SHANKARBHAI MAGANBHAI PRAJAPATI vs DIVL. MANAGER, L.I.C.

THAT the complainant who was serving in State Government as Police Sub Inspector had taken three money back policies with accident benefits from the opposite party. The total amount of all the policies comes to Rs. 1,10,000/-. The age of the complainant on the date of the accident was 35 years. It appears that all the three policies were in force when the complainant Police Sub Inspector met with the scooter accident on 17.7.89. While he was going on scooter, dashed with AMTS bus and suffered fracture of spine with other injuries with complete paraplegia and bladder involvement. It also appears from the certificate given by the doctor as well as the certificate by the Addl. Director General of Police that the patient (complainant) was completely paraplagic. Column No. V(ii) of the Doctors'' certificate being important is reproduced as under : V(ii) Do you consider that the patient is now incapacitated and cannot follow his usual vocation and if so, please state : Yes. Recommended to do duties which can be performed on wheel chair table work only. In the column nature of deformity, injury in brief, disease or illness which contributed to the cause leading to disability, the doctor has stated that "fracture D 11 with complete para-plagia" and in the column of cause of disability the doctor has written "fracture spine D 11 followed cord injury" is responsible for the disability. The most important column is column V (ii)(c) which is the column regarding percentage of disability. The doctor has stated 100%. Column (d) is in respect to time required for recovering fully from the disability. The answer is "not likely to recover". The Insurance company has also produced and relied upon the letter of Addl. Director General of Police dated 11.1.93, which is in Gujarati, which gives the particulars of his emoluments and type of job the complainant was doing. He has further stated that he has been assigned table work where he is required to attend from 10.30 hrs. to 18.10. hrs. However, considering his physical handicap and out of grace, the government has given concession in duty hours. He has become totally handicapped. For coming to duty and for going out, he requires wheel chair and presence of one attendant. While going for nature''s call, he cannot go alone without the assistance of attendant. He requires attendant all 24 hours because he is totally handicapped below his waist. He, therefore, recommended the Government to award him some benefit.

IN the written statement filed by the INsurance company, it has in para 3(b) stated as under : "IN view of the clause relating to disability benefit, disability benefit is payable only in the case of disability, must be disability which is the result of an accident and must be total and permanent and such that there is neither then nor at any time thereafter any work, occupation or profession that the life assured can ever sufficiently do or follow to earn or obtain any wages, compensation or profit."

The INsurance company has not denied that the complainant has not met with the accident and that his disability is total and permanent and that he will be able to do occupation or profession, that the life assured can ever sufficiently do or follow or obtain any wages, compensation or profit. IN short, there is no dispute that the assured is not suffering total disability and it is also not disputed that he is not likely to recover from the disability. The next defence the INsurance Company has put forward is that the complainant has been continued in service by the Government at Computer Centre and life assured is gainfully employed drawing wages and, therefore, the clause of disability benefit is not applicable for the payment of disability benefits to the complainant. The second argument of the officers is that he is performing duties on wheel chair and doing table work and, therefore, they are not admitting the liability. The INsurance company has further stated that Dr. M.D. Pandit of Ahmedabad by questionnaire dated 25.4.90 has recommended the complainant to do the duties which can be performed on wheel chair, table work. Not only this, but the INsurance company has further stated in clause (g) as under : "When the policies stands lapsed, the same is required to be revival after examining the insurability, health, age and other relevant factors by the opponent. As the complainant had met with an accident and become disable the opponent has rightfully decided to revive the policies without accident benefit and permanent disability benefit at an extra premium of Rs. 5/- per 1000 S.A."

It may also be noted that if the complainant who has admittedly met with the accident and is totally disabled and cannot be gainfully employed by any person, under the policy would be entitled to get the additional amount of Rs. 1,10,000/- within the period of 10 years i.e. he will be able to get approximately Rs. 1000/- per month and his policy will be continued and he will not be required to pay any premium and on his death his nominee/widow will get Rs. 1,10,000/-and if he survives on maturity date he will get the same amount. The questions, therefore, arise for our consideration are : (1) As to whether the case of the complainant falls within the purview of disability which entitles him to get the benefit of the policy? (2) If the government by way of grace and out of pity continues him on service roll and calls him for attendance so that payment could be made, can the Insurance Company deny the claim of the complainant on the ground that the Government is paying him wages not on account of doing duty of Police Sub Inspector but out of grace and compassion? (4) Whether the complainant can be denied the benefit of waiver of premium by the Insurance Company? and (5) Whether the Insurance Company can deny the ultimate benefit of Rs. 1,10,000/- either to his widow if he dies before maturity or to him if he survives the maturity period?

