PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN ... - cioins.co…

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN-Dr. D.K. VERMA

Case of Mr. Jaimal Singh Vs PNB Metlife India Insurance Co. Ltd.

CASE NO-CHD-L-033-1920-1351

1. Name & Address of the

Complainant

Mr. Jaimal Singh, V P O – Kahdrori, Tehsil- Indora, Distt. Kangra ( HP)-176402 Mobile No.9816185700

2. Policy No: DOC

Type of Policy

Duration of policy/Policy period

21284450/20.03.2014

MetLife Easy Super

15(15) Rs. 50000/-

3. Name of the insured

Name of the policyholder

Jaimal Singh

do

4. Name of the insurer PNB Metlife India Insurance Co. Ltd.

5. Date of Repudiation NA

6. Reason for repudiation NA

7. Date of receipt of the Complaint 12.12.2019

8. Nature of complaint Less Payment

9. Amount of Claim Rs. 19000/-

10. Date of Partial Settlement NA

11. Amount of relief sought Rs. 19000/-

12. Complaint registered under

Rule no: Insurance

Ombudsman Rules, 2017

13 (1)(c)

13. Date of hearing/place 12.03.2020/ Chandigarh/24.03.2020 (Cancelled due

to lock down)

14. Representation at the hearing

For the Complainant Absent

For the insurer Mr. Nirmal Gulhane, Chief Manager Legal

15. Complaint how disposed Dismissed on merits

16. Brief Facts of the case:

On 12.12.2019, Mr. Jaimal Singh had filed a complaint against PNB Metlife India Insurance Co

Ltd. in respect of policy bearing no. 21284450. He has alleged that he paid the premiums for 5

years and the Insurance Company has refunded only Rs.231000/-on 11.06.2019 in his bank

account without any information. He has further stated that the company has paid less amount of

Rs. 19000/- . He has requested the company for payment of balance amount of Rs. 19000/- but

he did not get any suitable reply. Hence, feeling aggrieved, he approached this forum to seek

justice.

17) Cause of Complaint:

a) Complainant’s argument:

The complainant was absent on the day of hearing i.e. 12.02.2020 and he has requested vide

letter dated 16.03.2020 that he could not attend for rehearing of the case fixed on 24.03.2020.

The complainant has again stated in his letter that the insurance company has paid Rs.

19000/- less to him and requested to decide the case on merits.

b) Insurers’ argument:

The representative of the company attended the personal hearing fixed on 12.03.2020. He reiterated

the contents of the SCN and also informed that the policy bearing no. 21284450 was issued on

the basis of duly filled and signed application forms under the said policy and policy

documents were dispatched at the complainant’s address on 20.03.2014. A complainant had

first approached on 03.10.2019 alleging that he paid the premiums for 5 years and the

Insurance Company has refunded only Rs.231000/-on 11.06.2019 in his bank account. The

Insurer denied his allegation vide letter dated 03.10.2019 stating that renewal premium was

not received under the subject policy and due to which policy was moved to fund

discontinued status and accordingly the policy was foreclosed as per terms and conditions of

the policy.

18) The following documents were placed for perusal :-

a) Complaint to the Company

b) Reply of the Insurance Company

19) Result of personal hearing with both parties (Observations & Conclusion)

The complainant was absent on first hearing fixed on 12..03.2020 and again shown his

inability to attend the rehearing on 24.03.2020 due to health reasons vide his letter received in

this office on 19.03.2020. There is no option but to decide the case on merits, since sufficient

opportunities have been given to the complainant to present his case and the case cannot be

kept pending indefinitely. 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 policy was purchased in 2014 and the premium paying term of it was 15 years.

As no further premiums were paid under this policy after paying five yearly installments, the

Insurance Company seems to be right in foreclosing the policy as per terms and conditions of

the policy and refund the value of the policy in the bank a/c of the complainant policy holder.

The complainant could not produce any documentary proof in support of his allegations. Since

the policy was with risk cover and the benefit under the policy would vary according to

performance of particular insurance company depending upon various factors. Hence, the

payment made by insurer seems to be correct.

Dated at Chandigarh on 29th

day of May, 2020

Dr. D K Verma

INSURANCE OMBUDSMAN

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule No: 16 (1)/17 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Aruna Khanna Versus PNB Met Life Insurance Co. Ltd.

Complaint Ref. No.: DEL-L-033-1920-0892

Case No: LI/PNB/577/19

1. Name & Address of the

Complainant

Smt. Aruna Khanna,

N-107, Greater Kailash Part-I, New Delhi-110048

2.

Policy No.

