our decision which is purely based on policy condition and to set aside the complaint filed before

Honororable Ombudsman.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that the points mentioned in the

averments. The Respondent Insurer submitted that the points mentioned in the averments.

4. The respondent company has given two suggestions for the closure of the complaint as mentioned in the averments.

Point 1,To claim 1/3rd amount Rs. 1,27,734/- and invest 2/3rd in new pension plan. Point 2, To surrender the new pension

policy after 3 months of issuance. Pension products offered by the insurance companies have a special role to play in

promoting and protecting the social security by provision of stable and adequate retirement income. It’s clear the insurer

has acted as per the terms of the policy and IRDA guidelines. Considering the facts of the case the complaint is not tenable

hence dismissed.

In the result, an AWARD is passed for Dismissal of the complaint.


Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

AWARD NO.IO/KOC/A/LI/0009/2021-2022

PROCEEDINGS OF


(UNDER RULE NO. 13 1(c) READ WITH RULE 14 OF







: Mr. K Asokan

Aswathy Bhavan, Erattayal, Marutha

Road Post, Palakkad 678007

2. Policy Number

: 18098653


: Mr. K Asokan


: HDFC Standard Life Insurance Co. Ltd.


: 25.02.2021


: Refund of 5th premium paid


: --

8. Date of hearing

: 23.04.2021


c) For the Complainant

: Mr. K Asokan(Online)

d) For the Insurer : Mr. Vinay Prakash (Online)

AWARD

This is a complaint filed under Rule 13 1(c) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding refund of 5th premium paid. The complainant, Mr. K Asokan is the policyholder.

1. Averments in the complaint are as follows: The Complainant stated that he has been dealing with HDFC Standard Life

Insurance Company under Client ID 50628360 until July 2020, when the client ID was changed to EC171281 when he

took a new policy. HDFC Life Super Income Plan Policy No. 18098653 with yearly premium Rs. 102250/-, total 5 premiums

were paid until Dec.2019. As the NRE account was to be cancelled, Rs. 102250/- due on 26.12.2020 was paid in advance

on July 15 through Debit Card associated with the NRE Account. HDFC Life sent a message that premium early payment

will refund. Refund amount was received on 18.11.2020 after opening of new SB Resident Account. While trying to pay

December due online, the system was showing Rs.212090/- due. On enquiry, it was revealed that December 2019

premium was shown upaid for which receipt and bank statement was submitted. No response has been given by the

Company. December 2020 could not be paid because of this issue.

Approaching this Hon’ble Forum to direct the Company to account for December 2019 premium and let the payment of

December 2020 be accepted without interest.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the

complainant had availed the Super Income Insurance Policy bearing No.18098653 as incepted from 28th

December 2015, and the policy was issued subject to terms and conditions as mentioned therein. The

complainant had to pay premium of Rs.1,00,000/- annually for the premium paying term of eight years.

The complainant has made a complaint stating that his policy attained lapsed status in spite of complainant

paying the premium in the month of December-2019, however what really transpired was that complainant

paid advance premium of Rs.102250/- in the month of July-2020 from his HDFC bank credit card account No.

512967XXXXXX6819 and the company has refunded back the said sum premium into his premium account on

16th July 2020 as under the policy no advance premium was acceptable and later the complainant once again

raised charge back request with HDFC bank on 29th October 2020 and we requested the HDFC bank not to

debit our account for the disputed premium sum vide our mail dated 29th October 2020, however the HDFC

bank went ahead debited the premium sum of Rs.102250/- from our account as a result the policy lapsed and

attained paid-up status. The relevant excerpt of the mail dated 29th October 2020 is reproduced below-

Therefore the allegations made by the complainant that the company has cancelled the policy and has not

refunded the premium sum of Rs. 102250/- is baseless allegation, as the premium sum was credited back into

the HDFC Bank account bearing No.50100359874144 on 20th November 2020. Under these circumstances we

humbly submit that the complaint is devoid of merits and allegations made are false and baseless. Therefore

Hon’ble Ombudsman may be pleased to dismiss this complaint and thus rendered justice.

3. I heard the Complainant and the Respondent Insurer through online hearing held on 23.4.2021. The Complainant

submitted that as he had wanted to close his NRE Account, he paid the December, 2020 due premium in July 2020 itself.

However, the company refunded the same and credit was received only on 18.11.2020 after opening a new SB Resident

account. While trying to pay the December 2020 due premium, the system was showing 2019 due also as unpaid and

couldn’t remit the premium. There was no request made for refund of December 2019 premium. The Respondent

Insurer submitted that the policyholder failed to inform the company regarding the closure of his NRE Account through

which advance premium was paid. As advance premium was not to be accepted in this policy, the same was refunded

and credited to him on 26.7.2020 under ARN No. 75503720210041200076948. The complainant contested the said

refund as he had closed his account. The Respondent Insurer contented that since the complainant raised the charge

back request, the bank debited the company account and hence the FUP is shown as December, 2019.

4. In the facts and circumstances of the case, the undersigned is convinced that the claim of the Insurer to have refunded

both 2019 and 2020 premiums when only one premium due 2020 was paid in advance, requires interference. The Insurer

has not adequately addressed the concern of the Complainant and has put him in trouble by their callous acts. The

Company failed to track the refund amount paid in July 2020 and blames the complainant for the charge back request.

The Respondent Insurer is requested to investigate into the refund made on 26.7.2020, as the complainant claims to

have closed his account and refund the same to him. The Insurer also is to reinstate the policy by accepting both the

premiums @ Rs. 100000/- and Rs. 102250/-(inclusive of tax and other levies), due on December 2019 and 2020 without

interest, subject to medical reports.

As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30 days

of receipt of the award and intimate compliance of the same to the Ombudsman.


(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Anil AR

Kailas,Kongal Paravur(P.O) Kollam

691301

2. Policy Number

: 10065922


: Mr. Anil AR


: Reliance Nippon Life Insurance Co. Ltd.


: 01.04.2021


: Rejection of Critical Insurance claim


: --

8. Date of hearing

: 27.04.2021



: Mr. Anil AR(Online)

b) For the Insurer : Mr. Joysulla Sudhakar (on line)

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding rejection of Critical Insurance claim. The complainant, Mr. Anil AR is the policyholder.


The Complainant stated that he had a critical illness policy from 2004.He had to undergo angiogram and angioplasty on

4.11.2020 and submitted the claim but the respondent insurer rejected the claim hence approached the forum seeking

justice.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted That the Company had

received a duly filled and signed proposal form’s dt.30-03-2004 for issuance of Life Insurance policy on the life of the Mr.

Anil AR policy 10065922, Also he had submitted a duly filled and signed Benefit Illustration under which he had agreed

to the benefits, charges, terms & conditions and risk factors of the proposed plan.

A copy of the Proposal Form, copy of premium receipt along with the confidential report signed by the complainant ,

With the customer declaration for submission of Application , the policy document has been submitted to the forum.

Further it is also relevant to inform that at the time of purchasing the said policy the policyholder had himself signed the

below mentioned declaration: “I understand and agree that the statement in this proposal form shall be the basis of this

contract between me and Reliance Nippon Life Insurance Co. Ltd...I agree that I will inform the Company if between the

date of this proposal and the date of issuance of the policy about any change in my general health, occupation, financial

position or if any other proposal or application to any other insurance Company on my life is declined, postponed or

accepted other than the standard terms so that the Company may consider the term of acceptance.. I further declare

that the statements in this proposal are true and I have disclosed all information which might be material to Company

while issuing the policy contract....I declare that the Company has disclosed and explained all the information related to

this product and riders to me and I declare that I have understood the same before signing this proposal form, in case of

fraud, including the act of concealment of material facts, the policy contract shall be cancelled immediately by forfeiture

of all premiums or in case of suppression of material facts the policy contract shall be treated in accordance with the

Section 45 of Insurance Act,1938 as amended from time to time.”

Thus based on the aforementioned declaration made by the policyholder and after the receipt of first premium amount

they said policy was issued to him and the policy documents were duly dispatched at the communication address of the

Complaint on time, which was not disputed by the customer within the “Free look period as per the IRDA rules &

regulations provision.

It is germane to mention that the Company in accordance with clause 4.1 & 6.2 of the Insurance Regulatory and

Development Authority (Protection of Policy holder’s Interests) Regulations, 2002, had sent to you the policy documents

along with the proposal form and a welcome letter which clearly mentions that in case Policyholder is not satisfied with

the features or the terms and conditions of the policy he/He can review/withdraw/ return/ alter the details of the policy

within 15 days i.e. under the “Free Look period” provision.

Further it is to be submitted that the Company had never received any request for Free look cancellation or any grievance

relating to the subject policy within the mandate period of 15 days from the receipt of the policy documents and as such

it can be deemed that you had understood the features, terms and conditions of the subject policy. Hence, the subject

policy continued as per the schedule mentioned in the policy terms & conditions, Policy document(PD) was dispatched

to the customer on time. Customer has never complained about PD not received in past.

Further that after availing the aforesaid Policy, the Life Assured sent the first written complaint dated on 17 th February

,2021 i.e. after 15 years to the ombudsman from the date of issuance of the Policy.

Further, after investigating the policy on the basis of the complaint received from the customer, angiogram and

angioplasty is not covered under Critical illness as per the terms and conditions.

Further it is pertinent to inform to this Hon’ble Ombudsman that, the said policy complaint is not entertain-able, It is

further pertinent to mention herein that the complainant had preferred the complaint in the year 2021 in the month of

February . RNILC addressed the complaint with closure of the complaint raised with the RNLIC , It is pertinent to mention

only to bring his complaint under the jurisdictional purview of the Ld. Ombudsman has raised the complainant .As per

the enclosed Terms and conditions of the policy clearly sating what all are covered in the critical illness as per the policy

document , we are reproducing the terms and conditions for the sake of Ombudsman authority as enclosed below,

Heart attack

The death of a portion of heart muscles as a result of inadequate blood supply as evidenced by an episode of typical

chest pain, new elector-cardio graphic changes and by elevation of cardiac enzymes. Diagnosis must be confirmed by a

Consultant Physician.

ii) Coronary Artery By-Pass Graft Surgery

The undergoing of Open Heart Surgery on the advice of a Consultant Cardiologist to correct narrowing or blockage of

one or more Coronary arteries with bypass grafts. Angiographic evidence is required to support the necessity of the

Surgery. Balloon Angioplasty, LASER OR ANY catheter based procedure are not covered.

iii) Heart Valve Replacement

The undergoing of Open Heart Surgery on the advice of a Consultant Cardiologist to repair or replace one or more an

abnormal heart valves.

iv) Aorta Surgery

The undergoing of Open Heart Surgery for a disease of or injury to the aorta needing excision and surgical. replacement

of the aorta with a graft. For the purpose of this definition, aorta shall mean the thoracic and abdominal aorta but not

its branches.Policy Document herewith marked as Annexure C.

Hence the present complaint is liable to be dismissed for being an abuse of the established process of law. It is also

pertinent to mention herein that the complainant had preferred the complaint with a nefarious motive of wriggling out

of a lawful contract of insurance entered by him with the company. It is also very pertinent to mention herein that the

complainant had availed the entire services against the premium paid by him for the said policy as the company had

covered the risk associated with the complainant’s life for the year for which the premium was paid by his in the said

policy and if any mis-happening would have happened with the complainant the company would have honored the

contract by paying the applicable, Sum assured or death benefit to its dependents/nominee in performance of the said

contracts of insurance. Thus, the contract of insurance has been completed for the period for which the premium was

paid by the complainant herein and he had availed the entire services against the premium paid by him and had enjoyed

the risk cover for the entire said period.

Hence It is most humbly being submitted herein that the complainant had instituted the present complaint with the

nefarious motive of causing wrongful loss to the company and with a motive to benefit from his own default and breach

of the said contract of Insurance and there arose no cause of action at any time in favor of the complainant and against

the company for the institution of the present complaint. The present complaint is liable to be dismissed without any

relief for being an abuse of the process established for the benefit of the genuine complainants

Hence in light of the facts as stated above the present complaint is liable to be dismissed without any relief.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he had an ecg variation and

blood test was also done. The local hospital suspected a heart attack and referred him to Kollam hospital where he

underwent angiogram. Since the claim for the hospitalization was rejected by the respondent company, approached the

forum for justice. The Respondent Insurer submitted the points mentioned in the averments.

4. As per the terms and conditions of the policy angiogram and angioplasty is not covered under Critical illness

.Considering the facts of the case there is no merit in the complaint.


Dated this the 31st day of May 2021.

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF


(UNDER RULE NO. 13 1(f) READ WITH RULE 14 OF







: Mr. Shyam Madhavan,

VP 2/346, KRA-57, "Madhushree",

Manikandeswaram P O, Vazhayila,

Thiruvananthapuram - 695013

2. Policy Number

: 51006821808


: Mr. Shyam Madhavan


: SBI Life Insurance Co. Ltd.


: 05.04.2021


: Non renewal ofpolicy


: --

8. Date of hearing

: 26.05.2021



: Mr. Shyam Madhavan (Online)

b) For the Insurer : 1

AWARD

This is a complaint filed under Rule 13 1(f) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is regarding Non renewal ofpolicy. The complainant, Mr. Shyam Madhavan is the policyholder.


The Complainant stated that he had enrolled in SBI Smart Scholar Child insurance Plan program Policy No. 510 06281

808 in Dec 2014, and has been making regular payments for the past 5 Years. The payments were auto debited from his

ICICI bank account (ECS). However, in July 2020, the Auto-debit failed due to insufficient account in the bank. He had

topped up his bank account after this. The next 2 months, the Auto debit was not initiated, even though there was

sufficient funds in his bank, and after this SBI Life decided to withdraw the Policy. There was no communication from SBI

regarding the same, and he was informed only in Dec 2020, via the SBI agent. Although the Policy document of SBI Smart

scholar clearly states that the revival period is 2 years, SBI is refusing to revive the policy, by citing rules not mentioned

in the policy document.

Approaching this Honourable Forum to direct the Insurer to reinstate the policy as he is ready to pay the required

outstanding amount and any late fees, as stipulated, to revive this policy.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the complaint has

been filed for revival of the policy No. 51006821808. However, the demand for revival is untenable as the Company did

not receive a request for revival of the policy within the notice period of 30 days. As on date, the policy has discontinued

and an amount of Rs. 14, 96,363.17/- is payable towards discontinued fund value under the policy.

SBI Life Smart Scholar policy bearing no. 51006821808 was issued to the Complainant with date of commencement as

09/12/2014 for a policy term of 17 years.

Renewal premiums under the policy were payable on the 09th of every month during the premium paying term of 10

years.

The Company received a mandate for auto-debit of renewal premiums. The Company received premiums until the due

date 09/07/2020.

Renewal premiums payable on 09/08/2020 and onwards were not received by the Company and in accordance with the

terms and conditions of the policy, the policy discontinued.

Under Section 64VB of the Insurance Act, no insurer shall assume any risk in India in respect of any insurance business

unless and until the premium payable is received by him/her in advance or is guaranteed to be paid to the insurer in the

manner prescribed by the rules framed under the Insurance Act. It is therefore, submitted that the advance payment of

the premium under a policy is not only a contractual obligation but also a legal mandate for the continued assumption

of risk under a policy of insurance.

In the instant case, it is an admitted fact that the policy discontinued due to non-payment of renewal premium for the

due date 09/08/2020.

The Complainant had the option to choose to revive his policy within the stipulated period of 30 days. However, the

Complainant did not do so.

Further, as per IRDAI (Linked Insurance Products) Regulations, 2013, as per Regulation 13, “Obligations of an insurer

upon discontinuance of a policy before lock-in period”, under sub-clause (a), “Where a policy is discontinued, the insurer

shall take the following steps to enable the policyholder to exercise the option as stipulated in Regulation 12 herein:

Send a notice within a period of fifteen days from the date of expiry of grace period to such a policyholder to exercise

the said options within a period of 30 days of receipt of such notice:

Provided that where the policyholder does not exercise the option within the notice period of 30 days, the treatment of

such policy shall be subject to provisions stipulated in Regulation 15 herein.”

Regulation 15 of the aforementioned Regulations applies to obligations of the Insurer upon Surrender of the Policy.

The Company received a duly filled and signed proposal form bearing no. 51AH632471 dated 31/10/2014 in the name of

the Complainant for grant of insurance cover.

Solely based on the information contained in the proposal form, believing the information contained therein to be true

and complete, SBI Life Smart Scholar policy bearing no. 51006821808 was issued to the Complainant with date of

commencement as 09/12/2014 for a policy term of 17 years. Renewal premiums under the policy were payable on the

09th of every month during the premium paying term of 10 years.

The Company received a duly filled mandate for auto-debit of renewal premiums. Accordingly, the Company received

renewal premiums until the due date 09/07/2020. Renewal premiums payable on 09/08/2020 and onwards were not

received by the Company and in accordance with the terms and conditions of the policy, the policy discontinued. Auto-

debit of renewal premium for the due date 09/08/2020 failed with the reason “DP NOT AVAILABLE. ACCT CANN”. The

same was intimated to the Complainant vide letter dated 15/08/2020

The Premiums are remitted through the Bank only. Thus the premium remittance arrangements are purely between the

Bank and the customers and the Company has no locus in these arrangements. Without prejudice to the same, it is

humbly submitted that it was the duty of the complainant to ensure that the premiums are paid and his policy is kept in

force.

The Company has sent SMS to his registered mobile number 9645950501 informing him that failure of auto debit due to

insufficient fund and assisting him to pay renewal premium through online mode. Hence the contention of the

complainant that he has not received any communication is vehemently denied.

As per clause no. 6 of the terms and conditions of the policy document, “Discontinuance of Premiums”,

“6.1 If you have not paid any premium due within the Grace Period, we will send you the Discontinuance Notice within

15 days from the date of expiry of Grace Period. Non-receipt of the notice however, will not be construed as a breach of

any contractual obligation on our part.

6.2 In the notice we would state that that you are entitled to exercise one of the following options upon discontinuation

of the policy:

6.2.1 Either to Opt to Revive the policy within 2 years or

6.2.2 To opt for Complete Withdrawal from the policy.

You would have the following option in addition to the above two options if the discontinuance is after the lock-in period:

6.2.3 Convert the policy to paid-up status (option available only when all the premiums have been paid at least for the

first five policy years)

6.3 You should choose your option within a period of 30 days from the date of receipt of notice.”

In the instant case, the Company had sent notice of discontinuance wherein the Complainant was requested to exercise

one of the following options upon discontinuation of the policy: Either to opt to Revive the policy within 2 years or to

opt for Complete Withdrawal from the policy, within a period of 30 days from the date of receipt of the notice.

However, in the instant case, the Complainant did not opt to revive his policy within the stipulated period of 30 days,

and in accordance with the terms and conditions of the policy, it was deemed that the Complainant had opted to

completely withdraw from the policy.

As per clause no. 6.7 of the terms and conditions of the policy,

“6.7 If you opt to completely withdraw from the policy during the notice period or if you do not exercise any of the

options within the notice period, then:

………………………………………………………………………………………………….6.7.2 If premium is discontinued after first 5 policy years:

6.7.2.1 Fund value as on the date of receipt of your option or as on the last day of the discontinuance notice period if no

option is exercised, as the case may be, will be paid to you immediately.”

As the Complainant did not opt to revive the policy within the period of 30 days as provided in the terms and conditions

of the policy, the policy has been discontinued. Thus, an amount of Rs. 14, 96,363.17/- is payable towards discontinued

fund value under the policy. The Complainant is therefore, requested to approach the nearest SBI Life branch and furnish

the requisite documents to enable the Company to release the amount payable to the Complainant. Thus, the demand

of the Complainant for revival of the policy is untenable as per the terms and conditions of the policy.

The complainant was supposed to opt for revival of policy or complete withdrawal of policy as per the terms and

conditions of the policy within 30 days. If the complainant wanted to revive the policy, he should have opted for revival

within 30 days which he did not do. As a result, the policy discontinued and the discontinued fund value is payable.

Hence, the complainant’s request to revive the policy is not tenable as per the terms and conditions of the policy.

As per the terms and conditions of the policy, which is the evidence of the insurance contract, the Company has no

contractual liability to revive the policy in violation of the terms and conditions of the policy which are duly approved by

the IRDAI. Hence, no deficiency in service can be alleged on the part of the Company.

If every complainant resorts to this type of complaints and if such complaints are entertained, it sends a wrong signal to

the public resulting in a plethora of vexatious and baseless litigations across the industry and puts the industry in

jeopardy.

The IRDAI is the Regulator of the Insurance Industry and has been issuing several regulations and guidelines for the

welfare of the insuring public and the insurance companies have to operate within those regulations without exception.

The Regulator has effective superintendence and control over the industry and all the products are duly approved by the

IRDAI to ensure that the Customers’ interests are protected.

The Company incurs considerable expenses in issuing a policy believing that the customers will abide by the terms and

conditions of the policy. The Company holds the Public money in trust. Making payments outside the terms and

conditions of the policy will cause loss to the insuring public.

A contract has to be interpreted as per the terms and conditions of the document evidencing the contract. The Policy

Bond is the evidence of the contract of Insurance and both the Insurer and the insured are bound by the terms and

conditions of the contract. The policy bond, which is the evidence of the insurance contract, does not provide for opting

for revival of the policy beyond the stipulated period of 30 days. Hence, the complaint may be dismissed.

Compassion cannot overturn law. Hence, the demands of the Complainant on compassionate grounds are untenable.

The Company received various communications, which were duly replied to.

It is expected of the proposer to have ascertained the terms and conditions of the policy before signing the proposal

form. Thus the action of the Insurer to repudiate the claim is as per the terms and conditions of the policy.

Compassion that is concern for the sufferings or misfortune of the Complainant is one thing but that cannot overturn

law.

A contract has to be interpreted as per the terms and conditions of the policy.

3. I heard the Complainant and the Respondent Insurer through online hearing. The Complainant submitted that the

premiums were remitted by ECS debit every month from his bank account for 5 years. However in June, 2020 due to

insufficient funds, the premium payment did not get auto debited. The Insurer did not inform about this although funds

were arranged within two days in June, 2020. When approached for revival, the Insurer has denied revival of policy. The

Respondent Insurer submitted that as per terms and conditions of the policy, since the revival request was not made

within 30 days from the date of receipt of notice, it was deemed that the complainant had opted to completely withdraw

from the policy. The discontinued fund of Rs. 14936363.17 is available against a total premium payment of Rs. 1360000.

The complainant expressed his desire to continue with the policy, which has run for 5 years and 8 months.

4. In the facts and circumstances of the case and the submissions made by either party during the hearing, the

undersigned is convinced that the insurer has acted as per the terms and conditions of the policy. However, the Insurer

may provide one more opportunity to the Insured to revive the policy by paying the premiums with interest, subject to

satisfactory medical requirements to be met by the insured.

In the result, an award is passed, directing the Respondent Insurer to revive the policy on receipt of revival requirements

from the complainant, within the priod mentioned hereunder. No cost.




(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Balagopal V B

Gokulam, Vikas Road, Thrikkakara,

Kochi - 682021

2. Policy Number

: 52894958


: Mr. Balagopal V B


: Reliance Nippon Life Insurance Co. Ltd.


: 17.03.2021


: To get the refund


: --

8. Date of hearing

: 26.05.2021



: Mr. Balagopal V B(online)

b) For the Insurer : Mr. Joysulla Sudhakar (Online)

AWARD


complaint is regarding the refund of premium. The complainant, Mr. Balagopal V B is the policyholder.


The Complainant stated that Policy No. 52894958 was availed at the behest of Ms. Sheela Pious by paying first instalment

premium of Rs. One lakh. The concern of inability to pay the premium for 6 long years was voiced to her, being a senior

citizen with no regular income. It was informed by her that in case premium could not be paid, after completion of three

year period, refund of premium is possible. Due to financial constraints, further premium could not be paid and was

informed to the representatives. On 10.3.2020 SMS was received that the policy stands terminated from 9.3.2020 due

to non-payment of premium during the revival period. Due to lock down, the matter could not be taken up. Being a

senior citizen of 69 years, approaching this Honourable Forum to direct the Insurer for an amicable settlement.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the Company had

received a duly filled and signed proposal form’s dt.06-03-2017 for issuance of Life Insurance policy on the life of the

Mrs.Aswathy Libish policy 52894958.

He had submitted a duly filled and signed Benefit Illustration under which he had agreed to the benefits, charges, terms

& conditions and risk factors of the proposed plan.

The Details of the said policy has been mentioned as under:

Policy no. 52894958

Plan Name Reliance Increasing income plan

Name of Life Assured Mrs. ASWATHY LIBISH

Proposal Date 06-03-2017

Policy issuance date 03-03-2017

Premium amount Rs.99,386/-

Mode Yearly

Policy Term 12 years

Premium Payment Term 06 years

Sum Assured on Death 9,63,860/-

At the time of purchasing the said policy the policyholder had himself signed the below mentioned declaration:

“I understand and agree that the statement in this proposal form shall be the basis of this contract between me and

Reliance Nippon Life Insurance Co. Ltd…I agree that I will inform the Company if between the date of this proposal and

the date of issuance of the policy about any change in my general health, occupation, financial position or if any other

proposal or application to any other insurance Company on my life is declined, postponed or accepted other than the

standard terms so that the Company may consider the term of acceptance.. I further declare that the statements in this

proposal are true and I have disclosed all information which might be material to Company while issuing the policy

contract….I declare that the Company has disclosed and explained all the information related to this product and riders

to me and I declare that I have understood the same before signing this proposal form, in case of fraud, including the act

of concealment of material facts, the policy contract shall be cancelled immediately by forfeiture of all premiums or in

case of suppression of material facts the policy contract shall be treated in accordance with the Section 45 of Insurance

Act,1938 as amended from time to time.”

Thus based on the aforementioned declaration made by the policyholder and after the receipt of first premium amount

the policy was issued to him and the policy documents were duly dispatched at the communication address of the

Complaint on time, which was not disputed by the customer within the Free look period as per the IRDA rules &

regulations.

The Company in accordance with clause 4.1 & 6.2 of the Insurance Regulatory and Development Authority (Protection

of Policy holder’s Interests) Regulations, 2002, had sent the policy documents along with the proposal form and a

welcome letter which clearly mentions that in case Policyholder is not satisfied with the features or the terms and

conditions of the policy he/He can review/withdraw/ return/ alter the details of the policy within 15 days i.e. under the

“Free Look period” provision.

The Company had never received any request for Free look cancellation or any grievance relating to the subject policy

within the mandate period of 15 days from the receipt of the policy documents and as such it can be deemed that you

had understood the features, terms and conditions of the subject policy. Hence, the policy continued as per the schedule

mentioned in the policy terms & conditions. Policy document was dispatched to the customer on time. Customer has

never complained about Policy document not received in past. As per track proposal policy received on 23/03/2017 via

(Speed Post Chennai) pod no is ET418060685IN .

After availing the aforesaid Policy, the Life Assured sent the first written complaint dated on 29th, December, 2020 i.e.,

after 3years 9 Months from the date of issuance of the Policy. RNLIC addressed the complaint raised with the closure

letter dated 30/12/2020. Customer complaint letter expressed inability to pay future premium further as a reason for

his grievances

After investigating the policy on the basis of the complaint received from the customer, we have not found any such

evidences to verify. Also Complainant has not provided any such irrefutable evidences to be verified by the Company.

The complaint is not entertainable, as the complainant had preferred the complaint in the year 2021 in the month of

March 16th, only to bring his complaint under the jurisdictional purview of the Ld. Ombudsman Hence the present

complaint is liable to be dismissed for being an abuse of the established process of law.

The complainant had preferred the present complaint with a nefarious motive of wriggling out of a lawful contract of

insurance entered by her with the company. It is also very pertinent to mention herein that the complainant had availed

the entire services against the premium paid by him for the said policy as the company had covered the risk associated

with the complainant’s life for the year for which the premium was paid by him for the LA, in the said policy and if any

mis-happening would have happened with the complainant the company would have honored the contract by paying

the applicable Sum assured or death benefit to his dependents/nominee in performance of the said contracts of

insurance. Thus, the contract of insurance has been completed for the period for which the premium was paid by the

complainant herein and he had availed the entire services against the premium paid by him and had enjoyed the risk

cover for the entire said period. Hence It is most humbly being submitted herein that the complainant had instituted the

present complaint with the nefarious motive of causing wrongful loss to the company and with a motive to benefit from

his own default and breach of the said contract of Insurance and there arose no cause of action at any time in favor of

the complainant and against the company for the institution of the present complaint. The present complaint is liable to

be dismissed without any relief for being an abuse of the process established for the benefit of the genuine complainants.

Hence, in light of the facts as stated above the present complaint is liable to be dismissed without any relief.

3. I heard the Complainant and the Respondent Insurer through online hearing. The Complainant submitted that the

policy was availed in 2017 when he was having a consultancy arrangement. However, the policy was taken in the name

of daughter, as his age was advanced. The concern about financial constraints to pay premium for 6 years was voiced to

the Insurance Advisor who assured that even if further premium could not be paid, the amount will be returned after

three years. The complainant admitted not to have gone through the policy document to educate himself about the

terms and conditions of the policy. The Respondent Insurer submitted that as per the policy conditions the policy

acquires any paid up value only if 3 years premium is paid. If the complainant had concerns regarding payment of

premium, he could have availed the free look cancellation option within 15 days of issue of policy. Since only one

premium is paid, the same will be forfeited and policy cancelled.

4. In the facts and circumstances of the case, and the submissions made by either party during the hearing, the

undersigned is convinced that the Insurer has acted as per the terms and conditions of the policy. Free look period was

given with option to seek cancellation of policy if he was not agreeable to the terms and conditions of the policy. The

insured had not opted for cancellation of policy. The company has covered the risk associated with the life for the year

for which the premium was paid. The complainant on his part, has not paid the regular premiums and has breached the

contract of insurance.



(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. HARIPRASAD P

VASANTH, TC 9/1382,

SASTHAMANGALAM P O, 695010

2. Policy Number

: 00514829; 03326997


: Mr. HARIPRASAD P


: Exide Life Insurance Company Ltd.


: 22.03.2021


: cancellation of policy and refund of

premium


: --

8. Date of hearing

: 26.05.2021



: Mr. HARIPRASAD P(Online)

b) For the Insurer : Mr. Mukund Sharma (Online)

AWARD


complaint is regarding cancellation of policy and refund of premium. The complainant, Mr. HARIPRASAD P is the

policyholder.


The Complainant stated that Rs. 4177.50 was remitted and Policy 00514829 under the caption Basic Policy Reassuring

Life Endowment with Revisionary Bonus Rider – ADDD Benefit – ADDDB Plan was availed on 30.10.2006. The same is

maturing on 27.10.2022.

Similarly, Exide Life Insurance Nirmal Jeevan Policy No. 03326997 was availed on 30.3.2016 by paying Rs. 6217.80. The

same is maturing on 31.3.2030.

Only one premium has been remitted in the above two policies. Due to loss of job could not remit the further premium.

When requested for refund of premium company has refused.

Approaching this Honourable Forum to direct the Insurer to refund Rs. 4177.51 and Rs. 6217.80.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that Exide Life denies all

the allegations made by the Complainant in the said complaint on the ground that they are false, unfounded and not

based on merits and the demands therein are not sustainable. Exide Life would like to state that the Complainant has

not disclosed the facts as it transpired.

On receipt of duly filled up proposal forms from the Complainant, Exide Life issued the policy nos. bearing 00514829 &

03326997.

The policy schedules along with Welcome Letters and the Terms and Conditions for the said policies were dispatched to

the Complainant’s address vide Registered Post as mentioned in the proposal forms and the same were delivered to the

Complainant

The key details of the policies are reproduced in the below mentioned tabular format for immediate reference.

Policy No. 00514829 03326997

Policy Name Exide Life Reassuring Life

Endowment Plan with RB

Exide Life Nirmal Jeevan

Insurance Plan

Policyholder Mr. P Hariprasad Mr. P Hariprasad

Life Assured 26.10.2006 30.03.2016

Policy Commencement Date 27.10.2006 31.03.2016

Premium Amount Rs.4,180/- Rs.6,220/-

Total Premium Amount Paid Rs.4,180/- Rs.6,220/-

Premium payment Schedule Semi-Annual Annual

Premium payment Term 16 years 15 Years

Sum Assured Rs.123,500/- Rs.125,918/-

Policy Term 16 Years 15 Years

It is a universally accepted proposition that a person is presumed to have full understanding of the terms and conditions

along with other ancillary details before concluding purchase of any insurance product and thereby accords his/her free

consent to the same.

“Declaration” under Section XII, was also signed by the Complainant as a part of the proposal form, the relevant portions

of which are reproduced as hereunder:

“I declare that the answers and statements made by me in this proposal form have been made after fully understanding

features of the policy, nature of questions and the importance of disclosing all material information……. I have been

explained the policy/riders terms and conditions and I fully understand the benefits and risks associated with it.”

Further the proposal forms, under Section III clearly defined the plans, premium paying terms, policy terms and premium

installment amounts and the same were within the complete knowledge of the Complainant at the time of filling up the

proposal forms. No part of the policy schedules, welcome letters or the terms and conditions make any mention of

features otherwise than in the proposal form. The Complainant with his absolute understanding duly consented to the

terms and conditions of the present policies in question and is bound by the same. The Complainant has further declared

the below details in the proposal forms.

The Complainant has provided the KYC documents for the policies and has paid the premium out of his free will and it

establishes that complainant is well aware of the premium payable for the policies, its pertinent to note that the

Complainant is a Graduate who is presumed to be aware of the sanctity of his signatures on a document and thus he is

estopped from denying the contents of the proposal forms duly signed by him at the proposal stage as well as the

contents of any documents related to the captioned policy signed thereafter. The Complainant has not denied his

signatures and hence remains undisputed. Therefore, any new allegations of signature forgery at the stage of hearing

should not be entertained at all by the Hon’ble Ombudsman.

The Complainant in his Complaint to the Hon’ble Ombudsman has alleged that he cannot continue paying for the policies

as he is facing financial constraints hence seeking cancellation of his policies. Exide Life vehemently denies the allegations

which are vague, baseless and devoid of any merits, and puts the Complainant to the strict proof of his allegations.

Therefore, no other benefits other than the ones stated in stated in the proposal form.

We put the Complainant to strict proof of his allegations with regard to his income.

The Complainant has not specified his allegations in the Complaint letter addressed to the Hon’ble Ombudsman. This

indicates that he intends to bring up additional allegations during the hearing and wants to take undue advantage of this

Hon’ble Ombudsman.

Furthermore there is a reasonable suspicion that Mr. P Hariprasad (Complainant) has sourced the policy no. 03326997

to his daughter in the authority of an agent bearing advisor code- 60311703 of our company to achieve sales targets &

make financial gains. We request the Hon’ble Ombudsman to not entertain such instigated & malicious complaints in

order to save the precious time of this Hon’ble Forum.

The Complainant has not approached our Complaints and grievance cell regarding the issue of the policies prior to

lodging the Complaint before the Hon’ble Ombudsman which is a procedural requirement. But given the fact that the

Complainant approached the Hon’ble Ombudsman on April 2021 and the policies were sourced in October 2006 & March

2016 there has been an inordinate delay of more than 15 years from the expiry of Free Look Period for Policy No.

00514829 & an inordinate delay of more than 5 years from the expiry of Free Look Period for Policy No. 03326997 which

is huge & unsubstantiated.

Therefore, Exide Life submits that in the light of the averments made above, no leverage should be given to the

Complainant unless he is able to substantiate his allegations with any proof whatsoever.

Under the guidelines issued by the Insurance Regulatory and Development Authority of India under Regulation 10 (1) of

Protection of Policyholder’s Interest Regulation, the policyholder is at liberty to review the terms and conditions of the

policy and has the option to cancel the policy by stating the reasons for his/her objection within 15 days of the receipt

of policy bond. However, the Complainant failed to exercise the “Free Look Period” option and did not revert to us within

the 15 days from the receipt of the policy bonds with complaints on the terms and conditions or any other reasons for

that matter. It was, therefore, presumed legally, that the Complainant was duly satisfied with the issued Policies, which

is self-evident from Complainant’s conduct in not exercising the right of cancelling the policies within the “Free Look

Period”.

Seeking for cancellation within the stipulated Free-Look cancellation period is the duty of the Complainant in case he/she

is not satisfied with the policy sourced.

The Company cannot be made liable for any deliberate omission made in this regard. Condonation of delay in the instant

complaint, if granted without any shred of proof of mis-selling will lead to gross miscarriage of justice and will set a poor

precedent.

A person who affixes his signature to a proposal which contains a statement which is not true, cannot ordinarily escape

from the consequence arising there from by pleading that he chose to sign the proposal containing such statement

without either reading or understanding it. That is because, in filling up the proposal form, the agent normally, ceases to

act as agent of the insurer but becomes the agent of the insured and no agent can be assumed to have authority from

the insurer to write the answers in the proposal form.

The Complainant wanting to wriggle out of the contract has intentionally twisted the facts and is trying to misrepresent

before this Authority. In the light of the aforementioned submissions, facts, circumstances and material documents and

in the interest of justice and equity, we pray this Hon’ble Ombudsman to dismiss the complaint as being devoid of any

merit. Further, we pray the Hon’ble Ombudsman that no adverse orders are passed in the matter without giving us an

opportunity of being heard.

3. I heard the Complainant and the Respondent Insurer through online hearing held. The Complainant submitted that he

had paid only one premium each in the two policies. Due to his depleting financial condition, he does not want to

continue with the policy and wanted a refund of the same. The Respondent Insurer submitted that the complainant

himself has sourced the two policies and is well aware of the terms and conditions of the policy. Unless 3 years premium

has been paid, the policy does not acquire any paid up value. Nothing is payable under the above policies.

4. In the facts and circumstances of the case and the submissions made during the hearing, the undersigned is convinced

that the Insurer has acted as per the terms and conditions of the policy. It is the bounden duty of the complainant to

go through the terms and conditions of the policy for which a look out period has been provided and complainant could

have gone through the terms and conditions of the insurance policy after receiving the same and should have opted out

in respect of this policy if he was not agreeable for the said terms and conditions of the policy and the said terms and

conditions are detrimental to his interest. He has not exercised his right of look out period. He could have refused to

continue the policy. He has not done so. He is deemed to have accepted the terms and conditions of the policy and

agreed to pay the premiums to fulfil his part of the contract. After enjoying insurance cover for the premium period, he

is stopped now to request for refund of the said premium.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF






INSURANCE OMBUDSMAN, KOCHI



: Mr. T N PRASANNAKUMAR

THAYYIL HOUSE; THODUPUZHA;

IDUKKI;

2. Policy Number

: U330231756


: Mr. T N PRASANNAKUMAR


: Tata AIA Life Insurance Co. Ltd.


: 26.02.2021


: Non receipt of claim


: --

8. Date of hearing

: 23.04.2021



: Mr. T N Prasannakumar (Online)

b) For the Insurer :

Mr. P B Ganapathy(online)

AWARD


complaint is regarding non receipt of claim. The complainant, Mr. T N PRASANNAKUMAR is the father-in-law of the

policyholder who resides abroad.


TATA AIA life Insurance Policy No. U330231756 was availed from Cochin and was submitted for surrender in 2015. Rs.

69251/- was sent by cheque No. 69251/- to home address in Thodupuzha. Since he was at US and unaware of the

cheque, the same got stale and was presented for revalidation on 19.9.2019. Details of account in Catholic Syrian Bank,

Thodupuzha was given in company format to transfer the money. However, money was not credited. On enquiry, the

officials clarified that the above policy is closed and payment was given on 18.12.2018 for Rs. 76331.63 However, no

such credit is there in the account.

Approaching this Honourable Forum to direct the Insurer to settle the value at the earliest.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that the policy/product

was “Tata AIA Life Invest Assure II Policy”. The Life Assured Mr. Manoj Anikottil Raveendran has paid a total premium of

Rs. 60,000/- and the said policy was issued on 11-10-2007. The premium paying term was 20 years & policy term was 20

years in the said policy and Sum Assured of Rs. 2,00,000/-

The complainant has alleged that the LA has not received the surrender cheque though the initial payment of the

surrender cheque was sent to the customer and the same was not presented in time due to his negligence. However

basis a request from the customer and we being a customer delighted organisation have obliged and provided the revised

surrender cheque of Rs.76,331.63/- drawn on HDFC Bank dtd. 08-01-2018 bearing no. 603229. The said cheque has been

presented to Axis Bank, Thodupuzha branch on 31-01-2018. On presenting the said cheque the said amount has been

credited to the customer account and the clearance certificate for the same has been procured by TALIC which states

that the said cheque has been credited to Account no.00600350142659 and the Beneficiary name is mentioned as Manoj

Anikottil Raveendran and the presenting Bank is Axis Bank. Ltd, Thodupuzha.

