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. K.V. PRAKASH V/s BHARTI AXA LIFE INSURANCE COMPANY LIMITED Complaint No: BNG-L-008-1819 – 0346 & 0349 Award No: IO/BNG/A/LI/0119, 120/2019 -2020 1. Name & Address of the Complainant Mr. K.V. Prakash #3998/B, 2nd Cross, Near Ullala RTO, Vishwaneedam Post Bangalore -560091 (M):8235156864 / 8310504533 2. Policy No: 501-2845367 501-3712517 Type of Policy: Life Life Name of the Policy: Bharti Axa Life Secure Bharti Axa Elite Commencement of Policy/ Policy Income Plan Advantage Plan Period/PPT 16.02.2015 16.11.2015 Premium Amt 15 Years/05 Years 12 Years/12 years 54,000/- 46,000/-
3. Name of the Insured Mrs. K.P. Srilatha (Under both the policies) Name of the Policyholder 4. Name of the Respondent Insurer Bharti Axa Life Insurance Company Limited 5. Date of Repudiation/ Rejection 02.09.2016 6. Reason for repudiation/ Rejection Cancellation of policy beyond ‘Cooling Off Period’ not allowed 7. Date of receipt of Annexure VI-A 13.12.2018 8. Nature of complaint Issued new policy on a cheque which was issued towards renewal premium for old policy. 9. Amount of claim (1) ₹. 54,000/- (2) ₹. 46,000/- + Interest on both policies 10. Date of Partial Settlement N A 11. Amount of relief sought ₹. 1,00,000/- + Interest 12. Complaint registered under Rule No 13(1) (c) & (d) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 10/04/2019 - Bengaluru 14. Representation at the hearing a) For the Complainant Mr. Anchan – Son of the Complainant b) For the Respondent Insurer Mr. Kotresh –Area Sales Manager 15. Complaint how disposed Resolved 16. Date of Award/Order 02.07.2019
17. Brief Facts of the Case: The complaint emanated due to refusal of refund of premiums paid by the complainant while availing the said policies by the Respondent Insurer (RI). Though he represented his issues to the G.R.O. (Grievance Redressal Officer) of the RI, they stood by their earlier decision. Hence he has approached this Forum for redressal of his grievances.
18. Cause of Complaint: - a. Complainant’s argument: The Complainant in his complaint letter dated 04.12.2018 (copy of the Complaint addressed to RI) stated that he availed the 1st policy in the name of his wife bearing policy number 501-2845367 on
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16.02.2015 by paying an amount of ₹. 54,000/-. Later on 04.11.2015, the Complainant received a telephonic call from the representatives of the RI, wherein they informed him that the next premium on the said policy was due in February 2016, and if he paid the said premium before 15.11.2015 he would be eligible for a discount of ₹.8,000/. Subsequently, when the sales representatives of the RI visited the Complainant in person, without consulting anybody, the Complainant issued a cheque for ₹.46,000/- and mentioned the said policy number on the back of the cheque and the same was debited in his bank account also. These representatives also obtained the signature of the Complainant on ECS/Direct Debit mandate form. All along he thought that he had issued the cheque for renewal premium for the said policy. Though he received a speed post during December 2015, he did not open the tappal, as he was very much confident that the cheque he had issued during Nov 2015 was for renewal premium for the first policy. When the RI contacted the Complainant for payment of renewal premium on the first policy, he was in for a rude shock and when he opened the tappal, he found that it contained a new policy. When he contacted the representatives of the RI, they remained incommunicado. Hence, he has approached this Forum seeking cancellation of one of the policies and adjust the premium thereon towards the renewal premium on the other policy. b. Respondent Insurer’s argument: The RI vide their SCN received on 28.03.2019 has admitted to the issue of both the policies after receipt of all the requirements in order. The RI issued the said policy as per the requirements of the Complainant and despatched the same to the Complainant with ‘Cooling Off’ cancellation clause and the policy holder has received the same. The Complainant never reverted back to the RI and invoke the ‘Free Look Cancellation’ provision, but instead raised the complaint for the first time on 24.08.2016 i.e. after 1 year from the date of issue of the said policy, that the RI issued the 2nd policy from the cheque issued by the Complainant towards the renewal premium of the first policy and hence wanted to cancel both the policies and seeking refund of the premium thereon. After evaluating the complaint, and verifying their records, the RI expressed their inability to cancel the said policies, as the Complaint approached them beyond ‘Cooling Off’ period, no mis-selling was involved and the Complainant did not raise any issues during the PIVC call, and accordingly the RI replied to the Complainant vide their letter dated 02.09.2016. Thereafter the Complainant approached the G.R.O. of the RI, wherein the GRO ‘Upheld’ the earlier decision of the RI.
The RI further stated that they have put in place the PIVC (Pre-Issuance Verification Call), the core objective of this call being an exercise to confirm and satisfy at RI’s end, that the Complainant has understood the key features of the policy without any ambiguity and no grievance thereafter. The RI effected PIVC on the Complainants mobile number that was available as per their records and the Complainant did not raise any concern or issue and was in complete agreement with the terms and conditions of the policy.
The RI further stated that the RI is neither aware nor privy to the communication the Complainant had with the persons who are alleged to have given false representation to the Complainant, as there is no material proof submitted by the Complainant. The RI never issues policies which are at variance with the one that is stipulated by IRDAI as issuance of any policy which is in variance with provisions of the Regulator attracts penal action. Further the RI fully complies with regulation of Sec 41 of Insurance Act 1938. Further, the RI time and again has cautioned general public against false assurance given by fraudulent intermediaries through various media. In spite of these alerts, if the Complainant chose to transact with such people it would be at his own risk. Further the Complainant has never alleged any kind of ‘forgery’ and admitted of receipt of both the policies in time and hence the RI has no role in the allegation of Complainants ‘Mis-Selling’.
The RI has covered the risk for the duration for which the premium is paid and the policy has been issued as per the requirements of the Complainant, and he has approached the RI ‘Out of Free Look Page 2 of 113
Period’. The RI has conducted investigation and as there was not mis-selling activity involved, the Complainant is estopped from seeking cancellation of his policy. The allegations made by the Complainant is mere ruse to come out of the contract. For all the reasons mentioned therein, 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)(c)(d) 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 this is a case of mis-sale of the said policies.
During the personal hearing on 10.04.2019 the son of the Complainant informed the Forum that the sales representatives of the RI cheated his father and utilised the premiums paid by his father for issuing the new policies instead of adjusting the amount to old policies.
Since this was a distant – tele marketing sale, the forum asked the representatives of the RI to play PIVC calls (both Pre & Post Sale). But the RI did not have call recordings. This is in violation of guidelines on Distance Marketing of Insurance Products issued by IRDA vide their circular ADMN/GDL/MISC/059/04/2011 dated 05.04.2011.
From the records placed before the Forum, it is observed that the Complainant availed the first policy in the name of his wife bearing policy number 501-2845367 on 16.02.2015 by paying annual premium of ₹.54,000/- . The next premium was due on 16.03.2016. As per the Complainant version, he received a telephone call on 04.11.2015, that if the Complainant paid the premium due in Feb 2016 on the old policy, now ( i.e. during Nov 2015) the Complainant would be eligible for discount of ₹. 8000/- on the premium paid.
The Forum notes the Complainant should have been vigilant enough at the time of issuing the cheque. Without verifying the antecedents of the caller, the Complainant issued the cheque for an amount of ₹. 46,000/-. The RI, instead of adjusting the amount for the renewal premium due, on the old policy, issued a new policy.
The RI vide their mail dated 25.06.2017 have informed that they are ready to cancel the policies in question and issue a new single premium ULIP policy by transferring the funds from these policies after following due process. The new policy would not have ‘Free Look Cancellation’ option.
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 ’Resolved’.
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
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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 02nd day of July 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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 Mrs A B MADHURA PRASAD V/s LIFE INSURANCE CORPORATION OF INDIA Complaint No: BNG-L-029-1819-0597 Award No: IO/BNG/A/LI/0121/2019-2020 1. Name & Address of the Complainant Mrs. A B Madhura Prasad Sai Ra, D-102, Chartered Coronet 102/2,Arakere, MICO Layout L&T South City Main Road Bangalore - 560076 Mob # 9980567541/713844176 2. Policy No: 713844176 Type of Policy: Life Name of the Policy: Varishtha Pension Bima Yojana Commencement of Policy/Mode Of 28.03.2004/Monthly Pension 3. Name of the Insured Mrs. A B Madhura Prasad Name of the Policyholder 4. Name of the Respondent Insurer LIC Of India –Bangalore Division – 1 5. Date of Repudiation/ Rejection 28.01.2019 6. Reason for repudiation/ Rejection - 7. Date of receipt of Annexure VI-A 18.03.2019 8. Nature of complaint Non Receipt of Pension Since Dec 2018 9. Amount of claim Release of Annuity 10. Date of Partial Settlement N A 11. Amount of relief sought Release of Annuity + Interest 12. Complaint registered under Rule No 13(1) (b) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 28.05.2019 - Bengaluru 14. Representation at the hearing a) For the Complainant Self b) For the Respondent Insurer Mr. N Satyanarayana Rao, Manager (Claims) 15. Complaint how disposed Allowed 16. Date of Award/Order 02.07.2019
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17. Brief Facts of the Case: The complaint emanated due to non payment of monthly annuity by Respondent Insurer (RI). RI and the Grievance Redressal Officer (G.R.O.) of the RI did not resolve the issue. Hence Complainant approached this Forum for redressal of grievance.
18. Cause of Complaint: - a. Complainant’s argument: The Complainant vide his letters on various dates has stated that he has not received the annuity under the impugned policy since December 2018. He further stated that after receipt of form from RI, Chennai office he has submitted the Life certificate in November, 2018 with the help of Mr Vittoba who handed over it personally to Officer in Charge of Bengaluru Office. Once again in the month of December 2018, Chennai office has sent letter to submit the life certificate, the same was done by Mr Vittoba who again handed it over to concerned officer in Bengaluru Office.
The Complainant further submitted that on the first working day of the calendar month he used to get credit alert of ₹ 2,000/- from his bank. When he verified the entries online he could not find the entry. The same was brought to the notice of Grievance cell. On 28.01.2019, a letter was written to CBO-26, 140,Marshalls Road, Egmore, Chenani -600008 complaining about the non receipt of pension amount and requested them to transfer policy papers to Bengaluru Office.
Aggrieved with the non-receipt of response from RI, the Complainant registered a complaint with this Forum. b. Respondent Insurer’s argument: The RI vide their letter dated 14.05.2019 has submitted the following information 1) Monthly annuity from 12/2018 to 02/2019 @ ₹ 2,000/- was paid by Chennai JD/JA office on 16.03.2019. 2) Monthly annuity for 03/2019 and 04/2019 was paid by Bengaluru JD/JA office on 22 and 25 April, 2019 respectively. 3) Policy master was transferred as per the Complainant request to 61A – Basavanagudi branch office and annuity is being serviced by JD/JA cell, Bangalore
RI further submitted that they have informed the payment particulars of 16.03.2019 to RI vide their email on 19.03.2019.
19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal: - 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 before the Forum is, whether there is delay in release of annuity by RI. During the personal hearing, both the parties reiterated their earlier submissions.
The Forum from the letter submitted by RI notes that the RI’s Chennai office released the annuity pertaining to 12/2018, 01/2019 and 02/2019 on 16.03.2019 and RI’s Bangalore office released the annuity payments pertaining to 03/2019 and 04/2019 on 22.04.2019 and 25.04.2019 which clearly shows the delay in servicing the annuity policy.
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Both the offices of RI have clearly failed to provide the service to their customer as per the contract and delayed the annuity payments. Regulation 14.2.(vi) of Protection of Policyholders Interests Regulations, 2017 clearly says that “The interest payments shall be paid by the Life Insurer suo moto without waiting for specific demand from the insured/claimant.” The Forum finds that RI has violated Regulation 14.2. (iv) of Protection of Policyholders Interests Regulations, 2017 of Insurance Regulatory and Development Authority of India, while settling the delayed annuity payments.
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 pay the interest on delayed annuity payments at 6.25% + 2% penal interest.
The complaint is Allowed.
22. Compliance of Award:
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 2nd July, 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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. S PRAKASH V/s LIFE INSURANCE CORPORATION OF INDIA Complaint No: BNG-L-029-1819-0478 Award No: IO/BNG/A/LI/0122/2019-2020 1. Name & Address of the Complainant Mr. S Prakash #675,46th Cross,8th Block Jayanagar Bangalore-560070 Mob # 9482872648 Email ID : [email protected] 2. Policy No: 890627934 Type of Policy: Life Name of the Policy: Jeevan Suraksha Commencement of Policy/ Policy 11.02.1997/14 Years Period/PPT
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3. Name of the Insured Mr. S Prakash Name of the Policyholder 4. Name of the Respondent Insurer LIC Of India –Bengaluru Division 1 5. Date of Repudiation/ Rejection 26.10.2018 6. Reason for repudiation/ Rejection Error in Printing the Policy Bond 7. Date of receipt of Annexure VI-A 31.01.2019 8. Nature of complaint Non Payment of Annuity as per the Policy Schedule. 9. Amount of claim ₹.14928/- + Interest for late payment + 3 lakhs as damages. 10. Date of Partial Settlement 01.03.2012 onwards 11. Amount of relief sought ₹.14928/- + Interest for late payment + 3 lakhs as damages. 12. Complaint registered under Rule No 13(1) (f) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 21.05.2019 – Bengaluru 14. Representation at the hearing a) For the Complainant Self b) For the Respondent Insurer Mr Bheemsen Rao, Manager(Claims) 15. Complaint how disposed Allowed 16. Date of Award/Order 02.07.2019
17. Brief Facts of the Case: The complaint emanated due to non payment of annuity as per the vesting date in policy schedule by Respondent Insurer (hereinafter referred as RI). RI and the Grievance Redressal Officer (G.R.O.) of the RI did not resolve the issue. Hence Complainant approached this Forum for redressal of grievance.
18. Cause of Complaint: - a. Complainant’s argument: The Complainant stated that he purchased the impugned policy in the year 1997 for a premium payment term of 14 years, which would vest on 22.07.2010 and pension would start on 22.08.2010 as per the policy schedule received by him from the RI.
The Complainant stated that 1. As per the policy schedule vesting date is 22.07.2010 2. As per the policy schedule date of first annuity payment is 22.08.2010 3. RI has disbursed the first annuity payment from Feb, 2011 4. RI paid commutation amount in Feb,2011
The Complainant submitted that RI has unilaterally forced their decisions regarding his policy payments without honouring the contract of insurance as printed in the policy schedule. He further submitted that despite complaining to RI regarding his grievance, they have not paid his annuities from 22.7.2010 to 08.02.2011.
Aggrieved, the Complainant registered a complaint with this Forum, requesting to resolve the issue at the earliest. b. Respondent Insurer’s argument: The RI vide their letter dated 22.02.2019 submitted to the Forum that though vesting date printed on policy schedule was 22.07.2010, the actual vesting date as per terms and conditions of the policy is 08.02.2011. However, as a very special case they have paid an annuity amount of Rs 14,928/- on 22.02.2019 pertaining to the period from 22.07.2010 to 08.02.2011.
19. Reason for Registration of complaint: -
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The complaint falls within the scope of Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal: - 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 before the Forum is whether the annuity payments made by the RI were as per policy schedule.
During the personal hearing, both the parties reiterated their earlier submissions. The Forum notes that the 1. RI has not sent any endorsement during the premium payment period for correction in the policy schedule. 2. RI has informed the Complainant about the changes in the vesting and first annuity payment dates only after the receipt of complaint from him. 3. RI has paid the arrears of annuity payment after the complainant approached this Forum. In the light of above, the Forum finds that RI has unilaterally changed the vesting date and violated the policy schedule.
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 pay interest on the delayed annuity and commutation payments at 6.25% + 2% penal interest.
The complaint is Allowed.
22. Compliance of the Award: The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017: a. 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 02nd July, 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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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. HARI OM JAIN BOTHRA V/s LIFE INSURANCE CORPORATION OF INDIA Complaint No: BNG-L-029-1819-0437 Award No: IO/BNG/A/LI/0135/2019-2020 1. Name & Address of the Complainant Mr. Hari Om Jain Bothra S/o Gautam Chand Bothra/Jain “Suvidha Annexe” D Block,2nd Floor, Flat no 212 Near SBI, Opp Convent School Keshwapur, Hubballi - 580023 Mob # 08762563978 2. Policy No: 639160236 Type of Policy: Life Name of the Policy: Jeevan Saral Commencement of Policy/ Policy 08.11.2008/15 Years Period/PPT 3. Name of the Insured Mr. Hariom G Bothra Name of the Policyholder 4. Name of the Respondent Insurer LIC of India – Dharwad 5. Date of Repudiation/ Rejection 24.12.2018 6. Reason for repudiation/ Rejection Surrender value paid as per terms and conditions of the Policy 7. Date of receipt of Annexure VI-A 18.01.2019 8. Nature of complaint Short Settlement 9. Amount of claim ₹.2,50,000 + ₹.32,427 + ₹.1,20,000 + Loyalty additions and Final bonuses 10. Date of Partial Settlement 17.11.2018 11. Amount of relief sought ₹.2,50,000 + ₹.32,427 + ₹.1,20,000 + Loyalty additions and Final bonuses 12. Complaint registered under Rule No 13(1) (f) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 28.05.2019 - Bengaluru 14. Representation at the hearing a) For the Complainant Written Submissions given by the Complainant b) For the Respondent Insurer S.B.Turamari, Manager (CRM) 15. Complaint how disposed Dismissed 16. Date of Award/Order 08.07.2019
17. Brief Facts of the Case: The complaint emanated due to short settlement done by Respondent Insurer (hereinafter referred as RI). RI and the Grievance Redressal Officer (G.R.O.) of the RI did not resolve the issue. Hence Complainant approached this Forum for redressal of grievance.
18. Cause of Complaint: - a. Complainant’s argument:
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The Complainant stated that he purchased the said policy in the year 2008 for a period of 15 years and that the amount of total premium paid under this policy by him was ₹. 1,20,100/- for a period of ten yearly premiums till 2017.
The Complainant stated that 5. As per the clarification contained in Rajasthan Patrika Publication dated 06.03.2016 on “Jeevan Saral Bima Policy” as stated by retired Deputy Revenue Officer of HDMC, Hubballi by name Sri J Kadappanavar , the period of the policy was for 10 years only . 6. Though his policy term was 15 years as per policy schedule as per the above clarifications he claimed that the term of the policy must be for ten years only. 7. He had surrendered his policy bond to LIC, Hubballi on 16.11.2018 and got only ₹. 1,09,390/- as a final payment from RI, which was ₹. 10,710/- less than the total premiums paid by him. 8. The amount of additional loyalty calculated on surrender value basis was ₹. 45,075/- which was incorrect and actual amount was much higher. 9. The amount of Guaranteed Surrender Value (GSV) mentioned in the surrender quotation sheet ₹. 32,427/- was also not paid to him. 10. The Total Surrender value ₹. 1,54,465/- paid to him was incorrect.
The Complainant submitted that RI has unilaterally extended his term of the policy from 10 years to 15 years. He further submitted that RI should treat the term of his policy as 10 years and full maturity benefit amount along with applicable bonuses are to be paid to him.
Aggrieved with the resolution provided by the RI and the GRO of RI the Complainant approached this Forum for redressal of his grievance. b. Respondent Insurer’s argument:
The RI vide their letter dated 20.01.2019 submitted to the Forum that 1. Jeevan Saral is a policy with benefits like Risk cover equal to 250 times of basic monthly premium, Refund of all premiums paid (except 1st year premium, any extra premium and premiums with respect to accident rider and term rider benefits), Loyalty additions payable on death if policy is in force for ten full years. 2. Maturity sum assured is defined depending upon the age at entry and term of the policy. It is calculated based on premium tables. The factor for the Complainants age 33 years, for 15 years term is ₹. 19,046 * ₹. 1,000 (monthly premium) %100= ₹. 1,90,460/- which was mentioned on the policy schedule. 3. Maturity sum assured for 10 years term policy is ₹. 10,939 * ₹. 1,000 (monthly premium) %100 = ₹.1,09,390/-. Loyalty addition @ 355 for 10 years, per 1000 proportionate to maturity sum assured is ₹. 45,075/- 4. Total surrender value paid to the complainant after receipt of his surrender request was ₹. 1,09,390 + ₹. 45,075 =₹. 1,54,465/-
RI further submitted that surrender value paid to the Complainant was as per the terms and conditions of the policy.
19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal: - 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.
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21. Result of personal hearing with both the parties (Observations & Conclusions): The issue before the Forum is, whether the surrender payment made by the RI is appropriate.
During the personal hearing, RI reiterated their earlier submissions where as the Complainant expressed his inability to attend the personal hearing session and requested the Forum to consider his written submissions vide his letter dated 24.05.2019.
The Forum notes that the 4. Complainant availed the impugned policy in the year 2008 for a term of 15 years which is printed correctly in the policy schedule. 5. Complainant’s reliance on the “Rajasthan Patrika Publication” regarding the term of the policy is found incorrect as the policy schedule is the legal contract between insurer and the insured. 6. Policy schedule received by the complainant clearly shows the term of policy, maturity, death and accident benefit sum assured and terms and conditions of the policy without any printing errors. 7. Complainant has not opted for free look cancellation when he found the term of policy as 15 years which was printed in the policy schedule and his allegations on the RI that they have not apprised him of the term of policy is found incorrect.
The Forum after going through the surrender quotation and the terms and conditions of the policy, the surrender value paid by the RI is found in order. In the light of above, the Forum finds the decision of RI is in line with terms and conditions of the policy.
AWARD
Taking into account, the facts & circumstances of the case, and the submissions made by RI during the course of Personal hearing and written document of Complainant, the Forum finds the decision of the Respondent Insurer is in order and does not require any interference at the hands of the Ombudsman.
Hence, the complaint is Dismissed.
Dated at Bengaluru on 08th day of July, 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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. PODAVEESH.S. BANAKAR V/s PNB METLIFE INDIA INSURANCE COMPANY LIMITED Complaint No: BNG--L--033--1920– 0065 Award No: IO/BNG/A/LI/0144/2019--2020 1. Name & Address of the Complainant Mr. Podaveesh. S. Banakar # 106, Vishweshwar Nagar Hubli – 580032 Karnataka State
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(M):9448450376 2. Policy No: 20380570 Type of Policy: Life –ULIP Name of the Policy: MET Smart Life Commencement of Policy/ Policy 19.07.2010 Period/PPT 31 Years 3. Name of the Insured Mr. Podaveesh. S. Banakar Name of the Policyholder 4. Name of the Respondent Insurer PNB MET life India Insurance Company Limited 5. Date of Repudiation/ Rejection NIL 6. Reason for repudiation/ Rejection Auto Foreclosed
7. Date of receipt of Annexure VI-A 27.05.2019 8. Nature of complaint Policy Fore-closed even though all the premiums under the policy are paid 9. Amount of claim ₹. 2,77,210 10. Date of Partial Settlement N A 11. Amount of relief sought ₹. 2,77,210/- + Interest 12. Complaint registered under Rule No 13(1)(f) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 28/06/2019 - Bengaluru 14. Representation at the hearing a) For the Complainant Self b) For the Respondent Insurer Mr. Sagar –Assistant Manager 15. Complaint how disposed Allowed 16. Date of Award/Order 11.07.2019
17. Brief Facts of the Case: The complaint arose due to the ‘Fore-closure’ of the policy by the RI without any intimation to the Complainant. In spite of his representations to GRO, there was no response from them. Being aggrieved, he has approached this forum.
18. Cause of Complaint: - a. Complainant’s argument: The Complainant vide his letter dated 16.03.2019 stated that he availed the said policy on 19.07.2010 for a period of 20 years by paying annual premium of ₹.36,000/- and has paid all the premiums up to 19.07.2018. There after the RI ‘Fore-Closed’ the said policy and sent the ‘Fore-Closed’ amount of ₹.10,790/- to his bank account. The reason given by the RI was that the fund value of the policy had gone below the minimum amount. He was shocked to receive a paltry sum ₹ 10,790/- after having paid ₹3,06,000/- as total premium over a period of 10 years. He approached the G.R.O. for a clarification on the issue. But the G.R.O. has not even supplied the ‘Fund Statement’. Aggrieved and cheated by the RI, the Complainant has approached this Forum for justice. b. Respondent Insurer’s argument: The RI vide their SCN dated 19.06.2019 stated that the RI issued the said policy based on the requirements submitted by the Complainant and despatched the same along with ‘Cooling Off Cancellation Clause’ to the Complainant who has received the policy bond. The Complainant has paid the premium up to April 2018. This being a ULIP policy, as the fund value was less than one annual premium, the policy was ‘Foreclosed’ as per policy terms and conditions and the same was intimated to the Complainant. Thereafter the Complainant approached the RI about the negative returns he received on the said policy which was analysed and replied to by the RI.
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As the RI has acted as per policy terms and conditions and the Complaint filed by the Complainant is false and frivolous, the RI prayed for dismissal of the same.
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.
20. The following documents were placed for perusal: - 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 the action of ‘Foreclosing’ the said policy by the RI is in order.
The Forum notes that the RI has issued a ULIP policy to a very senior citizen who was aged 68 years at the time of issuing the said policy, for a term of 31 years with maturity on his attaining 99 years. On scrutiny of the fund statement sent by the RI on 22.06.2018 it is observed that due to the Complainants advanced age, majority of the premium paid by the Complainant has gone towards appropriation of risk cover charges. No notice/reminders for payment of renewal premium was found sent by the RI. As the Complainant did not pay the premium due on April 2018, the policy was ‘Foreclosed’. Forum notes that the action to ‘Foreclose the policy is in line with para 3.23 of the terms and conditions of the policy.
