proceedings before - the insurance ombudsman, lucknow

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Sri Rakesh Kumar…………..……....……………………………………. Complainant

V/S

Life Insurance Corporation of India……………………………………………Respondent

COMPLAINT NO: LCK-L-029-1718-0571 Order No. IO/LCK/A/LI/0421/2019-20

1. Name & Address of the Complainant Sri Rakesh Kumar, 111/472,

Brahm Nagar,

Kanpur- 208012

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

234226995

Health Insurance

3. Name of the life insured

Name of the policyholder

Sri Rakesh Kumar

Sri Rakesh Kumar

4. Name of the insurer LIC of India

5. Date of Repudiation/Rejection 20.03.2017

6. Reason for repudiation/Rejection Suppression of material facts (Habits)

7. Date of receipt of the Complaint 10.10.2017

8. Nature of complaint Repudiation of Health Insurance claim

9. Amount of Claim ---

10. Date of Partial Settlement ---

11. Amount of relief sought ---

12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule

2017

13. Date of hearing/place On 27.02.2020 at 10.15 am at Lucknow

14. Representation at the hearing

a) For the Complainant Sri Rakesh Kumar

b) For the insurer Mrs. Madhu Lata Joshi

15. Complaint how disposed Dismissed

16. Date of Award/Order 27.02.2020

17. Sri Rakesh Kumar (Complainant) has filed a complaint against LIC of India (Respondent)

alleging wrong repudiation of Health Insurance claim.

YKS

COMPLAINT NO: LCK-L-029-1718-0571 Order No. IO/LCK/A/LI/ 0421/2019-20

Brief Facts of the Case:-

18. The complainant in his complaint has stated that the policy was purchased by him on

18.03.2008 on yearly premium of Rs. 15000/- and last premium was paid on 14.03.2017. His

grievance is against LIC for wrongful rejection of his health insurance claim and subsequent

cancellation of his policy for the reason of ―preexisting disease‖. He has mentioned that first

detection of illness was noticed about 6-7 months prior to his hospitalization. He has mentioned

that he was not under the habit of tobacco chewing. He has approached this forum for

redressal of his grievance. He has requested to pay the health insurance claim payment and

restoration of his policy.

Written reply/SCN:-

19. In their reply/ SCN dated 27.11.2017, RIC has stated that claim papers were received on

16.08.2016 at DO and were sent to TPA. The claim was for the surgery of Ca Left Buccal

Mucosa. The claim case was rejected by TPA vide letter dated 30.09.2016. The TPA observed in

medical papers that the claimant was having the habit of pan/tobacco chewing since 20 years,

and this material fact was not disclosed in proposal form. The claim was reviewed by DODRC on

09.03.2017 and the decision of TPA was uphold with the cancellation of the policy. Then

decision was communicated on 20.03.2017.

20. The complainant has filed a complaint letter, annexure VI A, correspondence with respondent

while respondent has filed SCN.

21. I have heard the complainant as well as respondent representative and perused the record.

Findings:-

22. Undisputedly insured complainant Rakesh Kumar was covered under the ―LIC Health Plus

Policy- Plan 901‖ since 2008. He was paying the premium of Rs. 15,000/- per annum. He filled

in the proposal form. In the year 2016 he had some problems in his oral cavity. Then he

consulted Jograj Singh Memorial Hospital, Farrukhabad on 11.05.2016 wherein he informed the

Doctor that he is in the habit of Paan chewing for the last 20 years. He was referred to Rajiv

COMPLAINT NO: LCK-L-029-1718-0571 Order No. IO/LCK/A/LI/ 0421 /2019-20

Gandhi Cancer Institute & Research Centre, Delhi where he got registered at CR No. 200992.

He was examined wherein it was mentioned on the OPD card clinical notes that he is chronic

tobacco chewing for the last 40 years. Subsequently he was diagnosed with Carcinoma Left

Buccal Mucosa (CT3N1MO). The consultant Doctor was Dr. A. K Diwan, Director and Senior

Consultant Department of Surgical Oncology.

23. Complainant insured submits the claims which were repudiated by the respondent vide

letter dated 20.03.2017 of Senior Divisional Manager, Division Office, LIC, Kanpur wherein the

cause of repudiation was as under:-

No.

Repudiation

code

Cause of Repudiation with particulars

H01 Insured member having habit of paan chewing/Tobacco since 20 years

from the date of manifest of current illness. This habit (material fact) was

not disclosed in the proposal form at the time of taking up of the policy.

24. Aggrieved by the repudiation of claim, complainant has moved to this forum. Complainant

submits that he was never in the habit of chewing pan or tobacco. He was not suffering from

any disease prior to the taking of the policy. He has not concealed any material information in

the proposal form.

25. Repudiation was made on the basis of non-disclosure and concealment of the habit of

chewing tobacco and paan at the time of the proposal form. In the OPD description of Jograj

Singh Memorial Hospital, Farrukhabad as well as in the OPD card of Rajiv Gandhi Cancer

Institute & Research Centre, Delhi it is mentioned that the insured complainant was in the

habit of chewing paan for the last 20 years and for chewing tobacco for the last 40 years.

26. In order to make a deep scrutiny of the matter respondent LIC was asked to furnish a

certificate of the concerned doctor. In compliance a certificate dated 31.12.2019 of Dr. A. K.


Diwan, Director and Senior Consultant Department of Surgical Oncology of Rajiv Gandhi Cancer

Institute & Research Centre, Delhi is submitted which is as under:-

―This is to certify that Mr. Rakesh Kumar, Cr. No. 200992 came to this hospital on 12/05/2016

with the complaint of growth in left Buccal Mucossa for 6 months duration. As per hospital

record he had history of chronic tobacco chewing for 40 years reformed 1 and half year back,

pan masala 20 yrs left 6 weeks back.‖

27. An opportunity was given to the insured complainant to rebut this document but the

complainant could not file any certificate or material to rebut the certificate of Dr. Diwan. It may

be observed that Rajiv Gandhi Cancer Institute & Research Centre, Delhi is an institute of

national repute. Certificate by the Director of the Surgical Oncology could not be put to

suspicion or any doubt can be raised about it. Certificate was issued on the basis of hospital

record. In such circumstances I do not find any reason to disbelieve the certificate of Dr. Diwan

dated 31.12.2019. Oral statement of the insured complainant to the effect that he was not in

the habit of chewing the tobacco or paan prior to submission of the proposal form could not be

accepted.

28. Clause 22 (xii) of the policy bond provides as under:-

―Xii

If any of the insured or the claimant shall make or advance any claim knowing the same to be

false or fraudulent as regard amount or otherwise, this policy shall immediately become void

and all claims or payments in respect of all the Insured under this policy shall be forfeited. Non-

disclosure of any health event or ailment/condition/sickness/Surgery which occurred prior to the

taking of this policy, whether such condition is relevant or not to the ailment/disease/ Surgery

for which the insured is admitted/ treated shall also constitute Fraud.‖

29. In the proposal form insured complainant in column no. 1 has mentioned that neither he

smokes nor consumed any form of tobacco or alcohol. This relates to the health event of the

insured which is covered under the definition of fraud in the policy bond. Accordingly claim was


repudiated on the ground of concealment of material fact which amounts to fraud and the

policy was cancelled.

30. On the basis of discussion made above I am of the view that claim of the complainant

insured has rightly been repudiated by the respondent which did not call for any interference.

Order:-

31. Complaint is dismissed.

32. Let the copy of award be given to both the parties.

Date: 27.02.2020 (Justice Anil Kumar Srivastava)

Place: Lucknow Insurance Ombudsman

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF UP


Mr. Rais Aalam…………. ………………..……....…………………..………. Complainant

V/S

Life Insurance Corp. of India …….…..…....…………………………….………Respondent


1. Name & Address of the Complainant Mr. Rais Aalam

Ansar Nagar

Kanpur

2. Policy No:

Type of Policy

Duration of policy/DOC

234018389

Jeevan Tarang

21.11.2007

3. Name of the insured


Mr. Rais Aalam

Mr. Rais Aalam

4. Name of the insurer Life Insurance Corp. of India

5. Date of Repudiation/Rejection -

6. Reason for repudiation/Rejection -


8. Nature of complaint Amount less paid on surrender

9. Amount of Claim

10. Date of Partial Settlement

11. Amount of relief sought


2017

13. Date of hearing/place On 18.02.2020 , 10.30 am at Lucknow


a) For the Complainant Absent

b) For the insurer Sri. Harinath Kumar

15. Complaint how disposed Allowed


17. Mr. Rais Aalam (Complainant) has filed a complaint against Life Insurance Corp. of India

(Respondent) alleging payment of less amount on Surrender of policy.

MS



18. Mr. Rais Aalam has lodged his complaint on 06.12.2018 stating that less amount was paid

by the Life Ins. Corp. of India on surrender of his policy. The complainant has stated that he

was in need of money so he surrendered his policy before maturity of the policy. In branch

office the complainant submitted surrender forms and there he got surrender value quotation

showing amount as Rs.2,59,295/=. The complainant has stated that when he received

surrender value in his account, it was Rs. 1,80,000/= which was a Less Rs. 79,295/= from

original surrender quotation. He has written to branch for payment of remaining amount

repeatedly, as well as Divisional Office but with no result. Being aggrieved he has approached

this forum for the redressal of his grievance.

Written Reply/SCN:-

19. In their SCN/reply, the RIC has stated that due to technical problem, this happened. The

RIC has made payment of Rs.79,295/= through NEFT on 29.03.2019.

20. The complainant has filed a complaint letter, annexure VI A, correspondence with

respondent while respondent has filed SCN with enclosures.

21. Despite notice complainant is not present. I have heard the respondent representative and

perused the record.

Findings:-

22. Main concern of the complainant is that an amount of Rs. 79295/- was not paid to him

when he surrendered his policy. As per the SCN of the respondent the amount of Rs. 79295/-

has been paid to the complainant in his account through NEFT. An amount of Rs. 1,80,000/-

was paid to the complainant on 20.11.2017. Difference amount Rs. 79295/- was paid on

29.03.2019. Why payment was delayed and if delay was made then the complainant insured is

entitled for penal interest. It is not a sweet will of LIC to withhold the payment and make the

payment subsequently.


23. In such circumstances although the complainant has received the payment of Rs. 79295/-

but he is entitled for penal interest at the rate of 8.25 percent per annum from 20.11.2017 to

29.03.2019.

Order:-

24. Complaint is partially allowed to the extent that the respondent would make the payment of

penal interest at the rate of 8.25 percent per annum on an amount of Rs. 79295/- from

20.11.2017 to 29.03.2019 within 30 days to the complainant.






Sri Ram Narayain Misra…………. ………………..……....………………. Complainant

V/S

Life Insurance Corp. of India…………………....…....…………………………Respondent

COMPLAINT NO: LCK-L-029-1819-0574 Order No. IO/LCK/A/LI/0355 /2019-20

1. Name & Address of the Complainant Sri Ram Narayain Misra

Vill. Bhadaipur, Post Dikauli

Distt. Shravasti

2. Policy No:

Type of Policy


236648105, 226653904

Wealth Plus

31.03.2010, 08.05.2010



Sri Ram Narayain Misra






8. Nature of complaint Surrender Amount less paid

9. Amount of Claim




2017



a) For the Complainant Sri Ram Narayain Misra

b) For the insurer Mr. Heera Singh



17. Sri Ram Narayain Misra (Complainant) has filed a complaint against SBI Life Insurance

Co. Ltd. (Respondent) alleging that less amount was paid on surrender.

MS



18. Sri Ram Narayain Misra has lodged his complaint on 25.01.2019 stating that less amount

was paid by the company Life Ins. Corp. of India on surrender of his policies. The complainant

has stated that he deposited total 3 premium of Rs.60000/= under both the policies. On

surrender of these policies he received only Rs.27,799 /= and Rs. 31,710/=respectively for his

policies.He has further stated that on 12.09.2013 value of his policies was Rs.37,139.49 and

Rs.39,294.65.On surrender he was paid less than 50% of his deposit amount. He received

surrender value amount after two month 26/28 days late so delayed interest was also claimed

by the complainant. The complainant has raised his dis-satisfaction on working method of the

corporation that even branch manager and responsible employee does not know what is to be

done and assured him that correspondence with higher office is continued and arrear with

interest will be paid . He approached RIC`s divisional office but nothing was heard from them.

The complainant was not satisfied. Being aggrieved he has approached this forum for the

redressal of his grievance.

Written reply/SCN:-

19. In their SCN/reply, the RIC has stated that as per policies terms and conditions under policy

nos.236648105 surrender value of Rs.27799/= was paid on 26.06.2018. In Policy

No.236653904 surrender value of Rs.31710/= was paid on 06.08.2018 to the policy holder. At

the time of proposal the age of insured was 65 years and risk premium, other charges and

charges for extended risk cover was deducted as per rules. RTI application and complaint letter

was duly replied by the RIC. Copy of terms and condition of the policy and NAV chart for both

the policies was also enclosed with SCN. As per respondent letter dated 31.01.2020 they have

paid penal interest of Rs. 548/= and Rs. 645/= under both policies due to late payment.





Findings:-

22. Policies were taken under the plan TT 801-08 Wealth Plus. An amount of Rs. 60,000/- was

deposited under both policies but on maturity after 8 years insured received Rs. 27799/- and

Rs. 31710/- only. Main concern of the complainant is that he got less amount.

23. It was the policy under ‗Wealth Plus Plan‘ where the maturity value was paid in accordance

with the terms and conditions of the policy bond. Highest NAV during the last 7 years or on the

date of maturity was to be paid. Charges under the head of administration and mortality were

deducted by the insurer. Hence the maturity amount was paid in accordance with the terms and

conditions of the policy bond. Complaint lacks merit and liable to be dismissed.

Order:-


25. Let the copies of award be given to both the parties.





Mr. Ashok Kumar Singh………………………………....……....………………. Complainant

VS

Life Insurance Corporation of India………………………………….………...Respondent


1. Name & Address of the Complainant Mr. Ashok Kumar

Vill. & Post- Khanpur

Dist. Mirzapur - 231306

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

286635868

Endowment Plan Table-48

28.04.2009

N/A

10 years

3. Name of the insured /


Mrs. Chandrawati Singh

Mrs. Chandrawati Singh

4. Name of the insurer Life Insurance Corporation of India

5. Date of Repudiation/Rejection N/A

6. Reason for repudiation/Rejection N/A


8. Nature of complaint Surrender Value not paid

9. Amount of Claim 500000/-


11. Amount of relief sought Surrender Value is not paid

12. Complaint registered under Rule Rule No.13(1)(f)of Insurance Ombudsman

Rule 2017

13. Date of hearing/place 13.02.2020 at 10.15 A.M.



b) For the insurer Mr. Shri Prakash

15. Complaint how disposed Dismissed as settled


17. Mr. Ashok Kumar Singh (Complainant) has filed a complaint against Life Insurance

Corporation of India. (Respondent) alleging Surrender Value has not been made.

YKS



18. As per the complaint, complainant had taken one policy no. 286635868 on the life of his

wife Smt. Chandrawati Singh for Rs. 500000/- under Single Premium mode for 10 years on

28.04.2009 from LIC of India. As per policy condition, Life assured had applied for Loan on

30.10.2017,but she had not received Loan amount. Hence she approached the L.I.C. Branch

where they have informed that the loan of Rs. 365000/- has paid on 07.02.2013 but it has been

reversed on 09.03.2013 due to NEFT rejection. After that he had not received this amount.

Being aggrieved, the complainant approached this forum for the redressal of his grievance.

Written reply/SCN:-

19. In SCN/reply dated 22.01.2020, RIC has stated that aforesaid policy no. 286635868 was

issued under T-T 18-10(1) ON 28.04.2009 on the life of Ashok Kumar Singh. Policy holder has

deposited Rs.415525/- and status of the policy was ‗FORECLOSED‘. Policy holder has applied for

surrender and the surrender value was Rs. 434974/- . As the policy was Auto Foreclosed, hence

payment could not be made. Policy became matured on 28.04.2019 and maturity value was Rs.

663730/- was paid to policy holder.

20. The complainants have filed a complaint letter along with other relevant papers while

respondent has filed SCN without enclosures. But Annexure VI A is not enclosed.

21. Despite notice complainant is not present. I have heard the respondent representative and

perused the record.

Findings:-

22. Complainant had taken the policy under ‗Single Premium Plan‘ in the name of his wife, he

wanted to surrender the same on the value which was not being paid by the insurance

company. In the SCN submitted it is mentioned that the policy was in foreclosed stage.

However on maturity of the policy an amount of Rs. 6,63,730/- has been paid to the

complainant. Accordingly complaint become infructous and is disposed off.


Order:-

23. Complaint is disposed off.

24. Let copy of award be given to both the parties.





Mr. Atma Prakash………………………………....…….........………………. Complainant

VS

Life Insurance Corporation of India…………………………………………...Respondent


1. Name & Address of the Complainant Mr. Atma Prakash

S/O Late Mahadev Prasad Gupta

Vill. – Aghua

Post- Kiundaspur , Machhalishahar

Dist. Jaunpur - 212401

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

245606910

Jeevan Akshay Plan

……………..

30.10.2016

………..



Mahadev Prasad Gupta

Mahadev Prasad Gupta





8. Nature of complaint Interest on Claim amount

9. Amount of Claim ……….

10. Date of Partial Settlement …………..

11. Amount of relief sought Interest on Claim amount


Rule 2017



a) For the Complainant Mr. Atma Prakash

b) For the insurer Mr. Dileep Kumar Tiwari



17. Mr. Atma Prakash (Complainant) has filed a complaint against Life Insurance Corporation of

India. (Respondent) alleging that interest on delayed payment was not made.

YKS



18. As per the complaint, complainant‘s father had taken one policy no.245606910 on the life

under Pension Plan and opted option ‗F‘ .His father expired on 30.10.2016 and he was the

nominee under the policy. He submitted claim form to the branch on 31.01.2017. But he had

not received the claim amount. LIC has informed him that wrong option was feeded under the

policy and the matter is referred to the higher office. After a long time he received only claim

amount without interest. Being aggrieved, the complainant approached this forum for the


Written reply/SCN:-

19. In SCN/reply dated 06.02.2020, RIC has stated that aforesaid policy was issued by their

Mungrabadshahpur Branch under Varanasi Division. But by mistake option ‗J‘ was captured in

place of option ‗F‘ at the time of data capturing. This information was also delivered to claimant

on 10.03.2018 in reply of RTI. Now the case is referred to SDC, we will made the payment to

claimant.

20. The complainants have filed a complaint letter, Annexure VI A along with other relevant

papers while respondent has not filed SCN with enclosures.


Findings:-

22. At the very outset it is clear that the policy was taken by Shri Madhav Prasad. Admittedly

option ‗F‘ was claimed by the insured but option ‗J‘ was feeded in the system inadvertently but

till date even after the lapse of about 2 years correction is not made by LIC. Consequently

payment is also not made to the complainant who is the nominee of insured.

23. It is a case of gross negligence on the part of officers of LIC, Varanasi, Division Varanasi.

The most revealing fact is that when the mistake came to their knowledge even then they did

not correct the same. In such circumstances I have no option but to allow the complaint with a

direction to the insurance company to correct the option and make the payment within 30 days.


Order:-

24. Complaint is allowed. Respondents are directed to make the payment of claim under the

policy within 30 days positively.

25. Let copy of award be given to both the parties.





Mr. IFTIKHAR ASHRAF SIDDIQUE.…….…….....……………………………. Complainant

V/S

SBI Life Insurance Co. Ltd...……………………………………….……………..…Respondent


1.

Name & Address of the Complainant Mr. Iftikhar Ashraf Siddque

Moh.- Kaziyara

Post- Khairabad

Sitapur- 261131

2. Policy No:

Type of Policy

DOC

Duration of policy

22000922105

Annuity Plus Plan

29.03.2013

11 years



Mr. Iftikhar Ashraf Siddque

Mr. Iftikhar Ashraf Siddque

4. Name of the insurer SBI Life Insurance Co. Ltd




8. Nature of complaint Mis-selling


10. Date of Partial Settlement Pension Rs.2935/- P.M.

11. Amount of relief sought Refund of Amount

12. Complaint registered under Rule Rule No. 13(1)(f) of Ins. Ombudsman Rule

2017

13. Date of hearing/place 24.02.2020 at 10.15 am



b) For the insurer Mohd. Tarique Khan



17. Mr. Iftikhar Ashraf Siddque (Complainant) has filed a complaint against SBI Life Insurance

Co. Ltd. (Respondent) alleging mis-selling of policy.

YKS



18. As per the complaint, complainant had taken an Annuity Policy no.22000922105 of Rs. 5.00

lac on 29.03.2014 from SBI Binaura branch. Claimant is getting annuity of Rs.2935/- per month.

But due to some business problem, he was in need of money. Hence he has surrendered the

policy. But company denied to pay the amount by informing that the amount will be refunded

only after his death. Being aggrieved, the complainant approached this forum for the redressal

of his grievance.

Written reply/SCN:-

19. In their SCN/reply dated 13.1.2018 RIC has stated that policy was issued on the basis of

duly signed proposal form for Insurance from the policyholder .The policy is issued under

Annuity Plan and annuity is being paid to complainant. Further they stated that once the

annuity started, it could not be surrendered. Even Loan is also not available under this plan.

20. The complainant has filed a complaint letter & correspondence with respondent and copy of

policy document while respondent has filed SCN with enclosures. Annexure VI A NOT

ENCLOSED.

21. Despite notice complainant is not present. I have heard the respondent representative

and perused the record.

Findings:-

22. Undisputedly the complainant has taken ―Annuity Plus Plan‖ with date of

commencement as 28.03.2014. One time premium of Rs. 5 lakhs was deposited wherein

annuity of Rs. 2935/- per month is being paid to the complainant. Complainant contention

is that he wants to get back his amount. As per the terms and conditions of the policy bond

complainant is entitled for annuity for the terms of the policy which is being regularly paid

to him. In case of any mis-happening nominee would be entitled for the capital refund.


Policy was issued as per the terms and conditions of the policy bond accordingly payment is

being made to the complainant. Complaint is devoid off merit and is liable to be dismissed.

Order:-







Mr. Jai Prakash Tewari……………....……..…....………………..…………. Complainant

VS

Life Insurance Corporation of India…………………………………………...Respondent


1. Name & Address of the Complainant Mr. Jai Prakash Tewari

VILL.- Oauha

Post- Belasain(Machhali Sahar)

Jaunpur -222143 (U.P.)

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

311743118

Money Back Plan

28.12.2002

N/A

15 years



Mr. Jai Prakash Tewari

Mr. Jai Prakash Tewari





8. Nature of complaint S.B. payment due on 2014 not received


10. Date of Partial Settlement -

11. Amount of relief sought S.B. payment wiyh Interest

12. Complaint registered under Rule Rule No.13(1)(a)of Insurance Ombudsman

Rule 2017



a) For the Complainant Mr. Jai Prakash Tewari

b) For the insurer Mr. Sukhbir Singh



17. Mr. Jai Prakash (Complainant) has filed a complaint against Life Insurance Corporation of

India. (Respondent) alleging Survival Benefit due on 2014 has not been made.

YKS COMPLAINT NO: LCK-L-029-1819-0398 Order No. IO/LCK/A/LI/0371/2019-20


18. As per the complaint, complainant had taken one policy no. 311743118 for Rs. 50000/-

under T-T 106-15 (12) from LIC of India on 28.12.2002. As per policy condition, he had to get

S.B. payment on 2006, 2010 and 2014 Complainant had not received survival benefits due on

28.12.2014. Hence he approached the L.I.C. Branch for payment of survival benefits due on

28.12.2014 with interest. But he had not received the payment. Policy has already been

matured on 28.12.2017. He got the maturity value. Being aggrieved, the complainant

approached this forum for the redressal of his grievance.

Written reply/SCN:-

19. In SCN/reply dated 14.02.2020, RIC has stated that survival benefits payment of Rs.

20000/-due on Dec-2014 has been made on 30.03.2019 through NEFT and maturity payment

has also been made on 07.012.2017.

20. The complainant has filed a complaint letter, ANNEXYRE VI A along with other relevant

papers and respondent has filed SCN.


Findings:-

22. The complainant is the policy holder of a plan ‗Jeevan Surabhi‘ with profits. Undisputedly

survival benefits were to be paid to him in 2006 and 2010. Insured received the survival benefits.

But the survival benefits of the 2014 were not paid to him. Then he made a representation but of

no avail. In the SCN the only fact mentioned is that the Branch Office CBO 3, Allahabad has made

the payment of survival benefits due in December, 2014 on 30.03.2019.Maturity amount is also

paid on 07.12.2017. It means that the payment was made with a long delay. LIC has not

compensated the insured for the delayed payment. It is to be looked into by the LIC Officers as to

why delayed payment was made. However interest of the insured has to be protected. Accordingly

he is entitled for the penal interest for the delayed payment. Accordingly complaint is liable to be

allowed.


Order:-

23. Complaint is allowed. Respondents are directed to pay the penal interest at the rate of 8.25

percent per annum at Rs. 20,000/- with an effect from December, 2014 till 30.03.2019 within 30

days. Let a copy of order be sent to the Senior Divisional Manager, Allahabad for information and

necessary action.






Mr. Lal Ji Chauhan ………………………………....……....…….……………. Complainant

VS

Life Insurance Corporation of India……………………………………………...Respondent


1. Name & Address of the Complainant Mr. Lal Ji Chauhan

Village_Malahath ,

Post- Dabethua

Varanasi- 221403 (U.P.)

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

285986351 / 566394747

Jeevan Varsha Plan

26.02.2009

N/A

09 years



Mr. Lal Ji Chauhan

Mr. Lal Ji Chauhan





8. Nature of complaint Policy Fraudly surrendered



11. Amount of relief sought Maturity Value


Rule 2017




b) For the insurer Mr. H C S Brijwal



17. Mr. Ram Prakash (Complainant) has filed a complaint against Life Insurance Corporation of

India. (Respondent) alleging that his policy was fraudulently surrendered and amount was

adjusted in third party policy.

YKS



18. As per the complaint, complainant had taken from LIC of India one policy no. 285986351

under ―Jeevan Varsha plan‖ for Rs. 100000/- with half yearly premium of Rs.8295/- for 09 years

term on 26.02.2009. Policy was due to mature on 26.02.2018, hence he has given Original

Policy bond with other relevant papers to LIC agent Mr. Ramapati Srivastava. But he did not get

the maturity amount. After vigorous follow-up, complainant came to know that the maturity

amount of Rs. 1,22,239/- of this policy has already been transferred in the policy no.

566394747 of Mr. Akhilesh Kumar. Complainant has further stated that he has never given any

request for transfer of his policy money to another policy than how LIC at his own used his

money for new business of another person. Being aggrieved, the complainant approached this

forum for the redressal of his grievance.

19. In SCN/reply dated 11.02.2020, RIC has stated that policy no. 285986351 was matured on

26.02.2018 and maturity amount of Rs.129500/- was due for payment. But policyholder has

given a request letter to recycle this amount and accordingly the amount was adjusted in new

policy no. 566394747 of his son Mr. Akhillesh Kumar. Later on Mr. Akhilesh Kumar has

requested to cancel the policy during Free Look Period. Hence the policy no.566394747 was

cancelled and amount refunded to Mr. Akhilesh Kumar.


respondent has filed SCN with enclosures. Annexure VI A is also not enclosed.

21. Despite notice complainant is not present. I have heard the respondent representative

and perused the record.

Findings:-

22. Complainant Lal Ji Chauhan was the policy holder of the policy no. 285986351 which got

matured and the maturity amount was recycled for purchase of a new policy no. 566394747 in

the name of his son Akhilesh Kumar on the request of complainant. Subsequently Akhilesh

Kumar exercises his right for cooling off and an amount of Rs. 127601/- was refunded to


to Akhilesh Kumar. Policy was issued in the name of Akhilesh Kumar on his proposal from.

Amount was recycled on the request of Complainant Lal Ji Chauhan. Akhilesh Kumar exercised

his right for withdrawl of amount during cooling off period. Accordingly the complainant is

devoid of any merit and is liable to be dismissed.

Order:-







Mr. Moti Lal Prajapati.…….…….....…………………………………………. Complainant

V/S

SBI Life Insurance Co. Ltd...……………………………………………..………Respondent


1. Name & Address of the Complainant Mr. Moti Lal Prajapati

E-5(A), New Defence Colony

Utethia

Raebareli Road

LDA Colony

Lucknow- 226012

2. Policy No:

Type of Policy

DOC

Duration of policy

56012474203

Flexi Smart Plan

31.03.2012

10 years



Mr. Moti Lal Prajapati

Mr. Moti Lal Prajapati





8. Nature of complaint Policy wrongly terminated by company

9. Amount of Claim -


11. Amount of relief sought Revive the policy


2017



a) For the Complainant Mr. Moti Lal Prajapati




17. Mr. Moti Lal Prajapati (Complainant) has filed a complaint against SBI Life Insurance Co.

Ltd. (Respondent) alleging that company has wrongly terminated his policy.

YKS



18. As per the complaint, complainant had taken a policy no.56012474203 with monthly

premium of Rs. 10000/- on 31.03.2012 from SBI Life Insurance Co. Ltd. Claimant has further

stated that the policy was issued under ECS mode and the premiums were deducted from his

account from April-2012 to December 2016 without interruption. In January 2017, complainant

has received a message that premium for the month of Jan-2017 is not deposited due to

insufficient amount in the account. Complainant has informed that this is his salary account and

this month salary was credited on 31.01.2017, but this time cheque was floated on 25.01.2017

and again on 31.01.2017. Claimant was ready to deposit the said premium with interest. Hence

he submitted all required papers for revival, but it was not accepted by the company and they

have refunded Rs. 556381.28 only. Being aggrieved, the complainant approached this forum for

the redressal of his grievance.

Written reply/SCN:-

19. In their SCN/reply dated 24.10.2018, RIC has stated that above policy was issued on the

basis of duly signed proposal form for Insurance from the policyholder .The policy is issued

under ― Flexi Smart Plan.‖ Policy bond was dispatched at the registered address of the policy

holder. Terms and conditions of the policy and the benefits payable under the policy were

clearly mentioned in the policy document issued to the complainant. Premium was deducted

through ECS on 31st of every month. But the premium due on 31.01.2017 was not received due

to insufficient amount in the account. Hence the policy became lapsed and was not revived

within 12 months. Thereafter company has refunded the lapsed terminated amount of Rs.

556351.81 to the complainant on 06.04.2018.

20. The complainant has filed a complaint letter Annexure VI A & correspondence with

respondent and copy of policy document while respondent has filed SCN with enclosures.



Findings:-

22. Undisputedly complainant was insured with the respondent with a monthly premium of Rs.

10,000/-. He was paying the premium since March 2012. Premium was to be deducted from his

bank account through ECS Mode. In January, 2017 premium could not be debited from his bank

account due to inefficient funds. Complainant received a message on his mobile. Therefore, the

policy got in a lapse mode. After the lapse of a period of 12 months i.e. January, 2018 the

company refunded the value lapsed terminated amount of Rs. 5,56,351.81/- to the complainant

on 06.04.2018.

23. Complainant submits that he contacted the official of respondent in July, 2017 for revival of

policy but the same was not done. Even the revival proposal was not received. He received the

amount of Rs. 5,56,351.81/- in April, 2018 which was even lower than the actual amount

deposited by him.

24. Undisputedly premium due in January, 2017 was not debited in the account of complainant

due to inefficienct fund. Grace period was 30 days after which policy got lapsed. In the

condition no. 8 of the policy bond revival procedure is given wherein the relevant portion is as

under:-

―You can revive your policy during its revival period of 12 months from the due date of the

earliest premium not paid. Such revivals are subject to all the following:-

8.8 You cannot revive after the revival period.‖

25. When the revival period had lapsed then the surrender value was deposited in the account

of complainant.

26. The complainant did not avail the facility of grace period to deposit the premium amount or

the revival period for the policy. Accordingly the surrender value was paid in accordance with

the terms and conditions of the policy bond which did not require any interference. Complainant

is liable to be dismissed.


Order:-







Mr. Om Prakash Tripathi .…….……..............................………………. Complainant

V/S

SBI Life Insurance Co. Ltd...…………………………………………….………Respondent


1. Name & Address of the Complainant Mr.Om Prakash Tripathi

CH B- 206,

Sunrise Appartment

Mansarovar Yojna, Kanpur Road

Lucknow- 227817

2. Policy No:

Type of Policy

DOC

Duration of policy

32934374003

Group Credit Insurance Plan

29.04.2013

11 years



Mr. Om Prakash Tripathi

Mr. Om Prakash Tripathi





8. Nature of complaint Refund the Extra premiums deducted

9. Amount of Claim 26020/- with interest

10. Date of Partial Settlement --


Refund of Extra premiums.


2017



a) For the Complainant Mr. Om Prakash Tripathi




17. Mr. Om Prakash Tripathi (Complainant) has filed a complaint against SBI Life Insurance Co.

Ltd. (Respondent) alleging poor servicing of the company.

YKS



18. As per the complaint, complainant had taken a housing loan of Rs. 7.00 lakh on 29.04.2013

from SBI Jagdishpur branch. Bank in order to secure the housing loan, issued an insurance

policy (SBI Raksha) with a premium of Rs. 13010/-. Claimant has repaid the total housing loan

on 05.05.2014, but bank continued to debit insurance premium from account till 2016.On

persuasion, Bank has refunded only one premium of Rs.13010/- but excess two premiums has

yet to be refunded. Being aggrieved, the complainant approached this forum for the redressal

of his grievance.

Written reply/SCN:-

19. In their SCN/reply dated 25.01.2018,2018, RIC has stated that above policy was issued on

the basis of duly signed proposal form for Insurance from the policyholder .Renewal premium

deducted as per auto debit mandated form and deactivation request was not received. On

receipt of surrender request, surrender value of Rs.13244/-was paid as per terms and condition

of the Master Policy.

20. The complainant has filed a complaint letter Annexure VI A & correspondence with

respondent and copy of policy document while respondent has filed SCN with enclosures.


Findings:-

22. Undisputedly complainant had taken a loan of Rs. 7 Lakhs for house building from the SBI,

Jagadishpur Branch on 29.04.2013. As a collateral security loan was insured to the respondent

and the policy no. 32934374003 was issued. As per complainant he deposited the EMI‘s of loan

regularly and paid the remaining amount in lump-sum in 2014. Controversy arose when the

respondent continue to receive the premiums of insurance cover till 2016 when the complainant

gave an application for surrender on 24.10.2016. A surrender value of Rs.13244/- was paid to

the complainant.


23. Complainant submits that since he has already re-paid the loan he premium debited by the

respondent be refunded.

24. Clause 10.3 of the policy bond related to pre closure of loan which reads as under:-

―Pr-closure of Loan

If a member repays entire loan outstanding before the policy term, any one of the following will

happen:

10.3.1. Member may continue member policy as per the death benefit as mentioned in COI.

10.3.2 Member may surrender member policy and avail surrender benefit as applicable.‖

25. No intimation was provided either by the complainant or by bank to respondents for

surrender of the policy. It is note-worthy that the life of the insured was covered under the

policy bond. As soon as the intimation was received by the respondent, surrender value was

paid in account of the complainant. Complainant himself was the person assured under the

policy bond. It was his duty to inform the respondent about closure of the loan account. Hence

if the complainant himself has not communicated to the respondents regarding closure of the

loan account respondent could not be held responsible in any manner. As soon as they received

the information they refunded the surrender value in accordance with the terms and conditions

of the policy bond which did not require any interference. Accordingly complainant is liable to

be dismissed.

Order:-







Mr. Salik Ram………………………………...............……....………………. Complainant

VS

Life Insurance Corporation of India……………………………………………...Respondent


1. Name & Address of the Complainant Mr. Salik Ram

S/O Late Ram Kuber

Vill. – Sarai Lili URF Khojapur

Tehsil- Phoolpur

Dist. Allahabad - 212402

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

316292151

Jeevan Akshay Plan

11.09.2017

---

-



Mr. Salik Ram

Mr. Salik Ram





8. Nature of complaint Surrender of policy



11. Amount of relief sought 2000000/-


Rule 2017



a) For the Complainant Mr. Sanjay Kumar Pal

b) For the insurer Mr. Sukhbir Kumar



17. Mr. Ashok Kumar (Complainant) has filed a complaint against Life Insurance Corporation of

India. (Respondent) alleging mis-selling of policy.



18. As per the complaint, complainant had taken one policy no.316292151 on the life under

‗Jeevan Akshay Plan‘ under Single premium mode for Rs.20,00,000/- with option ‗F‘ on

11.09.2007.Claimant has further stated that agent has told him that it is a Pension plan and can

be surrendered any time. Unfortunately his wife became ill. Hence he approached LIC to

surrender his policy but they have informed him that this money can only be refunded after his

death. Being aggrieved, the complainant approached this forum for the redressal of his

grievance.

Written reply/SCN:-

19. In SCN/reply 14.02.2020, RIC has stated that they have not received any request for

surrender of his policy from complainant. Quarterly Pension of Rs. 33825/- is being paid

regularly to complainant from 01.10.2017. Complainant has opted option ‗F‘, hence he can

surrender his policy only in case of critical illness.


respondent has filed SCN with enclosures. Annexure VI A not received.


Findings:-

22. Complainant Mr. Salik Ram has taken a single premium policy under ‗LIC Jeevan Akshay- VI‘

on 11.09.2017 with deposit of Rs. 20 Lakhs. Unfortunately he felt ill and got paralytic attack. He

was treated in Priti nursing Home, Allahabad. He applied for the surrender of the policy on

02.11.2018. But the policy was not allowed to be surrendered and a pension of Rs. 33825/- on

quarterly basis is being paid to him. It is a case which shows clearly negligence on the part of

officers of the LIC, Branch, Phoopur as well as Divisional office, Allahabad. A reminder was also

sent by the complainant insured by speed post to Divisional Office, Allahabad on 30.11.2018 but

of no consequence.


23. Even the SCN submitted in this case is nothing but waste paper. In the complaint itself it is

mentioned that insured is suffering from paralysis. Copy of letter written by insured to the

branch office, Phoolpur, Allahabad is also annexed but no reply is given in the SCN regarding

the ailments as well as application moved by the insured complainant rather it is stated in the

SCN that if the complainant would move the application it would be dealt with. It shows that

with ulterior motive the concerned officers of the LIC have withheld the matter. No response

was given to the insured on his application. Why it was done? It is a matter of enquiry to the

undertaken by the Competent Authority but it is a case wherein the punishment should be

awarded against the concerned officers. Today the copy of medical papers was provided by the

insured which are provided to the respondent representative. Complainant is suffering from

paralysis. It is a fit case where respondents should allow the complainant for surrender of his

policy.

24. Having considered the ailment as well as the delay the complaint is allowed with a direction

to the respondent to decide the complainant application for surrender within 15 days.

Order:-

25. Complaint is allowed. Respondent are hereby directed to decide the insured application for

surrender of policy within a period of 15 days after giving an opportunity of hearing to the

insured. If the insured is not satisfied with the decision of the respondent he would be at liberty

to move again in accordance with rules.






Mrs. Varsha Gupta………………..……....…………………………….…………. Complainant

V/S

L.I.C. of India……..…...……………..………..…………………………..………...Respondent


1. Name & Address of the Complainant Mrs. Varsha Gupta

W/O Late Sudhir Gupta

67 , Nyaya Nagar Colony

Jhunsi

Dist.- Allahabad- 211019

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

315974677

Jeevan Tarun Plan

31.08.2015

14.09.2016

01y & 13 days



Manaansh Gupta

Sudhir Gupta

4. Name of the insurer L.I.C. of India

5. Date of Repudiation/Rejection 30.11.2017

6. Reason for repudiation/Rejection Illness of Proposer prior to proposal


8. Nature of complaint P.W.B. Disallowed



11. Amount of relief sought Allow P.W.B. under the policy

12. Complaint registered under Rule Rule No.13(1)(b)of Insurance Ombudsman Rule

2017



c) For the Complainant Mr. Rajendra Prasad Gupta

d) For the insurer Mr. Sukhbir Gupta



17. Mrs. Varsh Gupta (Complainant) has filed a complaint against LIC of India (Respondent)

alleging that P.W.B. of insured Manaansh Gupta was allowed after her husband‘s death.

YKS


Brief Facts of the Case: -

18. The complainant has stated that her husband had taken a policy no.315974677 on the life

of his son Manaansh Gupta from LIC of India on 28.08.2015 with Premium Waiver Benefits.

Unfortunately her husband expired on14.09.2016. She had submitted all claim papers but L.I.C.

has disallowed P.W.B. under the policy. After that she had also appealed before Zonal Manager

of LIC who also upheld the previous decision. Being aggrieved, the complainant approached this

forum for the redressal of her grievance.

Written reply/SCN:-

19. In SCN/reply dated 13.07.2018, RIC has stated that Proposer Late Sudhir Gupta had taken

a policy no.315974677 on the life of his son with P.W.B on 28.08.2015.Under PWB, premium is

waived after the death of proposer till assured attains the age of 18 years. In this policy

proposer died but claim was repudiated by LIC on the ground of wrong declaration of good

health statement submitted by proposer. As per P.D. Hinduja National Hospital & Medical

Research Center Certificate dated 06.10.2014, proposer was suffering from Cancer. But these

facts were not disclosed in proposal forms. Had this fact been mentioned in proposal form, LIC

would not have accepted the proposal with PWB. Hence P.W.B was disallowed under the policy.

20. The complainants have filed a complaint letter Annexure VI A, along with other relevant

papers while respondent has filed SCN with enclosures.


Findings:-

22. Deceased life assured had taken the policy on 28.08.2015 while he died on 14.09.2016.

Claim was repudiated on the ground that he was suffering from ailments of lung cancer but this

fact was not disclosed in the proposal form. Accordingly the claim was repudiated and PWB

claim was also repudiated.


23. It is not in dispute that the DLA had taken the policy in the name of his son Mannansh. DLA

expired due to cancer. He was suffering prior to the commencement of policy. Accordingly his

claim was repudiated with PWB repudiation.

24. Having considered the fact and circumstances I am of the view that claim has rightly been

repudiated which need not require any interference. Accordingly complaint is liable to be

dismissed.