In the circumstances and for the reasons as aforestated, we submit that this complaint is untenable and it is prayed that

the same may be dismissed after informing the complainant/customer to check for these details with his Bank.

3. I heard the Complainant and the Respondent Insurer through online hearing. The Complainant reiterated the facts in

the complaint and submitted that the policy holder had no account in Axis Bank and the claim of the Insurer to have

refunded the amount is not maintainable. The Respondent Insurer submitted that the company had revalidated the

surrender cheque of 2015 and issued fresh cheque along with added interest in 2018, which has been cleared.

4. The Insurer was provided 15 days time for getting the details of the bank account to which the amount has been

credited. However, on 12.5.2021 the complainant requested for withdrawal of the complaint on the reason that the

surrender cheque which was revalidated was credited to the family account of in the name of the father of the policy

holder. Since he was hospitalized due to heart problems, this information was not passed on to the son. However, on

realizing that the amount has been received, he requested for withdrawal of the complaint.


Dated this the 31st day of May, 2021.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. Zacharia George

Kandathilparambil House Edathua

South Edathua 689573

2. Policy Number

: 5854796


: Mr. Zacharia George


: ICICI Prudential Life Insurance Co. Ltd.

5. Date of receipt of Complaint : 01.04.2021


: Short fall in Surrender paid


: --

8. Date of hearing

:



: Settled before hearing


AWARD


complaint is regarding short fall in Surrender paid. The complainant, Mr. Zacharia George is the policyholder.


The Complainant stated that Policy No. 5854796 was surrendered on 16.7.2020 at ICICI Prudential Life Insurance,

Alappuzha Branch. As per the NAV for the fund for 16.7.2020, the value is Rs. 2478139.39 (NAV Rs. 85.5393 * 28970.77

units); whereas, the amount received was only Rs. 2447050.99. There is a short payment of Rs. 31088.30. In spite of

many follow ups, the Insurer was not willing to rectify the mistake.

Approaching this Honourable Forum to direct the Insurer to resolve the issue.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that The policyholder has

h i g h l i g h t e d concern with regards to the policy with details as mentioned in the t a b l e below. The

C o m p a n y was in receipt of duly s i g n e d application form along with the relevant supporting and KYCs for

issuance of the said po l icy . The policy n u m b er 05854796 was p r o p o s e d by Mr. Zacharia George (the

Policyholder/complainant) on the life of his spouse, Ms. Lagi Zacharia (the life assured)

Application number PP06928862 Disputed Policy Number 05854796 Name of the Proposer Mr. Zacharia George Name of the Life Assured Ms. Lagi Zacharia Plan name ICICI Pru Life Time Super Pension Sum Assured Zero death benefit Proposal Received date August 03, 2007 Risk commencement date August 03, 2007 Policy issuance Date August 05, 2007

Premium amount Rs.300,000/- Frequency mode Yearly Policy & Premium paying term 10 years Policy status Surrender on July 15, 2020 Policy document dispatch date August 17, 2007 Policyholder contact number 8113850642 Total disputed amount Rs.31,088.3/- (difference amount of fund value

dated July

15, 2020 and July 16, 2020) Policyholder’s Concern and

demand

Policyholder is in receipt of less surrender

value he has given the surrender request on

July 16,2020 however he is in receipt of

surrender amount (100% fund value) as per

the NAV of July 15, 20202 hence denuding

refund of difference amount of fund value

The policyholder had opted for a pension plan, ICICI Pru Life Time Super Pension policy number 05854796

issued on August 05, 2007 with an annual premium of Rs.300,000/- for 10 years premium paying and

policy term as mentioned in Table 1.

In consonance with the provisions of Regulation 6 (2) & 4 (1) of the Insurance Regulatory and Development

Authority (Protection of Policy Holder’s Interest) Regulations, 2002, the policy document along with the

copy of the proposal form was sent across at the policyholder registered communication address via

courier on August 17, 2007.

The Electronic Benefit Illustration (EBI) very clearly and in an illustrative manner explains the policy details,

premium payment term and premium frequency, the premium allocation charges etc.

The policyholder has paid the premiums for three policy years in the said policy. The total p r e m i u m s received

by t h e C o m p a n y including the first year premium is Rs.900,000/- (Rupees Nine Lakh Only) received

through cheque payment issued from Bank of Baroda.

The vesting date for the policy number 05854796 was on August 03, 2017 hence prior to the vesting

date proactive communication was sent to the policyholder’s registered email address

[email protected] on March 07, 2017 informing him about the various annuity options

available on policy maturity.

The Company has also initiated annuity call on “04772212099” prior to the policy vesting date, however

was unable to establish contact due to invalid number.

mailto:[email protected]

On July 05, 2017 the policyholder approached the Company requesting for vesting postponement for next

three years till August 03, 2020. Accordingly the Company had processed the request and the policy got

postponed till August 03, 2020 as per his request. The Company has sent the policy postponement

confirmation email to his registered email address [email protected] on July 14, 2017.

The policyholder has executed financial transactions like fund switch through website on March 27,

2020 wherein 100% funds was switched from Flexi Balanced Fund II to Pension Maximiser Fund.

The policyholder had requested for unit statement for the period January 01, 2020 to April 03, 2020 on

April 03, 2020. Accordingly the unit statement has been shared with the policyholder.

The policyholder had approached the Company’s touch point on July 11, 2020 stating that he is an

urgent of funds and enquiring policy related details like premature withdrawal and the applicable

taxes. Accordingly clarification was shared with the policyholder through email dated July 12, 2020.

On July 13, 2020 the policyholder approached the Company stating that in the current scenario

(COVID19) he is in need of funds and hence, would like to surrender the policy and submitted his

bank account details and KYC documents for processing the surrender request. Additionally he also

asked if there are any surrender charges applicable on policy surrender and informed that post receiving

the confirmation on the charges he will submit his written consent to surrender the said policy.

Simultaneously on J u l y 15, 2020 h e a g a i n approached the C o m p a n y asking to expedite the process

as he is in urgent need of funds and requested for NAV value as on dated July 15, 2020 with the clarification

about surrender charges or GST etc. is applicable on policy surrender.

On the basis of the email confirmation received on dated July 13, 2020 and July 15, 2020 asking to expedite

the process the Company has executed the surrender in the policy number 05854796 on July 15, 2020

and has processed the refund of surrender payout amounting to Rs.2,447,050.99/- (Rupees Twenty Four

Lakh Forty Seven Thousand Fifty and Ninety Nine Paise Only). The said amount has been processed and

credited via NEFT to the policyholder’s Bank of Baroda account number 2506XXXXXXX344 on July 23,

2020 and the payout detail was communicated to the policyholder via email on July 24, 2020.

Meanwhile, the Policyholder has visited our touch point (branch) on July 16, 2020 and has submitted the

policy surrender request documents to initiate further.

On July 30, 2020 i .e ., Post 7 days of receiving the surrender payout amount the policyholder approached

the Company stating that he is receipt of less surrender amount. Additionally he also claimed that he had

mailto:[email protected]

submitted the surrender request on July 16, 2020 by visiting our Company’s touch point (branch) and

demanding for the NAV benefit which has arrived as differential amount of Rs.31,088.3/-.

Post reviewing the details it was informed to the policyholder that the Company was in receipt of the

surrender request on July 15, 2020 via email accordingly the same was executed and the surrender

amount of Rs.2,447,050.99/- (100% fund value) has been processed and credited to his bank account. The

surrender amount has been initiated in lines of policy terms and condition and denied his demand for refund

for any a d d i t i o n a l amount. The c o m m u n i c a t i o n was sent via email on August 01, 2020.

The policyholder had approached the Company multiple times stating that he had approached the Company

earlier in July 2020 with the reconsideration request. However the Company has not addressed his

q u e r y completely and informed the policyholder that the surrender amount has been correctly processed

as per request received hence no additional amount is payable. We have taken this as learning and the

Company assures to take corrective actions to avoid such instances in future.

The policyholder has approached the Insurance Ombudsman office, Kochi in April 2021 that policyholder

has disputed on the NAV benefit stating he had given a policy surrender request on July 16, 2020

however his request is executed with a NAV dated of July 15, 2020. Post evaluating the above concern it

was identified that The policyholder was interacting with the Company’s touch point (email channel)

between July 11, 2020 and July 15, 2020 enquiring on the surrender process and the charges applicable.

In his email he mentioned that he wants to know the charges before he confirms on the surrender.

However here the touch point has assigned the said policy to trigger surrender and accordingly the

same got executed on July 15, 2020.

The next day the Policyholder has v is i ted our branch Alleppey (Kerala) and opted for surrender physically.

The branch triggered surrender online through Company’s website on July 16, 2020. Further it was also

identified that the transaction was triggered on July 15, 2020 as it was not authorized, system

allowed another touchpoint (branch) to trigger and authorized the surrender payout on July 16,

2020. Due to technical glitch we have identified that policyholder should get the NAV of July 16, 2020. The

difference in the NAV is Rs.31,088.54/- (Rupees Thirty One Thousand Eighty Eight and Fifty Four Paise Only).

The difference in amount as per calculation done from the fund value as on dated July 15, 2020 and

July 16, 2020 respectively is as below:

Fund Value Amount Date Fund Value Amount (Rs.)

Fund value as on July 15, 2020 (A) 24,47,050.99

Fund value as on July 16, 2020 (B) 24,78,139.53

Differential Amount (A-B) 31088.54

We have communicated the above decision for refund of difference amount to the policyholder via email

dated April 24, 2021 and has requested the policyholder to provide his consent to enable us to process

refund amount to his bank account. On receipt of the policyholder’s consent the Company shall credit the

differential loss amount of 31,088.54/-. A communication has b e e n sent to the p o l i c y h o l d e r via email

dated April 24, 2021.

While we accept the learnings and feedback with regards to the communications shared with the

policyholder and process, we humbly request the Honourable Ombudsman to consider the above

and below facts. Further, we assure to take corrective actions to ensure the same is not experienced

by our policyholders or claimants in future.

We have also shared the feedback with concerned team and the officials has been sensitised to ensure

that such instances do not occur again in future. We trust the Ombudsman Office shall find the above

response in order.

3. The Complainant vide his e-mail dated 3rd May, 2021 submitted that ICICI Prudential Life Insurance Co had contacted

him and resolved the issue by paying the balance amount due. The balance amount Rs 31088.54 was credited to his

account on 1st May 2021 and his complaint has been resolved. He requested to withdraw the complaint.

4. In the result, an AWARD is passed for Dismissal of the complaint.


Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF


(UNDER RULE NO. 13 1(d) READ WITH RULE 14 OF







: Mr. Elvin Robert

x1/584A(1),Chadayangat House T and R

Cross Road Thoppumpady Kochi

682005

2. Policy Number

: 3920673


: Mr. Elvin Robert


: Kotak Mahindra Life Insurance

Company


: 01.04.2021



premium


: --

8. Date of hearing

:



: Settled before hearing


AWARD

This is a complaint filed under Rule 13 1(d) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is cancellation of policy and refund of premium. The complainant, Mr. Elvin Robert is the policyholder.


The Complainant stated that the policy No. 3920673 was taken in his name from Kotak Mahindra Bank, Ernakulam Branch

in the month of December 2017 for Rs.1 lakh without his consent. He has not received the policy document of the policy

till now and he requested to cancel the policy using the Free look period option as soon as he came to know about this.

According to IRDAI guidelines, the Free look period allows to cancel the policy and get a refund within 15 days of receipt

of the policy document. Since he has not received the policy document, he wants to get the policy cancelled and get the

full refund. The Insurer has rejected the request and has not received a satisfactory response from the insurer despite

escalating to all levels in the grievance team of the insurer.

He already has a similar policy for which he is paying premiums since 2015 and hence not willing to continue with the

duplicate one which is issued in his name without his knowledge.

There was a debit from his account around December 2018 for Rs.1 lakh towards renewal premium for the above policy

and he was in the assumption that the renewal premium that has been auto debited from his account in 2018 is towards

his old policy which started in 2015. Since he has not received any policy document, he is completely unaware of the

policy.

Hence approaching this Honourable Forum to kindly investigate and issue orders for cancellation and refund of all the

premiums debited from his kotak mahindra bank account towards life insurance policy no. 03920673 with Kotak Life

Insurance.

2. The Respondent Insurer submitted via e-mail dated 3.5.2021 that the client has withdrawn the complaint in pursuance

to settlement payout of Rs.197848/- released to his preferred account on 30th April 2021. The Complainant also agreed

for resolving of his case.

3. In the result, an AWARD is passed for Dismissal of the complaint.


Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF


(UNDER RULE NO. 13 1(f) READ WITH RULE 14 OF







: Mr. RATHEESH KUMAR V

RENJITH BHAVANAM; MALLIKA;

THATTAYIL PO; ADOOR 691525

2. Policy Number

: 61886122


: Mr. RATHEESH KUMAR V


: ICICI Prudential Life Insurance Co. Ltd.


: 08.03.2021



premium


: --

8. Date of hearing

: 14.05.2021



: Mr. Ratheeshkumar V (online)

b) For the Insurer : Mr. Naveen (online)

AWARD

This is a complaint filed under Rule 13 1(f) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The

complaint is cancellation of policy and refund of premium. The complainant, Mr. RATHEESH KUMAR V is the policyholder.


The Complainant stated that he had a current account with ICICI Bank from which a deduction of Rs. 45925 was deducted

towards a Life Insurance policy, which was not required for me. When objected, the staff informed that it will be

cancelled and cash will be refunded within 7 days. No refund came and now the second instalment message is received.

The Manager has informed that nothing can be done now.

Approaching this Honourable forum to direct the Insurer to resolve the issue.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted that The policyholder

has highlighted concern with regards to the policy whose details are as given below:

Application number OS12422339 Disputed Policy Number 61886122

Name of the Proposer & Life Assured Mr. Ratheesh Kumar Plan name ICICI Pru iProtect Smart Sum Assured Rs.50,00,000/- Proposal Received date November 29, 2019 Risk commencement date December 28, 2019 Policy issuance Date December 28, 2019 Premium amount Rs.45,325 /- Frequency mode Yearly Policy term 49 years Premium paying term 10 years Policy status Lapsed Policy document dispatch date Digital policy document credited to Electronic

Insurance Account on December 31, 2019 to NSDL

account number 1000020896378

Policyholder contact number 8606013933 Total disputed amount Rs.45,325/- (total premium amount)

Policyholder’s Demand Policy cancellation and refund of total premium paid

The Company was in receipt of duly signed application form along with the relevant supporting and KYCs for

issuance of the said policy. The policy number 61886122 was opted on the life of Mr. Ratheesh Kumar

(hereinafter referred as the Policyholder, life assured and complainant).

Based on the information provided in the application form, the Company issued the policy number

61886122 with the annual premium, premium payment term and policy term as mentioned in the table

1.

In consonance with the provisions of Regulation 10 (1) (i) & 8 (1) of the Insurance Regulatory and

Development Authority of India (Protection of Policy Holder’s Interest) Regulations, 2017 the digital

welcome kit was credited to the policyholder’s Electronic Insurance Account (EIA) NSDL account

number 1000020896378 in accordance to table 1.

The Company has sent proactive SMS communications related to policy issuance, policy term and policy

document dispatch details on the mobile number "8606013933” mentioned on the application

form.

SMS sent on December 29, 2019

Dear Customer, Congratulations! your application for ICICI Pru iProtect Smart plan is accepted and your

policy is issued with policy no. 61886122.

SMS sent on January 2, 2020

Dear Customer, policy documents of your policy no. 61886122 are available on @link . Enter the first

four letters of your name in lower case and date of birth in ddmm format to view them now.

SMS sent on January 3,2020

Your ICICI Pru Life IPROTECT SMART policy No. 61886122 has been issued. Sum Assured: Rs. 5000000 .Policy

Term 49 years. Premium Amount: Rs. 45325 .Payment Frequency Yearly .Premium Due Date 28-Dec-

20 .For more details visit www.iciciprulife.com


http://www.iciciprulife.com/

Dear Customer, policy documents of your policy no. 61886122 are available on www.ipru.co/?iud8ajna.

Enter the first four letters of your name in lower case and date of birth in ddmm format to view them

now.


Your renewal premium of Rs. 45591 is due for ICICIPru policy 61886122. Kindly contact our Operations

Manager Sachin Jacob on 8289868783 today for assistance. T&C apply. Ignore if paid.


Attention!!! Your life cover of Rs 5000000 is no longer active due to non-payment of premium for your

ICICIPru policy 61886122. Pay premium of Rs 45607 online at www.ipru.co/?nzc8ssuw or call 1860-266-

7766 for payment assistance. Ignore if paid.

SMS sent on February 1, 2021

Welcome Kit for Policy No 61886122 dispatched on 27/01/2021 via Speed Post awb no EA053168612IN .You

will receive in 21 days. You can also track the status on www.indiapost.gov.in

SMS sent on February 11, 2021

We have not received premium of Rs 45716 for ICICIPru policy IPROTECT SMART, 61886122. Don't risk losing

benefit of life cover worth Rs 5000000. To pay online visit www.ipru.co/?ovb6swdu . T&C apply . Ignore if

paid.

SMS sent on March 3, 2021

Your ICICIPru IPROTECT SMART , 61886122 is lapsed. Total outstanding premium as on date is Rs.45898

including late fee of Rs.573 . Please pay immediately to restart life cover worth Rs.5000000 and avoid

higher late fee charges. To pay online www.ipru.co/?kjetn6lj . Ignore if paid.

As per terms and condit ions of the policy, in case of any disagreement with the policy, a policyholder is

required to approach the company within 30 days from the date of receipt of the policy document. We

hereby inform that the Company did not receive any complaint from you regarding the said matter

within the stipulated period thereby confirming that the terms and conditions were agreed upon.

http://www.ipru.co/?iud8ajna

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http://www.indiapost.gov.in/

http://www.ipru.co/?ovb6swdu

http://www.ipru.co/?kjetn6lj

The Company further submits that as per our records, the policyholder had never approached the

Company with any grievance regarding the subject policy within the stipulated period and also never

raised any dispute in regards to the subject policy. Only on December 11, 2020 i.e., after eleven months

and 15 days the policyholder approached, expressing dissatisfaction against the said policy and

demanding cancellation and refund of premium paid.

Post reviewing the policyholder’s concern and considering all the above facts mentioned above

the Company had denied the allegations raised by the policyholder since the request for policy

cancellation was received beyond free look period and the policy related details were sent to the

policyholder via SMS’s on his registered number update in the proposal form. The decline decision was

communicated with the policyholder via email on December 13, 2020.

The policyholder had approached the senior management in month of January 2021 stating non receipt

of policy documents and demanded cancellation and refund. As no additional facts were identified,

the Company stood by the decision and triggered acknowledgement slip for request places for

cancellation in freelook and necessary clarification was shared via email.

The policyholder has approached the Insurance Ombudsman office, Kochi in April 2021 with the

aforementioned concern. We have reviewed the details and state the following:

a. The policy w a s i s s u e d basis policyholder’s consent and p o l i c y d o c u m e n t was delivered at

the registered communication address. Details of the same are already stated in the letter

above.

b. The SMS and email pertaining to policy issuance, policy document dispatch details, policy term, next

premium due date were sent to the policyholder’s registered mobile number and email address.

c. The policyholder did not raise any concern within the free

Look period

d. The Company had also dispatched the Physical policy document via Ordinary post to the

policyholder’s registered communication address on January 6, 2020.

e. Policyholder is an educated person and salaried with good income. He has given the consent

for the issuance of the said policy and signed all relevant documents and also paid the

premium amount.

Considering all the above facts we decline the policyholder’s demand for refund of any amount.

It is stated that Insurance being a contract between the Policyholder and the Company, both

parties are governed by the terms and conditions mentioned in the policy document and all the

benefits are payable as per the said policy terms and conditions. In view of the same, the Company

is not liable to make any payment to the policyholder.

3. I heard the Complainant and the Respondent Insurer through online hearing held on 14.5.2021. The Complainant

submitted that he was working in Kuwait and was having savings account in ICICI Bank. Policy was canvassed by the Bank

officials while he came on leave. However, the next day itself had requested them to cancel the policy. However, he

admitted that no written request was given for cancellation within the free look period. He expected the Bank officials

to send cancellation request. The Respondent Insurer submitted that there was no free look cancellation request made

by the complainant. Policy was issued based on the duly signed application form along with relevant documents.

4. In the facts and circumstances of the case and the submission made by either party during the hearing, the

undersigned is convinced that the Insurer has acted as per the terms and conditions of the policy. The complainant has

not submitted any cancellation request in writing during the free look cancellation period. Though he informed the bank

officials for cancellation of policy, there was no tangible material to infer that the request was made in writing within the

stipulated period. As per section 10(1) of IRDAI (Protection of Policyholders Interests) Regulations, 2017 the policyholder

has a free look period of 15 days (30 days in case of electronic policies and policies obtained through distance mode)

from the date of receipt of the policy document, to review the terms and conditions of the policy and where the

policyholder disagrees to any of those terms or conditions, he has the option to return the policy to the insurer for

cancellation. The complainant has not done so. Once ‘cooling off’ period of 15 days is over, policy documents become

binding on both the parties and the contents therein are also biding on both. Hence, there is no interference warranted

against the action of the Insurer who has acted as per the terms and conditions of the policy.



(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF









: Mr. C.Mohan

Chief Manager(Audit) State Bank of

India FIMM,RBO 2, Kurunji

Complex,Coimbatore 641018

2. Policy Number

: 794162033, 794163061


: Mr. C.Mohan


: LIC of India


: 01.04.2021


: To refund the excess loan interest

collected


: --

8. Date of hearing

: 27.04.2021


e) For the Complainant

: Mr. C Mohan(Online)

f) For the Insurer : Ms. Salaja (online)

AWARD


complaint is to refund the excess loan interest collected. The complainant, Mr. C.Mohan is the policyholder.


The Complainant stated that he had two insurance policy no794162033 and 794163061 which matured in 2019 and

2020.Loan was availed from these policies but not a single reminder for loan interest dues was received from the

respondent insurer. On maturity of policy no 794163061 35% interest was charged as loan interest on maturity. Policy

no794162033 is still in force but the policy certificate is not returned even after the loan is closed. Many mails were sent

to the Kollam branch for the maturity amount and to reduce the loan interest also. This issue was taken up with

CRM(customer redressal manager) and Divisional Manager. But the result was not there. Hence request the forum to

intervene recalculate the loan interest and refund the excess amount collected.

2. The Respondent Insurer entered appearance and filed a self contained note. It is submitted the facts and circumstances

of the case.

Policy No. 794162033 Kollam No 2 Branch

Plan &Term 149 (JeevanAnand)16 years-SSS

Sum Assured 150000

Date of Commencement 06/11/2003

Date of Maturity 06/11/2019

Loan taken on 17/04/2012 Rs. 73000/-

Maturity amount Paid on 19/08/2020

Rs 116235/-

Gross amount Rs 260250/-

Loan and Loan Interest deducted Rs 144015/-

Policy No. 794163061 Kollam No 2 Branch

Plan &Term 90-16

Sum Assured 100000

Date of Commencement 28/07/2004

Date of Maturity 28/07/2020

Loan taken on 17/04/2012 Rs. 35000/-

Maturity amount Paid on 12/10/2020

Rs 96559/-

Gross amount Rs 170800/-

Loan and Loan Interest deducted Rs 74241/-

The loan under the policy was taken on 17/04/2012 from Kannur 2 Branch. No interest was paid against the loan from

the date of loan. Loan interest accrued @ 9 % compounding half yearly amounting to Rs 68947/- along with loan amount

of Rs 73000/- was recovered from Maturity amount and the claim was settled on 19/08/2020. The Policy docket on

transfer in was misplaced and the Branch was unable to locate the same at the time of settlement of claim.

However the Branch is now ready with the policy bond and will be dispatched to his address.

Regarding Policy No 794163061, the policy has matured on 28/07/2020 and the claim was settled on 12/10/2020. A loan

of Rs 35000/- was taken from the policy on 17/04/2012 and no interest was paid against the loan.

LIC did not have a systematic procedure for sending default notices for loan interest dues. Loan interest default

intimation was send along with premium notices for premiums which are being paid directly. No separate notices are

being sent. The cited policy being a SSS policy no intimation for payment of loan interest was sent to the complainant.

However while issuing loan cheque, a separate covering letter will be issued to the policyholder mentioned the amount

and dates on which the interest is to be paid.

As such the amount of loan and loan interest deducted from Claim amount for both the policies is correct and no refunds

can be made to the complainant.

Based on the above facts, we would request you to kindly consider the material facts at the time of judgement.

3. I heard the Complainant and the Respondent Insurer. The Complainant submitted the points mentioned in the

averments and reiterated that in spite of repeated mails did not get a proper a response. The Respondent Insurer

submitted the calculation of loan interest to the forum as given below and confirmed that the loan interest was taken

till date of maturity as per the loan terms and conditions.

LOAN & LOAN INTEREST CALUCALTION UNDER POL.NO.794162033

Date of Maturity 06.11.2019

Date of Loan 17.04.2012

15 Hlf years and 19 days @ 9%

Loan Outstanding 73000/-

1.93527 x 73000

141274.71

141274.71 x 9 x 19

100 360

671.05

Total Loan with Interest = 141274.71 + 671.05 = 141945.76

Total recovery made from MC = 141946 + 2068 (2 Unpaid premia @ 1034/-) = 144014

LOAN & LOAN INTEREST CALUCALTION UNDER POL.NO.794163061

Date of Maturity 28.07.2020

Date of Loan 17.04.2012

16 Hlf years and 101 days @ 9%

Loan Outstanding 35000/-

2.02236 x 35000

70782.6

70782.60 x 9 x 101

100 360

1787.26

Total Loan with Interest = 70782.60 + 1787.26 = 72569.86

Total recovery made from MC = 72570 + 1671 (1 Unpaid premia) = 74241/-

The respondent company has quoted the penal interest for both the policies on forums direction.

Policy number 794162033=5993

Policy number 794163061=1302.

4. It is clear from the submission that the loan interest was calculated as per the loan terms till date of maturity .But

claim settlement was not properly followed up and the latest communication to the complainant that could be submitted

to the forum regarding the same is 13.8.2020.Hence the forum directs the respondent insurer to settle the penal interest

for the delayed payment for both the policies

In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.7295/- , within the period

mentioned hereunder. No cost.




Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,

MUMBAI (MUMBAI METRO & GOA)

(UNDER RULE NO. 16(1)17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – SHRI VINAY SAH

Complaint No.: MUM-L-029-2122-0127

Award No: IO/MUM/A/LI/O0 /2021-22

Complainant: Mr. N.J.Motiwala

Respondent: LIC of India

Name and address of the complainant Mr. N.J.Motiwala / Mumbai

Policy No. 909929543

Name of Insured, DOB, Age at proposal Late Mrinalini J.Motiwala , 29.11.1923, 94 yrs

Date of commencement 23.7.2018

Name of the Insurer LIC of India

Date of Death 25.1.2019

Plan and Premium paying term LIC’s Jeevan Akshay VI ( 189 Plan)

Purchase Price, Annuity Amt and its

Mode

3Lacs, Rs. 22155 , Yearly Mode

Date of first Annuity Payment 23.7.2019

Date of receipt of the complaint at GRO 23.1.2021

Date of receipt of the complaint at OIO 1.2.2021

Nature of Complaint Non Receipt of annuity for period from 23.7.2018 to

25.1.2019

Amount of relief sought 11500/-

Rule of Insurance Ombudsman Rules,

2017 under which the complaint was

registered

13(1) (b)

Date of hearing/ place 31.5.2021 / Mumbai ( On Line)

Representation at the hearing

a) For the complainant Mr. N.J.Motiwala

b) For the Insurer Ms. Savita Joshi

Complaint how disposed By issuing the Award

Date of Award 31.5.2021

1. Contentions of the complainant:

The complainant, Mr.Nitin Motiwala ,nominee under the policy , stated that hisMother had purchased the

above policy in July 2018 by investing Rs. 3 Lacs plus GST wherein first annuity was payable on

23.7.2019.However, she expired on 25.1.2019.LIC had settled the death claim for only Rs. 3 Lacs but did not

pay any interest.It was told to him that as she had opted for yearly payment of Annuity and she expired within

1 year, she was not entitled for annuity.Complainant followed up the issue with higher office. He argued that

at the time of sale, the fact that under yearly option of annuity, paymentwould commence after completion

of 1 year , was not properly conveyed. Had it were explainedproperly, she would have chosen the option as

Monthly / Quarterly. As such no pension was paid to her.Instead there is loss of Rs. 5040/- paid by her towards

GST at the time of proposal.As the company had held the money since July 2018 till death, he has requested

to pay the annuity from the date of commencement of policy till date of death.LIC rejected the request saying

that the annuitant had exercised F type Annuity option.As per the said option, annuity payments would have

been paid as long as Annuitant were alive. The annuity payment would cease on the death of the Annuitant

and purchase price would have been payable to the nominee.Further, as per terms and conditions of the policy

annuity in part is not payable.As in the proposal form there is no mention anywhere that no annuity will be

payable for the period between preceding annuity payment and the date of death,he requested the forum to

help him to get relief.

2. Contentions of the Respondent:

The Respondent contended vide SCN dt. 11.2.2021 that the policy was issued under Immediate Annuity plan

189-1 ( Jeevan Akshay –VI ) with date of commencement as 23/07/2018 for purchase price Rs 3,00,000/-. In

the proposal form, the mode of Annuity payment was opted as Yearly.First Annuity Installment was due on

23/07/2019 but the policy resulted into claim due to death of Annuitant on 25.1.2019 and death intimation

was received by company on 16.2.2019 .

The F type Annuity option was exercised by the Annuitant . As per the said F option , Annuity payments will

be paid as long the Annuitant is alive . The Annuity payment will cease on the death of Annuitant and the

purchase price will be payable to the nominee .

Since date of death of Annuitant was before the due date of Annuity installment the same was not payable .

In regard to complainant’s claim for Annuity amt for the period 23.7.2018 till death of death , as per the terms

of policy conditions as enumerated in first Page , first Para itself which states that, “But where the annuity

ceases on the death of Annuitant ,no part of the said annuity shall be payable or paid for such time as may

elapse between the date of payment immediately preceding the death of Annuitant and day of his/her

death.”So ,as per the terms and condition of the policy , annuity in part for the period from 23.7.2018 to the

date of death of the Annuitant is not payable.

Further, the policy was issued with the provision of “Free Look Period” clearly means that the policyholder had

option to return the policy document and claim the refund of premium deposited during the free Look Period

of 15 days after receipt of policy document, if Terms and Conditions were not agreeable. Policyholder did not

exercise the said option. Complaint may therefore be dismissed.

3. Observations and conclusions:

After going through the documents on records and from the submissions made, the forum observed that:

1. The complainant’s Mother, Late Mrinalini Motiwala had purchased the above policy in July 2018with purchase price of 3 Lacs and annuity of Rs. 22,155/- payable yearly.

2. Annuitant expired on 25.1.2019 and Death intimation had been received by the company on 16.2.2019. 3. As the mode of payment of annuity was yearly, an annuity of Rs. 22,155/- due on 23.7.2019 is not

payable in view of the death of annuitant on 25.1.2019 4. On the First Page First Para of the policy bond, it is mentioned that “But where the annuity ceases or

determines on the death of Annuitant ,no part of the said annuity shall be payable or paid for such time as may elapse between the date of payment immediately preceding the death of Annuitant and day of his/her death, the subsistence of life of the annuitant at twelve o’clock on the day on which the said annuity falls due being duly certified from time to time in such manner as the corporation may require”

5. Proposal form is a basis of contract and policy bond is a legal document predominantly contains the conditions and privileges available to the policyholder.

Thusthe settlement of death claimby the Respondent is done as per the terms and conditions mentioned in

the policy and cannot be faulted with.

Considering the above facts, the Forum awards as follows:

AWARD

Under the facts and circumstances of the case, the complaint is not sustainable and the case is disposed of

accordingly.

It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him,

if he so decides to move any other Forum/Court as he may consider appropriate under the law of the land

against the Respondent insurer.

The attention of the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules,

2017:

a. As per Rule 17(6) of the said rules the Insurer shall comply with the award within thirty days of the receipt

of the award and intimate compliance of the same to the Ombudsman.

b. As per Rule 17(8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Mumbai, this 31st day of May, 2021.

(Vinay Sah)

INSURANCE OMBUDSMAN, MUMBAI

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands)

(UNDERRULENO.16/17OFTHEINSURANCEOMBUDSMANRULES, 2017)

Ombudsman Name: P.K.RATH

CASEOFCOMPLAINANT– MR. RAJDIP DATTA

VS

RESPONDENT: LIFE INS. CORPN. OF INDIA, KMDO-I.

COMPLAINT REF: NO: KOL-L-029-2021-1076

AWARD NO: IO/KOL/A/LI/0113/2021-2022

1. Name &Address of The Complainant : MR. RAJDIP DATTA C/o - Chunilal Dutta, Madhusudan Sarani, North

Ghoshpara, Bally, PS - Nischinda, Howrah-711227.

2.

Type Of Policy: Life / Health / General : LIFE.

Policy Details: Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term 4O9269958 200000 28.1O.2O2O 16O69 75 15

3. Name of insured : MR RAJDIP DATTA

4. Name of the insurer : IFE INS. CORPN. OF INDIA.

5. Date of receipt of the Complaint O2-March-2021

6. Nature of Complaint : Name of Police Station not corrected properly in the

Policy Bond and wants a fresh Policy Bond.

7. Amount of Claim 0.00

8. Date of Partial Settlement :

9. Amount of relief sought :

10. Complaint registered under Insurance : Ombudsman Rules 2017

13 (1) (g).

11. Date of hearing Place of hearing

19-May-2021/27.05.2021

Kolkata


a)For the Complainant : MR. RAJDIP DATA

b)For the Insurer : MR. AMIT BISWAS

13. Complaint how disposed : By conducting online hearing

14. Date of Award : 28-May-2021

Brief Facts of the Case:

1. Complainant took the policy in question on 28.10.2020.

2. On getting the policy bond found that name of Police Station wrongly entered as Nadia instead of ARAMBAG.

3. On request necessary correction made in the policy master but manual correction in Policy Bond again wrongly corrected as AMAMBAG instead of ARAMBAG.

4. Being dissatisfied with the servicing of the insurer he demands for issue of fresh Policy Bond with proper correction in the address portion to avoid future complications.

5. Appealed before the insurer for fresh policy bond on 07.01.2021 but no response received from the insurer.

6. As per SCN received from the insurer they have made necessary correction in the policy master and requested policyholder to send the original policy bond for necessary correction but no policy bond received. On getting the policy bond necessary correction will be made.

Contention of the complainant:

The complainant alleged that on getting the policy bond he noticed that Name of Policy Station wrongly entered as Nadia instead of ARAMBAG. On request necessary correction made in the Policy Master but Manual Correction made in the Policy Bond again wrongly made as AMAMBAG instead of ARAMBAG. Being dissatisfied with the servicing of the insurer appealed before the insurer on 7.1.2O21for issue of fresh Policy Bond with proper address to avoid future complications but no response received from the insurer.

Being aggrieved appealed before this office for redress of the matter.

Contention of the Respondent:

AS per SCN received from the insurer, they have made necessary correction in the policy master and requested life assured to send the original policy bond for necessary correction but no policy bond received till date. On getting the policy bond from the life assured, they will certainly make necessary correction in the policy bond.

Observation and conclusions:

It is observed that necessary correction has already been made in the policy master but not in the policy bond. Insurer is ready to make necessary correction in the policy bond only on getting the policy bond

from the life assured but the life assured is not willing to get the corrected policy bond and wants to get a fresh policy bond and for that he is ready to bear the necessary cost in this regard.

AWARD

Taking into account the facts and circumstances of the case, the submissions made by both the

parties present during the course of hearing and after going through all relevant documents on

record, it is observed that the life assured under the policy is willing to get one fresh policy

bond with correct name of Police Station and ready to bear necessary cost. In view of the above

fact, I am of opinion that since the life assured under the policy is ready to bear necessary total

cost to issue a fresh Policy Bond, the insurer is directed to issue a fresh Policy Bond with correct

name of Police Station, on getting the necessary total cost involved to issue a fresh Policy Bond

and receiving of Original Policy Bond from the life assured at the earliest with an intimation to

this office. The insurer is also requested to issue a suitable letter to the life assured under the

policy mentioning total amount to be deposited with break up figure to issue a fresh policy

bond.

Hence, the complaint is disposed of.

22) The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rule 2017.

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of the receipt of the

acceptance letter of the Complainant and shall intimate the compliance to the Ombudsman.

Dated at Kolkata on 28th Day of May, 2021

SHRI P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands) (UNDER

RULE NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman Name: P. K. RATH

CASE OF COMPLAINANT– Rashi Mundhra

VS

RESPONDENT: IDBI Federal Life Ins.Co.Ltd.



1.

Name & Address of The Complainant Rashi Mundhra BA - 48, Salt Lake City, Sector - I, 1st Floor, Kolkata - 700 064.

2.

Type of Policy: Life

Policy Details: Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term 4001125282 2017 100000 07

3. Name of insured Rashi Mundhra

4. Name of the insurer IDBI Federal Life Ins.Co.Ltd.


6. Nature of Complaint Policy servicing related grievances against insurers

and their agents and intermediaries.


8. Date of Partial Settlement NIL

9. Amount of relief sought Rs.100000.00

10. Complaint registered under Insurance Ombudsman Rules 2017

Rule 13(1)(f)


19.05.2021

Kolkata


a) For the Complainant Mrs. Rashi Mundhra

b) For the Insurer Ms. Yuri Jain

13. Complaint how disposed By conducting online hearing

14. Date of Award 26.05.2021


1. The complainant alleges that in spite of paying three premiums the Insurance Company terminated the policy.

2. The policy is with lapsed status and the Company offered her to revive it with Rs.295694.00 and necessary documents against three outstanding installments on 20.11.2020. A series of emails were exchanged between the two sides.

3. Being house wife she is afraid of losing the hard earned money paid as premium as the policy

stands terminated due to non- payment of due premiums.

4. Finally approached to this Office on 22.02.2021


1. The complainant mentions that she wants to get back Rs.100000.00.

2. During hearing, the complainant has argued for compensation against the harassment she faced.


No Self- Contained Note has been submitted by the Insurance Company.

Instead informed through a mail dated 12.05.2021, they have initiated a settlement with the complainant and

agreed to cancel the existing policy and issued a fresh policy bearing no.4001444646, single premium ULIP

policy with the consent of the complainant.

Accordingly, the old policy stands cancelled and the new policy on life of Mrs. Rushi Munddhra commenced on

31.03.2021 with Rs.100000.00 single premium.

The complainant being agreed to this, still expressed interest to participate in the hearing on 19.05.2021.


Both the parties attended the on-line hearing on 19.05.2021.

The representative of the Insurance Company mentioned that with the consent and duly signed Proposal Form, by the complainant they issued a new policy of Rs.100000.00 single premium on life of Mrs. Rushi Munddhra commenced on 31.03.2021. It was also stated that some amount that was deposited by the complainant for revival, has been refunded to the complainant and provided proof of it via email dated 21.05.2021. The old policy has been cancelled by the Company and the copy of the new policy has been produced to this office on 12.05.2021, through Email.

AWARD

Taking into account the facts & circumstances of the case, the submissions made by both the parties during the

course of hearing and after going through the documents on record it is observed that the Complainant made

allegation of termination of the policy and fear of losing money invested.

As both the parties have agreed to settle the above Complaint, the Company has already converted the amount

towards a single policy of Rs.100000/- on the life of the complainant, the case is dismissed without providing any

relief to the Complainant.

Hence, the Complaint is treated as disposed of.

Dated at Kolkata SHRI P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands) (UNDER

RULE NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman Name: P. K. RATH

CASE OF COMPLAINANT– Manoj Kumar Gupta

VS

RESPONDENT: Kotak Mahindra Life Insurance Company



1.

Name & Address of The Complainant Manoj Kumar Gupta Baneshwar More, Siliguri, Near Siliguri Decor, Siligui - 734 006.

2.