During the personal hearing on 28.06.2019, the Complainant expressed utter shock as to how his policy got ‘Foreclosed’ when he has paid ₹. 3,06,000/- as total premium over a period of 10 years. All along, he was paying the premium regularly, but did not receive any notice/fund statement/unit statement about the status of his policy during a period of 10 years.
Forum asked the representatives of the RI as to whether they have sent any fund statement to the complainant as per Protection of Policy Holders Interest Regulations 2017. The RI sought one week’s time to verify their systems and get back which was allowed. But even to this date, the RI has not reverted back on this count.
Forum observes that the RI should not have sold the said ULIP policy to the complainant presently 79 years keeping in view of his advanced age where all the amount paid by him has yielded negative returns.
Forum further notes that as early as in 2005, IRDAI vide their circular bearing reference CIR/032/IRDA/ACTL/DEC/2005 has laid down guidelines in respect of ULIP policies which are reproduced below:-
14. Furnishing Statement of Accounts:-
14.1. Unit statement account shall form a part of the policy document.
14.2. Unit statement shall make a reference to the terms and conditions applicable under the respective policy document.
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14.3. Unit statement shall be issued on every policy anniversary and also as and when a transaction takes place.
Further, Regulation under 19.1 of Protection of Policy Holders Interest Regulations 2017, as framed by IRDAI, under the heading ‘General Principles’, states that:-
1. “Every life insurer shall inform policy holders whose participating policies are in force at least once in a year, the bonus accrued to their policies the value of their ULIP policies as the case may be through a letter/e-mail/any other electronic mode”.
From the above, it is to be noted that supplying of fund statement is mandatory in all ULIP policies and the same is to be sent to policy holders. Non-issuance of the fund statement amounts to serious service deficiency. Had the RI issued the fund statement as required, the Complainant would have had the opportunity to take appropriate decision to continue the said policy or not.
Considering the full circumstances of the case, the Forum notes that this is a clear case of ‘Serious Deficiency of Service’ coupled with ‘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 refund total premiums received under the policy together with interest at 8.25%(6.25% bank rate + 2% as per Sec 14(ii) of Policy Holders Protection Rules 2017) from the date of foreclosure i.e. 16.08.2018 till the date of payment.
Hence, 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 11th day of July 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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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 LEONARD ABHRAM CORREIA V/s HDFC LIFE INSURANCE COMPANY LIMITED Complaint No: BNG-L-019-1920-0039 Award No: IO/BNG/A/LI/0150/2019-2020 1. Name & Address of the Complainant Mr Leonard Abhram Correia Munnavar Apts, Flat #301 3rd Floor, #294, Thimmaiah Road Bangalore-560051 Mob: 8310227781 Email: [email protected] 2. Policy No: 14974518 Type of Policy: Life Name of Policy HDFC Life Sampoorn Samridhi Insurance Plan Commencement of Policy/ Policy 28.02.2012/7/7 Yrs Period/PPT 3. Name of the Insured Mr Leonard Abhram Correia Name of the Policyholder 4. Name of the Respondent Insurer HDFC Life Insurance Company Limited 5. Date of Repudiation/ Rejection 29.03.2019 6. Reason for Repudiation/Rejection Maturity payment paid as per terms and conditions of the policy. 7. Date of receipt of Annexure VI A 03.05.2019 8. Nature of complaint Shot settlement and Incorrect TDS deductions 9. Amount of claim ₹. 6,15,56.73/- + Refund of 1% TDS charged 10. Date of Partial Settlement 06.03.2019 11. Amount of relief sought ₹. 6,15,56.73/- + Refund of 1% TDS charged 12. Complaint registered under Rule No 13 (1) (b) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 21.06.2019/Bengaluru 14. Representation at the hearing a) For the Complainant Self b) For the Respondent Insurer Mr Vinay Prakash, Sr.Manager-Legal 15. Complaint how disposed Dismissed 16. Date of Award/Order 17.07.2019
17. Brief Facts of the Case: The complaint arose due to the repudiation of request made by the complainant for refund of TDS and higher maturity amount payout by Respondent Insurer (hereinafter referred as RI). RI and the Grievance Redressal Officer (G.R.O.) of the RI did not resolve the issue. Hence Complainant approached this Forum for redressal of grievance.
18. Cause of Complaint: - a. Complainant’s argument: The Complainant availed the impugned policy in the year 2012 for a premium payment period and term of 7 years.
The Complainant stated that 1. He was approached by an employee of RI in February 2012 with an assurance to double the money in 7 years.
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2. He received an amount of ₹. 3,64,379.40/- in 2019 , an interest of only ₹. 14,379.40/- was given by RI after 8 years. 3. Many emails sent to them had same reply i.e., the returns were as per terms and conditions of the policy but they had not even provided the bonuses as assured in the policy. 4. That they have deducted the TDS of 1% on his returns though he eligible for deduction free payment because he is a senior citizen. 5. That the RI did not allow him to see their General Manager of Finance Controller when he visited RI’s office. 6. That the emails sent to RI regarding refund of 1% TDS were answered with a statement “sorry for inconvenience 1% is mandatory as per the Govt and regulator guidelines”.
The Complainant further submitted that emails written to the RI and GRO of RI were answered upholding their decision for deduction of TDS @1%. Aggrieved with the resolution provided by the RI and the GRO of RI the Complainant approached this Forum for redressal of her grievance. b. Respondent Insurer’s argument:- The RI in their reply dated 20.06.2019 stated that
1. They emphatically deny all the allegations that are set out in the complaint except those that are specifically admitted herein. 2. The policy was issued on the basis of a duly signed proposal form submitted by the Complainant and the terms and conditions of the policies were duly communicated to him. The impugned policy has other benefits like death benefit and accidental death benefit coverage for the life of the insured apart from the maturity benefit. 3. They have sent the policy document along with the terms and conditions of the policy which also includes the benefit illustration of the policy to the Complainant and he had right to opt out in the free look period if the terms and conditions of the policy were different from what were assured to him during the sale of the policy. But the Complainant continued with the policy for 7 years, this shows that the Complainant is aware of all the terms and conditions of the policy. 4. An amount of ₹. 3,68,060/- was payable on maturity of the policy on 28.02.2019, in compliance with the Income Tax Act , 1% TDS was deducted under section 194DA and an amount of ₹. 3,64,379.40/- was paid to the Complainant account. This also includes (revisionary bonus, interim bonus, terminal bonus and enhanced terminal bonus) as shown below.
Sum Reversionary Interim Terminal Enhanced Maturity TDS 1% (-) Actual Assured Bonus Bonus Bonus Terminal Benefit Payment Bonus
₹.2,10,320 ₹.26,290 ₹.5,258 ₹.52,580 ₹.73,612 ₹.3,68,060 ₹.3,680.60 ₹.364379.40
Therefore on the basis of the above submissions RI requested for dismissal of the complaint.
19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal: - p. Complaint along with enclosures, q. Respondent Insurer’s SCN along with enclosures and r. Consent of the Complainant in Annexure VIA & Respondent Insurer in VII A.
21. Result of personal hearing with both the parties (Observations & Conclusions):
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The issue which requires consideration is whether RI’s decision to repudiate the 1% TDS refund request made by the Complainant is appropriate. During the course of personal hearing, both the parties reiterated their earlier submissions.
In addition to what was stated above RI further submitted that before the maturity of the policy Complainant had to choose between two options 1. Enhanced cover option and 2. Enhanced cash option. The payouts in this instant case were made in accordance with the option 2 selected by the Complainant. Had the Complainant opted for Option 1, he would have got similar benefits plus extended death benefit upto 99 years.
Forum after going through the documents and submissions made by both the parties notes that
1. Maturity payouts made by the RI are in order and they are in accordance with the terms and conditions of the policy. The payout also includes the bonuses as mentioned in the policy document.
2. 1% TDS deduction made is in compliance with the Income Tax Act. Under section 194DA of the said act “Any person responsible for paying to resident any sum under life insurance policy, including the sum allocated by way of bonus on such policy other than the amount not includible in the total income under clause (10D) of section 10, shall at the time of payment thereof, deduct income-tax thereon at the rate of [one] percent”.
3. Insurance Industry is different from Banking Industry. Returns from banks are based on the amount deposited with them and prevailing interest rates whereas Insurance Contracts are based on the risk and returns opted by the customers. While part of the premium goes towards investment to enable insurer to give returns on the policy, part of the premium goes towards covering the life risk of the insured based upon his occupation, age and other factors. The apportionment of the premium depends upon the age, health etc., of the insured at the time of availing the said policy. The policy was taken by the Complainant in 2012 when he was 58 years old. The premium towards the risk would be higher at his age. Hence Complainant’s averment that he got meagre amount of ₹. 14,379.40/- as interest for 7 years is not accepted.
In the light of above facts, the Forum finds the decision of RI is in line with terms and conditions of the policy.
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 in order and does not require any interference at the hands of the Ombudsman.
Hence, the complaint is Dismissed.
Dated at Bengaluru on 17th day of July, 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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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 Mrs UMADEVI G V/s DHFL PRAMERICA LIFE INSURANCE COMPANY LIMITED Complaint No: BNG-L-013-1920-0037 Award No: IO/BNG/A/LI/0151/2019-2020 1. Name & Address of the Complainant Mrs Umadevi G #52/28 III Main, 7th Cross, G T layout Arehalli, Uttarahalli,Bengaluru-560061 Mob: 9742558782 Email: [email protected] 2. Policy No/Certificate No: GC000006N907200 Type of Policy: Certificate of Insurance (Group Credit Life) Name of Policy DHFL Pramerica Group Credit Life+ Commencement of Policy/ Maturity 30.04.2017/29.04.2029 Date 3. Name of the Insured Mrs Umadevi G Name of the Policyholder 4. Name of the Respondent Insurer DHFL Pramerica Life Insurance Company Limited 5. Date of Repudiation/ Rejection 03.01.2019 6. Reason for Repudiation/Rejection Surrender value paid as per terms and conditions of the policy. 7. Date of receipt of Annexure VI A 09.05.2019 8. Nature of complaint Short Settlement 9. Amount of claim ₹. 30,369/- 10. Date of Partial Settlement 23.11.2018 11. Amount of relief sought ₹. 30,369/- 12. Complaint registered under Rule No 13 (1) (b) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 21.06.2019/Bengaluru 14. Representation at the hearing a) For the Complainant Self b) For the Respondent Insurer Mr Sanjay Agarwal, Sr Training Manager 15. Complaint how disposed Dismissed. 16. Date of Award/Order 17.07.2019
17. Brief Facts of the Case: The complaint arose due to the repudiation of Complainant’s full premium refund request by Respondent Insurer (hereinafter referred as RI). RI and the Grievance Redressal Officer (G.R.O.) of the RI did not resolve the issue. Hence Complainant approached this Forum for redressal of grievance.
18. Cause of Complaint: - a. Complainant’s argument: The Complainant purchased the impugned policy on 25.04.2018 as collateral to the Housing loan availed from DHFL. She stated that she has approached the RI on 15.11.2018 and surrendered the policy as she has foreclosed the loan amount.
The Complainant stated that on 22.11.2.018 she had received only ₹. 22,523/- from RI whereas the premium amount paid is ₹. 52,569/-. Though total loan amount was repaid to the DHFL, RI did not refund the premium in full. She stated that these deductions were neither informed to her while availing the policy nor available in the policy bond.
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The Complainant further submitted that letters written to the RI and GRO of RI were answered upholding their repudiation decision. Aggrieved with the resolution provided by the RI and the GRO of RI the Complainant approached this Forum for redressal of her grievance. b. Respondent Insurer’s argument:- The RI in their SCN dated 07.05.2019 submitted that
5. The policy was issued on the basis of a duly signed application form along with KYC documents submitted by the Complainant and the terms and conditions of the policies were duly communicated to her. 6. They received surrender request from the Complainant on 15.11.2018 citing the reason as foreclosed the loan amount. The same was processed and surrender amount of ₹. 22,523/- was paid on 22.11.2018 to her account as per the terms and conditions of the policy. As per the terms and conditions of the policy surrender values is calculated using the formula 60% of single premium paid multiplied by (Unexpired coverage term/Total coverage term) multiplied by (Coverage in force/ Coverage sum assured) 7. The allegation that the surrender value details are not mentioned in the terms and conditions of the policy is baseless as they are available on the third page of the policy document under head of Surrender section. The Policy document was delivered to her on 12.05.2017, she should have opted for free look period if she was not satisfied with the terms and conditions of the policy which did not happen in the instant case.
The RI submitted that the said complaint is not maintainable in the eyes of law and the same may be dismissed on the aforementioned grounds.
19. Reason for Registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017.
20. The following documents were placed for perusal: - s. Complaint along with enclosures, t. Respondent Insurer’s SCN along with enclosures and u. Consent of the Complainant in Annexure VIA & Respondent Insurer in VII A.
21. Result of personal hearing with both the parties (Observations & Conclusions): The issue which requires consideration is whether RI’s decision to repudiate the Complainant’s request is appropriate. During the course of personal hearing, both the parties reiterated their earlier submissions.
Forum after going through the documents and submissions made by both the parties notes that the surrender value paid by the RI is in order and the details of the surrender calculation is very much available in the policy terms and conditions along with values to be considered for surrender in the policy document.
Furthermore, having entered into a 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 the 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
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Insurer is in order and does not require any interference at the hands of the Ombudsman.
Hence, the complaint is Dismissed. Dated at Bengaluru on 17th day of July, 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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. K. SRISHNA SHETTY V/s LIFE INSURANCE CORPORATION OF INDIA Complaint No: BNG--L--019--1819– 0527 Award No: IO/BNG/A/LI/0153/2019--2020 1. Name & Address of the Complainant Mr. K. Krishna Shetty ‘Akshaya’ Anuradha Nursing Home Road Soppugudde, Thirthahalli Shimoga District – 577432 (m):9902212569 2. Policy No: 629402727 Type of Policy: Life - ULIP Name of the Policy: LIC’S Wealth Plus Policy ( Plan No 801) Commencement of Policy/ Policy 31.03.2010 Period/PPT 8 Years/(1) 3. Name of the Insured Mr. K. Krishna Shetty Name of the Policyholder 4. Name of the Respondent Insurer LIC Of India – Shimoga DO 5. Date of Repudiation/ Rejection NIL 6. Reason for repudiation/ Rejection NA 7. Date of receipt of Annexure VI-A 18.02.2019 8. Nature of complaint Unit Statement not furnished to the Policy Holder 9. Amount of claim ₹. 28,500 /- 10. Date of Partial Settlement N A 11. Amount of relief sought ₹. 28,500/- + Interest 12. Complaint registered under Rule No 13(1)(f) of Insurance Ombudsman Rules, 2017 13. Date of hearing/place 21/05/2019 - Bengaluru 14. Representation at the hearing a) For the Complainant Self b) For the Respondent Insurer Mr. Narayana – Manager(C.R.M.) 15. Complaint how disposed Dismissed 16. Date of Award/Order 29.07.2019
17. Brief Facts of the Case: The complaint arose due to non-issuance of the unit statement by the Respondent Insurer (RI) as per the request of the Complainant. Though he appealed to Grievance Redressal Officer (G.R.O.) of the RI, there was no response from them. Hence he has approached this Forum for redressal of his grievances. 18. Cause of Complaint: - a. Complainant’s argument:
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The Complainant vide letter dated 09.06.2018 stated that he availed the captioned policy from the RI in the year 2010. It is a ULIP policy. As per the terms and conditions of the policy, the RI is required to send the UNIT statement on the policy anniversary also as and when any transactions take place. By not providing the UNIT statement at regular intervals, the RI has deprived the Complainant of knowing the state of investment under the policy. As such on the date of maturity, the Complainant received a meagre return of ₹.1306/- over a period of 8 years. This lapse on the part of the RI, has deprived the Complainant the option of surrender/partial withdrawal for a better investment which would fetch him better return than the said policy at that time. Hence, the Complainant has approached the Forum seeking directions to the RI, to make good the loss that he incurred. b. Respondent Insurer’s argument: SCN NOT Received.
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.
20. The following documents were placed for perusal: - a. Complaint along with enclosures, b. 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 non-issuance of the policy fund statement as required by the RI, has resulted in deficiency of service and caused financial loss to the Complainant.
The Complainant did not attend the hearing on 21.05.2019 and requested the Forum for a second hearing. Hence another chance was given to the Complainant. During the course of personal hearing on 24.07.2019 both the parties reiterated their respective stand.
The Forum after careful examination of records, and during the personal deliberations, has observed that the Complainant availed ‘LIC’s Wealth Plus Policy’ (Plan No 801) on 31.03.2010 for a period of 8 years by paying a single premium of ₹. 40,000/-. It is a risk-cum-investment ULIP policy wherein on the life assured surviving to the end of the policy term an amount equal to the policy holders fund value shall become payable. Policy Holders Fund value on surviving the policy term shall be based on the highest NAV achieved by the fund over the first 7 years of the policy Or the NAV s applicable at the end of the policy term whichever is higher. In addition, the policy has an extended cover for a period of 2 years from the date of the expiry of the policy term. In an unfortunate event of death of the life assured after the policy term but before the expiry of the extended life cover period an amount equal to the sum assured under the basic sum assured shall become payable.
The Forum observes that under condition 22 of the policy bond, it is specifically mentioned that ‘UNIT’ statement shall be issued on every policy anniversary and as and when a transaction takes place.
The Forum asked the Complainant whether he has received any fund statement in respect of his Policy and the Complainant denied having received any fund statement during the term of the policy. The Forum asked the RI about the details and proof for having despatched the ‘UNIT’ statement to the Complainant.
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From the records made available to the Forum by both the parties, it is observed that the RI has not issued the UNIT fund statement to the life assured/policy holder/Complainant as per policy conditions. The Complainant filed RTI on 24.04.2018 seeking ‘copy of all communication provided to him in respect of this policy’ from 31.03.2010 to 31.03.2018. The RI accordingly supplied all the documents which they had provided to him in this respect except UNIT fund statement which clearly shows that the RI did not issue any fund statement during the policy tenure of 10 years.
During the personal hearing on 24.07.2019, the RI could not effectively convince the Forum about the despatch on ‘UNIT FUND STATEMENT’ on the said policy, every policy anniversary. The RI showed the despatch register wherein they have sent the statements to the policy holders. During the hearing the RI could not show any proof of having issued fund statement as per policy conditions to the Complainant. Hence, the Forum concludes that RI had not issued any fund statement to the Complainant during the term of the policy. Non issuance of the statement to the policy holder/complainant amounts to violation of policy conditions printed in the policy and also as per Regulation 19(1) of the Protection of Policy Holders Interest Regulations 2017 which require every insurer to inform the policy holders at least once in a year the value of the ULIP policies through a letter/e-mail/any other electronic mode.
On the other hand, the contention of the Complainant that had the RI issued the UNIT fund statement regularly as per the policy he would have taken appropriate decision whether to continue the said investment or not is unacceptable to the Forum either as, the amount invested by the Complainant is not for investment, but for ‘Risk-Cum-Investment Policy’. The Forum further observes that the Complainant has enjoyed the risk cover on his life under the said policy for full term and the said policy matured on 31.03.2018 and an amount of ₹. 41306/- has been paid as maturity claim. Further, the risk on the Complainants life is being covered by the RI till the extended term i.e. up to 31.03.2020
It was incumbent on the Complainant to go through the policy conditions. On non-receipt of the fund statement during the long term of contract of eight years, the Forum notes that he never sought the said statement from the RI other than through R.T.I. application.
Though there is deficiency of service on the part of the RI in sending UNIT statements to the Complainant, the Forum does not find any justification to meddle with the policy as it would hamper the insurable interest the Complainant has under the policy and deprive the Complainant and his family of valuable insurance cover till 31.03.2020. Hence the Complaint request to this Forum for making good the loss on his investment is set aside.
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 ‘Dismissed’.
Dated at Bengaluru on 29th day of July 2019
(NEERJA SHAH) INSURANCE OMBUDSMAN FOR THE STATE OF KARNATAKA
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PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF M.P. & C.G. (UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017) Mr. Akhilesh Prasad Sharma…………………………………….. Complainant V/S DHFL Pramerica Life Insurance Co.Ltd.…………..………...……Respondent COMPLAINT NO: BHP-L-013-1920-0032 ORDER NO: IO/BHP/A/LI/ 0121 /2019- 2020 1. Name & Address of the Mr. Akhilesh Prasad Sharma Complainant 13 BN SAF,Family Line no.9, Lashkar Camp, Gwalior 2. Policy No: 00573043 Type of Policy DHFL Pramerica Smart Fee protect Duration of policy/Policy period 27.02.2018 3. Name of the insured Mr. Akhilesh Prasad Sharma Name of the policyholder -same- 4. Name of the insurer DHFL Pramerica Life Insurance Co.Ltd. 5. Date of Repudiation/ Rejection 24.10.2018 6. Reason for Repudiation/ Rejection Out of free look period 7. Date of receipt of the Complaint 12.04.2019 8. Nature of complaint Non consideration of Free look cancellation 9. Amount of Claim Premium amount 10. Date of Partial Settlement 11. Amount of relief sought Premium amount 12. Complaint registered under Rule Rule No. 13(1)(f) Ins. Ombudsman Rule 2017 13. Date of hearing/place 02.07.2019 at Bhopal 14. Representation at the hearing For the Complainant Absent For the insurer Mr.Rohit Singh, Manager OPS 15. Complaint how disposed Allowed 16. Date of Award/Order 02.7.2019
Mr. Akhilesh Prasad Sharma (Complainant) has filed a complaint against DHFL Life Insurance Co. Ltd. (Respondent) alleging non consideration of free look cancellation request. Brief facts of the Case - The complainant has stated that he had taken above policy from Gwalior Branch of respondent company. Due to financial problem he had sent request for cancellation of policy through speed post no. EI137890339IN on 12.10.2018 but his request was not considered on the ground of lapse of free look period. He has further stated that thereafter he has received policy bond on 17.01.2019 through speed post EI18008441IN. The complainant has further stated that respondent‟s employee has submitted forged receipt of policy and later on respondent has sent policy bond on 17.01.2019. The complainant has approached this forum for redressal of his grievance.
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The respondent has stated that policy was issued on the basis of proposal form signed by the complainant and was hand delivered in his unit to the complainant himself on 21.08.2018. Policy acknowledgement was signed by him. On 17.10.2018 company has received free look cancellation request of complainant dated 12.10.2018 which was declined as out of free look period.
The complainant has filed complaint letter, Annex. VI A and correspondence with respondent, while respondent have filed SCN with enclosures. During hearing complainant remained absent. I have heard the representative of the respondent at length and perused papers filed on behalf of the complainant as well as the Insurance Company. Above policy was issued on 27.02.2018 to the complainant. As per complainant he had sent request for cancellation of policy to the Head Office, Gurgaon of respondent company on 12.10.2018 which was rejected by the respondent stating that the request is beyond free look period and sent him policy bond through speed post no. EI18008441IN which was received by him on 17.01.2019. A letter sent to Branch Manager, Gwalior of respondent company by the complainant received by the respondent on 19.01.2019 is on record which reveals that complainant had again requested to cancel his impugned policy. The representative of the respondent has argued that the policy bond was delivered by hand to the complainant in his Unit on 21.08.2018. Photocopy of acknowledgement of receiving of policy has been filed by the respondent in which date of receiving of document is mentioned as 21.08.2018. Below acknowledgement receiving of above acknowledgement at respondents Gwalior branch shows the date of receiving as 05.10.2018. It is not disputed that first request for cancellation was sent on 12.10.2018 which was received by the respondent on 17.10.2018. Photocopy of customer acknowledgement also shows the signature of the complainant. Photocopy of proposal form has been filed by the respondent upon which signature of complainant are there. Signature of complainant upon customer acknowledgement and proposal form, seems that both the signatures are not signed by the same person and there is clear difference between above two. Besides this below signature date is mentioned as 21.08.2018 which also seems to be not written by the complainant if compared with the photocopy of Questionnaire filed by the respondent as Annexure A. Said acknowledgement was reached to the Branch of the respondent on 05.10.2018. It also creates a reasonable doubt about the acknowledgement on 21.08.2018. If the acknowledgement was taken by the representative of the respondent on 21.08.2018 why it was sent to their branch of same city on 05.10.2018 after a lapse of one and half month. It also creates a doubt about the acknowledgement. During hearing the representative of the respondent was asked to show
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any rule of the company for sending the document through Sales Manager. The representative of the respondent could not show any rule showing that the documents can be sent through the representative of the Company for receiving the same by the complainant. Hence view of respondent company that the documents were received on 21.08.2018 is not acceptable. As per complainant later on, the documents were sent to him on 17.01.2019 through Speed post and after receiving he had again requested the respondent‟s branch at Gwalior for cancellation of policy on 19.01.2019. In view of above discussion, view of complainant that he had requested for cancellation of policy within free look period is acceptable. Under above circumstances complainant is liable to get his premiums refunded and hence complaint is liable to be allowed. In the result the complaint is allowed and respondent is directed to cancel the impugned policy and refund the premiums deposited, to the complainant. Let a copy of award be sent to complainant and respondent insurance company for compliance within 30 days.