Order:-







Mr. Vijay Yadav………………………………....……………….…..………………. Complainant

VS

Life Insurance Corporation of India…………………………..…………………...Respondent


1. Name & Address of the Complainant Mr. Vijay Yadav

5/141 , Vilpul Khand

Gomti Nagar

Lucknow - 226010

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

212579018

Jeevan Suraksha Plan

28.04.2000

N/A

18 Years



Mr. Vijay Yadav

Mr. Vijay Yadav





8. Nature of complaint Less amount of Pension

9. Amount of Claim 781/- Per Month since 28.02.2018

10. Date of Partial Settlement Pension of Rs. 2990/- Per Month

11. Amount of relief sought 781/- Per Month since 28.02.2018


Rule 2017



a) For the Complainant Mr. Vijay Yadav

b) For the insurer Mr. Rishi Misra



17. Mr. Vijay Yadav (Complainant) has filed a complaint against Life Insurance Corporation of

India. (Respondent) alleging that he is getting less pension of Rs.781/- per month since

28.05.2018.

YKS


Brief Facts of the Case:- 18. As per the complaint, complainant had taken one policy no.212579018 on 28.04.2000 on

his life under ―Pension Plan‖ and opted option ‗F‘ with monthly mode of pension without

commutation (But in the policy bond, option ‗E‘ is printed). In the option letter provided by LIC,

it is clearly mentioned there that under option ‘F‘, monthly pension would be Rs. 3771/- per

month. But he is getting pension Rs.2990/- per month .Claimant has further stated that in

another case, LIC is paying high pension of Rs. 5731/-per month under policy no. 232130946 to

someone else. Claimant has written many letters to Sr. Divisional Manager LIC Lucknow but he

did not respond to all his notices. Being aggrieved, the complainant approached this forum for

the redressal of his grievance.

Written reply/SCN:-

19. In SCN/reply dated 19.02.2020, RIC has stated that under this policy, proposal date was

30.12.2000 and proposal was completed on 10.01.2001 with date backing as

28.04.2000.Notional cash option was Rs. 3,99,500/-.Annuity amount of Rs. 2990/- is being

released by IPP Cell with the detail calculation as follows—

Date of birth (LA) 01.05.1957

Date if commencement 28.04.2000

Deferred Period 18 YEARS

Age at vesting 60years

Annuity rates per annum 83.60 (Per 1000 of cash option_

Incentive rate under high cash option 89.80

NCO 399500/-

Hence Annuity per month 89.80 x 399500

1000 x 12

= Rs.2990/-

20. The complainants have filed a complaint letter, Annexure VI A along with other relevant

papers while respondent has not filed SCN with enclosures.



Findings:-

22. Undisputedly complainant insured had taken ―Jeevan Suraksh (Endowment Funding) policy‖

with guaranteed conditions at the age of 42 years. Date of proposal was 30.12.2000. It was

back dated and the commencement date was 28.04.2000. Date of start of the annuity was

28.04.2018. Notional cash option value was Rs. 3,99,500/- which was also the purchase price.

The instalment was 10037/- per annum with a sum assured Rs. 1,70,000/-. Table no. 122 E

was applicable with a default annuity option ‗E‘, an amount of Rs. 3452/- is mentioned in the

policy bond. In the policy bond there was a provision for exercising the option for annuity which

was to be exercised at least 6 months before the vesting date. All these facts are undisputed

but the whole problem arose when the option was sought from the insured by the branch of

respondent. Initially the option was sought vide an e-mail 14.11.2017 and 21.08.2018. In both

these communications table for exercising the option was attached wherein the option ‗F‘

monthly annuity was shown as Rs. 3771/- per month as annuity. It is further submitted that this

amount was shown in both the letters sent by the respondent hence there is no occasion of any

mistake. Complainant is getting Rs. 2990/- per month only while he should receive Rs. 3771/-

per month.

23. Respondent representative submits that the annuity is in accordance with table and the

chart which is feeded in the master computer. No change in the annuity amount can be made

manually. If any amount other than this amount is mentioned in the letters it a manual mistake

but the master computer system would not accept any other calculation done manually. It is

further submitted that if no response is given by the branch it is mistake on the part of LIC for

which respondent‘s LIC is submitting its apology.

24. In the SCN chart is attached for calculation:-

―ANNUITY RATES PER ANNUM PAYABLE FOR THE ANNUITY OPTION –F- ANNUITY PAYABLE

FOR LIFE WITH RETURN OF PURCHASE PRICE ON DEATH OF THE ANNUITANT FOR CASH

OPTION OF RS. 1000 WHERE DEFEREMNT PERIOD IS 11 YEARS AND ABOVE ONLY‖

According to it at the age of 60 years in monthly annuity the amount would be Rs.83.60/- per

thousand coupled with it an incentive at the rate of Rs. 6.20/- is added as high cash option


accordingly the total amount comes to Rs. 89.80/- per thousand. On the amount of cash option

that is Rs. 3,99,500/- the annual annuity would be Rs. 2989.58/- or round off Rs. 2990/-.

25. I have also gone through the charts coupled with the policy bond. Option ‗F‘ was exercised

by the complainant. The charges and the calculation submitted by the respondent LIC clearly

shows that the annuity would be Rs. 2990./- .However in the letter sent to the complainant the

amount of monthly annuity is shown as Rs. 3771/- only It is serious mistake. It is recommended

that the Senior Divisional Manager, Lucknow should hold an enquiry for fixing the liability for

the lapse so that such type of lapses may not occur in future.

26. Complainant submits that a certificate of maturity of the policy may be issued to him so that

in future he may not face similar type of problems. Let a copy of this award be sent to Senior

Divisional Manager, LIC, Lucknow for information and necessary action.

Order:-

27. Complaint is disposed off. A certificate of maturity along with the sum which the

complainant or his nominee (as the case may be) would be entitled be provided to the insured

at his registered address within a period of 30 days.






Sri Ram Narayain Misra…………. ………………..……....………………. Complainant

V/S

Life Insurance Corp. of India…………………....…....…………………………Respondent


1. Name & Address of the Complainant Sri Ram Narayain Misra

Vill. Bhadaipur, Post Dikauli

Distt. Shravasti

2. Policy No:

Type of Policy


236648105, 226653904

Wealth Plus

31.03.2010, 08.05.2010









8. Nature of complaint Surrender Amount less paid

9. Amount of Claim




2017



a) For the Complainant Sri Ram Narayain Misra

b) For the insurer Mr. Heera Singh



17. Sri Ram Narayain Misra (Complainant) has filed a complaint against SBI Life Insurance

Co. Ltd. (Respondent) alleging that less amount was paid on surrender.

MS



18. Sri Ram Narayain Misra has lodged his complaint on 25.01.2019 stating that less amount

was paid by the company Life Ins. Corp. of India on surrender of his policies. The complainant

has stated that he deposited total 3 premium of Rs.60000/= under both the policies. On

surrender of these policies he received only Rs.27,799 /= and Rs. 31,710/=respectively for his

policies.He has further stated that on 12.09.2013 value of his policies was Rs.37,139.49 and

Rs.39,294.65.On surrender he was paid less than 50% of his deposit amount. He received

surrender value amount after two month 26/28 days late so delayed interest was also claimed

by the complainant. The complainant has raised his dis-satisfaction on working method of the

corporation that even branch manager and responsible employee does not know what is to be

done and assured him that correspondence with higher office is continued and arrear with

interest will be paid . He approached RIC`s divisional office but nothing was heard from them.

The complainant was not satisfied. Being aggrieved he has approached this forum for the


Written reply/SCN:-

19. In their SCN/reply, the RIC has stated that as per policies terms and conditions under policy

nos.236648105 surrender value of Rs.27799/= was paid on 26.06.2018. In Policy

No.236653904 surrender value of Rs.31710/= was paid on 06.08.2018 to the policy holder. At

the time of proposal the age of insured was 65 years and risk premium, other charges and

charges for extended risk cover was deducted as per rules. RTI application and complaint letter

was duly replied by the RIC. Copy of terms and condition of the policy and NAV chart for both

the policies was also enclosed with SCN. As per respondent letter dated 31.01.2020 they have

paid penal interest of Rs. 548/= and Rs. 645/= under both policies due to late payment.





Findings:-

22. Policies were taken under the plan TT 801-08 Wealth Plus. An amount of Rs. 60,000/- was

deposited under both policies but on maturity after 8 years insured received Rs. 27799/- and

Rs. 31710/- only. Main concern of the complainant is that he got less amount.

23. It was the policy under ‗Wealth Plus Plan‘ where the maturity value was paid in accordance

with the terms and conditions of the policy bond. Highest NAV during the last 7 years or on the

date of maturity was to be paid. Charges under the head of administration and mortality were

deducted by the insurer. Hence the maturity amount was paid in accordance with the terms and

conditions of the policy bond. Complaint lacks merit and liable to be dismissed.

Order:-


25. Let the copies of award be given to both the parties.



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SH. C.S.PRASAD

CASE OF MRS. SANJU DEVI V/S LIFE INSURANCE CORPORATION OF INDIA

COMPLAINT REF: NO: NOI-L-029-1920-0236

AWARD NO:

1. Name & Address of the Complainant

Smt. Sanju Devi W/O Sh. Gyan Prakash Pandey P.O. Shiromani Nagar, Tehsil.- Shahbad Hardoi, Uttar Pradesh, 241124

2. Policy No: Type of Policy Duration of policy/Policy period

222842801 Life Plan 20/20

3. Name of the insured Name of the policyholder

Smt. Sanju Devi Smt. Sanju Devi

4. Name of the insurer Life Insurance corporation of India

5. Date of Repudiation NA

6. Reason for repudiation NA


8. Nature of complaint Non-Receipt of Survival Benefit Payment due on 14.12.2017

9. Amount of Claim Rs.10,000/-

10. Date of Partial Settlement NIL

11. Amount of relief sought Rs.10,000/-

12. Complaint registered under IOB rules

13 (1) (b)

13. Date of hearing/place 13.12.2019 at Noida


c) For the Complainant Absent on both days

d) For the insurer Sh. Sunit Kumar, AO

15 Complaint how disposed Award

16 Date of Award/Order 26.2.2020

17)Brief Facts of case:- This complaint is filed by Smt. Sanju Devi against the decision of LIC of India relating to non payment of survival benefit payment under policy no.222842801 issued on her own life.

18)Cause of Complaint:- Non-Receipt of Survival Benefit Payment.

a) Complainants argument :- The complainant stated that she had taken a Money Back policy from LIC of India on 14.12.2007 with policy term of 20 years. She further stated that she has not received second survival benefit payment which was due on 14.12.2017. The complainant had written to the insurer and had visited Branch office but till date she had not received the due payment.

b)Insurers’ argument:- The insurer stated that Policy no. 222842801 was issued on the life of Smt. Sanju Devi under plan and term 75/20 on 14.12.2007. As per terms and conditions of policy 2nd survival benefit payment which was due on 14.12.2017 has been paid through NEFT in her bank account A/C no. 025110410005807 with Avadh Gramin bank. The complainant had submitted NEFT mandate alongwith copy of pass book of Avadh Gramin Bank to the insurer on 18.12.2012 and survival benefit payment has been made to the mentioned account.When the complainant approached insurer with correct account number , the insurer wrote a letter to the Bank manager on 7.4.2018 for recovery of amount from the concerned account holder and credit the amount to the complainants account.

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:- Personal hearing of the case was held on13.12.2019 and 18.2.2020 . The complainant was absent on both days . The insurer attended the hearing on both days. The insurer submitted that as per terms and conditions of policy 2nd survival benefit payment which was due on 14.12.2017 has been paid through NEFT in her bank account A/C no. 025110410005807 with Avadh Gramin bank. The complainant had submitted NEFT mandate alongwith copy of pass book of Avadh Gramin Bank to the insurer on 18.12.2012 and survival benefit payment has been made to the mentioned account. The insurer is not at fault as the complainant herself had given wrong bank details, but the fact is that the insured has not received the survival benefit of the policy. Therefore the insurer is directed to facilitate the recovery of amount from the bank and its credit to the complainant‘s account as early as possible,

AWARD

Taking into account the facts and circumstances of the case and the submissions made

by the insurer during the course of hearing, the complaint is dismissed.

The complaint is disposed off accordingly.

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

the Ombudsman.

Place: Noida. C.S. PRASAD

Dated: 26.02.2020 INSURANCE OMBUDSMAN

(WESTERN U.P. & UTTARAKHAND)

PROCEEDINGS BEFORE




CASE OF NIKHIL CHANDNA V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Sh. Nikhil Chandna H. No.341, Ram Nagar Ghaziabad, U.P.-201009


253067424 Life plan 25/16


Sh. Nikhil Chandna Sh. Nikhil Chandna


5. Date of Repudiation 15.9.2018

6. Reason for repudiation

NA


8. Nature of complaint Fradulently loan taken by someone against the policy

9. Amount of Claim Rs.175000/-plus interest on loan


11. Amount of relief sought Rs.122500


13.1.d

13. Date of hearing/place On 18.2.2020 at Noida


a) For the Complainant Sh. Nikhil Chandna, Self

b) For the insurer Sh. A.P. Gautam, AO



17)Brief Facts of case ;- This complaint is filed by Sh. Nikhil Chandna against Life Insurance Corporation of India relating to fraudulently loan taken by somebody else against the policy issued on his life.

18)Cause of Complaint:- Fraudulently Loan taken by someone against the policy issued on his life

a)Complainants argument:- The complainant stated that he had taken a policy number 253067424 from LIC on 20.1.2003. The complainant had paid all the premiums on time to LIC and after few months of last premium payment in 2018, he got a SMS from LIC to pay interest on loan against the policy. The complainant had never applied for loan against the policy. The complainant complained the same to LIC in August 2018and the insurer had not taken any action against the person who forged his signatures and opened a fake Axis Bank Account with his first name only and managed to get cheques from LIC drawn in the name of ―Nikhil‖. The LIC has not been able to investigate the matter for the last one year. The complainant has sent 3 letters and 12 messages to the insurer and visited to the branch but of no use, hence approached this forum for resolution.

Insurers’ argument:- The insurer stated that a policy no. 253067424 was issued on the life of Nikhil Chandna on 22.1.2003 under Jeevan Shri Plan.The insurer received requests for duplicate policy bond and policy loan for Rs.75000/-on 31.8.2009, Rs.102250/- on 12.11.2009 and Rs.122500/- on 14.5.2019. Accordingly duplicate bond was issued and loans were granted. When the complainant approached the insurer that he had never applied for loan, the matter was investigated by the insurer and the complainant‘s allegations were found to be true. The investigation report had been submitted to higher office for remedial action.


20) The following documents were placed for perusal. a) Complaint Letter b) Repudiation Letter c) Policy Document d) SCN

21)Observations and Conclusion;- Personal hearing in the case was fixed on 18.2.2020. Both the complainant and insurer attended the hearing and reiterated their submissions. The complainant submitted that he had taken a policy number 253067424 from LIC on 20.1.2003. The complainant had paid all the premiums on time to LIC and after few months of last premium payment in 2018, he got a SMS from LIC to pay interest on loan against the policy whereas policy bond is in his custody. Fraudulently loan was taken by somebody else against the policy for Rs.75000/-on 31.8.2009, Rs.102250/- on 12.11.2009 and Rs.122500/- on 14.5.2019. The complainant complained the same to LIC in August 2018.

The insurer submitted that the facts as alleged by the insured have been found correct. The matter was investigated by Sh. Randhir Singh, Manager on 21.5.2019.The observations were submitted to higher authorities on 6.12.2019 for remedial action.

It is observed that the insurer has admitted the contents of the complaint but failed to take corrective action even after reasonable time.

Hence the insurance company is directed to remove all outstanding loan and consequent liabilities from the policy immediately under intimation to us.

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 is directed to remove all outstanding loan

and consequent liabilities from the policy immediately under intimation to us.






the Ombudsman.




PROCEEDINGS BEFORE




CASE OF SH. BRIJENDRA KUMAR BANSALV/S LIFE INSURANCE CORPORATION OF

INDIA


AWARD NO:


Sh. Brijendra Kumar Bansal Flat No. 403, 3rd Floor, Radha raman Paradise Peer Kalyani, Ghatia Azam Khan Agra, Uttar Pradesh-282004


208441323 Life Plan


Sh. Brijendra Kumar Bansal Sh. Brijendra Kumar Bansal




Not Permissible


8. Nature of complaint Non Receipt of Annuity

9. Amount of Claim Rs.24000/-


11. Amount of relief sought Rs.24000/-


13.1.b



e) For the Complainant Absent

f) For the insurer Sh. Arvind Shrivastava,AO



17)Brief Facts of case ;- This complaint is filed by Sh. Brijendra Kumar Bansal against Life Insurance Corporation of India relating to Non Receipt of Annuity under policy number208441323 issued on his life.

18)Cause of Complaint:- Non Receipt of Annuity under the Policy.

a)Complainants argument :- The complainant stated that he had taken a policy named Pradhan Mantri Vaya Vandan Yojana having number 208441323 from Life Insurance Corporation of India on single premium purchase price of Rs.289157/-. The date of commencement of policy is 27.11.2018 instead of 4.11.2018. The Branch Office has corrected the DOC to 4.11.2018.But the complainant has not received first annuity installment till date.

Insurers’ argument:- The insurer stated that proposal under the policy number 208441323 was registered on 27.11.2018. The BOC No. 4776dated 17.11.2018 for Rs.289157/- was adjusted under the policy and proposal was also completed on 27.11.2018.The back dating is not allowed under immediate annuity plan. Hence date of NB completion from 27.11.2018 to 4.11.2018 is not permissible.



21) Observations and Conclusion;- Personal hearing in the case was held on18.2.2020 . The complainant was absent but the insurer attended the hearing on 18.2.2020. The insurer submitted that amount of proposal was deposited on 17.11.2018 by cheque for Rs.289157/-which was realized on 21.11.2018.The completed proposal along with other documents was submitted by the agent on 27.11.2018, and on same day policy was issued with date of commencement as 27.11.2018. Since the cheque was realized on 21.11.2018 , date of commencement can not be corrected to 4.11.2018. The annuity amount of Rs.24000/- has already been paid on 27.11.2019 to the complainant. In view of above, I find no reason to interfere with the decision of insurance company.




AWARD

Taking into account the facts and circumstances of the case and the submissions made by

both the parties during the course of hearing, I see no reason to interfere with decision of

insurance company.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P AND UTTARAKHAND

UNDER THE INSURANCE OMBUDSMAN RULES, 2017 OMBUDSMAN – Sh. C.S.PRASAD

CASE OF Mr. CHANDRASHEKHAR MISHRA V/S SBI LIFE INS. CO. LTD. COMPLAINT REF: NO: NOI-L-041-1920-0524

AWARD NO:


Mr. Chandrashekhar Mishra Tiwari Nagar, Ist Bindu Khatta, Post-Lalkuan, Distt. Nainital, Uttrakhand-262402, Nainital, Uttarakhand

2. Policy No: Type of Policy Duration of policy/Policy Premium payment period

35109675108 SBI Shubh Nivesh Whole Life Plan 15/15 years


Mr. Chandrashekhar Mishra Mr. Chandrashekhar Mishra

4. Name of the insurer SBI Life Insurance Co ltd



Less Surrender Value Paid


8. Nature of complaint Less Surrender Value Paid

9. Amount of Claim Rs.74,837-

10. Date of Partial Settlement NA

11. Amount of relief sought Rs.74,837/-( Rs Premiums paid i.e. 1,84,931 less Surrender Value Received Rs.1,10,094/-

12. Complaint registered under Rule no: of IOB rules

13(1)(g)

13. Date of hearing/place 12.2.2020/Noida


g) For the Complainant Sh. Chandra Shekhar Mishra

h) For the insurer Ms. Anjali, AVP, SBI Life

15 Complaint how disposed Dismissed


17) Brief Facts of the Case: This is a complaint filed by Mr. Chandrashekhar Mishra against the decision of SBI Life Insurance Company Limited relating to non receipt of full premiums on surrendering the insurance policy no- 35109675108 with date of commencement 02.02.2016 and term of 15 years with annual premium of Rs. 4978/- with basic sum assured of Rs.7,00,000/-. The insured stated that he had received the policy bond after eight months of policy issuance date.

18) Cause of Complaint: Less surrender amount paid

(a) Complainants argument: The complainant stated that he had purchased one policy on 02.02.2016 with 15 years term and had paid the regular installment of Rs 4978/- per month from 02.02.2016 to 02.03.2019 i.e. for 03 years and had thus deposited Rs. 1,84,931/-. He had received the policy bond after 8 months of the Policy issuance. The agent has stated that he would receive pension of Rs. 40,000/- after maturity of 15 years by paying premium amount of Rs. 4978/- per month. But when he received the policy bond, no such terms and conditions were mentioned in the policy bond. The Insured then applied for surrender of the said policy. He received less amount than the premiums paid in the said policy. Thereafter, he preferred a complaint to this office on 21.11.2019 for resolution of his grievance.

(b) Insurers’ argument: The insurer denied the allegation made by the complainant vide their SCN dated 12.12.2019 stating that policy holder had applied for above plan on 02.02.2016 and had paid renewal premiums upto 02.03.2019. The policy was issued on the basis of a duly filled signed proposal form. The original policy document was dispatched to the policyholder in month of March 2016 through speed post on 03.03.2016. Thus the allegations

that he received the policy document after 8 months of issuance of policy is baseless and thus denied. The insured never complained about the late receipt of the policy bond or challenged the terms and conditions of the policy. Further the Company received the surrender request from the complainant under the policy on 13.12.2019. The complainant had paid the renewal premium for 3 years and having paid the renewal premium , the allegation of mis-selling made are baseless and vexatious. The Complainant had also availed the insurance cover for the period for which premiums were paid by him. The Policy has been surrendered and the surrender value of Rs. 1,10,094/- was paid as per terms and conditions of the Policy. Surrender of the policy extinguishes all the rights under the policy. The Company has duly paid the amount payable under the policy and nothing further is payable.

At this time, after enjoying the risk cover of Rs. 7 lakh for three years and after receiving the surrender value, the complainant is demanding refund of premiums which is not maintainable. Further the complainant is Post Graduate and Head Constable General Duty in ITBP. The complainant did not write any complaint to the Company regarding the terms and conditions of the policy.

19) Reason for Registration of Complaint: Scope of the IOB rules, 2017

20) The following documents were placed for perusal. a) Complaint b) Copy of complaint to the Insurance Company c) Reply of the Insurance Company d) SCN Dated 12.12.2019

21) Observations & Conclusions: Both Insured and Insurer were present and reiterated their submissions. The insured submitted that he had got the policy bond from the postman after 8 months but could not produce any evidence to substantiate his claim. The Insured submitted that he had paid Rs. 1.85 lakhs to Insurer for total premium amount, but received only Rs. 1.10 lakhs as surrender value. It is noticed that the complainant had paid premium for three years from 2016 to 2019, and complained for the first time only after 3 years and 7 months from the issuance of policy. On going through the facts and circumstances of the case and on perusal of documents on records, I find that the surrender value has already been paid to the complainant and as on date, Policy is not in the record of the Insurer. The surrender value has also been paid as per terms and conditions of the policy. In view of the facts and circumstances of the said case, the complaint deserves no merit and is dismissed.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017:

a. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall furnish to the insurer within a period of 15 days from the date of receipt of this Award, a letter of acceptance that the Award is in full and final settlement of his claim.

b. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days of the receipt of the acceptance letter of the Complainant and shall intimate the compliance to the Ombudsman.

Place: Noida. (C.S.PRASAD) Dated: 12.2.2020 INSURANCE OMBUDSMAN


AWARD

Taking into account the facts and circumstances of the case and on perusal of records , and the

submissions made by Insurance Company during the course of hearing, the complaint is devoid

of merits and hence dismissed.

PROCEEDINGS BEFORE




CASE OF SAURABH GUPTA V/S HDFC LIFE INSURANCE COMPANY LTD.

COMPLAINT REF: NO. NOI-L-019-1920-0370

AWARD NO:


SH. Saurabh Gupta, I-773, 10th Avenue Sector -166, Gaur CVity -2 Greater Noida (WEST) U.P. - 201306


15148027 Life DOC – 29-05-2012 30 Years (PPT – 30 Years)


Sh. Saurabh Gupta, Sh. Saurabh Gupta,

4. Name of the insurer HDFC LIFE Insurance Company LTD.

5. Date of Repudiation 3/6/2019

6. Reason for repudiation Non-refund of premium after adjustment.


8. Nature of complaint Non refund premium amount after deactivation of auto debit.

9. Amount of Claim Rs. 9617/-

10. Date of Partial Settlement -nil-

11. Amount of relief sought Rs. 9617/-


Yes

13. Date of hearing/place 25.02.2020/ NOIDA


a) For the Complainant Sh. Saurabh Gupta

b) For the insurer Sh. Ankush Saini, Sh. Kunal Aurora,

15 Complaint how disposed AWARD


17)Brief Facts of case ;- This is a complaint filed by Sh. Saurabh Gupta against the decision of HDFC Life Insurance Company Ltd., relating to non-refund of premium amount after deactivation of auto debit against Insurance policy No. 15148027.

18)Cause of Complaint:- Non refund of premium amount after deactivation of auto debit by the company.

a)Complainants argument :-The complainant alleged that he was sold the policy No. 15148027 on 29.05.2012 from the insurance company. The premium of the above policy was paid by auto debit facility through credit card. The complainant sent the request to the company for deactivation of auto debit facility. He wanted to surrender the above policy before due premium on 29.5.2019. He requested to refund the premium which was adjusted on 29.5.2019 by the company. The insurance company denied his request to refund of adjusted premium. The complainant has approached Insurance Ombudsman for redressal of his grievance.

Insurers’ argument:- Insurer denied the allegations and contended that the above policy was issued on the basis of duly signed proposal forms and related documents submitted by the complainant. The complainant is an educated person and all the features of the said policy were explained to the complainant by our sales representative. The policy bond was also delivered on the address of the policy holder registered within the record of the company. The insurance company stated that the policy was issued under term insurance plan and there is no provision of the surrender value under this plan. It was also intimated to the complainant that the deactivation of the auto debit could not done since he has not approached prior to the 12 days from the next premium due date. The complainant is not entitled to claim any refund as

the insurance company has run the risk of the insured`s life and invested the money received as premium. The allegations made by the complainant in his complaint are denied being false and incorrect.



21) Observations and Conclusion :- Both the parties appeared for personal hearing on 25.02.2020 and reiterated their submissions. The complainant, Sh. Saurabh Gupta stated that he sent the request to the company for deactivation of auto debit facility for premium due on 29.5.2019. The insurance company received and adjusted the premium but not refunded till date after various request. The insurance company argued that the complainant sent the request late. During the course of hearing, the insurance company agreed to cancel the policy and refund the premium of Rs.9617/- which was adjusted on 29.5.2019. under the above policy.





the Ombudsman.




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 insurance company is directed to cancel the policy

and refund its premium to the complainant, toward full and final settlement of the complaint.

Hence, the complaint is treated as closed accordingly.

PROCEEDINGS BEFORE




CASE OF SH. JITENDRA KUMAR V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:

1. Name & Address of the

Complainant

Sh. Jitendra kumar

Mohalla Kayasthana

Post Hempura, Almora

Uttar Pradesh-244221

2. Policy No:

Type of Policy

Duration of policy/Policy period

250215070

Life plan



Sh. Jitendra kumar

Sh. Jitendra kumar

4. Name of the insurer Life insurance Corporation of India




8. Nature of complaint Non-Receipt of Surrender Value

9. Amount of Claim NA


11. Amount of relief sought NA

12. Complaint registered under

IOB rules

13.1.d



i) For the Complainant Absent

j) For the insurer Sh. A.P.Gautam, AO



17)Brief Facts of case ;- This complaint is filed by Sh. Jitendra kumar against Life insurance

Corporation of India due to Non-Receipt of Surrender Value under policy no. 250215070 issued

on his own life.

18)Cause of Complaint:- Non-Receipt of Surrender Value

a)Complainants argument :-The complainant stated that that he had deposited the policy

document in the branch office for payment of surrender value but till date he has not received

the payment. Hence approached this forum for resolution of complaint.

Insurers’ argument:-The insurer stated that a policy number 250215070 was issued to Sh.

Jitendra Kumar on 19.2.1988 under Jeevan Dhara Plan no.96. The complainant had requested

for surrender of the policy. The insurer has not received the requirements of surrender i.e.

Discharge Voucher, I.D. Proof and original policy bond. Due to non receipt of requirements

insurer was unable to make payment of surrender value to the complainant.

19) Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules

2017.


a) Complaint Letter

b) Repudiation Letter

c) Policy Document

d) SCN

21) Observations and Conclusion;-Personal hearing in the case was held on 18.2.2020 .

The complainant was absent but the insurer attended the hearing . The insurer submitted

that the complainant has withdrawn his complaint of surrender of his policy vide letter dated

13.2.2020 and agreed for pension payment under the policy. The original withdrawal letter

of the complainant seen. In view of above complaint is dismissed.




PROCEEDINGS BEFORE



OMBUDSMAN – SH. C.S. PRASAD

CASE OF KISHORILAL GUPTA V/S LIFE INSURANCE CORPORATION OF INDIA



Complainant

Sh. Kishori Lal Gupta

H.no.63, Purushotam Vihar Colony

R.K.Mission Road, Kankhal

Haridwar, Uttarakhand

Pin-249408

2. Policy No:

Type of Policy


272419583

Life Plan



Sh. Kishori Lal Gupta

Smt. Jaimala Gupta



6. Reason for repudiation Not covered as per policy conditions


AWARD

Taking into account the facts and circumstances of the case and the submissions made by the

insurer during the course of hearing, the complaint is dismissed.


8. Nature of complaint Non Receipt of Major Surgical

benefit

9. Amount of Claim Rs.

10. Date of Partial Settlement Rs.4500/-



IOB rules

13.1.b



k) For the Complainant Absent

l) For the insurer Sh. I.S. Dugtal, Manager



17)Brief Facts of case ;- This complaint is filed by Sh. Kishori Lal Gupta against the decision

of Life Insurance Corporation of India relating to Non Receipt of Major Surgical benefit under

policy no. 272419583.

18)Cause of Complaint:- Non Receipt of Major Surgical Benefit under the policy.

Complainants argument ;- The complainant stated that he had taken a health policy

numer272419583 from LIC of India covering his spouse Smt. Jai Mala Gupta. His wife was

admitted to Artemis hospital, Gurugram on 12.5.2019 and was diagnosed of right ovarian

dermoid cyst. She was operated for Midline laparotomy with Bilateral Salpingo-Oophorectomy,

Adhesiolysis, Omental Biopsy and was discharged from hospital on 16.5.2019. The complainant

had submitted all claim papers related to Major Operation of his wife Smt. Jaimala Gupta to the

insurer. The complainant received payment of Rs.4500/- only in his bank account of ―Hospital

cash Benefit‖. The complainant did not receive the payment of Major Surgical Benefit. Hence

approached this form for payment of Major Surgical Benefit.

Insurers’ argument:- The insurer stated that a policy named Health plus having number

272419583 was issued on the life of complainant on 31.3.2009 covering his spouse. The

insured Smt. Jai Mala Gupta was admitted to Artemis hospital, Gurugram on 12.5.2019and

was diagnosed of right ovarian dermoid cyst .She was operated for Midline laparotomy with

Bilateral Salpingo-Oophorectomy, and was discharged from hospital on 16.5.2019.The insurer

received claim forms on 30.7.2019and two days Hospital cash Benefit‖of Rs.4500/- payment

was made to the complainant @Rs.2250/- per day. The Major Surgical Benefit was rejected as

the surgery performed is not listed in the allowed major surgery list of the policy, as per policy

conditions2(ii) and same was communicated to the complainant.

19) Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules

2017.


a) Complaint Letter

b) Repudiation Letter

c) Policy Document

d) SCN

21) Observations and Conclusion;- Personal hearing of the case was held on 18.2.2020.

The complainant was absent but the insurer attended the hearing . The insurer submitted

that the captioned policy is a defined benefit plan and is different from medi claim

reimbursement plan. In such plans predefined benefits are paid if the pre defined events

occur. Accordingly Hospital Cash Benefit‖of Rs.4500/- payment was made to the

complainant @Rs.2250/- per day. The Major Surgical Benefit was rejected as the surgery

performed is not listed in the allowed major surgery list of the policy, as per policy

conditions2(ii). The Major Surgical Benefit was correctly rejected as per policy terms and

conditions. I find no reason to interfere with the decision of insurance company.




AWARD

Taking into account the facts and circumstances of the case and the submissions made by the

insurer during the course of hearing, I see no reason to interfere with the decision of

insurance company.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF

KARNATAKA

(UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN –NEERJA SHAH

In the Matter of MR. SIJO JOHN V/s BHARTI AXA LIFE INSURANCE COMPANY

LIMITED Complaint No: BNG—L--008--1920– 0523 to 0536 (Total of 14 Complaints)

Award No: IO/BNG/A/LI/0406 to 0419/2019—2020 (Total of 14 Awards)


Complainant

Mr. Sijo John

# 2, Subbaiah Lane, Old Airport Road

Murugeshpalya, Bangalore – 560017

(M):9916098256

E-mail: [email protected]

2. Policy No:

Type of Policy:

Name of the Policy:

Commencement of Policy/ Policy

Period/PPT

Mode/Premium Amount

501-5135154 (1) 501-5271546

(2)

501-5891616

(3)

Life Life Life

Bharti Axa Life

Secure Income

Plan

Bharti Axa

Life Flexi

Save

Bharti Axa

Life

Super Series

12/12/2016 28/01/2017 12/06/2017

20 Years/10 Years 20 Years/5

years

20 Years/10

Years

Yearly/₹.

101,880/-

Yearly/

₹.51,967/-

Yearly/

₹.31,124/-

501-4916836

(4)

501-4729361

(5)

501-5568602

(6)

Life Life Life

Bharti Axa Life

Secure Income

Plan

Bharti Axa

Elite

Advantage

Plan

Bharti Axa Life

Samriddhi Plan

24/10/2016 12/08/2016 25/03/2017

20 Years/10

Years

10 Years/5

Years

10 Years/10

Years

Yearly / ₹.

25,470/-

Yearly/ ₹.

52,059/-

Yearly/

₹.51,875/-

501-4896954

(7)

501-5429334

(8)

501-

4051535(9)

Life Life Life

Bharti Axa

Elite

Advantage

Plan

Bharti Axa Life

Samriddhi

Bharti Axa Life

Advantage

28/09/2016 28/02/2017 15/02/2016

12 Years 10 Years 11 Years

Yearly/

₹.1,04,302/-

Yearly/

₹.25,983/-

Yearly/ ₹.

53,195/-

501-

5281586(10)

501-5031007

(11)

501-5455461

(12)

Life Life Life

Bharti Axa Life

Child

Advantage

Bharti Axa Life

Child

Advantage

Bharti Axa Life

Flexi Save

20/10/2017 18/11/2016 07/03/2017

11 Years/6

Years

11 Years/6

Years

20 Years/5

Years

Yearly/

₹.51,491

Yearly/

₹.12,677/-

Yearly/₹.

2,07,960/-

501-5042491 (13) 501-5453771 (14)

Life Life

Bharti Axa Elite

Advantage Plan

Bharti Axa Flexi Save

21/11/2016 08/03/2017

10 Years/ 5 Years 20 Years/ 5 Years

Yearly/ ₹.36,358/- Yearly/ ₹.31,125/-

3. Name of the Insured

Name of the Policyholder

Mr. Sijo John under Policies from Sl No (1) to ( 12)

Mrs. Eliyamma John Under Policy Number (13) &

(14)

4. Name of the Respondent Insurer Bharti Axa Life Insurance Company Limited

5. Date of Repudiation/ Rejection 19/10/2019

6. Reason for repudiation/ Rejection Policies cannot be cancelled beyond ‘Free Look

Period’

7. Date of receipt of Annexure VI-

A

09/01/2020

8. Nature of complaint Mis-sale

9. Amount of claim ₹. 8,39,806/- + Interest under all policies put together

10. Date of Partial Settlement N A

11. Amount of relief sought ₹. 8,39,806/- + Interest

12. Complaint registered under Rule

No

13(1) (c) & (d) & (f) of Insurance Ombudsman Rules,

2017

13. Date of hearing/place 05/02/2020 - Bengaluru


a) For the Complainant Self

b) For the Respondent

Insurer

Mr. Subramani– Relationship Manager


16. Date of Award/Order 07/02/2020

17. Brief Facts of the Case: The complaint emanated from the alleged mis-sale of the said 14 policies by the sales

representatives of the Respondent Insurer (RI). In spite of his representations to Grievance

Redressal Officer (G.R.O.) of the RI, his request was denied. Aggrieved, he has approached this

forum.

18. Cause of Complaint: -

a. Complainant’s argument: The Complainant vide his letter dated 19/11/2019 stated that he was approached by the agents of the

RI by making false promises and also with a promise of returning of ‘cash back’. Initially though

the Complainant did receive the cash back, it stopped suddenly by the end of 2017. When the

Complainant confronted with the agents, they could not give proper explanation but promised to

convert the impugned policies into ‘One Single Premium Policy’ without payment of renewal

premium under the said policies. Faced with financial difficulties as he is not able to service the

said policies, he has approached this Forum seeking cancellation of the said policies and refund of

premium thereon, as the sale of said policies were a ‘Mis-Sale’. The Complainant has also informed

the Forum that if it is not possible for the RI to refund the said premiums, then the Complainant has

sought directions to the RI to cancel the said policies and issue ‘One Single Premium Policy’ in

their place.

b. Respondent Insurer’s argument: The RI vide their SCN dated 03/02/2020 stated the Life Assured/Complainant after thoroughly

understanding the policy features and benefits applied for the said policies from the RI. The RI

issued the said policies along with ‘Free Look Cancellation’ clause and despatched to the

Complainant. The RI has put in place a mechanism of ‘PIVC’ (Pre-Issuance Verification Call)

where the RI makes a call before the issue of the said policies where the core objective of the said

call is to ensure and confirm at the RI’s end, that the Complainant has understood the key features

of the policies without any ambiguity and has no grievance in this regard. The Complainant has

received the policy documents. Thereafter the RI effected PIVC (Post Verification Call) to the

Complainant’s registered mobile number and the Complainant did not raise any objection during the

said call and also did not revert back to the RI during the ‘Free Look Period’ with regard to the

issues raised by him in his complaint, which confirms that the Complainant was in complete

agreement with the issue of said policies.

The RI further averred that the RI neither encourages any discrepancies to be crept in nor do they

intend to issue any policy based on incorrect information. The Complainant approached the RI for

the first time on 23/05/2018 alleging that the brokers has ‘Mis-Sold’ the said policies on the false

promise of ‘Cash Back’. After evaluating the said complaint and verification of records, the RI

concluded that they were prepared to cancel the policy bearing number 501-5969958, whereas the

RI could not take the same decision in respect of other 13 policies as no mis-selling activity was

involved in the sale of said policies and that the Complainant approached the RI beyond ‘Free Look

Period’.

The RI is neither privy to the communication the Complainant had with the persons who are alleged

to have given any representation to the Complainant nor do they intend to issue policies based on

false documentation and as such the allegation of ‘Mis-Sale’ of the said policies are denied by the

RI. Further the RI does not authorize any of its agents/brokers to offer any false promises or

benefits which to their customers which are at variance with product features. Further the

Complainant has not alleged any forgery of the documents which implies his admittance to singing

of the proposal and other documents required for issue of the said policies. Further the RI is fully

compliant of Sec 41 of

Insurance Act 1938 which does not allow any offer or any inducement directly or indirectly for

taking an insurance policy or for renewing the policy.

Immediately after receipt of the complaint from the Complainant the RI conducted due diligence of

the same and concluded that the complaint is bereft of merits and made on false grounds only to

wriggle out of the contract, and hence the RI rejected the Complainants request for ‘Cancellation of

the said policies’ and informed the Complainant accordingly vide their mail dated 23/05/2018. The

RI quoted some of the case laws decided by legal forums in support of their decision.

In the instant case, as the policy was issued as per the requirements of the Complainant and he also

consented for the issue of the said policy during the PIVC call, and he did not approach the RI

during ‘Free Look Period’, the RI prayed for the dismissal of the said complaint.

19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017 under Sec 13(1)(c),(d)

& (f) and hence, it was registered.

20. The following documents were placed for perusal: -

a. Complaint along with enclosures,

b. Respondent Insurer’s SCN along with enclosures and

c. Consent of the Complainant in Annexure VIA &and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): The issue to be decided by the Forum is, whether the sale of the said policies is a ‘Mis-Sale’.

During the personal hearing held on 05/02/2020 the Complainant informed the Forum that he had 2

insurance policies with the RI which matured in 2016. The agents of the RI promised ‘Cash Back’

if he availed the insurance policies with RI. In addition he was also promised ‘Fake promises. The

Complainant shared his card details with the concerned agent, and transferred the amounts

whenever the agents demanded the amounts from the Complainant. Further the Complainant

informed the Forum that he received an amount of ₹.87,497/- as ‘Cash Back’ in lieu of the

premiums paid by him. When the agents stopped giving ‘Cash Back’, he realized that he was lured

and trapped into purchasing new insurance policies, based on false promises, and hence he sought

to cancel the said policies alleging ‘MIs-Sale’. The Complainant informed the Forum that due to

change in his financial circumstances, he cannot continue the said policies, but requested if it was

not possible for the RI to refund the premiums paid on cancellation of the said policies, they may be

directed to issue ‘One Single Premium Policy’ in lieu of the said policies.

The RI did not submit the call recordings during the hearing, to substantiate their claim that the

Complainant had consented to the features of the policy as explained in the PIVC calls.

The Forum after careful scrutiny of records has observed that the Complainant availed chain of the

policies as mentioned above. He has submitted all the necessary documents for the issue of the said

policy. The RI has issued the said policies to the Complainant and despatched the policy documents

along with ‘Free Look Cancellation’ clause and despatched it to the Complainant and he has

received the same. The Complainant did not approach the RI seeking cancellation of the said

policies during ‘Free Look Period’. The Complainant has not brought out any evidence of ‘Mis-

Sale’ in support of his allegation.

The RI on their part, informed the Forum that they being customer centric organization, they are

prepared to cancel all the said 14 policies and issue ‘One Single Premium Policy’ in their place.

AWARD Taking into account, the facts & circumstances of the case, and the submissions made by

both the parties during the course of Personal hearing, the complaint is Allowed.


a. The Complainant shall submit all requirements/Documents required for settlement of award within 15 days of receipt of the award to the Respondent Insurer.

b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, 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.

Dated at Bengaluru on 07th day of February 2020

(NEERJA SHAH)

INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA


KARNATAKA



In the Matter of MRS. SHREE KALA HEGDE V/s HDFC STANDARD LIIFE INSURANCE

COMPANY LTD.