Type of Policy

Policy Term/Premium Paying Term

21657275

Major Illness Cover / Regular

10 years / 10 years

3. Name of the Insured

Name of the Policy Holder

Nitin Rai Khanna

Nitin Rai Khanna

4. Name of Insurer PNB Met Life Insurance Co. Ltd.

5. Date of Rejection 27.09.2019

6. Reason for Grievance Repudiation of critical illness claim


8. Nature of Complaint Repudiation of critical illness claim

9. Amount of Claim Rs. 5,00,000/-

10. Date of Partial Settlement ----

11. Amount of Partial Settlement ----

12. Amount of relief sought Rs. 5,00,000/-

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 on merits.

Hence, the complaint is treated as closed.

13. Complaint registered under Rule no:

Insurance Ombudsman Rules, 2017 13 (1) (b) any partial or total repudiation of claims by

the life insurer, General insurer or the health insurer. 14. Date of hearing 13.05.2020

Place of hearing Online via WhatsApp


a) For the Complainant Smt. Aruna Khanna,the Complainant

b) For the Insurer Smt. Kamaldeep Sagar, AGM (Legal)

16. Date of Award/Order 13.05.2020

17. Brief Facts of the Case:

Smt. Aruna Khanna, nominee and mother of life insured (hereinafter referred to as the

Complainant) has filed this complaint against the decision of PNB Met Life Insurance

Co. Ltd. (hereinafter referred to as the Respondent Insurance Company) alleging

repudiation of critical illness claim of policy number 21657275.

18. Cause of Complaint:

a. Complainant's Argument: The Complainant has alleged that her son had purchased one

policy “MetLife Major Illness Premium Cover” from PNB Met Life Insurance Co. on

26.08.2015 for Rs. 5,00,000 Sum Assured.Shri Nitin Rai Khanna (Life Assured) met with

an accident and admitted to Moolchand Hospital, Delhi on 04.08.2019 in a critical

condition of head injury with bleeding inside for one day, next day he was shifted to

Medanta Hospital, Gurugram and admitted there for 7 days in ICU. Claim intimation

letter in this regard sent to the Insurer on 11.09.2019, but the Insurer denied the claim on

27.09.2019 on the plea the Traumatic injury of the brain was excluded. The Complainant

again represented her case against the decision of the Insurer but the Insurer rejected it on

17.10.2019. Now, the Complainant approached this forum for relief and enclosed two

treating Doctor’s opinion dated 15.01.2020 and 11.01.2020.

b. Insurer's Argument: The policy was issued on 26.08.2015. The Insurer had on

11.09.2019 receivedclaim for reimbursement of medical expenses for Major Head

Trauma / Stroke suffered by the Nitin Rai Khanna (the Life Assured or, LA). The Insurer

denied the claim, vide letter dated 27.09.2019,reasoning that the injury of the LA did not

satisfy the definition of Stroke under the terms and conditions of the policy. On

17.10.2019 the Insurer again declined her claim vide Appendix-A and Sr. No. 17 under

the head of Major Head Trauma of Definition and Exclusions of Critical Illness Benefit

and rejected her request, besides under ‘Stroke’.

19. Reason for registration of Complaint: Mis-selling.

20. The following documents were placed for perusal:

a) Copy of policy.

b) Correspondence between the complainant and the Insurance Company.

c) Self Contained Note with annexures from the Insurer.

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

Case called. Parties are present and submit their arguments as stated in Para 18 above.

As per the Discharge Summary of Moolchand Medcity dated 04.08.2019, the Life Assured

(LA), who is also the policyholder, was brought to the hospital by the Police on that date

with alleged h/o physical assault when he was walking on the road and some person hit him

back after which he fell and got injury over his head. The Discharge Summary also noted

past h/o head injury. The same day, the LA got discharged against medical advice (LAMA)

as per his own wish. On 05.08.2019, he got admitted to Medanta Medicity. The Discharge

Summary of Medanta dated 19.08.2019 mentions that he had a fall on road in New Delhi on

05.08.2019. Thus there is conflict about the date of injury as noted in the Discharge

Summary of the two hospitals. However, this issue has not been contested by either party.

Therefore, it is considered as a fact that the LA suffered a head injury on either 04.08.2019 or

05.08.2019. The issue to be examined by this forum is as to whether this incidence of head

injury and subsequent treatment etc. entitle the benefit under the policy for the LA.

The policy covers 35 critical illnesses. Appendix A of the Policy describes the definition and

exclusions relating to these 35 critical illnesses. In the Claim Form dated 11.09.2019, the

critical illness has been mentioned as ‘Major Head Trauma’, which is listed at Item No. 17 in

the Appendix A. This entry defines ‘Major Head Trauma’ in the following framework,

namely,-

(i) It should be an accidental head injury caused solely and directly by accidental, violent,

external and visible means and independently of all other causes; and

(ii) The Accidental Head injury must result in an inability to perform at least three (3) of the

six listed activities of Daily Living either with or without the use of mechanical equipment,

special devices or other aids and adaptations in use for disabled persons. The six listed

activities are Washing, Dressing, Transferring, Mobility, Toileting and Feeding.