Dated : July 02, 2019 (G.S.Shrivastava) Insurance Ombudsman
Ms. Alka Banchor………………….……………..…………..….. Complainant V/S Bajaj Allianz Life Insurance Co.Ltd.……....………………..……Respondent COMPLAINT NO: BHP-L-006-1920-0090 ORDER NO: IO/BHP/A/LI/0133 /2019-2020
1. Name & Address of the Mrs. Alka Banchor, Complainant 95, Kosabadi, Korba, Raipur 2. Policy No: 0310744928, 0320141476 Type of Policy Investgain –Economy and Guarantee Assure Duration of policy/Policy period 21.01.14 & 27.12.14 3. Name of the insured Mrs Alka Bsnchor Name of the policyholder Mrs Alka Banchor 4. Name of the insurer Bajaj Allianz Life Insurance Co.Ltd. 5. Date of Repudiation/ Rejection -- 6. Reason for Repudiation/ Rejection -- 7. Date of receipt of the Complaint 16.05.2019 8. Nature of complaint Surrender of policy without consent 9. Amount of Claim -- 10. Date of Partial Settlement --
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11. Amount of relief sought Rs.10,00,000/- 12. Complaint registered under Rule Rule No. 13(1)(f) Ins. Ombudsman Rule 2017 13. Date of hearing/place 08.07.2019 at Bhopal 14. Representation at the hearing For the Complainant Smt Alka Banchor For the insurer Mr Manoj Dosumal Govarani, Zonal Legal Head 15. Complaint how disposed Dismissed 16. Date of Award/Order 09.07.2019
Mrs. Alka Banchor (Complainant) has filed a complaint against Bajaj Allianz Life Insurance Co. Ltd.(Respondent) alleging surrender of policy without her consent. Brief facts of the Case - The complainant has stated that she had taken above policies from the respondent company. Respondent‟s officer had surrendered her above policies without her knowledge and signature. She has made request about the matter many times but no satisfactory reply was given by the respondent. The complainant has approached this forum for redressal of her grievance. The respondent in their SCN have stated that the complainant is a thoroughly educated individual and can understand the terms and conditions given in the policy. The complainant had voluntarily given the documents required for issuance of policies and voluntarily surrendered the above policies by submitting the surrender form along with required documents. The picture of the complainant is also captured by the company as it is a practice to capture the image of the person who comes to surrender the policy. The surrender amount under above policies had already been paid to the complainant on 28.12.2016 and 06.01.2017 through NEFT. The complainant has rather cooked up a false story at this belated stage. The complainant has filed complaint letter, Annex. VI A and correspondence with respondent, while respondent have filed SCN with enclosures. Efforts for mediation failed. I have heard both the parties at length and perused papers filed on behalf of the complainant as well as the Insurance Company. Above two policies were issued on 21.01.2014 and 27.12.2014 for a sum assured as RS.2,22,000/- and RS.22,50,000/- respectively to the complainant. As per respondent the complainant had voluntarily surrendered these policies on 30.12.2016 and 26.12.2016 by submitting surrender forms along with required documents. After receiving surrender forms and documents the respondent had already paid the surrender amount on 28.12.2016 and 06.01.2017 through NEFT. The respondent has filed photocopies of surrender – partial withdrawal form, surrender value payable letter, PAN Card, Aadhar Card, Customer
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consent letter, specimen signature form for policy No. 0320141476 and photocopies of surrender - partial withdrawal form , PAN card, Bank passbook details, authorization letter, Aadhar card of Mr Shekhar Banchhore, Customer consent letter and cheque for policy No. 0310744928. Surrender – partial withdrawal forms and customer consent letter bears signature of the policy holder / complainant. The complainant has stated in her complaint that policies were surrendered without her knowledge and her signature. Signatures of the policy holder / complainant on surrender forms and other forms clearly reveals her consent for surrendering the policies. The complainant could not produce any evidence with respect to allegation of mis-selling. Mere allegation is not sufficient to bring the sale of policy under purview of mis-selling. The complainant is a graduate. She is supposed to go through the policy documents after its receipt. A person who signs any document is responsible for the contents mentioned in it. Hence the complainants argument that the policies were surrendered without her knowledge and signatures is not at all acceptable. Besides this surrender value payment were made on 28.12.2016 and 06.01.2017 and this complaint has been filed to this forum on 16.05.02019 which is at a very belated stage. In view of these facts and circumstances, I come to the conclusion that the insurance company has acted in accordance with the terms and conditions of the policy and on receiving surrender request from the complainant under above policies they had made payment of surrender value amount. Hence, complaint is liable to be dismissed. The complaint filed by Mrs. Alka Banchor stands dismissed herewith. Let copies of Award be given to both the parties.
Dated : July 09, 2019 (G.S.Shrivastava) Place : Bhopal Insurance Ombudsman
Mr. Madhu Pawar …...……………………………………….. Complainant V/S Life Insurance Corporation of India.……………………...……Respondent COMPLAINT NO: BHP-L-029-1920-0056 ORDER NO: IO/BHP/A/LI/0138 /2019-2020
1. Name & Address of the Mr. Madhu Pawar, Complainant Post Gajandoh Dist.Chindwara
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2. Policy No: 362748204 Type of Policy LIC’s Jeevan Akshay-VI Duration of policy/Policy period 22.06.2018 3. Name of the insured Mr.Madhu Pawar Name of the policyholder Mr Madhu Pawar 4. Name of the insurer Life Insurance Corporation of India 5. Date of Repudiation/ Rejection 27.03.2019 6. Reason for Repudiation/ Rejection Out of cooling period 7. Date of receipt of the Complaint 30.04.2019 8. Nature of complaint Issuance of different policy 9. Amount of Claim 10. Date of Partial Settlement 11. Amount of relief sought 12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule 2017 13. Date of hearing/place 10.07.2019 at Bhopal 14. Representation at the hearing For the Complainant Mr Madhu Pawar For the insurer Mr S V Iyer, Manager (CRM) 15. Complaint how disposed Dismissed 16. Date of Award/Order 10.07.2019
Mr. Madhu Pawar (Complainant) has filed a complaint against Life Insurance Corporation of India (Respondent) alleging issuance of different policy by the respondent with prayer of refund of purchase price deposited. Brief facts of the Case - The complainant has stated that he wants to take “Pradhan Mantri Vaya Vandana Yojana” policy but respondent had issued him another policy “Jeevan Akshay”. Complainant has made request for issuance of Pradhan Mantri Vaya Vandana Yojana policy or to refund money deposited by him but no action was taken by the respondent. The complainant has approached this forum for redressal of his grievance. The respondent in their SCN have stated that LA has not submitted the application in stipulated time for cooling off.
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. 362748204 under Plan 189 LIC‟s Jeevan Akshay – VI was issued in the name of complainant on 22.06.2018 in which date of first annuity payment was 22.07.2018. As per respondent policy was delivered in July 2018. Receiving of policy is not disputed as per complaint. The complainant has written a letter to the respondents Branch Manager, Parasia for cancellation and refund of amount which was received by the Branch of the respondent
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on 01.03.2019. This letter also bears a stamp of respondent branch showing receiving date as 30.11.2018 with receipt No. 21777. During hearing the representative of the respondent has stated that after receiving the request on 30.11.2018 letter was returned to the complainant for some compliance thereafter they again received it on 01.03.2019. Receiving of letter is very clear and nothing has been mentioned with respect to returning of the letter on 30.11.2018. Hence above argument of the representative of the respondent is not at all acceptable. Hence, it is clear that the request for cancellation of policy was received on 30.11.2018 by the respondent. It is also clear that the request for cancellation of policy and refund of amount was made after free look period. Copy of policy clearly states that the policy was under plan Jeevan Akshay – VI. The complainant could not produce any evidence with respect to allegation of mis-selling. Mere allegation is not sufficient to bring the sale of policy under purview of mis-selling. Complainant is supposed to go through the policy documents after its receipt. A person who signs any document is responsible for the contents mentioned in it. In view of these facts and circumstances, I come to the conclusion that the insurance company has issued the policy as per proposal of the complainant and made a reasonable offer to the complainant for cancellation within free look period which was not availed by complainant. Hence, complaint is liable to be dismissed. The complaint filed by Mr. Madhu Pawar stands dismissed herewith. Let copies of Award be given to both the parties.
Dated : July 10, 2019 (G.S.Shrivastava) Place : Bhopal Insurance Ombudsman
Mr. Rohit Banchor………………….……………..………….. Complainant V/S Bajaj Allianz Life Insurance Co.Ltd.……....…………….……Respondent COMPLAINT NO: BHP-L-006-1920-0083 ORDER NO: IO/BHP/A/LI/0134/2019-2020
1. Name & Address of the Mr. Rohit Banchor, Complainant 95, Kosabadi, Korba, Raipur 2. Policy No: 0293678512 - Supercash gain Silver 0310753333 – Invest Gain Type of Policy 0320141110 – Guarantee Assure Duration of policy/Policy period 0320220536 – Guarantee Assure 0315165708 – Guarantee Assure 0315654822 – Guarantee Assure
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21.12.13, 04.01.14, 26.12.14, 26.12.14, 02.05.14, 24.06.14 3. Name of the insured Mr. Rohit Banchor (for first five policies) Name of the policyholder Mr Rohit Banchor (for first five policies) And for Pol no. 0315654822 insured and policyholder is Ms Alka Banchor 4. Name of the insurer Bajaj Allianz Life Insurance Co.Ltd. 5. Date of Repudiation/ Rejection -- 6. Reason for Repudiation/ Rejection -- 7. Date of receipt of the Complaint 16.05.2019 8. Nature of complaint Surrender of policy without consent 9. Amount of Claim -- 10. Date of Partial Settlement -- 11. Amount of relief sought Rs.40,00,000/- 12. Complaint registered under Rule Rule No. 13(1)(f) Ins. Ombudsman Rule 2017 13. Date of hearing/place 08.07.2019 at Bhopal 14. Representation at the hearing For the Complainant Mr Rohit Banchor For the insurer Mr Manoj Dosumal Govarani, Zonal Legal Head 15. Complaint how disposed Dismissed as beyond pecuniary jurisdiction 16. Date of Award/Order 09.07.2019
Mr. Rohit Banchor (Complainant) has filed a complaint against Bajaj Allianz Life Insurance Co. Ltd.(Respondent) alleging surrender of policies without his consent. Brief facts of the Case - Brief facts of the Case - The complainant has stated that he had taken above policies from the respondent company. Respondent‟s officer had surrendered above policies without his knowledge and signature. He has made request about the matter many times but no satisfactory reply was given by the respondent. The complainant has approached this forum for redressal of his grievance. The respondent in their SCN have stated that the complainant is a thoroughly educated individual and can understand the terms and conditions given in the policy. The complainant had voluntarily given the documents required for issuance of policies and voluntarily surrendered the above policies by submitting the surrender forms along with required documents. The surrender amount under above policies had already been paid to the complainant on 30.12.2016, 06.01.2017, 19.01.2017, 06.01.2017, 06.01.2017 and 06.01.2017 through NEFT. The complainant has rather cooked up a false story at this belated stage. 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.
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This cumulative complaint pertains to policy Nos. 0293678512, 0310753333, 0320141110, 0320220536, 0315165708, 0315654822. These policy nos. are also mentioned in the letter sent to Grievance Redressal Officer of the respondent on 21.02.2019 and Annexure VI-A sent by the complainant to this forum. In Annexure VI-A amount of relief sought is mentioned as Rs.40,00,000/- . Copy of Regular Premium Schedule issued by the respondent with respect to above policies discloses the sum assured as Rs.6,13,000/-, Rs.2,18,000/-, Rs.84,00,000/-, Rs.37,00,500/-, Rs.6,09,000/- and Rs.2,33,000/- respectively totaling Rs.1,37,73,000/- . Since cumulative complaint for above six policies has been filed by the complainant in which total sum assured is Rs.1,37,73,000/- and amount claimed is Rs.40,00,000/-, this forum has no pecuniary jurisdiction to hear the complaint as per Rule 17 of Insurance Ombudsman Rule 2017. In view of above facts and circumstances, I come to the conclusion that this forum has no pecuniary jurisdiction to hear the complaint as per Rule 17 of Insurance Ombudsman Rule 2017. The complaint filed by Mr. Rohit Banchor stands dismissed as beyond pecuniary jurisdiction of this forum. Let copies of Award be given to both the parties.
Dated : July 09, 2019 (G.S.Shrivastava) Place : Bhopal Insurance Ombudsman
Mr. Soni Ram Saini ……………………………………………….. Complainant V/S DHFL Pramerica Life Insurance Co.Ltd.…………..………...……Respondent COMPLAINT NO: BHP-L-013-1920-0085 ORDER NO: IO/BHP/R/LI/ 0131 /2019-2020
1. Name & Address of the Mr. Soni Ram Saini, Complainant 322, AD Regtt. C/o 56 APO Morar Cant Gwalior, 2. Policy No: 00600026 Type of Policy DHFL Pramerica Smart Income Duration of policy/Policy period 15.05.2018 3. Name of the insured Mr. Lakhveer Singh Name of the policyholder -same- 4. Name of the insurer DHFL Pramerica Life Insurance Co.Ltd. 5. Date of Repudiation/ Rejection 09.01.2019 6. Reason for Repudiation/ Rejection Out of free look period 7. Date of receipt of the Complaint 14.05.2019 8. Nature of complaint Non consideration of Free look cancellation 9. Amount of Claim Premium amount 10. Date of Partial Settlement
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11. Amount of relief sought Premium amount 12. Complaint registered under Rule Rule No. 13(1)(f) Ins. Ombudsman Rule 2017 13. Date of hearing/place 05.07.2019 at Bhopal 14. Representation at the hearing For the Complainant Mr Soni Ram Saini For the insurer Mr Manmohan Srivastava, Asstt Manager 15. Complaint how disposed Recommendation 16. Date of Award/Order 05.07.2019
Mr. Soni Ram Saini (Complainant) has filed a complaint against DHFL Life Insurance Co. Ltd. (Respondent) alleging non consideration of free look cancellation request. Brief facts of the Case - The complainant has stated that he had taken above policy from the respondent. Due to financial problem he made request for cancellation of policy on 27.10.2018 via speed post no. EI175929565IN within free look period but his request was not considered. The complainant has approached this forum for redressal of his grievance. The respondent have stated that policy was issued on the basis of proposal form signed by the complainant and hand delivered to the complainant himself on 14.06.2018 and policy acknowledgement was signed by him. On 02.01.2019 company received free look cancellation request dated 02.01.2019 which was declined as out side free look period. The complainant has filed complaint letter, Annex. VI A and correspondence with respondent, while respondent have filed SCN with enclosures. The complainant has filed complaint letter, Annex. VI A and correspondence with respondent, while respondent have filed SCN with enclosures. Sincere efforts were made for mediation to resolve the subject matter of complaint. The complainant and the representative of respondent company were heard. During course of mediation, both the parties filed joint application (Mediation Agreement) duly signed by the complainant and the representative of respondent mentioning therein about settlement of the matter willingly and mutually and agreed to settle the subject matter of the complaint as follows –
The respondent DHFL Life Insurance Co.Ltd. has agreed to cancel the existing policy bearing no. 00600026 and refund the premium amount to the complainant. The Complainant has also agreed for the same.
As matter within parties has resolved mutually, hence the complaint is decided in terms of mediation/mutual agreement between both the parties. Compliance of above shall be intimated to this forum.
Let copies of this order be given to both parties.
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Dated: July 05, 2019 (G.S.Shrivastava) Place : Bhopal Insurance Ombudsman
Mr. Akash Jain ……... .………….…………………………………..….. Complainant V/S LIC of India ……………………………………….………….…..….,,,……Respondent COMPLAINT NO: BHP-L-029-1920-0133 ORDER NO: IO/BHP/A/LI/ 0151 /2019- 2020
1. Name & Address of the Mr Akash Jain Complainant Roopshree Paridhan Main Road Gandhiward, Narsingpur 2. Policy No: 303828149 Type of Policy 28.11.2017 Duration of policy/Policy period LICs Jeevan Akshay VI 3. Name of the insured Mr Trilok Chand Jain Name of the policyholder --same -- 4. Name of the insurer LIC of India 5. Date of Repudiation/ Rejection 6. Reason for Repudiation/ Rejection 7. Date of receipt of the Complaint 12.06.2019 8. Nature of complaint Non payment of annuity 9. Amount of Claim 10. Date of Partial Settlement 11. Amount of relief sought 12. Complaint registered under Rule Rule No. 13(1)(d) Ins. Ombudsman Rule 2017 13. Date of hearing/place 29.07.2019 at Bhopal 14. Representation at the hearing For the Complainant Mr. Akash Jain For the insurer Mr. Hrishikesh Barori, A.O. 15. Complaint how disposed Dismissed 16. Date of Award/Order 29.07.2019
Mr. Akash Jain (Complainant) has filed a complaint against LIC of India (Respondent) alleging non payment of annuity for four months. Brief facts of the Case - The complainant has stated that the DLA had taken the above policy from the respondent company by paying lumpsum premium of RS.36,00,000/- on 28.11.2017 and respondent had paid pension for one year. The DLA died on 16.04.2019. The respondent had not paid pension for the period from 28.11.2018 to 16.04.2019 for which he had approached the respondent company for non payment of annuity for above
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period but he was told that all payments made to him are in order and nothing is due to be paid to the complainant. The complainant has approached this forum for redressal of his grievance. The respondent in their SCN have stated that as per the terms and conditions of the above plan, complainant has opted for „F‟ option for annuity. Under this option, on the death of annuitant, annuity ceases and no proportionate annuity from the date of last annuity to date of death is payable, if paid, said amount will be recovered from the purchase price during the payment of death claim and same has been recovered. Annuitant died on 16.04.2019, in between due date of 1st and second annuity date, therefore only annuity due on 28.11.2018 was payable and the same has already been paid. 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.303828149 under plan 189 LIC‟s Jeevan Akshav VI was issued on 28.11.2017 to the annuitant in which first annuity payment date was 28.11.2018. As per complainant annuitant was paid one year annuity. During hearing the representative of the respondent has argued that annuitant had opted F option for annuity and under this option on the death of annuitant, annuity ceases and no proportionate annuity from date of last annuity to date of death is payable and on 28.11.2018 one year annuity was paid. As the death of annuitant occurred on 16.04.2019, the death claim was settled under annuity option F taken by the annuitant. Hence, the amount paid by the respondent is in accordance with the terms and conditions of the policy.
In view of the above facts & circumstances, I come to the conclusion that respondent has acted in accordance with policy terms and conditions and that there is no reason to interfere with the decision of respondent company and hence complaint is liable to be dismissed.
The complaint filed by Mr. Akash Jain is dismissed herewith.
Let copies of Award be given to both the parties.
Dated : July 29, 2019 (G.S.Shrivastava) Place : Bhopal Insurance Ombudsman
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN-Dr. D.K. VERMA Case of Mr. Sanjay Kaushal Vs Max Life Insurance Co. Ltd. CASE NO-CHD-L-032-1920-0155
1. Name & Address of the Mr. Sanjay Kaushal Complainant House No.- 3045, Sector 44 D, Chandigarh- 160034 Mobile No.- 6239639569 2. Policy No: DOC 852794494 / 08-08-2011 Type of Policy Non- Participating Plan Duration of policy/Policy period 3. Name of the insured Mr. Sanjay Kaushal Name of the policyholder Mr. Sanjay Kaushal 4. Name of the insurer Max Life Insurance Co. Ltd. 5. Date of Repudiation 6. Reason for repudiation NA 7. Date of receipt of the Complaint 10-04-2019 8. Nature of complaint Revival of policy 9. Amount of Claim 10. Date of Partial Settlement N.A 11. Amount of relief sought Refund of premium 12. Complaint registered under 13 [1][d] Rule no: Insurance Ombudsman Rules, 2017 13. Date of hearing/place 08-07-2019 / Chandigarh 14. Representation at the hearing For the Complainant Mr. Sanjay Kaushal For the insurer Mr. Prashant Singh, Deputy Manager- Legal 15. Complaint how disposed Agreement 16. Date of Award/Order 08.07.2019
17. Brief Facts of the case:
On 10-04-2019, Mr. Sanjay Kaushal had filed a complaint of revival of the policy against Max Life Insurance Co. Ltd. in respect of policy bearing no. 852794494. The complaint has alleged that due to unavoidable circumstances his old mobile number was not working on which he was receiving premium notices hence he did not deposit the due premium resulting the policy in discontinuation status. 18. In personal hearing the company agreed to settle the case, subject to issuance of new policy in lieu of previous lapsed policy number 852794494. Accordingly, an agreement was signed between the company and the complainant on 08.07.2019.
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19. 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 the days of receipt of this order for information and record.
To be communicated to the parties.
Dated at Chandigarh on 8th day of July, 2019
(Dr. D.K. VERMA) INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Dr. D K Verma Case of Shri Gurcharan Singh V/S LIC of India COMPLAINT REF: NO: CHD-L-029-1819-0102 1. Name & Address of the Shri Gurcharan Singh Complainant Vill Kammo Majra Kalan, Distt Sangrur 2. Policy No: 164464704 Type of Policy Jeevan Akshay (189) Duration of policy/Policy period 3. Name of the insured Shri Gurcharan Singh Name of the policyholder 4. Name of the insurer LIC of India 5. Date of Repudiation NA 6. Reason for repudiation NA 7. Date of receipt of the Complaint 08.05.2018 8. Nature of complaint Non-surrender 9. Amount of Claim NA 10. Date of Partial Settlement NA 11. Amount of relief sought Surrender Value 12. Complaint registered under 13.1(a) Rule no: 13. Representation at the hearing For the Complainant None For the insurer Ms Shylaja Bodh, AO(CRM) 14 Complaint how disposed closed 15 Date & Place of Hearing 15.07.2019/Chandigarh
16) Brief Facts of the Case:
On 08.05.2018, Shri Gurcharan Singh had filed a complaint in this office against LIC of India about non- surrender of his policy. He had purchased a policy bearing number 164464704 under jeevan Akshay plan
Page 36 of 113 on 24.12.2009 which could be surrendered as and when required. He sought surrender of the policy on 08.03.2018 which was declined as the policy could be surrendered only under specific medical conditions. Hence, feeling aggrieved, he has approached this forum to seek justice.
17) The Company has informed that as the policy bearing number 164464704 has been surrendered on 21.07.2018 and payment of RS. 9.5 lakhs has been made to the complainant through NEFT.
18) In view of the above, no further action is required to be taken by this office and the complaint is disposed off accordingly.
To be communicated to the parties.
Dated at Chandigarh on 15th day of July, 2019.
Dr. D K Verma INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Dr. D K Verma Case of Shri Manish V/S LIC of India COMPLAINT REF: NO: CHD-L-029-1819-0434 1. Name & Address of the Shri Manish Complainant S/O Sh. Lekhraj, H. No. 521, Committee Mohalla, Jain Chowk, Bhiwani, Haryana- 127021 2. Policy No: 504831360 Type of Policy Ulip plan Duration of policy/Policy period 3. Name of the insured Shri Manish Name of the policyholder 4. Name of the insurer LIC of India 5. Date of Repudiation NA 6. Reason for repudiation NA 7. Date of receipt of the Complaint 31.07.2018 8. Nature of complaint Non -payment of cooling off Claim 9. Amount of Claim NA 10. Date of Partial Settlement NA 11. Amount of relief sought Premium + interest + penalty+ action for delay 12. Complaint registered under 13.1(a) Rule no: 13. Representation at the hearing For the Complainant Complainant
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For the insurer Ms Vijay Nanda, Manager(CRM), Rohtak Ms Praveen Arora, AO(CRM), Rohtak 14 Complaint how disposed Closed 15 Date & Place of Hearing 15.07.2019/Chandigarh 16) Brief Facts of the Case:
On 31.07.2018, Shri Manish had filed a complaint in this office against LIC of India about nonpayment of cooling off claim under his policy bearing number 504831360. The complainant requested for cooling off of his two policies. On being followed up it was informed that there is some technical error due to which they were not able to process the claim. One refund was received after long delay and without interest but in the mentioned policy the refund was not received till date. Hence, feeling aggrieved, he has approached this forum to seek justice.
17) The Company has informed that the policy bearing number 504831360 has been referred to higher office for rectification of technical fault and is under process and the complainant will be paid interest as per rules.
18) The complainant has agreed to the submission of the company.
19) In view of the above, no further action is required to be taken by this office and the complaint is disposed off accordingly.
To be communicated to the parties.
Dated at Chandigarh on 15th day of July, 2019.
Dr. D K Verma INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Dr. D K Verma Case of Ms Anjana Rani V/S LIC of India COMPLAINT REF: NO: CHD-L-029-1819-0150 1. Name & Address of the Ms Anjana Rani Complainant W/O Late Sh. Jagdish Kumar Bansal, H.No. 569, Street No. 4, Mubarak Mahal Colony, Dhuri Road Sangrur Punjab-148001 2. Policy No: 162495828 Type of Policy Annuity Duration of policy/Policy period 3. Name of the insured Sh. Jagdish Kumar Bansal Name of the policyholder 4. Name of the insurer LIC of India 5. Date of Repudiation NA 6. Reason for repudiation NA 7. Date of receipt of the Complaint 18.05.2018 8. Nature of complaint Policy Servicing Issue 9. Amount of Claim NA 10. Date of Partial Settlement NA
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11. Amount of relief sought NIL Policy Bond Required 12. Complaint registered under 13.1(f) Rule no: 13. Representation at the hearing For the Complainant None For the insurer Ms Shylaja Bodh, AO(CRM) 14 Complaint how disposed closed 15 Date & Place of Hearing 15.07.2019/Chandigarh
16) Brief Facts of the Case:
On 18.05.2018, Ms Anjana Rani had filed a complaint in this office against LIC of India about non- receipt of policy bearing number 162495828 after payment of death claim. The complainant submitted the same with the insurer for getting claim and according to policy conditions the same was to be returned to the nominee after due endorsement. She complained to the Insurance Company but could not get any relief. Hence, feeling aggrieved, she has approached this forum to seek justice.
17) The Company has informed that the policy bearing number 162495828 was mistakenly sent to EDMS center for scanning along with other documents. However on receipt of complaint the same was handed over to the complainant on 12.07.2018. The same has also been confirmed by the complainant vide her letter dated 06.07.2019
18) Accordingly, the complaint is closed.
To be communicated to the parties.
Dated at Chandigarh on 15th day of July, 2019.