Complaint No: BNG-L-019-1920-0547

Award No: IO/BNG/A/LI/0420/2019-2020


Complainant

Mrs. Shreekala Hegde,

#1144, Ground Floor, 9th Cross,

8th Main, Ashok Nagar, BSK 1st stage,

Bangalore South, Bangalore-560050

Mob.:9902058242,

mail id.: [email protected]

2. Policy No:

Type of Policy:

Name of the Policy:


Period/PPT

Mode/Premium Amount

21056995

Life

HDFC Life Super Income Plan

10.01.2019

16 Years/ 8 Years

Yearly/ ₹. 38277/-



Mrs. Shreekala Hegde

4. Name of the Respondent Insurer HDFC Standard Life Insurance Company

Limited

5. Date of Repudiation/ Rejection 05.7.2019

6. Reason for repudiation/ Rejection Policy Cannot be cancelled beyond Free look

period

7. Date of receipt of Annexure VI-A 18.12.2019


9. Amount of claim ₹. 39,999/- + interest


11. Amount of relief sought ₹.39,999/-

12. Complaint registered under Rule 13(1)(c)&(f)of Insurance Ombudsman Rules,

No 2017

13. Date of hearing/place 05.02.2020 - Bengaluru



b) For the Respondent Insurer Mr. Vinay – Manager(legal)



17. Brief Facts of the Case: The complaint arose from the alleged mis-sale of the said policy by the Agents/Brokers/Sales

Representatives of the Respondent Insurer (RI). Though she represented to the RI about ‘Mis-Sale’

of the said policy, they refused to cancel the policy. Aggrieved, she has approached this forum.


a. Complainant’s argument:

The Complainant vide dated 18.12.2019 stated that during January,2019, she availed the policy

based on false promises made by the brokers (M/s Dealmoney Securities Private Limited) of RI,

that the said policy would be issued with onetime payment only, and that she could get back money

invested with her old policy. She acknowledged the bond on 18.01.2019, and she approached the

representatives of RI on 28.1.2019 to know updates on the policy, the said brokers dragged the

matter so that she could lose out on ‘Free look period’. She approached the RI seeking cancellation

of the said policy through mail dt. 27.6.2019, they rejected her cancellation request through mail dt.

5.7.2019 as it was beyond ‘Free Look Period’. Hence the Complainant has approached the Forum

seeking cancellation of policy and refund of premium paid.

b. Respondent Insurer’s argument:

The RI stated their SCN dt. 28.1.2020, that they have issued the said policy based on the correct

requirements received from the Complainant and despatched the policy bond along with ‘Free Look

Cancellation’ clause and she has received the same, the said policy is in lapsed condition from

9.1.2020 due to non-payment of renewal premium. The policy was routed through M/s Dealmoney

Securities Private Limited who are their party brokers of the RI and the promises made by the

Broker are their own and the complainant not bind the RI and that the policy is a standalone product

and not linked to any other policy. Further the RI averred that, as Customer Consent Document

(CCD) has been signed by her it shows that she understood the terms and conditions of the

Insurance policy as opted by her and policy illustration sent to the complainant’s mail.

As there is no deficiency of service on the part of the RI in servicing the said policy also of the fact

that the complainant approached the RI beyond ‘Free look period’ they have prayed for dismissal of

the said complaint.

19. Reason for Registration of complaint: -

The complaint falls within the scope of Insurance Ombudsman Rules, 2017 under Sec

13(1)(c)(d)&(f) and hence, it was registered.


d. Complaint along with enclosures,

e. Respondent Insurer’s SCN along with enclosures and

f. Consent of the Complainant in Annexure VIA &and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions):

The issue to be decided by the Forum is whether the sale of said policy is a ‘Mis-sale’.

During the personal hearing on 05.02.2020, the Complainant informed the forum that the

representatives of RI assured the complainant to provide the single premium but they issued the

bond under Yearly premium with premium paying term as 8 years. She submitted the mails and call

recordings to prove that she was misled to buy this policy. Though approached these agents, they

misled her by prolonging time to cross the ‘Free look period’.

The RI maintained their stand as per their SCN and RI played their call recordings.

The forum after careful examination of records and call recordings has observed that the

complainant was lured to avail the new policy, based on the old policy which she had with the RI.

These brokers informed the complainant surrendering her old policy she would get Rs.55000/-

which could be utilised for availing the said policy. These brokers faked their identity as ‘employee

of the RI’ gained the confidence of the complainant and promised her single premium policy. But

the policy bond issued on 18.1.2019 was an annual premium policy. As the complainant did not

want to continue the said policy she approached these brokers on 28.1.2019 which was well within

‘Free look period’. These agents kept on dragging the matter with a view/intention of policy getting

cancelled during ‘Free look period’. Further the complainant informed the forum that she was lured

by these brokers to answer all the questions in affirmative and as such she answered all the

questions in affirmative.

Considering the facts and circumstances of the case the forum treats the sale of the said policy as

‘mis-sale’


both the parties during the course of Personal hearing, the RI is hereby directed to cancel

the said policy without deducting any charges and refund the amount without interest.

The complaint is ALLOWED.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of

Insurance Ombudsman Rules, 2017:

a. The Complainant shall submit all requirements/Documents required for settlement of award

within 15 days of receipt of the award to the Respondent Insurer.

b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, 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.

Dated at Bengaluru on 10TH February, 2020.

(NEERJA SHAH) INSURANCE OMBUDSMAN



KARNATAKA



In the Matter of MR. SOMA.V. CHETTY V/s RELIANCE LIFE INSURANCE COMPANY

LIMITED Complaint No: BNG—L--036—1920—0548 To 0551 (Total 4 Complaints)

Award No: IO/BNG/A/LI/0422 to 0425 /2019--2020 (Total 4 Awards)


Complainant

Mr. Soma.V. Chetty

# 13, 19th Cross, Santhosh Vihar

Jakkur Main Road, Bangalore – 560092

(M):7022872209

2.

Policy No:

Type of Policy:

Name of the Policy:


Period/PPT

Yearly/Mode/Premium Amount

53260372(1) 53237173(2) 53226941(3)

Life Life LIfe

Reliance

Nippon Life

mart savings

Insurance

Plan

Reliance

Nippon Life

mart savings

Insurance

Plan

Reliance

Nippon

Premier

Wealth Ins

Plan

13/07/2018 11/06/2018 25/05/2018

10 Years/ 5

years

10 Years/5

years

10 Years/10

Years

₹.1,00,000/- ₹.1,00,000/- 5,00,000/-

53284627(4)

Life

Reliance Nippon Lie Classic Plan II

21/08/2018

15 Years / 15 Years

₹.1,00,000/-



Ms. Gagana. S. Chetty – Under Policy No 1, 2,

4,

Ms. Meenakashi – Under Policy No 3

Mr. Soma. V. Chetty under all the 4 policies

4. Name of the Respondent Insurer Reliance Nippon Life Insurance Company

Limited


6. Reason for repudiation/ Rejection Policies cannot be cancelled beyond ‘Cooling

Off Period’


A

06/1/2020


9. Amount of claim ₹. 8,00,000/- + Interest



12. Complaint registered under Rule 13(1) (f) of Insurance Ombudsman Rules, 2017

No





Insurer

Mr. Padmakar Tripathi. – Manager(Legal)

15. Complaint how disposed Resolved


17. Brief Facts of the Case: The Complaint is the result of ‘Rejection of Cancellation Request’ by the Respondent Insurer (RI)

on the policies held by the Complainant/Proposer. In spite of the Complainant approaching the

Grievance Redressal Officer (G.R.O.) of the RI, there was no response from them. Hence he has

approached this Forum seeking cancellation of the said policies and refund of premiums paid.


a. Complainant’s argument: The Complainant vide his letter dated 19/11/2019 stated that he met with an accident on 02/10/2017

and was hospitalized. During hospitalization and post hospitalization though he was bedridden, he

was approached by the Officials of the RI, to avail the said policies. Unaware of the policy terms

and conditions the Complainant availed the said 4 policies. As his financial condition and his

physical health condition deteriorated, he sought the cancel the said policies which was rejected by

the RI. Hence he has approached this Forum seeking cancellation of the said policies and refund of

premiums paid.

b. Respondent Insurer’s argument: The RI vide their SCN dated 29/01/2020 stated that the Complainant being an educated individual

chose to avail the said policies as envisaged in the proposal and other allied forms, by signing the

necessary documents for the issue of the said policies. As per the requirements of the Complainant,

the RI issued the said policies and despatched the policy document along with ‘Free Look

Cancellation’ clause to the Complainant and he has received the same. The Complainant has not

disputed the issue of the said policies and chose not to cancel the ‘Free Look Cancellation’ option

which establishes that there is no ‘Mis-Sale’ of the said policies.

The Complainant approached the RI for the first time on 18/07/2019 more than 1 year after the

issue of the said policies, and the delay has not been justified by the Complainant which points out

that no false assurances/benefits were promised at the time of solicitation of the said policies. It is

pertinent to note that the Complainant has preferred the present complaint with nefarious motive of

wriggling out of contract. Further the RI has covered the risk for the duration of which the premium

was paid by the Complainant. Had there been any mis-happening in the life assured life, the RI

would have honoured the claim. Further the RI averred that there is no deficiency of service on the

part of RI in servicing the said policies.

As the Complainant has failed to prove any allegations of ‘Mis-Sale’ and no cause of action has

arisen

in the said Complaint, and the fact that the Complainant did not approach the RI during ‘Free Look

Period’, the RI has prayed for dismissal of the said complaint.

19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017 under Sec 13(1)(f) and

hence, it was registered.


g. Complaint along with enclosures,

h. Respondent Insurer’s SCN along with enclosures and

i. Consent of the Complainant in Annexure VIA &and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): The issue to be decided by the Forum is whether this is a case of Mis-Sale.

During the personal hearing on 05/02/2020 the Complainant reiterated his stand as stated in the

complaint and said that the agents did not inform the nitty-gritties of the said policies, but insured

his family members and hence he sought to cancel the said policies and refund the premiums paid

thereon so that at least he could use the said amount for his medical treatment.

The RI on the other hand informed the Forum that the Complainant is only proposer, and the

policies are issued on his family members. As the Complainant did not approach the RI during

‘Free Look Period’, they are unable to cancel the said policies as per policy terms and conditions.

However they informed the Forum that, as a very special case, they have taken call to cancel the

said policies and refund the total premiums paid.

The Forum after careful scrutiny of records has observed that the proposer had a life threatening

accident on 24/10/2017 and was bed ridden from then onwards. Though the agents were fully

aware of his medical condition, and while he was in hospital and later in his house taking palliative

care, have enrolled the Complainant as proposer, and issued policies on the life of family members

of the Complainant. The Forum notes that the officials of the RI has not done proper due diligence

on their part and issued the said policies. Hence, the Forum treats the sale of the said policies as

‘Mis-Sale’.

AWARD Taking into account, the facts & circumstances of the case, and the submissions made by both

the parties during the course of Personal hearing, the RI is directed to cancel all the four

policies and refund the total premiums without any deductions and without interest.

Hence, the complaint is ‘Resolved’.


a. The Complainant shall submit all requirements/Documents required for settlement of award within 15 days of receipt of the award to the Respondent Insurer.

b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, 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.

Dated at Bengaluru on 11th Day of February 2020

(NEERJA SHAH)

INSURANCE OMBUDSMAN



KARNATAKA



In the Matter of MR. JAYARAJAN V/s HDFC STANDARD LIFE INSURANCE COMPANY

LIMITED Complaint No: BNG--L--019--1920– 0578

Award No: IO/BNG/A/LI/0427/2019--2020


Complainant

Mr. Jayarajan

# 1146 /B, 11th Cross

35th Main, J.P. Nagar

1st Phase, Bangalore – 560078

(M):9743999516

E-Mail: [email protected]

2. Policy No:

Type of Policy:

Name of the Policy:


Period/PPT

Mode/Premium Amount

19508308

Life- ULIP

HDFC SL Pro Growth Super II

29/08/2017

10 Years

Yearly/ ₹.3,00,000/-



Mr. Jayarajan

4. Name of the Respondent Insurer HDFC Standard Life Insurance Company

Limited


6. Reason for repudiation/ Rejection Policy Cannot be cancelled beyond ‘Free Look

Period’


A

23/01/2020






No

13(1)(f) of Insurance Ombudsman Rules, 2017





Insurer

Mr. Vinay Prakash – Manager(Legal)

15. Complaint how disposed Disallowed


17. Brief Facts of the Case: The complaint resulted from the alleged mis-sale of said policy due to the wrong information

displayed in the official website of the RI. In spite of his representations to Grievance Redressal

Officer (G.R.O.) of the RI, his request was denied. Aggrieved, he has approached this forum.


a. Complainant’s argument: The Complainant vide his letter dated 08/01/2020 stated that he availed the said policy based on the

false information given by the RI in their official website. In addition, the representatives of the RI,

also endorsed the same and they only suggested the ratio of amount to be diversified in different

funds and filled the proposal forms. When the Complainant verified the performance of the funds,

to his aghast, he realized that the value of his investments were dwindling down. Further the

information pertaining to his investment were not informed to him at regular intervals and he was

kept in dark by the RI. When he cross verified with the sales representatives of the RI, they advised

the Complainant to continue paying the premiums in order to avail maximum benefits and returns.

As he availed the said policy based on escalated and fudged figures and graphs which are not the

true facts, it amounted to cheating the policy holders by keeping him in dark, and hence he has

sought this Forums help in cancelling the said policy and refund of premiums paid.

b. Respondent Insurer’s argument: The RI vide their SCN dated 30/01/2020 stated that the Complainant availed the said policy on

29/08/2017 for a period of 10 years by paying an annual premium of ₹.3,00,000/-. The RI issued

the said policy for a death benefit of ₹.21,00,000/-with a ‘Lock-In’ period of 5 years. The

Complainant chose to invest 30% of the premium paid in ‘Income Fund’ & 70% of the premium in

‘Opportunities Fund’. In order to avail the maximum benefit, the Complainant is supposed to pay

all the premium in time till the date of maturity. The RI issued the said policy subject to Market

Risk, which is specifically mentioned in the policy terms and conditions. Further the policy terms

clearly states that the investment risk portfolio has to be borne by the policy holder.

The RI dispatched both the hard copy and soft copy of the policy documents along with ‘Cooling

Off Cancellation clause’ to the Complainant on 31/08/2017 and he has received the same on

02/09/2017. The Complainant did not approach the RI with regard to any discrepancy during ‘Free

Look Period’ and continued to pay 2 annual premiums due 2017 & 2018. As further premium has

not been paid by the Complainant, the policy is in lapsed condition as per terms and conditions of

the policy.

The said policy being a ‘ULIP’ policy, the features of the said policy were explained to the

Complainant and the Complainant has filled up the proposal forms after fully understanding the

terms and conditions of the said policy. Under this policy, the risk of investment portfolio is to be

borne by the policy holder and the increase or decrease in fund value is subject to market risk and

the RI has no say in it. The Complainant allegation of the RI guaranteeing the return of 52% is

denied as even otherwise the rate of return is only bench mark. The policy broacher clearly states

that the past performance is not necessarily an indication of future performance. The names of the

funds the RI offer under this plan do not in any way indicate the quality of the plan and its future

prospects or returns.

The contention of the Complainant that he was not provided the fund statement from time to time is

denied as the Complainant accessed his one line account by using his personal credentials to check

the fund value and the Complainant lastly accessed his fund account on 22/09/2018 at 10.41.P.M.

As the allegation made by the Complainant is false, baseless, and untenable and manipulated, the RI

has prayed the Forum for dismissal of the said complaint.

19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017 under Sec 13(1)(d)&(f)

and hence, it was registered.


j. Complaint along with enclosures,

k. Respondent Insurer’s SCN along with enclosures and

l. Consent of the Complainant in Annexure VIA &and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): The issue to be decided by the Forum is whether this is a case of ‘Mis-Sale’.

During the personal hearing on 05/02/2020 the Complainant informed the forum that he is an

esteemed customer of the HDFC bank and whenever there was an adequate balance in his bank

account, the agents would approach him and advise him to avail an insurance policy. In this case,

the agents explained the features of the said policy and also promised better returns on the same.

The said agents on their own, filled up the proposal forms and based on the trust he had with the RI,

he availed the said policy by paying an annual premium of ₹.3,00,000/- P.A. Because of the trust

the Complainant had with the RI, he did not cross verify the credentials about the said investment

with the RI. After 1 year, he realized that his investment was dwindling down. Even their official

website promised 14% return on investment. As per IRDA regulations, the RI did not send the fund

statement. As he felt cheated he sought the Forums help in cancelling the said policy and refund of

premiums paid.

The RI reiterated their stand as stated in their Complaint.

The Forum after careful scrutiny of records has observed that the Complainant availed the said

policy on 29/08/2017 by paying an annual premium of ₹.3,00,000/-. It is ‘HDFC SL Pro Growth

Super II’ a ‘ULIP’ policy for a period of 10 years where upon death of the Life Assured during the

term of the policy,( while the policy is in full force) death sum assured of ₹.21 lakhs is payable and

upon maturity unit fund value is payable. In all the policy documents, it is clearly mentioned that

the said policy is a Unit Linked Policy and subject to Market Risk and the investment risk in

investment portfolio is to be borne by the policy holder’. The Complainant has paid the premium

due in 2017 & 2018. As the next premium due on 29/08/2019 is not paid, the policy is in lapsed

condition.

The Complainant approached the RI for the 1st time about the ‘Mis-Sale’ and cheating on

12/09/2019 which is beyond 2 years after the policy was issued.

The Forum notes that the brochure/sales literature/screen shot from the web site of the RI is only for

the purpose of soliciting the business. Since these are ULIP products the value of the policy depends

on various factors, like market risk, type of funds...etc. Further the said policy is ULIP-CUM-

Investment Policy’, where in part of the premium paid by the assured is appropriated towards

covering the risk of the policy holders and balance amount available is invested in units. As the

Complainant was of advanced age of 56 years and the death sum at risk is ₹.21 lakhs, the amount

available for investment is less thereby resulting in less number of units being allotted to his unit

account.

Insurance is a contract based on good faith and it is the bounden duty of the prospect to not only fill

the proposal forms himself but also authenticate that he has understood the benefits and features of

the policy. The proposal form filled by the Complainant clearly states that “All Unit Linked

Policies are different from traditional insurance policies and are subject to different risk factors. In

unit linked policy the investment risk in your chosen investment portfolio is borne by you”.

Against column 10 of the proposal form the Complainant has clearly opted for 30% of the amount

to be allocated to Income Fund and 70% to Opportunities Fund. The Contention of the

Complainant that he did not fill up the proposal form and the concerned agents/sales representatives

filled up the proposal forms is not appreciated as the Complainant cannot pass the responsibility of

not having fully understood the features of the policy upon the agent.

The Hon. Supreme Court vide their Judgement in the case of Civil Appeal No 4261 of 2019 arising

out of SLP (C) 14312 of 2015 in Reliance Life Insurance CO Ltd & Anr Vs Rekhaben Naresh Bhai

Rathod where it has been held as follows:-

“31. “Finally, the argument of the respondent that the signatures of the assured on the form were taken without explaining the details cannot be accepted. A similar argument was correctly rejected in a decision of a Division Bench of the Mysore High Court in VK Srinivasa Setty v Messers Premier Life and General Insurance Co Ltd21 where it was held:

― Now it is clear that a person who affixes his signature to a proposal which contains a statement which is not true, cannot ordinarily escape from the consequence arising therefrom 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. If an agent nevertheless does that, he becomes merely the amanuensis of the insured, and his knowledge of the untruth or inaccuracy of any statement contained in the form of proposal does not become the knowledge of the insurer. Further, apart from any question of imputed knowledge, the insured by signing that proposal adopts those answers and makes them his own and that would clearly be so, whether the insured signed the proposal without reading or understanding it, it being irrelevant to consider how the inaccuracy arose if he has contracted, as the plaintiff has done in this case that his written answers shall be accurate”.

Further the Forum notes that as the Complainant had access to his status of the policy from his own

login, the Complainant should have taken adequate care to exercise due diligence to know the fund

position. The Complainant holding a high responsible position should have exercised due diligence

while availing the said policy. In addition, the Complainant has not approached the RI during ‘Free

Look Period’.

Considering the facts and circumstances of the case, as the Complainant has not brought out any

evidence of ‘Mis-Sale’ as alleged by him, the Forum does not treat the sale of said policy as ‘Mis-

Sale’.


both the parties during the course of Personal hearing, the complaint is ‘Disallowed’.

Dated at Bengaluru on 11th Day of February 2020

(NEERJA SHAH)

INSURANCE OMBUDSMAN



KARNATAKA



In the Matter of MR. SURESH.B. V/s SHRIRAM LIFE INSURANCE COMPANY

LIMITED Complaint No: BNG—L—0043--1920– 0553, & 0554

Award No: IO/BNG/A/LI/0428 & 0429/2019--2020


Complainant

Mr. B. Suresh

‘Parvathy Nilaya’ Near Town Police Station

Kolar -563101

(M):9845280889


2.

Policy No:

Type of Policy:

Name of the Policy:


Period/PPT

Mode/Premium Amount

Sum Assured

LN021000025789 (1) LN021000010863 (2)

Life - ULIP Life - ULIP

Shriram Shri VIdya

Plus II

Shriram Shri VIdya

Plus II

15/09/2010 26/04/2010

25 Years 25 Years

Yearly/30,000/- Yearly/ ₹.30,000/-

₹.6,00,000/- ₹.10,00,000/-



Mr. B. Suresh – Under Both the policies

4. Name of the Respondent Insurer Shriram Life Insurance Company Limited

5. Date of Repudiation/ Rejection NIL

6. Reason for repudiation/ Rejection NIL


A

08/01/2020

8. Nature of complaint Mis-sale & Policy Foreclosed





No

13(1)(f) of Insurance Ombudsman Rules, 2017





Insurer

Mr. Sagar–Assistant Manager

15. Complaint how disposed Disallowed


17. Brief Facts of the Case: The complaint resulted due to alleged ‘Mis-sale’ of the said 2 policies by the sales representatives of

the Respondent Insurer (RI). Further the RI foreclosed policy number LN 021000010863 without

the knowledge of the Complainant. Even though he represented to the RI about the said ‘Mis-Sale’

and ‘Foreclosure’ there was no response from them. Aggrieved, he has approached this forum.


a. Complainant’s argument:

The Complainant vide letter dated 06/12/2019 stated that the in the year 2010, the agents of RI

induced the Complainant to avail the said policies without fully explaining the benefits and features

of the said policies. Keeping the future of his children in mind, as the benefits looked attractive the

Complainant availed the said policies by raising loan from the bank. After paying 7 years premium,

he realized that the value of the said policies was not appreciating and when he sought the details of

the policies from the RI, there was no information forth coming from them. Though he informed

the RI about the exorbitant charges on the said policies, which is inhuman, arbitrary and unilateral

there was no response from them. The RI vide their letter dated 12/06/2019, informed the

Complainant about the foreclosure of the policy bearing number LN021000010863 and the amount

payable was ₹. 2865/- as against the total premium ₹.2,10,000/- which is absolutely contrary to the

rules and regulations framed by the Govt of India but the RI is silent on the 1st policy held by the

Complainant. Further, the RI has not received any unit fund statement, periodically to enable him

to know the value of the said policies. Hurt by the way the RI has handled the investments of the

Complainant, he has approached this Forum seeking cancellation of the said policies and refund of

total premiums paid under both the policies.

b. Respondent Insurer’s argument: The RI vide their SCN dated 30/01/2020 stated that the Complainant proposed the said ULIP

policies on his life by submitting the necessary requirements and as per the requirements of the

Complainant the RI issued the said policies and sent the policy documents along with ‘Free Look

Period’ and the Complainant has received the same. It is a ‘ULIP’ which gives both insurance and

investment benefit in a single integrated policy unlike pure insurance policy. The Complainant did

not approach the RI during the ‘Free Look Period’ with regard to any discrepancy in the policy and

also continued to pay the renewal premiums up to 2016. The next renewal premium which was due

on 15/09/2017 was not paid by the Complainant. Though the RI sent automated reminders, to the

Complainant to pay the renewal premiums, the Complainant has not paid the same and as such the

policy is in lapsed condition. As the Complainant has not revived the said policy during the

‘Revival Period’ and hence the policy went into ‘auto-surrender mode’.

The Complainant for the first time sent a letter dated 02/03/2018 to the RI seeking details of the

fund statement and accordingly the RI vide their letter dated 21/03/2018 replied and clarified all the

details of the fund management. The Complainant opted the fund ‘Maximus -100% and as per his

option the RI invested his money and the fund details were sent to the Complainant on periodical

basis at the given address of the Complainant. Further the Complainant is having complete freedom

to check the NAV details and fund performance from the official website of the RI.

The Complainant also paid ‘Top-Up’ premium in respect of both the policies in 2011, which proves

that the Complainant had complete knowledge about the product. The RI further averred that they

have covered the risk for the duration for which the premium is received and hence they rejected the

Complainant’s demand for refund of premiums.

The Complainant has approached the Ombudsman after 1 year after contacting the RI, besides the

Complaint is false, baseless, as he is trying to take undue advantage by suppressing the real facts,

the RI has requested for dismissal of the said complaint.

19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017 under Sec 13(1)(f) and



m. Complaint along with enclosures,

n. Respondent Insurer’s SCN along with enclosures and

o. Consent of the Complainant in Annexure VIA &and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions): The issue to be decided by the Forum is whether this is a case of ‘Mis-Sale’ and whether there is

any deficiency of service on the part of the RI in servicing the said policy.

During the course of personal hearing the Complainant reiterated his stand as per his complaint and

informed the Forum that he did not receive the fund statement at regular intervals.

The forum after careful scrutiny of records has observed that the Complainant availed the said

policies in the year 2010 by paying annual premium of ₹.30,000/-. It is ULIP policy which is ‘Risk-

Cum-investment policy’, where part of the premium paid by the Complainant is used for risk cover

and balance is invested in ‘ULIP- Market’. The benefits are payable as per policy terms and

conditions.

In the case on hand, the sum assured in respect of the sum assured under the 1st policy bearing

number LN021000025789 is ₹.6,00,000/-, whereas under the 2nd policy bearing number

LN021000010863 is ₹.10,00,000/-. The risk premium under the policy number LN021000025789

will be less as compared to policy number LN021000010863 in view of the higher sum assured

opted by the Complainant. Thus the amount available for investment under the 2nd policy is less

compared to the 1st policy. As such the amount allotted as units will be less in respect of policy

number LN021000010863. As the life assured has not paid the premium from 2017 onwards the 2nd

policy got foreclosed.

The Forum notes that as per terms and conditions of the policy, the RI is supposed to send ‘Unit

Fund Statement’ every time there is a transaction on the policy and on every policy anniversary. The

RI informed the Forum that as per their office procedure, they have sent the fund statement to the

Complainants address by ‘Ordinary Post’ and submitted the copies of the ‘UNIT Fund Statement’

issued to the Complainant since 2012.

The Forum notes that the Complainant has availed the said 2 policies in 2010 and did not approach

the RI during ‘Free Look Period’ and continued to pay renewal premiums for 7 years thereafter.

The RI has covered the risk on the policy for which the premiums are received under the said

policies. In an untoward incident, the RI would have discharged their liability as per policy terms

and conditions. The Complainants allegation that the mortality charges are exorbitant, arbitrary, is

not acceptable as the same were informed to him in the benefit illustration which formed part of

policy document.

As the Complainant has approached the Forum after 9 years and not brought out any evidence of

‘Mis-Sale’ in support of his allegations, no ‘Mis-Sale’ is established.


the parties during the course of Personal hearing, the complaint is ‘Disallowed’.


(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,

STATE OF KARNATAKA


OMBUDSMAN – NEERJA SHAH

In the matter of Mr AJIT ANTONY LEANDER S V/s KOTAK MAHINDRA LIFE INSURANCE

CO LTD




Complainant

Mr Ajit Antony Leander S

#4/1, 2nd cross, Dobbaspet,

Vasantha Nagar,

Bengaluru -560001

Mob: 7760061932

Email Id: [email protected]

2. Policy No

Name of the Policy

Commencement of Policy

Policy Period/Premium Paying

Term

09029901

Kotak Assured Savings Plan

31.10.2018

15/10 Years



Mr Ajit Antony Leander S

4. Name of the Insurer Kotak Mahindra Life Insurance Company

Limited


6. Reason for Repudiation/ Rejection Request not received within free look period

7. Date of receipt of Annexure VIA 07.01.2020

8. Nature of complaint Cancellation of Policy

9. Amount of claim ₹. 1,40,000/-

10. Date of Partial Settlement Nil

11. Amount of relief sought ₹. 1,40,000/-


No:

13(1)(c) of Insurance Ombudsman Rules, 2017

13. Date of hearing/place 05.02.2020/Bengaluru



b) For the RI Mr M Raghavendra, Manager



17. Brief Facts of the Case: The complaint emanated from rejection of request to refund premium by cancelling the policy. His

request was rejected as it was received beyond free look period. Hence, the Complainant

approached this Forum for redressal of his grievance.

18. Cause of Complaint:-

a. Complainant’s argument: The Complainant in his letter and submissions made to the Respondent Insurer stated that he

availed the aforesaid policy along with 5 policies for him and his mother out of father’s retirement

money. Presently his father was not in a position to pay renewal premium of all these policies due to

the financial issues. His father was able to renew 4 policies using the hand loan money from his

well wishers. He approached the RI to cancel and refund the first year premium of two policies

including the aforesaid policy to repay the hand loan. His request was rejected by the RI. He

requested the Forum for redressal of his grievance by refunding the premium paid by him.

b. Respondent Insurer’s argument: The Respondent Insurer in their SCN dated 23.01.2020 stated that

1. The Complainant is the wife of the sourcing agent of the aforesaid policy availed the policy

by completely filling the proposal form and submitted the same along with necessary

documents.

2. The Original Policy document was dispatched to the registered address of the Complainant

on 02.11.2018 through Blue Dart via AWB No. 42758411183

3. They received first complaint for cancellation of the policy approximately 5 months after the

date of issue of the policy which is beyond the freelook cancellation period.

The Complainant’s father being the Agent and Nominee of the Policy has also received a lump sum

amount as commission for issuance of the policy, which was not mentioned in the complaint. Below

is the table that shows the amount of commission paid to him.

LA Code Agent name Policy

Number Commission Gross

Commission TDS Amt Net

Commission 60558657 P Sudesh Kumar 9025747 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025735 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025723 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025710 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025951 14,850.48 17,523.56 876.18 13,974.30 60558657 P Sudesh Kumar 9025951 403.73 476.41 23.82 379.91 60558657 P Sudesh Kumar 9029901 35,593.15 41,999.91 2,100.00 33,493.15

The RI further submitted that, the insurance policy in question is a contract and the terms and

conditions under the policy in question are binding on both the parties to the contract and the strict

adherence of the same is expected from both the parties as such the RI cannot accept the request of

the Complainant nor the company can be directed for any refund of the deposited premium to the

Complainant against the terms and conditions of the policy.

The RI stated that the Forum does not have jurisdiction to entertain the present complaint as the

same is against the Insurance Ombudsman Rules, 2017 and does not come under Rule 13 of said

rules. They in present case has not caused or refrained itself from doing anything that would amount

to breach or wrong in any manner. Hence the complaint is liable to be dismissed.

19. Reason for Registration of complaint:- The complaint is within the scope of Insurance Ombudsman Rules, 2017.

20. The following documents were placed for perusal:- a. Complaint along with enclosures,

b. SCN of the Respondent Insurer along with enclosures and

c. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.

21. Result of personal hearing with both the parties (Observations & Conclusions):- The issue before the Forum is, whether the rejection of refund of premium request by RI is

appropriate. During the personal hearing, both the parties reiterated their earlier submissions.

Since the Complainant has approached this Forum regarding the dispute over premiums paid or

payable by her, the complaint is entertainable under Rule 13 (1) (c) of the Insurance Ombudsman

Rules, 2017 as such the contention of the RI that the complaint does not come under Rule 13 is not

accepted.

The Complainant has not disputed about the premiums paying term. The money paid for the

insurance is essentially for risk cover and cannot be equated with the money deposited in a bank

which can be withdrawn as and when sought by the depositor. RI has already provided the said risk

cover during the policy period for which premium is paid. No deficiency of service has been

noticed on the part of RI in this case. The Complainant’s request to refund the premium paid to RI

due to his inability to pay further premiums owing to financial difficulty does not hold good as the

terms and conditions of the policy do not provide such option to exit from the contract.

Forum notes that father of the Policyholder is the agent for the RI. It was expected that he would

prudently enter into the insurance contract after ascertaining his capacity to pay for the premiums

under the policy.

Having entered into the contract of insurance, the Complainant and the insurer are bound by the

terms and conditions of the policy schedule and can withdraw from the same as per existing terms

and conditions only. Under these circumstances the Forum finds no reason to interfere with the

decision of RI.

AWARD

Taking into account, the facts & circumstances of the case, and the submissions made by

both the parties during the course of Personal hearing, the Forum finds the decision of the

Respondent Insurer is found to be in order and does not require any interference at the hands

of the Ombudsman.

Hence, the complaint is Dismissed.

Dated at Bengaluru on 24th day of Feb, 2020




STATE OF KARNATAKA



In the matter of Mrs MARY MARGRET V/s KOTAK MAHINDRA LIFE INSURANCE CO LTD




Complainant

Mrs Mary Margret

#4/1, 2nd cross, Dobbaspet,

Vasantha Nagar,

Bengaluru -560001

Mob: 9611157170


2. Policy No

Name of the Policy



Term

09025951


10.11.2018

15/10 Years



Mrs Mary Margret


Limited




8. Nature of complaint Cancellation of Policy

9. Amount of claim ₹. 60,000/-


11. Amount of relief sought ₹. 60,000/-


No:








17. Brief Facts of the Case: The complaint emanated from rejection of request to refund premium by cancelling the policy. Her

request was rejected as it was received beyond free look period. Hence, the Complainant

approached this Forum for redressal of her grievance.


a. Complainant’s argument: The Complainant in her letter and submissions made to the Respondent Insurer stated that she

availed the aforesaid policy along with policies for her son out of husband’s retirement money.

Presently her husband was not in a position to pay renewal premium of all these policies due to the

financial issues. Her husband was able to renew 4 policies using the hand loan money from his well

wishers. She approached the RI to cancel and refund the first year premium of two policies

including the aforesaid policy to repay the hand loan. Her request was rejected by the RI. She

requested the Forum for redressal of her grievance by refunding the premium paid by her.

b. Respondent Insurer’s argument: The Respondent Insurer in their SCN dated 23.01.2020 stated that

4. The Complainant is the wife of the sourcing agent of the aforesaid policy availed the policy

by completely filling the proposal form and submitted the same along with necessary

documents.

5. The Original Policy document was dispatched to the registered address of the Complainant

on 12.11.2018 through Blue Dart via AWB No. 35727543655

6. They received first complaint for cancellation of the policy approximately 5 months after the

date of issue of the policy which is beyond the freelook cancellation period.

The Complainant’s husband being the Agent and Nominee of the Policy has also received a lump

sum amount as commission for issuance of the policy, which was not mentioned in the complaint.

Below is the table that shows the amount of commission paid to him.

LA Code Agent name Policy

Number Commission Gross

Commission TDS Amt Net

Commission 60558657 P Sudesh Kumar 9025747 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025735 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025723 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025710 12,711.84 14,999.98 750.00 11,961.84 60558657 P Sudesh Kumar 9025951 14,850.48 17,523.56 876.18 13,974.30 60558657 P Sudesh Kumar 9025951 403.73 476.41 23.82 379.91 60558657 P Sudesh Kumar 9029901 35,593.15 41,999.91 2,100.00 33,493.15

The RI further submitted that, the insurance policy in question is a contract and the terms and

conditions under the policy in question are binding on both the parties to the contract and the strict

adherence of the same is expected from both the parties as such the RI cannot accept the request of

the Complainant nor the company can be directed for any refund of the deposited premium to the

Complainant against the terms and conditions of the policy.

The RI stated that the Forum does not have jurisdiction to entertain the present complaint as the

same is against the Insurance Ombudsman Rules, 2017 and does not come under Rule 13 of said

rules. They in present case has not caused or refrained itself from doing anything that would amount

to breach or wrong in any manner. Hence the complaint is liable to be dismissed.


20. The following documents were placed for perusal:- d. Complaint along with enclosures,

e. SCN of the Respondent Insurer along with enclosures and

f. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.



Since the Complainant has approached this Forum regarding the dispute over premiums paid or

payable by her, the complaint is entertainable under Rule 13 (1) (c) of the Insurance Ombudsman

Rules, 2017 as such the contention of the RI that the complaint does not come under Rule 13 is not

accepted.

The Complainant has not disputed about the premiums paying term. The money paid for the

insurance is essentially for risk cover and cannot be equated with the money deposited in a bank

which can be withdrawn as and when sought by the depositor. RI has already provided the said risk

cover during the policy period for which premium is paid. No deficiency of service has been

noticed on the part of RI in this case. The Complainant’s request to refund the premium paid to RI

due to her inability to pay further premiums owing to financial difficulty does not hold good as the

terms and conditions of the policy do not provide such option to exit from the contract.

Forum notes that husband of the Policyholder is the agent for the RI. It was expected that he would

prudently enter into the insurance contract after ascertaining his capacity to pay for the premiums

under the policy.

Having entered into the contract of insurance, the Complainant and the insurer are bound by the

terms and conditions of the policy schedule and can withdraw from the same as per existing terms

and conditions only. Under these circumstances the Forum finds no reason to interfere with the

decision of RI.

AWARD

Taking into account, the facts & circumstances of the case, and the submissions made by

both the parties during the course of Personal hearing, the Forum finds the decision of the

Respondent Insurer is found to be in order and does not require any interference at the hands

of the Ombudsman.

Hence, the complaint is Dismissed.

Dated at Bengaluru on 24th day of Feb, 2020




STATE OF KARNATAKA



In the matter of Mr MOHAMMED RASOOL V/s KOTAK MAHINDRA LIFE INSURANCE CO

LTD




Complainant

Mr Mohammed Rasool,

370, Ground Floor, Akbar Nagar,

Shikaripalya, Near Mecca Masjid

Bengaluru -560105

Mob: 6362378763


2. Policy No

Name of the Policy



Term

09971056


17.08.2018

15/10 Years



Mr Mohammed Rasool


Limited





9. Amount of claim ₹. 40,000/- + Interest


11. Amount of relief sought ₹. 40,000/- + Interest


No:








17. Brief Facts of the Case: The complaint emanated from rejection of request to refund premium by cancelling the policy on

grounds of mis-sale. His request was rejected as it was received beyond free look period. Hence, the

Complainant approached this Forum for redressal of his grievance.


a. Complainant’s argument: The Complainant stated that one Mr Anurag Pradhan and Branch Manager of RI, Koramanagala

Branch mis-sold the aforesaid policy. He further stated that he sent many emails and was

continuously in touch with RI for reversal of his premium to his bank account but the same was

rejected by the RI. He also alleged that the cheque amount and cheque date was mentioned by

representatives of RI themselves.

The Complainant submitted Whatsapp text chat he had with the representative of the RI and the

copy of the complaint letters written to the RI. He requested the Forum for redressal of his

grievance by refunding the premium paid by him.

b. Respondent Insurer’s argument: The Respondent Insurer did not submit the SCN. The repudiation email sent to the Complainant on

17.10.2018 states that his request for cancellation of policy was rejected as it was received beyond

freelook period.


20. The following documents were placed for perusal:- a. Complaint along with enclosures,

b. SCN of the Respondent Insurer along with enclosures and

c. Consent of the Complainant in Annexure VI-A and Respondent Insurer in VII-A.



RI’s contention is that the Complainant failed to approach them within free-look period. In addition

to what was submitted earlier Complainant further submitted that the representative of the RI

approached him offering health insurance along with the life insurance. He stated that he

approached the representative of the RI, Mr Anurag Pradhan immediately after seeing the policy

bond for cancellation of the policy as he was the single point of contact during the solicitation.

When the representative stopped responding to his calls, he approached the RI via emails for

cancellation of the policy. He also stated that the representative pleaded him to withdraw his

complaint as it would jeopardise his job and assured Complainant that he will ensure to get his

premium refunded within one year without fail.

Forum notes that the

1) Policy was procured through bancassurance channel. The banker of Complainant who

solicited the policy and RI are sister concerns.

2) Electronic copy of the policy was sent to the Complainant on 25.08.2018.

3) First written communication from the complainant to the RI vide his email was on

27.09.2018 which is beyond 15 days from the date of receipt of electronic copy.

The Complainant was asked to produce any proof to prove the mis-sale. The Complainant produced

Whatsapp chat with the representative of RI wherein the Complainant is heard as telling the

representative--

“As per your words I trusted you and I was quite that the amount will get reversal after 1 year again

your changing your words this time I’ll not take the same step.”

“If I come to the branch I’ll make issues please understand, at any cost I want the funds back”

“You committed that the amount will get reversal after a year”.

Trusting you is my big mistake.”

In the conversation the representative is seen to be evading stating that--

“Sir, I have spoken to everyone. I don’t know how to do it.”

Thus there is enough evidence by way of Whatsapp chat wherein the Complainant was assured for

refund after one year from the premium payment date and the representative of RI was still trying to

convince him that he is on the job and hiding the fact that it is not possible to refund premium now.

The above facts prove beyond doubt that the Complainant was misled by the representative of RI’s

banking channel partner. RI is vicariously responsible for the acts of the representatives or their

agents and is liable to refund the premium with interest.

AWARD Taking into account, the facts & circumstances of the case, and the submissions made by both the

parties during the course of Personal hearing, the Respondent Insurer is directed to refund the

premium with interest for delayed payment at 6.25% + 2% Penal interest as laid down under

Regulation 14 of IRDAI (Protection of Policy Holders Interest) Regulations, 2017.

The complaint is Allowed.

22. Compliance of Award: The attention of the Complainant and the Insurer is hereby invited to the following provisions of


a. The Complainant shall submit all requirements/Documents required for settlement of award

within 15 days of receipt of the award to the Respondent Insurer.

b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, 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.

Dated at Bengaluru on 25th day of February, 2020




KARNATAKA



In the Matter of MR. SHARATH. N. V/s DHFL PRAMERICA LIFE INSURANCE

COMPANY LIMITED Complaint No: BNG--L--013--1920– 0556

Award No: IO/BNG/A/LI/0434/2019--2020


Complainant

Sri. N. Sharath S/O Niranjan Murthy

# 56, 1st Cross, 1st Main

Niveditha Nagar Mysore - 570022

(M):9739459983


2. Policy No:

Type of Policy:

Name of the Policy:


Period/PPT

Mode/Premium Amount

GC000027019R100/GC000027

Life – Group

DHFL Pramerica Group Credit Life +

01/03/2019

3 Years

Single Premium / ₹.70,870/-



Mr. Niranjana Murthy. M.