Type of Policy: Life

Policy Details: Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term

74251842 1250500 31.03.2020 31.03.2048 31.03.2020 156953 28/ YLY 10

3. Name of insured Manoj Kumar Gupta

4. Name of the insurer Kotak Mahindra Life Insurance Company


6. Nature of Complaint Policy servicing related grievances


8. Date of Partial Settlement NIL

9. Amount of relief sought 0.00


Rule 13(1)(f)- Policy servicing related grievances against insurers and their agents and intermediaries.


19.05.2021

Kolkata


c) For the Complainant Mr. Manoj Kumar Gupta

d) For the Insurer Ms. Nivedita Bhattachatjee


14. Date of Award 26.05.2021


1. The Complainant, Sri Manoj Kumar Gupta purchased one Unit Linked Policy bearing no.74251842, commenced on 3103.2020. 2. The policy was sourced through Kotak Mahindra Bank Ltd. 3. It is alleged that the Complainant received the har copy of the policy on 07.11.2020 and applied for cooling off on 13.11.2020 citing the cause that the terms and conditions were not suitable for him. He also mentioned that it would not be possible for him to continue with such high premium for a long period as his business was not running well due to Covid situation. 4. The Complainant also sent two emails on 08.01.2021 & 07.02.2021 to the Insurance Company. 6. Finally, not getting any positive response from the Company, he approached this office on 26.02.2021.


The complainant mentions that, 1. He applied for cancellation of the policy he purchased within the Free Look Period but, the Company denied the claim. 2. He wants the refund of premium paid and cancellation of the policies.

Contention of the Respondent: The Insurance Company stated in their Self-Contained Note that,

1. After understanding that it was a life insurance plan, the complainant signed and executed the Proposal Form where the plan opted for, the no. and quantum of premiums he would have to pay were mentioned.

2. As per circular dated 30.03.2020 as a consequence of the ongoing Covid crisis, IRDAI had allowed delivery of electronic copies of the policy contract wherever the email id of

the policy holder is available. In this case the complainant has not disputed the correctness of his registered email id.

3. After receiving the proposal and other required documents through digital mode, the policy was dispatched via electronic mode and delivered at the registered email id of the complainant. But he has admitted that he could not check the same due to lack of awareness of the same.

4. As the email id provided by the complainant is of his business, it is illogical proposition that he would not check the same on a regular basis and hence refuted.

5. The first letter written to the Company seeking cancellation was in 25.08.2020 which was 2 months prior to the receipt of the physical copy which indicates that on the basis of electronic copy he requested for cancellation. But as it was beyond the FLP of 30 days, the same was not tenable.

6. urther it has to be mentioned that along with the physical copy, the covering letter attached, notifying that the FLP was applicable from the delivery of email.

7. The premium is given by the insured, to cover the risk for a given period, and the insurer covers the risk for the period for which the premium has been paid and hence since the risk stood covered for the period for which premium has been paid, no right to claim repayment of the premiums paid towards the subject policy.

8. As the complaint is devoid of merits, it deserves to be dismissed by the Hon’ble Ombudsman.


1. Both the parties attended the on-line hearing on 19.05.2021.

1.

2. The complainant has narrated the story of mis-selling of the policy on the pretext of providing security against bank loan. Being a rice mill owner, his earning has gone down due to Covid situation. He wanted to cancel the policy as not suitable for him.

3. The representative of the Insurance Company reiterated the same points mentioned in their SCN and vehemently denied the allegations. She has pointed out that, the email id is used for the business purpose of the complainant and the date of first complain in August, 2020 indicates that he received the policy documents via email after commencement in March, 2020. Moreover, the complainant did not mention anything about bank loan in his complaint. The income of the Complainant is Rs.1200000/- as per Proposal Form indicates he has the capacity of paying the premium.

AWARD

Taking into account the facts & circumstances of the case, the submissions made by both the parties during the course of hearing and after going through the documents on record it is observed that the Complainant received the digital copy of the policy document through email after commencement of the policy. As no merit was found in this case and the Complainant failed to substantiate his allegation of mis-selling and lack of servicing against the respondent Company with any documentary evidence, the case is dismissed without providing any relief to the Complainant. Hence, the Complaint is treated as disposed of.

Dated at Kolkata

SHRI P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands) (UNDER RULE

NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman Name : P.K.RATH

CASE OF COMPLAINANT – Bibhudan Bera

VS

RESPONDENT: Life Insurance Corporation of India (Kharagpur)

COMPLAINT REF: NO: KOL-L-029-2021-1019 AWARD NO: IO/KOL/A/LI/ 0106 /2021-2022

1.

Name & Address Of The Complainant Bibhudan Bera Vill+ PS: Bhabanipur PO: Debhog, Dist: Purba Medinipur - 721 657.

2.

Type Of Policy: Life

Policy Details:

3. Name of insured Bibhudan Bera & Kalyani Bera (wife)

4. Name of the insurer Life Insurance Corporation of India (Kharagpur)

5. Date of receipt of the Complaint 15-Feb-2021

Policy Number Major Surgical Benefit From Date To Date DOC Premium Policy Term Paying Term

499722562 5 lac / 2 lac 31-Jul-2012 31-Jul-2024 31-Jul-2012 20000 12/Yearly 12

6. Nature of Complaint Repudiation of claim under health insurance policy

7. Amount of Claim 32200

8. Date of Partial Settlement

9. Amount of relief sought 29000


Rule 13(1)(b) — any partial or total repudiation of claims by an insurer.


12-May-2021 Kolkata


a)For the Complainant Shri Bibhudan Bera

b)For the Insurer Shri G. P. Roy


14. Date of Award 24-May-2021


i) The Complainant, Sri Bibhudan Bera, purchased one unit linked health insurance policy bearing no. 499722562 from Haldia Branch of Life Insurance Corporation of India on 31.07.2012. ii) The policy was issued on the lives of Sri Bibhudan Bera (Principal Insured) and Smt Kalyani Bera, his wife, for Major Surgical Benefits of Rs.5 lac and Rs.2 lac respectively with yearly premium of Rs.20,000/- for a term of 12 years. iii) Sri Bibhudan Bera was admitted to Minimal Access Surgery Clinic Pvt. Ltd. At Tamluk on 05.03.20219 to undergo Hernioplasty and was discharged on 08.03.2019. iv) He applied for reimbursement of hospitalization expenses amounting to Rs.32,2000/- on 23.07.2019 which was declined by the Insurer vide their letter dated 19.10.2020 due to non-disclosure of pre-existing illness in the proposal form submitted by the Complainant while purchasing the policy. v) The Complainant was aggrieved by the decision of the Insurer and lodged his complaint to this office on 15.02.2021 for redressal.


i) That he purchased the health policy on 31.07.2012 and was operated on 05.03.2019. ii) That the claim had been made after 6 years of issuance of the policy which was rejected on the ground of suppression of previous illness iii) That he had undergone an operation 12 years prior to this policy which should not be considered for settling the present claim. iv) That though he paid a total premium of Rs.1,80,000/- @ Rs.20,000/- for 9 years but the Insurance Company denied to settle the claim of Rs.29,000/-.

Contention of the Respondent: The contention of the Insurance Company according to their Self-Contained Note (SCN) dated 15.03.2021 is as follows: i) That the Complainant, Sri Bibhudan Bera, took a health policy (Health Protection Plus) bearing no. 499722562 on 31.07.2012 being the principal insured along with his wife Smt. Kalyani Bera as other insured member. ii) That the Insurer received the claim from the Complainant on 23.07.2019. iii) That as per the discharge summary dtd.08.03.2019 issued by Minimal Access Surgery Clinic Pvt. Ltd., he was diagnosed with Left Inguinal Hernia (LIH) & Left Ventricular Hypertrophy (LVH), underwent Hernioplasty + Eversion of sac under SA. iv) That he had history of surgery for hernia before 10 years i.e., before the date of commencement of the policy (31.07.2012) and the same was not disclosed in the proposal form signed by the complainant. v) That is suppression of material fact which had a bearing on underwriting decision towards acceptance of the proposal. vi) That the non-disclosure of material facts (previous disease/sickness/surgery) comes under the clause pre-existing disease and accordingly the same is rejected under code H01 i.e. PED, Pre-existing illness irrespective of prior treatment or advice, applicable under the plan. vii) That the claim was repudiated and the policy becomes void from the date of decision i.e. 14.10.2020 as per terms and conditions of the policy.


Both the parties attended the online hearing on 12.05.2021.

The Complainant, Shri Bibhudan Bera, admitted that he underwent hernioplasty way back in 1994 i.e. almost

18 years before taking this policy in 2012 and hence it was mentioned as recurring hernia in the discharge

certificate of his hospitalization in respect of present claim for hernioplasty done on 05.03.2019. He stated

that he was intimated about the repudiation of his claim and cancellation of policy thereof by LIC of India

after one year of submission of his claim and consequently he had deposited one more installment of

premium in between.

The representative of the Insurance Company clarified that the Complainant did not disclose the previous

history of hernioplasty in the proposal form while taking the policy in 2012 which constrained the insurer in

proper assessment of risk during acceptance of the proposal. Hence, the claim was repudiated as per policy

terms and conditions.

AWARD

Taking into account the facts & circumstances of the case, the submissions made by both the parties during

the course of hearing and after going through the documents on record it is observed that the claim in

respect of undergoing hernioplasty and eversion of Sac pertaining to health insurance policy of the

Complainant, Sri Bibhudan Bera, was repudiated by the Insurer on the ground of non-disclosure of material

fact regarding pre-existing disease. It is noted that the letter of repudiation was issued by the Insurer on

19.10.2020 i.e. almost 15 months after submission of claim and cancelled the policy w.e.f. 14.10.2020

without refunding the premium accepted subsequent to the date of claim. It is also noted that the policy

was issued on 31.07.2012 and the claim preferred by the Complainant for undergoing hernioplasty on

05.03.2019 i.e. more than 6½ years of taking the policy.

As such the decision of repudiation of claim due to non-disclosure of previous history of surgery way back in

1994 is in violation with Section 45 of Insurance Act and the cancellation of policy effected by the Insurer is

not justified as the repudiation was decided on the basis of non-disclosure of pre-existing disease.

Hence, the claim is admissible on principle and the Insurance Company is directed to settle the claim as per

terms and condition of the plan with reinstatement of the policy.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance




Sd/-

Dated at Kolkata on 24th Day of May 2021 SHRI P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,Kolkata (States of West Bengal, Sikkim and Union Territories of Andaman & Nicobar Islands) (UNDER RULE

NO.16/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

Ombudsman Name: P.K.RATH

CASE OF COMPLAINANT – SRI SUJAY PAL

VS

RESPONDENT: Reliance Nippon Life Insurance Co. Ltd. (Mumbai)



1.

Name & Address Of The Complainant Sri Sujay pal C/o - Anil Krisha Mandal, Sujay Pal Andul Golapbagan, Andul Mouri, Sankrail, Howrah - 711 302.

2.

Type Of Policy: Life

Policy Details: Policy Number Sum Assured From Date To Date DOC Premium Policy Term Paying Term

18396887 282962 12.01.2011 12.01.2021 12.01.2011 25101 10/Y 5

3. Name of insured Mr. SUJAY PAL

4. Name of the insurer Reliance Nippon Life Insurance Co. Ltd. (Mumbai)

5. Date of receipt of the Complaint 19-FEB-2021

6. Nature of Complaint Non receipt of Rs 282962, the Sum assured on date of maturity.


8. Date of Partial Settlement

9. Amount of relief sought 282962


13(1)(f )


12-May-2021

Kolkata


a)For the Complainant Mr. Sujay Pal

b)For the Insurer Mr. Shadab Hussaini

13. Complaint how disposed By conducting online hearing om 12.05.2021

14. Date of Award 31st-May-2021


Sri Sujay Pal purchased instant policy under Reliance Super Five Plus which commenced on 12.01.2011, premium payable@75000/- for 5 years till due 2015. Mr Pal paid all 5 years annual premium & in January 2016 received the Sum Assured amount of Rs 282962/- being the survival benefit amount at end of premium paying term.

Thereafter at end of policy term that is 12.01.2021 Mr Pal received an amount of Rs 104646/- being the accrued bonus on the said policy, payable on maturity as per policy condition.

Complainant alleges that as per third page of main policy bond, benefit payable on maturity is Sum assured & accrued bonus. Aggrieved he wrote an email to Reliance on 18.01.2021 & Company responded on 02.02.2021 that payments are correctly made & that they are unable to comply with his request. Thereafter some more email exchanges has been made between both parties. Among these emails Mr Sujay Pal wrote one email to Company dated 8.2.2021where he has written the subject of mail as ‘difference between third page of my policy bond policy number 18396887 which I have & what you have sent me.’Company responded on 11.02.2021 that maturity benefits have been appropriately paid to Mr. Pal. Company clarified terms & condition of policy contract with respect to benefits payable on survival & maturity of policy further adding that Rs 277302.08 processed on 15.01.2016 & Rs 104646.30(accrued bonus) processed on 12.01.2021 are correctly done & as such they were unable to comply with request.


Complainant alleges that Company has not paid him the amount of Rs 282962/- as written on 3rd page of policy bond & only vested bonus has been paid.

That he has paid total Rs 376640-(approx.) to Company by way of total 5 premiums but Company has returned him Rs 387608.30(total)


Vide Self Contained Note (SCN) received on 11.05.2021 Insurance Company submitted that:

1. That after going through the key benefits and terms of the products the Complainant chose to avail the said policies of the Company

2. The Customer has paid 5 premiums in the said policy amounting to Rs. 3, 76,527/-

3. That the complainant approached the company with a written complaint regarding less payment

n 18-Jan-21. That after investigating the complaint and verifying its records, the company resolved the complaint on 01-Feb-21 through closure letter/mail.

4. The subject policy matured on 12-Jan-21 and the amount payable as per the applicable policy scheme and terms and conditions have been duly paid to the customer. Payable amount of Rs. 1,04,646 has been paid to the customer after deducting the necessary charges as per terms and conditions of the policy

5. That the amount paid is duly in consonance as per the issued and applicable policy scheme and terms and conditions, which was also accepted and agreed by the complainant at time of policy issuance. That it is an afterthought of the customer to gain the money by making false statement. The complainant

was provided with the policy document soon after issuance of the policy and therefore he was well versed

with all the terms and conditions of the present policy and now is raising false allegations with the malafide

intention to receive unwarranted benefits.

6. Further it is to inform you that, the Company has paid the amount as per terms and conditions of the policy which is enumerated in the policy bond which was dispatched to the complainant

7. at time of proposal the complainant also signed the benefit illustration from wherein the same surrender amount is reflecting which Company had paid to the complainant.

8. that nowhere in the policy bond is written that the customer will receive an amount of Rs. 2,82,962 upon survival or at the time of maturity on 12-Jan-2021. In fact, the policy schedule specifically mentions the amount and/or benefits payable date wise. Accordingly, the amounts/benefits mentioned therein are duly paid to the customer as and when applicable. The customer is mistaken and raising false allegations on company for less payment wherein as per version

of the complainant, an amount Rs. 2,82,962 and other benefits are payable upon survival or maturity in

2016 and 2021, both. However, this is a completely a false narrative and not in consonance of the policy

scheme.

2.


3. Both parties were present during the hearing. Party reiterated his contention that he was paid less amount on maturity date contrary to what was written on policy bond received by him when he purchased the policy in 2011.

4. Representative of Insurance Company reiterated their stand as submitted in the Self-Contained Note.

It has been observed from the papers submitted by complainant to this office that:

5. On the page of Policy schedule (being 3rd page after introductory page & FPR page) received by complainant it was typed ‘on survival of Life Assured to 12th January 2021 Rs 282962/- will be payable & on survival of Life Assured to 12.01.2016 Rs 282962.00 vested bonuses will be payable.’

6. Complainant has also submitted copy of policy bond which he writes was received by him from Company on 27.02.2021( on record is an email from Company dated 27.02.2021 wherein they have requested Mr Sujay Pal to check the digital copy of his Life Insurance Policy.) & on that is written –

7. ‘On survival of life assured to 12.01.2016 Rs 282962/- will be payable

8. On survival of Life Assured to 12.01.2021 vested bonuses will be payable.’

9. Under Policy condition & privileges –under Terms & conditions-Point2.Basic Benefits, it is written -‘The Company will pay the vested bonus on survival of the Life Assured on date of maturity’

Also on record is present email forwarded by Company to complainant dated 08.02.2021 wherein they

acknowledge complainant’s grievance regarding difference between 3rd page of his policy bond present with

him & the policy bond they had sent him.

AWARD

Taking into account the facts & circumstances of the case, the submissions made by both the parties during the

course of hearing and after going through the documents on record it is observed that Complainant Sri Sujay Pal

has submitted to this office one copy of policy bond wherein as per policy schedule under benefits payable, Rs

282962/- is payable on survival of the Life Assured to 12th January 2021.

As such Insurance Company is directed to pay the balance amount of Rs 178316/- to the complainant, being

difference between payable amount Rs 282962/- & the amount already paid by Company on 12.01.2021 of

Rs 104646/-

Accordingly, the complaint is disposed of.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance




Dated at Kolkata on 31st Day of May, 2021 SHRI P K RATH

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SH. C.S.PRASAD

CASE OF Mr. ASHISH JAIN V/S ICICI LIFE INSURANCE COMPANY LTD. COMPLAINT REF: NOI-L-021-2021-0882

AWARD NO:

1. Name & Address of the Complainant Mr. Ashish Jain,

Flat A1-1001,

Golf City, Plot No.8,

Tower-A-1, Sector 75,

NOIDA (U.P.) -201307

2. Policy No:

Type of Policy

Duration of policy/Premium paying

term

83137257,

LIFE, DOC-27.10.2020

15/07 YEARS

3. Name of the insured

Name of the policyholder

Mr. Ashish Jain,

Mr. Ashish Jain,

4. Name of the insurer ICICI Life Insurance Company Limited.

5. Date of Repudiation/Maturity 20.11.2020/08.12.2020

6. Reason for repudiation/Maturity

Correct Maturity amount not reflected on

Electronic Policy Bond.


8. Nature of complaint Misc.

9. Amount of Claim Maturity Benefits Rs. 26,24,778 /- on Policy

Bond.

10. Date of Partial Settlement Nil

11. Amount of relief sought Maturity Benefit Rs. 26,40,016/- as per

illustration.

12. Complaint registered under

IOB rules

YES

13. Date of hearing/place 09.04.2021/ NOIDA


a) For the Complainant Mr. Ashish Jain

b) For the insurer Ms. Nitu Singh

Ms. Shaheen Sheikh

15 Complaint how disposed Settlement

16 Date of Award/Order 7.5.2021

17)Brief Facts of case :- This is a complaint filed by Mr. Ashish Jain against the decision of ICICI Life Insurance Company Ltd., relating to Maturity Benefits Rs. 26,24,778 /- instead of Rs.26,,40,016/- filled in Electronic policy document and the policy issue processing was delayed by 6 days after the realization of premium amount by the company under Insurance policy No. 83137257.

18) Cause of Complaint:-

Complainants argument :- The complainant alleged that he was issued the above policy on 27.10.2020 by the insurance company while he had completed all policy related formalities on 21.10.2020 along with first premium. But the electronic policy bond was issued on 27.10.2020 with delayed 6 days from the first premium receipt. The maturity benefits were shown on the illustration/Sheet given to him during the sale as Rs. 26,40,016/- but insurance company issued policy bond with maturity benefit Rs. 26,24,778/-. The complainant is not satisfied with the service of the insurance company. He lodged his complaint with the insurance company. The company rejected his request. The complainant has approached the Insurance Ombudsman for redressal of his grievance.

Insurers’ argument:- Insurer stated and contended that the company had received duly filled online application form numbered OS15078749 for insurance policy with an annual premium of Rs.2,09,001 for limited pay (07 Years), policy term of 15 years with Rs.20,00,000/- coverage sum assured on 17.10.2020 and policy was issued on 27.10.2020 i.e. 10 days from the receipt of proposal which is in accordance with Protection of Policyholders Interests Regulations 2017. The Electronic Benefit Illustration (EBI) mentioning the maturity value of Rs.26,40,000/- was generated on October 17, 2020 at the time of filling the proposal form and the issuance of the policy was done on October 27, 2020 and policy holder`s date of birth is October 26, 1977. Hence on the date of policy issuance on 27.10.2020 the policyholder`s age changed from 42 (age at the time of EBI generation) to 43 years (age on the date of policy issuance), due to which the maturity value reduced from Rs. 26,40,000/- to Rs. 26.24,000/- Considering as a special case the insurance company has taken a view to reissue the above mentioned policy with back dated risk commencement date of October 25,2020 i.e. date before the birthday, wherein the policy holder will be eligible for the maturity value of Rs. 26,40,000/- on the date of maturity as mentioned on the Electronic Benefit Illustrations.

19) Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules 2017.

20) The following documents were placed for perusal. a) Complaint Letter b) Repudiation Letter c) Policy Document d) SCN

21) Observations and Conclusion :- Both the parties attended the online hearing on 9.4.2021 and reiterated their submission. The complainant was annoyed due to alleged apathy of the respondent in not resolving the matter instantly. The insurer explained the cause of difference of maturity amount in benefit illustration at the time of sale and the policy bond. The insurer accepted their mistake and expressed their willingness to issue a fresh policy with the correct maturity value as shown in the illustration at the time of sale subject to the complainant giving the consent for it. The complainant insisted on compensation for this service deficiency. It is observed that the complainant was mainly aggrieved because of the apathy of the insurer in keeping the matter pending since October 2020. I find that the explanation given by the insurance company regarding difference in maturity value as shown in benefit illustration at the time of sale and policy bond as in order. But on being pointed out, the respondent insurer should have taken a call to rectify. However, during the hearing the Insurance company accepted their mistake and assured to rectify it. The respondents have tendered apology too. It is recommended that the insurance company rectifies the mistake as committed during hearing without insisting for the consent as in his complaint he had requested for it. Insurance Ombudsman Rules provide for awarding compensation to the extent of loss suffered by the complainant. In the instant case, as no financial loss was suffered by the complainant, the awarding compensation is ruled out. However, the insurer is advised to be more sensitive towards the customers.

RECOMMENDATION

Taking into account the facts and circumstances of the case and the submissions made by both

the parties during the course of hearing, it is recommended that the insurance company

rectifies the mistake as committed during hearing without insisting for the consent as in his

complaint he had requested for it.

The complaint is treated as closed accordingly.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the insurance Ombudsman Rules 2017: As per Rule 16 (3) the insurer shall comply with the terms of the recommendation immediately but not later than fifteen days of the receipt of such recommendation, and inform the Ombudsman of its compliance.

Place: Noida. C.S. PRASAD Dated: 07.05.2021 INSURANCE OMBUDSMAN (WESTERN U.P. & UTTARAKHAND)


UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SHRI C. S. PRASAD

CASE OF SAJJAD ALAM V/S BAJAJ LIFE INSURANCE CO. LTD. COMPLAINT REF NO: NOI-L-006-2021-0916

AWARD NO:

1. Name & Address of the Complainant Mr. Sajjad Alam M-104, Pamacisis Apartments Sector -70 Noida UP- 201309 M- 9735032911

2. Policy No: Type of Policy Duration of policy/Policy period

0078051522 LIFE 25/25 Years

3. Name of the insured Name of the policyholder

Mr. Sajjad Alam Mr. Sajjad Alam

4. Name of the insurer B ajaj Life Insurance CO.

5. Date of Rejection No reply

6. Reason for rejection Wrong Surrender value paid

7. Date of receipt of the Complaint 4-03-2021

8. Nature of complaint Wrong payment

9. Amount of Claim

10. Date of Partial Settlement nil


12. Complaint registered under IOB rules

yes

13. Date of hearing/place 11-05-2021/ NOIDA


a. For the Complainant Mr. Sajjad Alam

b. For the insurer Mr. Nikhil Upadhyay

15 Complaint how disposed Award

16 Date of Award/Order 11-05-2021

17 . Brief Facts of the case : The complainant had maintained the policy since 2007 but in 2020 the insurer black listed him , so he applied for surrender value payment . But he has complained that the insurer has paid less amount as surrender value. He applied to the insurer 21-01-2021 for cancellation of the policy and refund of money, but the insurer did not reply.

18. Cause of the complaint:

A. Complainant argument: The complainant stated that he was having the above policy. He said that once he paid premium through credit card but the next premium was auto deducted by insurer through credit card by instruction of the insurance company. After some time he came to know that his policy was black listed, and harassed by insurance company, he applied for surrender of policy. The complainant stated that he had paid Rs. 4 lacs and received as surrender amount Rs. 1.7 lacs only. He wants the correct surrender value of his policy.

B. Insurer’s argument: The insurance company has stated that the complainant was maintaining the policy since 2007 where payment was done in half yearly mode in June and December every year. He paid premium till June 2019 but for December 2019 he paid premium through his credit card but he didn’t paid his credit card bill so the bank recovered the amount of premium from the insurance company. The insurer stated that they are sure that in no case, where the card holder pays once by credit card, the next time auto deduction by the recipient company could be possible. The insurer submitted the payment statement wherein it was shown that the complainant was in practice of payment by credit card from many years. The complainant was blacklisted by the company because the amount was due for payment and paid premium was recovered from the insurer and the complainant did not try to pay the due premium by other mode also. The insurance company was sending him revival notices, which was confirmed by the complainant, confirms that there was no restriction for further premiums payment. The complainant applied for surrender value and was paid to him but complainant stated he was paid less amount. The complainant paid around Rs 3.75 lacs as premium and SV paid of Rs 1,073980/- and two Survival benefits were also paid for Rs 55,000/- & Rs 82,500. The insurance company has provided the calculation also.

19. Reason for Registration of Complaint: Scope of Insurance Ombudsman Rule 2017.

20. Following documents were placed for perusal:

a) Complaint Letter b) Surrender calculation c) Surrender form

d) SCN

21. Observation and conclusion: Both the parties appeared for online hearing and reiterated their submissions. The complainant stated that his policy was blacklisted and after harassment from the insurance company, he applied for surrender of the policy but he was given less amount. He wants return of full amount paid by him. The insurer stated that while complainant was regularly paying the premium through credit card, blaming the insurer for auto collection through his credit card is wrong, otherwise he could ask the bank for showing the instructions received from insurer. Regarding blacklisting, it is an internal matter of the company where they put a flag to the policy ,which restricts the same type of wrong activity again, but allow the insured to pay money by other mode. The complainant might not be in position to further continue the policy and taken the surrender vale and now raising irrelevant issues.

After going through the documents on record, and hearing the views of both parties, it is observed that auto collection through credit card of the policy holder is not possible without authorization by the credit card holder to the bank. If it is done, it is bank’s fault for which complainant can approach the bank. Since the payment received by the insurer was called back by the bank, the insurer black listed the policy, by which the complainant was allowed to pay further premiums through any mode other than credit card. During the hearing, the complainant was asked if he wants to continue his policy, by returning the amount of SV received, he could get the policy reinstated, but the complainant refused to return any money. He himself surrendered his policy and insurer has paid the SV per as per the company rules mentioned in the policy document. The request of the complainant for refund of his deposited amount is set aside.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, the insurer has paid the correct surrender value as per the company rules mentioned in the policy document and request of the complainant for refund of his deposited amount is set aside.


Place – Noida (C. S. PRASAD) Date- 11.05.2021 INSURANCE OMBUDSMAN

Western U.P. & Uttarakhand

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C. S. PRASAD

CASE OF MR. VISHAL BISHT V/S AVIVA LIFE INSURANCE CO. LTD.

COMPLAINT REF NO: NOI-L-004-2021-0917

AWARD NO:

1. Name & Address of the Complainant Mr. Vishal Bisht House no- 839 Sector -29 NOIDA, UP- 201301 M- 9810387898


01920560 LIFE 12/12 Years Lapsed


Mr. Vishal Bisht Mr. Vishal Bisht

4. Name of the insurer Aviva Life Insurance CO.


6. Reason for rejection Free look period is over


8. Nature of complaint misselling



11. Amount of relief sought 52445.00


yes



For the Complainant Mr. Vishal Bisht

For the insurer Mr. Rishi Chadha



17 . Brief Facts of the case : The complainant has an insurance policy with Aviva Life Insurance company. The

insurer transferred his Survival benefit of the policy to the wrong account. The complainant wants correction,

so that he could utilize his money. When the insurer did not provide any solution, he applied by writing a

letter to the insurer 5-02-2021 for amount transfer to the correct account.

18. Cause of the complaint: Amount transferred to wrong account by insurer.

A. Complainant argument: Survival benefit was due to the complainant on 27-11-2020. The insurer asked the details of the account number where the amount was to be transferred and the complainant provided the details on 17-10-2020 but the complainant did not receive the money. When enquired, the insurer could not provide a proper reply. Later he got an SMS that the amount was transferred to his account which was previously given to the insurer by the complainant, which was not in use by the complainant due to some dispute with the bank and he could not withdraw the amount from this bank. The mistake is from the insurer, hence he wants that insurer to arrange his money back and also not happy with the working of the insurance company and wants full amount paid till date, should be returned to him.

B. Insurer’s argument: The insurer admitted that the new account details were provided by the complainant, but due to some technical problem the account correction was not done and transfer of money was done to the old account available with the insurer. The old account was active at that time too. The insurer stated that the complainant has a dispute with the bank with the reason of outstanding credit card bill and bank has created a lien on the account. The insurer requested to the bank that this transfer was by mistake and they should transfer to the correct account. But the bank declined the request. The insurer is willing to transfer to the new account to see the immediate needs, subject to the complainant executing the deed of undertaking cum indemnity in favor of the respondent company. The insurer stated that the complainant has not suffered any monetary loss and should cooperate with the insurer in resolution of the grievance.

19. Reason for Registration of Complaint: Scope of Insurance Ombudsman Rule 2017.

20. Following documents were placed for perusal:

a) Complaint Letter

b) Account details.

c) SCN

21. Observation and conclusion: Both the parties appeared for online hearing and reiterated their

submissions. The complainant stated that, despite providing the account details of Deutsche bank, well in

time, the insurer transferred survival benefit amount of Rs 52,445 /- to his account of HDFC bank, which was

already stored with them. The complainant had some dispute with HDFC bank, as the bank had lien on

complainant’s account, so he could not retrieve the money from HDFC bank. The insurer stated that the

complainant’s account was active at the time of money transfer hence amount got debited to the bank.

When the insurer asked the bank to return the money, as it was wrongly transferred and correction was

responsibility of the insurer. But the bank refused from returning the same stating that the amount belonged

to the account holder only and the complainant owed Rs. 151551.16 to the bank, and bank had adjusted the

received amount against due lien amount. The insurer admitted the mistake of wrong transfer and expressed

their willingness to pay the amount to the correct Deutsche bank to serve his immediate needs, subject to

complainant executing the deed of undertaking –cum –indemnity in favor of the insurer as per the language

already provided to the complainant.

After going through the documents on record, it is observed that this is a matter of transfer of amount to the

wrong account. The HDFC bank account also belongs to the complaint and is active too. However, the insurer

by admitting their mistake is ready to transfer the same amount to Deutsche bank in addition to the already

paid amount. In return they want from the complainant an undertaking of indemnity wherein he would

ensure that he would return the amount after settlement with the bank. The insurer has already conveyed

him the required details of the indemnity bond. I feel that the insurer is quite generous in paying the money

in addition to the amount already paid, their demand for undertaking- cum – indemnity bond is justified.

Hence the complainant is directed to complete the required papers and submit to the insurer and the insurer

to the transfer the amount to his Deutsche bank account.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties

during the course of hearing, the complainant is directed to submit the indemnity document to the insurer

and the insurer to transfer the amount to the desired bank account.


22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the

insurance Ombudsman Rules 2017:

As per Rule 17(6) the insurer shall comply with the award within thirty days of the receipt of the award and

intimate compliance of the same to the Ombudsman.

Place – Noida (C. S. PRASAD)

Date- 11.05.2021 INSURANCE OMBUDSMAN



UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SHRI C.S. PRASAD

CASE OF RAKESH KUMAR GUPTA V/S BAJAJ LIFE INSURANCE CO. LTD. COMPLAINT REF NO: NOI-L-006-2021-0937

AWARD NO:

1. Name & Address of the Complainant Mr. Rakesh Kumar Gupta 255-D Regal Shipra Sun City Shipra Mall Indrapuram UP- 201014 M- 9910450592


0324968286 LIFE 5/15 Years


Mr. Rakesh Kumar Gupta Mr. Rakesh Kumar Gupta

4. Name of the insurer B ajaj Life Insurance CO.


6. Reason for rejection Policy foreclosed


8. Nature of complaint Wrongly foreclosed the policy

9. Amount of Claim




yes



a. For the Complainant Mr. Rakesh Kumar Gupta

b. For the insurer Mr. Nikhil Upadhyay



17 . Brief Facts of the case : The complainant had purchased this policy with 5 year premium paying term but insurer foreclosed the policy after five years. He had sent his complaint to the insurer on 22-01-2021 but they did not reply. 18. Cause of the complaint: policy wrongly foreclosed. A. Complainant argument: The complainant stated that he was having the above policy with term 5/15 where

he had to pay the premium for five years and maturity amount of the policy would be active for 10 years more. The complainant has sent the copy of the policy document confirming the facts stated by the complainant. The complainant paid premium for five years and was assured that policy was for 15 years term and the premium paying term was only 5 years. But the insurer foreclosed the policy after 5 years, considering that the next due premium was not paid. When he received the foreclosed amount in his bank, he wrote to the insurer but the insurer did not reply to his query.

B. Insurer’s argument: The insurance company has stated that the Company has perused the records in the matter and have to admit that there has been a technical glitch in their system which has resulted in the Premium payment term of 5 years being shown as 15 years. As a result of the aforesaid glitch, the Company has foreclosed the Policy and paid a Foreclosure sum of Rs.3,60,475/- (Rupees Three Lakh Sixty Thousand Four Hundred and Seventy Five Only) against a premium receipt of Rs.2,50,000/- (Rupees Two Lakh Fifty Thousand Only). They are ready and willing to reinstate the said Policy under the Original Terms and Conditions with a 5 year Premium Payment Term and 15 Year Benefit Term on receipt of the total amount of Rs.3,60,475/- (Rupees Three Lakh Sixty Thousand Four Hundred and Seventy Five Only) paid to the customer in this case.

19. Reason for Registration of Complaint: Scope of Insurance Ombudsman Rule 2017. 20. Following documents were placed for perusal:

a) Complaint Letter b) Policy document c) Payment details d) SCN

21. Observation and conclusion: : Both the parties appeared for online hearing and reiterated their submissions. The complainant stated that his policy was wrongly foreclosed by the insurance

company while the policy was active because premiums were paid by him till premium paying term of 5 years. He said that this was a mistake on the part of the insurer and they should activate the policy so that he could get the benefits of the policy till the full term of 15 years. The insurer stated that on reviewing the details of the policy in their record, due to some technical fault, policy was showing with term of 15 years and also premium paying term of 15 years. So when the sixth year premium was not received, the policy was foreclosed and the foreclosed amount was transferred to the complainant’s account. The insurer agreed the mistake was at their end and were ready for correction and reinstatement of the policy. After going through the documents on record, and hearing the views of both parties, it is observed that the policy was foreclosed by the insurer due to technical glitch in their system. The insurer admitted the mistake and was ready for correction in the policy. The insurance company after foreclosing the policy transferred the foreclosed money, as per calculation of the policy rules to the insured account. The complaint wanted the reinstatement of the policy and insurance company is ready to reinstate the policy, provided the complainant returns the money paid to him by insurer as foreclosed amount. The complainant wanted to get his policy reinstated without recovery of the amount already paid to him, and the same to be deducted at the time of maturity of the policy. The insurer refused as this would be against insurance company rules which is fully justified. Hence the insurer is justified for not reinstating the policy without return of foreclosed amount by the complainant and request of the complainant is set aside. The complaint is dismissed. Place – Noida (C. S. PRASAD) Date- 28.05.2021 INSURANCE OMBUDSMAN



UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SH. C.S.PRASAD

CASE OF SH. SUSHIL CHANDRA VERM V/S LIFE INSURANCE CORPORATION OF INDIA COMPLAINT REF: NO: NOI-L-029-2021 -0741

AWARD NO:

1. Name & Address of the Complainant Sh. Sushil Chandra Verma

Mohalla Baksaria, Near Sita Ki Mathia,

Shahjajanpur, Uttar Pradesh- 242001

2. Policy No:

Type of Policy

Duration of policy/Policy period

223553501 and 223553851

---------- Life Plan-------------

10years

3. Name of the insured

Name of the policyholder

Sh. Sushil Chandra Verma and Mrs.

Sangam Verma

4. Name of the insurer LIC of India

5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Less Surrender Amount Paid

9. Amount of Claim Rs.

10. Date of Partial Settlement Rs.

11. Amount of relief sought Rs.

12. Complaint registered under

IOB rules

13 (1) ( b)

13. Date of hearing/place Online Hearing on 205.2021


a) For the Complainant Absent

b) For the insurer Mrs. Bhawna


16 Date of Award/Order 31.5.2021

17)Brief Facts of case ;- This complaint is filed by Sh. Sushil Chandra Verma against the decision of LIC of India relating to less maturity amount paid under policy number 223553501 and 223553851.

18) Cause of Complaint:-

Complainants argument :- The complainant stated that 2 policy number 223553501 and 223553851 were issued from LIC of India on 28.12.2009 with policy term of 20 years under the plan named,” Jeevan Saral. The complainant applied for surrender value of the policy in October 2020. Both the policies have same plan, same date of commencement and same policy term but the surrender value paid under the policy was different i.e in one policy surrender value paid was Rs. 65481/- whereas in other policy surrender value paid was Rs.82457/-. Hence the complainant approached this forum.

Insurers’ argument:- The insurer in their reply dated1.3.2021 stated that both the policies issued were Jeevan Saral for policy term of 20 years. As per policy conditions Maturity Sum Assured under the policy number 223553501 at age of 48 years was Rs.93825/- whereas under policy number 223553851 Maturity sum assured was Rs. 128735/- at the age of 37 years. Besides date of surrender was different i.e. 3.6.2020 and 27.10.2020 respectively. Since, the age and maturity sum assured at the inception of policy was different hence surrender amount paid was different. The surrender value payment has been made as per terms and conditions of the policy.

19) Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules 2017.

20) The following documents were placed for perusal. a) Complaint Letter b) Repudiation Letter c) Policy Document d) SCN

21)Observations and Conclusion ;-Online hearing in the case was fixed on 20.5.2021. The complainant could not attend the hearing The insurer attended hearing and reiterated their submissions.

It is observed from the records that as per policy conditions, Maturity Sum Assured under the policy number 223553501 at age of 48 years was Rs.93825/- whereas under policy number 223553851 Maturity sum assured was Rs. 128735/- at the age of 37 years. Besides, dates of surrender were different i.e. 3.6.2020 and 27.10.2020 respectively. It is to be noted that under life insurance policies, premium is based on the age of the insured, and under the subject policies there are two different insured persons having different ages of 48 year and 37 year. This difference of age is the reason behind difference in maturity value and surrender value paid.

As the policies were issued at different age and maturity sum assured was also different under both policies so the surrender value payment was also different. The surrender value payment has been made as per terms and conditions of the policy. I find no reason to interfere with the decision of insurance company.

AWARD

Taking into account the facts and circumstances of the case , I find no reason to interfere with decision of insurance company.

The complaint is disposed off accordingly.

Place – Noida (C. S. PRASAD) Date- 31.05.2021 INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE (STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)

(UNDER RULE NO: 16( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN - VINAY SAH

Case of Mr Ahmed Moh.Hussain Balubaid V/S India First Life Ins.Co.Ltd Complaint No: PUN-L-024-2021-0217

Award No:IO/PUN/A/LI/ /2021-2022

1. Name & Address of the Complainant: Mr.Ahmed M.HussainBalubaid , Thane

2. Policy No | Type of Policy: 10530950 , MahaJeevan plan

3. Dt of Com./Mode 23.05.2019 , YLY

4 Term/PPT| Premium Amount 15-15 , Rs.57416/-

5. Insurance Intermediary | Code No. Ashok Bora R0000012/Rap Infosystems

6. Name of the Prop | LA Mr.AhmedM.HussainBalubaid

7. Name of the Insurer: India First life Ins.Co.Ltd

8. Nature of complaint: Mis-sale

9. Relief sought: Cancellation of policy & refund of amount

10. Date of complaint Time Lag

30.06.2020 1Y1M

11. Date of Refusal by RI 22.10.2020

12. Date of receipt of the Complaint at OIO: 02.11.2020

During the online hearing held on 18.05.2021 through video conferencing,Mr.Ahmed M.HussainBalubaid (hereafter referred to as the complainant) and India First Life Ins. Co. (hereafter referred to as the RI- Respondent Insurer) representative, Ms.Nilofer Shaikh reiterated their earlier submissions.