Dr. D K Verma INSURANCE OMBUDSMAN
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Dr. D K Verma Case of Shri Harbans Singh V/S LIC of India COMPLAINT REF: NO: CHD-L-029-1819-0435 1. Name & Address of the Shri Harbans Singh Complainant H No. 10, Type-II, Punjab University, Residential Complex, Sector 25, Chandigarh 2. Policy No: 164650429 Type of Policy Wealth plus Duration of policy/Policy period 3. Name of the insured Shri Harbans Singh Name of the policyholder 4. Name of the insurer LIC of India 5. Date of Repudiation NA
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6. Reason for repudiation NA 7. Date of receipt of the Complaint 30.07.2018 8. Nature of complaint Less claim payment 9. Amount of Claim NA 10. Date of Partial Settlement NA 11. Amount of relief sought Rs 66104/- difference of Claim payment 12. Complaint registered under 13.1(a) Rule no: 13. Representation at the hearing For the Complainant Complainant For the insurer Ms Shylaja Bodh, AO(CRM) 14 Complaint how disposed Dismissed 15 Date and Place of Hearing 15.07.2019/Chandigarh 16) Brief Facts of the Case:
On 30.07.2018, Shri Harbans Singh had filed a complaint in this office against LIC of India about less payment of maturity claim under policy bearing number 164650429. The policy commenced in 2010 and he had paid 3 premiums of Rs 25000/- each, the maturity amount of Rs 58896/- was credited in his account instead of Rs 1, 25,000/- which was promised by the agent. He had complained to LIC Patiala, LIC Chandigarh as well as to Chairman LIC of India, but no response was received. Hence, feeling aggrieved, he has approached this forum to seek justice.
17) Cause of Complaint: a) Complainant’s argument: The complainant reiterated the contents of his complaint and added that a large number of units were deducted from his policy on account mortality and administrative charges and very meager amount was paid to him as maturity value. Also added, that in a similar policy from SBI he has got more money. b) Insurers’ argument: The Company has informed that as the policy bearing number1646500429 was a ULIP policy, taken on 31.03.2010 for SA 125000, for a term of 8 years. As per policy conditions on survival of policy term the highest NAV over first 7 years or at the end of policy term, whichever is more will be paid. Accordingly, he was paid Rs 58896/-. Moreover he was covered for Rs 125000 throughout 8 years and additionally for extended 2 full years till 31.03.2020 free of cost. A major portion of units were used as mortality charges for risk coverage as this policy was purchased at high age of 61 years.
18) The following documents were placed for perusal :- a) Complaint to the Company b) Reply of the Insurance Company
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19) Result of personal hearing with both parties (Observations & Conclusion)
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. The Insurance Company produced the statement of deductions of units made on account of mortality charges and administration charges, which was found in order. As insurance is basically coverage of risk which was covered under the policy for 8 years and was also available for an extended period of 2 years till 25.03.2020 without any further payment.
Taking into account the facts & circumstances of the case and the submissions made by the Company during the course of hearing, there is no need for any interference and the complaint is dismissed. Hence, the complaint is treated as closed.
Dated at Chandigarh on 15th day of July, 2019 Dr. D K Verma INSURANCE OMBUDSMAN
. PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)
INSURANCE OMBUDSMAN-Dr. D.K. VERMA Case of Ms. Padma Kapila Vs Birla Sun Life Insurance Co. Ltd. CASE NO-CHD-L-009-1819-0530
1. Name & Address of the Ms. Padma Kapila Complainant House No.- 237, Sector- 36 A, Chandigarh- 160036 Mobile No.- 9541279000 2. Policy No: DOC 007016065 / 26-04-2016 Type of Policy ABSLI Immediate Annuity Duration of policy/Policy period Rs. 489505/- 3. Name of the insured Ms. Padma Kapila Name of the policyholder Ms. Padma Kapila 4. Name of the insurer Birla Sun Life Insurance Co. Ltd. 5. Date of Repudiation 6. Reason for repudiation 7. Date of receipt of the Complaint 01-08-2018 8. Nature of complaint Pension not required due to higher age 9. Amount of Claim NA 10. Date of Partial Settlement NIL 11. Amount of relief sought Refund of premiums under the above policies 12. Complaint registered under 13.1.(d) Rule no: Insurance
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Ombudsman Rules, 2017 13. Date of hearing/place 16-07-2019 / Chandigarh 14. Representation at the hearing For the Complainant Ms. Padma Kapila For the insurer Mr. Rajeev Sharma, AVP 15. Complaint how disposed Agreement 16. Date of Award/Order 16.07.2019
17.Brief Facts of the case:
On 01-08-2018, Ms. Padma Kapila had filed a complaint of mis-selling against Birla Sun Life Insurance Co. Ltd. in respect of policy bearing no. 007016065. The complaint has raised the issue of pension which she does not want to receive further and need of money to meet her old age requirements. SCN submitted by the insurer is incomplete and irrelevant to points raised in complainant. 18. The representative of the company informed that the said policy was issued on the basis of duly filled and signed application forms and policy document was delivered at complainant‟s address. However, the company during the personal hearing agreed to cancel the policy bearing number 007016065 and refund the premium received therein without interest after deduction of pension paid earlier if any. 19. Accordingly, an agreement was signed between the Company and the complainant on 16.07.2019.
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 the days of receipt of this order for information and record.
To be communicated to the parties.
Dated at Chandigarh on 16th day of July, 2019
D.K. VERMA INSURANCE OMBUDSMAN
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Dr. D K Verma Case of Ms Jasveer Kaur V/S LIC of India COMPLAINT REF: NO: CHD-L-029-1718-1432 1. Name & Address of the Ms Jasveer Kaur Complainant Vill Bhame Kala, Distt. Mansa 2. Policy No: 301978419, 302255472 Type of Policy Duration of policy/Policy period 3. Name of the insured Late Shri Gurdit Singh Name of the policyholder 4. Name of the insurer LIC of India 5. Date of Repudiation NA 6. Reason for repudiation NA 7. Date of receipt of the Complaint 12.03.2018 8. Nature of complaint Non-payment of Accidental Claim 9. Amount of Claim NA 10. Date of Partial Settlement NA 11. Amount of relief sought Rs. 12. Complaint registered under 13.1(a) Rule no: 13. Representation at the hearing For the Complainant None For the insurer Ms Shylaja Bodh, AO(CRM) 14 Complaint how disposed closed 15 Date & Place of Hearing 15.07.2019/Chandigarh 16) Brief Facts of the Case: On 12.03.2018, Ms Jasveer Kaur had filed a complaint in this office against LIC of India about non- payment of accidental claim under policies bearing numbers 301978419 and 302255472 purchased by her late son Shri Gurdit Singh. He died in an accident on 16.10.2016 and the Insurance Company paid the basic claim on 28.02.2017. However, neither the due money-back was paid nor the accidental claim. Hence, feeling aggrieved, she has approached this forum to seek justice.
17) The Company has informed that both the policies bearing numbers 301978419 and 302255472 were purchased under Salary Saving Scheme. There were nine gaps under both the policies and hence, they were under auto-cover. Thus, as per terms and conditions of the policies, accident benefit was not payable whereas Basic Sum Assured of Rs 5 lakhs and 10 lakhs were paid. The company has also informed that Survival Benefit under both the policies is under process as it could not be paid due to 9 gaps in the policies and system does not make payment for more than 6 gaps. However the matter has been reviewed by DO Claims and branch has been instructed to proceed with the payments. It was further informed that Survival Benefit has been paid in both the policies on 14.06.2019
18) Neither the complainant nor her representative appeared for the personal hearing on 15.04.2019, 18.06.2019 and even today. However since the Basic Sum Assured and Survival benefit already stands paid to the complainant, the complaint is closed.
To be communicated to the parties. Dated at Chandigarh on 15th day of July, 2019. Dr. D K Verma INSURANCE OMBUDSMAN
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY (Under Rule No.17 (1) of the Insurance Ombudsman Rules, 2017) COMPLAINT REF: NO: CHN-L-006-1819-0739 Smt.D.Usharani Vs Bajaj Allianz Life Insurance Co. Ltd AWARD NO: IO/CHN/A/L/0012/2019-20
1. Name & Address of the Smt. D.Usharani, Complainant 5/2, Nellukadai Street, Poraiyur post, Tarangampadi Taluk. Nagapattinam -609307 2. Policy No/SA /DOC / 0036612115/Rs.2,00,000/23.01.2007 Pol. Term/Premium Paying Term 20years/20years Premium/Mode Rs.10,000/Annual Type of Policy Capital Unit Gain Size
3. Name of the Insured Smt.D.Usharani Name of the Policy holder Smt.D.Usharani Name of the insurer Bajaj Allianz Life Insurance Co. Ltd 5. Date of Policy Termination 20.09.2018 6. Grounds of Grievance Sudden foreclosure of policy 7. Date of receipt of the Complaint 07.02.2019 8. Nature of complaint Policy servicing related 9. Amount of Claim Rs.30,000/- 10. Amount /Date of Partial Settlement Rs.8,960/- (as surrender value)/20.09.2018 11. Amount of relief sought Refund of premiums with Interest
12. Complaint registered under Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017. 13. Date of calling SCN 14.02.2019 Date of receipt of SCN 08.04.2019 14. Date of hearing/place 26.04.2019/Chennai 15. Representation at the hearing For the Complainant Smt. D.Usharani For the insurer Smt. M.Vijayalakshmi 16. How the case disposed off Award 17. Date of Award 08.07.2019
18. Brief Facts of the Complaint:- The Complainant and the Insured Smt. D.Usharani stated that she had taken a policy from the Bajaj Allianz Life Insurance Company on 23.01.2007 for a sum Assured of Rs. 2,00,000 with yearly premium of Rs. 10,000/- for a term of 20 years and with premium paying term of 20 years. She paid the yearly premiums only for first 3 years and after that she had not paid any premium. She submitted that all of sudden the insurer sent her a letter dated 20.09.2018, stating that her policy was terminated due to non-payment of premiums from the 4th year onwards and alleged that the insurer has taken the termination action without giving any prior intimation and without getting her consent and made a refund of only Rs. 8,960 through a cheque dated 21.09.2018. She made a representation to the Grievance Redressal Officer (GRO) of the insurer vide her letter dated 08.01.2019. But the insurer did not respond to her. Hence she has approached this Forum for relief and for refund of premium of Rs. 30,000 paid by her.
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Insurer’s Version: The insurer stated in the Self-Contained Note (SCN) dated 28.03.2019 that the complainant had taken this policy on 23.01.2007 after knowing all the product features and conditions and without any undue pressure by others. The insurer submitted the copy of the proposal in support of this point. The complainant had the option to cancel the policy within 15 days free look period from the date of receipt of the policy, which she failed to do. The Insurer further stated that the complainant has paid only 3 annual premiums and not paid further premium and also not submitted any written revival application. So, she is not entitled any of the reliefs claimed or benefits under the policy. The insurer further stated that the policy got foreclosed due to non-payment of the regular premiums for 20 years as per the policy terms and conditions. The insurer also furnished the details of the communications 1. Renewal premium notice sent on 12.12.2008 and the history of calls which they made to the policyholder/complainant when the renewal premiums were not remitted. Since the policy was foreclosed, the company adhered to the terms and conditions of the policy and made the payout of surrender value of Rs. 8,960 to the complainant on 20.09.2018. Hence the insurer prayed the Forum to dismiss the complaint by taking the facts and circumstances of the case in to account.
19) Reason for Registration of Complaint: This is a case of alleged default in servicing of policies and comes within the scope of Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017.
20) The following documents were submitted to the Forum for perusal. a) Complainant’s letters dated 10.10.2018, 25.12.2018 and 07.02.2019 to this Forum. b) Complainant’s letter dated 08.01.2019 to the GRO of the insurer. c) Insurer’s letter of termination and the surrender value settlement on 20.09.2018. d) Copy of the Proposal and Policy Schedule. e) Annexure VI-A and consent furnished by the complainant. f) Insurer’s Self Contained Note (SCN) dated 28.03.2019. g) Fund statement as on 19.09.2018 21. Result of hearing with both parties (Observations & Conclusion): Based on the submissions of both the parties made during the hearing and documents submitted, it is observed as under:
1) The complainant has paid the annual premium only for first 3 years. The subsequent premiums due from 23.01.2010 onwards were not paid. .
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2) The insurer furnished details of renewal communications in the SCN. It is observed that a renewal notice was sent on 12.12.2008, perhaps for the premium due on 23.01.2009, which was paid by the complainant. As per call history submitted, various calls were made to the complainant in the months of January/February 2010 and also January 2011, but on none of the occasions, contact was established with the complainant. It appears that no written notice of lapse of the Policy was sent by the insurer to the complainant.
3) As per condition No.5(c) (ii) of the Policy,
“ if the policyholder has failed to revive the policy within the revival period of two years, the policy shall continue at the option of the policyholder with full Sum Assured and with the Additional Rider benefits being in force, until the Regular Premium Fund value falls below 150% of the Annual Premium payable, upon which:
The policy shall terminate and
All units shall be redeemed and a Surrender Value as per Sec (6) (c) is payable to the policyholder.
If the policyholder does not opt to continue the policy, then the policy would be terminated and the Surrender value will be paid.”
4) In the instant case, the policy had been kept alive by the insurer with Full Sum Assured and Additional Rider Benefit, till 19.09.2018 when the fund value fell below Rs.15,000/- i.e. 150% of the annual premium payable. However, to so continue the policy, the insurer should have obtained an option letter from the complainant as per policy condition 5(c) (ii), cited above. During the hearing, it was accepted by the insurer that they did not obtain any option letter from the complainant to continue the policy after 23.01.2012, the date on which the lapsed policy crossed the time limit of 2 years for revival. Since the option letter was not received by the insurer, the insurer should have settled the fund value as on 23.01.2012. Hence the action of the insurer in allowing the Policy to continue was in violation of terms and conditions of the Policy and is not justified. 5) The insurer is therefore liable to pay the fund value of the policy as on 23.01.2012 less the amount of Rs. 8,960 paid by way of Surrender Value to the complainant along with the interest. 6) The Complainant had taken up her grievance with the GRO of the Insurer vide her letters dated 08.01.2019 and 07.02.2019 to which there was absolutely no response from the insurer. The Forum expresses its displeasure over the lack of response from
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the insurer to the complainant’s appeal, which is in gross violation of Protection of Policyholders’ Interests Regulations, 2017 of IRDAI and the guidelines for Grievance Redressal by Insurers, forming part thereof.
AWARD
Taking into account the facts and circumstances of the case & the submissions made by both the parties during the course of the hearing, this Forum is of the opinion that Insurer’s decision to keep the policy (no. 0036612115) live till 19.09.2018 is not justified in the absence of complainant’s consent for the same. The insurer is therefore directed to pay the fund value of the policy as on 23.01.2012 less the amount of Rs. 8,960 paid by way of Surrender Value to the complainant along with the interest under Rule 17(7) of the Insurance ombudsman Rules. Interest shall be allowed on the gross fund value from 23.01.2012 and on the net amount after deduction of Surrender Value of Rs. 8,960 paid on 20.09.2018, from that date. The complaint is therefore admitted .
a. 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 intimate the compliance of the same to the Ombudsman. b. As per Rule 17(7) of the said Rules the complainant shall be entitled to such interest at the 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 Rules, the award of Insurance Ombudsman shall be binding on the insurers.
Dated at Chennai on this 8th day of July, 2019.
(M.VASANTHA KRISHNA) INSURANCE OMBUDSMAN STATE OF TAMIL NADU & PUDICHERY
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY (Under Rule No.17 (1) of the Insurance Ombudsman Rules, 2017) COMPLAINT REF: NO: CHN-L-006-1819-0840 Shri R.Janarthanan Vs Bajaj Allianz Life Insurance Co. Ltd AWARD NO: IO/CHN/A/L/0013/2019-20
1. Name & Address of the Shri R. Janarthanan, Complainant Plot No.8, 8th Cross, Prakash Nagar, Thiruverumbur, - 620013 2. Policy No/SA /DOC 0055202730/Rs.1,00,000/25.06.2007 Policy Term/Premium Paying Term 12years/12 years Premium/Mode Rs.5,000/Half-yearly Type of Policy ULIP-Bajaj Allianz New Unit Gain
3. Name of the Insured Shri R. Janarthanan Name of the Policy holder Shri R. Janarthanan Name of the insurer Bajaj Allianz Life Insurance Company Ltd 5. Date of Termination of Policy 27.04.2018 6. Grounds of Grievance Sudden foreclosure of policy 7. Date of receipt of the Complaint 07.02.2019 8. Nature of complaint Policy servicing related 9. Amount of Claim Rs.30,000/- 10. Date and amount of Partial 30.04.2018/Rs.303/- (surrender value Settlement settled) 11. Amount of relief sought Rs. 1,85,000/-
12. Complaint registered under Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017. 13. Date of calling SCN 15.03.2019 Date of receipt of SCN 08.04.2019 14. Date of hearing/place 26.04.2019/Chennai 15. Representation at the hearing For the Complainant Absent (Hospitalized) For the insurer Smt. D.Vijayalakshmi 16. How the case disposed off Award 17. Date of Award 08.07.2019
18. Brief Facts of the Complaint:- The complainant and the insured Shri R.Janarthanan had taken a ULIP policy (Bajaj Allianz New Unit Gain) from Bajaj Allianz Life Insurance Company Ltd on 25.06.2007 for a sum Assured of Rs.1,00,000 for a term of 12 years and Premium paying term of 12 years. The premium payable was Rs. 5,000 on half-yearly basis. The complainant had paid only the first 6 Half-yearly premiums i.e. for 3 years. After that he had not paid any premiums. In the year 2015, the complainant received a fund statement from the insurer for the period from 25.06.2014 to 24.06.2015. The complainant submitted that he noticed that his policy was a ULIP type policy only at the time of getting the above fund statement. He further submitted that the insurer sent him a letter dated 30.04.2018 stating that his policy was terminated due to the non-payment of premiums from the 4th year onwards and refunded an amount of Rs. 303
Page 48 of 113 through a cheque dated 30/04/2018. He alleged that the insurer had taken termination action without giving any prior intimation and without getting his permission. He sent a letter to the Grievance Redressal Officer (GRO) of the insurer vide his letter dated 10.01.2019 representing that once he has paid premiums for 3 years, his policy should be in force till the age of 70 years as per policy conditions and that policy can be surrendered at any time without deduction of any charges. Hence he requested the insurer to refund him the premium of Rs. 30,000/- along with interest. But the insurer did not send any reply to him. Hence the complainant has approached this Forum for relief. Insurer’s Version: The insurer stated in their Self-Contained Note (SCN) dated 28.03.2019, that the complainant had taken a ULIP policy on 23.01.2007 after knowing all the product features and conditions and without any undue pressure by others. They submitted a copy of the proposal in support of this point. The complainant had the option to cancel the policy within the free look period of 15 days from the date of receipt of the policy, which he failed to do. The Insurer further stated that the complainant has paid premiums only for 3 years and not paid further premiums and also not submitted any written application for revival of the Policy. So, the complainant is not entitled to withdraw the premium paid by him as the policy has not acquired any Surrender/Paid Up Value or any of the reliefs claimed or benefits under the policy. The insurer further stated that the policy got foreclosed due to non-payment of the regular premiums for 12 years as per the policy terms and conditions. The insurer also furnished the details of the renewal communications sent by them to the complainant, consisting of Renewal Premium Notices and history of calls made. Since the policy was foreclosed, the Company adhered to the terms and conditions of the policy and made the payment of Rs. 303/- by cheque on 30.04.2018. Hence the insurer prayed the Forum to dismiss the complaint by taking in to account above facts and circumstances.
19) Reason for Registration of Complaint: This is a case of default in servicing of policies coming within the scope of Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017. 20) The following documents were submitted to the Forum for perusal.
Complainant’s letter dated 10.01.2019 to the Forum. Complainant’s letter of December, 2018 to the GRO of the insurer. Insurer’s letter of termination and the surrender value settlement Copy of the Proposal and Policy Schedule. Annexure VI-A and consent furnished by the complainant. Insurer’s Self Contained Note(SCN) dated 28.03.2019. Insurer’s Fund statement dated 26.03.2019 21. Result of hearing with both parties (Observations & Conclusion):
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1. The Insured had paid premium only for the first 3 years. The subsequent premiums were due from 26.06.2010 onwards were not paid. 2. The insurer furnished details of renewal communications in the SCN. It is observed that renewal notices were sent in November 2008, May 2009, November 2009 and May 2010. As per call history submitted, a call was made to the complainant on 08/02/2017, but no contact seems to have been established with the complainant. It appears that no written notice of lapse of the Policy was sent by the insurer to the complainant, or any notice for revival. 3. As per condition No.12(c) of the Policy, “If the unpaid regular premium was due after the first three Policy Years, and the Policyholder has failed to make the payment before the expiry of the aforesaid grace period:
(i) The policyholder will be given an opportunity to revive the policy within two years from the first unpaid Premium, subject always to Section 34 below. During this limited period for revival, the policy shall be continued levying all appropriate charges as per Section 25 until the Fund Value falls below an amount equivalent to one annual Premium (NAV) across all the funds. At the end of the two years i.e. period for revival if the policy is not revived, the Policyholder can opt to continue the Policy subject to deduction of all charges as per Section 25 until the Fund Value falls below an amount equivalent to one annual premium (NAV) across all the funds.
(ii) If the policyholder does not opt to continue the policy after the revival period, the policy shall be terminated by paying the Fund value.
(iii) When the Fund value in respect of Regular Premium falls below an amount I equivalent to one annual premium, the Policyholder will be intimated about this in writing and the Policy shall be terminated by paying the Fund value”.
4. In the present case, the insurer allowed the policy to be live up to 10.04.2018, without obtaining the complainant’s consent, whereas the time limit for of two years for revival of the Policy expired on 25.06.2012. This was in violation of clause 12(c) (i) above. The insurer terminated the Policy on 10/04/2018, once the Fund value fell below the annual premium payable, as per clause 12(c)(i) above.
5. The insurer also confirmed at the time of hearing that they have not received any option letter from the policyholder to continue the policy after the expiry of revival period. In the absence of such option letter, the insurer was not justified to continue the Policy till 10.04.2018.
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6. Hence the Forum is of the opinion that the insurer is liable to pay the Fund value of the policy as on 25.06.2012 (at the end of the two years from the date of the first unpaid premium) as per condition 12(c) (i) of the Policy.
7. It is observed that the Complainant took up his grievance with the Grievance Redressal Officer of the Insurer vide his letter dated Nil in the month of December 2018, to which no response was received from the insurer. The Forum expresses its strong displeasure over the lack of response from the insurer, which is in gross violation of Protection of Policyholders Interests Regulations of IRDAI and the guidelines for Grievance Redressal by insurers forming part thereof.
AWARD
Taking into account the facts and circumstances of the case & the submissions made by both the parties during the course of the hearing, this Forum is of the opinion that
Insurer’s decision to continue the policy (no. 0055202730) till 10.04.2018 was not justified as the insurer had not obtained the consent of the complainant for the same. The insurer
is therefore directed to pay the complainant the Fund value of the policy as on 25.06.2012, less the amount of Rs. 303, already paid. The complainant is also eligible for interest as per Rule 17(7) of the Insurance Ombudsman Rules, 2017.
The Complaint is, therefore, allowed.
The attention of the Insurer is drawn to the following provisions of the Insurance Ombudsman Rules, 2017:
d. 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 intimate the compliance of the same to the Ombudsman. e. As per Rule 17(7) of the said Rules, the complainant shall be entitled to such interest at the 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. f. As per Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the insurers. Dated at Chennai on this 8th day of July, 2019.
(M.VASANTHA KRISHNA) INSURANCE OMBUDSMAN STATE OF TAMIL NADU & PUDUCHERY
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY (Under Rule No.17(1) of the Insurance Ombudsman Rules, 2017) COMPLAINT REF: NO: CHN-L-043-1819-0849 Smt. Isakkiammal Vs Shriram Life Insurance Co. Ltd AWARD NO: IO/CHN/A/L/0016/2019-20
1. Name & Address of the Smt.M.Isakkiammal, Complainant MIG-46, TNHB Colony, Velachery, Chennai – 600 042. 2. Policy No 091000139145/ 091000139392/ Sum Assured (SA) INR 63000 INR 63000 Date of Commencement (DOC) 31.11.2010 31.11.2010 Term/ /Premium Paying Term 10Years/1Year 10Years/1Year Premium/Mode INR 50,000/Single INR 50,000/Single Type of Policy ULIP-Ujjwal Life SP ULIP-Ujjwal Life SP
3. Name of the Insured Mr.Poolpandi@Pulidurai Mrs.Tamil Selvi Name of the Policy holder Mr.Poolpandi@Pulidurai Mrs.Tamil Selvi 4. Name of the Insurer Shriram Life Insurance Co. Ltd. 5. Date of Rejection Not applicable 6. Grounds of Grievance Non-settlement of Surrender Value 7. Date of receipt of the Complaint 02.01.2019 8. Nature of complaint Policy servicing related grievance 9. Amount of Claim INR1,00,000 10. Date of Partial Settlement Not applicable 11. Amount of relief sought INR 50,000+ INR 50,000+ maturity value
12. Complaint registered under Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017. 13. Date of calling SCN 15.03.2019 Date of receipt of SCN 15.04.2019 14. Date of hearing/place 30.04.2019/Chennai 15. Representation at the hearing For the Complainant Smt.M.Isakkiammal For the insurer Mrs. Mahalakshmi 16. How the case disposed off Award 17. Date of Award 08.07.2019
18. Brief Facts of the Complaint:- The Complainant and the assignee of the policies Smt. M.Isakkiammal in her complaint letter dated 02.01.2019 to the Forum stated that she is holding 2 nos. of ULIP policies issued by Shriram Life Insurance Company on the life of 1.Poolpandi@Pulidurai and 2. Smt. Tamil Selvi for a Sum Assured of INR 63,000 each with a Single premium of INR 50,000 each for a term of 10 years which were assigned in her favour and registered by insurer on 22.05.2014 and 21.06.2011 respectively. She submitted that she has paid INR 50,000 to each of the above policyholders, in consideration of the above assignment. Since she was in need of money, she wanted to surrender the policies and therefore she submitted Indemnity Bond ( as she had lost the original policy bonds), proof of identity and the surrender value quotation to the Shriram Chits Branch office, Nanganallur on 3rd October, 2018. She alleged that the respondent insurer is delaying the payment of
Page 52 of 113 surrender value by calling for the proof of identity, PAN card and some other details of the Original Policyholders (Life Assured) and has not yet settled the amount. Hence she has approached this Forum for relief. Insurer’s Version: In the Self Contained Note (SCN) dated 08.04.2019, the insurer stated that the complainant Smt. Isakkiammal had earlier worked in Shriram Chits, Tamil Nadu at its Tirunelveli Branch and she was involved financial irregularities, whereby she had made her family members and close friends as Chit subscribers and also obtained insurance policies in the name of her friends and relatives and got the said policies assigned in her name. The insurer further stated that she has misused her position and thereby caused financial loss to a tune of INR 11 lakhs. Further it was stated that the complainant and her sister were involved in financial irregularities whereby they have misappropriated the fund of third parties and against the same a police complaint was filed before the Tirunelveli Police Station, and was registered vide FIR No.24/2015, against Smt. Isakkiammal and her family members under Sections 420, 406,467, 468, 48, 120(B) of Indian Penal Code and the same is pending. The two policies which are the subject matter of the present complaint are also part of the pending investigation under FIR No. 24/2015, and the same warrant investigation by the concerned Police authorities. Hence the Insurer has requested this Forum to dismiss this complaint on this ground alone.