M/S. Indus Ind Bank Ltd

4. Name of the Respondent Insurer DHFL Pramerica Life Insurance Company

Limited


6. Reason for repudiation/ Rejection Suppression of material facts


A

07/01/2020

8. Nature of complaint Repudiation of Terminal illness benefit





No

13(1)(b)of Insurance Ombudsman Rules, 2017





Insurer

Mr. Sanjay Agarwal – (S.T.M)

15. Complaint how disposed Partly Allowed


17. Brief Facts of the Case: The complaint is the result of repudiation of ‘Terminal Illness Benefit’ claim by the Respondent

Insurer (RI) on the policy held by the father of the Complainant. Aggrieved, by the repudiation

decision of the RI, he has approached this forum.


a. Complainant’s argument: The Complainant vide his letter dated 19/12/2019 stated that his father obtained two life insurance

housing loan policy out of which one policy claim is ₹. 33,89,289/-, and for the other policy the

claim is ₹. 6,97,500/- . The RI repudiated the ‘Terminal Illness Claim’ under both the policies citing

‘Pre-Existing Illness’. Hence, the Complainant has lodged the Complaint in this Forum seeking

directions to RI to settle the ‘Terminal Illness Benefit’ in respect of said Policy (2nd policy) whereas

he wants to approach the consumer forum in respect of first policy. The RI has repudiated the

‘Terminal Illness Claim’ on the said policy on the grounds of ‘Pre-Existing Illness’ which is

unreasonable. Hence he has approached this Forum seeking resolution to his complaint.

b. Respondent Insurer’s argument: The RI vide their SCN dated 22/01/2020 stated that the insurance contract is a contract of

‘Uberrima Fides’ which is based on the principle of ‘Utmost good faith’. The Life Assured after

duly understanding the terms and conditions of the policy, applied for the issue of the said policy

and the RI has issued the same as per the requirements of the Complainant. The RI received the

claim form from the life assured on 05/09/2019 claiming Terminal Illness Benefit claim’ under both

the policies. The RI conducted an investigation into the said claim, and during the investigation it

came to light that the life insured was suffering from Hypertension, Migraine, Chest Pain, and

Fibromyalgia since February 2014 as confirmed by Medical Report of ‘Apollo BGS Hospital’

Mysore. It is clear from the material on record that the Life Assured was suffering from the said

diseases from 2014 which was prior to the date of commencement of the first policy in 2017.

Disclosure of the material fact is very important criteria for deciding whether to issue the said

policy or not. Even though the RI specifically asked the question about the health and habits of the

life assured, he chose to write ‘NO’ in the proposal form. As the life assured concealed the

material fact, the RI repudiated the said ‘Terminal Illness Benefit’ claim within the circumference of

legal provision and informed the life assured about their repudiation decision vide their mail dated

18/10/2019. The RI quoted various case laws decided by legal and judicial forms in support of their

decision.

Further, the RI averred that the Complainant has filed a similar case in the Consumer Forum on the

same subject and as such as per principle of ‘Res-Subjudice’, the litigation in this Forum is not

maintainable to avoid multiplicity of litigation.

As the Complaint by the Complainant is unjust, unreasonable and devoid of merits, the RI has

prayed for dismissal of the said complaint.

19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017 under Sec 13(1)(b) and



p. Complaint along with enclosures,

q. Respondent Insurer’s SCN along with enclosures and

r. Consent of the Complainant in Annexure VIA &and Respondent Insurer in VII A.

21. Result of personal hearing with both the parties (Observations & Conclusions):

The issue to be decided by the Forum is whether the repudiation of the ‘Terminal Illness Benefit’

claim by the RI is in order.

During the personal hearing on 05/02/2020 the Complainant informed the Forum that his father

availed housing loan from M/S Indus Ind Bank and the Bank Officials advised him to avail the said

policy from the RI as a collateral to the Housing Loan. At the time of issuing the said policy the RI

never subjected the life assured to a medical examination. Further the proposal forms were not

filled by the life assured and he only signed the proposal form. The life assured was not suffering

from any of the dreaded diseases prior to the issuance of the policy as alleged by the RI. The life

assured was diagnosed to have the ‘Terminal Illness’ only on 30/08/2019 which was after the

commencement of the policy and hence the repudiation of the said claim by the RI is unfair and

unjust. The Complainant also averred that the ‘Certificate of Insurance’ issued to the life assured

clearly says that the ‘Terminal Illness Benefit’ is payable. Hence, the Complainant prayed the

Forum to direct the RI to honour the claim as per terms and conditions of the policy. The

Complainant also submitted the case laws which are of similar in nature where other judicial forms

have allowed the benefit of insurance in the favour of policy holders/beneficiaries. The

Complainant reiterated that they had not filed any case in other forum in respect of both the policies

and hence prayed the Forum to decide the case in their favour.

The RI on the other hand reiterated their contention as per their SCN and informed the Forum that

the Complainant had filed a similar case in ‘Consumer Forum’. Further as soon as they received

intimation about the ‘Terminal illness claim’, they conducted investigation into the same, and

during the investigation, it came to light that the life assured was suffering from ‘Pre-Existing

Illness’, and hence they repudiated the ‘Terminal Illness claim’. As the repudiation of the ‘Terminal

Illness Claim’ was in order, they prayed the Forum for dismissal of the said claim.

The Forum after careful scrutiny of the documents and records placed before it, has observed that,

the life assured availed a housing loan of ₹.1,20,00,000/- on 26/12/2017 and the said loan had the

collateral security of an insurance policy for an equal amount vide the Group Insurance Policy

certificate number GC0000270654800 which was issued on 30/12/2017. The said policy was issued

under ‘Plan A’ which covers both the risk of death and the risk of terminal illness. The date of

commencement of both the cover was on 30/12/2017 and ended on 29/12/2019. The said policy

covered the sum assured of ₹.1,20,00,000/- with ‘Terminal Illness Benefit’ of ₹.33,89,289/- . The

Complainant in his complaint letter has informed the forum that he would prefer to challenge the

‘Repudiation Decision’ of the RI in Consumer forum. Hence this Forum has not registered the

Complaint in respect of the said policy. Besides the claim amount was for more than ₹.30 Lakhs.

In addition to the above, the life assured availed a loan of ₹.36,08,000/- on 26/02/2019 and the said

loan is covered by the Group Insurance Policy issued by the RI vide Certificate Number

GC000027019R100 dated 01/03/2019. This policy is before the forum for decision. The Coverage

sum assured under the said policy is ₹.35,00,000/- and the ‘Terminal Illness Benefit’ is for ₹.

6,97,500/-. The coverage commenced under the said policy on 01/03/2019 and the cover expires on

28/02/2022. The beneficiary will be entitled to benefits as mentioned in the Certificate of insurance

subject to the terms and conditions of the Policy. As it is a ‘Group Insurance Policy’ the RI issued

‘Certificate of Insurance’ to the beneficiary i.e. the life assured and ‘The Master Policy’ is issued to

the financial institution i.e. M/S Indus Ind Bank.

On perusal of the terms and conditions of the certificate of insurance it is observed that under plan

‘A’ the life assured is eligible for death benefit and also ‘Terminal illness’ benefit.

The Forum called for the copy of the Master Policy from the RI that was issued to M/S Indus Ind

Bank. Accordingly the RI forwarded the copy of the Master Policy, bearing number GC000027

issued to M/S Indus Ind Bank, on 09/06/2017. On perusal of the policy documents in the ‘Master

Policy under Part C –Specific Terms and Conditions’ it is observed that under Plan ‘A’ & under Plan

‘B’ the benefits as stipulated is payable. It states that the terminal illness benefit shall be payable to

the insured member by the Company subject to fulfilment of the following conditions:-

1. The insured member is diagnosed with terminal illness when the insured member insurance

coverage under the policy is in force;

2. Such terminal illness is certified by two company appointed registered medical practitioners

specializing in the relevant filed of medicine.

3. The insured member is not undergoing any form of treatment other than palliative treatment.

On fulfilment of all the above conditions the Company will pay a lump sum amount equal to 6

Equated Monthly Instalments (EMI)/Monthly Loan instalments as specified in the certificate of

insurance. The ‘Terminal Illness Benefit’ is available only once during the coverage term.

However on death of the insured member, the death benefit as per section Two (a)(a) will also be

payable.

On close observation and scrutiny of the ‘Application for DHFL Pramerica GROUP CREDIT LIFE

+ UIN: 140N039V02’ i.e. the proposal submitted by the life assured while availing the said ‘Group

Insurance Policy’, It is noted that with regard to the questions on health and habits of the life

assured, the life assured has answered as ‘NO’ in the Application form. Further, the proposer/life

assured has warranted the truth of the answers given by him shall be the basis for the issuance of the

said policy and that he agrees that the said form shall constitute part of the application for

insurance(s) and that failure to disclose any material fact known to him may invalidate his

insurance(s) and that in case of ‘Fraud’ or ‘Mis-Representation’ by the said life assured, the policy

shall be cancelled immediately by paying surrender value if any. Subject to the same being

established by the Company in accordance with Sec 45 of the Insurance Act 1938, he undertakes to

make available to the Company and/ or its representatives such records/documents. …..etc.

The Forum observes that ‘Application/Proposal Form’ forms part of policy documents.

The life assured was admitted to the Sparsh Hospital on 01/08/2019 and discharged on 08/08/2019

and was diagnosed to have ‘MANTLE CELL LYMPHOMA- BLASTOID VARIANT STAGE IV

WITH Complex karyotype post first cycle R-CHOP, Culture Negative Febrile Neutropenia and the

treating Doctors vide their certificate dated 30/08/2019 certified that the life assured was at Stage IV

high risk and that he required Chemotherapy followed by bone marrow transplant for his care. The

said disease is in well advanced stage and that he is at the risk of death in next 6 months due to

disease or treatment process. It is a ‘Terminal Illness’ and that he would not be able to pursue his

duties or profession in the future.

The RI on the other hand submitted to the Forum vide the prescription dated 24th August 2016 that

the life assured was K/C/O/ Hypertension & Fibromyalgia. Ongoing through the prescriptions

dated 27/02/2016, 17/07/2015, 02/01/2015, 15/11/2014, 21/10/2014 the life assured was K/C/O of

Hypertension and had dyspeptic symptoms and other illness was on medication for the same. The

Complainant health condition worsened in August 2019 when he was diagnosed for Mantle Cell

Lymphoma vide the discharge summary of Sparsh Hospital dated 08/08/2019 which was subsequent

to the issue of the policy.

The Forum notes that the basic underlying principle of insurance is ‘Uberrima Fides’ which means

‘utmost good faith’. Both the parties to the contract should disclose true and material information

which is binding on the contract. The Complainant did not disclose the ‘Pre-Existing illness of

Fibromyalgia, Hypertension, and was on continuous medication for the same. Had the Life Assured

disclosed true picture of his health conditions to the RI, the underwriting decision of the RI would

have been different. The Forum observes that the Hon. Supreme Court vide their judgement in the

case of Reliance Insurance Company Ltd Vs Rekhaben Naresh Bhai Rathod –Civil Appeal No 4261

of 2019 –Arising out of SLP(C) 14312 of 2015, (under Para 21, 22, 23, 24,25, 26, & 28) has held

that ‘Non-Disclosure of Material information’ rescinds the contract of insurance. To that extent the

Forum concludes that there is ‘Suppression of Material Facts’.

The Complainant’s contention that his father did not fill up the proposal form and he only chose to

sign on the back of it does not come to his rescue. In this connection the Hon. Supreme Court in the

case as mentioned supra has held as under:-

“31 Finally, the argument of the respondent that the signatures of the assured on the form

were taken without explaining the details cannot be accepted. A similar argument was correctly

rejected in a decision of a Division Bench of the Mysore High Court in VK Srinivasa Setty v Messers Premier Life and General Insurance Co Ltd21 where it was held: ― Now it is clear that a person who affixes his signature to a proposal which contains a statement which is not true, cannot ordinarily escape from the consequence arising therefrom 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. If an agent nevertheless does that, he becomes merely the amanuensis of the insured, and his knowledge of the untruth or inaccuracy of any statement contained in the form of proposal does not become the knowledge of the insurer. Further, apart from any question of imputed knowledge, the insured by signing that proposal adopts those answers and makes them his own and that would clearly be so, whether the insured signed the proposal without reading or understanding it, it being irrelevant to consider how the inaccuracy arose if he has contracted, as the plaintiff has done in this case that his written answers shall be accurate.‖

However, the Forum observed that the RI has informed all the terms and conditions of the policy,

benefits payable, SAVE clause of Sec 45 to the Master Policy Holder i.e. M/S Indus Ind Bank i.e.

the Master Policy Holder and not to the beneficiary as the contract of insurance is between the RI

and the master policy holder and not the Life Assured. The beneficiary/life assured is only entitled

to the benefit under the said contract of insurance.

Further the Forum has noted that as per the certificate issued by the Doctors of ‘Sparsh Hospitals’,

the life assured required chemotherapy followed by bone marrow transplant for his care. The Forum

finds that neither of the three conditions of the policy enumerated at page 4 supra are fulfilled by the

Complainant. Hence, the life assured is not eligible for the ‘Terminal Illness Benefit’.

However in the proposal/Application at the end of the proposal form, the Complainant has declared

that in the event of any untrue averment contained in the proposal then the said policy shall be

cancelled by paying ‘Surrender value’ if any subject to the same being established by the Company

in accordance with Sec 45 of Insurance Act 1938.


the parties during the course of Personal hearing, the RI is directed to cancel the said policy

and pay the ‘Surrender Value’ together with interest at 8.25% (6.25% bank rate +2% as per

Regulation 14(iv) of Policy Holders Protection Rules 2017 from the date of Rejection of the

Terminal Illness Claim i.e.08/11/2019 to till the date of payment. .

Hence, the complaint is ‘Partly Allowed’.


c. The Complainant shall submit all requirements/Documents required for settlement of award within 15

days of receipt of the award to the Respondent Insurer.

d. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, 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.


(NEERJA SHAH)

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF M.P. & C.G.


Mr.Brij Kishore Malvia …………………………………………….. Complainant

V/s

LIC of India ………………….………….…………………….………….……Respondent

COMPLAINT NO: BHP-L-029-1920-0389 ORDER NO: IO/BHP/A/LI/ 0264 /2019-2020


Complainant

Mr. Brij Kishore Malvia

Malviya Niwas, Badiyakhedi, Sehore

Madhya Pradesh

2. Policy No:

Type of Policy


351839366

Table No.89-16

13.02.2009



Mr Brij Kishore Malvia

Mr Brij Kishore Malvia


5. Date of Repudiation/ Rejection --

6. Reason for Repudiation/ Rejection --


8. Nature of complaint Financial loss

9. Amount of Claim --


11. Amount of relief sought Rs.15,000/-

12. Complaint registered under Rule Rule No. 13(1)(d) Ins. Ombudsman Rule 2017

13. Date of hearing/place 03.02.2020 at Bhopal


For the Complainant Brij Kishore Malvia

For the insurer Ms Manisha Bhatnagar Manager CRM


Mr. Brij Kishore Malvia (Complainant) has filed a complaint against LIC of India

(Respondent) alleging financial loss with respect to his payment of maturity.

Brief facts of the Case - The complainant has stated that he had taken the above policy from

the Sehore Branch of the respondent company and the policy matured on 31.03.2019. But

due to negligence on the part of the Branch Office, maturity amount was paid to him late in

June, 2019 due to which he faced financial loss. He has written letters to Sr Divisional

Manager and Manager (CRM) in this regard but has got no response so far. This situation has

arisen as policy records could not be seen in the Branch. He has therefore approached this

forum for redressal of his grievance.

The respondent in their SCN have stated that above policy was issued on the life of

complainant on 28.03.2003. Policy matured on 28.03.2019. The requirements along with

policy bond were submitted by PH on 31.05.2019 and maturity payment was made on

03.06.2019. As per rules if the payment is made after 30 days of the date of receipt of

complete requirement the penal interest is payable. The PH has made a complaint in this

regard on 19.06.2019 which was replied on 29.06.2019 by the Branch. The payment is made

as per rules and no penal interest is payable in the matter.

The complainant has filed complaint letter, Annex. VI A and correspondence with respondent,

while respondent have filed SCN with enclosures.

I have heard both the parties at length and perused papers filed on behalf of the complainant

as well as the Insurance Company.

Policy No.351839366 was issued on 28.03.2003 with maturity date as 28.03.2019. As per

SCN, maturity payment was made on 03.06.2019 to the complainant. Thereafter complainant

had sent a letter to the respondent stating that as respondent had made delayed payment hence

interest for delayed period be allowed to him. Respondent, through their letter dated

29.06.2019 which was with reference to complainant’s letter dated 19.06.2019, had informed

the complainant that he had completed the formalities for making payment on 31.05.2019 and

payment was made on 03.06.2019 hence no interest is payable. During hearing representative

of the respondent by referring copy of Dispatch Register of December 2018 has argued that

maturity intimation was sent to the complainant on 04.12.2018 and complainant had

submitted the formalities on 31.05.2019. Photocopy of Dispatch Register of December, 2018

has been filed by the respondent. Complainant has opposed the above argument and argued

that no intimation was given to him except a letter was received in July 2019 in which he was

asked to submit NEFT details, etc. for making payment of the policy. Photocopy of above

letter dated 31.05.2019 has been filed by the complainant which is a reminder letter of


respondent. Mentioning of reminder letter indicates that previously a letter had been sent to

the complainant which as per respondent was dispatched on 04.12.2018. As after receiving

documents and details from complainant on 31.05.2019 payment was made on 03.06.2019

hence there is no delay on the part of the respondent and is not liable to pay interest for the

said delayed period. In the result, complaint is liable to be dismissed.

The complaint filed by Mr Brij Kishore Malvia stands dismissed herewith.

Let copies of the order be given to both the parties.

Dated : Feb 03, 2020 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman

Mr Anubhav Neema ……. .…………………………………..….. Complainant

V/s

Aegon Life Insurance Co. Ltd. ….…………………………….…….Respondent

COMPLAINT NO: BHP-L-001-1920-0413 ORDER NO: IO/BHP/A /LI/ 0276 /2019-2020

Mr Anubhav Neema (Complainant) has filed a complaint against Aegon Life Insurance Co.

Ltd. (Respondent) with prayer of refund of premium with interest.


Complainant

Mr Anubhav Neema

11, Diamond Colony, New Palasia,

Indore

2. Policy No:

Type of Policy


518081632600

Term Plan

31.08.2018



Mr Anubhav Neema

Mr Anubhav Neema

4. Name of the insurer Aegon Life Insurance Co.Ltd.




8. Nature of complaint ECS Mandate taken without consent, not being

stopped inspite of request and refund of

premium



11. Amount of relief sought Refund of premium+ Interest+ Legal Charges

12. Complaint registered under Rule Rule No. 13(1)(f) Ins. Ombudsman Rule 2017



For the Complainant Mr Kushal Kalyani, Friend

For the insurer Absent

15. Complaint how disposed Partially allowed


Brief facts of the Case - The complainant has stated that he had applied for term plan but

company’s representative has filled the form and got it signed from him without his

knowledge. The company should have sent him copies of all the signed documents during 15

days free look period but they did not do so. Before debiting ECS respondent should have

informed him atleast 7 days before but they did not do so. He had submitted ECS stop request

with company. He through his manager, Mrs Sangeeta Kalyani contacted the representative of

the company from 21st to 28th August for confirmation whether there is ECS Mandate or not

and she confirmed that there was no ECS mandate in the policy. Even though an amount of

Rs. 19,088/- was debited from his account on 31.08.2019 through ECS. He complained to the

respondent but they are not at all interested to admit their fault. He has therefore approached

this forum for redressal of his grievance.

The respondent in their SCN have stated that proposal for above policy was submitted

online and had been verified by OTP which was sent to complainant’s mobile number on

16.08.2018. Since the proposal is an online proposal there is no question of any fraud or

forgery of any signature on the proposal form, nor does any issue arise on account of mis-

selling. The complainant himself submitted ESIC application form dated 24.08.2018. In the

present case NACH request was processed whereby it is evident that there is no signature

mismatch and signatures have been done by the account holder. After going through the key

benefits complainant chose to avail the said policy. Complainant has never approached the

company within free look period. First time he has submitted request for cancellation of

NACH / ESIC on 12.10.2019. Complainant is aware that he has mentioned his bank details

and opted for NACH while applying the policy. The complainant approached the company

with a request to cancel the policy only on 24.10.2019 i.e. almost after a year from the

issuance of policy which is very much beyond free look period. The policy was issued in

August 2018 and the policy bond had been delivered at the address of the policyholder.

Moreover complainant earlier opted for higher sum assured of Rs.2crore with premium

amount of Rs.31,388/- however for best reason known to him has reduced premium amount to

Rs.19,088/- for sum insured of Rs.1.10 crore which proves that customer is very much aware

of policy terms and conditions.



During hearing respondent company remained absent. I have heard the representative of the

complainant and perused papers filed on behalf of the complainant as well as the Insurance

Company.

Policy No.518081632600 was issued to the complainant on 31.08.2018 and complaint has

been filed for refund of premium along with interest, legal expenses and mental harassment.

Respondent had sent a mail dated 14.02.2020 in which it has been mentioned by the

respondent that since their representative failed to appear they will settle the case by

refunding the premium. Hence with this email, it is clear that respondent is ready to refund the

premium deposited under the policy. As per respondent, complainant had filed a complaint

before the respondent on 24.10.2019 for cancellation of policy almost after one year from the

issuance of the policy and complainant had reduced Sum assured and premium amount after

issuance of policy. Hence it is clear that complainant was aware of the terms and conditions of

the policy. As the complainant had prayed for cancellation after the expiry of free look period

hence interest and legal expenses are not payable. With respect to mental harassment,

evidence is required, to which this forum has no right hence, question of mental harassment

cannot be considered by this forum. In the result, complaint is liable to be allowed partially to

the extent of refund of premium.

The complaint filed by Mr.Anubhav Neema is partially allowed with directions to the

respondent to refund the premium deposited under the policy within 30 days from the date of

receipt of this award.




Mrs Shruti Jain ..……..……………………………………….. Complainant

V/s

Kotak Mahindra Old Mutual Life Ins Co.Ltd ........................……Respondent



Complainant

Mrs Shruti Jain

W/o Late Shri Sandeep Jain

E-6/MIG 23 Arera Colony, BHOPAL

2. Policy No:

Type of Policy


9033681, 9034136

Kotak Preferred Smart Life plan

30.10.2018, 30.10.2018



Mr Shashwat Jain / Ms Shreshta Jain

Mr Sandeep Jain

4. Name of the insurer Kotak Mahindra Old Mutual Life Ins Co.Ltd


6. Reason for Repudiation/ Rejection Non disclosure of material facts at the time

Mrs Shruti Jain (Complainant) has filed a complaint against Kotak Mahindra Old Mutual Life

Ins Co.Ltd (Respondent) alleging non-waiver of premiums.

Brief facts of the Case - The complainant has stated that after the death of her husband

(policyholder) on 21.05.2019 she requested the respondent to waive the premium under both

the policies as per the policy terms but respondent has rejected saying no medical conducted

during application on said policy while the policyholder had given all required information

asked by the Agent and required for the application. She has therefore approached this forum

for redressal of her grievance.

The respondent in their SCN have stated that the above policies were issued on

30.10.2018 to the DLA on the basis of the proposal forms submitted by him and the policy

holder had also opted for Life Guardian Benefit Rider which provides for waiver of future

premiums liability in event of death of policyholder subject to terms and conditions of the

policy. DLA died on 21.05.2019 and claim intimation was received on 17.07.2019 informing

the death of the policy holder and thus requesting to waive the rest of the premiums due under

the policy. In order to verify the authenticity of the said claim, it was investigated and it was

found that the deceased policy holder who was covered under Life Guardian Benefit was a

diagnosed case of Coronary Artery Disease, Triple Vessel Disease, Hypertension, Type II

Diabetes Mellitus, Left Ventricular LV Dysfunction and was undergoing treatment for the

same prior to the date of signing the proposal form. The existing medical history of the

deceased policyholder were not disclosed at the time of application of the proposal there by

denying the chance of fair assessment to the company for evaluation of risk. Though there

were specific questions in the proposal form regarding the medical history, the details of the

existing medical history were not disclosed by the DLA at the time of proposal. If the

policyholder failed to disclose true and correct material facts to the insurer, then the policy

obtained by the policyholder stands vitiated and the policy holder or any person claiming

of issuance of policy


8. Nature of complaint Non waiver of premium for policies



11. Amount of relief sought Only premium waiver as per policy




For the Complainant Mrs Shruti Jain and Mr M K Jain,

Complainant & Father in law

For the insurer Ms Shweta Joshi, Manager



under it is not entitled for any benefits under the policy. Further the claimant at the time of

intimation of the claim has also misrepresented details regarding pre-existing medical history

of the client by stating that they were not in possession of any medical records and the client

was not suffering from any pre-existing medical disease as per the claim intimation form.

Thus it is evident that even the claimant has attempted to suppress the correct medical history

from the company by providing misleading facts and hence claim was repudiated on

19.08.2019.



I have heard both the parties at length and perused papers filed on behalf of the complainant as

well as the Insurance Company.

Policy Nos.9033681 and 9034136 were taken by the DPH on the life of Mr Shashwat Jain and

Ms Shreshta Jain on 30.10.2018. Deceased policy holder expired on 21.05.2019 and after

death of DPH, complainant/mother of both the insured had applied through claim for waiver of

premiums under both the policies which were repudiated by the respondent stating non-

disclosure of material facts relating to previous ailments of DPH at the time of issuance of

policies. The representative of the respondent has argued that on investigation it was found

that the deceased policyholder was a diagnosed case of CAD, Triple Vessel Disease,

Hypertension, Type II Diabetes Mellitus, Left Ventricular Dysfunction and was undergoing

treatment for the same prior to the date of signing the proposal. Patient’s case file of Akshaya

Hospital shows that patient / DPH was brought to the hospital on 21.05.2019 at 07.15 AM and

expired at 07.30 AM. In patient case file it has been mentioned by the Hospital that DPH was a

k/c/o CAD, HTN, DM along with Post CABG 2014. It is also mentioned in case file that DPH

was operated for CABG in 2014 at Medanta Hospital, Gurgaon. Discharge Summary of

Medanta Global Health Private Limited shows that DPH was admitted on 08.03.2014,

discharged on 29.03.2014 and was diagnosed with Coronary Artery Disease, Triple Vessel

Disease, Hypertension, Type II Diabetes Mellitus and LY Dysfunction and underwent CABG

on 10.03.2014. Policies incepted on 30.10.2018 and from above medical records it is

established that DPH was suffering from above ailments prior to signing the proposal forms

and above ailments were pre-existing. Respondent has filed proposal forms of the policies in

which DPH had denied of having Hypertension, Diabetes, CAD or any form of heart ailment,

LV Dysfunction. Hence it is clear that DPH had not disclosed and suppressed material facts

relating to previous ailments. In view of above facts and circumstances, respondent has rightly

repudiated the claim for waiver of premiums under both the policies and acted in accordance

with the terms and conditions of the policies. In the result, complaint is liable to be dismissed.

The complaint filed by Mrs Shruti Jain stands dismissed herewith.

Let copies of Award be given to both the parties.



Mr Krishna Kant Nagar .………….…………………………………..….. Complainant

V/s

LIC of India ……………………………………….………….…..……… Respondent

COMPLAINT NO: BHP-L-029-1920-0468 ORDER NO: IO/BHP/A/LI/ 0290/2019-2020

Mr. Krishna Kant Nagar (Complainant) has filed a complaint against LIC of India

(Respondent) alleging non payment of maturity amount.


Complainant

Mr Krishna Kant Nagar

174, Alakhdham Nagar

Ujjain, Madhya Pradesh

2. Policy No:

Type of Policy


341999904

New Jeevan Suraksha Policy with profits

13.02.2004









8. Nature of complaint Non payment of maturity amount



11. Amount of relief sought --

12. Complaint registered under Rule Rule No. 13(1)(d) Ins. Ombudsman Rule 2017



For the Complainant Mr Krishna Kant Nagar

For the insurer Mr Ajab Rao Sonare, A.O.



Brief facts of the Case - The complainant has stated that he had taken above policy from

Dussehra Maidan Branch of respondent company at Ujjain and the policy had matured on

13.02.2019 but he did not get any prior intimation from respondent informing him the same.

He has further stated that at the time of taking the policy he had given his address as 174,

Alkadham but respondent has noted it as Alaknanda Nagar as a result of which he did not get

any correspondence sent by respondent to him due to their mistake. As he was not keeping

good health and developed Hernia, on 18.04.2019 he requested respondent to make him

lumpsum payment of maturity sum under the above policy but the same was rejected by the

respondent. Thereafter he visited the Branch Office Ujjain of respondent company when he

was informed that they had sent letter dated 09.08.2019 but the same was not delivered to his

address as respondent had noted wrong address in the policy. Finally respondent on their own

surrendered the policy and adjusted the same by way of giving pension. But entire mistake is

on the part of the respondent company as they had noted the address wrongly in their records.

As he had to undergo Hernia operation and is in need of money, he has approached this forum

for redressal of his grievance.

The respondent in their SCN have stated that the said policy is basically annuity pension

policy and it is mentioned in the policy bond itself. As per policy condition, there is no

provision of maturity or payment of lmpsum amount as there is no maturity date for policy.

Under this policy there is vesting date which indicates when the policy will be vested in the

name of annuitant. All details like date of vesting, date of first annuity, date of last premium

payment, payable for how many years, etc. is already mentioned clearly in the policy bond.

There is provision in the policy that it can be surrendered after payment of 2 full years

premium, but before the vesting date. In the instant case, policy holder has never submitted

any application to surrender the policy. Policyholder was informed regarding various pension

options available vide registered letter dated 30.11.2018 (Reg. No.EI965272223IN( i.e. before

date of vesting 13.2.2019 and 06.03.2019 (Reg No.EI9559772061IN). But both the letters

retuned undelivered. Policyholder submitted letter on 23.04.2019 stating that the policy was

assigned to Bank of Maharashtra and had not submitted loan repayment papers to LIC for re-

assignment and requested for lumpsum amount of policy due to medical reasons and

submitted medical documents. Subsequently LIC informed policy holder on 09.08.2019 that

the policy cannot be surrendered after vesting date and requested to submit option letter for

pension, which was delivered to the policyholder by hand on 23.08.2019. The policyholder

thereafter submitted letter dated 26.08.2019 stating that the address on the policy document is

incorrect. The life assured is paying premium since 15 years, but has never pointed out the

problem in address. Policyholder is educated and was working in Bank as Class I Officer and

has paid premium for 15 years. He has purchased the policy knowing full that it is annuity

pension plan and complaint submitted by him for lumpsum payment is after thought.





Complainant was issued Policy No.341999904 under Plan New Jeevan Suraksha with profits

with Table No.147-15 on 13.02.2004. The Plan is a deferred annuity plan. The date of vesting

of annuity was 13.02.2019. The complainant was eligible to receive annuity from the date of

vesting. As per special provisions No.3 of the policy conditions, on survival to the vesting

date, the annuitant will receive annuity at rates as applicable to the version of the New Jeevan

Akshay plan current at the time of vesting and the option for the annuity type is to be

exercised atleast 6 months before the date of vesting. As per condition No.7 of the policy, this

policy can be surrendered for cash at any time after the completion of two years from the date

of issue but before the date on which the annuity vests. As per policy conditions, there is no

provision of maturity or payment of lumpsum amount. As per SCN, the policyholder was

informed regarding various pension options available vide registered letter dated 30.11.2018

(Regd. No.EI965272223IN) i.e. before date of vesting 13.02.2019 and another letter on date

06.03.2019 (Regd.No.EI9559772061IN). Both letters were returned undelivered. The

complainant had raised issue of minor mistake in address in policy record. The complainant

has also stated that the policy was assigned to Bank of Maharashtra and has not been re-

assigned. The representative of the respondent has contended that the complainant was in

receipt of the policy document 15 years before and had been paying premium for 15 years.

The address was printed on the premium paid receipts as well for the past 15 years. During all

these years, the complainant had never complained of minor mistake in address in the policy

and never approached respondent for correction in the address. The complainant submitted

letter on 23.04.2019 (after the date of vesting) and requested for lumpsum amount of policy,

due to medical reasons and submitted medical documents. The respondent informed the

complainant on 09.08.2019 that policy cannot be surrendered after date of vesting and

requested to submit option letter for pension which was delivered to the complainant by hand

on 23.08.2019. The complainant has not submitted the option letter for receipt of annuity.

Under the circumstances, the respondent has acted in accordance with above terms and

conditions of the policy and requires no interference by this forum. In the result, complaint is

liable to be dismissed.

The complaint filed by Mr Krishna Kant Nagar stands dismissed herewith.




Mr Anand Agrawal ……. .…………………………………..…….. Complainant

V/s

LIC of India ..….……………….…………………….….…………..Respondent


Mr Anand Agrawal (Complainant) has filed a complaint against LIC of India (Respondent)

with prayer to close the loan of the impugned policy and to get him original policy bond.

Brief facts of the Case - The complainant has stated that he had got the above policy from

Ganjbasoda on 28.01.2002 and till today he has not got the policy bond. On 14.01.2008, loan

for an amount of Rs.90,000/- has been released by the Branch for which he has not given any

application and neither he has been informed about it by the respondent. This year when he

had linked his mobile number to the policy, he got information that an amount of

Rs.2,60,000/- is due from him as on date towards the loan taken by him. He had therefore


Complainant

Mr Anand Agrawal

HDFC Bank Near Mill Road

Ganjbasoda, Madhya Pradesh

2. Policy No:

Type of Policy


351691266

112-25

28.01.2002



Mr Anand Agrawal

Mr Anand Agrawal





8. Nature of complaint Loan against policy given by LIC was not

taken by complainant and policy bond not

received



11. Amount of relief sought --




For the Complainant Mr Anand Agrawal

For the insurer Ms Manisha Bhatnagar, Manager (CRM) &

Ms Usha Seetaraman, Manager (Admn.), B.O.

Ganjbasoda



written to the respondent to give him details as to what type of loan has been sanctioned. Till

26.12.2019 he has not got any response from the respondent. He has therefore approached this

forum for redressal of his grievance.

The respondent in their SCN have stated that policy No351691266 was issued on the

life of the complainant on 28.01.2002. Loan of Rs.90,000/- was availed under policy on

14.01.2008 and cheque No.6492 was prepared vide transaction No.5590 Vr dated 14.01.200.

The loan amount Rs.90,000/- was adjusted in BOC 4609, Mr Anand Agrawal dated

14.01.200. BOC was further adjusted towards policy No.352629778 under Plan 181-20 with

single premium of R.90,000/- on the life of the complainant. Loan was issued on the receipt

of application and policy bond from the policy holder. Loan application is not available but

policy bond is available in Branch. Policy No.352629778 was surrendered on 31.12.2013 and

Surrender value of Rs.98,609/- was paid vide transaction No.8595 dated 31.12.2013. Out of

this, an amount of Rs.68,609/- was again utilized towards issue of BOC No.5700 dated

31.12.2013 which was further adjusted issue of policy No.301501647 single premium on the

life of the Shri Anand Agrawal and balance amount of Rs.31,718/- was refunded to him vide

cheque No.26640 on 18.01.2014. The cheque was encashed in the account of the Shri Anand

Agrawal. For policy 301501647 proposal form was filled by the complainant and all

necessary documents like KYC, Photo ID etc. were given by him. Under policy 301501647

SB of Rs.15,000/- was paid through NEFT in his registered account of PNB on 18.12.2016.

Loan amount of Rs.90,000/- u/p 351691266 was disbursed on receipt of loan application form

and policy bond from PH. Loan amount of Rs.90,000/- and S.V. amount u/p 352629778 was

reinvested in the policies on the life of the Shri Anand Agrawal.





Complainant has complained that he took policy No.351691266 from LIC of India on

28.01.2002 and he is not in receipt of the policy bond till date. He has come to know in

September, 2019 through an SMS form LIC that a loan of Rs.90,000/- has been obtained on

this policy. He did not have any information about the said loan and has requested the

respondent to give full details of the loan but no documents were provided to him. Stating

above, complainant has prayed for giving policy bond of policy No.351691266 and to close

the loan stated to have been given by the respondent. Respondent in their SCN have stated

that impugned policy was issued to the complainant on 28.01.2002 and a loan of Rs.90,000/-

was availed by the complainant on 14.01.2008 against this policy. The entire loan amount of

Rs.90,000/- was adjusted towards purchase of new single premium policy No.352629778 in

the name of complainant under plan and term 181-20. They further stated that this policy

No.352629778 was surrendered on 31.12.2013 and a surrender value of Rs.98,609/- was paid

out of which Rs.66,891/- was again utilized towards issuance of a new single premium policy

No.301501647 in the name of the complainant and the balance amount of Rs.31,718/- was

refunded to the complainant through cheque No.26640 dated 18.01.2014 which was encashed

by the complainant. Under policy No.301501647 they have paid survival benefits of

Rs.15,000/- through NEFT in complainant’s registered account of PNB on 18.12.2016.

Complainant during hearing has filed a written statement wherein it is mentioned that policy

No.352629778 for Rs.90,000/- was purchased by him by making payment of premium in cash

which was surrendered in 2013 and he had received an amount of Rs.31,718/- through cheque

and out of remaining amount of Rs.66,891/- he had purchased a new policy No.301501647.

He has further mentioned that he has received two survival benefits of Rs.15,000/- each

under policy No.301501647.

In complainant’s written statement filed at the time of hearing it is stated by the complainant

that it was in his knowledge that policy bond of policy No.351691266 might have been

received in 2002 by his cousin, Mr Vinod Agrawal his agent. It is pertinent to mention that

complainant had raised concern over non receipt of policy bond of policy No.351691266 after

a period of 17 years. During hearing also complainant has accepted that the policy was with

Mr Vinod Agrawal, Agent / cousin brother. Representative of the respondent has argued that

loan is processed only after the receipt of loan application and original policy bond from

policy holder and during hearing has shown original policy bond of policy No.351691266

(with endorsement of loan payment of Rs.90,000/-) which is in their custody as loan is

outstanding against this policy. A photocopy of bond bearing No.351691266 has also been

filed by the representative of the respondent. Raising concern after 17 years with respect to

non-receipt of policy bond and now admission by the complainant that policy bond was with

the Agent / his cousin corroborates the facts stated by the representative of the respondent. It

has also been admitted by the complainant that policy No.352629778 for Rs.90,000/- was

purchased by him by giving cash and the same was surrendered by him in 2013 and utilized

the portion of the surrendered amount to purchase another new policy bearing No.301501647

and the balance amount was received through cheque. It is also admitted by complainant that

in policy No.301501647 he had already received two Survival Benefit payouts. From the

version of both the parties, the bone of contention is that whether policy No.352629778 was

purchased by paying single premium of Rs.90,000/- out of loan proceeds against policy

No.351691266 as stated by respondent or by making cash payment as stated by the

complainant. In SCN respondent has stated that after sanctioning loan against the policy,

proceeds were issued with cheque No.6492 vide Transaction No.5590 dated 14.01.2008

(printout of voucher enquiry filed by respondent) which was utilized for purchase of new

policy No.352629778. The premium collection received for this policy No.352629778 was

vide BOC No.4609 dated 14.01.2008 for Rs.90,000/- received by cheque (Printout of BOC

collection / adjusted details as per office records filed by respondent). The complainant has

not filed any evidence showing that policy No.352629778 was purchased in cash. The

representative of the respondent has argued that as the matter of taking of loan is of year

2008, loan application is not traceable at this point of time and however efforts are being

made to trace it. The complainant has mentioned in his complaint that loan was raised without

his application and in connivance with the agent and Branch Manager of the respondent. This

contention leads towards some criminal act / fraud which cannot be considered by this forum.

Hence under the circumstances and above allegation of the complainant, this forum cannot

consider the prayer of closure of loan. For his above allegation and closure of loan,

complainant may seek remedy from a Competent Court. In the result, complaint is liable to be

dismissed.

The complaint filed by Mr Anand Agrawal stands dismissed herewith.




PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017) OMBUDSMAN - Shri I. SURESH BABU

Complaint Ref. No.HYD-L-036-1920-0552, 0553 Award No. IO/HYD/A/LI/0279 & 0280 /2019-20

1. Name & address of the complainant Mr.M.B.Gopala Krishna Plot No.5, Old Vasavinagar Community Hall, Karkhana, Tirumalgherry Hyderabad- 500015

2. Policy No./Collection No. Type of Policy Policy term/Premium paying period

51621343, 51776811 Reliance Smart Pension Plan 10Years/15 Years

3. Name of the Policy holder Mr.M.B.Gopala Krishna

4. Name of the insurer Reliance life insurance Co Ltd.

5. Date of rejection 18/10/2019

6. Reason for Rejection As per conditions of policy.

7. Date of receipt of the Complaint 30/10/2019

8. Nature of complaint Mis sale of policy.

9. Amount of Claim Fund value on both the policies.


11. Amount of Relief sought Fund value on both the policies.


Rule No 13.1. ( d) of Insurance Ombudsman Rules

13. Date of hearing/place 29/01/2020/Hyderabad


a) For the complainant Self

b) For the insurer Mr.J.Sudhakar, Senior Executive.


16. Date of Order/Award 06/02/2020

17) Brief Facts of the Case:

Mr. M.B.Gopala Krishna filed a complaint stating that the insurer has wrongly

rejected his request for surrender of his policies and payment of total fund value in one

lumpsum.

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and

so it was registered.

18) Cause of Complaint: Mis sale of his policies.

a) Complainants argument:

Mr.M.B.Gopala Krishna took two insurance policies from Reliance Life Insurance

Company in June 2014.He paid premiums for two years and later discontinued payment

of premiums. He approached the insurance company after five years and requested the

insurer to pay the fund value but his request was rejected stating that only one third of the

fund value would be paid and he has to take pension policies for the balance amount.

Feeling cheated he decided to complain as he was assured by the agent while selling the

policies that he can get the total fund value if the surrenders the policies after five years.

b) Insurer’s argument:

Two Insurance policies bearing numbers 51621343 and 51776811 were issued to

Mr.Gopala Krishna on 09/09/2014after receiving the first premium along with the duly

signed and completed proposal forms. On 02/12/2019 he approached the company with

the request to surrender his policies and pay the total fund value of his policies. As per

conditions of the policy, one third of the fund value could be commuted and an annuity

policy would be issued for the balance amount. The same was informed to him.