(iii) The following are excluded: (a) Spinal cord injury; and (b) Head injury due to any other

causes.

The Insurer has repudiated the claim by examining the critical illness as ‘Stroke’, which is

listed at Item No. 20 in the Appendix A. This entry defines ‘Stroke’ as ‘Any cerebrovascular

incident producing permanent neurological sequelae’. There are three specific exclusions,

one of which is ‘Traumatic injury of the brain’. It is this Exclusion that the Insurer has used

to repudiate the claim vide letter dated 27.09.2019.

Subsequently, upon further representation submitted by the claimant along with more

documents, the Insurer reviewed the matter and communicated vide letters dated 17.10.2019

reiterating the rejection of the claim for ‘Stroke’ for same reasons and also informing that the

definition for ‘Major Head Trauma’ was also not getting satisfied.

The Complainant has not submitted any document to prove that the illness under claim had

led to a permanent inability to perform at least three (3) of the six listed activities of Daily

Living either with or without the use of mechanical equipment, special devices or other aids

and adaptations in use for disabled persons. Therefore, the Insurer was justified in

repudiating the claim relating to ‘Major Head Trauma’. As for the illness relating to stroke,

the Insurer was justified in repudiating the claim on the grounds of the Exclusion clause of

‘Traumatic injury of the brain’.

In the result, it is concluded that the repudiation was justified and the complaint is liable to be

rejected.

Award

The complaint is rejected.

(Sudhir Krishna)

Insurance Ombudsman, Delhi

13th

May2020

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 16 (1)/17 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Raj Kumar versus Bharti Axa Life Insurance Company Ltd.

Complaint Ref. No. DEL-L-008-1920-0982

Case No.: LI/BHARTI/645/19

1. Name & Address of the Complainant Shri Raj Kumar,

J&K 56, Laxmi Nagar, Shakarpur Baramad, Delhi-110092

2. Policy No:

Type of Policy

Duration of policy

Policy premium period

501-8469774

Life Insurance

N.A.

12 years


Name of the Policy holder

Raj Kumar

Raj Kumar

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

5. Date of Rejection. 30.01.2020.

6. Reason for repudiation Servicing Issue


8. Nature of complaint Servicing Issue

9. Amount of Claim N.A.

10. Date of Partial Settlement N.A.

17. Brief Facts of the Case: Shri Raj Kumar (hereinafter referred to as the Complainant) has filed a

complaint against the Bharti Axa Life Insurance Company Ltd. (hereinafter referred to as the Insurer

or the Respondent Insurance Company) alleging mis-selling of Insurance Policy No. 501-8469774.

18. Cause of Complaint:

a) Complainant's Argument: The Complainant had been approached by an agent of Bharti Axa Life

Insurance Company and lured to buy two insurance policiesin his name and his wife’s name. The

Complainant did not get the policy bonds as the address in the company’s record was incorrect. He

was constantly in touch over mail with the insurer and received one bond. The insurer did not

respond promptly to all his policy bond related questions. Thereafter when he contacted the agent

over telephone to inquire about the policy bond he was asked to trace it from the post office. They

did not respond correctly.As he was not getting any proper response from the agents he wrote to the

Complaints Unit of the Insurer on 16/01/2020, but did not get any positive response from the

Grievance Cell and the Complaints Unit of the Insurer. Therefore he approached this forum.

b) Insurer's Argument:The Insurer have stated in their Self Contained Note dated 30/04/2020 that the

Complainant had duly filled up and signed the proposal form and has voluntarily applied for the

product after completely understanding the features. Subsequently, the Insurer issued the policy

bondon 24/01/2019anddelivered on 01/02/2019 by Speed Post. The Insurer had thereafter effected

PIVC and had given a call to the policyholder on his registered mobile no. but in the said call, the

Complainant did not raise any concern or issue and was in complete agreement with the terms and

conditions of the policy. They had received the first complaint on 16/01/2020 asking for the policy

bond, which was beyond the free look cancellation period. The Insurer has offered to issue the

relevant policy bond in their letter dated 08/05/2020.