Further the insurer has submitted a copy of the letter from Shri Poolpandi @ Pulidurai.R, stating that he never executed any kind of assignment of the policy. On telephonic enquiry by the insurer with Smt. Tamilselvi, the other policyholder, she confirmed that the policy was assigned without her knowledge. The Insurer alleged that Smt. Isakkiammal is now trying to cheat them and the policyholders, Sri Poolapandi @ Pulidurai.R and Smt. Tamil Selvi .
19) Reason for Registration of Complaint: This is a case of deficiency in servicing of policies and comes within the scope of Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017.
20)The following documents were submitted to the Forum for perusal.
Complainant’s Letter dated 02.01.2019 to this Forum. Complainant’s letter dated 05.02.2019 to the Grievance Redressal Officer (GRO) of the insurer. Copies of the Policy Schedule ( 2 policies). Annexure VI-A and consent furnished by the complainant. Self Contained Note (SCN) of the insurer dated 08.04.2019. Copy of letter dated 15.12.2015 of Shriram Chits Tamilnadu P Ltd to Tirunelveli Police Shri Pulidurai’s letter dated 01.03.2019. Copies of the Conditional assignments duly registered by the Insurer.
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21. Result of hearing with both parties (Observations & Conclusion): Based on the submissions of both the parties made during the hearing and documents submitted, it is observed as under:
a) The assignment made in respect of both the policies is conditional and on a format meant to be used for making assignment in favour of wife or close relative. Love and affection is stated to be the consideration for the assignment and not any monetary consideration, contrary to the claim of the complainant. In the assignment pertaining to policy No. LN091000139145 (policyholder Mr Poolapandi@Pulidurai R), the relationship of the assignee to the policyholder/assignor is not mentioned but only the name of the assignee. In the assignment relating to Policy No. LN091000139392 (policyholder Mrs. Tamil Selvi), the name of the assignee is not mentioned, but only the relationship of the assignee to the policyholder as sister is mentioned. It is also observed that as per assignment made in both the cases, the policyholder retains the right to receive the payments to be made by the insurer under the Policy as also the maturity amount. The assignment also provides that in the event of the assignee predeceasing the policyholder and the policyholder surviving on the date of maturity, the right to receive the benefits under the Policy shall revert to the policyholder. This means that the assignee is entitled only to the death benefit under the Policy, in case the policyholder dies during the term of the Policy. Therefore, the assignee has no right to surrender the policy and receive the surrender value thereunder.
b) The insurer has submitted a copy of the letter from the policyholder Shri Poolpandi, which states that he never made any assignment of his policy in favour of the complainant Smt. Issakiammal. It was also submitted by the insurer in the SCN that Smt. Tamil Selvi claimed during a telecon that the complainant who is her distant relative had, with dishonest intention made her take the subject policy and later got it assigned in the latter’s name without her knowledge with an intention to avoid payment to her. During the hearing, the complainant confirmed that both the policyholders are not related to her.
c) It was also alleged by the insurer that the complainant had misused her position as a manager of Shriram Chits Tamilnadu Pvt Limited and involved herself in many financial irregularities and a Police case is also pending against her for cheating many policyholders including the two policyholders in the present case. Hence the insurer has denied and delayed the payment to the complainant.
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d) Notwithstanding the disclaimers of the policyholders, the fact remains that both the policies have been assigned and the assignments have been registered by the respondent insurer. Instead of rejecting the request of the assignee/complainant for payment of surrender value on the grounds that she is not entitled to the same in terms of the assignment clause, the insurer has cited extraneous reasons such as the alleged denial of assignment by the policyholders (perhaps an afterthought on their part) and the FIR filed by the police authorities against the complainant to deny her demand. The policyholders did not appear before the Forum. The insurer produced neither a copy of the FIR nor the current status of the case against the complainant, in support of their submissions. e) Nevertheless, the Forum is of the opinion that the complainant is not entitled to the surrender value of the policies in view of the wording of the assignment clauses, as discussed under (a) above. f) The Forum records its disapproval of the lack of response by the insurer to the representation made by the Complainant.
AWARD
Taking into account the facts and circumstances of the case & the submissions made by both the parties during the course of the hearing, this Forum is of the opinion that
Insurer’s rejection of the complainant’s request for payment of surrender value under both the policies is justified, although not on the grounds cited by them. The assignment clause does not entitle the complainant to receive the surrender value of the policies. TheIn Complaint case the decision is, therefore, of the dismissed. Forum is not acceptable to the complainant, she is at liberty to approach any other Forum/Court as she deems fit, against the respondent insurer.
Dated at Chennai on this 8th day of July, 2019.
(M.VASANTHA KRISHNA) INSURANCE OMBUDSMAN STATE OF TAMIL NADU & PUDICHERY
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF TAMILNADU & PUDUCHERRY (Under Rule No.17(1) of the Insurance Ombudsman Rules, 2017) COMPLAINT REF: NO: CHN-L-006-1819-0769 Shri Narasimhan Padmanabhan Vs Bajaj Allianz Life Insurance Co. Ltd. AWARD NO: IO/CHN/A/L/0018/2019-20
1. Name & Address of the Shri Narasimhan Padmanabhan Complainant New No.77, Manohar Street, South West Boag Road,T.Nagar,Chennai-17. 2. Policy No/Sum Assured 0060891027/INR 30,00,000 Date of Commencement 13.10.2007 Policy Term/Premium Paying Term 20years/20 years Premium/Mode INR 3,00,000/Annual Type of Policy Bajaj Allianz Capital Unit Gain
3. Name of the Insured Shri Narasimhan Padmanabhan Name of the Policy holder Shri Narasimhan Padmanabhan Name of the Insurer Bajaj Allianz Life Insurance Company Ltd. 5. Date of Rejection Not applicable 6. Grounds of Grievance Non-payment of partial surrender value 7. Date of receipt of the Complaint 18.02.2019 8. Nature of complaint Policy servicing related grievance 9. Amount of Claim INR 4,54,000 with interest 10. Date of Partial Settlement NIL 11. Amount of relief sought INR 4,54,000 with interest
12. Complaint registered under Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017. 13. Date of calling SCN 25.02.2019 Date of receipt of SCN 09.04.2019 14. Date of hearing/place 26.04.2019/Chennai 15. Representation at the hearing For the Complainant Mr.K.S.Padmanabhan For the insurer Mrs. D.Vijayalakshmi 16. How the case disposed off Award 17. Date of Award 08.07.2019
18. Brief Facts of the Complaint:- The complainant and the insured Mr. Narasimhan Padmanabhan had taken a ULIP policy (Capital Unit Gain Plan) from Bajaj Life Insurance Company Ltd on 13.10.2007 for a Sum Assured of INR 30,00,000 with a term of 20 years. The premium payable was INR 3,00,000 annually for a period of 20 years. The complainant submitted that he had applied to the insurer for partial withdrawal on 30.08.2018 and the amount was to be credited to his account in 7 working days. But the insurer has not given credit of the amount. The complainant made a representation to the insurer as required under Rule 14(3) of the Insurance Ombudsman Rules, 2017 but did not receive a response. Hence the complainant is requesting the Forum to intervene and direct the insurer to make the payment. The complainant has submitted the acknowledgement received from insurer of his request for partial withdrawal and copy of the Fund account Statement, in support of his complaint.
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Insurer’s Version: The insurer stated in their Self-Contained Note (SCN) dated 04.02.2019, that the complainant had submitted a proposal dated 17.08.2007 and on the basis of the information provided by the insured, they issued a ULIP Policy (Capital Unit Gain) No. 0060891027 on the life of the complainant for a Sum Assured of INR 30,00,000 with annual premium of INR 3,00,000. The risk commencement date was 13.10.2007 and the complainant has paid 3 annual premiums. The complainant had requested for partial withdrawal in 2014 and accordingly a payment of INR 5,40,000 had been made to him on 27.01.2014 .
According to the insurer the policy was foreclosed immediately after the partial withdrawal payment due to excess amount of partial withdrawal and the same was reversed to policy account on reinstatement. The complainant requested for the partial withdrawal a second time, but it was denied due to the reason that he is not eligible for partial withdrawal as per policy terms and conditions. Under the options clause of the policy bond, i.e. Clause 7(b), it is clearly mentioned that “(iii) for the purpose of partial withdrawals, each payment of Top Up premium shall have a lock- in-period of three years, unless the Top Up Premium is made in the last three policy years.”
Hence the insurer prayed the Forum to dismiss the complaint by taking above facts and circumstances in to account.
19. Reason for Registration of Complaint: This is a case of servicing deficiency which comes within the scope of Rule 13(1) (f) of the Insurance Ombudsman Rules, 2017.
20. The following documents were submitted to the Forum for perusal.
Complainant’s letter dated 10.12.2018 to this Forum. Copy of the proposal, Policy Schedule ,Terms and Conditions Partial Withdrawal Request registration letter dated 30.08.2018. Unit Fund statement dated 25.03.2019. Complainant’s letter dated 14.01.2019 to the Grievance Redressal Officer (GRO) of the insurer. Annexure VI-A and consent furnished by the complainant. Insurer’s Self Contained Note(SCN) dated 04.02.2019.
21. Result of hearing with both parties (Observations & Conclusion): 1) The complainant had paid three yearly premiums @ INR 3,00,000/- as per the fund statement provided with the SCN, and subsequently he paid INR 10,000/- as Regular Annual Premium for 7 years. During hearing, the insurer’s representative informed the
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Forum that the Sum Assured and Regular Annual Premium were reduced to INR 1,00,000 and INR 10,000 respectively and the revised premium was paid from the year 2010 onwards. 2) The complainant’s request for the second partial withdrawal was registered by the insurer on 28.08.2018 for an amount of INR 4,54,000, but the amount was not released. There was also no response to the representation made by the complainant against the non-payment. 3) The insurer claimed in the SCN that the policy was foreclosed at the time of the first partial withdrawal in 2014 since due to excess amount of withdrawal. But it appears no intimation thereof was sent to the policyholder/complainant and the insurer continued to accept the renewal premium which was paid for 7 more years. Moreover, a perusal of the fund statement does not show that there was an excess withdrawal and the Policy fund had enough Regular Units to allow the withdrawal. 4) The reason cited by the insurer for rejecting the current request of the complainant for withdrawal is that as per clause 7(b) of the Policy, there is a waiting period of 3 years for Top Up premium for the purpose of partial withdrawals. This is an irrelevant argument, since the complainant has not paid any Top Up premium. It is also observed that there was sufficient balance in the fund account by way of Regular Units to allow the partial withdrawal. 5) During the hearing, the insurer also took the plea that the second partial withdrawal could not be allowed in terms of clause 7(b), since after the withdrawal, the Regular Fund value would have fallen below 150% of the Annual Premium. This too, is an incorrect argument by the insurer, as the Regular Fund value after the second withdrawal would be more than 150% of the reduced Annual Premium of INR 10,000.
For the reasons stated above, the refusal of the insurer to allow the second partial withdrawal is not justified.
AWARD
Taking into account the facts and circumstances of the case & the submissions made by both the parties during the course of the hearing, this Forum directs the insurer to pay the complainant an amount of INR 4,54,000 by way of partial withdrawal and in addition pay interest as per Rule 17(7) of the Insurance Ombudsman Rules, 2017. The Complaint i s, th e refore, allowed .
22. The attention of the complainant and the respondent insurer is drawn to the following provisions of the Insurance Ombudsman Rules, 2017:
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g. 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 intimate the compliance of the same to the Ombudsman. h. As per Rule 17(7) of the said Rules, the complainant shall be entitled to such interest at the 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. i. As per Rule 17(8) of the said Rules, the award of Insurance Ombudsman shall be binding on the insurers. Dated at Chennai on this 8th day of July, 2019.
(M.VASANTHA KRISHNA) INSURANCE OMBUDSMAN STATE OF TAMIL NADU & PUDICHERY
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN UNDER THE INSURANCE OMBUDSMAN RULES, 2017 OMBUDSMAN – MS. SANDHYA BALIGA CASE OF HARI KRISHAN GUPTA V/S LIC OF INDIA COMPLAINT REF: NO JPR-L-029-1920-0091 AWARD NO: IO/JPR/L/A/1920/000
1. Name & Address of the Complainant HARI KRISHAN GUPTA 23/334/01, Swarnpath, Mansarovar, Jaipur Rajasthan -302020 2. Policy No: 193164408 Type of Policy Pension Plan – Jeevan Suraksha T-122 DOC / Duration of Policy 04.03.2001 / 17 years Capital Sum Guranteed 364000 3. Name of the insured HARI KRISHAN GUPTA Name of the policyholder HARI KRISHAN GUPTA 4. Name of the insurer LIC OF INDIA 5. Date of Repudiation N/A 6. Reason for repudiation N/A 7. Date of receipt of the Complaint 31.05.2019 8. Nature of complaint Less pension received 9. Amount of Claim .(3145.58 – 2724) 421.58 pm 10. Date of Partial Settlement N/A 11. Amount of relief sought (3145.58 – 2724) 421.58 pm 12. Complaint registered under 13 (1) (d) Rule no: of IOB rules 13. Date of hearing/place 16.07.2019 / Jaipur
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14. Representation at the hearing For the Complainant Sh. Hari Krishan Gupta For the insurer Sh. O. P. Meena & Sh. Sameer Lala 15 Complaint how disposed Award 16 Date of Award/Order 16.07.2019 / Award
17) Brief Facts of the Case:- Shri Hari Krishan Gupta ( 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 monthly) pension/annuity. 18) Cause of complaint: Complainants’ arguments:- The complainant stated that he had purchased a Jeevan Suraksha Pension Plan - policy no. 193164408 from LIC of India. Plan and term of the policy was 122-17. Capital Sum and guaranteed Addition was Rs 364000/-. Vesting date under the policy was 04.03.2018. Complainant received letter dated 03.07.2017 from LIC to exercise option for payment i.e. Lumpsum payment or monthly annuity, according to which the Annuity amount for the subject policy under option F was Rs.2724/- pm, and Annuity amount Rs. 3145.58 as mentioned on policy bond was as per option “D”. The complainant further submitted that at the time of purchase of policy, it was explained to him by LIC officials that pension amount under option “F” (Annuity for Life with return of purchase price on death) in the policy will be Rs. 3145.58 pm, and the same was also printed on the policy bond. LIC paid him pension for April 2019 @ 2724/- pm, while he was entitled to receive Rs. 3145.58 pm. The Insurance Company rejected his complaint on 14.02.2019, hence he approached this forum for redressal of his complaint. Insurers’ argument:- The Insurance Company in their SCN stated that amount of Monthly Annuity of Rs.3145.58 printed on the policy bond was for the option –D i.e. Annuity guaranteed for 15 years and life thereafter. As per the schedule of the policy bond, refer point “ Event on the happening of which annuity ceases or determines” it is clearly mentioned “ on the expiry of 15 years calculated from the date on which annuity vests or at the death of the annuitant, if later”. The Insurance Company also stated that as per their CO circular dated 25.09.1996, the annuity rates to be given in the policy schedule, would rates guaranteed for 15 years and life thereafter as per the rates under option”D”, accordingly annuity rates under option –D was printed on policy bond. In this case policy holder has opted for option –F and the annuity amount of Rs.2724/- is correct. 19) Reason for Registration of Complaint:- Case of less Annuity received.
20) The following documents were placed for perusal. a) Complaint letter b) Policy copy c) GRO Letter d) Option Letter e) Form VI A duly signed by the complainant. f) SCN and a form VIIA deal signed by the Insurance Company
21) Result of hearing with both parties (Observations & Conclusion) :- I heard both sides, the complainant and the Insurance Company. The complainant reiterated that at the time of purchase of policy it was explained by the Branch In charge of Insurance Company that
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pension amount under option “F” in the subject policy will be Rs. 3145.58 pm and the same amount of monthly annuity was also printed on the policy bond with option –F, but as per option letter dated 03.07.2017 received from the Insurance Company, monthly annuity amount under option F was shown as Rs.2724/-, which was not acceptable. The Insurance Company stated that at the time of proposal there was no provision to select any anuity option. Only before six month of vesting date, the policy holder had to select the option and in the option letter dated 03.07.2017, sent to the complainant, monthly annuity amount under option F was shown as Rs.2724/- only and annuity amount Rs. 3145.58 was shown under option D, which was correct.On perusal of documents exhibited and verbal submissions made, I find that since issuance of the subject policy in 2001, no communication was sent by the Insurance Company to the complainant for correcting the priting of option F and monthly annuity amount Rs. 3145.58 in the policy schedule. Accordingly an Award is passed with a direction to the Insurance Company to pay monthly annuity of Rs. 3145.58 under option F, as printed in policy bond, the evidence of the contract containing all terms and conditions.
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 pay monthly annuity of Rs. 3145.58 under option F, as printed in policy bond.
22) The attention of the Complainant and the Insurance Company is hereby invited to the following provisions of 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. b. 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
Place: Jaipur SANDHYA BALIGA Dated: 16.07.2019 ( INSURANCE OMBUDSMAN)
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AWARD NO. IO/KOC/A/LI/0020/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017)
Complaint No. KOC-L-029-1819-0095
PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI
AWARD PASSED ON 15.07.2019
1. Name and Address of : Mr. Pradeep Naick the complainant 48/592C TOOPEES, Cross road 1, Keerthi Nagar, Kochi - 682 026
2. Policy Number : 774166463
3. Name of the Insured : Mr. Pradeep Naick
4. Name of the Insurer : LIC of India
5. Date of receipt of : 20.06.2018 Complaint
6. Nature of complaint : Dispute regarding rate of pension paid under Pension Policy 7. Amount of relief sought : --
8. Date of hearing : 20.05.2019
9. Parties present at the hearing a) For the Complainant : Mr. Pradeep Naick
b) For the Insurer : Ms. Valsa V.J.
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute regarding rate of pension paid under Pension Policy. The complainant, Mr. Pradeep Naick is the policyholder.
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1. Averments in the complaint are as follows:
The complainant is covered under a pension policy from the respondent insurer. The complaint is regarding low fund value and rate of pension. According to the complainant, the returns on his investment are approximately 6.8% based on which he will be paid pension lifelong and at about the same rate where as the interest rates were in the range of 9.5-10% when he purchased the policy. The complainant states that the policy taken by him was a pure pension plan without any life cover and there was no mention in the policy document regarding the low rates used to arrive at the maturity value. It is also complained that the pension amount intimated before vesting was Rs 18254/- for option „F‟ and it was reduced to Rs.17893/-without stating any reason after exercising the same option. The complainant has approached this forum seeking direction to the insurer to provide suitable relief.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the policy issued was a deferred annuity policy with a term of 15 years where annuity is payable at the rates of „Jeevan Akshaya‟ plan of the company prevailing at the time of vesting. The amount of annuity will be on the basis of the annuity purchase price which will be the notional cash option together with reversionary bonus at the time of vesting. This has been stated in the policy document also. It is further stated that the rate of annuity under the subject plan is not guaranteed and is payable at the rates applicable for immediate annuity plan (Jeevan Akshaya) prevailing at the time of vesting. It is again submitted that the immediate annuity plan prevailing at the time of vesting of the subject policy is „Jeevan Akshaya- VI‟ with revised annuity rates with effect from 01.12.2017. There are 10 types of annuity options and the complainant had chosen option „F‟ where annuity is payable throughout the life time of the annuitant with return of purchase price to the nominee on death of the annuitant. It is again submitted that the purchase price of the given policy is calculated as Rs 270492/- (NCO- 179996/- , Bonus for 15 years – 82618/- and rebate on NCO-7878/- ) and yearly annuity is calculated as Rs 17893/-.
3. I heard the complainant and the respondent Insurer. The complainant submitted that the insurer provided low returns on his investment which was far less than that of a bank deposit and the rate of pension was calculated at interest rates prevailing on the date of vesting ,but fixed thereafter, with no scope for upward revision. The respondent Insurer submitted that it has been disclosed in the policy document that the annuity is payable at the rates of Jeevan Akshaya plan and the amount of annuity is based on the annuity purchase price which will be the notional cash option together with Reversionary Bonus at the time of vesting.
4. It is specified in the policy document that the annuity will be paid at the prevailing rates under the „Jeevan Akshaya‟ plan of the insurer. It has been informed by the insurer that there was a revision in the annuity rates of „Jeevan Akshaya‟ plan with effect from 01.12.2017 which was applicable at the time of vesting of the subject policy and annuity rate was fixed accordingly.
Since the insurer has acted as per the terms and conditions of the policy, I do not find any reason to interfere with the decision of the insurer.
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In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 15th July 2019. Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
AWARD NO. IO/KOC/A/LI/0022/2019-2020
PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-029-1819-0109
PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI
AWARD PASSED ON 15.07.2019
1. Name and Address of : Mrs. Laila Siddique the complainant Vilayil Puthen veedu, Inchavila P O, Perinad, Kollam
2. Policy Number : 786219583
3. Name of the Insured : Mrs. Laila Siddique
4. Name of the Insurer : LIC of India
5. Date of receipt of : 29.06.2018 Complaint
6. Nature of complaint : Dispute on annuity payment
7. Amount of relief sought : --
8. Date of hearing : 20.05.2019
9. Parties present at the hearing a) For the : Mrs. Laila Siddique
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Complainant
b) For the Insurer : Ms. Valsa V.J.
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute on annuity payment. The complainant, Mrs. Laila Siddique is wife of the the policyholder. 1. Averments in the complaint are as follows:
The complainant‟s husband had taken an annuity policy from the respondent insurer on 21.10.2014. After his death, the matter was intimated to the insurer. But since the intimation was given late, the insurer paid the last annuity (yearly) which had fallen due by this time and while settling the death claim, this amount along with broken period annuity was recovered from the claim amount. The complainant argues that as per the policy conditions, they are eligible for proportionate annuity. She has approached this forum seeking direction to the insurer for payment of proportionate annuity. 2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the subject policy was issued with Date of Commencement 21.10.2014, purchase price Rs 25 lakhs and mode of annuity „yearly‟. Broken period annuity of Rs 5585/- for the period 21.10.2014 to 31.10.2014 was paid on 16.02.2016. Again, yearly annuity of Rs 188875/- each was paid for the period 01.11.2014 to 31.10.2015 (due 10/15), 01.11.2015 to 31.10.2016 (due 10/16) and 01.11.2016 to 31.10.2017(due 10/17). It is again submitted that the annuitant expired on 02.06.2017 and hence was not eligible for the annuity due on 21.10.2017 which was released by the insurer since the death intimation was received on 30.01.2018 only. It is again submitted that as per policy provisions the policy is not eligible for proportionate annuity. and this is mentioned in the policy document which reads, “where the annuity ceases or determines on the death of the annuitant, no part of the said annuity shall be payable or paid for such time as may elapse between the date of payment immediately preceding the death of the annuitant and the day of his/her death, the subsistence of the life of the annuitant at twelve o‟clock on the day on which the said annuity falls due being duly certified from time to time in such manner as the corporation may require‟. Again, it is submitted that the annuity plans have been priced taking into account the mode of payment of annuity and also the probability of survival of the annuitant at the time of each payment due. Since the annuitant was eligible for annuity due on 21.10.2015 & 21.10.2016 only, the excess amount paid Rs 194050/- was deducted from death claim proceeds.
3. I heard the complainant and the respondent Insurer. The complainant submitted that since her husband lived upto 02.06.2017, he was eligible to get proportionate annuity for the period of 7 months. The respondent Insurer submitted that as per policy provisions, the annuitant is not eligible for proportionate annuity and this has been mentioned clearly in the policy document.
4. It is found that the insurer has acted as per the terms and conditions of the policy. Hence I do not find any reason to interfere with the decision of the insurer.