19) Reason for Registration of Complaint:- Mis sale of policies.


a)Request letter by complainant to Insurance company.

b)Reply by Insurance company

c)Complaint letter by the complainant to Ombudsman

d) P form by the complainant.

21) Result of hearing with both parties (observations & conclusion):

Pursuant to the notices issued by this office both the parties attended the hearing

held at Hyderabad on 29/01/2020

On close consideration of submissions made by both the parties during the course

of personal hearing, it was observed that an agent of Reliance life Insurance

approached the complainant and marketed an insurance policy. While selling the policy

the agent told him that,he may withdraw the fund value at the end of the fifth

year.Trusting him, the complainant took two policies with himself as the proposer and his

wife as the life assured. He took one policy with Rs.1,00,000/- as the annual premium and

the other policy with an annual premium of Rs.3,00,000/-. He paid premiums for two years

and stopped paying premiums from the third year. As advised by the agent he approached

the insurance company after five years of taking the policies and requested the insurer to

pay the fund value. He was informed by the insurer that he would get only one third of the

fund value and he has to take a pension policy for the balance amount. As he was sold the

policies with an assurance that he would get the total fund value after five years, he

approached Mr.Dasari Ramesh,Branch Manager of the insurance company who was

instrumental in marketing the policy to him. Mr.Dasari Ramesh assured him that he would

followup with the concerned authorities and see that he would get the total fund value.

Then, the branch manager gave a mail to the customer service centre of the insurance

company informing that the policy was sold by their sales team with an assurance that the

amount could be withdrawn after five years. It was clear from the mail that the complainant

was sold the policy with the assurance that he could withdraw the total fund value after five

years as the branch manager himself had stated in his mail that the policy was sold with

that assurance. Even in the policy bond it was no where mentioned that only one third of

the fund value would be paid but it was only mentioned that the surrender value would be

paid to the extent allowed by the Income tax regulations. Had the complainant been

informed that only one third of the fund value would be paid and he has to necessarily take

a pension policy for the balance amount, he would not have taken the policy at all.

In view of the above Forum feels that the complainant may be paid the total fund

value on both the policies.

AWARD

Taking into account the facts and circumstances of the case and submissions made by

both the parties during the course of personal hearing the insurer is directed to pay the

total fund value on both the policies in one lumpsum to the complainant.

In result the complaint is allowed.

Dated at Hyderabad on the 6th day of February 2020.

( I SURESH BABU )

INSURANCE OMBUDSMAN FOR THE STATES OF A.P.

TELANGANA AND CITY OF YANAM


(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

OMBUDSMAN - Shri I. SURESH BABU

Complaint Ref. No. HYD-L-009-1920-0519

Award No.IO/HYD/A/LI/0306/2019-20

1. Name & address of the complainant

Ms.Tahera Khan 17-3-118/26/1, Yakutpura colony, Imambada Hyderabad-500024

2. Policy No./Collection No. Type of Policy Premium paying term/Policy Term

005986762 BSLI Vision Plan- GSB Pay 18 18 years/60 years


Ms.Tehara Khan

4. Name of the insurer Birla Sun Life Insurance Company Ltd

5. Date of Rejection by Insurer 23/07/2019

6. Reason for rejection Policy Terminated.


8. Nature of complaint Mis sale

9. Amount of Claim Rs.47,544/-


11. Amount of Relief sought Rs.47,544/-


Rule No.13.1(f) Insurance Ombudsman Rules.



a) For the complainant Ms.Reshma Khan, Daughter of complainant.

b) For the insurer K.Srikanth, Senior Executive.




Ms.Tahera Khan complained that the insurer had wrongly terminated her

policy without giving any intimation.

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017

and so it was registered.

18) Cause of Complaint: Policy terminated without intimation..

a) Complainants argument:

Ms.Tahera khan took an insurance policy from the insurer on 05/03/2013 after

paying the first annual premium of Rs.47544/-. The representative who marketed the

policy toild her that standing instructions were given to Karur Vysya bank to recover the

premium from her accont and credit to the account of Birla life insurance company. Due to

ill health she was not able to verify if the amount was being recvovered from her account

or not. On 23/07/2019 she approached the insurance company and enquired about the

status of her policy. She was schoked to be informed by the insurer that her policy has

been terminated by the insurer stating that the premiums were not received from her. She

requested the insurer to refund the first premium paid by her as she did’nt receive any

reminder notice from the insurer for payment of premium or termination of policy. The

insurer rejected her request stating that the policy was tereminated as per terms and

conditions. Hence, she decided to complain with the Insurance Ombudsman for justice.


An insurance policy bearing number 005986762 was issued to Ms.Tehera Khan

on 05/03/2013 after receiving the duly signed and completed proposal form along with the

first annual premium of Rs. 47,544/- . A lertter dated 23/07/2019 was received from the life

assured requesting for information regarding the status of her policy. As the renewal

premiums on the policy were not received since 2014 onwards, the policy was terminated

in 2016 as per conditions of the policy and the same was informed to her.

19) Reason for Registration of Complaint: Termination of policy by insurer without

intimation.


a) Complaint letter to the insurer.

b) Rejection letter by the insurer.

c) Complaint letter by the complainant to the ombudsman.

d) Self contained note by the insurer.

21) Result of hearing with both the parties (observations & conclusion) :

Pursuant to the notices issued by this office representatives of both the parties

attended the hearing held in Hyderabad on 22/01/2020.


of personal hearing, it was observed that, the life assured Ms.Tahera Khan had an SB

account with Karur Vysya bank. As the bank had a tie up with Birla Life Insurance

company, she was persuaded by the bank representatives to take an insurance plan from

Birla life insurance company. As she was not much educated and studied only upto 10th

class, she just signed in the proposal form which was later filled by the representative. It

was observed that the policy was issued with a policy term of 60 years( when the life

assured attains 100 years age). Issuing a policy to a women of 40 years age with a policy

term of 60 years was a mis sale. Had she been informed that the policy term was 60 years

she would have not taken the policy at all. During the course of hearing the complainant

was questioned as to why the further premiums were not paid after paying the first

premium. The complainant stated that, the representative had informed that, the

premiums would be recovered from the bank account every year. It was observed from the

copy of the proposal form that the option for direct deduction of premium from bank

account was not given. As the proposal was not filled by the life assured it was clear that

the representative informed the life assured that premium would be recovered from her

bank account directly but ticked the option of direct payment . As the source of income of

the life assured was mentioned as ‘Rental income’ in the proposal from, it was clear that

she did’nt have any dependents as the rental income would continue even after her.

Issuing a life insurance policy to a woman who did’nt have any dependents on her income

was itself a mis sale. Instead of a life insurance policy she would have preferred a health

insurance policy, had the details of the policy been explained to her by the representative

while selling the policy. It was clear that the policy was issued to her just to attain the

insurance policies target of the bank.

In the self contained note(Point No.5) the insurer stated that the policy bond was

despatched to the policy holder on 06/03/2013 via courier and the same was delivered to

her on 07/03/2013, but the courier number and courier service through which it was sent

was not mentioned in the self contained note.The complainant had also stated that the

policy bond was not received from the insurer. When the insurer was asked to submit the

acknowledgement of the life assured having received the policy bond, it was stated that

the acknowledgement slip was not available as it was a six year old record. This

contention of the insurer was not at all correct, as the policy bond is the most important

document in an insurance contract. The insurer knew very well that life insurance contracts

are long term contracts and all the records should be preserved till the end of the contract

period. When a record was not maintained properly for six years, then how would the

records be maintained till sixty years, which is the term of the policy?.

The life assured approached the insurer on 20/07/2019 for the status of the policy

and was informed that the policy was terminated for non payment of renewal premium.

The life assured was also informed by the insurer that several communications were sent

to her, reminding her regarding payment of renewal premium. The life assured stated that,

she did’nt receive even a single reminder or notice from the insurer regarding payment of

renewal premium. In the self contained note (point No.9) the insurer stated that, because

of non payment of renewal premium which was due on 05/03/2014, the policy went into

lapsed condition on 05/04/2014, but in the letter dated 23/07/2019 sent to the life assured,

and in several mails sent to her after that letter, the insurer informed that the policy went

into lapsed status on 05/03/2014. It was clear that the insurer was very casual even while

sending important communications to the policy holders. In the self contained note(point

No.9) the insurer had stated that the policy was terminated on 05/03/2016, as the life

assured failed to revive the policy within two years from date of lapsation. When the date

of lapsation was 05/04/2014, then the policy should have been terminated on 05/04/2016

and not on 05/03/2016, but the insurer informed the life assured that her policy was

terminated on 05/03/2016 which was not correct. It was also observed that the insurer

did’nt send any intimation to the life assured before terminating the policy. When the

insurer claims to have sent notices to the life assured for payment of renewal premium, the

insurer should have sent an intimation to the life assured when a crucial decision to

terminate the policy was taken, atleast to give a last opportunity to the life assured for

reviving the policy. It was clear that the insurer was very casual at every stage while

dealing with the policy holder.

It was a clear case of mis sale and the insurer was also not able to submit any

evidence to establish that, the policy bond was delivered to the life assured . Leave alone

acknowledgement of the life assured, the insurer did’nt even submit copies of the

renewal premium reminders, lapsation notices and policy termination intimation sent to the

life assured.

In view of the above Forum feels that the ends of justice would be met if the

premium paid is refunded to the life assured.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by

both the parties during the course of personal hearing the insurer is directed to refund the

premium paid by the life assured.

In result the complaint is dismissed.

Dated at Hyderabad on the 24th day of February 2020

( I SURESH BABU ) INSURANCE OMBUDSMAN

FOR THE STATES OF A.P. TELANGANA AND CITY OF YANAM


(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

OMBUDSMAN - Shri I. SURESH BABU

Complaint Ref. No.HYD-L-043-1920-0577

Award No. IO/HYD/A/LI/ 0307/2019-20

1. Name & address of the complainant Ms.Y.Vijayalakshmi H.No. 6-2-25/16, Gandhinagar, Amalapuram, Andhra Pradesh- 500050

2. Policy No./Collection No. Type of Policy Policy term/Premium paying period

LN110900078795 Sri Ram Sri Vikash plan. 05Years/03Years

3. Name of the Policy holder Ms.Y.Vijayalakshmi

4. Name of the insurer Shri Ram life insurance Co Ltd.

5. Date of rejection by Insurer. 17/07/2017

6. Reason for Rejection Policy Surrendered.


8. Nature of complaint Maturity not paid.

9. Amount of Claim Rs.1,00,000/-


11. Amount of Relief sought Rs.1,00,000/-

12. Complaint registered under Rule No 13.1. ( e) of Insurance Ombudsman Rules



a) For the complainant Self

b) For the insurer Mr.Shiva Shankar, Senior Executive.




Sri. Ms.Y.Vijayalakshmi filed a complaint stating that the insurer has not paid the

maturity amount of her policy in spite of repeated requests.

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and

so it was registered.

18) Cause of Complaint: Maturity not paid.

(a)Complainants argument:

Ms.Y.Vijayalakshmi took a single payment insurance policy from Sri Ram life

insurance company on 10/07/2009 after paying the first premium of Rs.50,000/-. She did’nt

receive the policy bond in spite of repeated reminders. After the policy matured, she

approached the insurance company and requested the insurer to pay the maturity amount.

She was informed that the policy was already surrendered. As she did’nt give any

application for surrender at anytime, she informed the same to the insurer and requested

the insurer to inform her the bank account into which the surrender amount was credited

but she did’nt receive any response from the insurer.


An Insurance policy was issued to Ms.Y.Vijayalakshmi on 10/07/2009 after

receiving the duly signed proposal form. A request for surrender of the policy was received

on 17/11/2012 and the surrender value of Rs. 35042/- was paid vide cheque number

061686 dated 21/11/2012. As per the banker’s confirmation the cheque was not encashed

and hence a fresh cheque bearing number 66541 dated 31/03/2013 was issued and the

same was encashed on 26/06/2013. A letter dated 03/07/2019 was received from the life

assured requesting for payment of maturity amount of the policy. As the policy was already

surrendered, the same was informed to her vide letter dated 17/07/2019.

19) Reason for Registration of Complaint:- Maturity amount not paid.


a)Request letter by complainant to Insurance company.

b)Reply by Insurance company

c)Complaint letter by the complainant to Ombudsman

d) P form by the complainant.

21) Result of hearing with both parties (observations & conclusion):

Pursuant to the notices issued by this office both the parties attended the hearing

held in Hyderabad on 05/02/2020.


of personal hearing, it was observed that the agent who sold the policy to the life assured

gave a wrong assurance to her that, if she paid a single premium of Rs.50,000/- she would

get a maturity amount of Rs.1,00,000/- after five years. As she was an uneducated

person, she trusted the agent and paid the premium on 10/07/2009 and signed in the

proposal from which was filled later by the agent. As she did’nt receive the policy bond,

she followed up number of times with the agent and the insurer but did’nt receive proper

response. In the self contained note the insurer stated that policy document was

dispatched to the life assured in time but the insurer did’nt mention the date, courier

number and courier service through which the policy bond was dispatched. The insurer

was also not able to submit the acknowledgement of the life assured having received the

policy document.

As the agent assured that, after five years she would receive the maturity amount,

the life assured approached the insurance company for payment of maturity amount. She

was shocked to be informed by the insurer that her policy was already surrendered and

the surrender cheque bearing number 066541 for Rs. 35041/- was encashed on

26/06/2013. As the life assured neither received the policy bond nor the surrender cheque

she informed the insurer tha,t she had not given any surrender application.

The complainant submitted a copy of her bank statement and it was evident from

the bank statement that she did’nt receive the surrender amount. During the course of

hearing the representative of the insurer was directed to submit details of the bank account

into which the surrender amount was credited. The representative of the insurer informed

that the amount was encashed through Indus Ind bank, Rajamundry by a person with the

same of the life assured but the insurer was not able to submit any other details like

address, ID proof etc, to confirm that the life assured and the person who encashed the

cheque are same. The insurer also stated that, in spite of repeated reminders the bank is

not giving the details of the account holder who has encashed the cheque. The insurer

further, stated that they are proceeding legally against the bank for not giving the details of

the account holder.The representative of the insurer had agreed that some fraud might

have taken place. It was clear that there was lack of proper control on systems and

procedures in company as it was not first time that a policy was being surrendered by a

third person without the knowledge of the concerned life assured.

As the insurer was not able to submit any evidence to establish that the policy bond

was delivered to the life assured and, as the insurer was also not able to submit details of

the account holder who encashed the cheque, Forum feels that ends of justice would be

met if the premium paid by the life assured is refunded.

AWARD

Taking into account the facts and circumstances of the case and submissions made by

both the parties during the course of personal hearing the insurer is directed to refund the

premium paid by the life assured.

In result the complaint is Allowed.

Dated at Hyderabad on the 25th day of February 2020 ( I SURESH BABU)

INSURANCE OMBUDSMAN FOR THE STATES OF A.P.

TELANGANA AND CITY OF YANAM

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF ODISHA

(UNDER RULE NO: 16(1)/17of

THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF (Sri Sukanta Kumar Sahoo Vs. Life Insurance Corporation of India,Cuttack)

COMPLAINT REF: NO: BHU-L-029-1920-0234

AWARD NO:BHU-A/LI/205/2019-2020

1. Name & Address of the Complainant Mr. Sukanta Kumar Sahoo, S/O- Late Gandharba Sahoo

At- Nakhara, Po- Phulnakhara, Khorda 754001

2. Policy No:

Type of Policy


831171194

Life

28.09.2018



Mr. Sukanta kumar Sahoo

- do-

4. Name of the insurer Life Insurance Corporation of India, Cuttack



7. Date of admission of the Complaint 27.08.2019

8. Nature of complaint Request for change of pension option

9. Amount of Claim Change of Option


11. Amount of relief sought Change of Option

12. Complaint registered under Rule no: of

Insurance Ombudsman Rules

13(1)(f)

13. Date of hearing/place 12.02.2020/ Bhubaneswar


For the Complainant Sukanta Kumar Sahoo

For the insurer Sunita Panda

15 Complaint how disposed Under Insurance Ombudsman Rule 17.


17) Brief Facts of the Case:-.The above said policy was purchased by the complainant on 28.09.2018 from the

present insurer. The name of the plan was Jeevan Shanti and it was a annuity plan. As per the policy conditions,

the LA would receive pension at different rates depending upon the option chosen by him at the time of

completion. The policyholder had opted option “F” (Immediate Annuity for life with return of purchase price) at

the time of completion. But, proposal was erroneously completed in option “E” i.e Immediate annuity with

guaranteed period of 20 years. In spite of his several request, correction could not be made. Hence, being

aggrieved he approached this forum for redressal.

The insurer on the other hand submitted SCN stating that this was a clerical mistake made at the time of data

key in. As the local office and Divisional office are not empowered to carry out the rectification of annuity option,

the matter was referred to their higher office along with all the required documents for rectification. The

acceptance and sanction is awaited. As and when the error is rectified, the option would be changed from “E” to

“F” at the branch office subject to refund of difference of annuity already paid to the policyholder.

18) Cause of Complaint:

a) Complainant’s argument:- The complainant stated thatthe above said policy was purchased by him on

28.09.2018 from the present insurer. The name of the plan was Jeevan Shanti and it was a annuity plan. As per

the policy conditions, the LA would receive pension at different rates depending upon the option chosen by him

at the time of completion. The policyholder had opted option “F” (Immediate Annuity for life with return of

purchase price) at the time of completion. But, proposal was erroneously completed in option “E” i.e Immediate

annuity with guaranteed period of 20 years without return of purchase price. In spite of his several request,

correction could not be made.

b) Insurers’ argument:- The insurer on the other hand pleaded that this was a clerical mistake made at the time

of data key in. As the local office and Divisional office are not empowered to carry out the rectification of annuity

option, the matter was referred to their higher office along with all the required documents for rectification. The

acceptance and sanction is awaited. As and when the error is rectified, the option would be changed from “E” to

“F” at the branch office subject to refund of difference of annuity already paid to the policyholder.

19) Reason for Registration of Complaint: - scope of the Insurance Ombudsman Rules 2017.

This is a complaint against non-correction of annuity option by the Insurer.


a) Photo copies of policy documents.

b)Photo copy of representation to Insurer and its reply.

21)Result of hearing with both parties(Observations & Conclusion):- After going through the argument and

submissions made by both the parties it was observed that, the complainant had opted for option “F” as mode of

pension payment in the proposal form. But at the time of data entry, the insurer had erroneously put option “E”

in place of option “F”. The was a clerical mistake made by the insurer which should be rectified immediately.

The policyholder should not be penalized for no fault. Hence, this forum is of the opinion that the insurer should

ensure that necessary correction is made within one month from the date of this award. The insurer is also

advised to recover whatever extra pension paid to him from the future pension.

22) The attention of the Complainant and the Insurer is hereby invited to the following provisions of


a. According to Rule 17(6) of the Insurance Ombudsman Rule 2017, the Insurer shall comply with the

Award within 30 days of the receipt of the award and shall intimate the compliance to the

Ombudsman.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by

both the parties during the course of hearing, it is awarded that the insurer has to ensure

that the necessary correction is effected within one month from the date of this award after

recovering whatever excess pension already paid to him

Hence, the complaint is treated as allowed accordingly.

b. As per rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in the

regulations framed under the Insurance Regulatory and Development Authority of India Act 1999, from the

date the claim ought to have been settled under the regulations, till the date of payment of the amount awarded

by the Ombudsman

c. As per rule 17 (8) of the said rule, the award of the Insurance Ombudsman shall be binding on the

Insurers.

Dated at Bhubaneswar on 12th Feb. 2020

(SURESH CHANDRA PANDA)

INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

PROCEEDINGS BEFORE





CASE OF (Mr. Madan Mohan Deo Vs. LIC of India Cuttack)



1. Name & Address of the Complainant Mr. Madan Mohan Deo, Flat no- 1002

Royal Lagoon, At/Po- Raghunathpur,

Via- Barang, Khurda- 754005

2. Policy No:

Type of Policy


582529230

Life

13.09.2005



Mr. Madan Mohan Deo

- do-

4. Name of the insurer Life Insurance Corporation of India, Cuttack




8. Nature of complaint Non- payment of interest






13(1)(b)



For the Complainant Madan Mohan Deo




17) Brief Facts of the Case:- The above said policy was purchased by the complainant on 13.09.2005 from the

present insurer. This was a money back policy in which 15% of Sum Assured is payable after every 4 years. The

policy matured on 13.09.2017. But after receipt of the maturity claim the policyholder found that the money back

due on 13.09.2009 was not paid to him. On verification the insurer also realized that the same was not paid to the

complainant. Hence, insurer made the payment of money back amounting Rs.7500/- on 10.10.2018. But

complainant is now demanding penal interest on the said amount which was delayed for about 9 years.

The insurer on the other hand submitted SCN stating that the concerned Branch has already paid an amount of

Rs.5057/- towards penal interest for late payment of SB due on 13.09.2009. Hence, the complaint may be

dismissed.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by him on

13.09.2005 from the present insurer. This was a money back policy in which 15% of Sum Assured is payable after

every 4 years. The policy matured on 13.09.2017. But after receipt of the maturity claim the policyholder found

that the money back due on 13.09.2009 was not paid to him. When he approached the concerned officials of CAB

Branch Cuttack they turned their deaf year to his complaint. Finally on verification, the insurer also realized

that the same was not to the complainant. Hence, insurer made the payment of money back amounting Rs.7500/-

on 10.10.2018 but without any intimation to the complainant. But complainant is now demanding penal interest

on the said amount which was delayed for about 9 years.

b) Insurers’ argument:- The insurer on the other hand submitted SCN stating that the concerned Branch has

already paid an amount of Rs.5057/- towards penal interest for late payment of SB due on 13.09.2009. Hence, the

complaint may be dismissed.


This is a complaint against non-payment of interest by the Insurer.




21)Result of hearing with both parties(Observations & Conclusion):- After going through the arguments and

submissions made by both the parties it was observed that the Survival Benefit due in the subject policy on

13.09.2009 was not paid in time. As the policy was serviced and maturity payment made by CAB Cuttack Branch

, the complainant approached the said branch for payment of unpaid survival benefit amount. But in spite of

several requests payment was delayed till 10.10.2018. The complainant was also not intimated regarding the said

payment. He came to know about the payment only when it was credited to his account. Further, the

complainant was also not paid any penal interest on the SB amount which was delayed for about 9 years.

Although, the insurer has paid penal interest of Rs.5057/- the complainant was not intimated regarding the same.

So it appears that, from the very beginning, the policy holder was harassed and kept in dark regarding the

various payments made to him. Even, the complainant also expressed his dissatisfaction over the amount of

interest paid to him. Hence this forum is of the opinion that the insurer should recalculate the interest at the rate

as specified by IRDA and intimate to the complainant in detail.





Ombudsman.




by the Ombudsman


Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE




AWARD


both the parties during the course of hearing, the insurer is directed to recalculate the

interest amount at the rate as specified by IRDA and pay the difference if any. Further,

the insurer is also advised to inform the complainant regarding this interest calculation

and payment in detail.



CASE OF (Mrs. Monalisha Parija Vs. Max Life Insurance co. ltd)



1. Name & Address of the Complainant Mrs. Monalisha Parija, B-107,

Grand Geej Garh Residential Complex,

Civil Lines, Hawa Sadak, Jaipur, Rajasthan 302006

2. Policy No:

Type of Policy


887214161

Life

06.12.2013



Mrs. Monalisha Parija

- do-

4. Name of the insurer Max Life Insurance Co. ltd




8. Nature of complaint Less payment of surrender value

9. Amount of Claim 24 Lakh


11. Amount of relief sought 24 Lakh



13(1)(d)



For the Complainant A K Parija

For the insurer Ananta Kumar Dhal



17) Brief Facts of the Case:-.The above said policy was purchased by the complainant on 06.12.2013 from the

present insurer. The policy term and premium paying term of the policy were 20 & 6 years respectively. The

complainant had paid annual premium @ Rs. 198000/- for 6 years. The policy was purchased from the insurer

through Axis Bank. At the time of purchase, the policy holder was told that both the terms and premium paying

terms of the policy would be 5 years. In addition to it she was also assured that after paying the premium for 3

years she would get around 29.7 lakh as maturity benefit, But after completion she came to know regarding this

discrepancy in policy conditions. In the meantime she was detected of suffering from uterine cancer. As she is in

need of sufficient cash, she wanted to surrender the policy for which she approached the insurer. But to her utter

surprise, she was told that she would get only 600000/- as surrender value whereas she had paid Rs.1188000/-.

Hence , being aggrieved she approached this forum for redressal.

The insurer on the other hand submitted SCN stating that the present complaint under reference is not

maintainable before the Hon’ble Ombudsman as the complainant purchased the said policy out of her own will.

The present complaint appears to be false as the complainant has been in touch with the respondent since the

purchase of the policy. However, the insurer stated that as a gesture of good will and exception the company is

ready to cancel the policy and refund the premium amount paid by the complainant only on medical grounds.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by her on

06.12.2013 from the present insurer. The policy term and premium paying term of the policy were 20 & 6 years

respectively. The complainant had paid annual premium @ Rs. 198000/- for 6 years. The policy was purchased

from the insurer through Axis Bank. At the time of purchase, the policy holder was told that both the terms and

premium paying terms of the policy would be 5 years. In addition to it she was also assured that after paying the

premium for 3 years she would get around 29.7 lakh as maturity benefit, But after completion she came to know

regarding this discrepancy in policy conditions. In the meantime she was detected of suffering from uterine

cancer. As she is in need of sufficient cash, she wanted to surrender the policy for which she approached the

insurer. But to her utter surprise, she was told that she would get only 600000/- as surrender value whereas she

had paid Rs.1188000/-.

b) Insurers’ argument:- The insurer on the other hand stated that the present complaint under reference is not

maintainable before the Hon’ble Ombudsman as the complainant purchased the said policy out of her own will.

The present complaint appears to be false as the complainant has been in touch with the respondent since the

purchase of the policy. However, the insurer stated that as a gesture of good will and exception the company is

ready to cancel the policy and refund the premium amount paid by the complainant only on medical grounds.


This is a complaint against less payment of surrender value by the Insurer.



b) Photo copy of representation to Insurer and its reply.


submissions made by both the parties it was observed that the complainant have paid the annual premium for 6

years as stipulated by the insurer in the policy bond. But she wanted to surrender the policy because of medical

reasons which is genuine too. However, the insurer have considered the case sympathetically and have agreed to

refund the premium as a gesture of good will on medical grounds. Hence, this forum is of the opinion that the

complainant should provide the NEFT details to the insurer so that premium amount would be credited to her

account.





Ombudsman.




by the Ombudsman


Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mr. Sudipta Ranjan Hota Vs. Max Life Insurance co. ltd)



1. Name & Address of the Complainant Mr. Sudipta Ranjan Hota, At/Po- Sason, Sambalpur

Dist- Samblpur- 768200

2. Policy No:

Type of Policy


25860210

Life

08.09.2014

AWARD

Taking into account the facts & circumstances of the case and the submissions made

by both the parties during the course of hearing, it is awarded that the total amount

of premium paid by the complainant is to be refunded by the insurer as full and final

settlement of the complaint.




Mr. Sudipta Ranjan Hota

- do-

4. Name of the insurer Max- Life Insurance Co. ltd.




8. Nature of complaint Less payment of Surrender value






13(1)(d)



For the Complainant Absent

For the insurer Ananta Kumar Dhal



17) Brief Facts of the Case:- The above mentioned policy was purchased by the complainant on 08.09.2014 from

the present insurer. The policy was solicited by Yes Bank which is a corporate agent of the insurer. As per the

policy conditions policy term and premium paying term of the policy were 45 & 7 years respectively. Annual

premium was paid by the LA @ Rs.194000/- for 5 years. As per the complainant, the company had committed to

pay Rs.1121039/- as surrender value in the said policy, but it paid Rs.1055139/- which is less by Rs.65900/-. In

spite of his repeated approach to the grievance cell, his grievance was not considered favorably. So finding no

other alternative, he approached this forum for redressal.

The insurer on the other hand submitted that as per policy conditions, the complainant was paid bonus twice

before the surrender of the subject policy. Total bonus paid to the complainant was Rs. 42613.55. The total

surrender value paid to the policyholder was Rs.1097753.01 which includes the bonus amount already paid to

him. However, the complainant was eligible for annual bonus of Rs.23211.35 for the year 2018. The company is

ready to pay the above said amount to the complainant. Hence, the complaint may be closed.


a) Complainant’s argument:- The complainant stated that the above mentioned policy was purchased by him on

08.09.2014 from the present insurer. The policy was solicited by Yes Bank which is a corporate agent of the

insurer. As per the policy conditions policy term and premium paying term of the policy were 45 & 7 years

respectively. Annual premium was paid by the LA @ Rs.194000/- for 5 years. As per the complainant, the

company had committed to pay Rs.1121039/- as surrender value in the said policy, but it paid Rs.1055139/- which

is less by Rs.65900/-. In spite of his repeated approach to the grievance cell, his grievance was not considered

favorably.

b) Insurers’ argument:- The insurer on the other hand submitted that as per policy conditions, the complainant

was paid bonus twice before the surrender of the subject policy. Total bonus paid to the complainant was Rs.

42613.55. The total surrender value paid to the policyholder was Rs.1097753.01 which includes the bonus amount

already paid to him. However, the complainant was eligible for annual bonus of Rs.23211.35 for the year 2018.

The company is ready to pay the above said amount to the complainant. Hence, the complaint may be closed.


This is a complaint regarding less payment of surrender value by the Insurer.





submissions of both the parties it was observed that the company had paid Rs.1097753/- in place of Rs.1121039/-

as surrender value of the subject policy which is less by Rs.23286/-. The respondent company also submitted that

as per the terms and conditions of the policy the complainant was eligible for annual bonus of Rs.23211 for the

year 2018. The company has also agreed to make the above payment to the complainant. Hence, this forum is of

the opinion that the insurer has to pay Rs.23211/- to the complainant with interest from the date on which is was

due up to the date of this award.





Ombudsman.




by the Ombudsman


Insurers.



INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE





CASE OF (Mrs. Usha Agarwal Vs. HDFC Standard Life Ins. Co.ltd)



1. Name & Address of the Complainant Mrs. Usha Agarwal, W/O- Kishan Kumar Agarwal

Plot no- 1467/4171, Nuasahi, Siripur, Bhubaneswar

2. Policy No:

Type of Policy


16784643

Life

29.05.2014



Mrs. Usha Agarwal

4. Name of the insurer HDFC Standard Life Insurance

AWARD


both the parties during the course of hearing, a sum of Rs.23211/- Rupees Twenty three

thousand two hundred eleven only) along with interest as specified by IRDA from the

date of due up to the date of this award is hereby awarded to be paid by the Insurer to

the Complainant, towards full and final settlement of the claim.





8. Nature of complaint Cancellation of policy






13(1)(f)



For the Complainant Hitesh Agarwal

For the insurer S Panigrahi



17) Brief Facts of the Case:- The above said policy was purchased by the complainant from the present insurer

on 29.05.2014. The Sum Assured of the policy was Rs.3000000/- and annual premium was Rs.10886/-. The policy

term and premium paying term of the policy was 15 years. At the time of purchase the LA had submitted ITR

and occupation details to the insurer. But suddenly after completion of around 3.5 years of the policy, she

received one letter from the insurer wherein it was mentioned that the policy was cancelled and treated as null

and void on account of misrepresentation of occupation and income at the proposal stage. Hence, being

aggrieved she has approached this forum for redressal.

The insurer on the other hand submitted SCN stating that Life Assured is a housewife and dependent on

husband’s income. Since, housewives are restricted from opting term insurance plans, the said policy was

cancelled on account of misrepresentation of income and occupation. A detailed letter dated 25.09.2017 was sent

to the complainant requesting her to return the original policy bond along with NEFT form for refund of total

premium paid in respect of the said policy.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by the

complainant from the present insurer on 29.05.2014. The Sum Assured of the policy was Rs.3000000/- and annual

premium was Rs.10886/-. This was a purely term insurance policy and both the policy term and premium paying

term of the policy was 15 years. At the time of purchase the LA had submitted ITR and occupation details to the

insurer. But suddenly after completion of around 3.5 years of the policy, she received one letter from the insurer

wherein it was mentioned that the policy was cancelled and treated as null and void on account of

misrepresentation of occupation and income at the proposal stage. According to the complainant she had

submitted all the genuine papers along with the proposal. Hence, cancellation of the policy on this ground is a

question on her integrity.

b) Insurers’ argument:- The insurer on the other hand stated after a detailed investigation it was found that Life

Assured is a housewife and dependent on husband’s income. Since, housewives are restricted from opting of such

term insurance plans, the said policy was cancelled on account of misrepresentation of income and occupation. A

detailed letter dated 25.09.2017 was sent to the complainant requesting her to return the original policy bond

along with NEFT form for refund of total premium paid in respect of the said policy.


This is a complaint against unilateral cancellation of policy by the Insurer.





submissions made by both the parties it was observed that the policy was cancelled by the insurer unilaterally

after 3 years from the date of commencement of the policy. During the course of hearing the claimant also denied

to continue the policy any further. Hence, the insurer agreed to refund the total premium paid by the

complainant till the date of cancellation of the policy. The complainant is hereby advised to return the original

policy bond and submit the NEFT mandate to the insurer for return of the total premium paid by him. Hence,

this forum is of the opinion that the insurer has to return the total premium paid by the complainant.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both the

parties during the course of hearing, it is awarded that, whatever premium paid by the

complainant till the date of cancellation is to be refunded by the insurer as full and final settlement

against the complaint.






Ombudsman.




by the Ombudsman


Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mr. Ashok Kumar Rout Vs. Star union Dai Ichi Life Ins. Co.ltd.)



1. Name & Address of the Complainant Mr. Ashok Kumar Rout, C/o- Union Bank of India

Main Branch, 38 Ashok Nagar, Janpath Bhubaneswar

751009

2. Policy No:

Type of Policy


1322271

Life

NA



Mr. Ashok Kumar Rout

- do-

4. Name of the insurer Star Union Dai Ichi Life Insurance




8. Nature of complaint Policy bond not received

9. Amount of Claim Handover of policy bond


11. Amount of relief sought Handover of policy bond



13(1)(g)



For the Complainant Ashok Kumar Rout

For the insurer Vaibhav Srivastav



17) Brief Facts of the Case:- The above said policy was purchased by the complainant from the present insurer.

After completion of all formalities like medical tests etc, the LA received one SMS that the proposal is accepted

and policy no. 01322271 is issued. But till date the policy bond was not issued to the complainant. On verification

it was found that the policy bond was sent to local office of the insurer. Now they are demanding Rs.9000/- extra

for issue of the said policy bond. Hence, being aggrieved, he approached this forum for redressal.

The insurer on the other hand submitted SCN stating that the LA had applied for purchase of the above said

policy along with a proposal deposit of Rs.26125/- on 31.05.2019. From the proposal papers it was observed that

the LA was suffering from diabetes for last 9 years. So, he was asked to undergo medical tests. On 05.06.2019 the

complainant undergone the medical test and it was revealed that he was on oral medication for diabetes for last 3

years. So as per underwriting guidelines specific to the plan proposed, the company raised requirement for

signing “consent for health extra” form and pay an additional premium of Rs.8993/-. Owing to non-fulfillment of

the said requirements the company has refunded the deposited amount of Rs.26125/- on 15.10.2019 through

NEFT. Hence, the complaint may be dismissed.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by him from the

present insurer on 31.05.2019. After completion of all formalities like medical tests etc, the LA received one SMS

that the proposal is accepted and policy no. 01322271 is issued. But till date the policy bond was not issued to the

complainant. On verification it was found that the policy bond was sent to local office of the insurer. Now they

are demanding Rs.9000/- extra for issue of the said policy bond.

b) Insurers’ argument:- The insurer on the other hand pleaded that the LA had applied for purchase of the above

said policy along with a proposal deposit of Rs.26125/- on 31.05.2019. From the proposal papers it was observed

that the LA was suffering from diabetes for last 9 years. So, he was asked to undergo medical tests. On

05.06.2019 the complainant undergone the medical test and it was revealed that he was on oral medication for

diabetes for last 3 years. So as per underwriting guidelines specific to the plan proposed, the company raised

requirement for signing “consent for health extra” form and pay an additional premium of Rs.8993/-. But due to

some technical lag, one SMS was sent to the policyholder regarding the issue of policy. Unless and until the

proposer gives his consent for extra premium and deposit the same policy should not be issued. So the

policyholder was requested to give his consent and deposit the extra premium. Owing to non-fulfillment of the

said requirements the company has refunded the deposited amount of Rs.26125/- on 15.10.2019 through NEFT.

Hence, the complaint may be dismissed.


This is a complaint non- issue of policy bond by the Insurer.





submissions of both the parties it was observed that the complainant was a known case of type2 diabetic. He also

disclosed the same in the proposal papers for which he was asked to undergo some special medical tests by the

insurer. After medical test it was revealed that the proposer was on oral medication for diabetes mellitus for last

3 years. So the company rated up the risk and raised the requirement for signing “consent of health extra” form

and pay an additional premium of Rs.8993/-. However, the insurer admitted that the policy no. was allotted to the

proposal erroneously which was a technical flaw. In spite of several reminder by the insurer the complainant

neither deposited the extra premium nor submitted the consent form for extra premium for which the total

amount deposited by him was refunded on 15.10.2019 through NEFT. Hence this forum is of the opinion that the

complaint is devoid of any merit and should be dismissed.





Ombudsman.

b. As per rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified

in the regulations framed under the Insurance Regulatory and Development Authority of India Act

1999, from the date the claim ought to have been settled under the regulations, till the date of

payment of the amount awarded by the Ombudsman


Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mrs. Asha Singh Vs. HDFC Standard Life Insurance Co. ltd.)

AWARD


both the parties during the course of hearing the complaint is treated as dismissed.



1. Name & Address of the Complainant Mrs. Asha Singh, C/o- Ajaya Singh, C-560, CDA

Sector VIII, Cuttack

2. Policy No:

Type of Policy


10941510

Life

07.03.2007



Mrs. Asha Singh

- do-

4. Name of the insurer HDFC Standard Life Insurance




8. Nature of complaint Non-payment of Surrender value






13(1)(d)



For the Complainant Smt. Asha Singh

For the insurer S Patigrahi




present insurer. This was an unit linked insurance plan with Sum Assured of 4 lakh (Death SA) and extra health

benefit of Rs. 4 lakh. After completion of the policy LA was able to view the status of her policy through online.

But after July 2014 she was not able to view it through online. When she contacted HDFC Branch at Cuttack

Odisha she came to know that her policy was cancelled by the insurer unilaterally without any information to

her. According to her, she had applied for a health claim in the said policy in July 2014 which was denied by the

insurer. So she apprehend that the insurer has cancelled the policy as it came to know from the claim papers that

she was a heart patient. However, the paid-up value of the policy as on the date of cancellation has not been paid

to her till date. Hence, being aggrieved she approached this forum for redressal.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by her on

07.03.2007 from the present insurer. This was an unit linked insurance plan with Sum Assured of 4 lakh (Death

SA) and extra health benefit of Rs. 4 lakh. She has paid 5 annual premiums @ Rs. 20000/- each. After completion

of the policy LA was able to view the status of her policy through online. But after July 2014 she was not able to

view it through online. When she contacted HDFC Branch at Cuttack Odisha she came to know that her policy

was cancelled by the insurer unilaterally without any information to her. According to her, she had applied for a

health claim in the said policy in July 2014 which was denied by the insurer. So she apprehend that the insurer

has cancelled the policy as it came to know from the claim papers that she was a heart patient. However, the

paid-up value of the policy as on the date of cancellation has not been paid to her till date.

b) Insurers’ argument:- The insurer on the other hand pleaded that the policy was brought to paid-up status as

further premium were not paid since 2012. Only 5 annual premiums were paid by the complainant. As further

premiums were not paid and the policy was in paid up status some bode might have suggested her to surrender

the policy. So, now the insurer has refunded the paid-up amount of Rs.200561/- to the complainant through

NEFT, which has been credited to her A/C bearing no. 34349171999 in State Bank of India, Champa. Hence, the



This is a complaint against non payment of surrender value by the Insurer.





submissions of both the parties it was observed that the LA paid 5 annual premiums in respect of the subject

policy. As further renewal premiums were not paid, the policy became paid up. Further, the complainant’s

objection that she was forced to surrender the policy was strongly opposed by the insurer. The insurer pleaded

that as the policy was in paid-up status, somebody might have suggested him to surrender the policy. However,

insurer stated that an amount of Rs.200561/- has been refunded as surrender value of the policy to the

complainant which has been credited to her account through NEFT. Hence, this forum treat the complaint as

disposed of.





Ombudsman.






Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mr. Sabale Chetan Rajendra Vs. Aditya Birla Sun Life Insurance Co. ltd)



1. Name & Address of the Complainant Mr. Sabale Chetan Rajendra, 3rd NDRF BN. Qrtrs No. 08

C Block Mundali, Cuttack- 754006

2. Policy No:

Type of Policy


00705840

Life

10.12.2018



Mr. Sabale Chetan Rajendra

- do-

4. Name of the insurer Aditya Birla Sun Life Insurance


AWARD


by both the parties during the course of hearing, the complaint is treated as disposed

of as the surrender amount of Rs.200561/- has been paid by the insurer to the

complainant.

Hence, the complaint is treated as disposed of accordingly.



8. Nature of complaint Non- refund of premium






13(1)(b)



For the Complainant Sabale Chetan Rajendra

For the insurer Rabindra Maharana




present insurer. He received the policy document in the last week of December. On verification of the policy bond

he found some mistakes which he wanted to be corrected by the insurer. But instead of his repeated requests the

corrections were not effected for which he wanted to cancel the policy in Jan. 2019. But his request was not

entertained on the ground that free look cancelation period was over. Hence, being aggrieved he approached this

forum for redressal.

The insurer on the other hand submitted SCN stating that the company have decided to cancel the subject policy

and refund the total premium of Rs.4304.22 along with interest @ 8.5/ as a gesture of good will. Hence the



a) Complainant’s argument:- The complainant stated that the above said policy was purchased by him on

10.12.2018 from the present insurer. He received the policy document in the last week of December. On

verification of the policy bond he found some mistakes which he wanted to be corrected by the insurer. But

instead of his repeated requests the corrections were not effected for which he wanted to cancel the policy in Jan.