• The complainant has stated in his complaint that he was approached by the broker’s officials posing as personnel from Bajaj Finance with an offer of interest free loanof Rs.9 lac against purchase of policy.

• The complainant had already taken a loan from ICICI bank and was paying a high interest on it. He felt this was a good opportunity to save the interest portion by accepting their offer and repaying the old loan through it.

• The complainant purchased the policy bearing no.10530950 commencing on 23.05.2019 with annual premium of Rs.57416/-.

• When the complainant did not receive the promised loan he realised that he was cheated and approached the insurers for cancellation of policies and refund of premiums but the insurers rejected his request as it was beyond free look period.

• The complainant has also alleged signature forgery during the hearing.

• The complainant is a senior clerk ina college with an annual income of Rs.3.6 lac and unable to pay the yearly premiums.

• The RI in their SCN dated 13.11.2020 and during the hearing contended that: 1. The complaint had submitted duly filled and signed proposal form bearing no.203020299 with

relevant documents and the initial premium deposit in order to seek insurance policy under IndiaFirst MahaJeevan Plan.

2. Based on the proposal, premium and other relevant documents and information provided by the complainant, the RI had accepted the proposal form for granting insurance cover and issued policy bearing no. 10530950 under the said plan.

3. During the PIVC and Welcome call, it was specifically asked whether any bank loan, bonus from previous policy or locker facility was promised while selling this policy to which the complainant categorically denied.

4. In Welcome call complainant also acknowledged that he had received the policy document and had gone through them.

5. The welcome letter sent along with the policy document, clearly mentions that in case policyholder is not satisfied with the features or the terms and conditions of the policy, he can withdraw/return the policy under the “Free Look Period”. The complainant did not avail the free look period of 15 days as mentioned in the Welcome kit and raise any concern regarding mis-sale.

6. It is only on 1st July 2020 i.e. after one year from issuance of policy, when the complaint came for the first time for cancellation of the policy and refund of premium on the alleged ground of mis-selling. The company had duly conveyed the reason for denial of cancellation of the policy via letter dated 08.07.2020.

7. All the terms and condition of the said policy were well explained and mentioned in the policy document. It is crystal clear that the complainant has well understood the terms and conditions and the benefits of their policy. Further, afterthe receipt of the policy document along with the proposal form, the complainant had retained the same and did not raise any objection towards policywith any grievance regarding the policy or its terms and conditions which imply that the complainant was satisfied by the policy terms and conditions.

8. The RI, during the hearing, informed that they had called for explanation from the broker M/s RapInfosystems who are still working with the RI, and they have confirmed that there was no mis-selling.

9. The RI has refuted the complainant’s allegation of signature forgery as the complainant has admitted, during the PIVC, to have signed the documents.

10. The policy is in lapsed condition due to non payment of subsequent premiums.

The Forum observes that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium received through the intermediary acting on his behalf. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant should have been vigilant and raised his concerns earlier. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium. Award follows :

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy No. 10530950 on the complainant’s life and utilize the premium received under the policy to issue a single premium policy in the name of the complainant with a term of 5 years from new date of commencement, lock-in period of 5 years and without free look cancellation clause. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the

stipulated time for issuance of the single premium policy, the issue of issuing single premium policy would be closed and the complaint will be treated as dismissed. Hence the complaint is partially allowed.

Compliance of the Award:-

The attention of the Complainant and the insurer ishereby invited to the following provisions of Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on this day31st day of May 2021.

VINAY SAH INSURANCE OMBUDSMAN, PUNE


UNDER SECTION 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN–VINAY SAH

CASE OF Mr. Ashutosh KDagaV/S Reliance Nippon Life Insurance Co. Ltd. COMPLAINT NO: PUNE-L-036-2021-0086

Award No IO/PUN/A/LI/ /2021-22

1 Name / Address of Complainant Mr.Ashutosh KDaga, Solapur

2 Policy No. / Type of Policy 51873072/Reliance Smart Pension Plan

3 DOC/Premium/Mode/Term 30.10.2014/Rs 75000/-/Yly/15Y

4 Name of Proposer / Annuitant Mr.Ashutosh KDaga

5 Name of Insurer Reliance Nippon Life Insurance Co. Ltd.

6 Nature of Complainant Lumpsum surrender payout for pension policy refused

7 Relief sought Full amount of premium paid with interest at 15%

8 Reason for Rejection Full amount of surrender value cannot be paid for annuity policy

9 Date of 1st complaint to RI Date of Rejection by RI /Time lag

20.11.2019 17.08.2020 / 5yrs

10 Date of complaint to OIO 25.08.2020

• An online hearing, through video conferencing was held on 23.03.2021, where Mr. Ashutosh Daga (hereafter referred to as the complainant) and Ms.Anubha Gupta representative of Reliance Nippon Life Insurance (hereafter referred to as the RI – Respondent Insurer), reiterated their earlier submissions.

• The complainant has submitted in his complaint that he was approached by the RI’s officials who informed him that the existing Company was being taken over by another due to losses and after takeover the new Company will not continue with the policies issued previously and that his investment under his then existing policy bearing no.10623365 taken from RI would be lost unless he purchased another policy.

• The complainant has further stated that he was thus compelled to surrender his previous ULIP policy and purchase a new policy from the RI.The complainant purchased an ULIP pension policy from the RI, Reliance Nippon Life Insurance, bearing no.51873072 with date of commencement 30.10.2014 and annual premium of Rs75000/-and policy term of 15 years.

• The complainant has alleged signature forgery and that the policy documents received by him were not legible.

• The complainant had approached the RI in November 2015 for cancellation of policy and refund of premium. He was informed by the RI that they could not comply as the free look period had exhausted, and he would lose the initial amount if the policy was not continued.

• According to the complainant he had later raised a request for fund switching but he wasinformed by RI that the funds cannot be switched. However, he continued to pay the subsequent premiums for the next3 years.

• The complainant was in need of money and hence he approached the RI on 29.11.2019, after 5 years of lock in period, with a request of surrendering the policy. He requested that the full amount of Rs.340000/-should be paid into his bank account.

• The RI informed the complainant that as per the terms and conditions of the subject policy, he could get a maximum commuted value equal to 1/3rdof the fund valueson withdrawal and the remaining 2/3 rd fund value would have to be converted into an annuity policy.

• The complainant again requested the RI, vide his letter dated 22.05.2020, to pay him the full amount of Fund value of Rs.341832/- available under his policy as he was burdened with huge financial liabilities.

• The complainant did not receive favorable response from the RI, hence the complaint to the Forum.

• The RI, in their SCN and during the hearing havecontended that: 1. After going through the key benefits and terms of the products the complainant chose to avail

the said policies of the company on crystal clear terms and conditions of the said policies as envisaged in the policy application cum proposal forms which were duly signed and submitted by the complainant to the company for availing the policies.

2. The policy document was duly dispatched on 01.11.2014 to the complainant and the same has not been disputed by the complainant.

3. Further, on the RI’s internal findings based on the concerns raised by the complainant, it was found that there were no tampering or signature forgeries on the proposal forms duly signed by the complainant on the basis of which the subject policies were issued.

4. The terms and conditions were explained before the purchase of policy and during the PIVC, wherein the complainant had agreed to the terms and conditions of the policy. The complainant did not avail the free lookup clause at that point of time.

5. The complainant had an existing policy 10623365 issued in Mar.2007 with a premium amount of Rs.35000/-(5 premiums paid). This was surrendered on 13.10.2014 and an amount of Rs.276363.12 was refunded through onlinetransferand no Fund transferwas done. However, the new policy was issued in the same month.

6. The complainant’s request for refund of total premium paid amount under the instant policy was rejected vide mail dated 17.08.2020. The RI has informed that the current status of the

policy is discontinuance surrender payout.As per the terms and conditions of the subject policy, wherein, under the surrender clause (clause 4.2) it is mentioned that “Policyholder may surrender his policy after a period of five years from the commencement of the policy. The fund value under the base policy (including top-ups) less applicable discontinuance charges, if any will be paid to the policyholder according to the following options”. 1) To commute to the extent allowed under Income Tax Act and to utilize the balance

amount must be applied to purchase immediate annuity from Reliance Life Insurance Ltd., which shall be guaranteed for life, at the then prevailing annuity rate, or

2) To utilize the surrender value either to purchase a single premium deferred pension product of the same type from Reliance Life Insurance Company Ltd., if any.

7. The RI has expressed their regret towards their inability to comply with the Complainant’s request regarding payment of full surrender value amount.

The Forum observes that the IRDA circular dated 08.11.2011, interaliamentions that “On the date of surrender after the lock-in period, the policyholder shall have all the following options:

1)To commute to the extent allowed under Income Tax Act and to utilize the balance amount to purchase immediate annuity, which shall be guaranteed for life, at the then prevailing annuity / pension rate, or 2) To utilize the entire proceeds to purchase a single premium deferred pension product.

The Forum further observes that the policy was voluntarily taken by the complainant after fully understanding and accepting the terms and conditions of the policy.Forum notes that as per policy terms and conditions and provisions of IRDAI in this regard as stated above amaximum of 1/3rdamount of the total surrender value can be paid as commutation amount to the complainant and from the balance Fund value (2/3 of the total surrender value) annuity policy is to be purchased from RI,Reliance Life and full payout will not be made. The Forum also observers that the complainant has paida total of four premiums and he cannot deny being aware of the type of policy issued to him. In this case, it is also important to see the applicability of the cooling off provisions. The conditions under clause 1,’Free Look ‘are as follows: “In the event you disagree with any of the terms and conditions of the policy, you may return this policy to the company within 15 days (applicable for all distribution channels, except for distance marketing channels, which will have thirty days) of its receipt for cancellation, stating your objections, in which case you shall be entitled to a refund of the premium paid, subject only to a deduction of the proportionate risk premium for the period on cover and the expenses incurred by the insurer on medical examination of the life assured and stamp duty charges. In view of all the above facts the Forum opines that the complainant may surrender the policy in contention but he has to either avail of 1/3rdof the surrender value amount as commutation and an immediate annuity policy for balance 2/3rdof the surrender value amount from RI or opt for utilizing the full surrender value for purchasing a single premium deferred pension plan from RI as per the policy conditions. Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, the forum does not find any substance in the complaint. As such the complaint is dismissed.

Dated at Pune,on 31.05.2021



(UNDER RULE NO: 16 ( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN - VINAY SAH

Case of Mr Augustine Fernandes v/s ICICI Pru Life Insurance Co. Ltd. Complaint No: PUN-L-021-2021-0210

Award No:IO/PUN/A/LI/ /2021 -2022

1. Name & Address of the Complainant: Mr. Augustine Fernandes , Thane

2. Policy Nos | Details of Policies Pls Refer to chart

3. Name of the Prop | LA Mr. Augustine Fernandes

4. Name of the Insurer: ICIC Pru Life Insurance Co.Ltd

5. Nature of complaint: Mis sale

6. Relief sought: Refund of premium amount with interest

7. Date of 1st complaint to RI 03.02.2016


An online hearing was held on 18.05.2021 where Mr.Augustine Fernandes (hereafter referred to as the complainant) and Ms.Nitu Singh, representative from ICICI Pru Life Insurance Co.Ltd (hereafter referred to as the RI- Respondent Insurer), reiterated their earlier submissions.

• The complainant has claimed that the representative of broker and agents lured him into purchasing several policies with an offer of bonus amount payable on old policies. He has also alleged signature forgery in some policies

• The complainant has claimed to have purchased a total of 9 policies from 4 different insurers with an annual premium of Rs.205153.15.

• The complainant is employed as a driver in BMC with an annual income of Rs. 7 lacs and is not in a position to pay such exorbitant amount of annual premiums.

• The complainant approached the RI for cancellation of policies and refund of premiums but his request was rejected as it was beyond the free look period.

• The complainant has registered the complaint with the Forum for redressal.

• The RI during the hearing have contended that: 7. The complainant was issued the two policies 16166272 and 16532454 in December 2011 and

March 2012, respectively. The 1st complaint was received on 03.02.2016 after 5 years from

the issuance of 1st policy in contention. The F.P payment for the 3rd policy no.17040397 resulted in Cheque dishonour and hence not taken into contention.

8. The complainant has paid total two premiums, including initial premium under the policy no.16532454 and two renewal premiums and total of 3 premiums including the initial one, under policy no. 16166272.

9. During the hearing the RI informed that the policy no 16166272 has acquired paid up value and an approximate amount of Rs.25000/- to Rs.30000/- is payable under the policy.

10. The policy no. 16532454 is foreclosed after 2 years from first unpaid premium, due to non payment of subsequent premiums by the complainant.

11. The RI stated that it would be more beneficial for the complainant to surrender the policy bearing no.16166272 rather than delaying the payout till maturity of the policy.

12. The RI also brought to the fore the fact that the complainant is associated with the RI since the year 2006 and has purchased policies at regular intervals some of which were ULIP policies.

• Details of the policies:

POL NO NAME DTOC MODE TERM PPT PREM INS.CO. Broker

DOC DOR

16166272

Augustine Fernandes

03.12.11 YLY 15 07 24600.00 ICICI India info

03.02.16 25.02.20

17040397 F.P.cheque dishonour

Do 27.09.12 Do 15 07 29100.00 ICICI/ Bajaj Capital

Do Do

16532454 Do 31.03.12 Do 15 07 29500.00 ICICI / Dhaval Rana

Do do

19828723 Do 14.02.12 Do 15 05 24723.15 Reliance / AB Capital

DO 24.02.20

50667689 F.P cheque dishonour

Do 08.01.13 do 15 05 48789.00 Reliance / Shridhar Insurance

Do do

50905892 Do 31.03.13 Do 05 05 12515.00 Reliance / Jaiswal

Do Do

14523252 Do 29.07.11 Do 10 07 15000.00 HDFC / Mr.Hiren

Do 28.02.20


Do do

35007918704 Do 30.01.11 QLY 05 05 5926.00 SBI / NetAmbit

DO 21.02.20

9 POLS 205153.15

One of the insurer, HDFC Standard Life have agreed for settlement. Forum observes that in this case, the complainant has alleged in his complaint that he was lured by brokers’ representatives to buy 3 Policies with a total annual premium of Rs.83200/- from the RI. One of these policies bearing no 17040397 has resulted in CDA, hence the complaint is restricted to 2 policies i.e.16166272 and 16532454 while the total amount of first premium received by the RI is Rs.54100/-. The complainant has paid total 3 premiums including initial premium under the policy no 16166272 and the total 2 premiums, including initial premium under the policy no 16532454. The forum further observes that the complainant has approached the RI after a period of more than 4 years from issuance of the 1st policy in contention i.e policy no. 16166272 with commencement date 03.12.2011. The fact that the complainant has not complained about the previous policies, held with the RI, and that he has voluntarily paid renewal premium through cheque, for the subject policies, proves that he was interested in purchasing and continuing the policies.

The Forum notes that during the hearing the complainant admitted to the fact that he was unable to pay premiums due to financial constraints and hence wanted to cancel the policies and get refund of premiums. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties: 1) The Forum directs the RI to pay the acquired value under the policy no 16166272 to the complainant. 2) The Forum does not find substance in the complaint involving policy bearing no.16532454. Hence the complaint under policy no. 16532454 is dismissed. The complaint is hereby dealt with as per aforesaid award.


The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017: A) According to Rule 17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman. B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on 31.05.2021 VINAY SAH INSURANCE OMBUDSMAN, PUNE



Case of Mr Augustine Fernandes v/sReliance NipponLife Insurance Co. Ltd. Complaint No: PUN-L-036-2021-0211





4. Name of the Insurer: Reliance Nippon Life Insurance Co.Ltd


6. Relief sought: Refund of amount with interest

7. Date of 1stcomplaint to RI 03.02.2016



An online hearing was held on 18.05.2021 where Mr. AugustineFernandes (hereafter referred to as the complainant) and Ms.Anubha Gupta, representative from Reliance Life Insurance Co.Ltd (hereafter referred to as the RI- Respondent Insurer), reiterated their earlier submissions.

• The complainant has claimed that the broker cheated him into purchasing several policieswith an offer of bonus amount payable on old policies. He has also alleged signature forgery in some policies

• The complainant has alleged that he was lured by offer of Bonus from IRDA on purchase of policies and thus purchased a total of 9 policies from 4 different insurers with an annual premium of Rs.205153.15.

• The complainant has stated during hearing that he is employed as a driver in state BMC with an annual income of Rs7 lacs and is not in a position to pay such exorbitant amount of annual premiums.


• Hence the complainant has registered the complaint with the Forum for redressal.

• The RI in their SCN and during the hearing have contended that: 13. After going through the key benefits and terms of the products the complainant chose to avail

the said policies of the company on crystal clear terms and conditions of the said policies as envisaged in the policy application cum proposal forms which were duly signed and submitted by the complainant to the company for availing the policies.

14. The policy documents of policies bearing nos.50905892 and19828723 were duly dispatched to the complainant by Speed Post on 08.04.2013 &16.02.2012 respectively and the same has not been disputed by the complainant.

15. Further, on the RI’s internal findings based on the concerns raised by the complainant, it was found that there were no tampering or signature forgeries on the proposal forms duly signed by the complainant on the basis of which the subject policies were issued.

16. That the complainant approached them with a request to cancel the Captioned Policies on February17, 2016, after investigating the complaint and verifying its records, the company was unable to consider the request of the Complainant. Accordingly, the complaint was resolved on February 19, 2016wherein the Company declined the allegation of the complainant as the Complainant and that he had also approached us beyond the free look period of 15 days.

17. The complainant did not avail the free look period and chose to complaint of any such mis-sale only after exhaustion of the free look period of he said policies.

18. The complainant has provided no documentary evidence to substantiate his claim that the policy was sold to him on pretext of false promises.

19. The complainant being a prudent person is expected to have read the policy terms and conditions and taken the policy accordingly.

20. The RI in their SCN have submitted that the company is not privy to what has transpired between the complainant and the persons not authorised by the company in this regard, as mentioned in the complaint.

21. The RI further submitted that the payment made towards policy no 50667689 had resulted in cheque dishonour and the current status of the policy is No cash status- Reason insufficient Funds.

22. The complainant has paid only one premium under the other two policies bearing nos.19828723 & 50905892. The current status of both the policies is foreclosed.



DOC DOR

16166272,

Augustine Fernandes


03.02.16 25.02.20



Do Do

16532454 Do 31.03.12 Do 15 07 29500.00 ICICI / DhavalRana

Do do


DO 24.02.20



Do do

50905892 Do 31.03.13 Do 05 05 12515.00 Reliance / Ind.advisor

Do Do


Do 28.02.20


Do do


DO 21.02.20

9 POLS 205153.15

• One of the insurers, HDFC Standard Life has agreed for settlement.

• This is one of the cluster complaints registered with the Forum bearing nos.2021-0210 to 0213. As in policy bearing no.50667689 the First premium cheque no. 12120 dated 03.01.2013 drawn on Canara Bank was dishonored the current complaint is restricted to 2 policies bearing nos. 50905892 and 19828723 only involving a total premium of Rs.37500

The Forum observes that although thecomplainant had first approached the RI for cancellation of policies on 03.02.2016, the complainant has submitted a copy of email dated 24.02.2020,received from the RI, where they mentioned that they had rejected the complainant’s request for cancellation of the policies received by them on 17.02.2016 and stated that the policies were foreclosed in the Year 2015 and 2019 and no foreclosure value is payable towards the said policies. The complainant has approached the RI after a span of about 3 to 4 years after issuance of the policies which is an exorbitant delay. The Forum notes that during the hearing the complainant admitted to the fact that he was unable to pay premiums due to financial constraints and hence wanted to cancel the policies and get refund of premiums. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Forum does not find substance in the complaint. Hence, the complaint is dismissed.

Dated at Pune, on 31.05.2021




Case of Mr Augustine Fernandes v/s SBI Life Insurance Co. Ltd. Complaint No: PUN-L-041-2021-0213

Award No:IO/PUN/A/LI/ /2021 -2022




4. Name of the Insurer: SBI Life Insurance Co.Ltd



7. Date of 1st complaint to RI 03.02.2016



An online hearing was held on 18.05.2021 where Mr. Augustine Fernandes (hereafter referred to as the complainant) and Ms. Sampada Shetty, representative from SBI Life Insurance Co. Ltd (hereafter referred to as the RI- Respondent Insurer), reiterated their earlier submissions.

• The complainant has claimed that the broker cheated him into purchasing several policies with an offer of bonus amount payable on old policies. He has also alleged signature forgery in some policies

• The complainant has purchased a total of 9 policies from 4 different insurers with an annual premium of Rs.205153.15.

• The complainant has stated during the hearing that he is employed as a driver in BMC with an annual income of Rs.7 lacs and is not in a position to pay such exorbitant amount of annual premiums.


• The complainant has registered the complaint with the Forum for redressal.

• The RI in their SCN and during the hearing have contended that: 23. The crux of the complaint is against India Info-line and the present policy was sourced through

Netambit Insurance Broking India Ltd. 24. The complainant has paid renewal premiums under the policy thereby implying acceptance of

the terms and conditions of the policy. 25. The policy has been terminated in January 2015 due to non payment of renewal premium,

whereas the complainant has filed this present complaint in 2020. 26. The policy bearing no.35007918704 was issued to the Complainant with date of

commencement as 30.01.2011 for a basic sum assured of Rs.80000/- for a policy term of 5 years and premium paying term of 5 years with quarterly mode of premium payment.

27. The policy was issued based on the duly signed proposal form received by the RI. It is settled law that a person who signs the documents is totally responsible for the contents contained therein and cannot plead ignorance of the same.


29. The RI has received only 4 quarterly premiums under the policy. The policy lapsed due to non receipt of renewal premium due on 30.01.2012 and onwards.

30. As per the terms and condition of the policy, the policy acquires paid up value only if at least 3 years full policy years’ premiums have been paid. The policy was not revived within stipulated revival period of 3 years from the date of first unpaid premium. The revival premium ended on 30.01.2015.

31. The complainant has availed the insurance cover for the period for which premium was paid by him.

32. The complainant has not substantiated his allegations with documentary evidence.



DOC DOR

16166272

Augustine Fernandes


03.02.16 25.02.20



Do Do

16532454 Do 31.03.12 Do 15 07 29500.00 ICICI / Dhaval Rana

Do do


DO 24.02.20



Do do

50905892 Do 31.03.13 Do 05 05 12515.00 Reliance / Jaiswal

Do Do


Do 28.02.20


Do do


DO 21.02.20

9 POLS 205153.15

One of the insurers, HDFC Standard Life has agreed for settlement. Forum observes that in this case, the complainant has alleged in his complaint that he was lured by brokers’ representatives to buy 1 Policy with initial quarterly premium of Rs.5926/- from the RI. The complainant has paid a total of 4 premiums including the initial premium. Forum also observes the fact that he has paid 4 premiums which indicates that he was interested and willing to continue with the policy in contention. The Forum notes that the complainant has approached the RI after the completion of the policy term and after the policy had matured which is not justifiable and opines that the complaint is an afterthought on part of the complainant and the RI cannot be held responsible for the alleged mis-sale. Award follows:


Dated at Pune, on 31.05.2021 VINAY SAH INSURANCE OMBUDSMAN, PUNE



Case of MrsBebiKolekar V/S IDBI Federal Life Ins.Co. Complaint No: PUN-L-022-2021-0087


1. Name & Address of the Complainant: SmtBebiKolekar , Pune

2. Policy No | Type of Policy: Pls refer to chart

3. Dt of Com./Mode Pls refer to chart

4 Term/PPT| Premium Amount Pls refer to chart

5. Insurance Intermediary | Code No. 1000141747 , Mr Amir Hussain

6. Name of the Prop | LA SmtBebiKolekar

7. Name of the Insurer: IDBI Federal LifeIns.Co.



10. Date of complaint 20.01.2020



An online hearing was held on 27.04.2021 through video conference, where Mrs.BebiKolekar (hereafter referred to as the complainant) and Ms.DhanashreeJoshiand Ms.Yuri Jain,representatives of IDBI Federal Life Insurance Co.( hereafter referred to as RI-Respondent Insurer), submitted their contentions..

• The complainant has submitted that she was offered a loan against purchase of policies andsheended up purchasing three policies on her own life, and family members’ life, involving an annual premium amount of Rs 244999./- from the RI in this case.

• The complainant has further submitted that she is a widow and a farmer with very low annual income. She is not in a position to pay regular premiums.

• As informed by the complainant she had taken a loan against gold to source the policy premiums.

• When the complainant did not receive the promisedloan, she realised that she was cheated.

• The complainant approached the RI on 20.01.2020 for cancellation and refund of policies but the request was rejected on the grounds that it was beyond free look period.

• The complainant had purchased policies from other insurers Bharti Axa and Max Life, who have refunded the premiums after cancellation of policies.

RI in their SCN and during the hearing has contended that:

• The policies were issued after receiving duly signed documents from the complainant and her family members along with the required premiums and KYC.

• The PIVC was attended by the complainant’s son and he had agreed to all the terms and conditions explained therein.

• All the policies are in lapsed condition due to non payment of premiums.

• The RI stated that the complainant could either continue the policies by paying the premiums or convert the same into single premium.

• The RI had called for an explanation from the agent and he has confirmed that there was no mis-selling.

• Details of policies: POL NO NAME DTOC MODE TERM PPT PREM DOC Time

lag DOR

4001246784 BEBI KOLEKAR

10.10.18 YLY 15 15 80000 DO 1Y2M DO

4001247176 PRAVIN KOLEKAR

10.10.18 YLY 15 15 65000 DO 1Y2M DO

4001260681 SEETARAM PANSARE

26.11.18 YLY 15 15 99999 20.01.20 1Y2M 15.03.20

3 POLS 244999

• The complainant’s brother Mr.SeetaramPansare had also lodged a separate complaint with the Forum and was not entertained due to requirement of documents.

• The Forum observes that the complainant has purchased the policies within a short span of 2 months Another point to be noted is that renewal premium has not been paid in any of the policies.

• Considering the income of the complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase these number of policies with huge annual premium unless some additional promises / lurement has been given.

• This is a clear case of mis-sale as no one would purchase many policies and then not pay the subsequent premiums.

• The Complaint no PUN-L-032-2021-0088 involving Max Life Ins.Co. has been settled. The Forum also observes that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and receipt of First premium amount. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant should have been vigilant and approached the RI earlier. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid in part can be in part converted

into a single premium policy, so that complainant will not have the financial burden of paying regular premiums. Award follows :

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy Nos. 4001246784 on the complainant’s life,and Policy no.4001247176 on the life of complainant’s son ShriPravinKolekarand utilize the premiums received under the policies to issue a single premium policy ofRs100000/- in the name of the complainant with new date of commencement, with a term of 10 years from new date of commencement, lock-in period of 5 years and without free look cancellation clause andbalance amount left over after issuing single premium policy as above is to be refunded to the complainant. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, this issue of issuing single premium policy would be closed. However, RI is still required to refund the balance amount (total premium received less Rs.100000/- earmarked for issue of single premium) as stated above in full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.

Compliance of the Award:-The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017:

A) According to Rule -17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman.

B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers

Dated at Pune, 27.05.2021

VINAY SAH INSURANCE OMBUDSMAN,PUNE



Case of Mr Deepak KPhadol v/sHDFCStandard Life Insurance Co. Ltd. Complaint No: PUN-L-019-2021-0068


1. Name & Address of the Complainant: MrDeepak K Phadol,Nashik

2. Policy No | Type of Policy: 18676020

3. Dt of Com./Mode 10.09.2016 | Yly

4 Term/PPT| Premium Amount 15/10 | Rs.77101/-

5. Insurance Intermediary | Code No. SMC Broker

6. Name of the Prop | LA Shri Deepak K Phadol

7. Name of the Insurer: HDFC Standard Life Insurance Co.Ltf]d



10. Date of complaint 13/03/2018

11. Date of Refusal by RI 07/08/2019

12. Date of receipt of the Complaint at OIO: 31/07/2020

• Mr. Deepak Phadol (hereafter referred to as the complainant) has submitted in his complaint that he was approached by the broker’s officials with an offer of loan against purchase of insurance policies.

• The complainant has alleged that the offered loan amount was increased from 5 Lacs to Rs 9 Lacs at 0% interest for purpose of car loan.He purchased a total of four policies with an annual premium of Rs.250588/- from four different insurers.

• When the complainant did not receive the promised loan, he realised that he was cheated and approached the RI for cancellation of policy and refund of premium.

• The complainant’s request was not accepted by the RI as it was received beyond free look period. Hence he approached the forum for redressal.

Details of policies: POL NO DTOC MODE TERM PPT PREM SA CODE INS.CO. DOC DOR

18676020 10.09.16 YLY 15 10 77101.00 593326 SMC Brk.

HDFC 13.03.18 07.08.19

01330571 14.02.17 YLY 20 20 77108.00 675730 SB Brk. FG 13.03.18

03438010 31.10.16 YLY 15 7 48188.00 241943 SB Brk. EXIDE 13.03.18

0331505093 28.12.16 YLY 63 15 48191.00 930275 SB Brk. BAJAJ ALZ.

13.03.18

4 POLS 250588

The present complaint pertains to one policy bearing no.18676020 purchased from HDFC Life Insurance,the Respondent insurer(RI)

• An online hearing was held on 27.04.2021 where the complainant and the RI’s representative Mr.ChinmaySawant, reiterated their earlier submissions.

• The RI, in their SCN dated 27.04.2021 and during the hearing, have contended that:

1. The policy was issued after receipt of the duly signed application forms and premium amount submitted by the complainant.

2. The complainant did not raise any concern during the PIVC. 3. The policy document was despatched to the complainant on 23.09.20106 and he did not

revert back within 15 days of free look period. 4. The complainant is educated enough to understand the terms and conditions of the policy. 5. The complainant has approached the RI after a lapse of 18 months hence the request for

cancellation of policy could not be acceded. 6. The complainant had raised a request in the October 2017 for change of mode from annual to

quarterly and has paid 2 subsequentQuarterly premiums The complainant, during the hearing, has denied having paid any subsequent premiums. RI has informed by their mail dated 07.05.2021 that after change of mode from yearly to Qly claimant has paid 2 Qly premiums of Rs 20,505/- each.

• Forum notes that in this case, the complainant has been lured to buy four Policies having a total premium of Rs.250588/- from four different companies.

• These policies have been sold starting from 09.2016 to 02.2017 over a period of 5 months.

• Another point to be noted is that renewal premium has not been paid in any of the policies.

• It is absolutely clear that no one will purchase several policies with huge annual premium unless some additional promises / lurement has been given.

• This seems to be a clear case of mis sale as no prudent person will purchase 4 policies over 5 months and not continue with the policies.

• The Forum also observes that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium received through the intermediary acting on their behalf. As such the RI cannot be held fully responsible for the alleged mis-sale, whereas the complainant should have been vigilant and raised the issue earlier. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium. Award follows :

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy No. 18676020 on the complainant’s lifeand utilize the premium received under the policy to issue a single premiumpolicy of Rs100000/- in the name of the complainantwith a term of 10 years from new date of commencement, lock-in period of 5 years without free look cancellation clause and balance amount left over after issuing single premium policy as above is to be refunded to the complainant. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, this issue of issuing single premium policy would be closed. However, RI is still required to refund the balance amount (total premium received less Rs.100000/- earmarked for issue of single premium policy) in full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from

the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.

Compliance of the Award:- The attention of the Complainant and the insurer ishereby invited to the following provisions of Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on this day10thday ofMay 2021.




CASE OF SHRI. Gururaj P KitturV/S Bajaj Allianz Life Ins Co Ltd COMPLAINT NO: PUN-L-006-2021-0090


1 Name & Address of Complainant Shri Gururaj P Kittur, Pune

2 Policy No. Type of Policy

0359453828 / 0359455431 ULIP policy- Future wealth gain plan

3 Date of commencement / 12.03.2019 / / 12.03.2019 /

4 Term/PPT Premium / BSA Mode of Premium

25-05 25-05 Rs.200000/20 Lacs Rs.200000/20 lacs Yearly in both .

5. Name of Proposer/Life assured MrGururajKittur / MrsManjuKittur

6. Name of Intermediary/code no Agent- code no. 1003097354

7 Name of Insurer Bajaj Allianz Life Ins Co ltd

8 Nature of Complainant Mis-sale

9 Relief sought Compensation of 5 years prem for both policies(Rs 20 Lacs)

10 Date of complaint Date of Refusal by RI Time lag

04.06.2020 22.07.2020 1Y 3M

11 Date of receipt of complaint at OIO 06.08.2020

• A hearing was conducted on 23.03.2021 through video conferencing. During the hearing Shri GururajKittur (hereafter referred to as the complainant) and Mr. Nikhil Upadhyay, representative of Bajaj Allianz (hereafter referred to as the RI- Respondent Insurer), reiterated their earlier submissions.

• The complainant has submitted that he was approached by representative of the RI,through owner of a broking firm with whom the complainant was workingand canvassed aULIP policy. According to the complainant he was informed by the owner of the firm and his employer that it was a different type of policy under which even if renewal premium was not paid from the second policy year, the funds would be safely invested in the market there will be no loss. He could even withdraw up to 70% of fund value. He purchased two policies one on his own life and one on his wife’s life, investing an amount of Rs. 2,00,000/- each, i.e. a total premium of Rs.400000/-.

• He has alleged that the policies were sold to meet the target of the agent.

• The complainant had approached the RI after one year two months from the date of commencement for cancellation of policies and refund of premiums. RI regretted cancellation of policies as the request was received after the free look period.

• The complainant has requested the Forum to direct the RI to for paying of Compensation of at least 5 years premium for both policies (Rs 20 Lacs) and penalty on premiums due 03/2020 which would have been levied for late payment by RI.

• The RI in their rejection letter dated 22.07.2020addressed to the complainant, and during the hearing hascontended that: 1)They have processed the policies on the basis of all the requirements viz. Proposal form, KYC and first premium received through agent acting on their behalf. 2)To ensure that the customer is in agreement to the policy terms and conditions, the policy holder is provided with a 15 days free look period option, during which period they can review the policy terms and convey if they do not agree with any of the provisions whereby they can seek refund of the initial premium by cancelling the policy. In this case they have not received any request within the free look period against the policy. 3) Both the policies are in lapsed status as no further premiums have been paid. The forum observes that the complainant is himself associated with the broking firm.

• The forum also observes that the policies seem to have been canvassed by the agent through the broking firm’s owner where the complainant was employed.As alleged by the complainant the policies appear to be sold forpersonal gains of agent/broker rather than considering the clients requirement.

• Forum also makes it clear to the complainant that it is not mandated to award the type of compensation as requested in his complaint

• The forum further observes that the complainant has taken the insurance policies on expectations of high return as well as safety and liquidity of the policy fund in case subsequent premiums were not paid.He has submitted all the documents and amount required by the company for completion of the case. As such RI cannot be held fully responsible for all the alleged mis-sale, and feels that the complainant should have been vigilant enough and should have approached the RI within the free look period if he wasnot satisfied with the policies. However, givingbenefit of doubt to the complainant, the forum feels that the premiums paid under the policies of Mr.GururajKittur of Rs.2,00,000 and MrsManjuKittur Rs.2,00,000/- can be converted into a single premium policies, so that the complainant shall not have the financial burden of paying regular premium.

Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel the policies bearing nos. 0359453828 in the name of Shri GururajPandurangKittur and 0359455431 in the name of Smt.ManjuGururrajKitturand utilize the premiums received under the policies to issue one Single premium policy of Rs. 2,00,000 on the life of Shri GururajDattatrayaKittur and another single premium policy of Rs.2,00,000 on the life of Smt.ManjuGururajKittur,both with term of 10 years from the New date of commencement, with a lock in period of 5 years without free look cancellation clause. If RI does not have single premium plan as per above criteria, then RI to refund the entire amount under the two policies. The complainant has to provide all documents required to issue the 2 single premium policies within 30 days from date of receipt of this award. If the complainant does not comply within stipulated period for the issuance of the single premium policies, the issue of issuance of the single premium policies would be closed and the complaint will be treated as dismissed. Hence the complaint is partially allowed.

Compliance of the Award:- The attention of the Complainant and the insurer is invited to the following provisions of The Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, 10.05.2021.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE

(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO) (UNDER RULE NO: 16( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - VINAY SAH Case of Mr Jagdish CRuiwale v/sKotak MahindraLife Insurance Co. Ltd.

Complaint No: PUN-L-026-2021-0031 Award No:IO/PUN/A/LI/ /2021-2022

1. Name & Address of the Complainant: Mr Jagdish C Ruiwale / Navi Mumbai

2. Policy No&Type of Policy: 03998311 / Lifetime Income plan(Pension plan)

3. Date of Commencement: 25.09.2019

4 Premium / Mode Annuity amount/Annuity frequency Date of 1st Annuity payment

Rs. 1221600/- / Single Rs 88573/- /Yearly 30.09.2020

5. Insurance Intermediary Individual Advisor

6. Name of the Insured/ Proposer Mr Jagdish C Ruiwale

7. Name of the Insurer: Kotak Mahindra Life Ins. Co. Ltd.

8. Nature of complaint: Delay in annuity payment

9. Relief sought: Compensation for delayed annuity payment or change in date of annuity payment.


11 Date of Refusal by RI 25.10.2019

12. Dt of receipt of the Complaint at OIO: 13.03.2020

A hearing was held on 10/03/2021 through video conferencing. During the hearing, Sri JagdishRuiwale(hereinafter referred to as the complainant) and Ms.Nivedita Bhattacharya, the representative of Kotak Mahindra Life Ins. Co Ltd. (herein after referred to as Respondent Insurer-RI) reiterated their earlier submissions.

• The complainant had availed Lifetime Incomepolicy bearing no 03995195 from RI on 20.08.2019 with release date of 1st annuityamount as 30.08.2020 with Option 6-“Last survivor Life time Income with 100% annuity to the surviving spouse and cash back on death of surviving spouse”. Post receipt of policy document, the complainant had gone through the details of the policy. After undergoing claim rules, he decided to change the nomination under the said policy from his son to nephew as his son is residing out of country and the complainant could not predict about his then residential status in case of demise of both annuitant and spouse. Hence he immediately applied for free look alteration request on 30.08.2019 for change in nomination from Son to Nephew and if not possible, then change the annuity option from option no 6 to option no 2 i.e. to Return of purchase price after death of annuitant.

• RI informed that nephew could not be the nominee as per rules. Hence, subsequently the complainant has applied for revised policy on 04.09.20219 with wife as nominee. The new policy bearing no 03998311 with yearly annuity mode and annuity option no 2 as mentioned above, has been issued to him on 26.09.2019 with 1stannuitypayment date as 30.09.2020. The complainant mainly contended that he should get the 1st annuity due at least on

04.09.2019 as on date of new proposal or he should get the amount of Rs. 9000/- towards

the compensation due to delay in issuing the policy. He approached the RI for the same but his request was denied and hence the complaint to the forum. RI in its SCN and theirmails and during the hearing, has contended that:

1. The policy bearing no 03995195 was issued on 23.08.2019with 1st annuity due date as 31.08.2019 on the basis of dully filled proposal form, premium remittance and other relevant requirements, annuity option and mode as requested.

2. Later on the complainant has requested on 30.08.2019 to change the nominee and also the annuity option. He has submitted free look alteration requestdated 04.09.2019 for the same. As such the earlier policy 03995195 was cancelled and the new policy bearing no 03998311 with the desired changes was issued on 25.09.2019 with 1st due date of yearly annuity as 30.09.2019 payable on 30.09.2020 as per policy conditions and mode (frequency) of annuity payment opted being yearly.

3. The complainant then approached RI on 24.10.2019, with request to change the annuity due date from 30th Sept to 4th Sept. every year OR for compensation amounting to Rs. 9000/- for delay in issuing new policy.

4. The RI vide their mail dt 24.10.2019 replied that the policy was altered as per the complainant’s request and hence there was delay in issuing new policy. Also RI has rejected the request of the complainant as it was beyond terms and conditions of the policy.

5. The complainant himself has requested for alterations in the policy and hence the new policy was issued to him in Sept. 2019. Hence as per policy terms and conditions, as the frequency

of payment of annuity is 1 year, the annuity was payable on the last date of the month after 1 yeari.e on 30.09.2020.

6. During the hearing the representative of RI, stated that1stannuity amount ofRs 90049/- was paid to the complainant on 30.09.2020 inclusive of proportionate annuity amount.