19. Reason for registration of Complaint: Servicing issue.

20. The following documents were placed for perusal:

a) Copy of policy

b) Copy of Complainants letter to the Insurance Company

c) Copy of Letter sent by the Insurance Company

d) Self Contained Note

11. Amount of Partial Settlement N.A.

12. Amount of relief sought Non-receipt of policy bond

13. Complaint registered under Rule No. of

the Insurance Ombudsman Rules, 2017

Rule 13(1)(d)- Misrepresentation of policy terms and

conditions at any time in the policy document or policy contract

14. Date of hearing/place 14.05.2020, Delhi, Online, via Webex


a) For the Complainant Shri Raj Kumar, the Complainant

b) For the Insurer Shri Harpal Singh, Financial Executive

16. Complaint how disposed/ date of

Award/Order

Award /14.05.2020

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

Case called. Parties are present and submit their arguments as stated in para 18 above.

The Complainant is a graduate by education and confirms that he had seen the details of his policy on

the website of the Insurer. He also states that he wants to cancel the policy and seeks the bond in

print only to enjoy the free-look cancellation as he is dissatisfied with the terms and conditions of the

policy.

The Insurer agrees to provide the details of proof of delivery of the policy document by speed post.

The Insurer has submitted copy of Consignment Tracking of India Post, which shows that the

Consignment No. EA915344687IN was delivered on 01/02/2019.

Upon examination of the arguments and evidence submitted by the parties, it is concluded that the

the Complainant had received the policy by speed post and should have seen it on the web-portal of

the Insurer as well. Furthermore, he was made aware of the Policy terms and conditions while filling

up the proposal form and through the pre-issuance verification call.

The allegation of non-delivery and mis-sale of the policy against the Insurer is not proved and the

complaint is liable to be rejected.

Award

The complaint is rejected.

(Sudhir Krishna)

Insurance Ombudsman, Delhi

14th

May 2020

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA

CASE OF SH KISHAN SINGH V/S PNB METLIFE INDIA INS. CO.P. LTD.

COMPLAINT REF: NO JPR-L-033-1920-0373

AWARD NO:IO/JPR/L/A/1920/00

1.

Name & Address of the

Complainant

Sh Kishan Singh

Bharatpur

2. Policy No:

Date of commencement

Sum Assured

Premium

22472233

13.02.2018

Rs.970223/-

Rs.95693/-



Sh Kishan Singh

Sh Kishan Singh

4. Name of the insurer PNB Metlife India Ins. Co.P. Ltd.

5. Date of Repudiation NA

6. Reason for repudiation Beyond free look period


8. Nature of complaint Missale

9. Amount of Claim Rs.100000/-

10. Date of Partial Settlement NA

11. Amount of relief sought Rs.100000/-


Rule no: of IOB rules

13 (1) d

13. Date of hearing/place 07.05.2020/Video Conferrencing


a) For the Complainant Sh Kishan Singh

b) For the insurer Ms Kamaldeep

15 Complaint how disposed Dismiss

16 Date of Award/Order 19.05.2020

17)Brief Facts of the Case:-Sh Kishan Singh, (herein after referred to as the complainant) had

filed a complaint against PNB Metlife India Ins. Co.P. Ltd.(herein after referred to as the

respondent Insurance Company) alleging missale of policy bearing no 22472233.

Cause of Complaint:

Complainants’ argument: The complainant stated that the PNB Metlife Endowment Saving

Plan Plus policy bearing no.22472233 favouring himself having commencement date 13.02.2018

with annual premium of Rs.100000./- for 10 years was issued to him .The complainant submitted

that his father was having two policies from SBI Life Insurance Company bearing no

44039022505 and 49005672503.He wanted money for his daughter’s marriage but he misguided

by the representative of the Insurance Company and was asked to deposit Rs.232000/- towards

GST under both policies with the promise that after two months he will get RS.1824000/- but he

did not get any money. The complainant further submitted that his father was misguided and

issued new policies of various Insurance Companies and subject policy was issued in favour of

complainant. When the complainant was came to know about the missale of the policy he lodged

a FIR No 0098 on 07.03.2019 against the persons involved in misselling of policies of various

Insurance Companies. He had also approached to the Insurance company for cancellation of the

policy and refund of premium amount on 23.04.2019.The complainant further submitted that he

also approached to the GRO on 29.05.2019.As he failed to get the relief so he approached this

forum for redressal of his complaint.

Insurers’ argument:- The responded Insurance Company in their SCN dated 13.03.2020 stated

that the policy was issued on the basis of a duly signed proposal form submitted by life assured.

The complainant was given15 day’s freelook period to raise concern in relation to terms and

conditions of the policy. The Insurance Company further submitted that the policy document was

dispatched to the complainant on 21.02.2018 through speed post vide POD No.EA174257593IN

and the same was duly delivered to the complainant on 03.03.2018 but the complainant has not

approached to the Insurance Company within free look period. The Insurance Company further

submitted that company received an email dated 06.10.2019 from the complainant stating policy

document not received. Therefore, the complainant’s request for cancellation of the policy and

refund of premium could not be acceded being beyond scope of the policy terms and conditions.