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In the result, an AWARD is passed for Dismissal of the complaint. Dated this the 15th July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
AWARD NO. IO/KOC/A/LI/0024/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-029-1819-0072 PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI AWARD PASSED ON 15.07.2019
1. Name and Address of : Mr. Shaji. R the complainant Kavil Edayil House, Eruva East, Eruva (P.O.), Kayamkulam - 690572
2. Policy Number : 395565074
3. Name of the Insured : Mr. Shaji. R
4. Name of the Insurer : LIC of India
5. Date of receipt of : 15.05.2018 Complaint
6. Nature of complaint : Dispute regarding adjustment of premium paid and subsequent lapsation of policy 7. Amount of relief sought : --
8. Date of hearing : 20.05.2019
9. Parties present at the hearing a) For the : Absent Complainant
b) For the Insurer : Ms. Nancy Samuel
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AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute regarding adjustment of premium paid and subsequent lapsation of policy. The complainant, Mr. Shaji. R is the policyholder. 1. Averments in the complaint are as follows:
The Complainant has taken a Jeevan Saral Policy on 28/03/2012 and premiums were remitted under Qly mode up to 28/10/2012 at Kayamkulam Branch Office. Subsequently, the mode of payment of premium has been converted to KGSD Scheme and premium @ Rs.510/-per month is being deducted from his salary. When he enquired about the Surrender Value of the policy, he was informed that the policy has been lapsed. He states that Mly. Premiums @ Rs.510/-were regularly deducted from his salary and being remitted to KGSD Department up to 03/2018. He reliably learnt that premiums deducted had not been adjusted towards his policy and as a result the policy got lapsed. He made several complaints to the insurer including the Grievance Cell, for which no action seems to have been taken. Hence, he filed a complaint before this Forum, seeking direction to the Insurer for updating all premiums paid towards the policy.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the policy was issued by one of the branches of the insurer and the mode of premium payment was opted as „quarterly‟ by the policy holder in the proposal for insurance. It is further submitted that the policy holder being a government employee wanted to include the policy under „ salary savings scheme‟ and requested for the same. But, inadvertently, an omission occurred in effecting the mode alteration. Eventhough the subsequent premia were deducted from his salary and remitted to the salary savings department, the policy master was not transferred to the department and hence the premia deducted were kept as policy deposit by the concerned department. It is submitted that, on pointing out the error, the mode of payment was altered to „ monthly salary savings scheme‟ and the premium has been regularized.
3. The complainant was absent. I heard the respondent Insurer who submitted that there was an inadvertent omission in effecting mode alteration and on pointing out the mistake, the same was corrected. 4. The respondent insurer stated that the mode of payment of subject policy was altered to monthly under „salary savings scheme‟ and the premium paid has been regularized. They have submitted a copy of status report of the policy also. In the result, an AWARD is passed for Dismissal of the complaint. Dated this the 15th July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
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AWARD NO. IO/KOC/A/LI/0029/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-029-1819-0199
PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 23.07.2019
1. Name and Address of : Mrs. Mini C P the complainant Nirmalyam, Dinesh Road, Chalad, kannur - 670 014
2. Policy Number : 799273934
3. Name of the Insured : Mrs. C.P. Laxmi
4. Name of the Insurer : LIC of India
5. Date of receipt of : 03.10.2018 Complaint
6. Nature of complaint : Dispute regarding payment on Pension policy 7. Amount of relief sought : --
8. Date of hearing : 21.06.2019
9. Parties present at the hearing a) For the : Mrs. Mini C P Complainant
b) For the Insurer : Ms. S.V. Meera
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute regarding payment on Pension policy. The complainant, Mrs. Mini C P is the policyholder.
Page 68 of 113
1. Averments in the complaint are as follows: The complainants diseased mother had taken a Jeevan Akshay policy on 15.12.2016 for a purchase price of 30,00,000 with yearly annuity of Rs.2,22,750/-. Her mother died on 9.9.2017. 1st instalment of annuity was due on 15.12.2017. Since the mother of the complainant died on 9.9.2017 before the due date of annuity she is claiming proportionate annuity of Rs1,70,000/-.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the policy is not eligible for proportionate annuity as per the policy condition. This is mentioned in the policy document which reads „where the annuity ceases or determines on the death of the annuitant no part of the said annuity shall be payable or paid for such time as may elapse between the date of payment immediately preceding the death of the annuitant and the day of his/her death, the subsistence of the life of the annuitant at twelve o‟ clock on the day on which the annuity falls due being duly certified from time to time in such a manner as the corporation may require”. Further it is clarified that annuity plans have been priced taking into account the mode of payment of annuity and also the probability of survival of the annuitant at the time of each payment due. Hence it is clear that proportionate annuity is not payable for the period elapsed between DOC and date of death so request to dismiss the complaint.
3. I heard the complainant and the respondent Insurer. The complainant submitted that she should get an interest for Rs.30,00,000/- lying with the insurer from date of issuance of the policy till date of death of her mother. The respondent Insurer submitted that it is very clear in the policy document that proportionate amount is not payable and all the amounts due on the policy was paid to the complainant on receipt of the death intimation in time. 4. On considering the facts and circumstances of the case the insurer acted strictly to the terms and conditions of the policy. In the result, an AWARD is passed for Dismissal of the complaint. Dated this the 23rd July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
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AWARD NO. IO/KOC/A/LI/0030/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-006-1819-0175 PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 23.07.2019
1. Name and Address of : Mrs. Noel Varghese Zachariah the complainant S/o Zacharia K Varghese, Poothicottu Karoor, Peringol, Kavumbhagom P O, Thiruvalla - 689 102
2. Policy Number : 152993001
3. Name of the Insured : Mrs. Noel Varghese Zachariah
4. Name of the Insurer : Bajaj Allianz Life Insurance Co. Ltd.
5. Date of receipt of : 06.09.2018 Complaint
6. Nature of complaint : Dispute regarding option exercised for fund management 7. Amount of relief sought : --
8. Date of hearing : 20.06.2019
9. Parties present at the hearing a) For the : Mrs. Zachariah K. Varughese Complainant b) For the Insurer : Ms. Srishti Nigam
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute regarding option exercised for fund management. The complainant, Mrs. Noel Varghese Zachariah is the policyholder.
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1. Averments in the complaint are as follows: The complainant has taken a insurance policy on 10.2.2010O from the respondent insurer. It is a unit linked policy “Bajaj Allianze Shield Plus”. The complainant opted for equity growth fund2.The amount invested was Rs 50,000.On the same day two same policies were taken for his siblings investing Rs 50,000 each. The amount accrued in his siblings policies is Rs1,48,000 each and on his own policy Rs1,00,026.The complaint is that the respondent insurer invested the in a fund which was not opted by the complainant. The matter was taken up with the grievance cell of the insurer but did not get a favorable reply. Hence the complainant has approached the forum seeking guidance to the insurer to compensate for the loss occurred to him due to wrong investment.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the complaint is incorrect unless specifically admitted by the company. Company says that the complainant had never raised any issue until the fund switch over took place. The company further mentions that since it‟s ready to compensate for any lost amount since its customer centric.
3. I heard the complainant and the respondent Insurer. The complainant was represented by his father Mr.Zachariah K Varughese. The complainant
Representative submitted that he had invested Rs 50,000 each on his three children in the same Ulip plan. His other two children got a maturity amount Rs 1,48,000 whereas his son Mr Noel Varghese Zacharaiah got Rs.1,00,026. He further submitted that the respondent insurer invested the amount which was not opted by the complainant and after pointing out the mistake the amount was invested in the plan requested by the complainant. In the process the complainant amount was not appreciated as the other two policies taken by his children. The respondent Insurer submitted that there was a mistake by the company in the investment of Rs.50,000 at the commencement of the policy and has agreed to Rs.1,39,793 towards the fund value on the policy to the complainant. Complainant has agreed to the quoted amount.
In the result, an award is passed, directing the respondent insurer to pay an amount of Rs 1,39,793 to the complainant within the period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 23rd July 2019.
Sd/- (POONAM BODRA)
INSURANCE OMBUDSMAN
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AWARD NO. IO/KOC/A/LI/0032/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-029-1819-0184
PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI
AWARD PASSED ON 23.07.2019
1. Name and Address of : Mr. N J Alex the complainant H NO 11/909, Nedodi, Fort Kochi Veli, Kohi 682 001
2. Policy Number : 771915493
3. Name of the Insured : Mr. N J Alex
4. Name of the Insurer : LIC of India
5. Date of receipt of : 18.09.2018 Complaint
6. Nature of complaint : Return of premium
7. Amount of relief sought : --
8. Date of hearing : 21.06.2019
9. Parties present at the hearing a) For the : Mr. N J Alex Complainant
b) For the Insurer : Ms. Valsa V J
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Return of premium. The complainant, Mr. N J Alex is the policyholder.
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1. Averments in the complaint are as follows: The complainant had taken an insurance policy from the respondent insurer on 28.5.2008 under salary savings scheme with a monthly premium of Rs 963.Premiums are remitted till 28.3.2011.Complainant mentions that he lost his job and could not continue remitting the premium. He filed a complaint before the forum seeking direction to the insurer to refund the premiums paid.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the policy is a Endowment type policy and as per policy conditions paid up value is acquired only if 3 years premium is remitted. Since the premium is remitted for 2yrs and 11 months nothing is payable and hence request the forum to dismiss the complaint.
3. I heard the complainant and the respondent Insurer. The complainant submitted that since the policy was is salary savings mode the policy holder had no idea about the premium positions and the respondent insurer also did not send him any status intimating the premium position or communication regarding the withdrawal of SSS scheme. Policy holder waited till the maturity date to claim the amount. The respondent Insurer submitted that since 1 monthly premium was short paid up value cannot be paid.
4. The policy holder is a laborer and does not have much educational qualification to understand the terms of the policy. He was working in USA Pool. Once the company closed premium deductions stopped .Since “the policy was taken under SSS scheme policy holder was not aware about the status of the policy. More over there was a lapse on the part of insurer. Insurer neither intimated the complainant the status of the policy or to convert the policy to direct mode of premium remittance.
Considering the facts and circumstance of the case to render justice paid up value have to be paid to the policy holder.
In the result, an award is passed, directing the respondent insurer to deduct one premium and pay the paid up amount within the period mentioned hereunder. No cost.
As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.
Dated this the 23rd July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
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AWARD NO.IO/KOC/A/LI/0034/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-041-1819-0136
PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 23.07.2019
1. Name and Address of : Mr. Paul Mathews the complainant Thekkekunnel House, Pothanicad P O, Ernakulam - 686 671
2. Policy Number : 39001994004
3. Name of the Insured : Mr. Paul Mathews
4. Name of the Insurer : SBI Life Insurance Co. Ltd.
5. Date of receipt of : 20.07.2018 Complaint
6. Nature of complaint : Dispute on surrender value
7. Amount of relief sought : --
8. Date of hearing : 21.06.2019
9. Parties present at the hearing a) For the : Mr. Paul Mathews Complainant
b) For the Insurer : Mr. Prasanth P.R.
AWARD This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute on surrender value. The complainant, Mr. Paul Mathews is the policyholder. 1. Averments in the complaint are as follows: The complainant had taken a pension plan unit liked policy in 2010 with a yearly premium of Rs5,00,000 for a premium paying term of 15yrs.Policy lapsed in 2011 for
Page 74 of 113 non-payment of renewal premium and the respondent company foreclosed the policy and paid the fund value Rs 4,40,967 in 2015 after deducting the surrender charges and TDS from the fund value of Rs 5,52,385. The complainant has a point that surrender charges and TDS are deducted illegally and claims refund of Rs 1,11,418(surrender charges Rs 93,099 +TDS Rs 18,319)with 18%.
The complainant has mentioned that in the policy it is mentioned that no surrender penalty from the 6th policy year irrespective of the number of premiums paid and as per Govt. of India tax regulations no need to pay tax for long term, more than three years investment scheme. Complainant approached the respondent grievance cell but did not get satisfactory reply. Hence approached the forum seeking direction to the insurer to settle the claim. 2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the complainant had taken a policy in 2010 with annual premium of Rs 5,00,000 for 15yrs.After the remittance of first premium subsequent premiums from 2011 were not remitted. Policy was lapsed and as per policy condition it was foreclosed and Rs 4,40,967 was paid to the complainant in 2015 .Fund value was Rs 5,52,385 less surrender charges 93,099(15% of fund value)TDS 18319(30.9% of 59286). As per the terms and conditions of the policy: Clause 5, Discontinuance of premiums 5.1 Discontinuance of premiums in first three policy years 5.1.2 If you have not paid 2nd or 3rd policy years premiums and do not revive your policy, then we will pay the fund value minus the Surrender charges, if any, at the end of the revival period. 5.1.4 We will continue to deduct FMC and policy administration charges. Clause 12 Charges: 12.3.1 We will recover charges from the fund value. 12.3.2 The surrender charges will be as per the following table
Years Surrender charges 1 15%
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2 10% 3 7.5% 4 5% 5 5% 6onwards NIL 12.3.3 Years, in the above table will refer to the number of completed years of premium paid.
Clause 16.10 Taxation As per 16.10.3 Taxes may change subject to future changes in taxation law. The complainant was a Non Resident Indian at the time of receipt of money. It is stated that TDS has to be deducted as per sec 195 IT Act 1961.Section 195 Tax Clause is for NRI,TDS rate applicable is 30.9% for a payouts up to 1crore.The company states that TDS was deducted as per the prevailing laws. The company states that surrender charges and TDS have been deducted as per the terms and conditions and the allegations of the complainant are baseless and request the forum to dismiss the complaint. 3. I heard the complainant and the respondent Insurer. The complainant submitted that the company deducted surrender charges and income tax which was against the conditions of the policy and claimed refund of amount deducted. The respondent Insurer submitted that the claim of the complainant was false and surrender charges and Income tax is deductable as per the policy conditions and quoted the conditions in the self contained note which is correct. Considering the facts of the case I don‟t find any merit for refund of the surrender charges and income tax.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 23rd July 2019. Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
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AWARD NO.IO/KOC/A/LI/0035/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-008-1718-0320
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 23.07.2019
1. Name and Address of : Mrs. J. Sreelekha Rajan the complainant Rajeevam, Vettiyar (P.O.), Mavelikkara. Pin - 690 558
2. Policy Number : 500-6120135
3. Name of the Insured : Mrs. J. Sreelekha Rajan
4. Name of the Insurer : Bharti AXA Life Ins. Co. Ltd.
5. Date of receipt of : 05.01.2018 Complaint
6. Nature of complaint : Dispute regarding refund of premium paid 7. Amount of relief sought : --
8. Date of hearing : 20.06.2019
9. Parties present at the hearing a) For the : Absent Complainant
b) For the Insurer : Mr.Vinod Kumar M.
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute regarding refund of premium paid. The complainant, Mrs. J. Sreelekha Rajan is the policyholder.
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1. Averments in the complaint are as follows: The complainant has taken a policy from the respondent insurer in 2010 with a annual premium of 20,000.She had remitted three annual premium till 2012.A total of 60,000 was paid by the complainant and stopped paying the premium as per the understanding given by the agent that she had to remit 3 years premium and she will get benefits, hence did not continue with the policy.
Now the policy got terminated and the complainant got an surrender amount of 20,000. The complainant is claiming refund of 60,000 paid towards premium. Since the respondent insurer did not bring any relief a complaint is filed seeking full refund of premium.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the complainant was issued a policy bearing No 500-6120835 based on a duly completed and signed proposal form.The complainant had a option to go through the policy and exercise the freelook cancellation within 15 days from receipt of the policy.Company received a complaint dated 5.8.2017 after 7 years of issuance of policy. The company states that the complainant is an educated person and prudent enough to understand the terms and conditions of the policy.
As per 4.5.2 it is noted in the policy as below:-
“Where the policy fund falls to the level of an amount equal to 120% of the annual premium or the policy fund is inadequate for the deduction of the applicable policy charges as per section 7 whichever is earlier, the policy shall terminated and the surrender value shall be paid” The respondent insurer states that the benefits were paid under the terms and conditions of the policy and request to dismiss the complaint.
3. I heard the respondent Insurer. The complainant had given consent to take her case in her absence and decide as per the merit of the case. The complainant wants refund of premium remitted for 3 yrs @20,000. The respondent Insurer submitted that it‟s a life insurance policy that offers financial protection in time of needs and premiums cannot be refunded. Policy holder stopped paying premiums after 3 yrs. In accordance to discontinuance clause in the policy bond, the minimum allowable limit is the minimum prescribed fund value that should be available under the policy. In case the fund value falls below this limit, the policy will be terminated and the fund value will be refunded. In this case also they acted as per the terms of the policy.
4. The policy was taken in 11.08.2010. In September 2013 a letter was sent from the Insurance Company about the discontinuance clause when the policy holder stopped paying the premiums. So the complainant cannot say that she was not aware of such a clause. This is an insurance policy and it cannot be compared with bank deposits. Considering the facts of the case I do not find any merits to refund the premiums. In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 23rd July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
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AWARD NO.IO/KOC/A/LI/0036/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-008-1819-0163
PRESENT: Ms. POONAM BODRA
INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 23.07.2019
1. Name and Address of : Mr. Cyril Albert the complainant Edamuriyil House, Kakkottumoola, Mayyanad P O, Kollam. Pin - 691 303
2. Policy Number : 501-5898934
3. Name of the Insured : Mr. Cyril Albert
4. Name of the Insurer : Bharti AXA Life Ins. Co. Ltd.
5. Date of receipt of : 21.08.2018 Complaint
6. Nature of complaint : Refund of premium
7. Amount of relief sought : --
8. Date of hearing : 20.06.2019
9. Parties present at the hearing a) For the : Mr. Cyril Albert Complainant
b) For the Insurer : Mr.Vinod Kumar M.
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Refund of premium. The complainant, Mr. Cyril Albert is the policyholder.
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1. Averments in the complaint are as follows: The complainant has taken a policy from the respondent insurer on 12.6.2017 with monthly premium of Rs 5036.08 for a premium paying term of 5yrs and policy term 10yrs.After remitting premium upto 12/2017 complaint fell ill and could not remit premium. Complaint has written to the Grievance cell for refund of premium and is yet to receive a reply from them. Hence he filed a complaint before the forum seeking direction to the insurer to refund the premium Rs 35.216.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the premiums are paid for 7 months and now the policy is in lapsed condition without paid up value. The company submits that the life assured has been covered under the foresaid policy for the premiums paid and the benefits are payable only according to the terms and conditions. The Policyholder was supposed to pay premiums for 5yrs but paid from June 2017 to December 2017 hence the policy has not acquired paid up status and nothing is payable under the policy. Further, company provides an option to revive the policy within 2 yrs from the date of first unpaid premium by making payment of all outstanding premiums and any procedure to be followed as per the company‟s underwriting rules. In view of the policy terms and conditions company request to dismiss the complaint.
3. I heard the complainant and the respondent Insurer. The complainant submitted that the he had taken the policy to save income tax. Now he not able to remit premiums since his earning is less and has a added responsibility of taking care of his daughter who is a widow and staying with him. He is requesting for 50% of the premiums remitted. The respondent Insurer submitted that the policy holder has to pay 5yrs monthly premium but has remitted only 7 monthly premiums and the policy is now lapsed. Only option given is to revive the policy as refund of premiums are not possible as per the terms of the policy and it has not acquired paid up value also.
4. It is very clear that the complainant had taken the policy to save his income tax and was fully aware of the terms and conditions of the policy. The insurer has also explained all the details of the policy to the policy holder and agreed to remit premiums for 5 yrs after thorough understanding. Considering the facts of the case I did not find any merit to cancel the policy and refund the premiums.
In the result, an award is passed, for “Dismissal” of the complainant.
Dated this the 23rd July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
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AWARD NO. IO/KOC/A/LI/0037/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-006-1819-0227
PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 23.07.2019
1. Name and Address of : Mr. Sunil Babu K N the complainant Sunil Sadanam, Pallippuram P O, Cherthala - 688 541
2. Policy Number : 58347820
3. Name of the Insured : Mr. Sunil Babu K N
4. Name of the Insurer : Bajaj Allianz Life Insurance Co. Ltd.
5. Date of receipt of : 29.10.2018 Complaint
6. Nature of complaint : Dispute regarding Refund of premium 7. Amount of relief sought : --
8. Date of hearing : 20.06.2019
9. Parties present at the hearing a) For the : Mr. Anilkumar G. Complainant b) For the Insurer : Ms. Srishti Nigam
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complainant, Mr. Sunil Babu K N is the policyholder.
1. Averments in the complaint are as follows: The complainant had taken 4 policies in 28.7.2007 by remitting Rs.12,000/- on each policy. Subsequent premiums from 2008 could not be paid by the complainant as had a major heart ailment .He underwent a bypass surgery at Lakeshore Hospital in 2008 for which the reports are enclosed. Now
Page 81 of 113 the complainant is requesting the refund of premiums 48,000 with 9% interest as he in great financial crisis because of his illness. Since the dispute could not be resolved with the respondent insurer a petition is filed before the forum.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the policies was issued based on the duly completed proposal forms and no concern was raised regarding the terms and conditions of the policy during the free look period. It is submitted that the policies in issue are “Capital Unit Gain Size One” whereas it is clearly mentioned in the policy document that if at least three full years‟ regular premiums have not been paid, the surrender charge will be 100% of the value of the Capital units. Hence the company is not liable to refund of the premiums. It is therefore, humbly request that the complaint may kindly be dismissed.
3. I heard the complainant and the respondent Insurer. The complainant was represented by his brother in law. The representative submitted that the complainant was a heart patient and was not able to travel. He further mentioned that since he is sick he is not going to work and needs money for medicines and children‟s education. So pleaded for refund of premium Rs.48,000/- remitted on 4 policies @ 12,000 each. The respondent Insurer submitted that the policy is a unit linked plan with payment of renewal premium for 20 years. The Company was sending notices to remit the renewal premium regularly and it is after 11yrs the complaint is coming with such a request. Insurer mentioned that it is clear in the policy document that in non-payment of regular premium for three full years, surrender charges will be 100% of the value of the capital units. Insurer further mentioned that it is an insurance policy where only single premium has been paid on all the 4 policy and refund of premiums is not possible as per the terms and conditions of the contract.
4. On consideration on the facts and evidences of the case I don‟t find any merit in the case to cancel the policy and refund the premium.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 23rd July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
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AWARD NO.IO/KOC/A/LI/0040/2019-2020 PROCEEDINGS OF THE INSURANCE OMBUDSMAN, KOCHI (UNDER RULE NO. 13(1)b READ WITH RULE 14 OF THE INSURANCE OMBUDSMAN RULES, 2017) Complaint No. KOC-L-029-1819-0137
PRESENT: Ms. POONAM BODRA INSURANCE OMBUDSMAN, KOCHI.
AWARD PASSED ON 23.07.2019
1. Name and Address of the : Mr. Gopal V K, complainant 36/1154, Pazhayanadakkavu, Gundu Rao Lane, Thrissur - 680 001
2. Policy Number : 789377332
3. Name of the Insured : Mrs. Alamelu Ammal R.
4. Name of the Insurer : LIC of India
5. Date of receipt of : 26.07.2018 Complaint
6. Nature of complaint : Dispute on payment under Pension policy 7. Amount of relief sought : --
8. Date of hearing : 20.06.2019
9. Parties present at the hearing a) For the Complainant : Mr. Gopal V K
b) For the Insurer : Ms. Vanaja D. Kamath
AWARD
This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Dispute on payment under Pension policy. The complainant, Mr. Gopal V K is the policyholder.
Page 83 of 113
1. Averments in the complaint are as follows. Complainant‟s deceased mother had taken Jeevan Akshay on 8.9.2016 for a purchase price of 5 lakh with yearly annuity of Rs.39,850/-. His mother died on 16.3.2018. 1st installment of annuity is due on 8.9.2018. Since the mother of the complainant died on 16.3.2018 before the due date of annuity he is claiming proportionate annuity from 1.10.2017 to 15.3.2018 Rs.18,123/- and broken period annuity Rs.2,511/- deducted from the purchase price. Since the complaint is not resolved he approached the forum seeking direction to the insurer for considering the amount.
2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the policy is not eligible for proportionate annuity as per the policy condition and hence broken period annuity was deducted and proportionate annuity not paid. This is mentioned in the policy document also, which reads “where the annuity ceases or determines on the death of the annuitant no part of the said annuity shall be payable or paid for such time as may elapse between the date of payment immediately preceding the death of the annuitant and the day of his/her death, the subsistence of the life of the annuitant at twelve‟o clock on the day on which the said annuity falls due being duly certified from time to time in such a manner as the corporation may require”. The annuity plan has been priced taking into account the mode of payment of annuity and also the probability of survival of the annuitant at the time of each payment due. Hence the respondent confirms that the claim has been settled as per policy condition.
3. Both the complainant and Respondent insurer has given consent for the Insurance Ombusman to act as mediator for the resolution of the complaint. Notice was issued from this forum for the appearance of parties for hearing. The complaint was represented by self. The respondent insurer was represented by their authorized official. They were heard. The complainant submitted that the pension policy was taken by his mother for yearly annuity and that the amount due from the date of commencement of policy till date of death of the annuitant was not given. The respondent Insurer submitted that the policy is not eligible for proportionate annuity as per policy condition and hence it was not paid. The condition is clearly mentioned in the policy document.
4. On consideration of facts and terms of the policy the under-signed is convinced that the respondent insurer has acted and settled the claim strictly as per the terms and conditions of the policy.
In the result, an AWARD is passed for Dismissal of the complaint.
Dated this the 23rd July 2019.
Sd/- (POONAM BODRA) INSURANCE OMBUDSMAN
Page 84 of 113
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKKIM AND UT OF A & N ISLANDS (UNDER RULE NO: 16( 1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN –K. B. Saha CASE OF MR. SIB SANKAR ADAK V/S RELIANCE NIPPON LIFE INSURANCE COMPANY LIMITED COMPLAINT REF: NO:KOL-L-036-1718-1167 AWARD NO: IO/KOL/A/LI/ 0187 /2019-2020
1. Name & Address of the Complainant Mr. Sib Sankar Adak, S/o: Bhagyadhar Adak, Vil.- Ramnagar, P.O.- Basudebpur, PS- Uluberia, Dist.- Howrah, PIN- 711 316, West Bengal, Mob. No.-9830654240. 2. Policy No: Pol. No.-52967286 Type of Policy Details of policy given in the Table below. Duration of policy/Policy period ----do------3. Name of the insured Mr. Sib Sankar Adak Name of the policyholder ------do------4. Name of the insurer RELIANCE NIPPON LIFE Ins. Co. Ltd. 5. Date of Repudiation N.A. 6. Reason for repudiation N.A. 7. Date of receipt of the Complaint 27/11/ 2017-- 8. Nature of complaint Non-settlement of Surrender Value. 9. Amount of Claim 40,000/- 10. Date of Partial Settlement N.A. 11. Amount of relief sought Rs.40,000/--- as per P form 12. Complaint registered under IOR,2017 13 (1) ( d ) 13. Date of hearing/place 08..07.2019 at 10.30 AM at KOLKATA 14. Representation at the hearing For the Complainant Mr. Sib Sankar Adak. For the insurer Shadab Hussain 15. Complaint how disposed BY CONDUCTING HEARING 16. Date of Award/Order 08.07.2019 17) Brief Facts of the Case:--The complainant alleged against the Ins. Co. on the following points: That he had been befooled by Co.’s Broker, namely, SMC Insurance Brokers Pvt Ltd, in buying one Reliance Gurr. Money Back Plan during May, 2017 in consideration of annual premium of Rs.40,000/-. In fact, it was proposed to utilize his building’s roof on monthly rental basis by the broker, in order to install one Reliance Jio Tower thereon and for that purpose, the above policy was sold to him. Thereafter on one pretext or other, in the name of security deposit, the Co. could collect a sum of Rs. 1,00,000/- from him. Not only this, they went on demanding more money in the name of I. Tax requirement etc. Thus he made total deposits of Rs.3,10,000/-.Studying the total situation, he could realize that he had been cheated by them and could not get any positive response from the Co. in materializing the program of installation. He thereafter approached the Consumer Forum for getting the surrender value of the policy, but failed. He then applied to the Ins. Co. for the same purpose, but it was declined by them on the ground of submission of the application beyond the free look period of 15 days. Finally, he took the recourse of the Office of Ombudsman for redressal of his grievance.