• Forum observes that the complainant himself has applied on 04.09.2019 for change in nomination and annuity option in free look period in case of first policy 0399515 and new policy bearing no 03998311 was issued to the complainant with desired changes on 25.09.2019 utilizing the policy amount under first policy.

• Forum observes that the terms and conditions regarding annuity payment date is clearly mentioned in policy document.

• Payment date of Annuities under “PartC” of Policy Conditions of the Policy mentions that: “Payment of Annuity will be made in arrears on the last day of month depending upon the frequency of payment chosen. Proportionate payment of Annuity will be made for the first policy month.”

• From above the forum is clearly opined in the instant case that as the policy was issued on 25.09.2019, the annuity date will be 30thSept. only and as the frequency of annuity payment was chosen is Yearly by the complainant, the 1st annuity payment date was on 30.09.2020.

• Accordingly, the 1st yearly annuity amounting to Rs. 90049/-inclusive of proportionate annuity of the first policy month,has been paid to the complainant on 30.09.2020.

• Further it is also observed that the complainant could have approach the RI if he was not satisfied with the provisions of the policy in contention but he has not availed this facility of free look period clause specifically for cancellation of policy within 15 days.

• Forum also observes from RI has submitted in their SCNthat the process of issuance of new policy in the event of change in plan components is equivalent to assessment of new policy. The documents provided for any policy alteration are sent to their head office for assessment at various levelpost which the policy was issued. Forum notes that complainant had himself applied for free look alteration on 04.09.2019 and accordingly the policy in contention was issued.

• Forum opines that RI has acted as per terms and conditions of the policy and there is no deviation. The forum does not find any substance in the complaint.

Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties the forum opines that the RI has acted rightly as per terms and conditions of the policy contract in terms of annuity payment dates and issue of payable annuity amount and no intervention is required by the forum. Hence the complaint is dismissed.




(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO) (UNDER RULE NO: 16 ( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - VINAY SAH Case of Mr K K Murukan v/s Reliance Nippon Life Insurance Co. Ltd.

Complaint No: PUN-L-036-2021-0038 Award No: IO/PUN/A/LI/ /2021 -2022

1. Name & Address of the Complainant: Mr K K Murukan, Vasai

2. Policy No | Type of Policy: 53605152 Fixed Money Guranteed Plan

3. Dt of Com./Mode 25.11.2019

4 Term/PPT | Premium Amount/Mode 15-10 | Rs.40000, S A- 364660 /Yly

5. Insurance Intermediary | Code No. North India Finserve | 22261767

6. Name of the Prop | LA Shri K K Murukan

7. Name of the Insurer: Reliance Nippon Life Ins. co. Ltd.


9. Relief sought: Refund of premium amount

10. Date of complaint / Time lag 21.01.2020 / 1M26D



Mr.K K Murukan (herein after referred to as the Complainant) had purchased a policy bearing no.53605152 from Reliance Nippon Life Ins. Co. Ltd. (herein after referred to as the Respondent Insurer – RI) on with an annual premium of Rs.40000/-.

• Complainant has submitted that he was contacted by a person on phone who identified himself as an agent of Reliance Life and canvassed a policy with a promise of multiple benefits like 6 lacs medical cover and cover for critical illness and major surgeries for 6 members of the family etc up to 5 years in case of PPT of 5 years and a maturity amount of Rs 8.15 Lacs. And much more benefits for 10 year PPT like 3 health checkups in a year and maturity amount of Rs 16.5 Lacs. The complainant has also submitted in his complaint that he was informed that he had to pay Rs 40000/- premium instead of Rs 50000/- as the agent was directly from Head office of Reliance Nippon Life Insurance at Mumbai.

• The complainant opted for a policy with a term of 15 years and premium paying term of 10 years.

• The complainant had given his native place address and hence did not receive the policy documents in time.

• When he received the documents at his residential address in Vasai, he realised that the policy is not a medical benefit plan but a regular life insurance one.

• The complainant requested the RI for policy cancellation and refund of premiums with interest which was rejected by the RI on the grounds that it was beyond free look period.

An online hearing was held on 17.03.2021, where the complainant and the RI’s representative, Ms. Anubha Gupta reiterated their earlier submissions.

• The RI, in their SCN and during the hearing, submitted that: 1. After going through the key benefits and terms of the products the complainant chose to

avail the said policies of the company on crystal clear terms and conditions of the said

policies as envisaged in the policy application cum proposal forms which were duly signed and submitted by the complainant to the company for availing the policy.

2. The policy document along with the terms and conditions was dispatched on 27.11.2019 and the receipt of the same has not been disputed by the complainant.

3. The complainant approached the RI with a request to cancel the captioned policy on 21.01.2020 after a span of almost 2 months which is beyond the free look period.

4. The complainant did not raise the issue during the PIVC nor did he avail the free look option.


• The complainant has mentioned the name and mobile no. of the fraudster who contacted and misguided him in his complaint.

• The forum observes that RI has not produced a copy of explanation from the intermediary regarding the allegations of mis-sale made by the complainant.

The Forum also observes that the complainant has wished to take a Mediclaim/medical benefit policy. He was misguided by the broker’s officials into believing that he was being issued a policy covering his and his family’s medical needs like Rs.6 lac cover for hospitalization, critical illnesses, major surgeries and free health check-ups and also high maturity amount etc. Forum notes that as the complainant’s permanent address was Kerala, the policy document was delivered there. Hence, there was a delay in receiving the policy documents and the complainant approached the RI after one month 26 days. It is observed that the broker had clearly misguided the complainant for his own benefit and the complainant has approached the RI for cancellation immediately on receipt of the documents at his residential address. The forum also observes that the complainant was vigilant enough and the complaint, though not made within free look period has been made within a reasonable time and the reason of not getting the policy bond in time, as stated by complainant seems plausible. Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy No.53605152 and refund the premium received under the policy to the complainant in full and final settlement of the complaint RI has to comply with the award, pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment. For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.

Compliance of the Award:- The attention of the Complainant and the insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on 06.05.2021 VINAY SAH INSURANCE OMBUDSMAN, PUNE



OMBUDSMAN - VINAY SAH Case of MrKalyan Roy V/S Kotak MahindraLife Ins.Co.


1. Name & Address of the Complainant: MrKalyankumar Roy,Navi Mumbai

2. Policy No | Type of Policy: 09130673| Assured saving plan

3. Dt of Com./Mode 05.02.2019 | YLY

4 Term/PPT| Premium Amount 15-10 | Rs.136998.00

5. Insurance Intermediary KMBL –Khargar/Bancassurance

6. Name of the Prop | LA MrKalyankumar Roy

7. Name of the Insurer: KotakMahindra life ins.co.




11. Date of Refusal by RI 08.05.2020 ,09.11.2020


An online hearing was held on 18.05.2021 through video conferencing where Mr.Kalyan Roy (hereafter referred to as the complainant) and Ms.Nivedita Bhattacharya on behalf of Kotak Mahindra Life Insurance Co.Ltd (hereafter referred to as the RI- Respondent Insurer), and reiterated their earlier submissions.

• The complainant was on a look out for short term investment. The complainant has alleged that the Kotak Mahindra Bank officials had canvassed a different product than the one issued to him.

• The complainant has submitted that he is a mechanical engineer who works as a consultant and does not have a steady income and hence was not interested in a long term investment. But the bank officials issued a regular term policy with an annual premium of Rs.136998/-.

• The complainant approached the bank officials several times for cancellation of the policy and refund of premium, but to no avail. Finally he approached the RI with his request which was rejected on the grounds that it was beyond free look period.

• The complainant is not in a position to pay the premium for the specified term. He had made it clear to the bank officials that he was looking for short term investment with any time liquidity.The complainant has also alleged that they had forged his signature and misused his money to issue a regular term policy.

• The complainant has approached the Forum for redressal.

The RI in its SCN and during the hearing has submitted that:

• The complainant as a proof of his understanding that it was a life insurance plan, the client signed and executed the proposal form and benefit illustrations, based on which the policy was underwritten and issued.

• A copy of the policy contract along with the terms and conditions was dispatchedby Blue Dart courier to the complainant on 07.02.2019and duly received by him.

• Prior to issuance of the policy, the company had conducted 3 verification calls to the registered contact number of the complainant. During the 1st call the complainant had raised his concern over the method used by the bank officials to get business. In the 2nd call he informed that the bank officials would be contacting him to address his issues. In the 3rd call the complainant stated that the sourcing agent had apologised to him for creating pressure on him to take the policy and that he is now ok with issuance of the policy.

• Thus it is evident that the complainant had expressed his concerns at the proposal stage itself which were duly addressed and after being satisfied with the resolution, he agreed for issuance of the policy.

• During the said call the complainant had admitted to have signed the proposal as well. Thus the allegations of not having knowledge of policy and signature forgery are baseless and a mere afterthought in order to procure cancellation much after free look period.

• The welcome letter was duly sent to the complainant along with the policy document, where it is clearly mentioned that there was a period of 15 days for the customer to return the policy under Free Look period and get the policy cancelled, in case the customer was not agreeable to any of the Terms and Conditions of the policy. The complainant did not avail the free look option within stipulated time.

• The complainant has paid only the subscription premium under the policy and no further premiums were paid under the policy. As a consequence of the same, the policy moved into lapsed mode effective 05.02.2020 and communications were sent to the complainant in this regard.

• The complainant had submitted a request for deactivation of auto debit facility on 30.01.2020, the reason for deactivation being quoted as “will pay online”. The same is clearly indicative of fact that the complainant had an intention to continue the policy by payment of premiums online.

• The RI are unable to take into consideration any promise of guarantee given by the sales representative without any valid acknowledgement being submitted by the complainant and consider his complaint.

The Forum notes that the complainant has submitted copy of a mail dated 09.11.2020, where the RI has informed about the closure of complaint. The Forumobserves that the complainant was pressurised by the bank officials to purchase the policy for helping in their performance and achieving their targets. The complainant purchased the policy as the bank manager had assured that it was suitable to his needs and he would facilitate withdrawal when required. The Forum also observes that the complainant has taken this insurance voluntarily and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium received through the intermediary acting on his behalf. As such the RI cannot be held fully responsible for the alleged mis-sale, the complainant is expected to be vigilant and should have raised his concerns earlier. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy No. 09130673 on the complainant’s life and utilize the premium received under the policy to issue a single premium policy in the name of the complainant with a term of 10 years from new date of commencement, lock-in period of 5 years and without free look cancellation clause. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, the issue of issuing single premium policy would be closed and the complaint will be treated as dismissed. Hence the complaint is partially allowed.

Compliance of the Award: - The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017: A) According to Rule 17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman. B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers

Dated at Pune,on 31.05.2021 VINAY SAH

INSURANCE OMBUDSMAN, PUNE



Case of Mr Khandu Veer V/S Future GeneraliIndia Life Ins.Co. Ltd. Complaint No: PUN-L-017-2021-0188


1. Name & Address of the Complainant: Mr Khandu Veer / Vashi, Navi Mumbai

2. Policy No | Type of Policy: 01475217 01481751 ( both Assured Money back policies)

3. Dt of Com./PT-PPT Premium / Mode

20.11.2018/20-10 21.12.2018/ 20-10 RS.489235/- YLY Rs. 391387/- YLY

4. Insurance Intermediary Alternate Channel

5. Name of the Life Assured Name of Policy Owner

Swapnil K Veer Kshitij K Veer Mr Khandu Veer (In both policies)

6. Name of the Insurer: Future Generali India Life Ins. Co. Ltd.


8. Relief sought: Cancelation of policy & refund of amount




An online hearing was held on 18.05.2021 where Mr Khandu Veer (hereinafter referred to as the complainant) and Ms.HarshitaChaudhari the representative of Future Generali India Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer- RI) reiterated their earlier submissions.

• The Complainant has stated in his complaint that he was in need of loan of Rs. 20 Lacs and he was in search of the same. In the meantime, he was contacted by an agentMr Abu Sad Khan who has his own financial institute and provides business and personal loans.

• The complainant was compelled to purchase2 policies from RI involving initial premium of around Rs. 900000/- for releasing the loan.

• The complainant has also alleged that the policies were issued in the names of his sons Swapnil and Kshitij instead of himself to avoid medical examination. According to the complainantboth his sons were unemployed but they were shown as employed with fabricated annual income.

• When the complainant enquired about the policies in context with loan, he came to know that the policies were mis sold to him; there was no loan available as additional benefit on the policies. The complainant felt that he was provided loan from bank only for paying the premiums. Hence, he approached the RI with the allegations of wrong information in proposal form and mis sale of policy andhad requested for cancelling the policy and refund of premium but his request was turned down. Hence, he approached the forum for relief.

• The present complaint pertains to 2 policies bearing no01475217on the life ofMrSwapnil Veer and 01481751 on the life of Mr.Kshitij Veer, both sons of the complainant, purchased from RI involving annual premium of Rs.880622/-

RI in their SCN dated 01.12.2020 and during the hearing has contended that: 1. The policies in contention were issued only after receipt of duly signed proposal form,

benefit illustration document, relevant documents and premium payment and PIVC.The details of polices were explained to the complainant by the sales representatives of RI.

2. The policy documents of both the policies were dispatched on 22.11.2018 &24.12.2018 respectively via Blue Dart courier.

3. The complainant first approached RI on 30.09.2019, nearly after 1 year 2 months from issuance of the policy with the allegations of fraud and cheating and request of cancellation of policy alongwith the refund of premium. RI had responded on 09.12.2019 and called for ITR for last 3 years prior to current policy issued and documents related to rental income from 3 properties, to investigate the allegations made by the complainant.Till the date of SCN the complainant has not submitted the requirements.

4. Only one premium has been paid under both policies. Hence both the policies are in lapsed status. The lapsation letters were also sent by RI on 21.12.2019 The complainant has never approached RI till the date of complaint and also, he did not raise any issue or concern during free look period. Hence his request was rejected as per free look period clause.

• During the hearing it was informed by the complainant that he is vegetable vendor at Byculla Market. He was in need of loan of Rs. 20 Lacs and he came into contact of the person

mentioned in the contention who provides business or personal loan. He was asked to invest the amount as security for loan purpose while the said amount was utilized for issuing the 2 policies in the names of his sons.

• Thus, complainant was mis sold2 policies involving huge annual premium of Rs. 880662/-with afalse promise of payment of loan of Rs. 20Lacs

• The complainant has availed the loan of Rs. 15 lacs then by Kotak Mahindra Bank on05.12.2018.

• Further it is observed by the Forum that the policies were sourced through 2 different intermediaries. RI could not produce copies of explanation called from them regarding issue of mis-sale raised by the complainant in his complaint.

• Anomaly is observed in premium amount and income of the complainant. The annual income of the complainant (policyowner) mentioned in the proposal forms is Rs. 15 lacs. ITR copy of last 3 years while taking the policy has been called for. The average income as per IT Returns was Rs. 684123/- while opting the policy and the policies were issued with a total annual premium of Rs. 880662/-

• During the hearing and in his complaint also the complainant has expressed his inability to pay the huge annual premium and also the installment of loan availed.

• Forum further notes that no prudent person will purchase the policies withsuch huge premium within a span of onemonth unless some additional benefits were promised.

• Another point to be noted is that renewal premium has not been paid in any of the policies. Considering the income of this complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase these number of policies and pay premium unless some promises / lurement has been given.

• This seems to be a clear case of mis sale as no prudent person will purchase 2 policies with such a huge premium within a month and not continue with the policies. However, the Forum also observes that the complainant has taken this insurance on enticement byfalse assurance and promise and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium etc. received through the intermediary acting on his behalf. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant cannot be pardoned for being imprudent and non-vigilant. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid in part can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium. Forum findssome substance in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy Nos. 01475217 on the life of complainant’s son ShriSwapnil Veer &01481751 on the life of the complainant’s son, Mr.Kshitij Veer and utilize the premiums received under the policies to issue 2 single premium policies of Rs 100000/each, one on the life of MrSwapnil Veer and another on the life ofMrKshitij Veer,bothfora term of 05 years from new date of commencement, with lock in period of 5 years without free look cancellation clause and refund the balance amount leftover after issuing the single premium policies. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policies within 30 days from date of receiving the award. If complainant does not comply with the requirements within the stipulated time for issuance of the single premium policies, this issue of issuing single premium policieswould be closed and thecomplaint will be treated as dismissed to the extent of above mentioned premium amount earmarked for the issue of the 2 Single premium policies. However, RI will still be required to refund the balance amount (Total premium received less premium amount earmarked for issue of 2 single premium policies)as stated above towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.

Compliance of the Award:- The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on 31.05.2021




OMBUDSMAN - VINAY SAH Case of MrKishor Salve V/SFuture GeneraliIndia Life Ins.Co.


1. Name & Address of the Complainant: Mr Kishor Salve , Nashik

2. Policy No& Details Pls refer to chart

3. Insurance Intermediary | Code No. Sridhar Insurance Brokers pvt,ltd.

4. Name of the Prop | LA Mr Kishor Salve

5. Name of the Insurer: Future Generali India Life Ins.co




An online hearing was held on 27.04.2021 through video conferencing where Mr.Kishor Salve (here in after referred to as the complainant) and Mr.Raktim Chowdhury, representative of Future Generali India Life (hereafter referred to as the RI- Respondent Insurer) reiterated their earlier submissions.

• The complainant has alleged in his complaint that he was lured into buying two policies from two different insurers with false promises of payment of bonus from IRDA and taxes thereof.

• The complainant purchased two policies, one each from Future Generali and Reliance Nippon involving an annual premium of Rs.85000/-.

• According to the complainant was under the impression that it was one time investment but later realised that it was a regular plan. He is unable to pay the premium for such a long span. When he approached the brokers regarding the term, they asked him to wait till the bonus was credited which would take another 20-25 days. Thus, the free look period had exhausted by the time he raised his concern with the insurers.

• The complainant has also alleged signature forgery.

• The complainant approached the insurers with a request to cancel the policies and refund the premiums but the same was rejected as the request was received beyond free look period.

• Details of policies: POL NO NAME DTOC MODE TERM PPT PREM CODE INS CO DOComp DOR

01285102 Kishor Salve

02.02.16 YLY 20 10 35000 Sridhar Ins Broker

FG Life Ins co.

08.06.19 18.07.19

** 52884843

Kishor Salve

15.12.2015 YLY 15 10 50000 Authentic Reliance Life Ins.

08.06.19 16.10.19

2Pols 85000

The RI, in their SCN dated 23.04.2021, has contended that:

• The policy was issued on the basis of the duly signed documents and premium amount submitted by the complainant.

• The complainant is an educated individual and would invest his funds only after completely satisfying himself with the product features or alternatively would get the product cancelled during the Free Look period if the product is not as per satisfaction.

• The policy document had been sent by the company along with the Welcome Letter on 05.02.2016 and delivered on 10.02.2016, which clearly mentions that in case policyholder is not satisfied with the features or the terms and conditions of the policy he can withdraw/return the policy under the Free Look Period provision. The complainant had retained the policy documents and did not raise any objections during the said free look period with any of his grievances regarding the policy or terms and conditions thereof.

• The complainant has signed the proposal form after he has read and understood the terms of the policy i.e premium payment term, policy term, premium amount, etc. and only then submitted

the same. It has been clearly mentioned on the Benefit Illustration Document that “Please read this document carefully before signing it”.

• During the PIVC it was clearly explained that the said policy is a regular policy and no installation of tower was assured at the time of prospecting for the policy, and it was also confirmed by the complainant that no undue inducements had been made to him.

• The complainant has paid 2 premiums against the said policy which means that he was well aware of the terms and conditions of the policy.

• The complainant has not disputed signing of documents for availing the subject policy. The company has neither compelled the complainant to purchase the subject policy nor has the company given any false promises to him. Therefore, it is highly improper on part of the complainant to allege mis-selling or signature forgery.

• The complainant has paid two premiums under the policy to date during which period the complainant has also enjoyed the insurance cover.

• The current status of the policy is “Paid up contract” due to non-receipt of renewal premiums after the payment of instalment premiums for first 2 years. Paid up letter dated 05.03.2018 had been sent to the complainant.

The Forum observes that the complainant has alleged that he purchased the policy on enticement but he has submitted all the required documents and First premium amount for completion of the policy and has paid one subsequent premium under the subject policy.He has also availed Insurance cover and services of RI for the relevant period.The complainant has raised the issue of mis-sale after a period of 3years and 5 months. The forum feels that there is exorbitant delay in approaching the RI for cancellation and refund under the policy. Forum opines that the complaint is an afterthought on part of the complainant and RI cannot be held responsible for the alleged mis-sale of the policy. Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties the forum does not find substance in the complaint. Hencethe complaint is dismissed.

Dated at Pune, on this day24th day of May 2021.




Case of MrKishor Salve V/SReliance NipponIndia Life Ins.Co. Complaint No: PUN-L-036-2021-0164


1. Name & Address of the Complainant: Mr Kishor Salve , Nashik

2. Policy No& Details Pls refer to chart

3. Insurance Intermediary | Code No. Sridhar Insurance Brokers pvt,ltd.

4. Name of the Prop | LA Mr Kishor Salve

5. Name of the Insurer: Reliance Nippon India Life Ins.co




An online hearing was held on 27.04.2021 through video conferencing where Mr.Kishor Salve (hereinafter referred to as the complainant) and Ms.Anubha Gupta, representative of Reliance Nippon India Life (hereafter referred to as the RI- Respondent Insurer) reiterated their earlier submissions.

• The complainant has submitted that he was lured into buying two policies from two different insurers with false promises of payment of bonus from IRDA and taxes thereof.

• The complainant purchased two policies, one each from Future Generali and Reliance Nippon involving an annual premium of Rs.85000/-.

• The complainant has also submitted that he was under the impression that it was one time investment but later realised that it was a regular plan. He is unable to pay the premium for such a long span. When he approached the brokers regarding the term, they asked him to wait till the bonus was credited which would take another 20-25 days. Thus, the free look period had exhausted by the time he raised his concern with the insurers.

• The complainant has also alleged signature forgery.

• The complainant approached the insurers with a request to cancel the policies and refund the premiums but the same was rejected as the request was received beyond free look period.

• Details of policies:

POL NO NAME DTOC MODE TERM PPT PREM CODE INS CO DOComp DOR


02.02.16 YLY 20 10 35000 Sridhar Ins Broker

FG Life Ins co.

08.06.19 18.07.19


15.12.2015 YLY 15 10 50000 Authentic Reliance Life Ins.

08.06.19 16.10.19

2Pols 85000

The RI, in its mail dated 16.10.2019 addressed to the complainant and during the hearing has contended that:

• The first request for cancellation was received by the RI on 14.01.2016 which is beyond the free look period of 15 days from the receipt of the policy document.

• The RI has thoroughly inspected the proposal form duly signed by the complainant used for issuance of the policy and have found no signs of tampering.

• Furthermore, the pre-issuance verification call made to the complainant prior to policy issuance shows that he had confirmed and agreed upon the details now raise for clarification.

• Given the above facts, this case cannot be treated as mis-selling complaint.

• The current status of the subject policy isForeclosedand the foreclosure value of Rs.7999.16 along with unapplied suspense refund for the amount of RS.344.80 has been paid to the complainant appropriately and the same has been received by the complainant.

• The forum observes that the complainant has been sold 2 policies with an annual premium of 85000 within a span of 2 months

The Forum alsoobserves that the Policy document of the subject policy was despatched by RI on 16.12.2015 and the complainant approached the RI for the first time for cancellation of policy on 14.01.2016, i.e within one month of dispatch of the policy.Eventhough the request is made beyond the free look period the complainant has approached the RI immediately regarding issue of mis-selling. The Forum opines that the RI does not seem to have investigated the matter in detail although the complainant had approached them within reasonable period for cancellation of the policy and refund of premium. The forum feels that the RI has responded to the complaint in a casual manner. Now when the complainant has approached the RI again after a span of more than 3 years, they have once again rejected his request citing expiry of free look period. The Forum finds substance in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum directs the Respondent Company to refund the entire premium received under policyno.52456970refund the entire premium received under the policy, after deduction of payments made earlier, if any, to the complainant. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.

Compliance of the Award: -

The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017: A) According to Rule 17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman.



VINAY SAH INSURANCE OMBUDSMAN.PUNE



CASE OF Mr.LaxmanKariyaV/S Max Life Insurance Co Ltd COMPLAINT NO: PUN-L-032-2021-0081


1 Name &Address of Complainant Mr.LaxmanKariya, Pune

2 Policy No. / Type of Policy 604767400 / Platinum wealth plan

3 Date of Comm / Mode 27.03.2019 / Annual

4 Plan /PPT Premium 10-5 | Rs.500000/-

5 Name of Proposer/ LA Age Mr.LaxmanKariya

6 Name of Intermediary Bancassurance/Axis Bank

7 Name of Insurer Max Life Insurance Co Ltd

8 Nature of Complainant Mis-sale

9 Relief sought Refund of premium

10 Date of First Complaint to Insurer Date of rejection by RI

06.05.2020 11.05.2020

11 Reason for rejection Beyond free look period

12 Date of complaint to OIO 19.08.2020

A hearing was conducted on 27.04.2021 through video conferencing. During the hearing Mr.LaxmanKariya (hereafter referred to as the complainant)and representative of Max Life Insurance (hereafter referred to as the RI-Respondent Insurer) Shri.Prashant Singh reiterated their earlier submissions.

• The complainant has stated in his complaint that he was approached by one Mr.PankajKashid, Relationship Manager from Axis Bank, with offer of higher returns on investments in the insurance product of the RI as compared to Fixed Deposits.

• Mr.Kashid managed to convince the complainant to purchase the policy for which he had to withdraw from his FD account.

• The complainant purchased the policy bearing no.604767400 but he has alleged that the policy details and important facts about the terms and conditions of the policy were not disclosed

completely by Mr.Kashid.He was also assured that in case of need anytime withdrawal of the amount would be ensured.

• The complainant has claimed that he had not received any verification call from the RI as claimed by them in their mail dated 23.06.2020.

• The complainant had taken loan from another bank and wanted to withdraw the amount invested in the policy.

• The complainant approached the Relationship manager and other officials of the bank and the RI.

• The complainant has further submitted that one of the RI’s officials took hissignature on free look cancellation form on 16.07.2020 and assured him that his amount of Rs.5 lacs will be directly remitted to his account within 3 working days.

• But the RI, in their communications has every time rejected the claim for refund stating that the case is out of free look period of 15 days.

• The complainant felt cheated and hence approached the Forum for justice. The RI in their SCN and during the hearing has contended that:

• The complainant, after going through the contents of the proposal form and understanding the scope of the same had submitted a duly filled and signed proposal form with the Company, based on which the RI issued the subject policy.

• The RI post issuance of the policy had duly dispatched the policy bond to the complainant. The complainant duly received the said policy bond which included the policy certificate along with relevant policy terms and conditions on 05.04.2019. The complainant was duly informed of the free look option but the complainant did not avail the same.

• A verification call had been made to the complainant prior to issue of the policy, wherein he confirmed the details of the policy proposed to be issued and accordingly the proposal submitted by him was processed.

• The complainant has paid only one premium under the subject policy and the policy got lapsed and discontinued due to non-payment of subsequent premiums.

• The renewal premium reminders were sent to the complainant on 27.04.2020 and 15.07.2020, but he failed to pay the subsequent premiums.

• The complainant first approached the RI on 24.07.2020 vide letter dated 03.07.2020 i.e. after expiry of 1 year, seeking cancellation of policy and alleging mis-selling of policy by the bank as the policy was sourced through Axis Bank. The same was rejected as the policy had fallen out of free look period as per the terms and conditions of the policy.

• The complainant did not raise his concerns during the welcome call and did not avail the free look option.

The Forum observes that the policy was sourced through bancassurance channel, where the bank officials misguided and compelled the complainant to purchase the policy. The complainant in all likely hood desiring and expecting the policy being proposed to be with high liquidity similar to Fixed Deposit scheme but with higher returns, but he was misguided by the bank officials and was issued a regular premium paying policy. The Forum notes that the complainant had approached the bank officials with his request for cancellation of the policy within a considerable period. Again the bank officials falsely promised a refund of premium which was rejected by the RI. The Forum also observes that the complainant has taken this insurance of his own free will and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium received through the intermediary acting on his behalf. As such the RI cannot be held fully responsible for the alleged mis-sale and the complainant should have been vigilant enough to have

raised the issue earlier. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy No. 604767400 on the complainant’s life and utilize the premium received under the policy to issue a single premium policy in the name of the complainant with a term of 10 years from new date of commencement, lock-in period of 5 years and without free look cancellation clause. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, the issue of issuing single premium policy would be closed and the complaint will be treated as dismissed. Hence the complaint is partially allowed.






Case of MrMadhavKotasthane V/S Bharti AxaLife Ins.Co. Complaint No: PUN-L-008-2021-0185


1. Name & Address of the Complainant: MrMadhavKotasthane , Wardha

2. Policy Nos and details of policies Pls refer to chart

3 Insurance Intermediary Pl refer chart

4 Name of the Prop | LA Mr.MadhavKotasthane

5 Name of the Insurer: Bharti Axa Life Insurance Co.

6 Nature of complaint: Mis-sale

7 Relief sought: Cancelation of policies& refund of amount

8 Date of 1stcomplaintto RI 19.12.2019

9 Date of Refusal by RI Pls refer to chart

10 Date of receipt of the Complaint at OIO: 22.10.20

An online hearing was held on 18.05.2021, where Mr.MadhavKotasthane (hereafter referred to as the complainant) and Mr.PavanPhutane, representative from Bharti Axa Life Insurance (hereafter referred to as the RI – Respondent Insurer), reiterated their earlier submissions.

• The complainant has stated in his complaint that the broker’s representatives approached the complainant with an offer of great returns and benefits in his retirement life, with a onetime investment with the RI.

• The complainant was lured into purchasing 3 policies from the RI with an annual premium of Rs.187998/-.

• The complainant has alleged that instead of a certificate for his onetime investment, he received three policies for regular premium which he had not solicited.

• The agents posing as Bharti Axa employees, sent the complainant a suspicious letter dated 10.08.2020 on his mail ID, which was typed on a fake IRDA letter head.

• The letter mentioned that the complainant would get a refund of Rs.387000/- on payment of 10% of the said amount, i.e Rs.38700/-.

• When the complainant did not receive the promised benefits he approached the RI for cancellation of policies and refund of premiums but did not get a favourable response.

• Details of Policies:

POL NO Broker DTOC MODE TERM PPT PREM INS.CO. DOC DOR 501-

8676311 SMC

Broker 22.02.19 YLY 12 12 39999.42 Bharti

Axa 19.12.19 -

501-8842210

Authentic 27.03.19 YLY 12 12 98999.16 Do 19.12.19 --

501-8962794

SMC 09.04.19 YLY 12 12 48998.99 Do 19.12.19 --

3 POLS 187997.57

The RI, in their SCN received on 17.05.2021 and during the hearing contended that: 1. The RI has issued the policies only after receipt of duly signed proposal form, illustrations of

benefits and other supporting documents and KYC and after verification by PIVC. 2. The complainant did not raise the issue during the PIVC nor did he avail the free look option within

the stipulated time. 3. The RI has put in an elaborate system to avoid any discrepancies and to address grievance of the

policyholders, if any. 4. The policy documents along with copies of all the supporting documents were dispatched to the

complainant as follows: 501-8676311 - dispatched on 25.02.2019 and delivered on 01.03.2019 501-8842210 - dispatched on 29.03.2019 and delivered on 01.04.2019 501-8962794 - dispatched on 11.04.2019 and delivered on 15.04.2019

5. The fact that the complainant retained the policy documents and did not invoke the free look option and did not revert within 15 days alleging any discrepancies, implies that he had agreed to whatever information was provided in the proposal form and was also in agreement with the policy terms and conditions mentioned in the policy documents. 6. The complainant has not alleged any forgery or fabrication of documents which indicates that he has voluntarily purchased the policies. 7. The complainant is educated enough to understand the terms and conditions of the policies. The policies were taken by the complainant through agent who is a third party insurance agent

/ broker. The company has many agents/brokers throughout the country and it is entirely at the discretion of the client to choose the policies suitable to them. The company doesnot authorize any of its agents to offer any false promises or benefits to its customers, which are at variance with its product features. 8. The RI in its SCN has submitted that the company is not privy to the communications the complainant had with the persons who are alleged to have given any representation to the complainant. The company denies that any such misrepresentation was made on behalf of the company. 9. The RI, in their SCN have stated that the complainant never approached them and has directly raised the complaint with the Forum. 10.The RI informed the Forum during the hearing that out of the 2 intermediaries, the broker SMCInsurance Brokers Pvt. Ltd isno longer working with them , although an explanation was called from them they have not responded. The Forum observes that though the RI has mentioned in their SCN that they were never approached by the complainant prior to registering the complaint with the Forum, the complainant has submitted copies of correspondence received from the RI dated 30.01.2020, 16.05.2020, and 21.05.2020.

• The Forum also observes that the complainant had purchased the policies voluntarily with an understanding that it would be a onetime investment and will provide huge benefits and submitted the required documents and premium amount of his own accord.As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant should have been vigilant and approached the RI earlier. However, giving benefit of doubt to the complainant, the Forum feels that part of the premium paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Respondent is directed to cancel policy Nos.501-8676311, 501-8842210 and 501-8962794 on the complainant’s life and utilize the total premium received under the policiesto issue a single premium policyon the complainant’s life, with new date of commencement, with a term of 10 years from the new date of commencement, lock in period of 5 years andwithout free look cancellation clause . If RI does not have a single premiumplan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policies, this issue of issuing single premium policywould be closed and the complaint will be treated as dismissed. Hence the complaint is partially allowed.

Compliance of the Award: - The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017:

A) According to Rule 17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman. B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers

Place: Pune Date: 31.05.2021




OMBUDSMAN - VINAY SAH Case of MrMangeshBhise and PushpaBhise V/S Bharti Axa Life Ins.Co.


1. Name & Address of the Complainant: Mr.Mangesh and Mrs.PushpaBhise

2. Policy No& details Pls refer to chart

3. Name of the Insurer: Bharti Axa lifeIns.Co.



6. Date of complaint/ Time lag 03.04.2020 / 2 to 3 months



An online hearing was conducted on 27.04.2021 through video conferencing, wherein Mr.MangehBhise (hereafter referred to as the complainant)himself attended the hearing and Bharti Axa (hereafter referred to as the RI- Respondent Insurer) was represented by Mr.PavanPhutane.During the course of hearing, both the parties reiterated their earlier submissions.

• The complainant has submitted that he was contacted by broker’s representatives and they induced him to purchase two policies with an offer of family holiday package and gold coins.When the complainant did not get the promised benefits after purchasing 2 policies from RI, he realized that he had been cheated and approached the RI for cancellation of policies and refund of premiums paid.

• RI rejected the request as it had been made after two years which is much beyond free ookthe complainant has claimed to have paid subsequent premiums under both the policies.

• Details of policies: POL NO NAME DTOC MODE TERM

/ppt PREM Intermediary DOC DOR

502-3887002

MangeshBhise

31.12.19 YLY 12 104499 Cotopaxi Ins Broker

03.04.20 24.04.20

502-3046633

PushpaBhise

17.02.20 YLY 12 62699 Cotopaxi ins Broker

DO DO

2 POLS 167198

• The RI in their SCN,have denied all the allegations of the complainant. 5. They issued the policies only after receipt of duly signed proposal form, illustrations of

benefits and other supporting documents and KYC and after verification by PIVC. 6. The complainant did not avail the free look option within the stipulated time although

policy documents with copies of proposal form were dispatched07.01.2020 and 19.02.2020 and delivered to the complainants on 10.01.2020 and 21.02.2020 respectively.

7. The RI has put in an elaborate system as an internal policy to avoid any discrepancies and to address grievance of the policyholders, if any. Also being a prudent person it is expected that the complainant must have gone through the terms and conditions of the policies and taken the policies accordingly.

8. The complainant has not alleged any forgery or fabrication of documents which indicates that he has voluntarily purchased the policies.

9. The first complaint was raised by the complainant on 23.04.2020 (as per SCN), which was beyond the free look period.

10. The complainant is educated enough to understand the terms and conditions of the policies.

11. The policies were taken by the complainant through agent who is a third-party insurance agent / broker. The company has many agents/brokers throughout the country and it is entirely at the discretion of the client to choose the policies suitable to them. The company doesnot authorize any of its agents to offer any false promises or benefits to its customers, which are at variance with its product features.

• The broker, COTOPAXI Insurance Brokers Ltd., is not working with the RI anymore. This complaint is for two policies bearing nos.502-3887002 and 502-3046633, involving annual premium of Rs 167198/-

• The RI vide their mail dated 11.05.2021 havesubmitted that 2 premiums are received for 2019& 2020 under policy no.502-3887002 while only one premium is received under policy no. 502-3046633.

• Forum notes that in this case, the complainant has been lured with an offer to buy the 2 Policies having a total annualpremium of Rs.167198/- from the RI.

• It is known fact that the many officials of the brokers tutor their clients for PIVC and compel their clients to conceal the false promises made to them. They give false assurances that proposal is in process etc ensure that the client does not approach the RI for cancellation of policies during the free look period.The RI has not produced a copy of explanation from the intermediary regarding allegations of mis-sale made by the complainant.

• It is absolutely clear that no one will purchase policies with huge annualpremium and pay premium unless some additional promises/ lurement has been given. The said policies are sold within a span of 2 months and are a clear case of mis-sale.

• The Forum also observes that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium remittance As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant should have been vigilant and approached the RI earlier.

However, giving benefit of doubt to the complainant, the Forum feels that part of the premiums paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum directs the Respondent Company to cancel the policies bearing nos.502-38887002on the Mr MangeshBhise’s life & 502-3046633 on the life of SmtPushpaBhise and utilize the available premiumamount to issue asingle premium policy for Rs. 100000/- on the life of Mr MangeshBhise, with a term of 10 years from new date of commencement with a 5-year lock in period and without free look cancellation clause and refund the balance amount leftover after issuing the single premium policy. If RI does not have a single premiumplan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, this issue of issuance of single premium policy, would be closed. However, RI will still be required to refund the balance amount (Total premium received less Rs.100000/- earmarked for issue of one single premium policy) as stated above, towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.







Case of Mr MayurG Patil v/sIndia First Life Insurance Co. Ltd. Complaint No: PUN-L-024-1920-0576


1. Name & Address of the Complainant: MrMayur GPatil, Nere ,Panvel

2. Policy No& details 10530179 10531163 MahaJeevan Plan Little Champ Plan

3. Dt.of Comm. / Term / Premium/Mode 16.04.2019 31.05.2019 15/15 22/14 Rs.59999/-Yly Rs.38999/-Yly

4. Insurance Intermediary | Code No. Rap Info Systems

5. Name of the Prop | LA Mr.Mayur GPatil

6. Name of the Insurer: India First Life Insurance Co.Ltd


8 Relief sought: Cancellation of policy &Refund of amount


During the online hearing held on 26.02.2021 through video conferencing, Mr.MayurPatil (hereafter referred to as the complainant) and Ms.Nilofer Shaikh, representative of India First Life Insurance Co. (hereafter referred to as RI – Respondent Insurer) reiterated their earlier submissions.

• The complainant has alleged in his complaint that he was approached by representatives of broker with an offer of interest free loan of Rs9 Lacs and was compelled to buy 2 policies from the RI involving a premium of Rs.100000/-.

• When the complainant did not receive the promised loan, he realised that he was cheated and approached the insurers for cancellation of policies and refund of premiums but the RI rejected his request as it was beyond free look period.

The RI in their SCN and during the hearing contended that: 1) The policy was issued after duly signed documents submitted by the complainant along

with the KYC and the required premium. 2) They had done a Welcome call on 23.04.2019 and 07.06.2019 for Policy no. 10530179 and

10531163 respectively wherein the complainant specifically confirmed that no loan was promised to him

3) The complainant did not raise the issue during the V-PIVC held on 14.05.2019 and 24.05.2019 where the term, plan, premium amount, etc were clearly mentioned and accepted by the complainant. The policy documents along with copy of proposal form and terms and conditions were dispatched on 18.04.2019 and 01.06.2019 and delivered on 20.04.2019 and 05.06.2019 respectively.

4) The 1stcomplaint was raised on 19.09.2019, after 5 months of issue of policy, which is far beyond the free look period and hence rejected and the same was conveyed to the complainant vide letters dated 26.09.2019 and 29.09.2019.

5) The complainant has not paid any subsequent premiums and the policies are in lapsed conditions.