19) Reason for Registration of Complaint: - Case of missale

20) The following documents were placed for perusal.

a) Complaint letter

b) Policy copy

c) GRO Letter

d) Form VI A duly signed by the complainant

e) SCN and a form VIIA duly signed by the Insurance Compa

21) Result of hearing with both parties (Observations and Conclusions):-Both the parties

appeared in the personal hearing through video conferencing (whatsapp calling) and

reiterated their submissions. The complainant accompanied by his father submitted that the

subject policy was issued to him on 13.02.2018 on the false promise of getting Rs.1824000/-

by the representative of the respondent Insurance Company but he did not get the money.

The complainant further submitted that he required money for his daughter’s marriage hence

he had approached to the Insurance Company on 04.07.2018 for cancellation of subject

policy followed by reminders on 23.04.2019 and 29.04.2019 but he did not get the relief. The

Insurance Company submitted that the company had received digitally filled duly signed

proposal form and he had also submitted a duly filled and signed Benefit Illustration under

which he had agreed to the benefits, charges, terms and risk factors of the proposed plan. The

Insurance Company further submitted that they had not received any complaints in the year

2018. The first complaint was received only on 06.10.2019 from the complainant stating

policy documents not received and they did not receive any complaint before email dated

06.10.2019.The Insurance Company further submitted that the welcome call was also made

to the complainant but complainant had not raised any concern during the welcome call

.After lodging complaint on 15.01.2019 for cancellation of the policy he paid renewal

premium which was also acknowledged during the hearing by the complainant.

During the hearing the complainant was asked to submit the copy of complaint dated

04.07.2018 and dispatch details also but he failed to submit the same till date. I find that the

complainant had purchased the subject policy on 13.02.2018 but he had applied for

cancellation of the policy on 15.01.2019 stating that he had received the policy and wanted to

cancel the policy as he was not agreeable to the terms and conditions of the policy. The

complainant did not submit the documents asked during the hearing. I also find that in his

complaint dated 06.10.2019 he had submitted that he had not received the policy .This is in

contradiction to his earlier statement.The complainant did not apply for cancellation of the

policy within free look and also paid renewal premium after making complaint for the

cancellation of the policy.

I see no reason to interfere with the decision of the Insurance Company.

Accordingly the complaint filed by the complainant is hereby dismissed.

22. The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017:

According to Rule 17(5) of Insurance Ombudsman Rules 2017,A copy of the Order shall be sent

to the complainant and the Insurer named in the complaint.

Place: Jaipur SANDHYA BALIGA

Dated :19.05.2020 INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE




CASE OF VINOD KUMAR SHARMAV/S KOTAK MAHINDRA LIFE INSURANCE COMPANY

COMPLAINT REF: NO. JPR- L-026-1920-0376


1. Name & Address of the Complainant Sh. Vinod Kumar Sharma

ORDER

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 hereby dismissed..

Pushkar Ajmer

2. Policy No:

Type of Policy

Purchase Price

DOC

09651572

Kotak Premier Money Back Plan

Rs. 500000/-

13.07.2017



Sh. Vinod Kumar Sharma

Sh. Vinod Kumar Sharma

4. Name of the insurer Kotak Mahindra Life Insurance Company

5. Date of Repudiation N/A

6. Reason for repudiation N/A




10. Date of Partial Settlement NIL




13 (1) (b)

13. Date of hearing/place 04.05.2020 / Video Conferencing


c) For the Complainant Absent(Request received for decision on

merits)

d) For the insurer Ms. Nivedita Bhattacharya



17) Brief Facts of the Case:- Sh. Vinod Kumar Sharma ( herein after referred as complainant) had filed a

complaint against Kotak Mahindra Life Insurance Company(herein after referred to as respondent Insurance

Company) alleging missale under Policy no.09651572.


Complainants’ argument: The complainant submitted that he had taken the subject policy no. 09651572 under

Money Back Plan from the respondent Insurance Company on 13.07.2017 with sum assured of Rs.500000 and

annual premium of Rs.63589/-.The Kotak Company agent Ms Pooja Sharma assured him that he would receive 30

Lakhs after 20 years (Premium Paying term 10 yrs and locking period of 10 yrs) and overdraft limit of Rs.3000000/-

after 62 days of issuing the policy. The complainant further submitted that he did not get the OD Limit. The

Complainant represented his case to the GRO on 30.12.2019 for refund of premium and cancellation of subject

Policy to the respondent Insurance Company but did not get any relief. Being aggrieved from the action of the

respondent Company, the complainant approached this forum for redressal of his complaint.