Details of the policy issued (Name of Broker : SMC Insurance Brokers Pvt Ltd.)
Pol.No. Plan PT/PP Inst.Pre Detail Dt. of first Duratio Pol. Bond Name of the Name T m. s of Complnt n Dispatch/Deliv & DOC Insrd/Propos prem. ery details. (yrs) Mode To Co. er. paid.
Page 85 of 113
Rel. 15/10 39,999.7 By 01/11/20 06 Not furnished Mr. S.Adak Gurr. 7 Chequ 17 mths 5296728 e (approx 6 / M.Bac yly ) k 10-05- 2017 Plan
18) Cause of Complaint: Mis-selling of policy by false commitment
a)Complainant’s argument :Already briefed under point 17
b)Insurer’s argument: SCN from Ins. Co. is yet to be received. Hence, it is not possible to include their comments herein.
19) Reason for Registration of Complaint: - Scope of the IOR,2017, Rule –13 (1 ) ( d )
20) The following documents were placed for perusal.
a) Complaint letter to Ombudsman & to the Ins. Co. ,b) Copy of the proposal & P form.
d) Copy of the FPR and policy schedule. ,e) Ins. Co.’s letter/e-mail & correspondences with the Co.of different dates after issue of the policy.
21) Result of hearing with both parties (Observation & Conclusion):
Both the parties were present during the course of hearing.
The Complainant submitted the points which were mentioned under serial no 17 and requested Ombudsman to refund the premium after cancelling the policy.
On the other hand representative of the insurance company agreed to refund the premium by cancelling the 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 revealed that one regular premium policy was sold with false promise. So insurance company is directed to refund Rs. 40000.00 after cancelling the policy with an intimation to this office.
22) The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017.
As per Rule 17(6) 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, 8th July 2019. K. B. Saha
INSURANCE OMBUDSMAN
STATES OF WEST BENGAL, SIKKIM AND UT OF A & N ISLANDS.
Page 86 of 113
.
PROCEEDINGS THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKKIM AND UT OF ANDAMAN & NICOBER ISLANDS (UNDER RULE NO: 16(1)/17 of THE INSURANCE OMUDSMAN RULES ,2017) OMBUDSMAN : K. B. SAHA
CASE OF: MR. SANJIT KUMAR SAHA VS LIFE INSURANCE CORPORATION OF INDIA
COMPLAINT REF NO: KOL-L-029-1718-1368
AWARD NO: IO/KOL/A/LI/0195/2019-2020
1. Name & Address of the Complainant MR. SANJIT KUMAR SAHA
S/O-LATE-RADHASHYAM SAHA
FLAT NO:C-17, 2ND FLOOR
GOSHTATALA NEW SCHEME
PO-GARIA
KOLKATA-700084
.2. Policy No: 462945401
Type of Policy ANNUITY POLICY, AS PER THE TABLE BELOW
Duration of policy/Policy period
3. Name of the insured SANJIT KUMAR SAHA
Name of the policyholder
4. Name & address of the insurer LIC OF INDIA, BURDWAN
Date of Repudiation -----
6. Reason for repudiation -----
7. Date of receipt of the Complaint 29.12.2017
8. Nature of complaint DELAY IN SETTLEMENT OF ANNUITY
9. Amount of Claim ----
10. Date of Partial Settlement NA
11. Amount of relief sought Rs.48000/- + Intt. As per P-Form
12. Complaint registered under Rule IOR 13(1) (A) 2017
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13. Date of hearing/place 09.07.2019 at KOLKATA
14. Representation at the hearing
For the Complainant Mr. Sanjit Kumar Saha
For the insurer Mr. Kamalesh Goswami, AO (Claims)
15 Complaint how disposed BY CONDUCTING HEARING
16 Date of Award/Order 15.07.2019
17. Brief Facts of the Case
POL. NO. D.O.C. NAME TABLE PREMIUM MLY ANNUITY
YLY As per pol. document:
462945401 15.12.1997 SANJIT KUMAR 122-20 RS.6385/- 4000/- WEF- 15.01.17. SAHA
The complainant had brought the following allegation against the insurer that :
i) The insurer had not started the Mly annuity payment @Rs4000/- per month as per the policy document wef : 15.01.2017, though the premium had been fully paid.
ii) The letter written to the insurer for payment of annuity remained unanswered.
iii) He claimed for due annuity payment with interest.
A) Complainant’s argument: Already explained in Point No. 17.
b) Insurers’ argument -- SCN received on 02.08.2018 with the following submissions :
i) Complainant purchased the policy on 15.12.1997. Since the policyholder initially opted for monthly pension under the policy the first instalment of monthly pension was due on 15.01.2018 i.e. one month after the date of vesting on 15.12.2017. However, the date was erroneously mentioned as 15.01.2017, instead of 15.01.2018 against the column of “date of 1st pension instalment’. ii) After the last premium was paid by the complainant on 15.12.2016 an option form was sent to his recorded address which remained unresponded. On getting information of change of address from the complainant, LIC again sent an option form wherein complainant desired to take pension instalment on Qly basis, instead of monthly basis as exercised earlier. Accordingly, pension on Qly basis was disbursed through NEFT and there was no deficiency in service on the part of the insurer.
19) Reason for Registration of Complaint :
Scope of The Insurance Ombudsman Rules, 2017
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20) The following documents were placed for perusal
a) Annexure – VI-A, b) complaint letter c) SCN
21) Result of hearing with both parties (Observations & Conclusion) :
Complainant’s submission : i) Repetition of points as contained in the complaint letter to Ombudsman Office. ii) Besides, he was dissatisfied with the insurer for not informing him in writing about erroneous mentioning of date of “1st pension instalment” in the policy document.
Insurer’s submission : i) Admitted inadvertent printing mistake in the policy about due date of “1st pension instalment” ii) However, they confirmed of having started paying annuity on quarterly mode as per option exercised by the policyholder. It was also informed that they already paid interest against delayed annuity payment to 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 was observed that there was an unintentional printing mistake in the policy document about the date of first installment of monthly pension. On rectification of the mistake, insurer has started paying annuity on quarterly interval as per choice of the complainant.
Since it was a printing error about commencement of date/month of annuity payment which was subsequently set right by the insurer with payment of annuity on the due dates, no relief is provided to the complainant against his complaint lodged to this Forum in respect of Policy No. 462945401.
The complaint accordingly is treated as disposed of.
22) The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017
As per Rule 16(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 15th day of July, 2019
K. B. SAHA
INSURANCE OMBUDSMAN
FOR THE STATES OF WEST BENGAL,
SIKKIM AND UT OF ANDAMAN & NICOBAR ISLAND.
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. PROCEEDINGS THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKKIM AND UT OF ANDAMAN & NICOBER ISLANDS OMBUDSMAN - MR. K.B. SAHA CASE OF: MR.SANJOY GHOSH VS LIFE INSURANCE CORPORATION OF INDIA
COMPLAINT REF NO : KOL-L-029-1718-1372 AWARD NO: IO/KOL/A/LI/0197/2019-2020
1. Name & Address of the Complainant MR. SANJOY GHOSH VILL-BIJRA, PO-AMADPUR PS-MEMARI DST-BURDWAN PIN- 713154 MOB.NO--9563686293 .2. Policy No: 489912267 Type of Policy ENDOWMENT . POL Duration of policy/Policy period 3. Name of the insured JHARNA GHOSH Name of the policyholder ----DO----
4. Name & address of the insurer LIC OF INDIA, BURDWAN Date of Repudiation ----- 20.03.2017 6. Reason for repudiation SUPPRESSION OF MATERIAL FACTS 7. Date of receipt of the Complaint 29.12.2017 8. Nature of complaint DELAY IN SETTLEMENT OF ANNUITY 9. Amount of Claim 1 -LAKH 10. Date of Partial Settlement NA 11. Amount of relief sought Rs.1.00 lakh as per P-form 12. Complaint registered under Rule IOR 13(1) (B) 2017 13. Date of hearing/place 09.07.2019 at OIO/Kolkata 14. Representation at the hearing For the Complainant Mr. Sanjoy Ghosh For the insurer Mr. Kamalesh Goswami, AO(Claims) 15 Complaint how disposed BY CONDUCTING HEARING 16 Date of Award/Order 15.07.2019
17. Brief Facts of the Case
POL. D.O.C. NAME TABLE PREMIUM DOD DURATION OF NO. (YLY) POL. 48991 28.06.14 JHARNA GHOSH 814-18- Rs.1635/ - 10.10.15 1y 3mth 2267 (18) 12dys
The complainant had lodged complaint on the following points that :
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1)The insurer had repudiated the death claim of her mother’s policy noted above while the other policy was settled by the insurer.
2) He expressed his disappointment knowing the reason of repudiation of claim by the insurer.
3) He appealed before the ombudsman to reconsider the death claim for its payment.
18) Cause of Complaint: Repudiation of Death Claim by insurer
a) Complainant’s argument :
Already briefed under point 17.
b) Insurer’s argument:
SCN received on 06.08.2018 with the following submissions : i) DLA purchased the policy on 28.06.2014 and died in October, 2015 which was treated as early death claim. ii) The cause of the death was mentioned by the Burdwan Medical College as CR failure in a case of viral meningitis with diabetic nephropathy. iii) From the relevant documents it was revealed that DLA was suffering from type-II diabetes mellitus, HTN with COPD since 15.08.2013 but she did not disclose the said ailments in the proposal dated 28.08.2014. iv) Since it was case of suppression of material facts on the part of the DLA LIC had repudiated the claim which was informed to the claimant vide letter dated 23.08.2017.
19) Reason for Registration of Complaint: -
Scope of the IOR 2017 - Rule -13 (1) ( b )
20) The following documents were placed for perusal.
a) Complaint letters to the Ombudsman
b) Complaints made to the Ins. Co.
b) Annexure VI A
d) Copies of correspondences of different dates.
e) SCN
21) Result of hearing with both parties(Observation & Conclusion) :-
Complainant’s submission :
Repetition of submissions as mentioned in Pont No.17
Insurer’s submission :
In addition to whatever stated in the SCN, insurer submitted the original prescription of the physician mentioning therein about suffering of the DLA in Type-II diabetes mellitus, HTN with COPD. They also
Page 91 of 113 informed the Forum that DLA had another policy for Rs.30000/- the death claim against which has already been settled.
AWARD
Taking into account facts & circumstances of the case and the submissions made by both the parties present during the course of hearing, it is observed that the DLA was suffering from Type-II diabetes mellitus, HTN with COPD since 15.08.2013 which was not disclosed in the proposal form dated 28.04.2018. In support of the above, insurer has produced the original prescription of Dr. S. Mondal, M.D. appearing therein the existence of the above diseases with related prescribed medicines for the same. Son of the DLA, who attended the hearing, also confirmed that her deceased mother was under the treatment of the said doctor. However, all these information were not disclosed in the proposal form and the death occurred within 3 years from the date of taking the policy which led to suppression of material fact and repudiation of death claim by insurer.
Since the proposal for policy was submitted with suppression of material facts the decision of the insurer of repudiation of death claim under Policy No. 489912267 is upheld. However, since the said suppression of material facts has no relation to fraudulent activity, the insurer is directed to refund the entire premium, collected on the policy till the date of repudiation, to the complainant/nominee under intimation to this Forum.
22) The attention of the Complainant and the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017:
As per Rule 16(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, this 15th day of July, 2019
K. B. SAHA
INSURANCE OMBUDSMAN
FOR THE STATES OF WEST BENGAL,
SIKKIM AND UT OF ANDAMAN & NICOBAR ISLAND.
Page 92 of 113
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATES OF WEST BENGAL, SIKKIM AND UT OF ANDAMAN & NICOBAR ISLANDS (UNDER RULE NO: 16(1)/17 of THE INRUANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – MR.K.B.SAHA CASE OF MR. TUSHAR PUTATUNDA V/S MAX LIFE INSURANCE COMPANY LIMITED, GURGAON COMPLAINT REF: NO:KOL-L-032-1718-1321 AWARD NO: IO/KOL/A/LI/ 0170 /2019-2020
Mr. Tushar Putatunda,
Flat- 1 A, 4 sight 36, 49, Dhalua, 1. Name & Address of the Complainant Sree Nagar Main Road, Kolkata- 700 152,
West Bengal, Mob. No.-98360 60601.
Policy No: Pol. No.- 846449379
2. Type of Policy Details of the policy are given in the Table below.
Duration of policy/Policy period ------do------
Name of the insured Mr. Tushar Putatunda,
3.
Name of the policyholder Mr. Tushar Putatunda
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 02 / 01 /2018-- at the office of Ombudsman.
8. Nature of complaint Less settlement of Surrender Value
9. Amount of Claim Rs.78,000/-
10. Date of Partial Settlement N.A..
11. Amount of relief sought Rs.78,000/-( approx.) as per Annex-VI-A
Complaint registered under
12. Rule no: 13 of Insurance Ombudsman 13 (1) ( f ) Rules, 2017.
13. Date of hearing/place 15-07-2019 AT KOLKATA
14. Representation at the hearing
For the Complainant Mr. Tushar Putatunda
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Mr.Jitendra Kumar Gartia, Mgr.Compliance, Max
For the insurer Life Insurance Co. Ltd.
15. Complaint how disposed BY CONDUCTING HEARING
16. Date of Award/Order 15-07-2019
17) Brief Facts of the Case:
The complainant alleged that he had been paid less amount against surrender of the above numbered policy as compared to the amount deposited by him to the Ins. Co.
In fact, he purchased the policy on being misguided by Axis Bank, Survey Park, Kolkata, the Corporate agent with the hope of getting a locker in the Bank as reported by him. The policy commenced in June 2012 and he paid three yearly premiums totaling a sum of Rs.1,50,000. Because of his economical crisis, he could not continue the policy any longer and preferred to surrender the policy in 2015 when he got a sum Rs.72,000/- only. Thus a sum of Rs.78,000/- was settled less than the amount deposited as premium.
He became aggrieved and took up the matter with the Ins. Co. in July, 2015, but his problems were not redressed. He also lodged complaint with the Consumer Affairs Deptt., at Salt Lake, Kolkata in March 2017 but he could not get any relief from them and it was disposed of by them on 24/03/2017.
Finally, he got his complaint registered with this forum on 02/01/2018 for redressal.
Details of the policy issued: -- (Name of the Corporate Agent: Axis Bank, Survey Park, Kolkata, and Code No. 431046):--
Pol No. & DOC 846449379 / 16-06-2012
Plan Name Life Gain Plus 20 Participating Plan (Max Life)
PT / PPT (Yrs) 20/6
Instl. Prem - Mode Rs. 48,502.24 YLY
Total Premium Paid Rs.1,48,503.20 (3Yly Instalments)
Name of Insured & Proposer Mr. Tushar Putatunda
Date of 1st complaint to Co. JULY-2015
Duration 3 Years
Name of the Sponsoring Agent AXIS BANK, SURVEY PARK,KOLKATA
Amount of Surrender Value Paid Rs.72,470.32
Remarks Less amount paid as S.V. against the deposited premium
18) Cause of Complaint: Less payment of Surrender Value when compared to the premiums deposited.
c) Complainant’s argument :
Already briefed under point 17
d) Insurer’s argument: As per SCN received from the insurer :-
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i) The aforementioned participating limited payment policy was purchased by the
complainant on 16-06-2012 being agreed upon terms and condition of the Policy as endorsed by him in the Proposal Form. No complaint had been filed within free look period.
ii) The Complainant applied for surrender of policy on financial reasons vide his letter dated 22.06.2015 and surrender value of Rs.72,470.32, calculated in adherence to Policy Terms and condition, was paid by the Ins. Co. on 24-06.2015.
iii) Surrender of the policy has been allowed as per conditions stipulated under point number 19 & 20 of part B and point number 3 of part D of Annexure of the policy bond as the annuitant had opted for “Annuity for life with return of purchase price”.
iv) On receiving the Surrender Value, the Complainant approached the Ins. Co. with an allegation of mis-selling of the policy i.e. after 3 years of purchasing the policy. The Ins. Co. tried to resolve the complaint explaining him the calculation formula of Surrender Value as per the policy condition through repeated e-mails to the complainant and confirmed that the amount of Surrender Value paid was correctly done in conformity with the terms and conditions of the policy.
19) Reason for Registration of Complaint: Scope of Insurance Ombudsman Rules,2017.
Rule 13 (1) (f)
20) The following documents were placed for perusal.
a) Complaint letter to Ombudsman & Ins. Co.
b) P - form
c) Copy of Premium Paid Certificate
d) Correspondences/E-mail etc. exchanged by the complainant and the Ins. Co.
21) Result of hearing with both parties (Observation & Conclusion):-
The hearing was attended by both the parties.
The Complainant submitted that he had not gone through the terms and conditions of the insurance policy before signing the proposal. He is not in proper understanding of the fact that the policyholder has to incur loss while surrendering a policy before completing the term of the policy and the rationale behind this.
The Cash Surrender Value (CSV) which was higher than the Guaranteed Surrender Value (GSV) in this case, had been paid to the complainant in conformity with the terms and condition of the policy with CSV rate approved by IRDAI.
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 company has settled the payment of surrender value to the complainant as per the terms and conditions of the policy which was clearly mentioned in the policy document. The complaint of less payment is not based upon discrepancy in any factual data or procedure followed in calculating the surrender value.
Hence, the complaint is disposed off without providing any relief to the complainant.
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22) The attention of the Complainant and the Insurer is hereby invited to the following provisions of 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, this 15th July, 2019
INSURANCE OMBUDSMAN
FOR THE STATES OF WEST BENGAL,
SIKKIM AND UT OF ANDAMAN & NICOBAR ISLANDS.
Page 96 of 113
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA) (UNDER RULE NO. 16(1)/ 17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBDUSMAN – SHRI Milind Kharat
Complaint No: MUM-L-008-1819-0722 Award No: IO/MUM/A/LI/ 00 /2019-2020 Complainant: Mr Avinash Dhanawade Respondent: Bharti Axa Life Insurance Company Ltd
Complaint No. MUM-L-008-1819-0722 Complainant Mr Avinash Dhanawade Respondent Bharti Axa Life Insurance Company Ltd Nature of Complaint Mis representation of policy terms
The Hon’ble Ombudsman, Mumbai
We, the above mentioned parties to the dispute, hereby submit our joint declaration before the Forum, that the above complaint has been amicably settled between us on 1.7.2019.
The Respondent has agreed to cancel policy bearing number 501-7785675 and settle the dispute by refunding the premium amount paid under the policy on receipt of all the requirements towards full and final settlement of the complaint and the complainant has agreed for the same.
Therefore, we jointly request you to treat the complaint as resolved and closed. Signature and address of Signature and Address of the Signature of Witness, Name and the Complainant Respondent Designation
Mr Avinash Dhanawade Mr Purohit Ritin Ms L P Dias (Complainant) Bharti Axa Life Insurance A.S., Office of Insurance Mumbai Company Ombudsman, Mumbai Mumbai
AWARD THE RESPONDENT IS DIRECTED TO COMPLY WITH THE TERMS OF SETTLEMENT AND SUBMIT THE COMPLIANCE REPORT TO THE FORUM WITHIN 15 DAYS.
Dated at Mumbai, this 1st July, 2019.
Milind Kharat INSURANCE OMBUDSMAN, MUMBAI
Page 97 of 113
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA) (UNDER RULE NO. 16(1)/ 17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBDUSMAN – SHRI Milind Kharat
Complaint No: MUM-L-021-1819-0691 Award No: IO/MUM/A/LI/ 00 /2019-2020 Complainant: Ms Roopa Kewal Sharma Respondent: ICICI Life Insurance Company Ltd
Complaint No. MUM-L-021-1819-0691 Complainant Ms Roopa Kewal Sharma Respondent ICICI Life Insurance Company Ltd
The Hon’ble Ombudsman, Mumbai
We, the below mentioned parties to the dispute, hereby submit our joint declaration before the Forum, that the above complaint has been amicably settled between us on 2.7.2019
The Respondent has agreed to pay further interest @ of 4.25% on the premium amount paid by the complainant under the policy bearing number 20816889 and settle the dispute on receipt of all the requirements towards full and final settlement of the complaint and the complainant has agreed for the same.
Therefore, we jointly request you to treat the complaint as resolved and closed. Signature and address of Signature and Address of the Signature of Witness, Name and the Complainant Respondent Designation
Mr Kewal Sharma (Spouse Ms Nitu Singh Ms L P Dias of Complainant Ms Roopa Ms Milan Panchal A.S., Office of Insurance Kewal Sharma) ICICI Life Insurance Company Ombudsman, Mumbai Mumbai Mumbai
AWARD THE RESPONDENT IS DIRECTED TO COMPLY WITH THE TERMS OF SETTLEMENT AND SUBMIT THE COMPLIANCE REPORT TO THE FORUM WITHIN 15 DAYS.
Dated at Mumbai, this 2nd July, 2019.
Milind Kharat INSURANCE OMBUDSMAN, MUMBAI
Page 98 of 113
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA) (UNDER RULE NO. 16(1)17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBDUSMAN – SHRI MILIND KHARAT
Complaint No.: MUM-L-013-1819-0763 Award No: IO/MUM/A/LI/OO /2019-2000 Complainant: Mr Sunil Madhukar Karvir Respondent: DHFL Pramerica Life Insurance Co Ltd.
Name and address of the complainant Mr Sunil Karvir/Mumbai Policy No. 00301242 Name of Insured, DOB, Age at proposal Mr Sunil Karvir /17.10.1967/46 years Name of the Insurer DHFL Pramerica Life Ins. Co Ltd. DOC 31.3.2014 Premium, mode Rs.48,345/- , Yearly Sum Assured Rs.2,13,000/- Date of first complaint to GRO 18.1.2018 Date of receipt of the complaint at OIO 26.6.2018 Nature of Complaint Mis representation of policy terms and conditions Amount of relief sought Refund of premium amount Rule of Insurance Ombudsman Rules, 2017 under 13(1) (d) which the complaint was registered Date of hearing/ place 23.5.2019 / Mumbai Representation at the hearing
a) For the complainant Mr Sunil Karvir b) For the Insurer Ms Pooja Kamat Complaint how disposed By issuing the Award Date of Award 10.7.2019
1. Contention of the complainant:
The Complainant purchased the above policy in the year 2014 as he was promised benefit of loan under the policy. He complied with the requirements for insurance and received the policy document. As he did not receive the promised loan amount, he felt that he was misrepresented about the insurance policy. He approached the Company for redressal of his grievance but his request was declined as he did not approach within the free look period. He has requested the forum to cancel the above policy and refund him the entire premium paid by him.
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2. Contentions of the Respondent:
The Respondent contended that complainant after duly understanding the terms and conditions of the policy filled up the application form, basis of which the policy document was issued in favour of the complainant. He submitted the KYC documents which implies that the complainant has read the terms and conditions of the contract. Further on 2.4.2014, he submitted a letter to the Company to rectify his date of birth which was wrongly mentioned by him in the application form. The policy document was duly delivered to his residential address. After issue of the policy, during the welcome call, he updated the mode of language to be in Marathi and also updated his mobile number. He also sought procedure to change the payment mode of the premium from annually to quarterly. He did not complain about policy taken on assurance of loan. The complainant has paid only 1 premium and failed to pay the renewal premium due 31.3.2015. Company also sent him Renewal Billing follow up notice dated 2.4.2015 intimating therein that the complainant has failed to pay his premium due 31.3.2015. On 27.4.2015, the complainant sent a change in premium mode form from Annual to Monthly. The complainant paid the renewal premium on 28.4.2015 by cheque. The said cheque got dishonored and the same was intimated to the complainant vide their letter dated 1.5.2015. As the policy remained in Lapsed mode, the premium frequency mode could not be changed to monthly premium and the same was intimated to the complainant on 5.5.2015. As per the Clause of Discontinuation of premiums the policy was auto surrendered with the amount of Rs.7252/- and the same was intimated to the complainant vide their letter dated 27.5.2017. The Complainant complained to the Company for the first time on 18.1.2018 that the policy was sold to him on assurance of loan. As he had agreed with the policy details and he has approached the Company after 3 years and 10 months from the date of issuance of the policy, his complainant was declined. The company refunded the surrender value of Rs.7747.13 to the complainant on 4.7.2018 vide NEFT. The Company has provided life cover to the complainant for the months he has paid the premium amount. As the Insurance Company has acted in adherence to the policy terms and conditions, the complaint may be dismissed.