• This Forum observes that the complainant was allegedly lured with a promise of loan and compelled to purchase the two subject policies involving annual premium of Rs.1 Lac.

• The Forum also observes that the RI, on 19.04.2021,has submitted to the Forum, mails received from the broker stating that there was no mis-sale on their part and also pre-sale call recording conducted by the broker.The caller, one Ms.Kavita, in the recording hasclearly mentioned that she is calling from Rap systems and sheasked the complainant about the plan details like name of product, term etc. and the complainant is heard confirming the details. The complainant has accepted that the premiums would be paid annually by him. Ms.Kavitahas specifically asked if any other benefits like loan, tower etc. were promisedas there were such spurious calls being made and the complainant has clearly denied any such enticement. It is clear from the recordings that there is no mis-sale. The complainant has confirmed having understood and accepted the terms and conditions of the product in both of these recordings.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum does not find substance in the complaint. Hence the complaint is dismissed.

Dated at Pune, on10.05.2021




Case of Mrs Nidhi Sharma V/S BhartiAxa Life Ins.Co. Complaint No: PUN-L-008-2021-0286 Award No:IO/PUN/A/LI/ /2021-2022

1. Name & Address of the Complainant: Mrs.Nidhi Sharma / Pune

2. Policy No | Type of Policy: 501-6761313 / Elite Advantage Plan

3. Dt of Com. | Term-PPT 17.02.2018 / 12-12

4 Premium | Mode Rs. 209000 / Annual

5. Insurance Intermediary IIFL Ins. Broker

6. Name of the Policyholder Name of Life Assured

Mr. Vijay Sharma Mrs.Nidhi Sharma

7. Name of the Insurer: BhartiAxa Life Ins. Co. Ltd.


9. Relief sought: Cancellation of policy & refund of premium




An online hearing was conducted on 24.05.2021 through video conferencing, wherein Mrs Nidhi Sharma,(hereinafter referred to as the complainant)&Mr. Vijay Sharma, husband of the complainant attended the hearing and BhartiAxa (hereafter referred to as the RI- Respondent Insurer) was represented by Mr.PavanPhutane.During the course of hearing, both the parties reiterated their earlier submissions.

• The complainant has submitted in her complaint that she was contacted by broker’s representatives and they canvassed her the policy with premium of Rs. 200000/- and with hugelumpsum benefits amounting to Rs. 53 Lacs during the maturity period and at the end of the term Rs. 45 Lacs. Thinking it to be a good scheme the complainant purchased the policy.

• The complainant has further stated that after receipt of the policy document, she found the discrepancy in the terms and conditions mentioned in the policy bond and benefits assured by the broker.She has also alleged that the broker’stelecaller had also informed that it was single premium policy while the policy turned out to be long term premium policy. She has further claimed in her complaint that this cheating caused hypertension and mental agony to her.As she felt deceived, she approached the RI on 24.01.2020 with complaint of mis selling of policy and requested for cancellation of policies and refund of premiums paid.

• RI rejected the request as it had been made after two years which is much beyond free look period. The complainant has claimed to have paid subsequent premium under the policy. The RI in their SCN received on 20.05.2021 and during the hearing has contended that : - 12. They issued the policies only after receipt of duly signed proposal form, illustrations of

benefits and other supporting documents and KYC and after verification by PIVC. 13. The complainant did not avail the free look option within the stipulated time although

policy document with copies of proposal form was dispatched 21.02.2018 and delivered to the complainant on23.02.2018 via Regd. Post.

14. The RI has put in an elaborate system as an internal policy to avoid any discrepancies and to address grievance of the policyholders, if any. Also being a prudent person, it is expected that the complainant must have gone through the terms and conditions of the policy and if not satisfied should have approached RI within free look period for cancellation of policy.

15. The complainant has not alleged any forgery or fabrication of documents which indicates that he has voluntarily purchased the policy.

16. The first complaint was raised by the complainant on 24.01.2020, which was after nearly 2 years from the receipt of the policy document and beyond the free look period. The same was replied back by RI on 06.02.2020 to the complainant.

17. The complainant is educated enough to understand the terms and conditions of the policy. 18. The policy was taken by the complainant through agent who is a third-party insurance

agent / broker. The company has many agents/brokers throughout the country and it is entirely at the discretion of the client to choose the policies suitable to them. The company does not authorize any of its agents to offer any false promises or benefits to its customers, which are at variance with its product features.

19. The subsequent premium due on 17.02.19 was also paid by the complainant. The policy is in lapsed status at present.

• The forum observes from the complaint that the complainant has been canvassed the policy in contention with some unrealistic benefits during the policy term and at maturity.

• During the hearing the complainant informed that she is in teaching profession (lecturer in college) whereas her occupation has been shown as Housewife in the proposal form.

• The illustration of projected benefits is attached with the complaint. But the same, being without any authorized signature and stamp of RI, cannot be treated as authentic document of RI.Also, the same cannot be treated as a part of policy document.

• The complainant has paid 2 premiums under the policy. The complainant herself informed during the hearing that due to family medical emergency, loss of job of husband due to pandemic etc. she could not pay the further premiums. Because of this, Mr. Sharma (Policy holder) approached RI in Jan 2020 for enquiry to close the policy but he was informed that the lock in period was 8 yrs, and he would get very less amount on surrender of the policy than the amount invested in premium. The complainant had been informed that the lock in period would be 3 years. When the complainant had found the anomaly, after paying the renewal premiumalso, she lodged the complaint formis sale of the policy.

• The forum further observes that if the complainant was not agreeable to the terms and conditions of the policy, should have applied for cancellation of policy within free look period; instead she retained the policy with her for 2 years and then complained about mis sale of policy.

• However, in spite of the above facts and observations, it is absolutely clear that no one will purchase policy with huge annual premium and pay premium unless some additional or unrealistic promises have been given.In the instant case, the complainant has been induced with unrealistic lumpsum benefits during and also huge maturity benefits at the end of the payment term.

• The Forum also observes that the complainant has taken this insurance voluntarily based on the false promises ofunrealistic benefitsand has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium remittance. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant being prudent and educated person, should have been vigilant and approached the RI earlier.However, giving benefit of doubt to the complainant, the Forum feels that part of the premiums paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium. The Forum finds some substance in the complaint.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum directs the Respondent Insurer to cancel the policy bearing no. 501-6761313on the life of complainant, Mrs.Nidhi Sharma and utilize the available premium amount under the policyto issue asingle premium policy for Rs.200000/- on the life ofMrs.Nidhi Sharma, with a term of 10 years from new date of commencement with a 5-year lock in period and without free look cancellation clause and refund the balance amount leftover after issuing the single premium policy.If RI does not have a single premiumplan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not

comply with the requirements within the stipulated time for issuance of the single premium policy, this issue of issuance of single premium policy wouldbe closed and the complaint will be treated as dismissed to the extent of above-mentioned premium amount earmarked for the issue of the Single Premium policy. However, RI will still be required to refund the balance amount (Total premium received less premium amount earmarked for issue of the single premium policy) as stated above, towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.







Case of MrNiyaz Ahmad Khan V/S Future Generali IndiaLife Ins.Co. Complaint No: PUN-L-017-2021-0173


1. Name & Address of the Complainant: MrNiyaz Ahmad Khan , Amaravati

2. Policy No | Type of Policy: 01311970 , Assured Money Back plan



5. Insurance Intermediary Net Ambit Insurance Brokers

6. Name of the Prop | LA MrNiyaz Ahmad Khan

7. Name of the Insurer: Future Generali IndialifeIns.Co.






An online hearing was held on 06.05.2021 through video conferencing where Mr.Niyaz Ahmad Khan Nazir Khan (hereafter referred to as the complainant) and Mr.Raktim Chowdhury, representative of Future Generali India Life Insurance Co.Ltd (hereafter referred to as the RI- Respondent Insurer), reiterated their earlier submissions.

• The complainant has submitted that he was approached by the broker’s officials with an offer of loan against purchase of insurance policies.

• The complainant was first induced to purchase one policy from Bharti Axa of Rs 50000/- and later one more policy bearing no.01311970 from Future Generali ,RI, with an annual premium of Rs.63000/- .He was assured that the policy amount will be refunded along with the loan amount and policy will get cancelled.

• Later the broker’s officials sold him 2 more policies, one from HDFC with a premium of Rs.30000/- and another from Exide Life Insurance with a premium of Rs.42000/-. Thus, he was compelled to purchase total 4 policies from four different insurer involving an amount of Rs.185000/-. The complainant did not receive the promised loan and realised that he had been cheated. He approached the insurers with a request for cancellation of policies and refund of premiums.

• Exide life and HDFC Standard Life complied with his request and the premium amounts were refunded to the complainant.

• The RI in this instance rejected the complainant’s request as it was beyond free look period.

• The RI in its SCN dated 05.05.2021 and during the hearing have contended the following:

1. The policies were issued after the complainant had submitted duly signed documents and KYC along with the required premium amount.

2. The features, terms and conditions of the respective policy plans under consideration were duly explained the complainant, and only after understanding the same in detail were the policies under consideration in the instant complaint were opted by him.

3. The policy document was dispatched to the complainant along with the Welcome letter mentioning that Policy holder could withdraw the policy under free look period if he was not satisfied with the same.However, he retained the policy documents and did not invoke the free look option and did not revert within 15 days alleging any discrepancies.

4. The complainant did not raise any objection during the PIVC wherein all terms and conditions of the respective plans were explained.

5. The complainant is an educated person and he was supposed to go through each and every terms and conditions of the policy.

6. The complainant approached the RI on 03.02.2017, after issue of policy and has submitted request for cancellation of the policies. The same could not be complied with due to the delay in raising the request.

7. The policy is in lapsed condition due to non-payment of subsequent premiums. A copy of lapsed letter dated 24.10.2017 was went to the complainant.

• The complainant has mentioned the names and mobile numbers of the persons who contacted him with fake offers .

• The forum observes that no further premium is received in the instant policy.

• The policy is sourced through Netambit Insurance Broker against whom number of complaints regarding mis-sale have been received by the Forum.The complainant has stated that HDFC Life and Exide Life have refunded the premium amounts to him.

• Forum also observes that the complainant has been lured and sold 4 policies from 4 different insurers involving a total annual premium of Rs 185000/- No person will purchase this number of polices with huge annual premium unless some additional promises or lurement is given .Forum opines that this is clear case of mis-sale as no prudent person will purchase this number of policies andpay first premium and not pay renewal premium.

The Forum furtherobserves that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC andfirst premium remittance. As such the RI cannot be held fully responsible for the alleged mis-sale. The Forum also observes thatthe complainant had approached the RI within a reasonable period with the complaint of mis-sale on 03.02.2017 which is not an exorbitant delay. Hence, giving benefit of doubt to the complainant, the Forum feels that there is substance in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum directs the Respondent Company to cancel the policy bearing no.01311970 and refund the entire premium received under the policy to the complainant in full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.






Case of Mr PareshShendeVs Exide Life Insurance Co Ltd Complaint No: PUN-L-025-2021-0233


1. Name &Address of the Complainant: Mr.PareshShende

2. Policy No: Type of Policy: 03591378 Guaranteed Income Insplan

3. Date of Commencement / Mode 12.07.2017 YLY

4 Term/PPTPremium Amount 20/10 Rs. 30000/-

5. Insurance Intermediary Net Ambit Insurance Broker

6. Name of the Proposer / LA Mr.PareshShende

7. Name of the Insurer: Exide Life Insurance Co.Ltd


9. Relief sought: Cancellation of policy and refund of premium

10. Date of 1st complaint to RI Time Lag Date of Refusal by RI

07.09.2018 1Y 2M 19.04.2019


An online hearing was held on 06.05.2021, through video conferencingwhere Mr.PareshShende (hereafter referred to as the complainant) and Exide Life Insurance Co.Ltd (hereafter referred to as the RI – Respondent Insurer) representative, Shri Mukund Sharma, reiterated their earlier submissions.

• The Complainant has submitted in his complaint that hewas contacted by Representatives of Brokerwith an offer of a loan of Rs.14lacs within 1 monthagainst purchase of policies. He has further stated that he was compelled to purchase 2 policies from two different insurance companies.

• When thepromised loan did not materialise, the complainant realised that he was cheated.

• The complainant waited for the loan to be processed, hence the delay in raising the complaint.

• The complainant approached the RI for cancellation of policy and refund of the premium amount, but they rejected his request on the grounds that it was beyond free look period.

• The complainanthas further submitted that he worksin a private firm and has an annual income of Rs.1.5 lacs. He has alsoalleged signature forgery,

• The complainant has stated that he is not in a position to pay further premiums. He had invested the amount as he had been promised a loan payment along with refund of onetime premium paid by him.

• The RI vide their SCN dated 02.12.2020, have contended that : 1. The RI admitted to have issued the policy bearing no.03591378 on receipt of duly filled up proposal form, KYC and premium amount from complainant. 2. The copy of policy document along with the terms and conditions was dispatched to the complainant’s address and the complainant has received the same. He failed to avail the free

look option within stipulated time span. The first complaint was received after a lapse of than one year and one month from expiry of free look period. He did not raise any concern during the PIVC. 3. The complainant being a graduate is presumed to have full understanding of the terms and conditions along with other ancillary details before concluding purchase of any insurance product and thereby accord his free consent to the same. 4. The RI places reliance on the Plan Summary signed by the complainant at the time of proposal. Based on this fact, the benefits, terms and conditions of the policies have been understood by the complainant and only after understanding the said policy terms and conditions the complainant has opted for the afore said policy. 5. The complainant has signed a declaration where it is mentioned that the answers and statements made by him in the proposal form have been made after fully understanding features of the policy, nature of questions and the importance of disclosing all material information. He has confirmed that he had been explained the policy/ rider terms and conditions and he fully understand the benefits and risks associated with it. 6. The allegations of signature forgery were raised after a delay of 1 year and 1 month from the lapse of the Free look period which raise a suspicion that they maybe instigated for the simple reason of getting through to file the complaint before the Forum. The complainant’s signature in the proposal form duly matches with his signature in the cheque and PAN card. Hence this disproves his allegation of signature forgery. 7. The RI places reliance on Advisor Confidential Report which clearly indicates that the advisor issued the captioned policy after due diligence. 8. The complainant has approached RI vide his letter dated 07.09.2018i.e after lapse of one year and onemonth after free look period 9. The complainant has signed a Joint Declaration Form which clearly states that: a. No Bonus in lieu of commission. b. No loan or Overdraft facility from any bank. c. No other benefit other than what is mentioned in the product brochure of the selected product would be payable or applicable.

The Forum observes that the RI has acted diligently and addressed all the complaints, like signature forgery, etc. raised by the complainant. Forum notes that while his signatures are matched by RI with his KYC documents and are found to be same .Forum further notes that complainant has not submitted any prooflike email,letter recording etcregarding alleged offer of Loan made to him against purchase of policies. The complainant has approached the RI withallegations of mis-sale and signature forgery after a delay of 13 months which is not justifiable. The forum opines thatthe complaint is an afterthought on part of the complainant and RI cannot be held responsible for the allegations made by the complainant. Award follows:


Place: Pune Date: 31.05.2021 VINAY SAH INSURANCE OMBUDSMAN, PUNE



Case of Mr. Parvez Khan VS ICICI Prudential Life Insurance Co. Ltd. COMPLAINT NO: PUN-L-021-1920-0794


1 Name & Address of Complainant Mr. Parvez Khan / Aundh, Pune

2 Policy No. / Type of Policy DOC/ Premium Mode/PT& PPT

01223056 (ULIP) 02844644 (ULIP) 27.12.2004/Rs.25000/- 25.05.2006/ Rs.36000/- YLY/ 18-18 YLY/ 22-22

3 Name of Insurer ICICI Prudential Life Ins. Co. Ltd.

4. Name of Policyholder/Life assured Mr Parvez Khan

5. Nature of Complainant Extra charges debited while unit allocation

6. Relief sought Recovery of loss and compensation for harassment

7. Date of complaint Date of Reply by RI

12.02.2009 & 04.09.2019 July 2009 & 12.09.2019

8. Date of receipt of complaint at OIO 14.02.2020

A hearing was conducted on 23.02.2021 through video conferencing. During the hearing Mr. Parvez Khan (hereinafter referred to as the complainant) and Ms. Nitu Singh, the representative of ICICI Prudential Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer-RI) reiterated their earlier submissions.

• The complainant had availed 2 Smart Kid Unit Linked policies bearing nos. 1223056 & 2844644 from RI in 2004 and 2006 respectively. The premiums were continued regularly. The complainant has submitted in his complaint that he observed excess debits from the units accounted for both the policies during the period 2007 to 2009 under the head of pay or waiver charges amounting to Rs. 29261+ service tax etc.

• The complainant has stated in his complainant that he then approached RI for clarification about the excess deduction and after vigorous follow up, RI finally refunded an amount of 29261/- in form of units under the policies

• According to the complainant in 2019, he observed increased charges towards mortality, pay or waiver, and administration charges. He had approached RI again but was not satisfied with the explanation given by RI. He was asked to close the policies instead. While applying for

closure he found mismatch in number of units in the system and statement of units, shared with him. RI had credited Rs. 4856.23/- as interest towards excess deduction of amount pertaining to the accounting year 2007 to 2009. Further in a face to face meet with the representative of RI, offered Rs. 20000/- as a settlement against both the policies to which the complainant did not agree.

• Subsequently the complainant being dissatisfied about the clarifications given to him, the complainant has approached the forum for relief.

RI in their SCN dt. 06.03.2020, mails and during the hearing has contended that: 1. The policies in contention, 01223056 & 02844644 were issued in Dec. 2004 and May 2006

with yearly premium of Rs. 25000/- & Rs. 36000/- respectively. The policy documents along with the copy of proposal forms were sent on 29.12.2004 & 27.05.2006.

2. As per their record, the policyholder had approached the company on 04.09.2019 seeking clarification on various charges levied for both the policies. Post receiving the clarification, the complainant reapproached the company on 11.09.2019 alleging the difference in calculation of units towards the excess deduction of payor waiver premiums till 2008 and asked for the compensation for the said loss. RI further stated that the statement was erroneously generated from a redundant system. It was informed to the complainant that due to technical issues; the payor waiver charges were incorrectly captured from 05.08.2006 to 25.07.2008 in both the policies. The complainant was further assured that the excess deductions had already been undertaken in the year 2008 and all the benefits were restored in the forms of units considering the respective NAVs of the dates of deductions, ensuring no loss to the complainant.

3. The complainant had requested to surrender both the policies on 23.09.2019 and the same were initiated for surrender. The policy nos. 01223056 & 02844644 were surrendered on 24.09.2019 & 26.09.2019 and the payout was processed to the complainant’s bank account directly

4. Further, as a special case, RI has also given interest of Rs. 4856.23/- on 29.09.2019 for the period of such excess deduction till the period of adjustment at 8.25% p.a.as approved by the regulator under the protection of policyholder’s interest Act.

5. As the complainant did not agree with the clarification given by the company, he had asked for the compensation for Rs. 52000/- for harassment and incorrect charges levied on his policies. Hence a face-to-face meeting was fixed with the complainant in which the company personnel had addressed all the queries of the complainant. The meeting ended up with the settlement of the said issue with an overall compensation of Rs. 20000/-. Accordingly, MOU was sent to the complainant but the same was declined for signing by the complainant and he demanded additional compensation.

• From all above, the forum observes that the complainant has rightly asked the clarification of the excess deduction of the charges from the units under both the policies. The company has accepted that the rider premium (pay or waiver charges) amount was erroneously deducted due to technical issue but the same were adjusted in the form of units in 2008 to his respective policies. The company has also taken care of restoring the benefits in the form of units considering the NAV at the time of deduction of the charges.

• Also, it is observed that the RI has paid interest at the applicable rate on such excess deduction.

• Multiple mail correspondence between the complainant and the company is observed. The clarification of all the charges and calculation of units has also been communicated to the complainant.

• The forum observes that as per mail dated 20.09.2019 RI has shared the unit statement under policy no 02844644 to the complainant wherein 10813.45 units are mentioned whereas actual units were 10770.25. As a special case the company has allotted differential units i.e. 43.20 units existed at that time.

• As the complainant was not convinced, finally the company had given him final offer of settlement of the said issue of excess deduction of charges, with overall compensation of Rs. 20000/- and MOU has been sent for the same to be signed by the complainant.

• In view of all above, the forum feels that the company has acted as per terms and conditions of the policies, except the service tax portion which was not clarified by RI properly, for which the company is offering Rs. 20000/- as compensation. Forum is not mandated to award any compensation from its side Award follows

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the forum finds that RI has acted as per terms and conditions of the two policies. The complainant may accept what the company is offering as compensation. The complaint is hereby disposed off.


VINAY SAH




Case of Mr Praveen Gupte&NeelaGupte v/sRelianceNippon Life Insurance Co. Ltd. Complaint No: PUN-L-036-2021-0092


1. Name & Address of the Complainant: Mr Praveen&NeelaGupte , Thane

2. Policy Noand Details Pls Refer to chart

3. Name of the Prop | LA Mr Praveen Gupte and Mrs NeelaGupte

4. Name of the Insurer: Reliance Nippon Life Insurance Co.Ltd


6. Relief sought: Refund of premiums

7. Date of complaint 08/11/2019

8. Date of Refusal by RI 15/11/2019

9. Date of receipt of the Complaint at OIO: 02/09/2020

An online hearing was held through video conference on 27.04.2021where Mr.PraveenGupte (hereafter referred to as the complainant) and Ms.Anubha Gupta, representative of Reliance Nippon Life Ins.Co.( hereafter referred to as the RI – Respondent Insurer), reiterated their earlier submissions.

• The complainantswere approached by telecallers who identified themselves as employee of Reliance Nippon Life Insurance and canvassed ‘Increasing income Plan ‘policy

• The complainant has submitted that he was canvassed policies with the following terms and benefits: 1. Single premium payment and policy term of 5 years. 2. Medical benefits of Rs.6lac per annum for 5 years on family floater with 1+5 members. 3. Joint cover between Life assured and proposer – Rs.6lac in natural death and Rs.12 lac in accidental death. 4. Guaranteed maturity benefit.

• The complainant had raised a queryvide email dated 22.03.2019, regarding the contradictions between the promises given by RI’s sales team over the phone and the actual contents of the policy document. The policy document does not make any mention of the benefits promised.The complainant has submitted a copy of reply mail dated 23.03.2019 in which it is mentioned that welcome letter is sent, benefits are confirmed.

• The complainant has alleged that the signatures on page nos.17 and 18 of the proposal form were forged. The complainant felt cheated and filed a police complaint dated 09.10.2019 which is pending for investigation at crime branch Thane.

• The complainant approached the RI on 08.11.2019 for cancellation of policies and refund of premium but his request was rejected on the grounds that it was beyond the free look period.

Hence complainant has approached the Forum for refund of premiums and compensation of Rs.1lac towards mental harassment and expenses incurred by him towards filing police complaint,etc.

Policy Details:

POL NO DTOC MODE TERM PPT PREM NAME CODE INS.CO. DOC DOR

53423576

Praveen/Koustubh

25.02.19 YLY 24 12 94999.00 PRAVEEN GUPTE

RFL Ins .Brk.

Reliance 08.11.19 15.11.19

53423356

Neela/Madhura

25.02.19 YLY 24 12 94999.00 NEELA GUPTE

RFL Ins.Brk

Reliance 08.11.19 15.11.19

2 POLS 189998.00

• The RI in their mail dated 20.08.2020, addressed to the complainant and during the hearing, contended that: 1. They have thoroughly inspected the proposal form duly signed by the complainant, used for

issuance of his policy and did not find any signs of tampering. 2. Both the policies were despatched on 06 .03.2019 by Speed post and duly delivered to the

complainants. 3. The complainant had confirmed and agreed upon the details, now raised for clarification, during

the PIVC. 4. The first request for cancellation was received on 08.11.2019 which was beyond the free look

period of 15 days from receipt of the policy documents. Hence, they could not comply with the complainant’s request for cancellation of the policies.

The Forum observes that:

• Both thepolices are sourced through RFL Insurance broker. RI has not produced copy of explanation regarding allegations of mis-sale made by the complainant in his complaint.

• The complainant had taken the policy voluntarily based on the benefits promised by the sales team / broker of the RI expecting them to be single premium policies with various medical benefits, joint life cover etc but the policies received were annual policies with term of 24 years and premium paying term of 12 years.

• As the policies were dispatched on 06.03.2019 and the complainant had approached the RI for clarification of the terms and conditions of the policy on 23.03.2019, it can be safely assumed that the complainant had expressed his dissatisfaction with the products well within free look period.

• The RI did not check the facts and affirmed vide their mail dated 23.03.2019 that the benefits of the issued policies were as promised to the complainant during the tele-sale, whereas, the same did not match with the benefits mentioned in the policy documents.

• Forum notes that the approach of the RI towards the complaint was prosaic and of negligence and they did not respond properly to the issues raised by the complainants.

The Forum finds substance in the complaint but would like make it clear at this point that it is not mandated to provide compensation for mental harassment and cost of commutationas demanded in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum directs the Respondent Company to cancel the policies bearing nos.53423576 and 53423356 and refund the entire premium received under the policy to the respective policy holders in full and final settlement of the complaint RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.


Dated at Pune, on this day 6th day of May 2021. VINAY SAH

INSURANCE OMBUDSMAN PUNE



Case of Mr Rahul Raje v/s Future Generali IndiaLife Insurance Co. Ltd. Complaint No: PUN-L-017-2021-0231


1. Name &Address of the Complainant: MrRahul Raje, Pune

2. Policy No:Type of Policy: 01272905 | 01274889 , FG Pears Guarantee | F G Assured MB Plan

3. Date of Commencement: 08.10.2015 | 31.10.2015

4 Term/PPT | Premium Amount 18/12 Rs.450000/- | 22/12Rs.200000/-

5. Insurance IntermediaryCode No. GVR Insurance Brokers

6. Name of the Insured: Proposer ShriRahul Raje

7. Name of the Insurer: Future Generali India Life Ins.co.Ltd.


9. Relief sought: Cancellation of policy &Refund of amount

10. Date of complaint / Time Lag 22.06.2018 | 2Y 8M


An online hearing was held on 06.05.2021 through video conferencing. During the hearing Mr.RajulRaje (hereafter referred to as the complainant) and the representative of Future Generali (hereafter referred to as the RI- Respondent Insurer), Mr RaktimChoudhary reiterated their earlier submissions.

• The Complainant has submitted that he was approached by the broker’s officials identifying himself as an employee of Bajaj Finance, with an offer of loan of Rs.50 lac and later another 20 Lac against purchase of 2 policies with a premium of Rs.650000/-

• The complainant issued two cheques for purchase of two policies of Rs.4.5lac and Rs.2 lac.

• When the complainant did not receive the promised benefits, he realised that he was cheated and approached the RI for cancellation of policies and refund of premium.

• The request was rejected by the RI as it was received beyond the free look period.

• The RI in its SCN dated 08.01.2021 and during the hearing, contended that: 1. The policy was issued on the basis of the duly signed documents and premium amount

submitted by the complainant. 2. The complainant is an educated individual and would invest his funds only after

completely satisfying himself with the product features or alternatively would get the product cancelled during the Free Look period if the product is not as per satisfaction.

3. The policy document had been sent by the company along with the Welcome Letter which clearly mentions that in case policyholder is not satisfied with the features or the terms and conditions of the policy he can withdraw/return the policy under the Free Look Period provision. The complainant had retained the policy documents and did not raise any objections during the said free look period with any of his grievances regarding the policy or terms and conditions thereof.

4. The complainant has signed the proposal form after he has read and understood the terms of the policy i.e premium payment term, policy term, premium amount, etc. and only then submitted the same.

5. During the PIVC it was clearly explained that the said policy is a regular policy and no installation of tower was assured at the time of prospecting for the policy, and it was also confirmed by the complainant that no undue offers had been made to him.

6. They received the 1st complaint from the complainant on 25.06.2018 i.e. two years and eight months after issuance of the policies, alleging mis-selling. The company post receipt of request for cancellation of policy verified the allegations levied by the policyholder and found no veracity in the same as the complainant’s signatures on the proposal form and benefit illustrations sheet for the policy are matching that itself indicates that he has signed the same after understanding the plain details and all information and benefits were duly explained at the time of proposal.

7. The RI has confirmed during the hearing that the broker GVR Insurance is no longer active. 8. The current status of the policies is Lapseddue to non payment of subsequent premiums.

The forum also observes that the complainant has taken the insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI processed the policy on the basis of all the requirements viz. proposal form,KYC, and first premium received through the intermediary acting on their behalf. As such the RI cannot be held fully responsible for the alleged mis sale, while the complainant should have been more vigilant and raised the issue earlier. However, giving benefit of doubt to the complainant, the Forum feels that part of the premium paid can be converted in to a single premium policy, so that the complainant will not have the financial burden of paying regular premium. Award follows :

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policies bearing nos. 01272905 and 01274889and utilize the premiums received under the policies to issue a single premium policy ofRs200000/- in the name of the complainant with new date of commencement, with a term of 10 years from the new Date of commencement, lock-in period of 5 years and without free look cancellation clause andbalance amount left over after issuing single premium policy as above is to be refunded to the complainant. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, this issue of issuing single premium policy would be closed and the complaint will be treated as dismissed to the extent of above mentioned premium amount earmarked for issue of the single premium policy. However, RI is still required to refund the balance amount (total premium received less premium amount earmarked for issue of single premium) as stated above in full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.


The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017: A) According to Rule -17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman. B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers





Case of Mr Sanjay Davari V/S Exide Life Ins.Co. Complaint No: PUN-L-025-2021-0223


1. Name & Address of the Complainant: Mr Sanjay B Davari , Kolhapur

2. Policy No | Type of Policy: Rrefer chart below for details 3. Dt of Com./Mode/PT-PPT/Premium

4. Insurance Intermediary

5. Name of the Prop | LA Mr Sanjay B Davari

6. Name of the Insurer: Pls refer to chart



9. Date of complaint Pls refer to chart

10. Date of Refusal by RI Pls refer to chart


An online hearing was held on 06.05.2021 where Mr Sanjay Davri (hereinafter referred to as the complainant) and Ms.Pravalika Reddy the representative of Exide Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer- RI) reiterated their earlier submissions.

• The Complainant has stated in his complaint that he was contacted by the representative of the broker and lured with offer of loan amounting to Rs. 5 Lacs against the insurance policy to be purchased from RI.

• The complainant has submitted that the representative ofthe broker compelled him to purchase 6 policies from different companies involving initial premium of Rs. 237780/- for releasing the loan.

• The complainant has also alleged that the fraudster had sent him a fake letter of electronic fund transfer from RBI for an amount of Rs. 886386/-

• When the promised loan was not realized, the complainant came to know that he was cheated. He approached the RI with the allegations of wrong information in proposal form and mis sale of policy and had requested for cancelling the policy and refund of premium but his request was turned down. Hence, he approached the forum for relief.

• The present complaint pertains to 1 policy bearing no 03522213 on the life of on the life of complainant, purchased from RI involving premium of Rs.30000/-

RI in their SCN dated 20.11.2020 and during the hearing has contended that:

• The policy in contention was issued only after receipt of duly signed proposal form, relevant documents and premium payment. Proposal stage verification call in which the complainant was explained all major terms and conditions of the policies was also made. The policy document was dispatched on 20.03.2017 and confirmed as delivered.

• Only one premium has been paid under the policy.

• The complainant first approached RI with his letter on12.04.2019, after 2 years from issuance of the policy with the allegations of fraud and cheating and request of cancellation of policy along with the refund of premium. RI had denied all the allegations and responded on 23.04.2019 stating the policy cannot be cancelled due to lapse of free look cancellation period.

• The complainant has never approached RI till the date of complaint and also he did not raise any issue or concern during the PIVC and also failed to approach RI during free look period. Hence his request was rejected as per free look period clause.

• The intermediary in the instant case, BUT International Ins. Brokers, is discontinued at present.

Details of policies :- Total 6 policies with initial premium of Rs. 237780/-

INS CO POL NO NAME DOC MODE

PPT

PREM Dt of complaint

Dt of Rejection

TIME LAG

Complaint NO

RELIANCE

Singhma Insurance

52834303

SANJAY DAVARI

31.12.16 YLY

16-08

30000 14.03.19 17.09.19 2 YRS 2 MNTHS

224

EXIDE

BUT Inter.

03522213

SANJAY DAVARI

16.03.17 YLY

15-07

30000 12.04.2019 23.04.19 2 YRS

223

Future Generali

Singhma Insurance

01324010

SANJAY DAVARI

05.01.17 YLY

20-10

36000

05.12.2018

14.03.2019

12.12.2018

04.10.2019

1YR 1 MNTHS

222 Future Geneali

BUT INTER.

01350553

SANJAY DAVARI

31.05.17 YLY

18-12

48000 1 YR 11 MNTHS

HDFC

19633171

SANJAY DAVARI

18.09.17 YLY

15-05

46890

1 YR 5 MNTHS

Singhma Insurance

19585767 SANJAY DAVARI

04.09.17 YLY

16-08

46890 14.03.19

17.09.19

1 YR 5 MNTHS

221

• This is one of the cluster complaint cases registered with the Forum, bearing nos. 221 to 224.

• The Complainant was induced to purchase 6 policies from 4 different insurers over a span of only 9months, by the brokers with the promise of payment of loan uptoRs. 5 Lacs against purchase of new policies.

• It seems that the representatives of the brokers allegedly gavea fake letter in the name of RBI, issued mail of fake images of Demand Draft, to gainhis trust.A copy of the fake letter is submitted to the forumwith the complaint.

• Forum notes that in this case, the complainant has been lured to buy 6 Policies involving a total premium of Rs.237780/-from 4 different companies.

• These policies have been sold from 12.2016 to 09.2017 over a period of only 9 months.

• No further premium has been paid in the instant policy.

• Further it is observed by the Forum that the policy was sourced through BUT International Ins. Broker which is inactive with RI at present. RI could not produce the letter of explanation for the allegations made.

• During the hearing the complainant has informed that he is working with ZilaParishad, Kolhapur. In the proposal form, it is mentioned that he is government employee, working as teacher in Kolhapur, having annual income of Rs. 350000/-

• Forum further notes that no prudent person with this income will purchase these number of policies with such huge total annual premium of Rs. 237780/- within a span of 9 months unless some additional benefits were promised.

• Another point to be noted is that renewal premium has not been paid in the policy. The income of the complainant in various proposal forms has been mentioned as Rs.500000/-. &Rs. 350000/- in some proposal forms. The intermediary, by not disclosing all insurance under consideration in the proposal forms, has knowingly not shared vital information and has got the cases completed. Considering the income of this complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase these number of policies and pay premium unless some additional promises / lurement has been given. Forum further observed that many brokers make practice to state that the offered benefit is in progress and stretch the policyholder up to free look cancellation period so that he could not approach RI within free look period.

• This seems to be a clear case of mis sale as no prudent person will purchase 6 policies over a period of 9 months and not continue with the policies. Forum finds substance in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy no. 03522213 and refund the entire premiums received under the policies to the complainant immediately towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment. For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.




(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)

(UNDER RULE NO: 16( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - VINAY SAH

Case of Mr Sanjay Davari V/S Future GeneraliIndia Life Ins.Co. Ltd.

Complaint No: PUN-L-017-2021-0222


1. Name & Address of the Complainant: MrSanjay B Davari , Kolhapur



5. Name of the Prop | LA MrSanjay B Davari







An online hearing was held on 06.05.2021 where Mr Sanjay Davri (hereinafter referred to as the complainant) and Mr. Raktim Chaudhari the representative of Future Generali India Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer- RI) reiterated their earlier submissions.

• The Complainant has stated in his complaint that he was contacted by the representative of

the broker and lured with offer of loan amounting to Rs. 5 Lacs against the insurance policy

to be purchased from RI.

• The complainant has submitted that the representativeof thebroker compelled him to

purchase 6 policies from different companies involving initial premium of Rs. 237780/- for

releasing the loan.

• The complainant has also alleged that the fraudstershad sent him a fake letter of electronic

fund transfer from RBI for the amount of Rs. 886386/-

• When the promised loan was not realized, the complainant came to know that he was

cheated. He approached the RI with the allegations of wrong information in proposal form

and mis-sale of policy andhad requested for cancelling the policy and refund of premium but

his request was turned down. Hence, he approached the forum for relief.

• The present complaint pertains to 2 policies bearing no01324010 & 01350553 on the life of

on the life of complainant, purchased from RI involving premium of Rs.84000/-


• The policies in contention were issued only after receipt of duly signed proposal form, relevant documents and premium payment. Proposal stage verification call in which the complainant was explained all major terms and conditions of the policies was also made. The policy documents were delivered on 03.06.2017 and 09.01.2017for the policy nos. 01350553 & 01324010 respectively.

• Only one premium has been paid under both policies.

• The complainant first approached RI on 05.12.2018, after nearly 2 years from issuance of the policy with the allegations of fraud and cheating and request of cancellation of policy alongwith the refund of premium. RI had responded on 12.12.2018 to the grievances categorically reiterating its inability to accede the complainant’s request.

• The complainant has never approached RI till the date of complaint and also he did not raise any issue or concern during the PIVC and also failed to approach RI during free look period. Hence his request was rejected as per free look period clause.

• Both the policies are in lapsed status as on date. Details of policies :- Total 6 policies with initial premium of Rs. 237780/-


PPT


Dt of Rejection

TIME LAG

Complaint NO

RELIANCE

Singhma Insurance

52834303

SANJAY DAVARI

31.12.16 YLY

16-08

30000 14.03.19 17.09.19 2 YRS 2 MNTHS

224

EXIDE

BUT Inter.

03522213

DO 16.03.17 YLY

15-07

30000 12.04.19 23.04.19 2 YRS

223

Future Generali

Singhma Insurance

01324010

DO 05.01.17 YLY

20-10

36000

05.12.2018

14.03.2019

12.12.2018

04.10.2019

1YR 1 MNTHS

222 Future Geneali

BUT INTER.

01350553

DO 31.05.17 YLY

18-12

48000 1 YR 11 MNTHS

HDFC

Singhma Insurance

19633171

DO 18.09.17 YLY

15-05

46890

14.03.19

17.09.19

1 YR 5 MNTHS

221 19585767 DO 04.09.17 YLY

16-08

46890 1 YR 5 MNTHS


• The Complainant was induced to purchase 6 policies from 4 different insurers over a span of only 9months, by the brokers with the promise of payment of loan upto Rs. 5 Lacs against purchase of new policies.

• It seems that the representatives of the brokers allegedly gave a fake letter in the name of RBI, issued mail of fake images of Demand Draft, to gainhis trust.A copy of the letter is submitted to the forumwith the complaint.

• Forum notes that in this case, the complainant has been lured to buy 6 Policies involving a

total premium of Rs.237780/-from 4 different companies.

• These policies have been sold from 12.2016 to 09.2017 over a period of only 9 months.No

further premium is paid under the Instant policies.

• Further it is observed by the Forum that the policies were sourced through 2 intermediaries. RI could not produce the letters of explanation called from them regarding allegations of mis-sale made by the complainant.

• During the hearing the complainant has informed that he is working with Zila Parishad, Kolhapur. In the proposal form also, it is mentioned that he is government employee, working as teacher in Kolhapur, having annual income of Rs. 500000/-

• Forum further notes that no prudent personwill purchase this number of policies withsuch

huge premium within a span of 9 months unless some additional benefits were promised.

• Another point to be noted is that the income of the complainant in various proposal forms has

been declared as Rs.500000/-. & Rs. 350000/- in some proposal forms. The intermediary, by

not disclosing all insurance under consideration in the proposal forms, has knowingly not

shared vital information and has got the cases completed. Considering the income of this

complainant and premium to be paid under all policies, it is absolutely clear that no one will

purchase this number of policies and pay premium unless some /lurement has been given.

• Forum opines that this is a clear case of mis sale as no prudent person will purchase so many

policies over a period of 9 months and not continue with the policies.

Forum finds substance in the complaint.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directedto cancel policy Nos.01350553 and 01324010 and refund the entire premiums received under the policies to the complainanttowards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment. For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.


The attention of the Complainant and the Insurer is here by invited to the following provisions of

Insurance Ombudsman Rules 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the

award within thirty days of the award and intimate compliance of the same to the Ombudsman.

b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding

on the Insurers.


VINAY SAH




Case of MrSanjay Davari V/S HDFC Life Ins.Co. Complaint No: PUN-L-019-2021-0221


1. Name & Address of the Complainant: Mr Sanjay B Davari , Radhanagari, Kolhapur










An online hearing was held on 06.05.2021 where Mr Sanjay Davri (hereinafter referred to as the complainant) and Ms.ShikhaDedhia the representative of HDFC Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer- RI) reiterated their earlier submissions.