2019. But his request was not entertained on the ground that free look cancelation period was over.

b) Insurers’ argument:- The insurer on the other hand pleaded that the company have decided to cancel the

subject policy and refund the total premium of Rs.4304.22 along with interest @ 8.5/ as a gesture of good will.

Hence the complaint may be dismissed.


This is a complaint against non- refund of premium by the Insurer.





submissions made by both the parties it was observed that, the demand of the complainant to cancel the policy

and refund the premium was genuine and justified. The premiums were directly debited from his bank account

as ECS mandate was submitted by the LA at the time of proposal. But insurer did not bother to make corrections

as required by the complainant. This is a grave negligence on the part of the insurer. However, insurer have

already cancelled the policy and refunded the premium amount with interest. Hence, the complaint stands

disposed.





Ombudsman.

AWARD


both the parties during the course of hearing, the complaint stands disposed.






Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Sri Krushna Chandra Sahoo Vs. LIC of India Cuttack DO)


AWARD NO: BHU-A/LI/223/2019-2020

1. Name & Address of the Complainant Mr. Krushna Chandra Sahoo, At- Rovers Street

Po- Buxi Bazar, PS- Lalbag, Cuttack- 753001

2. Policy No:

Type of Policy


846611101

Life

15.04.2017



Late Kuntala Sahoo

- do-

4. Name of the insurer LIC of India Cuttack DO




8. Nature of complaint Interest not paid






13(1)(b)



For the Complainant Krushna Chandra Sahoo




17) Brief Facts of the Case:- The above said policy was purchased by the wife of the complainant on 15.04.2017.

It was an immediate annuity plan and total amount invested was Rs.500000/-, The mode of pension payment was

yearly. Payment of pension in the said policy had started w.e.f 15.04.2018. But unfortunately LA died on

30.03.2019 and intimation regarding death was given to the insurer on 20.05.2019. The annuity due on

15.04.2019 was paid in time. When death claim was settled in favor of the complainant on 12.06.2019, the pension

due and paid on 15.04.2019 was recovered from the claim amount. The complainant’s claim was that as the

purchase price was held with the insurer for more than one year, he should be paid interest on that amount also.

Hence, being aggrieved, he approached this forum for redressal.

The insurer on the other hand submitted SCN stating that as per rules no proportionate annuity from the date of

last annuity to the date of death is payable. Hence, the amount was recovered from the total claim amount.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by his wife on

15.04.2017. It was an immediate annuity plan and total amount invested was Rs.500000/-, The mode of pension

payment was yearly. Payment of pension in the said policy had started w.e.f 15.04.2018. But unfortunately his

wife died on 30.03.2019 and intimation regarding death was given to the insurer on 20.05.2019. When death

claim was settled on 12.06.2019, the pension due and paid on 15.04.2019 was recovered from the claim amount.

The complainant’s claim was that as the purchase price was held with the insurer for more than one year, he

should be paid interest on that amount also.

b) Insurers’ argument:- The insurer on the other hand pleaded that as per rules, under benefit option “F”, on

death of annuitant annuity ceases and purchase price is returned to the nominee. No proportionate annuity from

the date of last annuity to date of death is payable. If nominee is not able to return the annuity cheques after date

of death or if annuity by way of ECS is credited to bank account after date of death, before settlement of death

claim, said amount of annuity will be recovered from the purchase price. So the complaint should be dismissed.


This is a complaint against non-payment of interest by the Insurer.





submissions made by both the parties it was observed that, as death of the annuitant occurred prior to the due

date of annuity ( annuity due on 01.05.2019), the said annuity is not payable. Further, as per rules, proportionate

annuity, as demanded by the complainant , from the date of last annuity to the date of death is not payable.

Hence, this forum is of the opinion that the complaint is devoid of any merit and thus is treated as dismissed.





Ombudsman.




by the Ombudsman


Insurers.



INSURANCE OMBUDSMAN


AWARD


both the parties during the course of hearing, the complaint is treated as dismissed.

PROCEEDINGS BEFORE





CASE OF (Mr. Santosh Kumar Jena Vs. LIC of India Berhampur DO)

COMPLAINT REF: NO: BHU-H-029-1920-0244


1. Name & Address of the Complainant Mr. Santosh Kumar Jena, Ar- Shantinagar

Po- Sunabeda, Dist- Koraput 763001

2. Policy No:

Type of Policy


573388379

Life

15.04.2013



Mr. Santosh Kumar Jena

- do-

4. Name of the insurer LIC of India Berhampur DO




8. Nature of complaint Non-payment of Surrender value






13(1)(b)




For the insurer Mrs. K Sabat



17) Brief Facts of the Case:- The above said policy was purchased by the complainant under Jeevan Saral plan

from the present insurer on 15.04.2013. The Death Sum Assured and premium paying term of the policy were

Rs.750000/- and 15 years respectively. He was paying quarterly premium @ Rs.9187/- against the said policy.

After paying the premium for 1 & half years the policyholder had stopped paying further premium due to his

health problems. Now he wants to surrender his policy and get back refund of whatever premium he had paid in

the subject policy. But as the premium has not been paid for minimum 3 years the policy has not acquired any

paid up value. So nothing is payable in the said policy. Hence, he approached this forum for redressal.

The insurer on the other hand submitted SCN stating that the policy can be surrendered after it has been in force

for at least 3 full years. As only 1 & half years premium has been paid against the said policy, the policy is in

lapsed status. Hence, the policy can not be surrendered. Hence, the complaint may be dismissed.


a) Complainant’s argument:- The complainant was absent during the course of hearing.

b) Insurers’ argument:- The insurer stated that the policy had commenced on 15.04.2013 and first unpaid

premium was 15.10.2014. The premium against the subject policy had been paid for 1 year and 6 months. As per

the policy terms and conditions “ The policy can be surrendered after it has been in force for at least 3 full years.

As only 1 and half years premium has been paid against the said policy, the policy was in lapsed condition. So,

the policy can not be surrendered.


This is a complaint against non-payment of surrender value by the Insurer.





submissions of the insurer, it was observed that the complainant only paid the premium against the said policy

for one and half years. He did not bother to pay the further premium for which it was in lapsed condition. As per

the terms and conditions, minimum 3 years premium has to be paid for a policy to acquire paid up value. Unless

a policy has acquired paid up value it can not be surrendered. So nothing is payable in this policy. Hence, this

forum is of the opinion that the insurer has rightly denied the payment of surrender value in respect of the

subject policy and thus the complaint is to be dismissed.





Ombudsman.




by the Ombudsman.


Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mr. Jaydev Mishra Vs. SBI Life Insurance, Co.ltd)



1. Name & Address of the Complainant Mr. Jaydev Mishra, Plot no- 2118

Sabar Sahi Lane, Kalpana Area, Bhubaneswar 751006

2. Policy No:

Type of Policy


19002241310

Life

23.11.2016



Mr. Jayadev Mishra

- do-

4. Name of the insurer SBI Life Insurance Co. ltd.




8. Nature of complaint Non-payment of Health insurance claim




AWARD


both the parties during the course of hearing, the complaint is to be treated as

dismissed.



13(1)(b)



For the Complainant Jayadev Mishra

For the insurer Pallavi Patnaik



17) Brief Facts of the Case:- The above said policy was purchased by the complainant from the present insurer on

23.11.2016.The basic Sum Assured in the subject policy was Rs.150000/-. In addition to it there were some riders which was

also opted by the complainant like, 1) Personal accident benefit rider, 2) Critical Illness rider etc. As the LA felt pain in his

chest, he was admitted in Apollo Hospital, Bhubaneswar on 19.03.2018 and after treatment was discharged on 23.03.2018.

During the course of treatment, the LA had undergone coronary angiogram and temporary pacemaker was implanted on

19.03.2018. Then as per the advice of the concerned Doctor, permanent pacemaker was implanted on 20.03.2018. Total

expenses of Rs. 377432/- was incurred by the complainant which he applied for reimbursement. But, the insurer refused to

pay any amount as the said treatment is not covered under critical illness rider of the policy.

The insurer on the other hand submitted SCN stating that, in case of critical illness, the benefit is payable only if it is proved

to the satisfaction of the insurer that the benefit is payable as per the terms and conditions of the policy. As per the discharge

summary of Apollo Hospital, the complainant was admitted on 19.03.2018 and discharged on 23.03.2018. In the discharge

summary, the diagnosis is mentioned as “Diabetes Mellitus, Hypertension, Hypothyroid, Symptomatic Complete Heart Block,

Normal Coronaries, Hyponatraemia”. As per Echo report, the impression was “NO RWMA” ( No regional wall motion

abnormality). Further, it is also mentioned that procedure was done for pacemaker- Dual chamber package on 20.03.2018.

Moreover, in the history also there is no mention about chest pain, which generally occurs during heart attack. So it is not

covered under critical illness rider, for which no payment was made.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by him from the present

insurer on 23.11.2016.The basic Sum Assured in the subject policy was Rs.150000/-. In addition to it there were some riders

which was also opted by the complainant like, 1) Personal accident benefit rider, 2) Critical Illness rider etc. As the LA felt

pain in his chest, he was admitted in Apollo Hospital, Bhubaneswar on 19.03.2018. First he was advised to go for an ECG

evaluation in which it was detected that there was complete AV block. So he was advised for coronary angiogram and

temporary pacemaker was implanted on 19.03.2018. Then as per the advice of the concerned Doctor, permanent pacemaker

was implanted on 20.03.2018. Total expenses of Rs. 377432/- was incurred by the complainant which he applied for

reimbursement. But, the insurer refused to pay any amount as the said treatment is not covered under critical illness rider of

the policy.

b) Insurers’ argument:- The insurer on the other hand pleaded that, in case of critical illness, the benefit is payable only if

it is proved to the satisfaction of the insurer that the benefit is payable as per the terms and conditions of the policy. As per

the discharge summary of Apollo Hospital, the complainant was admitted on 19.03.2018 and discharged on 23.03.2018. In the

discharge summary, the diagnosis is mentioned as “Diabetes Mellitus, Hypertension, Hypothyroid, Symptomatic Complete

Heart Block, Normal Coronaries, Hyponatraemia”. As per Echo report, the impression was “NO RWMA” ( No regional wall

motion abnormality). Further, it is also mentioned that procedure was done for pacemaker- Dual chamber package on

20.03.2018. Moreover, in the history also there is no mention about chest pain, which generally occurs during heart attack. So

it is not covered under critical illness rider, for which no payment was made.


This is a complaint against non-payment of Health claim by the Insurer.





submissions of both the parties it was observed that in addition to the basic sum assured the policy also provides

some benefits in case the LA is diagnosed as suffering from some critical illness. He was admitted in Apollo

Hospital Bhubaneswar on 19.03.2018 for chest pain and after doing ECG, it was found that there was a complete

AV block which could have been fatal if not treated immediately. Hence, temporary pacemaker was implanted

after doing coronary angiogram. Later permanent pacemaker was implanted on 20.03.2018. In the discharge

summary, it was mentioned that the LA received treatment for symptomatic complete heart block. Because of

this block he was advised to go for implantation of permanent pacemaker. This is the result of inadequate blood

supply to the heart which led to chest pain. So denial of this symptoms as heart attack by the insurer seems to be

ridiculous. In the policy schedule heart attack is mentioned as one of the critical illness. Hence, this forum is of

the opinion that the critical illness benefit is to be admitted by the insurer and payment is to be released

accordingly as per rules.

AWARD


by both the parties during the course of hearing, it is awarded that the critical illness

benefit is to be admitted by the insurer and payment is to be made as per rules.






Ombudsman.




by the Ombudsman


Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN-Dr. D.K. VERMA

Case of Ms. Kamla Devi Vs Bharti Axa Life Insurance Co.

CASE NO-CHD-L-008-1920-0593


Complainant

Ms. Kamla Devi ,

108, Old Anaj Mandi,

Near SBI Bank Karnal,

Haryana-132001

Mobile No. 9017223300

2. Policy No: DOC

Type of Policy


500-9894097/13.06.2013,

Bharti AXA Life Power Kid

20 (20) Rs. 13000/ Hly Status-Surrender



Ms. Kamla Devi (48)

do

4. Name of the insurer Bharti Axa Life Insurance Co.




8. Nature of complaint Not adjusting the premium due June 2018

9. Amount of Claim To get the policy Enforce.


11. Amount of relief sought NA


Rule no: Insurance

Ombudsman Rules, 2017

13.1.(c)

13. Date of hearing/place 22.01.2020 / Chandigarh


For the Complainant Mr. Anil Kumar (Husband)

For the insurer Mr. Rohit Kukreti BM

15. Complaint how disposed Award against the Insurer

16. Brief Facts of the case:

On 19.07.2019,Ms. Kamla Devi had filed a complaint against Bharti Axa Life Insurance Co.

Ltd in respect of policy bearing no. 500-9894097. The complainant stated that she had paid the

premiums under the policy up to January 2018 but the company auto terminated her policy due

to technical error and not adjusting the further premiums. She wanted to continue her policy

but the company is not giving any suitable reply. Hence, feeling aggrieved; she approached this

forum to seek justice.

17. Cause of Complaint:

a) Complainant’s argument:

The complainant was represented by her husband and he reiterated the contents of the

complaint and told that she had paid the premiums under the policy up to January 2018 but

the company auto terminated her policy due to technical error and not adjusting the further

premiums. She wanted to continue her policy but the company is not giving any suitable

reply.

b) Insurers’ argument:

The representative of the Company reiterated the contents of SCN dated 15.01.2020 and

informed that the complainant has filed a complaint on 23.05.2019 alleging that her policy

was surrendered without her concern and further the renewal premiums paid by her are not

reflecting in her policy. The Insurance Company has stated that due to nonpayment of

premiums due on 13.12.2017 the policy lapsed. Since the lapsed policy was not reinstated;

the same got auto surrendered on 26.03.2019 as per policy terms and conditions thereby

surrender value of Rs. 59386/78 was generated.

18) The following documents were placed for perusal:-

a) Complaint to the Company

b) Reply of the Insurance Company

19) Result of personal hearing with both parties (Observations & Conclusion)

On perusal of various documents available in the file and considering the submission of

complainant and representative of the Insurance Company, it has been observed that as per

schedule of the policy, premium of Rs. 13000/- is to be paid by the life assured by cash/

cheque semi annually from 13.06.2013 to 13.12.2032. The complainant policy holder was

paying the premium regularly and there was no dispute up to the premium due 13.06.2017

paid on 27.06.2017. It is evident from the online payment acknowledgement issued by

respondent Insurance Company that premium due for 13.12.2017 under the policy was paid

on 13.01.2018 vide transaction ID LAM25965032356 and the company cannot say that due

to nonpayment of premium due on 13.12.2017 the policy lapsed and is auto surrendered.

Moreover, the complainant policy holder is interested to continue her policy and she has not

encashed the cheque of surrender value issued by the Insurance Company. As such, the

Insurance Co. is held liable to reinstate the policy.

The attention of the complainant and the Insurer is hereby invited to the following provisions of


a. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall

comply with the award within 30 days of the receipt of the award and intimate compliance

of the same to the Ombudsman.

Dated at Chandigarh on 10th day of January, 2020

Dr. D K Verma

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)


Taking into account facts and circumstances of the case and submissions made by

both the parties during the course of hearing, the Insurance Company is directed

to reinstate the policy bearing number 500-9894097 subject to recovery of

pending premiums with interest from the complainant.

Hence, the complaint is treated as closed.

Case of Mr. K.C. Arora Vs PNB Metlife India Insurance Co. Ltd.

CASE NO-CHD-L-033-1920-0113


Complainant

Mr. K.C. Arora

C1/301, The Pranayam, Tigaon Road, Sector- 82,

Faridabad, Haryana- 121007

Mobile No.- 9811441485

2. Policy No: DOC

Type of Policy


22555161 / 07-05-2018

Endowment Savings Plan

Rs. 1lac



Mrs. Shruti Wadhwa

Mr. K.C. Arora

4. Name of the insurer PNB Metlife India Insurance Co. Ltd.



7. Date of receipt of the Complaint 22-04-2019

8. Nature of complaint Policy purchased for himself but issued in the name

of his daughter

9. Amount of Claim Refund of premium with interest




Rule no: Insurance


13 1 (d)

13. Date of hearing/place 10.10.2019/14.11.2019/ 10.01.2020 /Chandigarh



For the insurer Mr. Rajeev Sharma Sr. Manager Legal

15. Complaint how disposed Closed


On 22-04-2019, Mr. K.C. Arora had filed a complaint of mis-selling against PNB Metlife

India Insurance Co. Ltd. in respect of policy bearing no. 22555161. The complainant has first

time complained to the company on 15.01.2019. He alleged that policy was purchased for his

life but insurer issued policy in his daughter’s name. The Insurance Co. has declined his

cancellation request, hence being aggrieved; he approached this forum to seek justice.

17. As per SCN received from the Insurance Company on 09.10.2019 it is explained that the

said Policy bearing No. 22555161 has been cancelled and refund amount of Rs. 100000/-

credited to the complainant a/c on 30.08.2019

18. Observations & Findings:-The complainant was given opportunity of personal hearing

on 10.10.2019, 14.11.2019 & 10.01.2020 but neither the complainant nor his representative

turned up. However he confirmed vide e-mail dated 13.11.2019 that he has received Rs.

100000/- from the company and requested for interest at market rate on Rs. 100000/-. The

insurance company was represented by Mr. Rajeev Sharma Sr. Manager Legal on 10.10.2019,

14.11.2019 & 10.01.2020 who requested for dismissal of the complaint as the complaint of the

policy holder has already been allowed and sufficient opportunities have also been given to the

complainant to present his case. On perusal of various documents it is seen that the

complainant policyholder had filed the complaint for cancellation of policy on 26.11.2018 after

about 6 months from the issuance of the policy. Despite the fact that the complaint was made

much beyond the free look period, the Insurance Company has already refunded the principal

amount on 30.08.2019 before the date fixed for hearing before this forum. Since the principal

amount has already been refunded by the Insurance Company, the request for interest cannot be

considered.


the Company during the course of hearing, there is no need for any interference and the

complaint is closed.


Dated at Chandigarh on 10th day of January, 2020.

Dr. D. K. Verma

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH



Case of Mr. Nav Rattan Garg Vs PNB Metlife India Insurance Co. Ltd.

CASE NO-CHD-L-033-1920-0063


Complainant

Mr. Nav Rattan Garg

Flat No.- 11, GH-9, MDC-5, Panchkula, Haryana-0

Mobile No.- 9417252108

2. Policy No: DOC

Type of Policy


22655705 / 05-09-2018, 22654285/03.09.2018

Endowment Savings Plan

11 (11)



Mr. Mohit Garg

Mr. Nav Rattan Garg

4. Name of the insurer PNB Metlife India Insurance Co. Ltd.




8. Nature of complaint Assured minimum of 9% interest on deposited

amount

9. Amount of Claim Refund of premium




Rule no: Insurance


13 1 (d)

13. Date of hearing/place 14.11-2019 /10.01.2020 Chandigarh


For the Complainant Self

For the insurer Mr.Rajeeev Sharma Sr. Manager Legal

15. Complaint how disposed Award against insurer


On 12-04-2019, Mr. Nav Rattan Garg had filed a complaint of mis-selling against PNB

Metlife India Insurance Co. Ltd. in respect of policies bearing no’s. 22655705 and

22654285.The complainant has first time complained to the company on 30.03.2019. He was

assured for minimum 9% return on deposited amount however this assurance was not

mentioned in the policy bond.



The complainant reiterated the contents of his complaint and said that the Insurance Co.

has sold this policy to him with the assurance that he shall get minimum 9 % but it was not

mentioned in the policy.


The representative of the Company reiterated the contents of the SCN dated 04.10.2019 and

informed that the policies bearing no’s. 22665705 & 22654285 were issued on the basis of

duly filled and signed application forms under the said policies and policy documents were

duly delivered at the complainant’s address on 25.09.2018 & 20.09.2018 respectively. . The

complaint was received on 30.03.2019 after around six months of issuance of policy thus

prayed for the dismissal of the complaint.

18) The following documents were placed for perusal :-



c) Annexure VI- A


I have examined the various documents available in the file including the copy of the

complaint, Annexure-VI and the contents of the SCN filed by the Insurance Company. It is

observed that the said policies have been missold through misrepresentation of facts as the

complainant was misguided and allured to get the 9 % returns under the policies. It is a clear

case of mis-selling and unprofessional approach of the insurance company, merits for

cancelation of policies and refund of premiums to the complainant.

The attention of the complainant and the Insurer is hereby invited to the following provisions of


b. According to Rule 17(6) of the Insurance Ombudsman Rules, 2017, the insurer shall

comply with the award within 30 days of the receipt of the award and intimate compliance

of the same to the Ombudsman.

Dated at Chandigarh on 10th day of January, 2020.

Dr. D K Verma

INSURANCE OMBUDSMAN




Case of Mr. Sanjay Khana Vs Bharti Axa Life Insurance Co.

CASE NO-CHD-L-008-1920-1103


Complainant

Mr. Sanjay Khana

House No. 233,Rehri Colony,

Jammu, J & K -180005

Punjab

M obile No.

2. Policy No: DOC

Type of Policy


501-6270083/11.10.2017

Bharti AXA Elite Advantage

12 (12)



Mr. Anmol Khana

Mr. Sanjay Khana

4. Name of the insurer Bharti Axa Life Insurance Co.




8. Nature of complaint Policy Lapsed without intimation

9. Amount of Claim Refund of Premiums

Taking into account facts and circumstances of the case and submissions made

by both the parties during the course of hearing, the Insurance Company is

directed to cancel the policies bearing number 22665705 & 22654285 since

inception and refund the premiums collected there-in without interest or

deduction of any charges.



11. Amount of relief sought Refund of Premiums


Rule no: Insurance


13.1.(d)

13. Date of hearing/place 12.02.2020 / Chandigarh



For the insurer Mr. Ritin Purhoit, Sr. Executive

15. Complaint how disposed Agreement


On 16.10.2019, Mr. Sanjay Khana had filed a complaint against Bharti Axa Life Insurance

Co. Ltd in respect of policy bearing no 501-6270083. The complainant stated that the

Insurance Co. has cheated him and without any intimation his policy is lapsed. He wanted to

continue this policy. He had also written a letter to the Insurance Company for cancelation of

the policy on 12.09.2019 but the Co. did not give any suitable reply. Thus being aggrieved

with the Insurance Co. he approached this forum to seek justice.

17. The representative of the Insurance Co. reiterated the facts given in the SCN dated

31.01.2020 that the said policy bearing no. 501- 6270083 was issued on the basis of duly

filled and signed application form under the said policy and policy documents were duly

delivered at the complainant’s address on 24.10.2017. However, the Company agreed to

refund of premiums under policy bearing no. 501- 6270083 without interest and without

deductions of any charges.

18. The Company’s offer is accepted by the Complainant.

19. Accordingly, an agreement was signed between the Company and the complainant on

12.02.2020.

20. The complaint is closed with a condition that the company shall comply with the

agreement and shall send a compliance report to this office within 30 days of receipt

of this order for information and record.

To be communicated to the parties.

Dated at Chandigarh on 12th day of February, 2020.

Dr. D.K.VERMA

INSURANCE OMBUDSMAN




Case of Mr. Vinod Kumar Vs Bharti AXA Life Insurance Co. Ltd.

CASE NO-CHD-L-008-1819-1405


Complainant

Mr. Vinod Kumar

House No.- 335, Friendsf Colony, Near Park, Sirsa,

Haryana- 125055

Mobile No.- 99924211155

2. Policy No: DOC

Type of Policy


501-6538570 31.12.2017

Flexi Term with Critical Illness Benefit

Comprehensive Illness cover

10yrs/Rs.13377.86



Mr. Vinod Kumar

4. Name of the insurer Bharti AXA Life Insurance Co. Ltd.




8. Nature of complaint Repudiation of critical illness claim

9. Amount of Claim

10. Date of Partial Settlement Refund of premium

11. Amount of relief sought Payment of claim


Rule no: Insurance


13 1 (d)

13. Date of hearing/place 24-10-2019 / 11.12.2019/22.01.202/12.02.2020

Chandigarh


For the Complainant Self/Absent/Absent

For the insurer Mr. Rahul Gandhi,(24.10., 11.12.2019&22.01.2020)

Mr. Ritin Purhit, Sr. Executive (12.02.2020)



On 29-01-2019, Mr. Vinod Kumar had filed a complaint against Bharti AXA Life Insurance

Co. Ltd. in respect of policy bearing no. 501-6538570.He has alleged that he has taken the

above policy and when lodged the claim for critical illness, it was repudiated by the company

vide their letter dated 27.07.2018 on the grounds that he has been diagnosed for chronic liver

disease which he has not disclosed while taking the said policy and the said illness does not

satisfy the definition of End Stage Liver Failure which is covered as per the conditions of the

policy.



The complainant has attended the first personal hearing on 24.10.2019 reiterated the facts given

in the complainant but the case adjourned for next hearing on his request for producing some

more documents. The 2nd hearing was fixed on 11.12.2019 but vide e-mail dated 09.12.2019 the

complainant requested for next date. The 3rd hearing was fixed on 22.01.2020 but his brother

vide mail dated 20.12.2019 informed about the death of the complainant policy holder on

20.12.2019. The nephew of the complainant attended the hearing on 12.02.2020 and produced

the death certificate of Sh. Vinod Kumar (Complainant) and informed that he knows nothing

about the case and Smt Saroj ( Nominee) wife of Sh.Vinod Kumar could not attend the hearing

due to family limitations.


The representative of the Insurance Company reiterated the facts give in the SCN dated

15.10.2019 and explained that the said policy bearing no. 501-6538570 was issued on the basis

of duly filled and signed application form under the said policy and policy documents were

delivered on 19.02.2018. The complainant did not point out any discrepancy in the documents

and had paid the renewal premium also. The complainant submitted the claim intimation on

28.06.2018 and according to the claim forms it was found that the life assured was diagnosed

with Chronic Liver Disease, Portal HTN and Minimal Ascitis and was hospitalized for 02 days

and also ultra sound abdomen report dated 21.06.2018 states that Cirrhosis Liver WITH Portal

Hypertension, Splenomegaly with Minimal Ascetic and Mild Hepatomegaly. Accordingly the

said claim was repudiated as it did not fulfill the definition of ‘End Stage Liver Failure’ as the

definition says that all the three medical conditions have to be fulfilled. The representative has

also informed that the said policy will continue as per terms and conditions.

18) The following documents were placed for perusal :-



c) Repudiation letter dated 27.07.2018.


On going through the various documents available in the file and also hearing both the

complainant and the representative Insurance Company, it is observed that the above policy

Flexi Term with Critical Illness Benefit Comprehensive Illness cover was issued on

25.12.2017. The complainant had admitted regarding the receipt of the policy documents and

he could ask for the cancellation of the same, during the free look period of 15 days from the

date of receipt of the same, if the said conditions were not acceptable to him. He however did not

exercise such an option. Once, the free look period expired, and the complainant failed to

exercise his option of cancellation of policy, later on, he will only be governed by the terms and

conditions of the same. As per Discharge Summary of the Life Line Hospital Sirsa, the

complainant policyholder was admitted on 21.06.2018 and discharged on request on

22.06.2018. He was diagnosed for CLD (?NASH related) –PHTN- minimal ascitis with DM.

The complainant policyholder filed the critical Illness claim with the company on 28.06.2018. The

Insurance Company repudiated his claim vide letter dated 27.07.2018 on the grounds that it did not

fulfill the definition of ‘End Stage Liver Failure’ as the definition says that all the three

medical conditions have to be fulfilled. While going through the relevant Part B of the

policy document the definitions pertaining to the Critical Illness benefit End Stage Liver Failure is

defined in clause 11 which states as under :-

“1. Permanent and Irreversible failure of liver function that has resulted in all three of the

following:

i. Permanent jaundice; and

ii. Ascites;and

iii. Hapatic encephalopathy.

II Liver failure secondary to drug or alcohol is excluded.”

It is evident from the extracted relevant part B of the conditions of the policy document and the

hospital treatment record that the complainant is not entitled to the amount under critical illness

claimed as per terms and conditions and exclusion clauses of the Policy, duly received by him.

In view of the findings in the Hospital records, the claim has been, thus, legally and validly

repudiated by the respondent Insurance Company.

Dated at Chandigarh on 12th day of February, 2020

Dr. D K Verma

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH



Case of Mr. Bhagwan Dasand Ghavri Vs Birla Sun Life Insurance Co. Ltd.

CASE NO-CHD-L-009-1920-0958


Complainant

Mr. Bhagwan Dasand Ghavri

Shere Punjab House No.- Shastri Nagar, Mandi,

Gobindgarh, Punjab- 147301

Mobile No.- 9876011775

2. Policy No: DOC

Type of Policy


004200299 / 28-06-2010, Policy term 30 year ,Paying

term- 15

Dream Endowment Plan

Rs.104330- yly Sum Assured – 50 lac





4. Name of the insurer Birla Sun Life Insurance Co. Ltd.




8. Nature of complaint Wrongfully terminated policy /wants to reinstate the

policy



11. Amount of relief sought Requested for revival of the policy

12. Complaint registered under 13 1 (d)


by the Company during the course of hearing, there is no need for any interference

and the complaint is dismissed.


Rule no: Insurance


13. Date of hearing/place 06-12-2019 & 17.02.2020/ Chandigarh



For the insurer Sh. Nikhil Chhabra

15. Complaint how disposed Award for reinstatement of policy


17.Facts of the case:

On 30-09-2019, Mr. Bhagwan Dasand Ghavri had filed a complaint about unilaterally terminating

the policy against Birla Sun Life Insurance Co. Ltd. in respect of policy bearing no. 004200299.

The stated policy was once revived on 28.03.2014. The company has not posted letters about

termination of the policy if due premiums are not paid in time. The complainant wants to revive the

policy.

18. Complainant’s argument

Mr. Bhagwan Dasand Ghavri , the complainant, attended personal hearing and reiterated the

contents of complaint and submitted that in 2010 he has taken policy and regularly paid five

premiums and further premiums could not be paid due to some problems. He further submitted that

in 2019 insurance company has terminated his policy without serving any notice or asking for

revival of the policy and send a cheque of Rs. 30338.65/-. The said cheque was not encashed by

him. He made request to insurer for revival of the policy by depositing all outstanding premium but

insurance company denied. The complainant requested to direct the company to allow him revive

the policy so that his life risk cover would continue.

19. Insurers’ argument

The policy has been issued as per the information provided by the complainant in the application

form which has been duly signed by the complainant. ABSLI submitted that all the documents were

duly signed by the complainant, which he has not contested in this complaint. The total premium

paid under the policy is Rs. 730,310/-. The complainant approached the company for the first time

on 08-08-2019 which is 9 years after issuance of policy raising his concern towards the policy. The

policy got into premium discontinuance/ lapsed due to nonpayment of renewal premiums. The

complainant failed to revive the said policies and eventually the policies got terminated. The

termination refund payout cheque no 067516 dated 30 July 2019 of Rs. 30338.65 was sent to the

complainant as admitted in his complaint.. The complainant has not raised any concern with the

company within stipulated time which deems that all the terms and conditions were acceptable to

the complainant. The actual payment of benefits payable in this policy varies based on the actual

performance of investment fund chosen by the complainant and the premium paid are subject to

investment risk associated with capital markets.

20. The following documents were placed for perusal.

a) Complaint to the company. b) Reply of the insurer

c) Proposal Form. d) Policy Schedule

21. Result of Personal hearing with both parties (Observations & Conclusion

On perusal of various documents available in the file and considering the submission of

complainant and representative of the insurance company, it has been observed that the

insurer has terminated said policy of the complainant without prior intimation or notice for

depositing the outstanding amount with revival requirements/ formalities. Since the

complainant is ready to pay all unpaid premiums, the insurance company, cannot deny for

reinstatement of a policy and also deficiency in service on their part.

AWARD

Taking into account the facts & circumstances of the case and the submissions

made by insurance company during the course of personal hearing, the insurance

company is directed to reinstate the policy no. 004200299 by colleting all

outstanding premiums without interest & requirements by treating the policy as

in-force.


Dated at Chandigarh on 17.02.2020

Dr. D. K. Verma

INSURANCE OMBUDSMAN


(UNDER INSURNCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Dr. D K Verma

Case of Ms Rani Babita V/S Kotak Life Insurance Company Ltd.

COMPLAINT REF: NO: CHD-L-026-1920-0368


Complainant

Ms Rani Babita

w/o Sh. Rajeev Kumar, H No. 1557, C-I

Amar Vihar, Kesar Nagar, Jagadhari,

Yamuna Nagar, Haryana

2. Policy No:

Type of Policy


01726434

Assured savings Plan

15/10 years



Ms Rani Babita

4. Name of the insurer Kotak Life Insurance Company




8. Nature of complaint Wrong deduction of mortality charges



11. Amount of relief sought Mortality charges being deducted at

wrong rates


Rule no:

13.1( )


For the Complainant None

For the insurer Sh. Manish Mittal, AVP Legal

14 Complaint how disposed Dismissed in default

15 Date of hearing/place 19.02.2020 / Chandigarh


On 03.06.2019, Ms Rani Babita had filed a complaint in this office about wrong deduction of

mortality charges under policy bearing number 01726434. The complainant submitted that

while going through the statements of various years she found that company was deducting

mortality charges on a regular flat basis and gradually increasing with time instead of

decreasing. The matter was raised with the company and even after repeated reminders and

discussions the company has not taken corrective action. Hence, she has approached this office

to seek justice.

17) The company vide SCN dated 18.11.2019 informed that the mortality charges deducted were

not at flat rate but fluctuating depending on the sum at risk which in turn was dependent on

fund value, which is a variable component and was subject to market risks. Also on being

pointed out that in the policy the mortality charges were being deducted even after the sum at

risk reduced to zero, the same was due to a technical issue and was corrected since June 2018

and excess deducted have been infused in the funds. The policy matured on 30.09.2019 and an

amount of Rs 280520.57 was credited to the complainant’s account.

18) Neither the complainant nor his representatives appeared for the personal hearing on

05.02.2020 and 19.02.2020. The case is thus, dismissed in default and closed.


Dr. D K Verma

INSURANCE OMBUDSMAN


(UNDER INSURNCE OMBUDSMAN RULES, 2017)


Case of Sh. Rajeev Kumar Airon V/S Kotak Life Insurance Company Ltd.



Complainant

Sh. Rajeev Kumar Airon

H No. 1557, C-I Amar Vihar, Kesar

Nagar, Jagadhari, Yamuna Nagar,

Haryana

2. Policy No:

Type of Policy


02317313

ULIP Plan

15/10 years



Sh. Rajeev Kumar Airon

4. Name of the insurer Kotak Life Insurance Company




8. Nature of complaint Wrong deduction of mortality charges



11. Amount of relief sought 5 lakhs


Rule no:

13.1(g )


For the Complainant None

For the insurer Sh. Manish Mittal, AVP Legal

14 Complaint how disposed Dismissed in default

15 Date of hearing/place 19.02.2020 / Chandigarh


On 12.06.2019, Sh. Rajeev Kumar Airon had filed a complaint in this office about wrong

deduction of mortality charges under policy bearing number 02317313. The complainant

submitted that while going through the statements of various years he found that company was

deducting mortality charges on a regular flat basis and gradually increasing with time instead of

decreasing. The matter was raised with the company and even after repeated reminders and

discussions the company has not taken corrective action. Hence, he has approached this office to

seek justice.

17) The company vides SCN dated 18.11.2019 informed that the mortality charges deducted were

not at flat rate but fluctuating depending on the sum at risk which in turn was dependent on fund

value, which is a variable component and was subject to market risks. Also on being pointed out

that in the policy the mortality charges were being deducted even after the sum at risk reduced

to zero, the same was due to a technical issue and was corrected since July 2018 and excess

deducted have been infused in the funds.

18) Neither the complainant nor his representatives appeared for the personal hearing on

05.02.2020 and 19.02.2020. The case is thus, dismissed in default and closed.


Dr. D K Verma

INSURANCE OMBUDSMAN




Case of Satnam Singh V/S LIC of India



Complainant

Satnam Singh

S/O Sh. Charan Singh, Pasial, PO-

Behrampur, Tehsil & Distt- Gurdaspur,

Punjab

2. Policy No:

Type of Policy


471472100

Money back



Satnam Singh





8. Nature of complaint Less payment of bonus

9. Amount of Claim Rs 88000/-

10. Date of Partial Settlement 28.06.2019

11. Amount of relief sought Difference of 88000/- (desired) and Rs

54900/-(paid)


Rule no:

13.1(b)

13. Date & Place of Hearing 08.01.2020/24.02.2020/ Chandigarh



For the Insurer Mr. Deepak Bhotani (AO)

15. Complaint how disposed of Dismissed in default

16. Brief Facts of the Case:

On 29.07.2019, Satnam Singh had filed a complaint in this office against LIC of India about

less payment of bonus under the policy. The complainant submitted that he had taken a

money back policy and the first money back was paid on 28.06.2008 for Rs 30000/-, second

of Rs 30000/- on 28.06.2012 and the third was received on 28.06.2016 for Rs 40000/-. The

agent while selling the policy told him that he will receive an amount of Rs 88000/- as

bonus at maturity but the company is paying just Rs 54900/-. He has complained to the

company but did not receive the difference. Hence, feeling aggrieved, he has approached

this forum to seek justice.

The Company has informed that the policy bearing number 471472100 fvg Sh. Satnam

Singh

was issue under plan 106/12/15 for Sum Assured of Rs 100000/-. As per terms of the policy

the first money back was paid on 28.06.2008 for Rs 30000/-, second of Rs 30000/- on

28.06.2012 and the third was paid on 28.06.2016 for Rs 40000/-. Hence Rs 100000/- was

paid as SB under the policy. On maturity the complainant was paid Rs 54900/- as bonus as

per the following detail-

(i) Rs 495/- per thousand SA i.e Rs 495 X 100= 49500 AS Vested Bonus

(ii)Rs 34/- per thousand SA i.e Rs 34 X 100= 3400 AS Interim Bonus

(iii)Rs 20/- per thousand SA i.e Rs 20 X 100= 2000 AS Final Additional Bonus

That is Rs 49500 + 3400 + 2000= Rs 54900/- As declared by LIC of India.

17. Observations & Findings:-

The complainant was given opportunity of personal hearing on 08.01.2020 & 24.02.2020 but

neither the complainant nor his representative turned up. Non appearance in personal hearing

indicates that he has nothing to say in this matter. However, the insurance company was

represented by Mr. Deepak Bhotani (AO) who requested for dismissal of the complaint, since

sufficient opportunities have been given to the complainant to present his case and the case

cannot be kept pending indefinitely. It appears that the complainant doesn’t wish to pursue the

matter since there is no verbal or written communication from him in spite of best efforts by

this office. Under the circumstances, there is no option but to close the complaint and the case

is being dismissed in default.


insurance company during the course of personal hearing, the complaint in respect of

Policy bearing No. 471472100 , is dismissed in default.



Dr. D. K. Verma

INSURANCE OMBUDSMAN




Case of Ms Muni Devi V/S LIC of India



Complainant

Ms Muni Devi

W/O Ved Prakash, H No. 34, New Grain

Market, Hissar, Haryana.

2. Policy No:

Type of Policy


179956591



Ms Munni Devi





8. Nature of complaint Revival Regretted



11. Amount of relief sought Revival of policy or Refund of premium


Rule no:

13.1(f)

13. Date & Place of Hearing 21.11.2019/08.01.2020/24.02.2020/Chandigarh



For the Insurer Ms. Shylaja Bodh AO (CRM)

15. Complaint how disposed Dismissed in default


On 11.06.2019, Ms Munni Devi had filed a complaint in this office against LIC of India

about non revival of policy bearing number 179956591 by the company. The complainant

alleged that she has bought the policy in August 2015. She has to pay the premium twice in a

year. The premium due in February got late so she approached the company for premium

payment in August 2018. She was told that she has to undergo medical, which was done. But

she was found suffering from diabetes. So, the company denied revival. She requested that

either the premium may be enhanced or the premiums paid be refunded. On being refused

she has approached this forum to seek justice.

17. The Company has informed that as the policy bearing number 179956591 has been issued for

Sum Assured 3 lakhs with installment premium Rs 17453.50 half yearly. The policy lapsed

for nonpayment of premium and was received for revival. The same was sent to central office

for revival decision, which was rejected by them.

18. Observations & Findings:-

The complainant was given opportunity of personal hearing on 29.11.2019/08.01.2020 &

24.02.2020 but neither the complainant nor her representative turned up. Non appearance in

personal hearing indicates that she has nothing to say in this matter. However, the insurance

company was represented by Ms.Shylaja Bodh (AO) who requested for dismissal of the

complaint, since sufficient opportunities have been given to the complainant to present her

case and the case cannot be kept pending indefinitely. It appears that the complainant doesn’t

wish to pursue the matter since there is no verbal or written communication from her in spite

of best efforts by this office. Under the circumstances, there is no option but to close the

complaint and the case is being dismissed in default.


insurance company during the course of personal hearing, the complaint in respect of

Policy bearing No. 179956591, is dismissed in default.



Dr. D. K. Verma

INSURANCE OMBUDSMAN

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 16 (1)/17 of The Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Madhur Lata Bhatnagar V/S LIC of India (New Delhi)

Complaint Ref. No.: DEL-L-029-1920-0780

Case No.: LI/LIC/513/19


Complainant

Smt. Madhur Lata Bhatnagar

DZ-14, Ila Appt, Vasundhra Enclave, New Delhi-

110096

2. Policy No.

Type of Policy

Policy term/Policy Period

114876804

Annuity

5/5


Name of the policy holder

Madhur Lata Bhatnagar

Madhur Lata Bhatnagar

4. Name of insurer LIC of India

5. Date of Rejection N.A.

6. Reason for Grievance Non-surrender of policy


8. Nature of Complaint Non-surrender of policy


10. Date of Partial Settlement N.A.

11. Amount of Partial Settlement N.A.

12. Amount of relief sought Rs.

13. Complaint registered under Rule No.

of the Insurance Ombudsman Rules,

2017

Rule 13(1)(f)-policy servicing related

grievances against insurers and their agents and

intermediaries

14. Date of hearing/ Place of hearing 17.02.2020/Delhi


For the Complainant Smt. Madhur Lata Bhatnagar- Complainant

For the Insurer Smt. Kala Sivaramakrishnan, Manager (CRM)

16. Date of Award/Order Award/18.02.2020


Smt. Madhur Lata Bhatnagar (hereinafter referred to as the Complainant) has filed the complaint

against the decision of the LIC of India (hereinafter referred to as the Insurer or the Respondent

Insurance Company) alleging non-surrender of policy.


a) Complainant's Argument: The Complainant vide letter dated 25.11.2019 submitted that her

policy no. 114876804 got matured on 27.02.2012. She submitted documents for surrender of

policy on 07.03.2012 requesting condonation of delay of 7 days in submission of documents.