Insurers’ argument:- The respondent Insurance Company in its SCN dated 09.03.2020 submitted that the company

had received digitally filled duly signed proposal form and he had also submitted a duly filled and signed Benefit

Illustration under which he had agreed to the benefits ,charges, terms and risk factors of the proposed plan and

therefore clearly had complete understanding of the plan availed by him. The respondent Insurance Company further

submitted that the policy document for subject policy was dispatched on 14.07.2017 through speed post via way bill

no EM967320244IN and same was delivered to the complainant on 20.07.2017.Welcome call also made to the

complainant and during the said call the telecaller had specifically informed that neither IRDAI nor the company

offers any gifts or schemes on the existing or current policies. The Insurance Company further submitted that they

sent lapse notice dated 13.08.2018 and letter dated 13.11.2018 for intimation about revival period but they had not

received any response by the complainant. The complainant raised his complaint to the company on 18.12.2019

which was more than 2 years from the issuance of the subject policy.. Hence company denied for cancellation of the

policy and refund of premium.

19) Reason for Registration of Complaint: Missale


a) Complaint letter

b) Policy copy

c) Form VI A duly signed by the complainant.

d) SCN and form VIIA duly signed by the Insurance Company

21) Result of hearing with both parties(Observations and Conclusions):-The representative of the Insurance

Company appeared in the personal hearing through video conferencing (whatsapp calling) and reiterated their

submission.The complainant was not present as his consent for decision on papers submitted by him.The Insurance

Company submitted that the company had received digitally filled duly signed proposal form and he had also

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

risk factors of the proposed plan. The Insurance Company further submitted that he had applied for cancellation of

the subject policy on 18.12.2019 after a lapse of 2 years from the date of issuance of the policy. The Insurance

Company further submitted that they sent lapse notice dated 13.08.2018 and letter dated 13.11.2018 for intimation

about revival period but they had not received any reply. The complainant’s submission on the basis of complaint

letter and other documents was that the subject policy was issued to him on the false promise of getting 30 Lakhs

after 20 years (Premium Paying term 10 yrs and locking period of 10 yrs) and overdraft limit of Rs.3000000/-after

62 days of issuing the policy but he did not get the Overdraft limit. The complainant further submitted that he had

approached to the respondent Insurance Company on 18.12.2019 but his complaint was not considered.

I find that the subject policy was issued on 13.07.2017 and delivered to the complainant on 20.07.2017 but the

complainant approached to the Insurance Company on 18.12.2019 i.e. after 2 years from the issuance of the policy

also he had not responded revival notices sent by the Insurance Company. I also found that there was no cogent

reasoning given for delay in submitting for cancellation of the policy and refund of premium to the Insurance

Company or even to the Ombudsman Office. I see no reason to interfere with the decision of the Insurance

Company.

Accordingly, the complaint is hereby dismissed.

22) The attention of the Complainant and the insurer is hereby invited to the following provisions of the Insurance

Ombudsman Rules, 2017:

AWARD

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

both the parties during the course of hearing, the complaint is here by dismissed.

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.


Dated: 07.05.2020 (INSURANCE OMBUDSMAN)

PROCEEDINGS BEFORE




CASE OF SH NARENDRA MERTIA V/S KOTAK MAHINDRA LIFE INSURANCE COMPANY

COMPLAINT REF: NO. JPR- L-026-1920-0376


1. Name & Address of the Complainant Sh.Narendra Mertia

Jodhpur (Rajasthan)

2. Policy No:

Type of Policy

Purchase Price

DOC

03964494

Kotak Premier Income Plan

Rs. 500000/-

24.12.2018



Ms Arya Surana

Sh. Narendra Mertia

4. Name of the insurer Kotk Mahindra Life Insurance Company

5. Date of Repudiation N/A

6. Reason for repudiation N/A




10. Date of Partial Settlement NIL




13 (1) (b)

13. Date of hearing/place 05.05.2020 / Video Conferencing


e) For the Complainant Absent(Request received for decision on

merits)

f) For the insurer Ms. Nivedita Bhattacharya



17) Brief Facts of the Case:- Sh.Narendra Mertia ( herein after referred as complainant) had filed a

complaint against Kotak Mahindra Life Insurance Company(herein after referred to as respondent Insurance

Company) alleging missale under Policy no 03964494.