• The complainant has submitted that the representative ofthe broker compelled him to purchase 6 policies from different companies involving initial premium of Rs. 237780/- for releasing the loan.

• The complainant has also alleged that the fraudster had sent him a fake letter of electronic fund transfer from RBI for an amount of Rs. 886386/-

• When the promised loan was not realized, the complainant came to know that he was cheated. He approached the RI with the allegations of wrong information in proposal form and mis- sale of policy and had requested for cancelling the policy and refund of premium but his request was turned down. Hence, he approached the forum for relief.

• The present complaint pertains to 2 policy bearing nos. 19585767 & 19633171 on the life of on the life of complainant, purchased from RI involving premium of Rs.93780/-

RI in their Rejection mail dated20.09.2019 and during the hearing has contended that:

• The policies in contention were issued only after receipt of duly signed proposal form, relevant documents and premium payment and consent for issuing the policies. Proposal stage verification call in which the complainant was explained all major terms and conditions of the policies was also made

• The channel of premium payment was auto debit from bank account. As such the subsequent premium due in Sept. 2018 was also debited and adjusted under policy no. 19585767.

• The complainant first approached RI on 14.03.2019, after 1 year 6 months from issuance of the policy with the allegations of fraud and cheating and request of cancellation of policy along with the refund of premium. RI had denied all the allegations and responded on 20.09.2019 stating the policy cannot be cancelled due to lapse of free look cancellation period.

• “Free look cancellation option” is clearly mentioned on the very 1st page of the policy document which the complainant should have gone through.

• The complainant has never approached RI till the date of complaint and also he did not raise any issue or concern during the PIVC and also failed to approach RI during free look period. Hence his request was rejected as per free look period clause. RI clearly expressed their inability to refund the premiums received under both the policies in contention. However, during the hearing the representative of RI has

offered to utilise the premiums received under the 2 policies for conversion in to a new Single Premium Policy.



PPT


Dt of Rejection

TIME LAG

Complaint NO

RELIANCE

Singhma Insurance

52834303

SANJAY DAVARI

31.12.16 YLY

16-08

30000 14.03.19 17.09.19 2 YRS 2 MNTHS

224

EXIDE

BUT Inter.

03522213

SANJAY DAVARI

16.03.17 YLY

15-07

30000 12.04.2019 23.04.19 2 YRS

223

Future Generali

Singhma Insurance

01324010

SANJAY DAVARI

05.01.17 YLY

20-10

36000

05.12.2018

14.03.2019

12.12.2018

04.10.2019

1YR 1 MNTHS

222 Future Geneali

BUT INTER.

01350553

31.05.17 YLY

18-12

48000 1 YR 11 MNTHS

HDFC

Singhma Insurance

19633171

SANJAY DAVARI

18.09.17 YLY

15-05

46890

14.03.19

20.09.19

1 YR 5 MNTHS

221 19585767 04.09.17 YLY

16-08

46890 1 YR 5 MNTHS



• It seems that the representatives of the brokers allegedly gave fake letter in the name of RBI, issued mail of fake images of Demand Draft, to gainhis trust.A copy of fake letter is submitted to the forumwith the complaint.



• Further it is observed by the Forum that the policy was sourced through Singhma Ins. Broker which is inactive with RI at present. RI could not produce the letter of explanation for the allegations of mis-sale made by the complainant.


• Forum further notes that no prudent person with this income will purchase these number of policies with such huge total annual premium of Rs. 237780/- within a span of 9 months unless some additional benefits were promised/lurement was given.

• . However, forum observed that the complainant has paid subsequent renewal premium due in Sept. 2018 under one policy no 19585767 and then approached RI after 1 yr 6 mths for cancellation of policies and refund of the premiums which cannot be justified.

• This seems to be case of mis sale as no prudent person will purchase 6 policies over a period of 9 months and subsequently not continue with the policies.

The Forum also observes that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and receipt of first premium amount. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant cannot be pardoned for being imprudent and non-vigilant. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium.

Forum finds some substance in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties and during the hearing, the Respondent Insurer is directed to cancel policy nos. 19585767 & 19633171 on the life of complainant and utilize the premiums received under the policies to issue a Single premium policy in the name of complainant for 10 years from new date of commencement, with lock in period of 5 years without free look cancellation clause. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply with the requirements within the stipulated time for issuance of the single premium policy, the issue of issuance of single premium policy would be closed and the complaint will be treated as dismissed. Hence the complaint is partially allowed

Compliance of the Award:- The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on 25.05.2021 VINAY SAH INSURANCE OMBUDSMAN, PUNE



Case of Mr Sanjay Davari V/S Reliance Nippon Life Ins.Co. Complaint No: PUN-L-036-2021-0224


1. Name & Address of the Complainant: Mr Sanjay B Davari , Kolhapur










An online hearing was held on 06.05.2021 where Mr Sanjay Davri (hereinafter referred to as the complainant) and Ms.Anubha Gupta the representative of Reliance Nippon Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer- RI) reiterated their earlier submissions.


• The complainant has submitted that the representative of the broker compelled him to purchase 6 policies from different companies involving initial premium of Rs. 237780/- for releasing the loan.

• The complainant has also alleged that the fraudster had sent him the fake letter of electronic fund transfer from RBI for the amount of Rs. 886386/-

• When the promised loan was not realized, the complainant came to know that he was cheated. He approached the RI with the allegations of wrong information in proposal form and mis- sale of policy and had requested for cancelling the policy and refund of premium but his request was turned down. Hence, he approached the forum for relief.

• The present complaint pertains to 1 policy bearing no52834303 on the life of complainant, purchased from RI involving premium of Rs.30000/-


• The complainant chose to avail the policy in contention after going through the key benefits and terms of the products and submitted duly signed proposal form, KYC documents and premium amount.

• Pre-Issuance verification call as also arranged in which the complainant was explained all major terms and conditions of the policy. It was also informed to the complainant that no loan or bonus was being offered along with the policy. The policy was issued on 31.12.2016. The policy document was dispatched on 03.01.2017 via Speed post.

• Only one premium has been paid under the policy.

• The complainant first approached RI on 12.04.2019, after 2 years from issuance of the policy with the allegations of fraud and cheating and request of cancellation of policy along with the refund of premium. RI had denied all the allegations and responded on 15.04.2019 stating the policy cannot be cancelled due to lapse of free look cancellation period.

• The complainant has never approached RI till the date of complaint and also he did not raise any issue or concern during the PIVC and also failed to approach RI during free look period.

• The policy in contention is in foreclosed status at present.



PPT


Dt of Rejection

TIME LAG

Complaint NO

RELIANCE

Singhma Insurance

52834303

SANJAY DAVARI

31.12.16 YLY

16-08

30000 12.04.19

14.03.2019

15.04.19

17.09.2019

2 YRS 2 MNTHS

224

EXIDE

BUT Inter.

03522213

SANJAY DAVARI

16.03.17 YLY

15-07

30000 12.04.2019 23.04.19 2 YRS

223

Future Generali

Singhma Insurance

01324010

SANJAY DAVARI

05.01.17 YLY

20-10

36000

05.12.2018

14.03.2019

12.12.2018

04.10.2019

1YR 1 MNTHS

222 Future Geneali

BUT INTER.

01350553

SANJAY DAVARI

31.05.17 YLY

18-12

48000 1 YR 11 MNTHS

HDFC

Singhma Insurance

19633171

SANJAY DAVARI

18.09.17 YLY

15-05

46890

14.03.19

17.09.19

1 YR 5 MNTHS

221 19585767 SANJAY DAVARI

04.09.17 YLY

16-08

46890 1 YR 5 MNTHS



• It seems that the representatives of the brokers allegedly gave a fake letter in the name of RBI, issued mail of fake images of Demand Draft, to gainhis trust.A copy of the letter is submitted to the forumwith the complaint.



• No further premium has been paid in the instant policy.

• Further it is observed by the Forum that the policy was sourced through Singhma Ins. Broker Ltd. RI could not produce the letter of explanation for the allegations made.


• Forum further notes that no prudent person with this income will purchase this number of policies with such huge total annual premium of Rs. 237780/- within a span of 9 months unless some additional benefits were promised.

• Another point to be noted is that renewal premium has not been paid in the policy. The income of the complainant in various proposal forms has been mentioned as Rs.500000/-. &Rs. 350000/- in some proposal forms. The intermediary, by not disclosing all insurance under consideration in the proposal forms, has knowingly not shared vital information and has got the cases completed. Considering the income of this complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase this number of policies and pay premium unless some lurement has been given. Forum further observed that many brokers make practice to state that the offered benefit is in progress and use stalling techniques so that the policyholder does not approach the RI within freelook period for cancellation and refund under the policy.

• This seems to be a clear case of mis sale as no prudent person will purchase 6 policies over a period of 9 months and not continue with the policies. Forum finds substance in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy no. 52834303 and refund the entire premiums received under the policies to the complainant towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment. For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.





Case of Mr Sanjay Shinde Vs Exide Life Insurance Co Ltd Complaint No: PUN-L-025-2021-0225

Award No: IO/PUN/A/LI/ /2021 -2022

1. Name & Address of the Complainant: Mr. Sanjay Shinde, Solapur

2. Policy No: Type of Policy: 03664918 Life Income Advantage plan

3. Date of Commencement / Mode 03.11.2017 YLY

4 Term/PPT Premium Amount 24/12 Rs. 30000/-

5. Insurance Intermediary Net Ambit Insurance Broker

6. Name of the Proposer / LA Mr. Sanjay Shinde

7. Name of the Insurer: Exide Life Insurance Co. Ltd


9. Relief sought: Cancellation of policy and refund of premium

10. Date of 1st complaint to RI Time Lag Date of Refusal by RI

23.01.2019/27.03.2019 1Y 2M 30.03.2019/05.08.2019


An online hearing was held on 06.05.2021, through video conferencing where Mr. Sanjay Shinde (hereafter referred to as the complainant) and Exide Life Insurance Co. Ltd (hereafter referred to as the RI – Respondent Insurer) representative, Shri Mukund Sharma, reiterated their earlier submissions.

• The Complainant has submitted that he was contacted by Representatives of Brokers, posing as executives from Bajaj Finance, with an offer of a loan of Rs.5 lacs for a nominal interest rate, against purchase of some policies. He was compelled to purchase 3 policies from two different insurance companies.

• The complainant took constant follow up with the broker’s officials for the loan amount, but he realised he was cheated when the broker’s officials ignored his calls.

• When the complainant approached the insurers for cancellation of policies and refund of the premium amounts, they did not help him out; instead he was informed that a company based in Noida was making such fraud calls. The complainant opines that such calls have benefited the RI.

• The complainant has also stated that he works as peon with the civil hospital and receives net salary of Rs.15000/-.

• The other Insurance Company (HDFC Life) in a similar complaint has agreed for settlement The RI vide their SCN dated 02.12.2020 have contended that : 1. The RI admitted to have issued the policy bearing no.03664918 on receipt of duly filled up proposal form, KYC and premium amount from complainant. 2. The copy of policy document and terms and conditions was dispatched to the complainant’s address on 09.11.2017 and the complainant has received the same. He failed to avail the free look option within stipulated time span. The first complaint was received after a lapse of than one year and three months from expiry of free look period.

3. It is an accepted proposition that a person is presumed to have full understanding of the terms and conditions along with other ancillary details before concluding purchase of any insurance product and thereby accord his free consent to the same. 4. The RI places reliance on the Plan Summary signed by the complainant at the time of proposal. Based on this fact, the benefits, terms and conditions of the policies have been understood by the complainant and only after understanding the said policy terms and conditions the complainant has opted for the afore said policy 5. The allegations of signature forgery were raised after a delay of 1 year and 3 months from the lapse of the Free look period which raise a suspicion that they maybe instigated for the simple reason of getting through to file the complaint before the Forum. 6. The complainant has approached RI vide his letter on 27.03.2019 i.e after lapse of one year and three months after free look period 7. However, as an exceptional case and as a goodwill gesture, the RI have provided the complainant with the option of reduction in premium amount from Rs.30000/- to Rs.20000/- annually. 8. The RI requested the complainant to submit the required documents to avail the above option. However, the complainant did not revert and did not provide his consent and documents sought for the above option.

During the hearing, the RI representative has agreed to refund the premium under the policy. The policy in this case is sourced through M/s Net Ambit Insurance Broker. The Forum has come across many complaints involving the said Broker regarding mis-sale. The Forum observes that considering the income of this complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase 3 policies and pay first premium and not pay renewal premium premium unless some additional promises / lurement has been given. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties and as agreed by representative of RI during the course of hearing, the Respondent Insurer is directed to cancel the policy bearing no. 03664918 and refund the entire premium received under the policy to the complainant. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment. For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.

Compliance of the Award: -



Place: Pune, Date: 31.05.2021 VINAY SAH INSURANCE OMBUDSMAN, PUNE



Mr. Sanjay Kumar Sinha v/sBharti Axa LifeIns Co Ltd. Complaint No PUN-L-019-2021-0141 Award No IO/PUN/A/LI/ /2021-22

1 Name &Address of Complainant Mr Sanjay Kumar Sinha, Nagpur

2 Policy No.& Details Refer to chart

3 Insurance Intermediary SMC Ins Brokers

4 Name of Insured Mr Sanjay Kumar Sinha / Nupur Sinha

5 Name of Insurer Bharti Axa Life Insurance Co.Ltd

6 Nature of Complaint Mis sale


8 Reason for Rejection Beyond free look period

9 Date of receipt of Complaint to OIO 9 10 2020

An online hearing was held on 27.04.2021 through video conferencing, where Mr. Sanjay Kumar Sinha (hereafter referred to as the complainant) and Mr.PavanPhutane, representative of Bharti Axa Life Insurance Co.Ltd (hereafter referred to as the RI – Respondent insurer) reiterated their earlier submissions.

• The complainant has submitted in his complaint that he was approached by broker’s officials who identified themselves as employees of HDFC life by the broker’s officials, with an offer of bonus of Rs.80000/- accrued on his wife’s old policy against purchase of new policy. Later another offer of payment of Rs.1459068/- was made against investment made in Diamond category membership.

• The complainant was initially asked to invest an amount of Rs.30000/-. The complainant has further alleged that ,later, with an allurement of becoming a stake holder and membership of Diamond category, etc, he was compelled to purchase 10 policies from different insurers on his own life and the lives of his family and friends, involving an amount of Rs.732000/- invested by him and his friends.

• When the complainant did not receive any of the promised benefits and the broker’s representatives stopped taking his calls, he approached the RI for cancellation of policies and refund of premiums.

• The RI rejected his request on the grounds that it was received beyond free look period.

• The complainant has stated that he is surprised that details of his wife’s policy had been leaked by HDFC to outsiders giving rise to such fraudulent sourcing of policies.

• The details of policies are given below:

Ins Co Name Pol No

SA PT/PPT Prem

Dt.of comp

Del in compl

HDFC Sanjayk Sinha 21675304

535885

13. 07. 19

16/8 80000

03 03 20

8 M


200956

08. 02. 19

16/8 30000

03 03 20

One yr

Bharti Sanjayk Sinha 501-9141240

683449

21.05.19 .

12/12 63000

13 03 20

9 mths

Bharti Sanjayk Sinha 501-9139947

748532

24. 05. 19

12/12 69000

13 03 20

9 mths

Bharti Nupur Sinha 501-9716363 29. 07.

19 99000

13 03 20

7 mths

341000

Bharti Kunal Kumar 501-9799161 27. 08

.19 50000

13 03 20

7 mths

Bharti Kunal Kumar 501-9902906 06. 09.

19 48000

13 03 20

6 mths

Bharti Ranvijay Chauhan

502-1679187 1170303

28.09.19 12/12

99000 13 03

20 6 mths

Bharti Prakash Nigam

501-9739035 1114279

06.08.19 12/12

99000 13 03

20 7 mths

HDFC RajkamalRajak 21687178

573018

16. 07. 19

16/8 95000

03 03 20

8 mths

Total 391000

A total of 10 policies with an annual premium of Rs.732000/- The broker in all the cases is SMC Insurance Brokers

The RI in their SCN and during the hearing contended that: 20. The RI has issued the policies only after receipt of duly signed proposal form, illustrations

of benefits and other supporting documents and KYC and after verification by PIVC. 21. The policy documents along with terms and conditions and a copy of proposal form and

sales illustrations had been dispatched and delivered to the complainant. 22. The complainant did not raise the issue during the PIVC nor did he avail the free look option

within the stipulated time. 23. The RI has put in an elaborate system to avoid any discrepancies and to address grievance

of the policyholders, if any. 24. The complainant has not alleged any forgery or fabrication of documents which indicates

that he has voluntarily purchased the policies. 25. The first complaint was raised by the complainant on 13.03.2020, which was beyond the

free look period.

26. The complainant is educated enough to understand the terms and conditions of the policies.

The RI in its SCN has submitted that the company is not privy to the communications the complainant had with the persons who are alleged to have given any representation to the complainant. The company denies that any such misrepresentation was made on behalf of the company. 27. The broker, SMC Insurance Brokers Ltd., is not working with the RI anymore.

This is one of the 2 complaints registered with the Forum bearing nos.2021-140 and 141. Forum notes that in this case, the complainant and his friends have been lured to buy 10 Policies having a total premium of Rs.732000/- from 2 different companies. The complaint is restricted to the policies on the life of the complainant and his immediate family. The current complaint involves 3 policies bearing nos.501-9141240 & 501-9139947 on the complainant’s life and 501-9716363 on his daughter, Nupur Sinha’s life, involving a total premium of Rs.231000/-. The 10 policies have been sold starting from 022019 to 092019 i.e. over a period of 7 months. Another point to be noted is that renewal premium has not been paid in any of the policies. The intermediary, by not disclosing all insurance under consideration in the proposal forms, has knowingly not shared vital information and has got the cases completed. Considering the income of this complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase these number of policies and pay premium unless someadditional promises / lurement has been given.This seems to be a clear case of mis sale as no prudent person will purchase several policies over 7 months and not continue with the policies. The Forum also observes that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium received through the intermediary acting on their behalf. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant should have been vigilant and raised the complainant earlier within the free look period. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid in part can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium. Forum will also like to make it clear that it has not considered along with this complaint policies bearing numbers 501-9739035,501-9799161 and 501-9902906 proposed and issued on lives of individuals who are not part of the immediate family of the complainant.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum directs the Respondent Insurer to cancel the Policy Nos.501-9141240, 501-9139947 on the life of complainant and policy no.501-9716363 on his daughter Ms.Nupur Sinha’s life and utilize the available premium amount to issueone single premium policy for Rs. 100000/- on the complainant’s life, with new date of commencement with a term of 10 years from new date of commencement, lock-in period of 5 years and without free look cancellation clause and refund the balance amount leftover after issuing the single premium policy.

If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, this issue of issuing single premium policy,would be closed. However, RI will still be required to refund the balance amount (Total premium received less Rs.100000/- earmarked for issue of one single premium policy) as stated above, towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.



Place: Pune Date: 25.05.2021 VINAY SAH INSURANCE OMBUDSMAN,PUNE



Mr. Sanjay Kumar Sinha v/sHDFC Standard Life Ins Co Ltd. Complaint No PUN-L-019-2021-0140 Award No IO/PUN/A/LI/ /2021-22

1 Name & Address of Complainant Mr Sanjay Kumar Sinha, Nagpur

2 Policy No.& Details Refer to chart

3 Insurance Intermediary SMC Ins Brokers

4 Name of Insured Age Mr Sanjay Kumar Sinha / 56

5 Name of Insurer HDFC Standard Life Insurance Co.Ltd

6 Nature of Complaint Mis sale


8 Reason for Rejection Beyond free look period

9 Date of receipt of Complaint to OIO 9 10 2020

An online hearing was held on 27.04.2021 through video conferencing, where Mr. Sanjay Kumar Sinha (hereafter referred to as the complainant) and Mr.ChinmaySawant, representative of HDFC Standard Life Ins.Co.Ltd (hereafter referred to as the RI – Respondent insurer) reiterated their earlier submissions.

• The complainant has submitted in his complaint that he was approached by the broker’s officials, whoidentified themselves as representatives of RI, with an offer of bonus of Rs.80000/- on his wife’s old policy against purchase of new policy. Later another offer of payment of Rs.1459068/- was made against investment made in Diamond category membership.

• The complainant has also submitted in his complaint that he was initially asked to invest an amount of Rs.30000/-. Later, with an allurement of becoming a stake holder and membership of diamond category, etc, he was compelled to purchase 10 policies from different insurers on his own life and the lives of his family and friends, involving an amount of Rs.732000/- invested by him and his friends.

• When the complainant did not receive any of the promised benefits and the broker’s representatives stopped taking his calls, he approached the RI for cancellation of policies and refund of premiums.

• The RI rejected his request on the grounds that it was received beyond free look period.

• The complainant stated that he is surprised that details of his wife’s policy had been leaked by HDFC to outsiders and brokers’s officials giving rise to such fraudulent sourcing of policies.


Ins Co Name Pol No

SA PT/PPT Prem

Dt.of comp

Del in compl


535885 13 07 19

16/8 80000

03 03 20

8 M


200956 08 02 19

16/8 30000

03 03 20

One yr

Bharati Sanjayk Sinha 501-9141240

683449 21 05 19

12/12 63000

13 03 20

9 mths

Bharati Sanjayk Sinha 501-9139947

748532 24 05 19

12/12 69000

13 03 20

9 mths

Bharti Nupur Sinha 501-9716363 29 07 19 99000 13 03

20 7 mths

341000

Bharti Kunal Kumar 501-9799161 27 08 19 50000 13 03

20 7 mths

Bharti Kunal Kumar 501-9902906 06 09 19 48000 13 03

20 6 mths

Bharati Ranvijay Chauhan

502-1679187 1170303

28.09.19 12/12

99000 13 03

20 6 mths

Bharti Prakash Nigam

501-9739035 1114279

06.08.19 12/12

99000 13 03

20 7 mths

HDFC RajkamalRajak 21687178

573018 16 07 19

16/8 95000

03 03 20

8 mths

Total 391000

A total of 10 policies with an annual premium of Rs.732000/- The broker in all the cases is SMC Insurance Brokers

The RI in their SCN and during the hearing contended that:

• The policies were issued on the basis of duly filled electronic signed proposal form, customer consent document dated 11.02.2019 and 15.07.2019 respectively submitted by the complainant for the purchase of plan with premium amount, policy term and premium payment term as mentioned in the policy document.

• The complainant had been explained the terms and conditions of the subject policy and again during the pre-verification calls. The complainant is educated but did not raise any concern during these calls. It was made clear that the premium paid was for new policy and not renewal premium for old policies.

• The old policy bearing no 11499406 which was issued to the complainant’s wife MrsRina Sinha prior to policy no 15881756 had been surrendered previously by the complainant and a payment of Rs.131541.60 had been credited the bank account and duly communicated vide their letter dated 25.03.2013. Hence it is not plausible that he would receive any bonus on surrendered policy.

• The complainant had purchased policies previously too. He had surrendered one policy and requested cancellation of one policy during the PIVC, Hence, it is assumed that the complainant is well versed with the different aspects of insurance policy like purchase, cancellation, surrender, etc.

• The policy documents along with sales illustrations and copy of proposal form were duly dispatched and delivered to the complainant the complainant did not avail the free look period within the stipulated 15 days from receipt of policy documents.

• The complainant for the first time had registered complaint for subject policies bearing nos.21252140 and 21675304 vide his mail dated 13.11.2019 wherein he had alleged mis sale of policies.

• Only one premium has been received under both the policies and they are in lapsed status due to non-payment of subsequent premiums.

• The complainant has purchased the second policy after a span of 5 months after issuance of first policy in spite of his allegation that the 1st policy was mis-sold to him.

• The RI has further contended that these complaints are received in groups which are instigated and not genuine.

This is one of the 2 complaints registered with the Forum bearing nos.2021-140 and 141. Forum notes that in this case, the complainant himself and as alleged his friends have been lured to buy 10 Policies having a total premium of Rs.732000/- from 2 different companies. The complaint is restricted to the subject policies on the life of the complainant and his close relatives. The current complaint involves 2 policies on the complainant’s life involving a total premium of Rs.110000/-. The 10 policies have been sold starting from 022019 to 092019i.e.overa period of 7 months. Another point to be noted is that renewal premium has not been paid in any of the policies. The intermediary, by not disclosing all insurance under consideration in the proposal forms, has knowingly not shared vital information and has got the cases completed. Considering the income of this complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase these number of policies and pay premium unless some additional promises / lurement has been given.This seems to be a clear case of mis sale as no prudent person will purchase this no of policies over 7 months and not continue with the policies.

The Forum also observes that the complainant has taken this insurance on enticement and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and after receipt of first premium. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant should have been vigilant and raised the complainant earlier. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid in part can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium.Forum would like to make it clear that it has not considered along with the complaint policy bearing no. 21687178 proposed and issued on the life of an individual who is not part of the immediate family of the complainant.

Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum directs the Respondent Insurer to cancel policy Nos.21252140 & 21675304 on the life of complainant and utilize the available premium amount to issue single premium policy for Rs. 100000/- on the complainant’s life, with new date of commencement, with a term of 10 years from the new date of commencement, lock-in period of 5 years and without free look cancellation clause and refund the balance amount leftover after issuing the single premium policy to the complainant.

If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, this issue of issuing single premium policy would be closed. However, RI will still be required to refund the balance amount (Total premium received less Rs.100000/- earmarked for issue of one single premium policy) as stated above towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.


A) According to Rule 17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman. B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers .

Date: 25.05.2021 VINAY SAH

INSURANCE OMBUDSMAN,PUNE



Case of MrSatish V Bhalerao v/sAditya Birla Sun Life Ins Co Ltd. Complaint No PUN-L-009-2021-0132 Award No IO/PUN/A/LI/ /2021-22

1 Name&Address of Complainant Mr.Satish V Bhalerao, Nasik

2 Policy No.&Type of Policy Pl refer chart

3 Date of Com/FUP/mode Pl refer chart

4 PT/PPT/Prem/SA Pl refer chart

5 Insurance Intermediary Individual Advisor

6 Name of Insured Age Name of Policy holder

Pl refer chart Pl refer chart

7 Name of Insurer Aditya Birla Sun Life Ins co Ltd.

8 Nature of Complaint Policies Terminated ,Reinstatement not done

9 Relief sought Reinstatement of policies and restoration of loan amount.

10 Date of First Complaint to Insurer 28/6/2020

11 Reason for Rejection As per policy conditions

12 Date of receipt of Complaint to OIO 7/9/2020

An online hearing was held on 27.04.2021 whereMrSatishBhalerao (hereinafter referred to as the complainant) and Ms. Neha Patel, the representative of Aditya Birla Sun Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer- RI) reiterated their earlier submissions.

• The complainant had purchased two Unit Linked Policies from RI on his own life and on the life of his wife bearing policy nos.000056841 and 000141697 and having date of commencement as 03.01.2003 and 03.11.2003 respectively.

• The complainant has availed loan under both the policies.

• The complainant received notice dated 27.05.2020, informing him that both the subject policies had lapsed due to non-repayment of outstanding loan amount.

• The complainant has submitted that due to the pandemic situation and collapse of market the fund value under the 2 policies had reduced and hence the outstanding loan amount was higher than the fund value.

• Also due to the pandemic, the complainant had suffered financial losses and currently was not in a position to repaypay total amount of Rs.745000/-.which RI was insisting before consideration of Reinstatement.

• The complainant has requested the RI to favorably consider the reinstatement of his policies and restoration of loan amount as he has paid all the premiums regularly and due to the current situation was unable to pay the required amount.

• The RI rejected his request as the Fund Value under the policies was less than the outstanding loan amount.


Policy No Name of LA PT Prem DOC SA Lapsed on

Mode Loan o/s

000141697 NiveditaBhalerao 25/10 5123.7 3.11.03 210000 3/4/20 Qly 390153

000056841 SatishBhalerao 25/5 25341 3.01.03 125000 3/4/20 Yly 354587

The RI in their SCN dated 12.11.2020 and during the hearing, contended that:

• The complainant and his wife Mrs.NiveditaBhalerao had applied for the subject policies and the same had been issued on receipt of duly filled application form, the policy documents along with the copy of the application form was dispatched to the complainant’s mailing address and same was duly received by him.

• The complainant was given detailed description about the features of the said policy and was also apprised with its terms and conditions before signing of the said application. It was only after being completely aware as regards to the said policy premium, payment term, risk and consequences of the said policy and terms and conditions attached therewith in sales illustration, the complainant had applied for the same.

• The complainant applied for the loan under the subject policies vide assignment form dated 28.07.2017 and as per the terms and conditions of the policy, the loan request was processed on 28.07.2017 and the said policies were assigned to ABSLI. The said fact was informed to the complainant vide letter dated 03.08.2017.

• Further, it was clearly stated under the letter that in case the outstanding loan amount exceeds the policy fund value, the policy shall stand terminated.

• The said fact was also clearly explained in the policy contract which are as follows: Policy Loan:You can take an interest bearing policy loan at any time, subject to our then current administrative charges. The maximum policy loan may not exceed 90% of the Policy Fund Cash Value. The Loan Account will immediately increase by the amount of money we receive as loan repayment. Policy Lapse: Your policy will automatically lapse on the date the Policy Fund is less than zero. On that date, we will send you a notice requiring you to pay the Lapse Notice Amount within a Grace period of 30 days. The Lapse Notice Amount is equal to: 1. The Loan Account; plus 2. All coverage premiums due but unpaid since the beginning of the policy year; plus 3. All coverage premiums due in the next three policy months. If by the end of the grace period, we do not receive the full payment of the Lapse Notice Amount, your policy, together with all Coverage then its effect will be terminated. The date on which the policy and coverage terminate is the Lapse Date.

• The RI has stated that once the policy is lapsed due to policy fund value exceeding the loan amount’ repayment of entire loan amount is a condition precedent for reinstatement of the said policies. Further, the complainant has availed loan under the policies various occasions in the past, and hence he is well aware with the terms of the policy. Furthermore the complainant has two years’ time period from the Lapse date, to reinstate the policy by paying the outstanding loan amount.

• The policies solicited by the complainant are Unit Linked Plan (ULIP) and the same are subject to market risk. Being ULIP policies the actual payment of the benefit under the policies will vary based on the actual performance of the investment fund chosen by the complainant and the premium paid are subject to investment risk associated with the capital markets. The solicited policies are also subject to charges such as Fund Management Charge, Policy Administration charges and mortality charges, which are deducted as per the policy provisions.

• The RI has further clarified vide their mail dated 03.05.2021 that as per the terms and conditions of the repayment of loan: the customer can repay the loan as per his convenience. He /she can choose to pay in EMI’s or in lump sum. Loan interest rate changes every year. If the outstanding loan amount is equal to the fund value, the policy will automatically get lapsed. For revival of the policy, the customer has to pay the complete outstanding dues as per terms of the policy within two years from the date of lapsation.

• The outstanding loan amount required to be paid is Rs.354587.18 and Rs.390153/- under policy nos. 000056841 and 000141697, respectively.

The Forum observes that the policy condition regarding reinstatement of lapsed/Terminated mentions that Reinstatement is subject to the following: Evidence of insurability satisfactory to the RI with respect to the Life Insured & Payment of an amount equal to full Loan Account as of the Date of Lapse,Plus interest as a rate determined by the Company as their sole discretion. The Forum further observes that the complainant has availed the loan facility under the policies several times and he is also aware that the policies are ULIP policies where the returns are subject to market risk. The Forum also notes that it is specifically mentioned, in the terms of the policy, that if the outstanding loan amount is equal to the fund value, the policy shall get lapsed and repayment of full loan amount along with interest on loan due is precondition for consideration of Reinstatement. The Forum is of the opinion that the RI has acted in accordance with the terms and conditions of the policy contracts and has communicated requirements for reinstatement of the policies and as such there is no deviation. Award follows:




PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE (STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)+


CASE OF Mr.Shyam SharmaV/S LifeInsurance Corporation of India. COMPLAINT NO: PUN-L-029-2021-0073


1 Name /Relation with LA/AddressOf Complainant

Mr.ShyamSharma, Nagpur

2 Policy No. / Type of Policy 977606494 / JEEVAN AROGYA-PLAN NO 903

3 Date of Proposal / DOC/ 23.12.2011

4 Plan/Term/Mode / premium / 903-19-19 /QLY / Rs 4785 / Initial daily hospital cash benefit Rs4000/-

5 Name of Proposer/ LA Age Mr.VishnuChoithram Sharma , 61 yrs

6 Name of Insurer LIC OF INDIA

7 Nature of Complainant Inadequate claim paid

8 Relief sought Rs.180000/-(Rs 130000/- for claim &Rs 50000/-damages for harassment) as per Annx.VI-A

9 Date of regret by RI Dt of receipt of complaint to OIO

29.05.2020 06.08.2020

10 Reason for Rejection Claim correctly settled as per terms and conditions of policy

During the online hearing held through video conference on23.03.2021, Mr.Shyam Sharma (hereafter referred to as the complainant)and representative of LIC of India (hereafter referred to as the RI- Respondent Insurer)ShriShrikantVaidya,reiterated their earlier submissions.

• The complainant’s father, ShriVishnuCSharma, had purchased a JeevanArogya health insurance plan from the RI commencing from 23.12.2011.

• The complainant has submitted that his father was suffering from Malignant Salivary gland Tumor& a surgery was performed on him on February 2020 for removal of the tumor.The total expenditure of the hospitalization was Rs.92637/- but a meageramount of Rs.29000/-was settled by Respondent Insurer on 26.05.2020.

• The complainant was not satisfied with the claim amount and approached the forum requesting it to intervene for settlement of full claim amount which according to him is approx. Rs 1.50 lakhs.

• The RespondentInsurer has put forthitscontentions of claim amount settled for Surgery named “Essential (Primary) Hypertension (I10) Benign Neoplasm of Parotid Gland (D11.O). It was not covered under “Major Surgical Benefits” but under “other surgery benefits”.

• RI has further contented that Hospital cash Benefit (HCB)and Other Surgical Benefit(OSB) are payable under the said surgery as per policy terms and conditions.

• The RI has submitted copy of calculation of how the claim amount was settled is as follows: This is a fixed benefit health insurance policy plan no 903-Jeevan Arogya Plan Under this policy principle insured had opted “Hospital cash benefit” of Rs 4000/- per day and it increased 5% per year (i.e. Rs.200/-X 8yrs= Rs1600/-(from2012 to 2019) with no claim bonus of Rs.200/-i.e.Total Rs.5800 /- per day Total amount of Rs.4000+1600+200=Rs5800/- per day applicable HCB Total Hospitalization days are 2-1 day excluded: 1 day Total Hospital Cash Benefit(HCB) amount payable : Rs.5800/- Other surgical) benefits payable (OSB): Rs.23200/-

(HCB Rs, 5800/-X2daysX2times) Total claim amount payable /Paid:- Rs.29000/- As this ailment/surgery whether benign or malignant does not exist in the list of surgeries falling under Major surgeries prescribed in the policy, other surgical benefit has been approved. The claim has been admitted as per the terms and conditions of the policy. Forum observes that as per policy document and terms and conditions the surgery for“Essential (Primary) Hypertension Benign Neoplasm of Parotid Gland’

undergone by the complainant’s father does not fall in the category of’ Major Surgical Benefits’. Forum also observes RI has settled the claim 26.05.2020 under’ Other Surgical Benefits’ for an amount of Rs 29000/- Forum is of the opinion that RI has acted rightly as per the terms and conditions of the policy with respect to the claim under the policy and in responding to the issue raised by the complainant.

The forum does not find substance in this complaint. Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, the forum opines that the respondent Insurer has acted rightly as per the terms and conditions of the policy contract in terms of settlement of the claim and does not merit any intervention of the forum. Hence the complaint is dismissed.





Case of Sri Shivram M Gaikwad v/s Reliance Nippon Life Insurance Co. Ltd. Complaint No: PUN-L-036-2021-0226

Award No: IO/PUN/A/LI/ /2021 -2022

1. Name & Address of the Complainant: Sri Shivram M Gaikwad / Titwala, Dist Thane

2. Policy No | Type of Policy: 53563170 / Rel. Nippon Life Milestone Plan

3. Dt of Commencement / Mode 16.10.2019 / Yearly

4 Term/PPT | Premium Amount 15-10 / Rs. 416990/-

5. Insurance Intermediary | Code No. Individual Advisor

6. Name of the Prop | LA Sri Shivram M Gaikwad

7. Name of the Insurer: Reliance Nippon Life Ins. co. Ltd.


9. Relief sought: Refund of premium amount

10. Date of complaint / Time lag 09.09.2020, 15.09.2020

11. Date of Refusal by RI 14.09.2020, 24.10.2020


An online hearing was held on 06.05.2021 where Mr Shivram Gaikwad (hereinafter referred to as the complainant), Sri Sandeep Gaikwad, son of the complainant and Ms. Anubha Gupta the representative of Reliance Nippon Life Ins. Co. Ltd. (hereinafter referred to as Respondent Insurer- RI) reiterated their earlier submissions.

• The complainant has purchased the policy bearing no 53563170 from RI with the annual premium of Rs. 416990/- The complainant has submitted in his complaint that the policy was canvassed by company agent who had misguided the complainant with wrong information. The complainant was told that he has to pay the annual premium only for 2 years under Unit Linked Plan and the benefits can be withdrawn after 10 years.

• When the complainant received the policy document his CA informed him that the policy in contention was not a Unit linked policy and premium has to be paid for 10 years. The complainant also alleged that the income shown in the proposal form was also wrong. He is a retired person getting yearly pension around Rs. 1.90 lakhs only whereas the income mentioned in the proposal form is 7 lakhs per annum. He had visited RI’s office many times but the issue was not resolved. Finally, he approached RI on 12.09.2020 with the complaint and request for cancellation of policy with the refund of premium paid.

• RI has denied the request of the complainant with the reason of request beyond free look period. Hence the complainant moved to the forum for justice.

RI in its rejection mail dated 14.09.2020 and during the hearing has contended that : - 1. The policy in contention was issued after obtaining duly signed proposal form, relevant

document and premium amount and also effective PIVC. The policy document was despatched via Speed Post on 18.10.2019.

2. The complainant first raised his concern on 09.09.2020 about the premium paying term and requested to cancel the policy along with the refund of the premium. The complaint was received beyond free look period of 15 days from the receipt of the policy document. Hence, RI could not comply with the complainant’s request for cancellation of the policy.

3. The complainant has paid only initial premium. Thus, policy is in lapsed status at present. 4. During the hearing, the representative of RI stated that complainant’s son is also working in

the insurance industry as a Manager and the complainant could have shown the policy document to his son and applied for cancellation of policy within free look period of 15 days, if the policy was not as per terms and conditions in case same was assured by the agent.

• The forum observed from the complaint submitted that the complainant was misguided and misrepresented by canvassing the policy as Market linked plan with the premium paying term as only 2 years. However the policy sold to him was with premium paying term of 10 years and policy term of 15 years

• During the hearing, the complainant submitted that he was working as Safai Kamgar and now is a retired person with Mly pension of Rs. 15 to 16 thousand. The policy was purchased by him, utilising the amount of his retirement dues, presuming the premium was to be paid for only 2 years. Out of his retirement benefit of Rs. 17 lacs, he has paid the premium of Rs. 416990/- for the policy.

• During the hearing the son of the complainant informed that the agent in the policy in contention is residing near to their house and is familiar to them. Hence the complainant trusting him, had purchased the policy. The complainant has mentioned the name of the advisor who contacted and misguided him in his complaint.

• Forum observes that RI has not produced a copy of explanation regarding the allegations of mis-sale raised by the complainant in his complaint.

• From all above, it is clear that the complainant desired a policy with premium paying term of 2 years and a Market linked plan and was canvassed accordingly but actually given a different plan. No person with an average income from pension can afford to pay such a huge premium of Rs. 416990/- for 10 years. The complainant has submitted a copy of bank’s current passbook which clearly mentions the amount of pension.

• It is clear case of mis sale and misrepresentation. The agent had misguided the complainant by giving erroneous, untrue information about the policy more for his own benefits

• The forum notes that there is anomaly is in the actual income and the premium amount to be paid under the policy in contention.