But the Insurance Company had not responded to her complaint despite several visits. And

instead, after a gap of 20 months they started crediting an amount of Rs. 536/- p.m. without

her consent to this effect. She has now approached this forum for surrender of the policy

after deduction of amount paid as pension.

b) Insurer's Argument: The Insurance Company vide SCN dated 14.02.2020 submitted that

Policy no. 114876804 matured on 27.02.2012 and request for surrender of policy was received

on 07.03.2012. As per policy’s terms and conditions “An amount equal to the Fund Value held

in the Policyholder’s Unit account on the vesting date after allowing for an option to commute

a maximum of one-third of the Fund Value of units held in the Policyholder’s Unit Account

shall be compulsorily utilized to provide a pension based on the then prevailing immediate

annuity rates.” They further submitted that annuity had been credited in her account for the

period 01.03.2012 to 01.10.2017 @ Rs. 536/- p.m. The complainant lodged complaint in

November 2019 only. Hence, request for surrender of policy after date of vesting of policy

into annuity and credit of annuity for the period 01.03.2012 to 01.10.2017 cannot be

considered.

19. Reason for registration of Complaint: Mis-sale.

20. The following documents were placed for perusal:

a) Copy of policy.

b) Self Contained Note

c) Complaint

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

Case called. Parties are present and reiterate their respective arguments as noted in Para 18

above.

Complainant states that the policy had matured on 27.02.2012 (vesting date) and she had given

the application for surrender before the vesting date, but the agent had submitted the same to the

Insurer with a delay of 7 days. Moreover, Insurer started paying the annuity amount only after

20 months of vesting date, which was not justified. She states that if the Insurer could justify

their delay of 20 months, they could as well condone her delay, which is of only 7 days.

At this stage, Insurer offers to accept the surrender of the policy as of now and pay to the

Complainant the surrender value less the annuity payments made to the Complainant so far. The

Complainant accepts this offer and parties sign a conciliation agreement to this effect, which I

find fair and reasonable.

Award

The complaint is allowed in terms of the conciliation agreement signed by the parties today.

Accordingly, Insurer should settle the claim of the Complainant for surrender after vesting

of the Policy No. 114876804, within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

18.02.2020




Case of Youvendra Bains V/S LIC of India



1. Name & Address of the Complainant Shri Youvendra Bains

84, Pocket H-34, Sector-3, Rohini, New Delhi- 110085

2. Policy No.

Type of Policy


118625574

Life Insurance

814-21



Youvendra Bains

Youvendra Bains


5. Date of Rejection 19.01.2019

6. Reason for Grievance Wrong plan issued


8. Nature of Complaint Policy Servicing Related Complaint

9. Amount of Claim Change of plan



12. Amount of relief sought Change in Plan

13. Complaint registered under Rule No.

of the Insurance Ombudsman Rules,

2017

Rule 13(1)(f) policy servicing related grievances

against insurers and their agents and intermediaries



For the Complainant Shri PN Bains, Father of the Complainant

For the Insurer Sh. S.B Chugh – Manager (CRM)



Shri Youvendra Bains (hereinafter referred to as the Complainant) has filed the complaint against

the decision of the LIC of India. (Hereinafter referred to as the Insurer or the Respondent Insurance

Company) alleging issuance of wrong plan and non-receipt of policy bond.


a) Complainant's Argument: The Complainant vide letter dated 30.10.2019 submitted that he

had proposed for a different plan but the Insurance Company issued him another plan. He also

alleged non-receipt of policy bond. He has now approached this forum for change in plan

issued.

b) Insurer's Argument: The Insurance Company vide SCN dated

12.02.2020 submitted that due to oversight they had issued table no. 814-21-21 instead of 836-

21-15. They also approached Complainant several times for cool off cancellation application so

that fresh policy with correct table could be issued. But, the Complainant refused to submit

cool-off application. Now Table No. 836 desired by Complainant has been withdrawn by the

LIC of India. Hence, they are ready to offer cooling off cancellation action, if he gives consent

for the same and comply with requirements.

19. Reason for registration of Complaint: Mis-sale.


a) Self Contained Note

b) Complaint



above.

Insurer accepts that the policy issued to the Complainant was different than the one that he had

applied for. Insurer attributes this to the error in their office. Insurer states that the policy that

the Complainant had applied for is no longer in vogue and offers to issue a new policy with

similar features.

Complainant states that he has been struggling with the Insurer for past 14 months on this issue

and has also lost the income tax benefit during the period and would insist on getting the same

policy that he had applied for.

Keeping in view the arguments and evidence adduced by the parties, it is concluded that the

Insurer was in fault in issuing wrong Policy to the Complainant and, accordingly, the complaint

is liable to be accepted. In all fairness, Insurer should issue the policy sought for by the

Complainant with retrospective effect.

Award

The complaint is allowed and the Insurer is directed to issue the policy with features that was

applied for by the Complainant with retrospective effect, within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

18.02.2020




Case of Samedeen Khan V/S LIC of India




Complainant

Shri Samedeen Khan

H.No.148, Sangam Vihar, Dabar Colony, Loni

Gaziabad, U.P.

2. Policy No.

Type of Policy


125467574

Life Insurance

8/3



Samedeen Khan

Samedeen Khan


5. Date of Rejection N.A.

6. Reason for Grievance Non-receipt of full maturity


8. Nature of Complaint Non-receipt of full maturity




12. Amount of relief sought Rs. 120000 + Bonus + Penal Interest


No. of the Insurance Ombudsman

Rules, 2017

Rule 13(1)(f)– policy servicing related

grievances against insurers and their agents

and intermediaries



For the Complainant Shri Samedeen Khan- Complainant

For the Insurer Smt. Anjana Garg- Manager (CRM)



Shri Samedeen Khan (hereinafter referred to as the Complainant) has filed the complaint against

the decision of the LIC of India (hereinafter referred to as the Insurer or the Respondent Insurance

Company) regarding less maturity value received and non- receipt of information regarding ECS

dishonor.



had purchased policy no. 125467574 in March-2010. On maturity of the policy, the Insurance

Company paid him Rs. 82338/- instead of Rs. 120000/- as assured. Further, they did not deduct

last premium from his bank account and neither informed him about non-deduction of premium.

Because of this lapse, he had suffered financial loss in maturity claim. He has now approached

this forum for release of full maturity payment of Rs. 120000/- along with bonus and penal

interest.

b) Insurer's Argument: The Insurance Company vide SCN dated 13.02.2020 has submitted that

policy no. 125467574 was issued on 31.03.2010 with policy term of 8 years and premium

paying term of 3 years. Under the instant plan, maturity benefits are payable as follows-

“On the policyholder surviving the date of maturity an amount equal to the value of the units

held in the policyholder’s fund is payable as maturity claim. However, the bid value as on date

of maturity will be basis on the highest NAV over the first 7 years of the policy or the NAV as

applicable at the end of the policy term, whichever is higher”.

In the instant case, the Complainant paid only 2 premiums out 3, as the cheque for the 3rd

installment got dishonored. Since full premia were not received, therefore policy automatically

transferred to “auto foreclosed”. Auto foreclosure action is taken to safeguard policyholder’s

interest. On the date of foreclosure, units under policy were 6254.909 and NAV on the said date

was Rs. 13.1942. The fund value of Rs. 82382/- was paid on 26.09.2019 after deduction of Rs.

147/- on account GST and bank charges.

19. Reason for registration of Complaint: Non-receipt of full Maturity claim.


a) Copy of policy.


c) Complaint letter



above.

Complainant does not dispute that there was a temporary shortfall in his bank account, which

led to bouncing of the premium payment in February 2013.

The policy bond states that “On the Life Assured surviving to the end of the policy term, an

amount equal to the Policyholder’s Fund Value shall become payable. Policyholder’s Fund

Value on surviving the policy term shall be based on highest NAV achieved by the Fund over

the first 7 years of the Policy or the NAV as applicable at the end of the policy terms, whichever

is higher.”

Insurer had treated this policy as foreclosed on 2nd March 2015 owing to the one missing

monthly premium of February 2013. However, Insurer did not inform the Complainant about

the missing monthly premium in February 2013 or foreclosure on that score in March 2015.

Complainant states that the missing premium amount was a small sum of Rs. 2,000 and had the

Insurer informed him, he would have paid the same promptly.


Insurer was at fault in foreclosing the Policy without giving any intimation to the Complainant

and, accordingly, the complaint is liable to be accepted. In all fairness, Insurer should apply the

Fund Value norms as stated above.

Award

The complaint is allowed and the Insurer is directed to settle the claim by applying the

following norms:

a. The Policy No. 125467574 shall not be treated as foreclosed and be treated as

having run it full term.

b. The Fund Value shall be based on the highest NAV achieved by the Fund over the

first 7 years of the Policy or the NAV as applicable at the end of the policy terms,

whichever is higher.

c. In computing the Fund Value, the Insurer shall assume in the first instance that the

Complainant had paid the premium due in February 2013 amounting to Rs. 2,000.

d. In making the final payment, the Insurer shall deduct Rs. 2,000 only, towards the

premium not paid in 2013.

e. Insurer shall also pay interest to the Complainant as per the provisions to the PPHI

Regulations 2017, till the date the balance amount is actually paid into the bank

account of the Complainant.

f. Insurer should implement this Order within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

18.02.2020




Case of Chandresh Johnson V/S LIC of India




Complainant

Shri Chandresh Johnson

E-10, D, MIG Flats, Mayapuri, New Delhi-110064

2. Policy No.

Type of Policy


331527766

Whole Life Policy

21/82



Chandresh Johnson

Chandresh Johnson


5. Date of Repudiation N.A

6. Reason for Grievance Policy servicing related issues


8. Nature of Complaint Policy servicing related issues

9. Amount of Claim N.A



12. Amount of relief sought Waiver of Rs. 14000/-; Correction in Date of

Maturity and recalculation of GST.


No. 13 of the Insurance


Rule 13(1)(f) – policy servicing related

grievances against insurers and their agents and

intermediaries




For the Insurer Shri SB Chugh, Manager (CRM)



Shri Chandresh Johnson (hereinafter referred to as the Complainant) has filed complaint against

the decision of the LIC of India. (Hereinafter referred to as the Insurer or the Respondent Insurance

Company) regarding correction in maturity date, waiver of Rs. 14000/- as demanded by Insurer as

recovery and GST recalculation.


a) Complainant's Argument: The Complaint vide letter dated 01.11.2019 submitted that he had

applied for change in term of policy from 30 years to 21 years which the Insurance Company

implemented upon but did not change maturity date. For change in term an extra premium was

charged and on that extra premium they had levied exorbitant GST. Further, despite charging

extra premium, they are now demanding an extra premium of Rs. 14000/-. He has now

approached this forum for waiver of extra premium of Rs. 14000/- and correction in maturity

date along with recalculation of GST.

b) Insurer's Argument: The Insurance Company vide SCN dated 12.02.2020 submitted that

premium paying term under the policy was changed from 30 years to 21 years on the basis of

application received from the Complainant. Because of reduction in policy term, premium under

the policy was increased to Rs. 38574/- from Rs 24263/- . As the Complainant had already paid

14 installments therefore difference of premium of Rs. 200354/- [( Rs. 38574 – Rs. 24263/-) =

Rs. 14311 * 14 ] was charged. On difference of premium of Rs. 200354/- interest @ 9.5 p.a was

charged amounting to Rs. 194888/-.

GST of Rs. 35080/- has been charged on the interest portion i.e. on Rs 194888/- @ 18%.

However at the time of accounting of premium there had been an inadvertent error. They had

accounted premium p.a at Rs. 38229/- instead of Rs. 38574/-. Since, premium accounted is short

of Rs. 345 p.a and Rs 4830/- in total. Therefore, they had charged GST in excess of Rs. 880/- (

Rs. 4890/- * 18%). Hence, they will refund Rs 940/- to the Complainant after receipt of NEFT

documents (Rs. 880/- on account of excess GST and Rs. 60/- on account of alteration fee).

Further, the premium of Rs. 38229/- as conveyed earlier is wrong. Premium payable under the

policy is Rs. 38574/- p.a. They also confirm that the maturity date under the policy is

07.04.2088 and last premium due date is 07.04.2026. Also, the Complainant need not pay Rs.

14000/-.

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


a) Copy of policy.


c) Policy Bond


Case called. Complainant is absent. Insurer is present.

Insurer has sent a letter dated 12.02.2020 to this office informing that they have now identified

the error in the premium accounted in the policy account and have accordingly decided to refund

an amount of Rs. 940 to the Complainant towards excess GST and alteration fee. Further, the

premium of Rs. 38,229/- as conveyed earlier is wrong. Premium payable under the policy is Rs.

38,574/- p.a. They also confirm that the maturity date under the policy is 07.04.2088 and last

premium due date is 07.04.2026. Also, the Complainant need not pay Rs. 14000/- towards

recovery that was intimated to him before.

The complaint is disposed of in line with the clarification/offer of the Insurer stated above.

Award

The complaint is disposed of in line with the clarification/offer of the Insurer vide their letter

dated 12.02.2019, as follows

a. Insurer should refund an amount of Rs. 940 to the Complainant towards excess GST and

alteration fee.

b. The premium of Rs. 38229/- as conveyed earlier is wrong. Premium payable under the

policy is Rs. 38574/- p.a. .

c. The maturity date under the policy is 07.04.2088 and last premium due date is 07.04.2026.

d. The Complainant need not pay Rs. 14000/- towards recovery that was intimated to him

before.

Insurer should implement this offer within 30 days.

(Sudhir Krishna)

Insurance Ombudsman

18.02.2020




Case of Mayank Arora V/S Tata AIA Life Insurance Company Ltd.


Case No.: LI/TATA/516/19


Complainant

Shri Mayank Arora

10267-B, West Gorakh Park, ST No. 1, Shahdara,

New Delhi-110032

2. Policy No.

Type of Policy


C001641523

Life Insurance

21



Mayank Arora

Mayank Arora

4. Name of insurer Tata AIA Life Insurance Company Ltd.

5. Date of Repudiation N.A

6. Reason for Grievance Forfeiture of premium


8. Nature of Complaint Forfeiture of premium

9. Amount of Claim N.A





No. of the Insurance Ombudsman

Rules, 2017

Rule 13(1)(f)– policy servicing related

grievances against insurers and their agents

and intermediaries



For the Complainant Shri Mayank Arora- Complainant

Shri Prabhat Arora- Father of the Complainant

For the Insurer Shri Anmol Kishore, Manager-Legal



Shri Mayank Arora (hereinafter referred to as the Complainant) has filed the complaint against the

decision of the Tata AIA Life Insurance Company Ltd. (hereinafter referred to as the Insurer or the

Respondent Insurance Company) alleging forfeiture of premium.



was mis-sold policy no. C001641523. Yet on agent’s insistence he continued with the policy and

paid premiums for three years. However after three years, the Insurance Company forfeited total

policy fund of Rs. 94562/-. He has approached this forum for release of forfeited premium.

b) Insurer's Argument: The Insurance Company vide SCN dated

05.02.2020 submitted that there was an outstanding loan on the policy and policy fund was

forfeited because value of outstanding loan was higher than the surrender value. The same had

also been communicated to the Complainant vide their letter dated 22.02.2019.

19. Reason for registration of Complaint: Forfeiture of premium.


a) Copy of policy.


c) Complaint



above.

Complainant states that he had never sought for loan, but the Insurer on his own issued some

loan on his policies and subsequently forfeited the policy owing to non-payment of the loan

dues and premium. He also states that he wanted to cancel the policy soon after the issuance,

but was advised by the agent to pay the premium for three years, which he did, but still the his

policy got cancelled.

Insurer states that this policy has certain unique features, which have been well described in the

policy document. For instance, the policy provides for automatic premium loan (APL) to pay

the defaulted premium amount, so as to keep the policy alive. However, the APL is permitted

so long as the cash value is equal to or greater than the premium in default plus any indebtness

and subject to sufficiency of cash value of the policy. It was as per this feature of the policy that

the loan was raised against the policy as per the application made by the Complainant, but as

the Complainant failed to pay the premium beyond the APL limit, the policy got forfeited.


Insurer was not in fault and, accordingly, the complaint is liable to be rejected.

Award

The complaint is rejected.

(Sudhir Krishna)

Insurance Ombudsman

18.02.2020


(Under Rule 13 of the Insurance Ombudsman Rules, 2017)


Case of Sunita Srivastav versus HDFC Life Insurance Company Ltd.

Case No. 517/19


1. Name & Address of the Smt. Sunita Srivastav

C-545, Bhoomiheen Camp, Govindpuri,

Kalkaji,

Delhi-110019. Mobile No.: 9811703296

2. Policy No:

Type of Policy

Policy Term/Premium paying term

19966329

Conventional

15/15 years



Sunita Srivastav

Sunita Srivastav

4. Name of the insurer HDFC Life Insurance Company Ltd.



7. Date of receipt of the complaint 13.12.2019

8. Nature of complaint Non-refund of Premium after her husband’s

death

9. Amount of claim Rs. 95,000/-


11. Amount of relief sought Rs. 95,000/-

12. Complaint registered under Rule 13 (1) (d) of the Insurance Ombudsman Rules

2017

13. Date of hearing/place 11.02.2020, Delhi


a) For the Complainant In person

b) For the insurer Shri Kunal Aurora, Dy. Manager (Legal)

15. Complaint how disposed Award


17) Brief Facts of the Case: Smt. Sunita Srivastav (hereinafter referred to as the Complainant) has

filed the complaint against the HDFC Life Insurance Company Ltd. (hereinafter referred to as

the Insurance Company or the Insurer) for not refunding premium of her policy no. 19966329

after her husband’s death.


a) Complainant’s Argument:

The Complainant has alleged that she had taken a policy involving an annual premium of Rs.

90,909.The policy was issued under covering letter dated 28.02.2018. Her husband died in a car

accident on 23.03.2018, which was within a month of taking the policy and this led to financial

constraints for her family. In such circumstances, she requested the Insurer for cancellation of

her policy and refund of the premium owing to her financial difficulties, vide letter dated

09.04.2019. However, the Insurance Company did not refund the premium on the ground that

the request was beyond freelook cancellation period. She represented her case further, however

the same was also rejected vide reply dated 04.12.2019.

b) Insurer’s Argument:

The Insurance Company has submitted through their Self-Contained Note (SCN) that the policy

documents were delivered on 30.07.2019, whereas the concern was raised on 04.11.2019; as

such the request for cancellation was not considered.

19) Reason for Registration of Complaint:

Same as 18 (a) above.

20) The following Documents were placed for perusal:

a) Policy Documents

b) Correspondences between the Complainant and the Insurance Company

c) SCN by the Insurance Company

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


above.

At this stage, Insurer offers to cancel the policy and convert it into a single premium policy

with five years lock-in and no free-look cancellation option. Complainant accepts this offer and

parties sign a conciliation agreement to this effect, which I find fair and reasonable.

Award

The complaint is allowed in terms of the conciliation agreement signed by the parties today.

Accordingly, the Insurer should cancel the policy No. 19966329 and convert it into a single

premium policy with five years lock-in and no free-look cancellation option.

Parties should implement this agreement within 30 days.

(Sudhir Krishna)

Insurance Ombudsman, Delhi

February 2020

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA

CASE OF RADHEY SHYAM SINGHAL V/S L I C OF INDIA

COMPLAINT REF: NO. JPR- JPR – L – 029-1920-0341

AWARD NO: IO/JPR/A/LI/ /2019-2020


Complainant

Sh. Radhe Shyam Singhal 523, Barkatnagar,Tonk Phatak, Jaipur -302015

2. Policy No:

Type of Policy

Maturity SA

DOC / Term

197940901

Jeevan Saral

91770/-

28.02.2010 / 10 Years



Sh. Radhe Shyam Singhal

Sh. Radhe Shyam Singhal

4. Name of the insurer LIC OF INDIA ( DO- I, Jaipur)

5. Date of Repudiation N/A

6. Reason for repudiation N/A


8. Nature of complaint Less Maturity Claim being paid


10. Date of Partial Settlement 130772/-



Rule no: of IOB rules

13 (1) (b)

13. Date of hearing/place 12.02.2020 / Jaipur


For the Complainant Sh. Radhey Shyam Singhal

For the insurer Sh. N. K. Arora, (Manager (Claims)

15 Complaint how disposed Dismiss


17) Brief Facts of the Case:- Sh. Radhe Shyam Singhal ( herein after referred as complainant)

had filed a complaint against LIC of India (herein after referred to as respondent Insurance

Company) alleging less payment of maturity benefit claim under his Jeevan Saral policy no.

197940901.


Complainants’ argument: The complainant submitted that he had taken the subject Jeevan Saral

policy in 2010 from the respondent Insurance Company through LIC Agent Smt. Meena Jain and

Development Officer Sh. Hemant Gaur. They assured the complainant that in this plan he would

receive higher rate of return than Post office RD Scheme along with 250 times death risk coverage

of premium paid. A pamphlet was also given by them showing maturity payment of Rs.638712/-

after 10 years on payment of premium Rs. 3000/- per month and Death Claim of Rs. 750000/- in

case of death during the policy term. The complainant enquired the Agent about printing of

Maturity SA Rs 91770/- on the policy Bond. The Agent told that LIC software was not working

properly and assured that the complainant would receive more than Rs.6 lakh on maturity. The

complainant stated that against deposit of Rs. 367200/- as premium in 120 monthly installments, the

Insurance Company is going to pay him maturity amount of Rs.130772/- only. The complainant

submitted that if the actual maturity amount Rs. 130000/- would have been written on the policy

bond, he would have cancelled the same at the initial stage. The complainant approached the GRO

of Insurance Company but did not get relief. Being aggrieved he approached this forum for

redressal of his complaint.

Insurers’ argument:- The respondent Insurance Company in its SCN dated 24.01.2020 submitted that

maturity claim Rs. 130772/- (MSA Rs. 91770 + LA Rs.39002) will become due to the policyholder under the

said policy on his surviving up to the date of maturity. As per special features of above plan, Death Sum

assured was 250 times of monthly premium paid but the maturity sum assured differs for different entry

ages and terms. Maturity amount decreases on higher age which is mainly attributed to higher mortality

premium on advanced age. In this particular case the age of the proposer was 60 Years at the time of entry.

Maturity SA Rs. 91770/- and Death SA of Rs.7500000/- was also mentioned on the policy bond. Death Risk

coverage of Rs.750000/- sum assured was given from the age of 60 to 70 years. In addition to the life cover

some unique features as mentioned below were also available under this plan:-

1) Refund of all premiums ( excluding first Year premium ) along with Death Sum assured in case of

Death Claim

2) Auto Cover for 12 months where total premium paid for three years or more under the policy.

3) Partial Surrender facility after payment of premium for at least 3 years.

The Insurance Company stated that Yield on Jeevan Saral investment depends upon the experience of the

Corporation and it may vary from year to year. As per basic principles after charging risk cover premium,

the residual amount goes to the individual assurance funds. In this particular case the policyholder was in

advance age, therefore, risk cover premium was on higher side which had ultimate bearing on maturity

proceeds. As per terms and conditions of the said policy on maturity, Maturity Sum Assured and Loyalty

addition as declared by the policy applicable in the year of maturity will be paid to the policyholder.

Maturity sum assured mentioned as Rs. 91770/- on the policy Bond plus Loyalty Addition Rs. 39002/- is

correctly calculated as per terms and conditions of the policy.

19) Reason for Registration of Complaint: Less Maturity Claim received.


a) Complaint letter

b) Policy copy

c) Form VI A duly signed by the complainant.

d) SCN and form VIIA duly signed by the Insurance Company

21) Result of hearing with both parties (Observations and Conclusion): I heard both, the complainant and

the Insurance Company. The complainant submitted that he deposited Rs 367200/- during the policy term

of 10 years. The LIC Agent and Development Officer had assured him maturity payment of Rs. 638712/-. A

pamphlet was also given by them showing maturity payment of Rs.638712/- after 10 years on payment of

premium Rs. 3000/- per month. As per Insurance Company only Rs.130772/- is payable on maturity. The

respondent Insurance Company submitted that Maturity Sum Assured was Rs. 91770 /- and it was clearly

mentioned in the policy bond. The respondent Insurance Company reiterated Death Sum assured was Rs.

750000/-, which was 250 times of monthly premium paid. Maturity sum assured differs for different entry

ages and terms. Maturity amount decreases on higher age which is mainly attributed to higher Mortality

premium on advanced age. As such Maturity sum assured mentioned as Rs. 91770/- on the policy Bond

plus Loyalty Addition Rs. 39002/- was correctly calculated as per terms and conditions of the policy.

On perusal of documents exhibited and oral submissions made, I find that Maturity Sum Assured

Rs. 91770/- was clearly printed on the policy Bond. The Policy Bond was in possession of the

complainant during entire term of the policy. He could not produce any proof of having raised the

query with the Insurance Company regarding Maturity Sum Assured during the policy term.

Maturity sum assured Rs. 91770/- along with payable loyalty addition shall be paid as per terms and

conditions of the policy. In view of above, I see no reason to interfere with the decision of the

Insurance Company.

“Accordingly, the complaint is hereby dismissed.”

22) The attention of the Complainant and the insurer is hereby invited to the following provisions of

the Insurance Ombudsman Rules, 2017:

a. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall be

sent to the complainant and the insurer named in the complaint.

Place: Jaipur SANDHYA BALIGA

Dated: 12.02.2020 (INSURANCE OMBUDSMAN)

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA CASE OF SH SHYAM BIHAREE V/S BHARTI AXA LIFE INS.CO.LTD.

COMPLAINT REF: NO JPR-L-021-1920-0329 AWARD NO: IO/JPR/H/A/1920/000


Complainant

Sh Shyam Biharee, 207, Deenanathji ka

Rasta, chandpole Bazar, Jaipur.

2. Policy No:

Type of Policy

Commencement of the

policy/Prem. Paying Term

5000684836

Dream Life Pension Plan

04.02.2008

10 yrs.

AWARD

Taking into consideration the facts and circumstances of the case and submissions

made by both the parties during the course of hearing, the complaint is here by

dismissed.



Sh Shyam Biharee Sharma

Sh Shyam Biharee Sharma

4. Name of the insurer Bharti Axa Life Ins.Co.

5. Date of Repudiation

6. Reason for repudiation Beyond free look period


8. Nature of complaint Maturity not paid

9. Amount of Claim Rs.1,73,795 /-

10. Date of Partial Settlement NA-

11. Amount of relief sought Rs. 1,73,795 /-


Rule no: of IOB rules

13(2)

13. Date of hearing/place 13. 02 .2020 / Jaipur


For the Complainant Sh Shyam Biharee Sharma

For the insurer Sh Abhinav Vijayvargia

15 Complaint how disposed Recommendation


17). Sh Shyam Biharee Sharma (herein after referred to as the complainant) had filed a

complaint against the decision of Bharti Axa Life Insurance Co. Ltd. (herein after referred to

as respondent Insurance Company) alleging maturity not paid under Policy no. 5000684836


1. Complainants’ argument: The complainant submitted that he did not receive maturity

claim under policy No. 5000684836 on his life from the Respondent Company with

commencement date 04.02.2008 having premium of Rs.12,000/- payable yearly for 10

years. He was missold the policy with the promise to get 100 % of maturity benefits

after 10 years or as pension as per his choice on maturity , hence he opted for the said plan

and taken this policy. The complainant further submitted that , he has received some

amount in lum sum and a cheque of pension amount Rs. 173794.78/ in favour of Exide Life

Insurance Company. Now he wants that either he should be paid entire money to him lum

sum or pension through Bharti Axa Life Insurance Company only. He will not opt any

other Insurance Company for pension. The

complainant further submitted that when he came to know that subject policy was sold to

him on false promises he requested to the Insurance Company on 20. 08.2019 to take the

pension from Bharti Axa Life Ins. Co. only or the lum sum payment of maturity amount

of the policy. The complainant represented to GRO vide letter dated 26. 11 .2019, but did

not get any relief from the Insurance Company. Being aggrieved , the complainant

approached this forum for redressal of his complaint.

2. Insurers’ argument:- The Insurance Company in their SCN dated 03.02.2020 stated that

the subject policy no. 5000684836 was issued on 04.02.2008 with an annual premium of

Rs.12,000/ and he had paid regular premiums till the policy term of 10 years. The pension

plan attained vesting status on 04.02.2018. Prior to vesting, annuity quotation was sent to

the policyholder’s letter dated 12.02.2018 through courier. On February 18, 2019, the

Company has received a request for registration of pension option on vesting of the policy.

As per prior request, the claim was processed and a cheque dated 20.08.2019 bearing no.

463512 amounting to Rs. 1,73,794.78/- favering Exide Life Insurance Company was

handed over to the complainant to obtain pension from there. Further the balance amount

of Rs. 94,232.83/- was transferred to the complainant via NEFT as commuted value. The

Insurance Company further submitted that the company did not receive any request for

surrender/cancellation of the policy prior to the vesting date of pension plan, policy no.

5000684836. The said concern was raised to the Company , first time on 20.08.2019. The

complainant raised grievance of missale after the expiry of around ten years from the

issuance of the policy i.e. beyond free look period. As such complaint is not justified.

19) Reason for Registration of Complaint: Maturity claim not paid .


a) Complaint letter

b) Copy of Certificate of Insurance

c) Form VI A duly signed by the complainant.

d) SCN and a form VIIA duly signed by the Insurance Company

21) Before the hearing, all efforts were made to resolve the subject matter of complaint. The

complainant, Mr. Shyam Biharee Sharma and representative of Insurance Company Mr.

Abhinav Vijayvargia filed a joint application (Mediation form) duly signed by them for

amicable settlement as under:-

“The Insurance Company and the complainant mutually agreed for settlement of maturity

amount of the policy bearing no. 5000684836 for Rs. 1,73,794.78/ . The Insurance Company

agreed to refund the said maturity amount to the complainant in full and final settlement and

complainant also agreed for the same.

In view of the above facts, circumstances, I feel it just, fair and equitable to make the

recommendation about settlement of the complaint as full and final on the basis of mutual

agreement.

22) The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017:

d. According to Rule 16(2) of Insurance Ombudsman Rules, 2017, the complainant shall

furnish to the insurer within a period of 15 days from the date of receipt of this Award, a

letter of acceptance that the Award is in full and final settlement of his claim.

e. As per Rule 16(3) of the said rules the Insurer shall comply with the Award within 15 days

of the receipt of the acceptance letter of the Complainant and shall intimate the

compliance to the Ombudsman.

C.Copies of the Award to both the parties.

Place: Jaipur SANDHYA BALIGA

Dated: 13.02.2020 ( INSURANCE OMBUDSMAN)

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF WEST BENGAL, SIKKIM AND UT OF A & N ISLANDS

(UNDER RULE NO: 16(1)/17 of INSURANCE OMUDSMAN RULES, 2017)

OMBUDSMAN – SHRI PRADIP KUMAR RATH

CASE OF ---MR. SWAPAN KUMAR MAJI

V/S

BIRLA SUNLIFE INSURANCE CO. LTD.

COMPLAINT REF NO: KOL-L-009-1920-0542

AWARD NO:IO / KOL/A/LI/ 0513 /2019-2020


Complainant

MR. SWAPAN KUMAR MAJI

DAKSHIN KANYANAGAR, AMTALA, BISHNUPUR,

PIN – 743398, SOUTH 24 PGS, WEST BENGAL

E-mail ID:

MOB NO : 9432351659 2. Policy Nos.

Type of Policy


007905629

ADITYA BIRLA SUNLIFE IMMEDIATE ANNUITY

PLAN

3.

Name of the Annuitant

Name of the Policy Holder

SHRI SWAPAN KUMAR MAJI

SELF

AWARD

Taking into consideration the facts and circumstances of the case during the personal

hearing. The complaint is treated as disposed off accordingly.

4. Name & address of the insurer ADITYA BIRLA INSUANCE CO. LTD.

5. Date of Repudiation -----

6. Date of lodgement of complaint to

Insurer

23/07/2019


8. Nature of complaint NOT ALLOWING SURRENDERING OF

POLICY

9. Amount of Claim RS 78860/

10. Date of Partial Settlement ----

11. Amount of relief sought RS. 78860/

12. Complaint registered under IOR

2017

13(1)(c)

13. Date of hearing/place 07/01/2020 AT KOLKATA


For the Complainant Mr. Swapan Kumar Majhi

For the insurer Smt. Aparajita Bagchi

15 Complaint how disposed BY CONDUCTING HEARING AT KOLKATA

16 Date of Award/Order 10/02/2020

17 Brief Facts of the Case

POLICY

NO.

D.O.C. NAME T/PP

T

PREMIUM

INCLUDING

TAX

POL. BOND

RECEIVED

007905629

30/06/2019

Swapan kumar Maji 54/S.

P

Rs78860/

RECEIVED

Complainant’s Argument: 1. The complainant stated that his elder son Mr. Saraswata Maji had been suffering from

Rectum Cancer which need immediate operation. He had already admitted his son to Tata

Cancer Hospital, Rajarhat and according to their estimation, an amount of Rs.3.5 to 4 lakhs

would be required for operation and post operative treatment like chemotherapy.

2. In view of above, the complainant appealed to the Insurer on 23/07/2019 for refunding his

mney attached with the above annuity policy in one lumpsum so as to enable him to

overcome the financial hardship.

3. Being denied of his appeal by the Insurer, he lodged his complaint to this forum for

redressal.

Insurer’s argument: As per SCN, the Insurer expressed their inability to cancel the policy in view of the

fact that policy conditions of immediate Annuity policy does not permit any cancellation or surrender. Moreover, according to Insurer, free look cancellation is not applicable to any annuity policy originated from transfer fund from any existing deferred pension plan. They also informed that they could have considered the matter if the annuity policy would not originate from Empower Pension Plan. As such, they opted for dismissal of the complaint.

19) Reason for Registration of Complaint: Scope of The IOR, 2017

20) The following documents were placed for perusal by Complainant.

a) Annexure – VI-A, b) complaint letter c) complaint letter lodged to Insurer & their

Response, d) Copy of proposal e) Copy of Policy document.

21) Result of hearing with both parties (Observation & Conclusion):

Complainant’s Submission:

The complainant repeated all the points as mentioned in his complaint letter dated 03/09/2019. He added

that the Insurer initially had agreed to comply his request but later on they differed from their initial

assurance. He appealed to Insurer once again to consder his request for the sake of treatment of his son.

Insurer’s submission:

The Insurer repeated that the rules of empowered pension plan never supports cancellation or surrendering

of the policy under any circumstances. As such, they expressed their helplessness.

AWARD Taking into account the fact and circumstances of the case and after going through the documents on

record and the submissions made by both the parties during the course of hearing, it is observed that

there is no provision of surrender as per the policy terms and conditions.

Considering all the above, the views of the Insurance company is upheld by this forum without giving

any relief to the complainant.

Thus, the complaint is dismissed.

2) The attention of the Complainant and the Insurer is hereby invited to the following provisions

of Redressal of the Insurance Ombudsman Rules, 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 award and shall intimate the compliance to the Ombudsman.

Dated at Kolkata, the 10th day of February 2020.

S/d P. K. RATH

INSURANCE OMBUDSMAN

FOR THE STATE OF WEST BENGAL,

SIKKIM AND UT OF ANDAMAN & NICOBER ISLANDS

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKKIM, A&N ISLANDS

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN: SRI P.K.RATH

CASE OF MR. SAIDUR RAHAMAN V/S HDFC STANDARD LIC LTD(MUMBAI)

COMPLAINT REF: NO: KOL-L-019-1819-0965

AWARD NO: IO/KOL/A/LI/ 0527/2019-2020


Mr. Saidur Rahaman

Sonatore Para,Ward no. 04, Po. + Ps.

Suri, Rabindra Nath Thakur Road,

Beside Pasan Kali Mandir,

Birbhum,West Bengal- 731 101

Mob. 9474613146.

2.

Policy No:

Type of Policy


Pol. No: 14773123

Details of the policy are given in the

Table below.

--do--



Mr. Saidur Rahaman

--do--

4. Name of the insurer HDFC STANDARD LIFE INSURANCE CO. LTD.

(MUMBAI) 5. Date of Repudiation N.A.

6. Reason for repudiation N.A.

7. Date of receipt of the Complaint 08.02.2019 at the office of Ins.

Ombudsman

8. Nature of complaint Servicing related allegation

9. Amount of Claim N.A.


11. Amount of relief sought Rs.20137/- (Refund of 1st Premium +

Interest) as per Annexure-VIA


The Insurance Ombudsman Rules, 2017

Dispute with regard to servicing Rule

13(1)(f)

13. Date of hearing/place 11.02.2020 AT KOLKATA


For the Complainant Mr. Saidur Rahaman

For the insurer Mr. Sumit Saha & Ms. Koyel Ghosh

15. Complaint how disposed BY CONDUCTING HEARING



Details of the policy issued:

Pol. No. & DOC 14773123 & 12.12.2011

Plan Name HDFC SL Classic Assurae Insurance Plan

Name of Policyholder/Life assured Mr. Saidur Rahaman (Both)

PT/PPT Yrs. 10/07

Inst. Prem. & Mode Rs.20137/- & Yearly

Sum Assured Rs.123715/-

Date of Complaint to Insurance Company 13.01.2018

First unpaid premium Seven yearly premiums have been paid

Duration= (DOC – Date of Complaint) Months approx.

Pol. Bond Delivery Dispatched on vide POD No.

Name of Broker/ Agent. Miss. Swagata Shankha Mandal, Code: 00449815

The complainant had alleged against the Insurance Co. on the following points:

01. That the Complainant purchased one insurance policy from HDFC STANDARD LIFE INSURANCE CO.

LTD. (MUMBAI) on 12.12.2011 through an Agent/Broker namely with PT/PPT 10/07. He had

paid 7 yearly premiums by online or by cheque.

02. That he alleged that due on 12/2017 was debited twice @ Rs.20137/- and the last premium

paid on 31.03.2018. So One installment premium was paid in excess.

03. That the policy status was shown as paid up due to non-payment of premium.

As such, being dissatisfied with the decision of the insurer for denial of request for cancellation

of policy, the complainant has now approached this forum for redressal of his grievance.

18) Cause of Complaint: Mis-selling of policy with false promise of old policies cancellation

and refund of old policies premium.

Complainant’s argument: Already briefed under point 17.

Insurer’s argument:

SCN has been received from Insurance Company 03.02.2020.

01. They stated in their SCN that both the premiums against due on 12/2017 were inadvertently

deducted from bank account of the complainant twice @ Rs.20137/- were refunded on

29.12.2017. They received total 6 premiums. So the policy status is shown as “paid up”.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules, 2017.

Rule 13(1) (c), Policy was sold by making false assurance of cancellation and refund of old

policies premium.


a) Complaint letter to the Ombudsman & to the Ins. Co.

b) Annexure VIA/ P form.

c) Copies of proposal form, FPR and policy schedule.

d) Copies of correspondences.

21) Result of hearing with both parties (Observation & Conclusion):-

Both the parties attended the hearing.

Complainant’s submission:

01. During the course of hearing he submitted that premium paying term of the aforementioned

policy is 7 years with yearly mode of payment. He paid total number of premium nine. Out

of the nine installments of premium three installments were deposited by him on

27.11.2017(twice) online and again on 31.03.2018 by cheque vide no.747824 dated

31.03.2018 on UBI, New Market Branch against last due on 12.12.2017.

02. He acknowledged the receipt of two installments refunded the insurer on 29.12.2017.

03. Further he submitted that now the policy status should be “fully paid up” instead of “paid

up”.

Insurer’s submission:

The representative of the Insurer repeated what they had already said in their SCN. In addition to

that they agreed that it is a system generated fault and they will rectify the error at their earliest.

AWARD

Taking into account facts & circumstances of the case and the submissions made by both the

parties present during the course of hearing and after going through the relevant documents

on records, it is observed that the said policy status should be “fully paid up” instead of “paid

up”.

As such, it is evident that the insurer did not take any action to rectify the system error at

their end.

In view of all the above, the insurer is directed to rectify the policy status as “fully paid up”

intimating the complainant under intimation to this forum.

The complaint, accordingly, is treated as closed.


provisions of the Insurance Ombudsman Rules, 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 award and shall intimate the compliance to the Ombudsman.

Dated at Kolkata, 12th February, 2020

S/d Shri P.K.Rath

INSURANCE OMBUDSMAN

FOR THE STATES OF WEST BENGAL,

SIKKIM AND UT OF ANDAMAN & NICOBAR ISLAND

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKIM, A&N ISLANDS


OMBUDSMAN – MR.P.K.RATH

CASE OF MR. SOUMEN AICH

V/S

LIC of INDIA

COMPLAINT REF: NO: 1) KOL-L-029-1819-0474

AWARD NO: 1) IO/KOL/A/LI/ 0519 /2019-2020


Complainant

Mr. Soumen Aich 18/1C Uday Shankar Sarani,

First Floor,

Kolkata, West Bengal,

PIN : 700 033.

Mob No.9830106075

2. Policy No:

Policy Type/Duration/Period

416479234

DETAILS ARE IN THE TABLE

3. Name of the Insured/LA

Name of the proposer

Mr. Soumen Aich

------------------Do----------------------------

4. Name of the insurer LIC of INDIA (KMDO-II)

5. Date of Repudiation Not applicable

6. Reason for repudiation Not applicable


8. Nature of complaint

Delay in effecting the change of mode of

payment from Yearly to Monthly ECS

charging interest on premium thereby

9. Amount of Claim The amount of interest charged on premium paid

due to official delay

10. Date of Partial Settlement Not applicable

11. Amount of relief sought Rs 5,041/-


Insurance Ombudsman Rules’ 2017 13 (1) ( f )

13. Date of hearing/place 06-02-2020 AT KOLKATA


For the Complainant Mr.Soumen Aich

For the insurer Ms.Dipu Bala Sarkar, Manager (CRM) &

Mr.Ashesh Ghosh, A.O., LICI, KMDO-II

15 Complaint how disposed BY CONDUCTING HEARING

16 Date of Award/Order 10-02-2020


The complainant has alleged the following:-

i) That the Complainant purchased one Endowment Policy for Sum Assured of Rs.10 lakh on his

own life from LIC of India on 20-07-2005 for a term of 21 years with yearly premium of

Rs.48,664/-.

ii) That he deposited Rs.50/- as alteration fee on 20-06-2016 to change the mode of payment of the

policy to monthly ECS to facilitate direct deduction of premium from his HDFC Bank A/c.

iii) That the change of mode effected w.e.f. premium due on 20-07-2016 as per renewal premium

receipt was issued on 05-07-2016 for monthly premium of Rs.4,183/-.

iv) That he was informed by the Insurance Company that monthly deduction of premium from his

Bank account would be started automatically from the next monthly premium due on 20-08-

2016 but that did not happen.

v) That he never received any periodic premium alert or message regarding deduction of premium

in his mobile phone regarding this policy after change of mode of payment as promised the

Insurance Company.

vi) That the Agent did not show any interest at all in the process of changing the mode of payment

of the policy.

vii) That on contacting the Branch office in Oct.2017, he was told to deposit Rs. 66,499.88 to

regularize his policy which was in lapsed condition. He paid the said amount on 30-10-2017

which includes 15 monthly instalments of Rs.62,745/- from 20-08-2016 to 20-10-2017, interest

on premium of Rs.3,528/- and GST of Rs.1,513.64.

viii) That he had to pay penalty of Rs.5,041.64 i.e. the interest + GST amount, due to delay in

payment of premium for which he was not responsible.