Complainants’ argument: The complainant (Karta of Narendra Mertia HUF) submitted that Mr Sushant Paul

manager of Kotak Insurance Company suggested him for investment in Life Insurance policy for good return

as well as to avail Income Tax benefits u/s 80 C.The company executive again came to him with a proposal in

which he can obtain policy for any of his grand children’s life, aged minimum 3 years and more. Being a long

term plan for 23 years out of which he had to pay premium for 12 years, they had suggested policy on the life

of Aarya Surana , son of his daughter and subject policy was issued. The complainant further submitted that

he had consulted his tax adviser for filing of Income Tax and he came to know that he was not entitled for tax

benefit as life assured was not part of his HUF. He made complaint to the respondent Insurance Company on

28.11.2019 and on 05.12.2019 for cancellation of policy and refund of premium. He again approached to the

GRO 26.12.2019 but his complaint was declined by the respondent Insurance Company by mentioning “Tax

benefits on the premium(s) paid and the benefits received are subject to fulfillment of conditions as specified

under the prevailing tax laws and are subject to modification made there to from time to time ”vide their e

mail dated 20.12.2019.Being aggrieved from the action of the respondent Company, the complainant

approached this forum for redressal of his complaint.

Insurers’ argument:- The respondent Insurance Company in its SCN dated 09.03.2020 submitted that the

company had received digitally filled duly signed proposal form and he had also submitted a duly filled and

signed Benefit Illustration under which he had agreed to the benefits ,charges, terms and risk factors of the

proposed plan and therefore clearly had complete understanding of the plan availed by him. The subject

policy was issued in favour of his grandson, who was his daughter’s son and he was the proposer. The

respondent Insurance Company further submitted that the policy document for subject policy was dispatched

on 26.12.2018 through blue dart courier via AMB no 35926579864 and same was delivered to the

complainant on 29.12.2018. The complainant raised his complaint alleging loss of Income Tax benefit and

demanding cancellation of the policy and refund of premium to the company on 28.11.2019 and to GRO on

26.12.2019 which was more than 11 months from the issuance of the subject policy i.e. beyond free look

cancellation period Hence company denied for cancellation of the policy and refund of premium.

19) Reason for Registration of Complaint: Missale


a) Complaint letter

b) Policy copy

c) Form VI A duly signed by the complainant.

d) SCN and form VIIA duly signed by the Insurance Company

21) Result of hearing with both parties (Observations and Conclusions):-The representative of the

Insurance Company appeared in the personal hearing through video conferencing (whatsApp Calling) and

reiterated their submission. The complainant was not present as his consent for decision on merits on the

basis of documents submitted by him. The Insurance Company submitted that the complaint had also

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

terms and risk factors of the proposed plan. The respondent Insurance Company further submitted that the

policy document for subject policy was dispatched on 26.12.2018 through blue dart courier via AMB no

35926579864 and same was delivered to the complainant on 29.12.2018 but the complainant raised his

complaint on 28.11.2019 regarding tax benefit after approx. 11 months from the issuance of the policy..

The complainant’s submission as per complaint letter and other documents was that he had taken policy on

the life of his grandson as karta of HUF for getting rebate in Income tax but at the time of filing of Income Tax

return he came to know that he would not get Income Tax rebate for subject policy as life assured was his

daughter’s son and he was not entitled for tax rebate as per Income Tax Rules. He further submitted that he

approached to the respondent Insurance Company on 28.11.2019 but his complaint was not considered.

I find that the subject policy was issued on 24.12.2018 and delivered to the complainant on 29.12.2018 but

the complainant approached to the Insurance Company on 28.11.2019 i.e. after approximately 11 months

from the issuance of the policy. I also found that there was no cogent reasoning given for the undue delay in

submitting for cancellation of the policy and refund of premium to the Insurance Company or even to.

Therefore I see no reason to interfere with the decision of the Insurance Company.

Accordingly, the complaint is hereby dismissed.

22) The attention of the Complainant and the insurer is hereby invited to the following provisions of the

Insurance Ombudsman Rules, 2017:

a. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall be sent to the

complainant and the insurer named in the complaint.


Dated: 07.05.2020 (INSURANCE OMBUDSMAN)

Complaint No : MUM-L-036-1920-0194

Award No : IO/MUM/A/LI/0001/2020-21

Complainant : Mr. Pramod Jadhav

Respondent : Reliance Nippon Life Insurance Company Limited.

Representation for the hearing via video calling: a) For the complainant: Mr Pramod Jadhav b) For the Insurer: Mr Nikunj Chikani Date of Hearing: 19th May, 2020 Time:3.00 pm

The above mentioned parties attended the hearing through video calling on 19th May, 2020.