The Forum further observes that the complainant has taken this insurance trusting the agent and has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium remittance. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant cannot be pardoned for being imprudent and non-vigilant and not approaching the RI within the free look period.. However, giving benefit of doubt to the complainant, the forum feels that the premium paid in part can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium.

Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy No.53563170 and utilize the premiums received under the policies to issue a Single premium policy of Rs. 200000/- in the name of complainant for 10 years from new date of commencement, with lock in period of 5 years without free look cancellation clause and refund the balance amount leftover after issuing the 1 Single Premium Policy to the complainant. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply with the requirements within the stipulated time for issuance of the single premium policy, the issue of issuance of single premium policy would be closed. However, RI will still be required to refund the balance amount (Total premium received less Rs 2 Lac earmarked for issue of 1 Single Premium policy) towards full and final settlement of the complaint. RI has to comply with the award, pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment. For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.

Compliance of the Award:- The attention of the Complainant and the insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman.

b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on 27.05.2021 VINAY SAH INSURANCE OMBUDSMAN, PUNE



OMBUDSMAN - VINAY SAH Case of Shri ShripadBhaskarDabri VS Bharti Axa Life Ins co Ltd


1. Name & Address of the Complainant: Shri ShripadBhaskarDabri, Pune

2. Policy No: Type of Policy: 500-6699747 500-6699739

3. Date of Commencement: 13.12.2010 13.12.2010

4. Term /Premium /Mode Rs 10424/- / Rs 41500/- Both yearly

5. Policy term 10 years 10 years

6. Name of the Insured /Policyholder: Shri ShripadBhaskarDabri

7. Name of the Insurer: Bharti Axa Life Insurance Co Ltd

8. Nature of complaint: Defective servicing

9. Relief sought: Principal amount with interest Instead received amount equivalent to NAV

10. Date of complaint to RI Date of Refusal by RI / Time lag

25.11.2014 / 06.01.2018 30.04.2019 / 4 YEARS


An online hearing was held on18.02.2021 where Mr ShripadDabri (hereafter referred to as the complainant) and Bharti Axa (hereafter referred to as RI – Respondent Insurer) representative MrKishorKaranjkar made their submissions.

• The complainant had taken two policies from Respondent Insurer Bharti Axa Life Ins co ltd in the month of Dec.2010 for annual premium of Rs 10424/- and Rs 41500/-respectively.

• According to the complainant he had paid premiums for the subsequent years 2011, 2012and 2013. The complainant has further submitted that he realised in Dec.2014, that the premium paid for due Dec.2013 was not updated and hence he corresponded with the RI for the same.

• On 10th October 2014 the complainant wrote a letter to RI requesting for the return cheque/premium status update. However, no response was received from the RI.

• The company requested him to send the bank statementbut the complainant was not sure for which period it was required and he did not send the required statement.

• He received a letter dated 22.12.2015 along with a cheque amounting to 129138.45 Policy fund value after deduction of eligible discontinuance with covering letter that policy no. 500-6699739 stood terminated. Later Interest amount of Rs.1108.80 was also paid.

• The complainant is of the opinion that the total amount receivableunder both the policies till Dec 2017 was Rs.288571/-(500-6699739 Rs.188043/- and policy no 500-6699747 Rs.100528/-). Both the policies stand terminated.

• The complainant has submitted vide his mail dated 22.02.2021 to the forum that he has received the following amounts from RI 1) Policy no. 500- 6699739 i) Rs 129138.45 vide cheque no.288665 dated 22.12.2015 (ii) Rs

1108.80 vide cheque no. 396501 dated 03.02.2018 (Total Rs 130247.25) 2) Policy no. 500-6699747 - Nil

• The complainant has alleged that RI did not accept the premium for due Dec.2014 and on the other hand refunded the amount equivalent to fund value for both the policies and informed the complainant that the policies stand terminated.

• The complainant is of the opinion that the policy was wrongly foreclosed and the amount paid to him was very less. He opines that he should receive a full refund of the premiums paid. Hence the complaint.

• The RI, vide their SCN dated 17.02.2021, have contended that:

• 1. The policies were issued after the receipt of duly signed application, KYC and premium amount submitted by the complainant.

• 2. The terms and conditions of the policy were explained during the PIVC and a copy of the same was sent along with the policy documents.

• The RI hadon 28.11.2014, asked the complainant to furnish his bank statement in confirmation of the premium due for 2013 having been paid but the complainant provided the receipts of premium paid on 04.12.2014.

• 3. Under clause 4.3(1) of the policy bond, if the policyholder does not exercise any of the options within the grace period then the policy fund value net of discontinuance charge applicable for the policy year in which the policy was discontinued, shall be credited to the discontinued policy fund and shall become payable to the policyholder on completion of five policy years.

• 4. In accordance of the above, policies have been terminated by the RI due to non receipt of premium due of Dec. 2013and applicable surrender value has been paid.

• RI has confirmed by their mail dated 28.04.2021 that they have paid an amount of Rs 129138.45 by cheque dated 22.12.2015 and another amount of Rs 1108.80 by cheque dated 03.02.2018 as termination amount equal to S.V and interest amount respectively under policy no 500-6699739 and that nothing is paid under policy no 501-6699747.RI vide it’s mail dated 05.05.2021 has informed that the surrender value amount of Rs 6232/- under policy no.500-6699747 remained to be paid at that time due to technical reasons and they are ready to pay the same.

• The RI, vide their mail dated 24.03.2021 to the Forum, have confirmed having received a total of 3 premiums for the period 2010 to 2012; Rs.31218.62 under policy no.500-6699747 and Rs.124500/- under policy no.500-6699739.

• The Forum observes that the complainant has not submitted his bank statement to the RI as evidence of having paid premium due Dec.2013.He has also not provided the same to the forum.In absence of any evidence of the premium due Dec.2013 having been paid, the RI has rightly acted as per the terms and conditions of the policy contract with respect to the termination/lapsation of the policies in contention.

• The forum further observes that policy number 501-6699747 had acquired surrender value under the policy but remained unpaid, as submitted by RI vide their mail dated 05.05.2021. Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties the forum opines that: 1) Policy No. 500-6699739: - RI has acted as per terms and conditions of the policy contract regarding the termination procedure and payment of termination value under the policy. As such intervention of the forum is not required with respect to this policy. 2) Policy no. 500-6699747: - RI has acted as per terms and conditions of the policy regarding the lapsation procedure.However, RI is directed to pay the acquired valueunder the policy to the complainant immediately. Hence the complaint is partially allowed.

Compliance of the Award:- The attention of the Complainant and the insurer ishereby invited to the following provisions of Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Pune, on 17.05.2021 VINAY SAH INSURANCE OMBUDSMAN,PUNE



OMBUDSMAN - VINAY SAH Case of Mrs Snehal U More V/S Star Union Dai-Ichi Life Ins.Co.0


1. Name & Address of the Complainant: MrsSnehal U More / Talegaon, DistPune

2. Policy No/Type of Policy: 01196876/ Guaranteed Pension Plan

3. Date of Commencement /Mode 14.02.2018/ YLY

4 Term-PPT/Premium Amount 10-05 /Rs.95000/-

5. Insurance Intermediary Bancassurance-Union Bank of India

6. Name of the Prop | LA Mrs SnehalUttamMore

7. Name of the Insurer: SUD lifeIns.Co.



10. Date of complaint 08.03.19, 15.06.2020

11. Date of Refusal by RI 04.01.20, 01.07.2020


A hearing was conducted on27.04.2021 through video conferencing. During the hearing Mr.Uttam More, husband of Mrs.Snehal More and Mrs.SnehalMore(hereinafter referred to as the complainant)andMr.AnisKazi, the representative of SUDLife Ins. Co. Ltd.(hereinafter referred to as Respondent Insurer-RI) reiterated their earlier submissions.

• The complainant has submitted in her complaint that her husband had given Rs 1Lac to officialof Union Bank of India for investing in a Fixed Deposit in her name.Anamount of Rs. 100000/- was handed over to a bank officialfor opening a FD, instead he invested the same through Bancassurance channelin a policy of SUD Life insurance in her name.

• The complainant has further submitted that on receipt of the Policy document her husband immediately approached the bank for cancellation of the policy but he was asked to wait for 6 months. On enquiring after 6 months, they were assured that the policy would be cancelled after 2 years. Thus, the bank official was only giving false assurances to her. Hence, she approached RI with the request of cancellation of policy and refund of premium thereon which was rejected as it was received beyond the free look period.

• The complainant is in financial need for her medical reason and also her family is facing the financial problems. Her request was also rejected by RI. Hence, she has approached the forum for relief.

RI in their SCN dated 10.09.2020, correspondence with the complainant and during the hearing has contended that: - 1. The policy in contention was issued on 14.02.2018 after the receipt of duly signed proposal form,

relevant documents and required premium amount. The premium amount was directly transferred from complainant’s bank account. The policy document was also delivered on 10.03.2018 via speed post.

2. PIVC was also made effectively in the instant case. Product features, premium payment, free look cancellation clause etc. were explained in details to the complainant during PIVC.

3. The complainant had raised her concern about mis sale on 15.06.2020, almost 2 years from the date of receipt of policy document. She had never approached the company till the date of 1st complaint and also during free look period of 30 days. Hence the request of the complainant could not be considered.

4. The policy is in lapsed status as on date due to non payment of premium since 14.02.2019. And as only initial premium paid the policy has not acquired paid up value.

• Forum observes that in this case, the complainant has been sold a Pension policy from RI with annual premiums with term 10 years and PPT of 5 years while she and her husband desired to invest the amount in Fixed Deposit in the bank .

• The policy has been sourced through Bancassurance channel of Union Bank OF India. The complainant’s husband hadvisited the bank for opening the FD account with them but instead an Insurance Pension policy was issued in the complainant’s name. The bank official had allegedly taken the signatures of the complainant on the proposal form. Unknowingly the complainant had also signed it with the trust on him. But when she realized she was cheated they immediately approached the bank and also the RI for cancelation of the said policy and refund of the premium. However, every time she was given false assurance that the policy would get cancelled within 6 months , 2 years and so on.

• During the hearing the complainant stated that her husband is a retired person aged 67 years. He wanted to keep the amount which was drawn from his saving, in Fixed Deposit. But the same was utilized by bank official to issue an insurance policy. She is in need of money as her family is facing financial problem. She wanted to invest in the FD as the amount invested in FD can be withdrawnas and when required but the official cheated her and issued new insurance policy and that too with regular premium payment.

• The forum observes from the complaint submitted by the complainant, that there is only one earning member in her family with average income. During the hearing also the complainant’s husband informed that he is a retired person. No person with this income can afford to pay yearly premium of Rs.100000/-

• The complainant has mentioned the name of the fraudster in her complaint.

• RI also could not produce any letter of the explanation by the intermediary, if called, regarding the allegations made by the complainant in the complaint.

• The forum also notes that it is a known fact that many intermediaries use stalling tacticsof giving false assurances so that the client does not approach the insurer for policy cancellation within free look period.

The forum opines that it is a clear case of mis-sale and finds substance in the complaint. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties,the Respondent Insurer is directed to cancel policy no.01196876 on the life of the complainant and refund the total premiums received under the policy without any deduction to the complainant towards full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.



B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on 27.05.2021




Case of MrSohanlal R Mali V/S India First Life Ins.Co. Complaint No: PUN-L-024-2021-0111


1. Name & Address of the Complainant: MrSohanlal R Mali , Dombivali (E)

2. Policy No | Type of Policy: 10513452 , MahaJeevan plan



5. Insurance Intermediary | Code No. BUT International Ins.Broker

6. Name of the Prop | LA MrSohanlal Mali

7. Name of the Insurer: India First lifeIns.Co.



10. Date of complaint Time Lag

08.05.2019 8 Months



During the online hearing held on 27.04.2021 through video conferencing, Mr.Sohanlal Mali (hereafter referred to as the complainant) and India First Life Ins. Co. (hereafter referred to as the RI- Respondent Insurer) representative, Ms.Nilofer Shaikh reiterated their earlier submissions.

• The complainant was approached by the broker’s officials with an offer of bonus on his old policy with HDFC Ergo and under various pretexts like GST, Tax,etc and was compelled to buy4 policies from 3 different insurers involving a premium of Rs.205000/-.

• When the complainant did not receive the promised bonus, which was to be received within 90 days from issuance of 1st policy, he realised that he was cheated and approached the insurers for cancellation of policies and refund of premiums but the insurers rejected his request as it was beyond free look period.

• The RI in their SCN dated 25.09.2020 and during the hearing contended that: 11. The complaint had submitted duly filled and signed proposal form bearing no.203001581

along with relevant documents and the initial premium deposit in order to seek insurance policy under IndiaFirst MahaJeevan Plan. The complainant had even undergone medical test before issuance of policy thereby making it abundantly clear that he had every intent to purchase this policy and would have undergone its features before filling up the form and paying the initial premium.

12. The complainant is educated enough and it is assumed that he can understand the terms and conditions mentioned in the policy documents.

13. Based on the proposal, premium and other relevant documents and information provided by the complainant, the RI had accepted the proposal form for granting insurance cover and issued policy bearing no. 10513452 under the said plan.

14. During the PIVC held on 07.09.2018 and Welcome call on 13.10.2018, the complainant confirmed that he had applied for the said policy and also confirmed having understood and accepted the terms and conditions of the policy. The complainant denied having been promised any undue benefits like loan, etc.

15. The policy document was dispatched on 12.09.2018 by Speed Post and the same was delivered to the complainant on 18.09.2018. The complainant did not avail the free look period of 15 days as mentioned in the Welcome kit and raise any concern regarding mis-sale.

16. The RI is not responsible for the acts of the agent/brokers with respect to the details mentioned in the proposal form as the agent at the time of filling the proposal form act as the agent of the Policyholder.

17. The broker has shared call recordings and mails and the RI opines that there is no mis-sale. 18. The broker BUT International, is no longer working with the RI. 19. The subject policy is in lapsed condition as no subsequent premiums have been received.

The Forum observes that this is one of the cluster complaints bearing nos.2021-0110 and 0111.

• The complaint bearing no.0110 involving Bharti Axa Life was settled on 27.11.2020 vide Award no.IO/PUN/R/LI/0398/2020-2021.

• The complainant has not registered any complaint against HDFC Life for the amount invested by him. During the hearing he has mentioned that he had availed a loan from HDFC.

• Forum notes that in this case, the complainant has been lured to buy four Policies having a total annualpremium of Rs.205000/- from three different companies.

• Another point to be noted is that renewal premium has not been paid under the policy.

• It is absolutely clear that no one will purchase several policies and with high annual premium unless some additional promises / lurement has been given.

• This seems to be a clear case of mis sale as no prudent person will purchase several policies and not continue with them.

• The Forum also observes that the complainant has taken this insurance onenticementand has submitted all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis ofall the requirements viz. proposal form, KYC and after receipt of first premium. As such the RI cannot be held fully responsible for the alleged mis-sale, whereas the complainant should have been vigilant and raised the issue within the free look period. However, giving benefit of doubt to the complainant, the Forum feels that the premium paid can be converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium.

Award follows :

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel policy No. 10513452 on the complainant’s life and utilize the premium received under the policy to issue a single premium policy in the name of the complainant with a term of 5 years from new date of commencement, lock-in period of 5 years and without free look cancellation clause. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the

stipulated time for issuance of the single premium policy, the issue of issuing single premium policy would be closed and the complaint will be treated as dismissed. Hence the complaint is partially allowed.


The attention of the Complainant and the insurer ishereby invited to the following provisions of Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, on this day 24th day of May 2021. VINAY SAH INSURANCE OMBUDSMAN, PUNE



Case of Mr Subhash Desai v/sRelianceLife Insurance Co. Ltd. Complaint No: PUN-L-036-2021-0095


1. Name & Address of the Complainant: MrSubhash Desai , Thane

2. Policy No | Type of Policy: Pls Refer to chart

3. Dt of Com./Mode Pls refer to chart

4 Term/PPT| Premium Amount Pls refer to chart

5. Insurance Intermediary | Code No. Pls refer to chart

6. Name of the Prop | LA Shri Subhash Desai

7. Name of the Insurer: Reliance Nippon Life Ins.Co. Ltd.






An online hearing was held on 27.04.2021 where Mr.Subhash Desai (hereafter referred to as the complainant) and Ms.Anubha Gupta, representative from Reliance Life Insurance Co.Ltd (hereafter referred to as the RI- Respondent Insurer), reiterated their earlier submissions.

• The complainant has claimed that the agents of the company cheated and compelled him into purchasing several policies He has also alleged signature forgery.

• The complainant has purchased a total of 6 policies from the RI with an annual premium of Rs.232000/-.

• The complainant, aged 50 years, works as a decorator and is not in a position to pay such exorbitant amount of annual premiums.


• Hence the complainant has registered the complaint with the Forum for redressal.

• The RI in their SCN and during the hearing have contended that: 33. After going through the key benefits and terms of the products the complainant chose to avail

the said policies of the company on crystal clear terms and conditions of the said policies as envisaged in the policy application cum proposal forms which were duly signed and submitted by the complainant t the company for availing the policies.

34. The policy documents were duly dispatched to the complainant and the same has not been disputed by the complainant.

35. Further, on the RI’s internal findings based on the concerns raised by the complainant, it was found that there were no tampering or signature forgeries on the proposal forms duly signed by the complainant on the basis of which, the subject policies were issued.

36. The complainant approached the RI with a request to cancel the policies bearing nos.18312521 and 17553087 on 20.01.2012 and rest of the policies on 25.06.2013. After investigating the complaint and verifying its records, the company was unable to consider the request of the complainant. Accordingly the complaint was resolved on 0202.2012 and 29.06.2013 wherein the RI declined the allegation of the complainant and that he had also approached beyond the free look period of 15 days.


38. The complainant has provided no documentary evidence to substantiate his claim that the policies were sold to him on pretext of false promises.

39. The complainant being a prudent person is expected to have read the policy terms and conditions and taken the policy accordingly.


41. The RI further submitted that the payment made towards First premium of policy no 50989160 had resulted in cheque dishonour and the current status of the policy is No cash status- Reason insufficient funds.

42. The complainant has paid renewal premiums under the following policies: 2 premiums amounting to Rs.100122/- under policy no.18312521. 2 premiums amounting to Rs.100157/- under policy no. 17553087 Only one premium has been received under rest of the policies.

• Details of the policies: POL NO DTOC TERM/

PPT PREM Total

Prem Rcvd

SA CODE INS.CO. DOC DOR Prem

Received

Status

18312521 24/12/10 10/10 50000.00 100122 Reliance 27.04.19 24.05.19 2 Lapsed

17553087 23/07/10 22/22 50000.00 100157 Reliance Do Do 2 Lapsed

50966417 02/05/13 15/05 26959.06 27000 123500 AB Captl

Reliance Do Do* 1 Foreclosed

50938638 10/04/13 15/05 24998.29 25000 110050 AB Captl.


50996368 22/05/13 15/05 50000.71 50000 220120 AB Captl.


50989160 15/05/13 15/05 30000.22 F.P cheque

dishonour

132071 AB Captl.

Reliance Do Do 0 CDA

6 POLS 231958.28

Forum feels that in this case, the complainant to have been induced and compelled to buy 6 Policies with a total premium of Rs.232000/- from the RI. One of these policies bearing no.50989160 has resulted in CDA,hence the complaint is now restricted to remaining 5 policies bearing nos.18312521,17553087, 50966417, 50938638 and 50996368. The total amount of first premium received by the RI is Rs.202000/- and a renewal premium of Rs.100000/- was also received under two policies bearing nos.18312521 and 17553087. Thus the total premium amount involved is Rs.302000/-. The complainant had approached the RI on prior two occasions for cancellation of policies and refund of the premiums. Forum observes that these policies have been sold starting from 072010 to 052013 over a period of almost 3 years.Most of the policies are sourced through AB Brokers against whom forum has received number of complaints regarding mis-sale. Another point to be noted is that renewal premium has not been paid in the last three policies. The intermediary, by not disclosing all insurance under consideration in the proposal forms, has knowingly not shared vital information and has got the cases completed. Considering the income of this complainant and premium to be paid under all policies, it is absolutely clear that no one will purchase these number of policies and pay premium unless some additional promises were given. This seems to be a clear case of mis sale as no prudent person will purchase 5 policies over a period of three years and laternot continue with the policies.

The Forum observes that the complainant has taken this insurance by submitting all the documents and amount required by the company for completion of the case. The RI has processed the policy on the basis of all the requirements viz. proposal form, KYC and first premium received through the intermediary acting on their behalf. As such the RI cannot be held fully responsible for the alleged mis-sale, while the complainant should have raised the complaint earlier.However, giving benefit of doubt to the complainant, the Forum feels that the premium paid can be partially converted into a single premium policy, so that complainant will not have the financial burden of paying regular premium. Award follows :

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to cancel all the 5 policies in contentionand utilize the premiums received under the policies to issue a single premium policy ofRs200000/- in the name of the complainant with new date of commencement, with a term of 10 years, lock-in period of 5 years and without free look cancellation clause andbalance amount left over after issuing single premium policy as above is to be refunded to the complainant. If RI does not have a single premium plan as per the above criteria, then RI needs to refund the entire amount. The complainant has to provide all documents required to issue the single premium policy within 30 days from date of receiving the award. If complainant does not comply within the stipulated time for issuance of the single premium policy, this issue of issuing single premium policy would be closed and the complaint will be treated as dismissed to the extent of above mentioned premium amount earmarked for the issue of single premium policy. However, RI is still required to refund the balance amount (total premium received less premium amount earmarked for issue of single premium) as stated above in full and final settlement of the complaint. RI has to comply with the award pertaining to applicable refundable premium amount, within 30 days of receiving this award, failing which it will attract an interest @ of 2% above bank rate from the date of rejection to the date of actual payment.For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is partially allowed.


The attention of the Complainant and the Insurer is here by invited to the following provisions of Insurance Ombudsman Rules 2017:

A) According to Rule -17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award within thirty days of the receipt of the Award and intimate the compliance of the same to Ombudsman. B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers

Dated at Pune, 31.05.2021 VINAY SAH INSURANCE OMBUDSMAN,PUNE



Case of Shri SudhirManurkar VS Bharti Axa Life Ins co Ltd Complaint No: PUN-L-008-2021-0184


1. Name & Address of the Complainant: ShriSudhirManurkar, Thane

2. Policy No: Type of Policy: 500-8669664 / Monthly income Plan

3. Date of Commencement /Premium/Mode/ Term/PPT

25.05.2012 | Rs.45625/- Yearly/30/15Y

4. Name of the Insured /Policyholder: Shri SudhirManurkar

6. Name of the Insurer: Bharti Axa Life Insurance Co Ltd

7. Nature of complaint: Policy wrongly suspended

8. Relief sought: Reinstatement of Policy

9. Date of complaint to RI 24.08.2019 / 27.12.2019 / 16.01.2020


An online hearing was held on06.05.2021 where Mr.SudhirManurkar (hereafter referred to as the complainant)& his son Mr.ShardulManurkarand Mr.RamnareshKanojia, the representative of Bharti Axa (hereafter referred to as the RI – Respondent Insurer) made their submissions.

• The complainant had availed a policy from the RI in the month of May 2012 with an annual premium of Rs.45625/-.

• The complainant paidregular premiums for the subsequent years, up to the year 2017.The complainant had paid the premium for the due year 2018 through cheque.

• When the complainant visited the RI’s Thane branch, for payment of next due 2019, he was informed that the policy had been suspended as the premium due 2018 had not been received by the RI.

• The complainant was informed that the cheque had bounced due to discrepancy in date but the complainant’s bank statement does not reflect the transaction of cheque returned.

• The complainant has stated that he did not received any communication regarding the cheque having bounced.

• The complainant is of the opinion that the cheque was never deposited by RI as the year on the cheque was wrongly written as 2017 instead of 2018.

• Regardless of the above, when the complainant was asked to deposit the premium for both the dues of2018 and 2019, he had complied and paid a cheque of Rs.91248/- on 15.05.2019. However, the policy still remains suspended.

• When the complainant did not get any satisfactory response from the RI, he approached the Forum redressal.

The RI in their SCN received on 05.05.2021 and during the hearing contended that: 1. The policies were issued after the receipt of duly signed application, KYC and premium amount submitted by the complainant. 2. The terms and conditions of the policy were explained during the PIVC and a copy of the same was sent along with the policy documents.

3. The RI has claimed that the complainant has not approached them before and directly approached the Forum with his complaint.

4. The payment for premium due 2018 was made through cheque in month of May 2018 by the complainant which was dishonoured and same was communicated tothe complainant. 5. The RI had received the payment of Rs.91248/- towards reinstatement in May 2019 and

according to the RI’s policy there was counter offer issued to the customer which was not accepted by complainant. Decline request and refund of the said amount was processed however due to some technical issues said amount was not refunded back to the customer and an amount of Rs.94176.60 (Rs.91248 + accumulated interest) is currently lying with the RI.

6. The complainant in his complaint letter has mentioned that he wants to reinstate the subject policy which is accepted by the RI. For reinstating the said policy the complainant has to provide the following documents as mentioned in the premium quotation: Reinstatement form, Outstanding premium of Rs.136875/- ( ideally the complainant has to pay Rs.42699/- only as the amount of Rs.94176/- is lying with the RI), Declaration of Good health form, Covid 19 form.

7. The contract of insurance is an agreement between proposer and the RI wherein both parties to the contract accepts to abide by the express terms and conditions of the contract.

• The Forum observes that though the RI claims that the complainant has not raised the complaint with them prior to approaching the Forum, the complainant has submitted copies of email communications between the two.

• The Forum also observes that the RI has not refunded the premium amount till date although the counter offer made by them was not accepted by the complainant.

• The Forum also observes that after the counter offer dated 21.05.2019, the RI has not made any effort to either refund the deposit amount or get the policy reinstated for the past two years.The Forum opines that there is a deficiency in service on the part of the RI due to which the complainant has suffered a loss of insurance cover for the past three years.

• During the hearing the complainant has shown his willingness to continue the policy by immediately reinstating the same but without payment of any interest.

Award follows,

AWARD

Taking into account the facts and circumstances of the case and submissions made by both the parties, the forum directs the RI to inform the requirements for reinstatement of the policy to the complainant and process the reinstatement after waiving interest on the arrears of premium.

The complainant has to provide the required documents for reinstatement and balance amount for reinstatementas stated above under the policy within 30 days from the date of receiving this award. If complainant does not comply within the stipulated time for reinstatement of the policy with necessary requirements, the complaint will be treated as dismissed.

The complaint is hereby disposed off.

Compliance of the Award:- The attention of the Complainant and the insurer is invited to the following provisions of The Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within thirty days of the award and intimate compliance of the same to the Ombudsman. b) According to Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune,31.05.2021




Case of MrSuraj SHanmar V/S Future GeneraliIndia Life Ins.Co. Ltd. Complaint No: PUN-L-017-2021-0102


1. Name & Address of the Complainant: MrSurajSHanmar , Pune

2. Policy No | Type of Policy: 01595340 , FG New Assure plus



5. Insurance Intermediary Individual Advisor

6. Name of the Prop | LA MrSuraj SHanmar

7. Name of the Insurer: Future Generali India Life Ins.Co. Ltd.

8. Nature of complaint: Delay in refund of policy cancellation amount

9. Relief sought: Refund with interest and charges.




Mr.SurajHanmar (hereafter referred to as the complainant) had purchased a policy from Future Generali India Life (hereafter referred to as the RI – Respondent Insurer) on 29.02.2020 for an annual premium of Rs.522500/- which was paid by the complainant using three credit cards.

• The complainant approached the RI within free look period for cancellation of policy and refund of premium.

• The complainant has submitted that he had applied for free look cancellation and refund in March 2020 and the refund of premium was received in June 2020i.e. after a delay of almost 3 months.

• The complainant had paid the premium vide his credit cards and the delay in receiving refund of premium had cost him a large amount of penal interest, amounting to Rs.55000/-, on his credit card repayments.

• In spite of regular follow up with the RI, there was a delay of three months before he received the premium refund.

• The complainant has demanded interest on the delayed payment along with the refund of penal interest incurred by him on the credit card payments.

• The RIIn their mail dated 25.04.2020, addressed to the complainant, has stated that due to Corona virus outbreak and in accordance with the government guidelines of lockdown; the RI’s customer care service team was operating at less than optimal strength. Hence, the delay in processingthe policy cancellation and refund of premium.

An online hearing was held on 06.05.2021, where both the complainant and RI’s representative Mr.Raktim Chowdhury, submitted their contentions. RI in their SCN dated 06.05.2021 and the mail dated 25.04.2020 has contended that:-

1. The policy in contention was issued on 29.02.2020. The policy document has been delivered on 06.03.2020.

2. After delivery of the said document, the company has received Free Look Cancellation request from the complainant on 09.03.2020. Accordingly, RI has cancelled the policy in contention and refunded an amount of Rs. 518856/- in complainant’s bank account on 26.03.2020. The same was communicated to the complainant vide letter dt. 26.03.2020.

3. Further, it was submitted by RI that due to bank issue, the amount of refund was reflected on the complainant’s bank account on 19.05.2020. Due to this delay, RI has paid Rs. 6000/- as compensation, to the complainant through the NEFT on 06.07.2020.

4. RI admitted that there was delay in refunding the amount due to pandemic situation and lockdown declared by Government. The same was informed to the complainant on 25.04.2020.

The Forum observes that the RI has admitted to the delay in refunding the premium afterfreelook cancellation and has paid Rs.6000/- as compensation to the complainant. The complainant was assured payment within three days of his application by the RI’s customer care; instead the complainant could have been made aware of the reduced strength of the staff and about possible delay in payment and the complainant could have made alternate arrangements to reduce the penal interest on his credit card bills.However, the forum also observes that RI also could not process for the payment due to staff strength in lockdown period and the RI has apologized for the same, vide their mail dated 25.04.2020. At the same time, considering the huge refund amount, the complainant also has a right to ask the interest on the delayed payment. In view of all above, the forum feels that the complainants demand for interest on the delayed amount of refund amount is tenable. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both parties during the course of hearing, the Forum finds directs the Respondent Company to pay interest at bank rate on the applicable refund amount under policy no.01595340 from date of cancellation of the policy i.e. 26.03.2020, till the date of payment 19.05.2020 after deducting an amount of Rs 6000/- paid earlier to the complainant as compensation for the delay. For Bank rate, refer IRDAI (Protection of Policyholders’ Interests) Regulations, 2017, clause no.4 (3). In current case, bank rate to be reckoned as declared by RBI at the beginning of current financial year. Hence the complaint is allowed.






Case of Mr Suresh G Samrit v/sLife Insurance Corp. Of India Complaint No: PUN-L-029-2021-0219 Award No:IO/PUN/A/LI/ /2021-2022

1. Name & Address of the Complainant: Mr. Suresh G Samrit, Tumsar, DistBhandara

2. Policy No&Type of Policy:/Master Policy no.

Annuity no 707200000261 /GS/CA/21504

3 Annuity amount/Annuity frequency Date of 1st Annuity Annuity option

Rs. 3379/- / Monthly 04.11.2019 Annuity for 10 yrs& Life thereafter

4. Name of the member Mr. Suresh G Samrit

5. Name of the Insurer: LIC of India

6. Nature of complaint: Surrender of policy due to wrong annuity option

7. Relief sought: Rs. 540718/- Ann VI-A

8 Date of complaint 12.03.2020

9 Dt of receipt of the Complaint at OIO: 03.11.2020

A hearing was held on 6/05/2021 through video conferencing. During the hearing, Sri Suresh Samrit(hereinafter referred to as the complainant) and Mr.NarendraGhuge, the representative of LIC of India (herein after referred to as Respondent Insurer-RI) reiterated their earlier submissions.

• The complainant is a retired employee of M/S Sunflag Iron & Steel Co Ltd. The company has superannuation trust for the benefit of regular income in the form of pension to a retired employee. M/SSungflag is the master policy holder in the instant case. The annuity policy was

issued from the complainant’s superannuation fund with commutation and pension on the balance amount of fund after commutation.

• The complainant has submitted in his complaint that he was misguided about the annuity option to be filled in the pension claim form by the official of the employer. According to the complainant he is suffering from heart disease since 2013 and her daughter also was preparing for NEET examination. As such the complainant wanted to withdraw full amount accumulated in superannuation fund. The complainant alleged that he was forced to opt for annuity option as “Annuity for 10 yrs and Life thereafter”. He approached RI on 12.03.2020 with request for refund of superannuation fund in lumpsum for his medical requirement and expenses for higher studies of his daughter. The request was denied by RI and hence the complaint.

RI in its SCN dated 06.11.2020 and during the hearing stated that:

1. The annuity was processed after receiving the Intimation of Retirement form wherein all the details like date of retirement, cause of Exit, commutation option, pension option, mode of pension payment, beneficiary details etc along with the pension claim form which was duly signed by the member.The monthly annuity was to start from 04.11.2019

2. The annuity letter after ratification was also sent on 06.11.2019, to the complainant and The Trustee, Sunflag Iron & Steel Co.Ltd., wherein commutation amount and payment details, annuity amount, mode of annuity, due date of annuity is clearly mentioned.

3. The complainant approached RI for reimbursement of Superannuation Fund for his medical reason and expenses to be incurred for daughter’s higher studies. RI has replied to his mail mentioning that the said annuity was purchased by his employer as a pension benefit through superannuation trust which is governed by Income Tax act 1961 & Pension Rules/scheme set out by the aforesaid trust. As an annuitant, being beneficiary of the policy, he is not entitled to modify the benefits under the annuity. RI further stated that the main objective of Annuity Scheme is to provide regular income during lifetime after retirement. The annuity under policy in contention provides regular monthly annuity of Rs. 3379/- throughout the lifetime of the complainant.

4. Hence RI has requested the annuitant to continue the same. 5. The annuity has been started from 04.11.2019 and is being paid regularly till date.

• Form all above, the forum observes that the complainant was a member of Superannuation Scheme under Master policy number GS/CA/21504 held with RI. A certain amount from the salary was getting transferred to Superannuation fund which was utilised for issuing pension to the employee as a regular income after retirement.

• During the hearing the representative of RI stated, that the employee (beneficiary) has to fill the pension form prior to retirement and duly sign it and same is submitted to RI through the employer for further process of issuing annuity from his superannuation fund. He has option to commute 33% of the accumulated fund and the annuity is being issued on the balance amount. In the instant case the complainant has filled the form with annuity option “Annuity for 10 years and Life thereafter” and annuity mode as Monthly. He has opted for commutation and RI has processed it accordingly.

• It is also observed that the monthly annuity amounting to Rs. 3379/- is continued since 04.11.2019 till date. The complainant himself has chosen the option of commutation and annuity. The annuity has been purchased by the employer through a superannuation Trust which is governed by Income Tax Act & Pension Rules/Scheme set out by the said trust. Hence

the annuitant cannot interfere or modify the benefits. He is legally bound to adhere to the same as per above rules and Terms and conditions of the Master Policy.

The forum does not find substance in the complaint. Award follows:

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, the forum opines that the Respondent Insurer has acted as per the terms and conditions of the policy contract in processing and commencing of monthly payment under annuity no. 707200000261 utilising Superannuation fund of the complainant and requires no intervention of the forum. Hence the complaint is dismissed.





Case of MrVaijanath Lad V/S SBILife Ins.Co.Ltd. Complaint No: PUN-L-041-2021-0251


1. Name & Address of the Complainant: MrVaijanath Lad , Solapur

2. Policy No | Type of Policy: 50003130003 | SaralMahaAnand

3. Dt of Com./Mode 30.12.2010 | YLY Term/PPT| Premium Amount 10-10 | Rs.15000.00

5. Insurance Intermediary | Code No. Individual advisor | 16379779

6. Name of the Prop | LA Mr Vaijanath Lad

7. Name of the Insurer: SBI life Ins.co.Ltd.

8. Nature of complaint: Termination of policy and payment of termination fund not done correctly

9. Relief sought: Rs 63815/- plus interest on Rs 211729 /-from 14.02.2020 to 30.05.2020




An online hearing was held on 18.05.2021through video conferencing, where Mr.Vaijnath Lad (hereafter referred to as the complainant) and Ms.Sampada Shetty, representative of SBI Life (hereafter referred to as the RI- Respondent Insurer), reiterated their earlier submissions.

• The complainant had purchased an insurance policy from the RI on 30.12.2010 for a term of 10 years. He had paid regular premium up to 30.12.2018, i.e. for 9 years.

• The complainant has submitted in his complaint that due to the pandemic, he failed to pay the premium due 30.12.2019 and the RI’s offices were also closed during the period due to the pandemic from 23/03/2020.

• According to the complainant the RI terminated the policy and credited onlyan amount of Rs.147914/- out of Unit Fund Value which according to him was Rs.211729/-, to his account on 30.05.2020.

• The complainant has claimed that there is no mention of a period of 105 days for revival which was quoted by the RI in their response to the complainant’s query.

• The complainant has also denied that he had been sent any discontinuation letter.

• According to the complainant if the 30 days grace period and the discontinuation period of 15 days are considered from the last unpaid premium date, then the date of termination of policy should be 14.02.2020 and as per his calculations, the fund value on that date was Rs.211729/-.

• The complainant has demanded the balance amount of Rs.63815/- plus interest from the RI which was rejected by them. Hence the complainant has approached the Forum for redressal.

The RI in itsSCN dated 21.12.2020 and during the hearing has contended that:

• The renewal premium due under the policy no.50003130003on 30.12.2019, was not remitted by the complainant within the grace period of 30 days from the due date 30.12.2019.

• The grace period ended on 30.01.2020 and subsequently, the notice of discontinuance dated 03.02.2020 was sent to the complainant by ordinary post.

• The complainant had to exercise either of the two options, within a period of 30 days from the date of receipt of the notice either 1)revival of the policy or 2) complete withdrawal from the policy without any risk cover.

• However, during this period the complainant did not revive the policy. Hence the fund value was paid to the complainant on discontinuance of the policy.

• The RI has mentioned that the lockdown period started on 22.03.2020, whereas the notice of discontinuance was sent to the complainant dated 03.02.2020, which is almost a month prior to starting the lockdown and the complainant was having sufficient time to revive the policy during this period.

• The policy is unit linked wherein the return on the investment varies as per the performance of the capital market and the RI does not have any control over the capital markets. Hence, the complainant cannot demand the fund value as on a specific date.

• The RI paid the fund value as on the date of discontinuance of the policy and till the date of discontinuance the risk on the life of the complainant was insured.

• The RI has paid the fund value as per terms and conditions of the policy.

• The complainant has enjoyed the risk cover till the date of discontinuance of the policy i.e. till 30.03.2020, the RI would have to pay the sum assured in case of happening of the insured event till 30.03.2020 and hence his demand to pay the fund value as on date of 14.02.2020 is not tenable.

• The RI has received renewal premiums till 30.12.2018; the renewal premium due on 30.12.2019 was not received.

• The policy document clearly stated the consequences of the non payment of renewal premium. The relevant clauses being:

17.7.1 Grace Period: You can pay your premiums within a grace period of 30 days from the due dates for premium frequencies of yearly, half yearly and quarterly. In this case, the grace period expired on 29.01.2020. 8.1.2 Premiums: You are required to pay unpaid premium, if any, on or before expiry of discontinuance notice period. 6.9 In case, we have not received your communication before the expiry of the discontinuance notice period: 6.9.2.2 We will pay you the accumulated value of your discontinued policy fund value immediately. 7.6 You cannot revive after the expiry of the discontinuance notice period.

• The RI has sent the notice of discontinuance dated 03.02.2020, however the complainant did not revive the policy during the discontinuance notice period.

• Thus on the expiry of notice period, the RI paid the fund value Rs.147914.32 to the complainant on 30.05.2020 through direct credit in his bank account vide UTR no.SBIN220150733519. The receipt of the same is duly acknowledged by the complainant.

The Forum observes that the complainant has paid the premiums for 9 continuous years. The complainant has claimed that he did not receive the discontinuance notice though the RI has sent the same by ordinary post. The Forum opines that though the RI has moved the policy to discontinuance fund on 30.01.2020, the accumulated fund value for termination of the policy should be shifted as on 30.12.2019, i.ew.e.f the due date of the unpaid premium. The Forum hereby reprimands the RI for the callous manner in which the SCN has been submitted where the schedule mentions repudiation of death claim due to suppression of medical history. It is expected of the RI to take due care in future regarding submission of correct and properSCNs. Award follows:

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to calculate the Fund value as on 30.12.2019 and pay thedifferencein amount to the complainant if it is more than Rs. 147914/-, paid earlier as Fund value. The complaint is hereby disposed off.


Dated at Pune,on this31stday of May 2021


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