Being dissatisfied with the insurer’s indifference to

(i) To refund the interest charged on delayed payment of premium due to negligence on part of

insurer after change of mode of payment of his policy and

(ii) To detach the existing non-cooperative Agent from his policy by allocating a new one, the

Complainant approached this forum for redressal of his grievance.


Policy No. 416479234

Name of Life Assured Mr. Soumen Aich

Plan/Term/PPT Endowment Policy 14 / 21 / 21

DOC of Policy 20-07-2005

Sum Assured Rs. 10,00,000/-

Premium / Mode (From DOC to 20-07-2015) Rs.48,664/- (Yearly)

Premium / Mode (after change of mode of

payment on and from 20-07-2016) Rs.4,183/- (Monthly ECS)

Name of Agent / Code no. Sri Subhadip Mukherjee

(LIC10407400)

18) Cause of Complaint: Delay in effecting the change of mode of payment from Yearly to

Monthly ECS charging interest on premium thereby.

Complainant’s argument: In point No. 17 it is mentioned categorically.

Insurers’ argument: The submission of the Insurance Company as per the SCN received on

07-01-2019 is as follows:

(i) That no SMS alert was sent to the policyholder regarding pending premium.

(ii) That intimation on updates of the policy should have been reached to the policyholder in his

register mobile no.

(iii) That the concerned Agent was terminated w.e.f. 01-11-2015.

(iv) That the policyholders can approach the Grievance Redressal Officer on any working day

within office hours at the Branch Office to lodge his/her complaint.

(v) That the question of reversal of delayed payment interest does not arise as the amount

payable towards renewal premium was not deposited on time and not even within the grace

period as specified in the policy document.

19) Reason for Registration of Complaint:- Scope of the Insurance Ombudsman Rules 2017 :

Non-refund of interest charged on delayed payment of premium due to negligence on part of

insurer after change of mode of payment of his policy& Non-cooperation of the Agent concerned to

provide policy servicing – 13 (1) (f)


i) Complaint letter ii) P – form

iii) Proposal papers iv) SCN of the Insurance Company.

21) Result of hearing with both parties (Observations & Conclusion):

Both the parties attended the hearing on 06-02-2020 at the Office of the Insurance Ombudsman,

Kolkata.

The Complainant emphasized during the course of hearing that he applied for mode of payment of

premium of his policy from yearly to monthly ECS by depositing alteration fees on 20-06-2016 and

deposited 1st monthly premium due on 20-07-2016 over the counter on 05-07-2016. He was assured

by the insurer that the premium from next month onward would be deducted from his Bank a/c.

through ECS. But the deduction of premium from his Bank a/c. through ECS was not effected and

the Insurance Company never informed him about the gaps being generated in paying the premium

for 15 months. The policyholders have to depend on the Agents for these servicing related aspects

but he was totally frustrated by the indifferent attitude of his Agent. He finally went to insurance

office himself and arranged for payment of 15 monthly dues on 30-10-2017 with interest on

premium of Rs.3,528/- and GST of Rs.1,513.64. Thus he had to suffer the loss in terms of interest

and GST amounting to Rs. 5041.64 though the responsibility for this delayed payment of premium

goes to the Insurance Company itself for not informing him the gaps time to time.

The representative of the Insurance Company in his submission during the course of hearing

reported that the 1st ECS instalment premium was dishonoured by the Banker of the Complainant

which was duly intimated to the Complainant through Speed Post. He furnished documents

showing ECS Dishonour Despatch details of this policy under Complaint for settlement date 28-08-

2016 referring Speed post no. EW288743139IN sent to the Complainant on 08-09-2016. A Bank

charge of Rs.125/- was deducted from his account as a consequence of dishonoured payment

mandate due to insufficient fund.

He also mentioned that the concerned Agent of this policy was terminated on 01-11-2015 i.e. well

before the Complainant applying for change of mode of payment of premium of his policy.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both

the parties during the course of hearing, it is observed that the change of mode of payment

from yearly to monthly ECS was done by the insurer in due time on 05-07-2016 after receiving

the alteration fee on 20-06-2016. The first ECS deduction of premium from the Bank Account

of the Complainant was dishonoured by his Banker due to insufficient fund and the same was

intimated to the Complainant through Speed Post by the insurer. Thereafter the Complainant

deposited 15 monthly instalments with interest on 30-10-2017 for premium due on 08/2016 to

10/2017. As a part of the contract it is the primary responsibility of the policyholder to pay the

premium. But in this case the Complainant delayed to meet his responsibility of the contract

by paying the premium after receiving the dishonour notice from the insurer. He cannot

justify his delay in paying the premium for not receiving intimation from insurer repeatedly

during these 15 months as he must be aware that his Bank Account had not been debited with

the premium amount for such a long period of time. Further the amount of premium paid late

by the Complainant was held by him for this period of delayed payment. The Insurance

Company is supposed to pay the full benefit of the policy in terms of reversionary bonus to the

Complainant for this period of delayed payment of premium.

As such the claim of the Complainant to refund the interest part with GST on interest is not

justified.

Hence, the complaint is treated as disposed of without providing any relief to the

Complainant.



As per Rule 17(6) of the Insurance Ombudsman Rules 2017, the Insurer shall comply with the

Award within 30 days of the receipt of the award and shall intimate the compliance of the same to

the Ombudsman.

Sd/-

Dated at KOLKATA on 10th day of February 2020. P.K.Rath

INSURANCE OMBUDSMAN


SIKKIM and A&N ISLANDS

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKIM, A&N ISLANDS


OMBUDSMAN – MR.P.K.RATH

CASE OF MR. JITENDRA NATH BARIK

V/S

LIC of INDIA




Complainant

Mr. Jitendra Nath Barik

P-12, Tagore Park, Dr. R.N.Tagore Road,

PO-Sodepur, Road No.5,

Kolkata – 700 056, West Bengal.

Mobile No. 98313 49513

2. Policy No:


494726080




Mr. Jitendra Nath Barik

----------------------Do------------------------------

4. Name of the insurer LIC of INDIA (KMDO-I)




8. Nature of complaint Dispute with regard to payment of surrender value.

9. Amount of Claim Rs.1,00,000


11. Amount of relief sought Rs.1,00,000 (Purchase Price) as per P-form


Insurance Ombudsman Rules’ 2017 13 (1) ( a )

13. Date of hearing/place 06-02-2020 AT KOLKATA


For the Complainant Mr. Jitendra Nath Barik

For the insurer Ms. Mohua Bhattacharya, Manager (CRM),

LICI, KMDO-I





ix) That the Life Assured decided to invest in profitable & beneficial Market Plus-I Policy (ULIP)

with onetime payment of Rs.1 lakh by cash to the Agent of Life Insurance Corporation of India

attached to City Branch Office – 19 under KMDO-I.

x) That the money was deposited by the Agent to the office of the insurer on 28-06-2010.

xi) That the policy document and the first premium receipt were received by the Complainant

from the Agent after 2/3 months of depositing the money.

xii) That he got a letter from the Insurance Company on 23-05-2014 informing him for the first

time that the First/Single premium received under the aforesaid policy had not been paid to LIC

of India in proper procedure and also the matter was being investigated at their end which was

just like a bolt from the blue to him. He immediately contacted the Agent who told him that he

got the same information earlier but did not share it with him.

xiii) That as per instruction in the letter, he then met with the Manager (CRM) of KMDO-I on

27-05-2014 and handed over the required documents like the policy document, First Premium

Receipt, Proposal Deposit Receipt, KYC documents etc. along with his observation regarding

mode of payment (by cash /cheque) and to whom the payment was made.

xiv) That despite submitting all the documents on 27-05-2014, he again received a reminder

letter from the insurer on 21-01-2015 for furnishing the same documents within 7 days failing

which further action would be taken against the policy without giving him any further

intimation. He responded the same on 29-01-2015 through e-mail.

xv) That he also received a notice dated 01-07-2014 u/s 160 Cr.PC and 91 Cr.PC from the Sr.

Branch Manager, CBO-19 to appear before CBI investigation at Nizam Palace, Kolkata with

source of money paid by cash (>50,000/-) to purchase the policy along with Income Tax return,

PAN card etc.

xvi) That he is a senior citizen suffering from COPD, Hypertension etc. and needs money for his

medical treatment. So, he wants his invested money back from the Insurance Company

immediately.

Being dissatisfied with the insurer’s indifference to pay the surrender value of his policy, the

complainant has now approached this forum for redressal of his grievance.


Policy No. 494726080

Name of Life Assured Jitendra Nath Barik

Plan/Term/PPT Market Plus - I

191 / 10 / 01

DOC 28-06-2010

Proposal No. 4880

Date of proposal 28-06-2010

Premium/Mode 1,00,000/ Sgl

Sum Assured NIL

Name & Code No. of Agent Mr. Soumendra Chakraborty

(07738/412)

18) Cause of Complaint: Due to non-payment of surrender value of policy.


Insurers’ argument: No response /SCN received yet.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017:

Partial or total repudiation of claim by insurer – 13 (1) (b)


ii) Complaint letter ii) P – form

iii) Proposal papers iv) SCN received on the date of hearing

21) Result of hearing with both parties (Observations & Conclusion)

Both the parties attended the hearing on 06-02-2020 at the Office of the Insurance Ombudsman,

Kolkata.

The Complainant introduced himself as a retired Inspector of Kolkata Police. He stated that he is

regular investor in LIC of India and after retirement from service he contacted Sri Soumendra

Chakraborty, his known Agent of LIC of India, for purchasing a retirement policy for him. He

handed over to the Agent an amount of Rs.1 lakh in cash for purchasing a single premium Market

Plus I policy and the amount was deposited to the insurer by the Agent on 28-06-2010. The First

Premium Receipt & the Policy document were given to him by the Agent after 2/3 months. After 3

years in April 2014, the Agent asked him to give him a copy of the First Premium Receipt which he

did. He got a letter on 23-05-2014 from Sr. Divisional Manager of LIC, KMDO-I informing him for

the first time that the premium received under the policy had not been paid to LICI in proper

procedure and matter was being investigated at their end. On 07-07-2014 he received a letter from

the Sr.Branch Manager, CBO-19, requesting him to appear for examination by the CBI in respect of

source of money for the policy, his PAN card & Income Tax Return. He wants his policy money

back immediately.

The representative of the Insurance Company submitted during the course of hearing that the

aforementioned policy was fraudulently generated by utilizing LIC’s fund. After detection of the

fact that a good number of policies have been issued to different persons by misappropriating LIC’s

fund, the corporation then approached CBI to investigate the matter. A case bearing

No.RCO10102013A0035-CBI, ACB Kolkata has been registered by CBI subsequent to the

detection of fraud for mis-utilization of fund for issuing policy to different persons. CBI made an

investigation and submitted charge sheet in respect of the said case. The Corporation has

implemented the charge sheet issued by CBI. The case is still pending.

The representative of the Insurance Company also pointed out that the Complainant had stated that

the first premium was paid by cash but there has been no substantial evidence for making payment

in cash. Since there is discrepancy in the origin (first premium) of the policy no.494726080, they

cannot proceed for payment.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both

the parties during the course of hearing, it is observed that there is a significant discrepancy

in mode of payment of premium by the Complainant in respect of the policy under

complainant. The Complainant reported that he had paid the premium by cash to the Agent

whereas the first premium receipt issued by the Insurance Company shows that the amount

was received by cheque for the said policy. The Insurance

Company also reported that the policy was generated by utilizing their own fund like a good

number of other policies which were issued to different persons by misappropriating their

fund and subsequent to detection of fraud the matter was investigated by CBI. The case is

reported to be pending after issuance of charge sheet by CBI.

As such this is a case where monetary transaction is disputed by the Insurance Company

which may be caused by some fraudulent activities and the same is currently under judicial

consideration in other court of law.

Hence, the complaint is not maintainable on the same subject matter on which proceedings

are pending before any other court of law u/s 14(5) of I.O.Rules,2017 and the complaint is

treated as disposed of without providing any decision.





the Ombudsman.

Sd/-

Dated at KOLKATA on 19th day of February 2020. P.K.Rath

INSURANCE OMBUDSMAN


SIKKIM and A&N ISLANDS

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKKIM, A&N ISLANDS


OMBUDSMAN – P. K. RATH

CASE of RADHA RAMAN GHOSH V/S LIC of INDIA




Complainant

Mr. RADHA RAMAN GHOSH

92/1, MAULANA ABUL KALAM AZAD SARANI’

RUKMANI APARTMENT, FLAT- 10RC, KOLKATA

WEST BENGAL -700054

MOBILE NO. - 9831816751

2. Policy No:


496194103 DETAILS ARE IN THE TABLE



Mr. RADHA RAMAN GHOSH

SELF

4. Name of the insurer LIC OF INDIA

5. Date of Repudiation Not Applicable 6. Reason for repudiation Not Applicable 7. Date of receipt of the Complaint 26/09/2018 8. Nature of complaint Less Settlement of Foreclosed amount-13(1)(f)&(i) 9. Amount of Claim Rs.130126/

10. Date of Partial Settlement ---

11. Amount of relief sought Not Specified


Insurance Ombudsman Rules’ 2017 13 (1) (f)&(i)

13. Date of hearing/place 18/02/2020, AT KOLKATA 14. Representation at the hearing

For the Complainant Mrs. ANURADHA GHOSH (WIFE) For the insurer Mr. GOUTAM NANDAN

15 Complaint how disposed BY CONDUCTING HEARING 16 Date of Award/Order 19/02/2020


Pol No L.A. PLAN DOC Premium (Yly)

Term /PPT

1ST Comp to Ins Co

496194103 Mr. Radha Raman Ghosh

Ulip 10/03/2010 Rs. 1.5 lakh

08/03

26/09/2018


a) That he took a ULIP policy from LIC Arambagh Branch on 10/03/2010, for a term of 8 years

& premium paying term 3 years.

b) That, he could not pay the subsequent 2 yearly premium after paying the first premium

Rs.150000/ due to some unavoidable circumstances.

c) That, LIC took foreclosed action on 10/03/2013 due to nonpayment of consecutive

premiums.

d) That, LIC gave neither any intimation about the foreclosed action nor paid the foreclosed

amount as on 10/03/2013 to him.

e) That, the LIC instead of remitting the foreclosed amount, put the money as unclaimed

amount without giving any intimation to him.

f) That, LIC settled the unclaimed amount on 18/04/2018 and the amount is Rs.130126/ which

is less than the one

g) yearly premium paid.

h) As LIC did not pay the foreclosed amount on 10/03/2013 and without giving any intimation

to the policy holder, LIC kept the money with itself as unclaimed amount for 5 years, he is

entitled to get interest for the entire 8 years with bonus.

i) That, he is not satisfied with the reply of the Manager CRM, Howrah Division vide letter

dated 15/09/2018.

Being aggrieved, the complainant has now approached this forum for redressal of his grievance.

18) Cause of Complaint: Due to less payment of Foreclosed amount of the policy.


Insurer’s Argument: SCN not yet received. However vide letter dated 15/09/2018, the Mgr

(CRM) of Howrah Division clarified their payment as O.K.


Dispute over Less Payment of claim under rule – 13 (1) (f) &(i).


iii) Complaint letter, ii) Complaint letter lodged to Insurer, iii) P form, v) Reply of the Insurer.


Complainant’s Submission:

The wife of the complainant repeated all the points as mentioned in the complaint letter dated

26/09/2018. She questioned why the Insurer took the forecloser action without intimating the policy

holder and also why LIC did not pay the amount just after taking foreclosed action. She demanded

interest for the entire 5 years at an increased rate.

Insurer’s Submission: The representative of the Insurer refering their letter dated 31/08/2018

addressed to the complainant, mentioned that everything was explained in that letter. In the question

of- “When the policy went to discontinued fund and what amount”, the Insurer replied that the

amount transferred to discontinued fund was Rs.117249/ after foreclose action and interest on this

fund allowed with effect from 01/10/2015 to 17/04/2018 at the then prevailing rate as decided by

IRDA. In the question of “Why the payment not made just after taking the foreclosed action”, the

Insurer could not provide any specific reply and also could not confirm anything about giving any

notice to the complainant after 10/03/2013. He added that total interest calculated on unclaimed

amount was Rs.12877/ and a TDS deducted @10% on total a Interest as the interest amount was

more than Rs.5000/ .

AWARD

Taking into account the facts & circumstances of the case and after going through the

documents on record and the submissions made by both the parties during the course of

hearing, it is observed that the amount Rs.117249/ after taking foreclose action, not paid to the

complainant as per terms and conditions of the policy but the amount was kept with the

Insurer in unclaimed account without taking any follow up actions with the complainant.

Moreover, the Insurer paid interest on unclaimed amount w.e.f. 01/10/2015 as per interest

norms of discontinued fund.

Considering all the above, the Insurer is directed to calculate ‘interest’ on discontinued fund

from 10/03/2013 to 17/04/2018 at the then prevailing rate of savings bank interest + 2% extra

and to pay the balance interest to the complainant, under intimation to this office.

Hence, the complaint is disposed of.

The attention of the Complainant and the Insurer is hereby invited to the following provisions

of Insurance Ombudsman Rules, 2017:



the Ombudsman.

Dated at KOLKATA, the 19th day of February 2020.

S/d

P. K. RATH

INSURANCE OMBUDSMAN

FOR THE STATE OF WEST BENGAL, SIKKIM AND A&N ISLANDS

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKIM, A&N ISLANDS


OMBUDSMAN : Shri P.K. RATH

CASE OF KRISHNA SAHA V/S LIFE INSURANCE CORPORATION OF INDIA




Complainant

Mrs. Krishna Saha

W/o Late Nitai Saha, C/o Matri Bastralaya,

Vill : D/Rampur, PO : Barobisha, PIN : 736207

2. Policy No:


457963134




Nitai Saha

Self

4. Name of the insurer Life Insurance Corporation of India, Jalpaiguri Div.

5. Date of Repudiation Not Applicable

6. Reason for repudiation Not Applicable


8. Nature of complaint Dealy in settlement of claim

9. Amount of Claim Could not be ascertained


11. Amount of relief sought Penal interest for the period of delay in settlement +

Rs 10,000 for mental agony


Insurance Ombudsman Rules’ 2017

13 (1) ( A )

13. Date of hearing/place On 07-02-2020 at SILIGURI


For the Complainant Ms Krishna Saha

For the insurer Mr Ashoke Paul, AO




Pol No L.A. PLAN DOC Premium (yly)

Term /PPT

1ST Comp to Ins Co

457963134 Nitai Saha Endowment Assurance

08-11-2013 Rs 36,433 16/16 yrs 10-06-2017

Sum assured : Rs 5,00,000/-

Date of death : 18-02-2016

Duration of policy : 2 years 3 months 10 days

Date of death intimation : 19-03-2016

Date of payment of claim : 16-03-2018

Amount of death claim paid : Rs 5,63,000/- (SA + Bonus)


i) That the above policy was purchased by her deceased husband from the Alipurduar Branch Office of

LICI. That her husband unfortunately expired on 18-02-2016 and intimation of the same was sent to the

insurer’s branch office on 19-03-2016.

ii) That all necessary requirements were submitted to the insurer in June 2016 and after several persuasions

the claim was settled on 16-03-2018.

iii) That when she asked for penal interest due to delay in settlement, the insurer replied that penal interset is

not payable due to non-compliance of queries made by the insurer vide their letters dated 22-09-2016, 19-

12-2016, 15-06-2017, 09-11-2017 and 27-11-2017.

iv) That she has not received any of the above correspondences sent by the insurer. That when she asked for

RL no of the aforementioned letters the insurer replied that the queries were sent by ordinary post.

v) That on receipt of her e-mail in February’ 2018 the claim was settled on 16-03-2018 without submission

of any requirement as called for. As such it is requested that the insurance company may be directed to

pay penal interest for delay in settlement of claim.

18) Cause of Complaint: Due to delay in settlement of claim.

Complainants argument : In point No. 17 it is mentioned categorically.

Insurers’ argument: As per SCN received from the insurer –

i) The death of the life assured took place on 18-02-2016 and the nominee submitted claim

papers in June 2016.

ii) The life assured died due to Cerebral vascular accident and died at his own residence.

Post Mortem Examination has been done but PMR photocopy has not been submitted by

the claimant. A police report has been submitted.

iii) As per proposal form the DLA’s educational qualification was HS Pass but the column

of nature of age proof is blank. A Transfer Certificate of a primary school has been

submitted.

iv) The competent authority decided on 22-09-2016 to call for the following documents

a. All treatment particulars during the period from 31-12-2010 to 31-12-2013.

b. Photocopy of Post Mortem Report.

c. Photocopy of HS pass certificate, Admit card

v) The complainant did not submit the requirements called for vide item nos (a) & (c)

above. She replied vide her letter dated 28-11-2016 that DLA did not take any treatment

during the last 10 years before the date of death.

vi) The competent authority decided to call for requirements (a) and (c) and accordingly

reminder letters were sent to the claimant on 19-12-2016. The complainant replied vide

her letter dated 14-06-2017 that DLA did not meet any doctor from 31-12-2010 to 31-

12-2013 so she does not have any treatment particulars. She also replied that she does

not have HS Pass Certificate and Admit Card of DLA.

vii) The competent authority decided on 15-06-2017 to call for authenticity of School

Certificate from the relevant School and accordingly letter was sent to school authority

on 20-06-2017. As no reply was received reminders were sent on 09-11-2017 & 28-11-

2017 but no reply has been received and the letters have been returned undelivered.

viii) To avoid further delay the claim was admitted on 06-03-2018 and payment was made

to the complainant on 16-03-2018.

ix) Being custodians of the policyholders’ money it was tried to make all possible steps to

verify the bonafide of the claim as the sum assured was high. As such considerable time

was taken to settle the claim and so no reason is found to pay penal interest as claimed

by the complainant.


Dispute over premium paid or payable in terms of insurance policy – 13 (1) (c)


i) Complaint letter ii) P – form iii) Proposal papers

iv) SCN v) Post mortem report vi) Police Report

vii) Copies of correspondences between the two parties


Both the parties were present and participated in the hearing.

The representative of the insurance company submitted that on verification of the relevant

proposal form it was found that the field pertaining to nature of age proof was blank and as the

deceased life assured (DLA) had mentioned his educational qualification as HS Pass the same

document was sought from the claimant. He further stated that the claimant could not provide

the HS Pass Certificate of her deceased husband and she replied to the insurer on 14-06-2017

that she is unable to submit the same. The insurer’s representative further submitted that the

claim investigation in this instant case was delayed as because the complainant was not available

at her address mentioned in the policy document and had perhaps gone to her native place in

Assam and as such the Investigating Officer (I.O.) could not obtain all the required documents

and complete the investigation earlier.

The complainant cum claimant stated that she had to go to her native place in Assam to obtain all

the relevant documents which were called for by the insurance company as they had originally

migrated from Assam to West Bengal. She added that this had resulted in delay in submitting her

reply to the insurer. The complainant further stated that even though she had submitted the

documents which were in her possession and had informed the insurance company that she

cannot provide any other document the claim was delayed and it was only after several rounds of

persuasions the claim was settled on 16-03-2018.

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 death claim intimation was made on 19-03-2016 and thereafter the nominee

submitted all death claim papers in June 2016. This fact has not been denied by the insurance

company. The insurance company had called for requirements on 22-09-2016 and the

complainant had replied on 28-11-2016 stating that she does not have the required documents

pertaining to treatment of her deceased husband as no such treatment was undertaken.

The aforementioned fact is also confirmed by the Post Mortem report as well as the Police

Report both of which state that the Policyholder had died at his residence due to Cerebra

Vascular Accident (C.V.A.) - natural disease cause. The internal investigations carried out by

the insurance company could not reveal anything to the contrary. As such, it was unjustified

on the part of the insurer to go on insisting with the requirement of documents pertaining past

treatment particulars of the deceased life assured. Similarly the complainant had clearly

stated in her letter dated 19-12-2016 that she does not possess the HS Pass Certificate and

Admit Card of her deceased husband. The insurer could not obtain any definite information

in this aspect which would establish the fact that there was an active concealment of actual

age of the deceased life assured. There is no documentary evidence to establish the fact that

the deceased life assured made a deliberate understatement of age with the malafide intent to

obtain high value insurance cover from the insurance company.

From the above, prima facie, it is evident that there has been a direct violation of Section 8(3)

of IRDA (Protection of Policyholders’ Interests) Regulations, 2002 and section 14.2(i) of

IRDAI (Protection of Policyholders’ Interests) Regulations, 2017.

In view of all the above, the insurer is directed to pay interest @ 2% above bank rate on the

claim paid amount of Rs 5,63,000 from the date when reply to queries was provided to the

insurer by the complainant i.e. 19-12-2016 to the date of actual payment of interest.

Hence, the complaint is treated as disposed of.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of


As per Rule 17(6) of the Insurance Ombudsman Rules 2017, the Insurer shall comply with

the Award within 30 days of the receipt of the award and shall intimate the compliance of

the same to the Ombudsman.

Dated at KOLKATA on 17th day of February’ 2020.

P.K. RATH

INSURANCE OMBUDSMAN

FOR THE STATE OF WEST BENGAL, SIKKIM and A&N ISLANDS

PROCEEDINGS BEFORE




CASE OF RIVA JAIN V/S LIFE INSURANCE CORPORATION OF INDIA




Complainant Ms Riva Jain

C/o Ganeshmal Ajit Kumar Jain,

Rangpur Road, Ward No. 14, PO : Dinhata,

PIN : 736135, Cooch Behar, West Bengal

2. Policy No:


455988312



Name of the proposer Mrs Riva jain

Self

4. Name of the insurer Life Insurance Corporation of India, Jalpaiguri Div.

5. Date of Repudiation Not Applicable 6. Reason for repudiation Not Applicable 7. Date of receipt of the Complaint 23-09-2019 8. Nature of complaint Dispute with regard to excess premium paid 9. Amount of Claim Rs 4600/-


11. Amount of relief sought Rs 4600 + Interest


Insurance Ombudsman Rules’ 2017 13 (1) ( C )

13. Date of hearing/place On 07-02-2020 at SILIGURI 14. Representation at the hearing

For the Complainant Mr Ajit Kumar Jain (Father) For the insurer Mr Ashoke Paul

15 Complaint how disposed BY CONDUCTING HEARING 16 Date of Award/Order 14-02-2020


Pol No L.A. PLAN DOC Premium (yly)

Term /PPT

1ST Comp to Ins Co

455988312 Riva Jain Jeevan Anand 28-02-2011 Rs. 26,168 @@

69/21 yrs 09-08-2019

@@ Revised annual premium Rs 25,593


vi) That the above policy was purchased by her from Dinhata Branch Office of LICI with annual premium of

Rs 26,168 payable for a period of 21 years. That subsequently the installment premium was rectified by

the insurance company and it was reduced to Rs 25,593. vii) That the abovementioned premium rectification was effected by the insurer on 08-03-2019

and by this time eight yearly installments of premium had already been paid.

viii) That the complainant requested to the insurance company for refund of Rs 4600 [(Rs 2616 –

Rs 25593) 575 x 8] along with interest. But the insurer has not heeded to her request.

As such, the complainant has now approached this forum for redressal of her grievance.

18) Cause of Complaint: Non-refund of excess premium.

Complainants argument : In point No. 17 it is mentioned categorically.

Insurers’ argument: As per SCN received from the insurance co –

i) The premium was rectified as per internal audit report, after taking consent of the

insured. After lowering of premium one installment has been deposited by the

complainant on 12-03-2019.

ii) Application for refund of excess premium of Rs 4600 paid earlier has been received

from the complainant and the same has been approved after due scrutiny. For making the

payment letters have been sent to the complainant on 14-10-2019 and again on 01-11-

2019 for collection of Bank Details.

iii) However the Bank details have not been submitted. The complainant has been contacted

over mobile several times but she is not giving his bank details.

iv) As such, the refund of excess premium could not be effected due to non receipt of bank

details from the complainant.


Dispute over premium paid or payable in terms of insurance policy – 13 (1) (c)


ii) Complaint letter ii) P – form

iii) Proposal papers iv) SCN

v) Copies of correspondences made between the insurer and complainant.

vi) Policy document


Both the parties were present and participated in the hearing. The complainant was represented

by her authorised representative and father Mr Ajit Kumar Jain whereas the insurer was

represented by their official named in 14 above.

The complainant’s representative repeated the allegations against the insurance company which

the complainant has already mentioned in her complaint letter. He submitted that although the

complainant had lodged complaint with the insurer’s Divisional Office and Zonal Office, her

grievance has not been redressed. The representative submitted that as the insurer had contacted

the complainant only after the complaint had been lodged to the Ombudsman she decided to wait

for outcome of the same.

The insurer’s representative submitted that they have already communicated to the complainant

that they are willing to refund the excess premium and had asked for her bank details. He stated

that telephonic contact was made with the complainant but she did not comply with the

requirement. He further submitted that payment could not be made as because the relevant bank

details have not been made available by the complainant.

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 insurance company issued the first letter regarding intimation of refund

and calling of bank details to the insured cum complainant on 14-10-2019 whereas she had

lodged written complaint to the insurer on 09-08-2019 and thereafter she had submitted

complaint to the Office of the Insurance Ombudsman on 23-09-2019. As such, delay on the

part of the insurance company in redressing the genuine grievance of the complainant stands

established.

As such, the insurer is directed to refund the excess premium amount of Rs 4600/- to the

complainant along with interest thereon at 2% above bank rate from 09-08-2019 to the date of

making actual payment

Hence, the complaint is disposed of.

The attention of the Complainant and the Insurer is hereby invited to the following provisions of


As per Rule 17(6) of the Insurance Ombudsman Rules 2017, the Insurer shall comply with

the Award within 30 days of the receipt of the award and shall intimate the compliance of

the same to the Ombudsman.


P.K. RATH

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKKIM, A&N ISLANDS


OMBUDSMAN – P. K. RATH CASE of UDAY SANKAR PAUL V/S LIC of INDIA

COMPLAINT REF: NO: 1) KOL-L-029-1819-0547 AWARD NO: 1) IO/KOL/A/LI/ 0589 /2019-2020


Complainant

Mr. UDAY SANKAR PAUL

OAISHA COMPLEX-II, FLAT NO. -3A, 3RD FLOOR,

C1-185/A, NEW SANTOSHPUR, ROAD-1,

P.O- BIDHAN GHAR, KOLKATA-700066

MOBILE NO. -9674006790

2. Policy No:


839893262




MR. UDAY SANKAR PAUL

SELF

4. Name of the insurer LIC OF INDIA

5. Date of Repudiation Not Applicable

6. Reason for repudiation Not Applicable


8. Nature of complaint Less Payment of Interest on Annuity – 13(1)(i)

9. Amount of Claim Rs.720/


11. Amount of relief sought Rs.720/ + Interest thereon


Insurance Ombudsman Rules’ 2017

13 (1) (i)

13. Date of hearing/place 18/02/2020, AT KOLKATA


For the Complainant Mr. Uday Sankar Paul

For the insurer Mr. Ashesh Ghosh


16 Date of Award/Order 19/02/2020


Pol No L.A. PLAN DOC Annuity yearly

PLAN & TERM

1ST Comp to Ins Co

839893262 Mr. Uday Sankar Paul

189

28/08/2016 Rs.7020/ ----

28/05/2018


a) That the first Annuity which falls due on 28/08/2017has been paid by LIC on 01/11/2017, ie

after 64 days.

b) That, the Interest what LIC paid for delayed settlement is Rs.547/ but actually it should have

been Rs.1267/ as per complainant. So, Rs.720/ paid less as Interest.

c) That, he lodged complaint to Sarsuna Branch on 17/11/2017 for settlement of the difference

of Interest but till date, no reply obtained by the complainant.

d) Being aggrieved, the complainant has now approached this forum for redressal of his

grievance.

18) Cause of Complaint: Due to less payment of Interest on delayed settlement of Annuity..


Insurers’ argument: SCN not yet received. So, Insurer’s view can’t be furnished.

19) Reason for Registration of Complaint:- Scope of the Insurance Ombudsman Rules 2017:

Dispute over less payment of interest on delayed settlememt of Annuity rule 13 (1) (i).


iii) Complaint letter, ii) Complaint letter lodged to Insurer, iii) P–form, iv) copy of policy bond


The complainant repeated all the points as mentioned in his complaint letter dated 28/05/2018.

He also complained that the officials of LIC Sarsuna Branch as well as the Pension Cell at C R

Avenue harassed him day by day like a shuttle cock to get his delayed interest claim but even after

that LIC did nothing towards settlement of his grievances. He alleged that he had lost his valuable

time, energy & money and also suffered humiliation while moving to one office to other. He

appealed to this forum for giving him a compensation of Rs.1000/ towards his harrashment apart

from his demand of balance Interest Rs.720/.

Insurer’s Submission:

The representative of the Insurer informs that they have already settled the matter by paying the

difference of Interest Rs.720/ as per the demand of the complainant, on 11/02/2020 vide NEFT

crediting A/C number xxxxxxx0262 of Canara Bank, Santoshpur Branch and credited on

15/02/2020 (UTR number is N042201062555126). In the question of “Why LIC paid less interest

initially”, the representative replied that initial payment made on the basis of module interest. He

also clarified that final payment of interest made on the basis of Jeevan Akshay annuity rate which

is much higher than the savings bank interest rate. The Insurer appealed for closure of the complaint

as the balance interest already paid.

AWARD

Taking into account the facts & circumstances of the case and after going through the

documents on record and the submissions made by both the parties during the course of

hearing, it is observed that the Insurance Company has already settled the balance amount

Rs.720/ to the complainant and the rate of interest on delayed payment of annuity given is

much higher than the savings bank interest rate.

Considering all the above, the complaint is treated as closed without giving any furthur relief

to the complainant.

.Dated at KOLKATA, the 19th day of February 2020.

S/d

P. K. RATH

INSURANCE OMBUDSMAN

FOR THE STATES OF WEST BENGAL, SIKKIM & UT of A & N ISLAND

PROCEEDINGS BEFORE




CASE OF BABULAL DHAREWA V/S MAX LIFE INSURANCE COMPANY LTD




Complainant

Mr. Babulal Dharewa

S/o: Late Jiwraj Dharewa,

Ward No. 4, Sitalkuchi Road, P.O.-Mathabhnga,

Dist.-Cooch Behar, West Bengal, PIN-736146,

Mob. No.-9434444044.

2. Policy No:

Type/Duration/Policy period

Pol. No.-271292989

Details of the policy are given in the table below.



Mrs. Puspa Dharewa (Wife)

Mr. Babulal Dharewa.

4. Name of the insurer Max Life Insurance Co. Ltd., Gurgaon.

5. Date of Repudiation N.A.

6. Reason for repudiation N.A.

7. Date of receipt of the

Complaint 09/07/2018-- at the office of Ins. Ombudsman

8. Nature of complaint Alleged non-adjustment of Renewal Prem. for Aug.,

2017.

9. Amount of Claim Rs.55,000/- (For adjustment of premium)


11. Amount of relief sought Rs.55,000/- (For adjustment of premium)


Rule of IOR, 2017. 13 ( 1 ) (f)

13. Date of hearing/place 07-02-2020 at Siliguri


For the Complainant Mr. Babulal Dharewa

For the insurer Jitendra Kr Garna & Dr. Ashutosh Subhash Bhurke

15. Complaint how disposed BY CONDUCTING HEARING

16. Date of Award/Order 13-02-2020

17) Brief Facts of the Case: The complainant alleged on the following points:--

i) That he had purchased one traditional Money Back cum Endowment (Participating) Policy in

Aug, 2015 at Annual premium of Rs.61,050.10/- payable for 10 yrs.

ii) That he was offered discount @10% on renewal premium in Aug., 2017 by an intermediary over

phone and he paid the premium accordingly by remitting a sum of Rs.55,000/-( availing the

discount) by RTGS on 17-08-2017 through Central Bank of India, Mathabhanga Branch towards

renewal premium due Aug.,2017 for crediting the same to Co.’s A/c No.91922010008031

maintained with Synd. Bank, New Delhi.

iii) That later he learnt from the Ins. Co. in Sept.,2017, that the said amount had not been received

by them and the premium still remained unpaid. He was also issued one policy lapse intimation

letter on 27-09-2017 by them. He sent an e-mail to Axis Bank on 12-10-2017 in reply, followed by

one legal notice to the Co. on 16-11-2017.

iv) He lodged complaint with the Ins. Co. on 17-05-2018, but the problem remains unresolved.

Finally, being aggrieved, he got his complaint registered with this forum on 09/07/2018 for

redressal.

Details of the policy issued: --

Pol. No. & DOC 271292989 & 21-08-2015

Plan Name Max Life – Life Perfect Partner Super – 10 Pay

Name of Policyholder/Life assured Mr.Babulal Dharewa / Mrs.Puspa Dharewa

PT/PPT Yrs. 22/10

Inst. Prem. & Mode 61,050.10/- & Yly

Sum Assured 2,69,906/- (Maturity SA)

Date of Complaint to Insurance Company 17-05-2018

No. of premium paid 2

Duration 2 years 9 months

Policy Issue Date 21-08-2015

Name of Broker/ Agent. Axis Bank Ltd., Coochbehar,West Bengal,

Code No.-381217

18) Cause of Complaint: Alleged non- adjustment of premium in respect of Aug., 2017.

a) Complainant’s argument : Already briefed under point 17

b) Insurer’s argument: The findings of the Insurance Company as per SCN are as follows:

i) That 2nd yearly instalment premium was directly deducted from the bank account of the

complainant as mandated by him in proposal form. The 3rd instalment due on 21-08-2017 was

not received due to ECS bounce and the intimation of non-payment of the said instalment

premium was communicated to the complainant six times.

ii) That the complainant received a call from fraudsters on behest of the respondent company

with an offer to deposit the 3rd instalment premium at a discount 10%. In spite of being a well

educated person he fell prey to this trap out of greed to avail the discount of few thousand

rupees and transferred Rs.55,000/- to an unauthenticated bank account no. 396010100027131

of AXIS Bank through NEFT without verifying anything in this regard which was never

received by the respondent company.

iii) That the Complainant was advised to lodge complainants with the concerned banks and

with concerned police authorities since the Respondent Company did not receive the alleged

amount of Rs.55,000/-. The Company, on their own, lodged a complaint with the Bank in

whose account the Complainant had deposited the said amount as well.

iv) That the complainant could realise that he had been deceived by the miscreants and

suffered the loss due to his own foolishness only on receiving the reminder from respondent

company regarding non-payment of premium.

v) That the complainant became victim due to his own negligence and as such the respondent

cannot be penalized for the misdeeds of complainant himself.

vi) That the policy stood lapsed as the Complainant failed to make payment of the 3rd

instalment due on 21-08-2017 in spite of several reminders. The Complainant approached the

Company for revival of his policy in January 2019 and the policy was revived on payment of

Rs.1,22,700/-. Hence, the complaint should be dismissed.

19) Reason for Registration of Complaint: Scope of Insurance Ombudsman Rules, 2017.

13 (1) (f)-Other servicing aspect of the policy-alleged non-receipt of renewal premium and its

adjustment.


a) Complaint letter to the Ombudsman & the GRO of the Ins. Co.

b) Annexure-VI A/ P Form.

c) Correspondences by e-mail/ letters.

d) Copies of the FPR/Proposal/Policy Schedule.

e) Copies of the Legal notice dt.16-11-2017 and its reply dt. 21-12-2017.

f) Copy of the Fund Transfer RTGS sheet dt 17-08-2017, evidencing the remittance of amount of

Rs.55,000/-

g) SCN of Insurance Company.

21) Result of hearing with both parties (Observation & Conclusion):-

Both the parties were present and participated in the hearing.

The complainant stated that he was a small trader located at Mathabhanga, West Bengal and had

purchased the policy through Axis Bank. He further submitted that he has already paid two

premiums and thereafter he had received a communication offering him 10% discount towards

payment of the third premium. He admitted that he was induced with the offer as it provided him

with an opportunity to save money towards the renewal premium of the policy and accordingly

transferred an amount of Rs 55,000 through RTGS to a designated Bank account. The

complainant added that after some time when he received reminder from the insurer for payment

of due renewal premium he realized that he has been cheated and tried to lodge FIR with

Coochbehar police but was informed that he has to lodge the same with Cyber Crime Cell of

Siliguri Police. The complainant submitted that he did not further pursue the matter.

The insurer’s representative submitted that the amount of Rs 55,000/- has not been received by

the insurance company. They added that the complainant was requested to lodge complaint with

the Cyber Crime Cell of Police and that they would also help in further resolving the issue by

taking up the matter with the law enforcing authorities but the complainant has not done the

same. The insurer’s representatives stated that they are willing to fully co-operate with the

complainant in uncovering the truth provided he lodges police complaint.

AWARD

Taking into account the facts and circumstances of the case, the submissions made by both the

parties during the course of hearing and after perusal of the documents on record it is

observed that the complainant could not submit any receipt or documentary evidence of

payment / transfer of Rs 55,000/- into the insurance company’s account. It is also observed

that the amount paid by the complainant was credited into a third party account and the same

does not pertain to the Max Life Insurance Company Ltd. As such, the Insurance Company

cannot be made liable for this act.

Hence the complaint against the insurer has no merit and the same is dismissed without any

relief to the complainant.


P.K. RATH

INSURANCE OMBUDSMAN


proceedings before - the insurance ombudsman, lucknow

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