3. Observations and conclusions:
The Forum observed that the complainant purchased the above policy in 2014 and paid the 1st premium. He paid an amount of Rs.8971/- by cheque towards renewal premium, which was dishonored by his bank. The Respondent Company informed the complainant of the same vide their letter 1.5.2015. It has been observed that as the complainant has failed to pay the renewal premiums, the policy was in a lapse mode. And as per the Company’s clause of Discontinuation of premiums, the policy was auto surrendered with the amount of Rs.7252/- and the same was intimated to the complainant vide their letter dated 27.5.2017. The Forum has also observed that the complainant first approached the company in January 2018 that is after more than 3 years from issuance of the policy. The Insurance Company has provided life cover for the period the premium was paid. The company has refunded to the Complainant the surrender value of Rs.7747.13 on 4.7.2018 vide NEFT.
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It is observed that the Insurance Company has acted in adherence to the policy terms and regulations set by IRDAI. The complainant has not produced any evidence in support of the allegations made by him. A mere allegation against the Respondent without any cognate evidence has no merit. The Forum cannot give credence to unsubstantiated allegations.
AWARD Under the facts and circumstances of the case, the complaint made by Mr. Sunil Madhukar Karvir against DHFL Premerica Life Insurance Company Ltd. does not sustain.
It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him, if he so decides to move any other Forum/Court as he may consider appropriate under the law of the land against the Respondent insurer.
The attention of the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017. a. As per Rule 17(6) of the said rules the Insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman. b. As per Rule 17(8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Mumbai, this 10th day of July, 2019.
(Milind Kharat) INSURANCE OMBUDSMAN, MUMBAI
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA) (UNDER RULE NO. 16(1)17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBDUSMAN – SHRI MILIND KHARAT
Complaint No.: MUM-L-021-1819-0608 Award No: IO/MUM/A/LI/O /2019-20 Complainant: : Ms Neeru Surinder Khanna Respondent: ICICI Prudential Life Insurance Co.Ltd.
Name and address of the complainant Ms Neeru Khanna/Mumbai Policy No. 05437439 Name of Insured, DOB, Age at proposal Ms Neeru Khanna, 19.11.1949/58 years Name of the Insurer ICICI Prudential Life Insurance Co Ltd DOC 25.6.2007 Policy term 20 years Premium, Mode 12,090/- Yly
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Sum Assured Rs.20,00,000/- Advisor Icici Bank Ltd Rlg Date of receipt of the complaint at OIO 11.12.2018 Rule of Insurance Ombudsman Rules, 2017 13(1)(b) under which the complaint was registered Date of hearing/ place 15.5.2019 / Mumbai Representation at the hearing c) For the complainant Mr Sachin Surinder Khanna (son of the complainant) d) For the Insurer Ms Nitu Singh Ms Milan Panchal Complaint how disposed By issuing the Award Date of Award 22.7.2019
1. Contention of the complainant:
The Complainant was approached by an ICICI Bank agent who sold her the Hospital Care policy in the year 2007. She was informed features of the policy such as Hospital care, any kind of hospitalization expenses would be covered for 20 years to the amount totaling to Rs.20 lakhs. Out of which a maximum of Rs.4 lakhs could be claimed in any given year. In June 2018, she was hospitalized for a period of 15 days and incurred hospitalization expenses of Rs.4,50,000/-. As against this, she was paid Rs.23,000/- by the Insurer. She had taken up the matter with the GRO of the Company and the IGMS for a redressal but has not received any satisfactory resolution. She has requested the Forum to look into her grievance .
2. Contentions of the Respondent:
The Respondent contended that complainant purchased the above policy. Based on the information provided by the complainant, the Company issued the above policy on 26.6.2007. The Company sent the policy documents and the welcome kit duly dispatched to the address of the Complainant on 27.6.2007 via Blue dart courier. The Company received the hospitalization claim on 15.6.2018 for hospitalization of the life assured. She was hospitalized on 15.6.2018 to 30.6.2018 for ‘Idiopathic Pulmonary Fibrosis with Superadded Infection’. In terms and conditions of the above policy and the plan applied for which is Plan ‘A’, total amount payable was Rs.23,000/- which was credited via NEFT to the life assured on 18.7.2018. Details of the Hospital Care Plan A are: Rs.1000/- per day X 15 days = Rs.15,000/- plus Rs.5000/- against Intensive Care Unit Benefit and Rs.3,000/- for Convalescence Benefit. The Company further submitted that in the year 2010, the Company has paid two claim payment of total of Rs.1 lakh for surgery undergone by the complainant under the above policy as the applicable terms and conditions. The Insurance being a contract between the policyholder and the company both parties are governed by the Terms and Conditions mentioned in the policy document and all the benefits are payable as per the said policy terms and conditions. The present status of the policy is ‘In force’ In view of the above, the Company is not liable to make any further payment under the policy for the subject claim.
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3. Observations and conclusions:
The Forum observed that the complainant purchased the above policy in June, 2007 and has been paying premiums regularly. The complainant was hospitalized in June, 2018 and submitted hospital treatment bill of Rs.4,50,000/-. The Company made a payment of Rs.23,000/- on 18.7.2018 as detailed above . The Forum on hearing both the parties and on going through the policy document, observed that the complainant had applied for Plan A and the same was mentioned in the policy certificate under Benefits. During the hearing, the representative of the complainant stated that while purchasing the above policy in the year 2007, the brochure given to them then in the year 2007 did not mention of any Plan A,B,C,D. The Forum called for the said brochure from both the Complainant and the Insurers. It has been observed that the Complainant has vide her letter dated 20.5.2019 informed the Forum that she is unable to locate the brochure which she got 12 years ago. The Respondents have produced the brochure of 2007, wherein Plan A,B,C,D have been mentioned. It has also been observed that complainant has availed of claim payment for surgeries undergone in 2010 and the Company has made a payout of a total of Rs.1 lakh for the surgeries which is in accordance with the plan opted for by the complainant. In view of the above, the Forum observed that the Company has acted as per the applicable terms and conditions of the policy document Considering the above facts the Forum ordered as follows:
ORDER Under the facts and circumstance of the case, the complaint lodged by Ms Neeru Khanna against ICICI Prudential Life Insurance Co Ltd is not sustainable and the case is disposed of accordingly.
It is particularly informed that in case the award is not agreeable to the complainant, it would be open for her, if she so decides to move any other Forum/Court as she may consider appropriate under the law of the land against the Respondent insurer.
The attention of the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017: a. As per Rule 17(6) of the said rules the Insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman. b. As per Rule 17(8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Mumbai, this 22nd July, 2019.
(Milind Kharat) INSURANCE OMBUDSMAN, MUMBAI
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA) (UNDER RULE NO. 16(1)17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBDUSMAN – SHRI MILIND KHARAT Complaint No.: MUM-L-032-1819-0665 Award No: IO/MUM/A/LI/OO21 /2019-20 Complainant: Mr Caetano Fernandes Respondent: Max Life Insurance Company Ltd. Name and address of the complainant Mr. Caetano Fernandes Policy No. 828044750 Name of Insured, DOB, Age at proposal Mr Caetano Fernandes,14.12.1951, 59 years Name of the Insurer Max Life Insurance Co Ltd DOC 13.1.2011 Premium paying term 41 years Policy Term Upto age 100 Premium, Mode Rs.25,000/-Yearly Sum Assured Rs.310053/- Reply from GRO 21.5.2018 Broker/Agent Axis Bank Ltd Date of receipt of the complaint at OIO 19.9.2018 Nature of Complaint Surrender value Amount of relief sought Refund of premium Rule of Insurance Ombudsman Rules, 2017 13(1) (b) under which the complaint was registered Date of hearing/ place 25.6.2019/ Mumbai Representation at the hearing e) For the complainant Mr Caetano Fernandes f) For the Insurer Mr Mayur Pandit Mr S Ramesh Complaint how disposed By issuing the Award Date of Award 22.7.2019
1. Contention of the complainant: The Complainant purchased the above policy in 2011 on his retirement from his services. He was not informed that he need to pay premiums for 41 years. He was informed that he could withdraw after completion of lock in period of 5 years. He regularly paid 7 yearly premiums. When he enquired, he was offered only the bonus. He was shocked to know that he would not get returns on the premium paid by him. On 15.2.2018, he approached the Company for surrender of the policy and was informed of the surrender value of Rs.92837/-. Being in urgent need of money, he accepted and surrendered his policy. However, he received only Rs.68176/-.
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He approached the Company who informed him that it was a system error that they mentioned Rs.92837/-. He has requested the forum to help him get refund of premiums paid by him under the above policy.
2. Contentions of the Respondent: The Respondent contended that complainant purchased the above policy. He paid for 7 yearly premiums and thereafter submitted his request dated 14.2.2018 for surrender of his policy. The said request was duly considered and the surrender value of Rs.68,176.66/- was transferred to the bank account of the complainant vide NEFT and the same was informed to the complainant vide letter dated 20.2.2018. The grievance arose only after the receipt of surrender value. The complainant has alleged receipt of less surrender value. The Company has informed the complainant vide mail dated 26.2.2018 that the surrender value of Rs.92,837/- was including the payment of Rs.25,302.09 for which transaction bounced. The said amount was deducted from the surrender amount and transferred to the bank account of the complainant. In view of the rightful recovery made by the Company, of Rs.25,302.09 from the surrender value of Rs.92,837/- , the complaint be dismissed.
3. Observations and conclusions: The Forum observed that the above policy was purchased in 2011 by the complainant at the age of 59 years. The complainant was not informed of the premium paying terms of 41 years. He was informed of the lock in period of 5 years. After paying premiums for 7 years, he approached the Company for surrender of his policy. He was informed of the surrender value of Rs. 92,837/-. As he was in dire need of money, he agreed for the same. But, he received only Rs.68,176.66/-. The Forum observed that the complainant at the age of 59 years was sold a plan with premium paying term of 41 years. However, during the hearing the Respondents have agreed to pay the promised surrender value ie the amount deducted from the surrender value. In view of the above, the case stands disposed of.
Dated at Mumbai, this 22nd July, 2019.
(Milind Kharat) INSURANCE OMBUDSMAN, MUMBAI
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA) (UNDER RULE NO. 16(1)17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBDUSMAN – SHRI MILIND KHARAT
Complaint No.: MUM-L-008-1819-0764 Award No: IO/MUM/A/LI/O /2019-20 Complainant: Ms Shweta Sawant Respondent: Bharti Axa Life Insurance Company Ltd.
Name and address of the complainant Ms Shweta Sawant/Mumbai Policy No. 501-7424747 Name of Insured, DOB, Age at proposal Ms Shweta Sawant/13.2.1986/32years Name of the Insurer Bharti Axa Life Insurance Co Ltd DOC 31.5.2018 Policy term/Premium paying term 12/12 years Premium, Mode Rs.27500/- Yearly Sum Assured Rs.2,82,181/- Broker/Agent India Infoline Insurance Brokers Pvt. Ltd Date of receipt of the complaint at OIO 27.12.2018 Nature of Complaint Repudiation of claim Amount of relief sought Not mentioned Rule of Insurance Ombudsman Rules, 2017 13(1) (d) under which the complaint was registered Date of hearing/ place 24.5.2019/ Mumbai Representation at the hearing
g) For the complainant Ms Shweta Sawant h) For the Insurer Mr Dubey Pawan Complaint how disposed By issuing the Award Date of Award 29.7.2019
1. Contention of the complainant:
The Complainant purchased the above policy alongwith mediclaim policy because they were covering Pregnancy treatment. She was conveyed that she needs to submit only her discharge card once she is discharged from the hospital after her delivery. She delivered a baby and has been in touch with the Company representatives. On checking her status she was told that Rs.27,000/- was approved. Dissatisfied with the amount, she took up the matter with the higher ups of the Company. On 26.11.2018, she was told that her claim got rejected as pregnancy is not covered in this claim. She feels that she is misled by the Company and the brokers. She has approached the Ombudsman for quick response from the Company and a positive reply from Ombudsman.
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2. Contentions of the Respondent:
The Respondent contended that the complainant purchased the above policy in May, 2018. She submitted a claim of Hospitalization dated 12.11.2018 towards hospitalization for treatment arising from pregnancy. The policy was issued based on the signed proposal form and documents submitted by the complainant and after conducting the pre issuance verification call, the Company issued the policy bond along with the covering letter mentioning that 15 days’ time period is provided to verify the documents and reply if any discrepancies exist. The policy was issued in May, 2018 and the same was dispatched on 4.6.2018 at the address mentioned in the proposal form. The Company sent the policy document along with copies of all the supporting documents to her to enable her to go through the details in entirety once again. The complainant did not invoke the free look option nor raised any concern with the terms and conditions of the policy, implying that she agreed with the policy terms and conditions. After five months from the issuance of the policy, the Company received a claim of Hospitalization dated 12.11.2018 towards hospitalization for treatment arising from pregnancy. After evaluating the claim and verifying the documents, the Company was unable to consider the request of the Complainant as according to the terms of the policy clause 8, it is specifically mentioned that hospitalization for treatment arising from pregnancy is excluded for hospitalization benefits. Accordingly her claim was repudiated vide communication dated 21.11.2018. Clause 8: Terms and conditions following Exclusion for the Hospitalization Benefit: The Company shall not be liable to make any payment if hospitalization or claims are attributable to, or based on, or arise out of, or are directly or indirectly connected to the following: Hospitalization for treatment arising from pregnancy and it’s complication which shall include childbirth or miscarriage. The complainant thereafter made a complaint dated 10.12.2018 that the product benefits are different from what was promised and that mentioned on the policy document, hence she did not want to continue with the policy and was seeking refund. The company responded to her on 17.12.2018 stating that they did not receive any communication from her regarding cancellation/alteration in the policy within the said free look period, implying that she was in agreement with the terms and conditions of the policy issued to her. The above policy was issued as per her own requirement and based on the documents executed by her. Prior to issuing the policy, Pre Issuance Verification Call was made to the complainant , the core objective of which is to confirm and satisfy that the policyholder has understood the key features of the policy without any ambiguity. The complainant being an educated and prudent person is expected to have read the policy terms and conditions of the policy taken. If there was any alteration or discrepancies observed by her, she should have immediately approached the Company within the free look period. The complainant has in her own option chosen to invest through the broker. The Company denies the allegation as no material or proof has been submitted by the complainant about the misrepresentation made on behalf of the company. The issue raised by the complainant is a mere ruse to get out of the policy which she does not seek to continue and seek refund of the premium paid. In view of the above submissions, the case may be dismissed.
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3. Observations and conclusions:
The forum observed that the complainant purchased the above policy in May, 2018 because it covered pregnancy. Her hospitalization claim dated 12.11.2018 for pregnancy treatment was rejected by the Company. The Company after evaluating the claim, conveyed to the complainant on 21.11.2018 that they were unable to consider her request in accordance with the terms of policy clause no.8. Hospitalization for treatment arising from pregnancy is excluded for hospitalization benefits. The Forum observed that the Company has acted as per the applicable terms and conditions of the policy document. The Insurance being a contract between the policyholder and the company both parties are governed by the Terms and Conditions mentioned in the policy document and all the benefits are payable as per the said policy terms and conditions. The complainant thereafter made a complaint dated 10.12.2018 that she did not want to continue with the policy alleging that the product benefits mentioned in the policy document are different from what was promised to her. The Forum observed that the complainant first approached the company in November, 2018, that is after more than 6 months from receipt of the policy. The Forum also observed that the complainant has not produced any evidence in support of the allegations made by her. A mere allegation against the Respondent without any cognate evidence has no merit. The Forum cannot give credence to unsubstantiated allegations.
In view of the above the Forum awards as follows:
AWARD Under the facts and circumstance of the case, the complaint lodged by Ms Shweta Sawant against Bharti Axa Life Insurance Co Ltd is not sustainable and the case is disposed of accordingly.
It is particularly informed that in case the award is not agreeable to the complainant, it would be open for her, if she so decides to move any other Forum/Court as she may consider appropriate under the law of the land against the Respondent insurer.
The attention of the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017: a. As per Rule 17(6) of the said rules the Insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman. b. As per Rule 17(8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Mumbai, this 29th day of July, 2019
(Milind Kharat) INSURANCE OMBUDSMAN, MUMBAI
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PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA) (UNDER RULE NO. 16(1)17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBDUSMAN – SHRI MILIND KHARAT Complaint No.: MUM-L-009-1819-0624 Award No: IO/MUM/A/LI/OO /2019-20 Complainant: Mr Ramakant Pai Respondent: Aditya Birla SunLife Insurance Company Ltd.
Name and address of the complainant Mr Ramakant Pai/Mumbai Policy No. 005927447/46/48 Name of Insured, DOB Ms Vatsala Pai, 1.6.1945 Mr Murlidhar Pai, 20.1.1958 Mr Ramakant Pai, 6.9.1943 Name of the Insurer Aditya Birla SunLife Insurance Co Ltd DOC 25.1.2013 Premium paying term 10 years Premium, Mode Rs.1,20,000/- each(Yearly) Date of first complaint to GRO 23.10.2018 Date of receipt of the complaint at OIO 5.12.2018 Nature of Complaint Misrepresentation of policy terms Rule of Insurance Ombudsman Rules, 2017 13(1) (d) under which the complaint was registered Date of hearing/ place 7.5.2019 / Mumbai Representation at the hearing i) For the complainant Mr Ramakant Pai j) For the Insurer Mr Preetesh Kubal Complaint how disposed By issuing the Award Date of Award 12.7.2019
1. Contention of the complainant: The complainant stated that he purchased the above policies in January, 2013 for self, his wife and brother. He paid monthly contribution of Rs.10,000/- each for 5 years, though the term of the policy was 10 years, on the assurance that he would get lump sum amount in January, 2018 after the lock in period of 5 years. He had taken the above policies, so that he would receive the lumpsum amount and would be able to repay the bank loan taken for purchase of a house.
In January, 2018, he approached the Company, where the manager of the branch obtained a letter from him for ECS cancellation. In April, 2018, the Branch Manager sent an Assistant from the Company to his house and obtained signatures on blank forms. Within few days he received 3 new policies bearing nos. 005927446/005927447/005927448. He also received a payout of one-third amount each under the above policies and remaining two-third of the amount was converted into the 3 new policies bearing nos. 005927446/005927447/005927448. He has stated that he is 75 years old, wife 73 years old and brother 60 years old.
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He has requested the Forum to help him get the lumpsum amount under the above 3 policies instead of the yearly annuity. He has stated that there is no source of earnings to pay off the bank housing loan.
2. Contentions of the Respondent: The Respondent contended that the complainant applied for the above policies in January, 2013 on his life, his wife’s and brother’s life. All the three applied for Empower Pension Plan which was a ULIP Plan. On receipt of all requirements, policy bearing numbers 005927447/005927446/005927448 were issued on 25.1.2013. The policies were delivered at the Registered address of the complainant on 18.2.2013. There was no revert from the part of the complainant during the free look period. The complainant paid five premiums under each of the above policies. The complainant on 7.3.2018, requested the Company to surrender the policy in accordance with the policy provisions. Simultaneously in accordance with the Surrender Clause, the complainant submitted an application form and chose to utilize two-third of the surrender value to an immediate annuity plan. The said request was acceded by the Company and out of the surrender value of Rs.7,18,855.14, one-third amount being Rs.2,47,220.56, Rs.7,04,704.53, one-third amount being Rs.2,39,458.96 and Rs.7,04,331.20, one-third amount being Rs.2,39,037.49 respectively were credited to the account of the customer on 11.4.2018, 11.4.2018 and 17.4.2018 respectively and two-third of the amount being Rs.4,71,634.58, 4,65,245.58 and 4,65,293.71 respectively were utilized towards issuance of following immediate annuity plan bearing nos. 007503914 on 31.3.2018 in the name of Ms.Vatsala Pai, 007503915 on 10.4.2018 in the name of Mr. Murlidhar Pai and 007503916 on 16.4.2018 in the name of Mr. Ramakant Pai. The above policies were surrendered in accordance with the policy terms and conditions. The provisions of surrender are in accordance with the IRDAI Regulations which allows the policyholder to commute 1/3rd of the amount in accordance with the Income Tax Act and to purchase from the remaining 2/3rd amount, immediate annuity plan. In view of the provisions and rules governing the same, the Company cannot accede to the request of the complainant for whole of the surrender amount. In view of the above, Ombudsman be pleased to dismiss the complaint.
3. Observations and conclusions: The Forum observed that the Complainant purchased the above policies on his life, wife’s and brother’s. He paid regular premiums for Five years. It has been observed that in March, 2018, the complainant requested for surrender of the policies after the lock in period and chose to utilize 2/3rd of the surrender value to an immediate annuity plan. Accordingly the Company has made a payout of 1/3rd of the surrender value to each of the above policy holders and 2/3rd towards issuance of immediate annuity. The new policies for Immediate Annuity were issued to the complainant. It has been observed that the provisions of the policies states that Free-look period will not be applicable for transfer of purchase price for this policy from any existing deferred pension plan. The Respondent Company has followed the IRDAI guidelines which explicitly states that upon surrender after the lock-in period, the surrender value shall be utilized to commute to the extent allowed under the Income Tax Act and to utilize the balance amount to purchase
Page 110 of 113 immediate annuity from the same insurer or to utilize the entire proceeds to purchase the single premium deferred pension product from the same insurer. As per the regulations, option for pension products, the policyholder cannot claim payout of the total fund value. In this case the free look period would not be applicable, as the fund value was transferred from an existing deferred Pension Plan viz Empower Pension Plan to an Immediate Annuity Plan. The above clause is in accordance with the IRDAI regulations. As the Respondents have acted as per the provisions of the policy terms and conditions of the policy/plan opted by the complainant, the complaint is not sustainable. AWARD Under the facts and circumstance of the case, the complaint made by Mr.Ramakant Pai against Aditya Birla Sunlife Insurance Co. Ltd. is not sustainable and the case is disposed of accordingly.
It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him if he so decides to move any other Forum/Court as he may consider appropriate under the law of the land against the Respondent insurer. The attention of the Insurer is hereby invited to the following provisions of the Insurance Ombudsman Rules, 2017: a. As per Rule 17(6) of the said rules the Insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman. b. As per Rule 17(8), the award of Insurance Ombudsman shall be binding on the Insurers.
Dated at Mumbai, this 12th day of July, 2019.
(Milind Kharat) INSURANCE OMBUDSMAN, MUMBAI
PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SMT. SANDHYA BALIGA CASE OF SH. RAVI B SHARMA V/S SBI LIFE INSURANCE COMPANY LIMITED COMPLAINT REF: NO: NOI-L-041-1819-0579 AWARD NO: 1. Name & Address of the Complainant Sh. Ravi B Sarma Eden 14, Royal Garden Estate Sector 61, Noida , Uttar Pradesh-201301 2. Policy No: 2B502384504 & 2B497519608 Type of Policy Life Plan Duration of policy/Policy period 3. Name of the insured Sh. Ravi B Sarma Name of the policyholder Sh. Ravi B Sarma 4. Name of the insurer SBI Life insurance company Limited 5. Date of Repudiation 31.01.2019 6. Reason for repudiation Beyond Free Look Period 7. Date of receipt of the Complaint 15.03.2019 8. Nature of complaint Forgery and refund of premium 9. Amount of Claim Rs.16 Lakh 10. Date of Partial Settlement None 11. Amount of relief sought Rs.16 lakh 12. Complaint registered under 13 (1) (d)
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IOB rules 13. Date of hearing/place Noida on 21.06.2019 14. Representation at the hearing For the Complainant Sh. Ravi B Sarma, Self For the insurer Anjali Chahar, AVP 15 Complaint how disposed Award 16 Date of Award/Order 10.07.2019
17) Brief Facts of the Case:- This complaint is filed by Sh. Ravi B Sarma against SBI Life Insurance Company Limited relating to forgery under policy bearing no‟s 2B502384504 & 2B497519608.
18) Cause of Complaint:- Forgery of Signatures. a) Complainants argument :- The complainant stated that he had purchased 2 policies bearing no‟s 2B502384504 and 2B 497519608 on 29.11.2017 for annual premium of Rs.6 lakh and Rs.10 Lakh respectively. While going through the policy documents received against the above policies , the complainant found that his signatures were forged and was signed by someone else in case of policy no. 2B49759608 on page nos. 55,56,57,59 &60. Similarly in case of policy no. 2B 502384504 his signatures were forged and signed by someone else on page nos. 50,52,56,57,58,59,60,75 &76.This is against the basic ethics and tenets between SBI Life Insurance and the client. The complainant therefore requested for cancellation of policy and refund of premium of Rs.16 Lakh along with interest immediately to his SBI account. b) Insurers’ argument:- The insurer stated that 2 policies bearing no‟s 2B502384504 and 2B497519608 had been issued on the life of Sh. Ravi B Sarma on the basis of duly executed proposal form on 29.11.2017 on annual premium of 6 Lakh and 10 lakh respectively. The company had received complaint on 24.01.2019 from the complainant regarding forged signatures and company had advised the complainant vide their mail on 29.03.2019 to provide his specimen signatures and same had not been provided till date. Further the complainant had not represented beyond free look period of 15 days from the receipt of policy document. The insurer advised the complainant to submit fresh proposal form and Benefit Illustration for incorporating the necessary changes in the captioned policies. In view of above insurer was unable to accede to request for cancellation of policy and refund of premium.
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) Result of hearing with both parties(Observations & Conclusion);- Both the complainant and insurer appeared for personal hearing which was held on 21.06.2019 and reiterated their submissions. The complainant stated that this is a case of forgery of his signatures. The insurer stated that they had informed the complainant on 29.03.2019 to provide his specimen signatures. The complainant had not provided his signatures till date to the insurer. The complaint requires a thorough investigation and examination and Cross-examination of witnesses . As per Insurance Ombudsman Rules2017 complaint does not fall under rule 13 (1) (a) to 13 (1) (i )and is outside purview.
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 complaint is dismissed.
The complaint is thus disposed off accordingly.
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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. SANDHYA BALIGA Dated: 10.07.2019 INSURANCE OMBUDSMAN (WESTERN U.P. & UTTARAKHAND)
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