The submissions made by both the parties were heard. The complaint has been settled

between the complainant and the Respondent as the Insurance Company/Respondent has

AWARD

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

both the parties during the course of hearing, the complaint is here by dismissed.

agreed to settle the complaint by refunding to the complainant the premium

amount(Rs.30,000/-) paid under policy bearing no. 52344811 less amount(Rs.4352/-) already

paid to the complainant as full and final settlement of the complaint and the complainant has

agreed to the same before the Hon’ble Insurance Ombudsman, Mumbai.

ORDER

The Respondent, Reliance Nippon Life Insurance Company Ltd. is hereby ordered to refund Rs

25648/ to the complainant Mr Pramod Jadhav,(i.e. the amount Rs 30000/- received under the

above policy bearing no. 52344811 less the amount of Rs 4352/- already paid under the policy)

within 30 days from date of receipt of this order.

Dated at Mumbai, this 19th day of May, 2020.

MILIND KHARAT

INSURANCE OMBUDSMAN, MUMBAI

Complaint No : MUM-L-008-1920-0604 Award No : IO/MUM/A/LI/0005/2020-21

Complainant : Mr Raju Gupta

Respondent : Bharti Axa Life Insurance Company Limited.

Representation for the hearing via video calling: a) For the complainant: Mr Raju Gupta b) For the Insurer: Mr Ritin Purohit Date of Hearing: 20th May, 2020 Time: 4.00 pm




agreed to settle the complaint by refunding to the complainant the premium amount of

Rs.30,000/- paid under policy bearing no. 501-7320325, and Rs.34,000/- paid under policy

bearing no. 501-7530220 as full and final settlement of the complaint before the Hon’ble

Insurance Ombudsman, Mumbai.

ORDER

The Respondent, Bharti Axa Life Insurance Company Ltd. is hereby ordered to refund to the

complainant Mr Raju Gupta, the total premium amount of Rs.64,000/- paid under policy

bearing no. 501-7320325 and 501-7530220 within 30 days from date of receipt of this order.

There is no other relief.

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.


MILIND KHARAT




Complainant : Mr. Sadanand Ghogale

Respondent : Reliance Nippon Life Insurance Company Limited.

Representation for the hearing via video calling: a) For the complainant: Mr Sadanand Ghogale b) For the Insurer: Mr Nikunj Chikani Date of Hearing: 20th May, 2020 Time:3.00 pm


The submissions made by both the parties were heard.

The complaint has been settled between the complainant and the Respondent as the Insurance

Company/Respondent has agreed to settle the complaint by cancelling the policies bearing nos.

50890254 and 51066263 and to convert the amount of premium of Rs. 50,000/- and Rs. 69,689.85/-

respectively paid under the policies into a Single Premium Policy towards full and final

settlement of the complaint and the complainant has agreed to the same before the Hon’ble

Insurance Ombudsman, Mumbai.

ORDER

The Respondent, Reliance Nippon Life Insurance Company Ltd. is hereby ordered to cancel

policies bearing nos. 50890254 and 51066263 and to convert the premium of Rs.1,19,689/- paid

by the complainant, Mr Sadanand Ghogale into a Single Premium policy, on receipt of all the

requirements within 30 days from date of receipt of this order.

This conversion would be applicable without the Free Look Provision.


MILIND KHARAT




Complainant : Mr Vijay Gavhane


Representation for the hearing via video calling: a) For the complainant: Mr Vijay Gavhane b) For the Insurer: Mr Ritin Purohit Date of Hearing: 22nd May, 2020 Time:3.40 pm

The above mentioned parties attended the hearing through video calling on 22nd May, 2020.



agreed to settle the complaint by cancelling the policy and refunding to the complainant the

premium amount of Rs.30,000/- paid under policy bearing no. 501-8676378, as full and final

settlement of the complaint before the Hon’ble Insurance Ombudsman, Mumbai.

ORDER


complainant Mr Vijay Gavhane, the premium amount of Rs.30,000/- paid under policy bearing

no. 501-8676378 within 30 days from date of receipt of this order. There is no other relief.

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.

Dated at Mumbai, this 22nd day of May, 2020.

MILIND KHARAT




Complainant : Ms Vijaya Parab


Representation for the hearing via video calling: a) For the complainant: Ms Vijaya Parab b) For the Insurer: Mr Ritin Purohit Date of Hearing: 20th May, 2020 Time:3.20 pm




agreed to settle the complaint by cancelling the policy and refunding to the complainant the

premium amount of Rs.62700/- paid under policy bearing no. 501-7026237, as full and final

settlement of the complaint before the Hon’ble Insurance Ombudsman, Mumbai.

ORDER


complainant Ms Vijaya Parab, along with Bank rate of interest, the premium amount of

Rs.62,700/- paid under policy bearing no. 501-7026237 within 30 days from date of receipt of

this order. There is no other relief.


MILIND KHARAT


Documents

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN ... - cioins.co…