To our opinion, there is no doubt that the complainant has met with the accident, he has been seriously injured and his spine having been fractured resulting into total paraplagia, if he goes to the market he will not be employed by any person because he is not capable of doing any work and according to Ms. Sharma, learned Advocate for the complainant, his mental condition is such that he is not able to properly talk or feed. He is not a normal person. That the disability is permanent and cannot be cured in future even according to the medical opinion. That he requires or the person''s attendance 24 hours so much so that while going for nature''s call also he requires somebody to attend. .

THE certificate of the Addl. Director General of Police which is also relied upon by the Insurance Company where he has recommended continuance in service which appears to be advantageous to the Insurance Company clearly states that the complainant is totally handicapped, cannot pursue his ordinary and usual household affairs, much less the capacity to do any useful commercial work. Therefore, we are of the opinion that the case of the complainant totally falls within the requirements of the policy. It cannot be doubted that this complainant can ever get any job or can sustain himself without the help of attendant. His incapacity is irreversible and total. Now the only question that arises for our consideration is that if either State Government or any third party, out of pity and compassion and grace helps him, continues him on pay roll without taking any useful work or usual duty as Police Sub Inspector, will such benefit received by the insured entitles the Insurance Company to refuse the benefits of the policy?

IT may not be forgotten that this Insurance Company has been nationalised with a view to serve the society and not to raise technical defence and objections. The speech of Shri C.D. Deshmukh, the then Finance Minister on the eve of the promulgation of the Life Insurance (Emergency Provision) Ordinance 1956 being important is reproduced hereunder : "The nationalisation of Life Insurance will be another milestone on the road the country has chosen in order to reach its goal of a socialistic pattern of Society. In the implementation of the Second Five Year Plan, it is bound to give material assistance. Into the lives of millions in the rural areas, it will introduce a new sense of awareness of building for the future in the spirit of calm confidence which insurance alone can give. IT is a measure, conceived in a genuine spirit of service to the people. IT will be for the people to respond, confound the doubters and make it a resounding success."

(Reproduced from Manual for Agents) The second question that arises is that by granting this benefit by continuing the complainant in service by the Government, will the complainant loose the future benefits of the policy? He shall be required to pay premium if he wants to continue the policy as if he is a fit and proper person. It is not understandable why the Insurance Company tries to say that they are extending the benefits and prepared to take his premium with additional Rs. 5/- for Rs. 1000/- sum assured. We are not impressed by the offer made by the Insurance Company. It would have been more appropriate for the Insurance Company to waive the insurance premium which they have not done. We are told that after sore time when it was brought to the notice by some relatives, the complainant tried to pay premium to continue the policy till the dispute is decided but the same was not accepted and it has already lapsed and thereafter in the written statement this offer has been made in Clause 3(g). We are not impressed by this offer of the Insurance Company. Once we come to the conclusion that the case of the complainant falls within the four corners of the policy and he is entitled for the benefit, what has happened to him or what help he will get either from the State Government or from any other person is extraneous consideration. The liability is a liability under a contract. If the case falls within the purview of the policy, he is entitled to the benefits of the policy if the benefits of the policy is not dependent upon the subsequent events which is extraneous to the contract between the parties. The complainant has taken the policy, paid the premium and met within the accident and disability is permanent and total. His physical condition is not fit to get any work, even to maintain himself, because he cannot sustain himself without the help of third party for which he has to pay and incur cost. Even on principles, if the complainant gets the benefit from outside, the Insurance company cannot take advantage and deny the payment. In these circumstances, we are of the opinion that the complainant was entitled to all the benefits from the day when he met with the accident and the Insurance Company was liable to give all the benefits that are available under the policy. The Insurance Company having failed to do so is, therefore, liable both for interest and damages to the complainant. We, therefore, direct that the Insurance Company shall pay all the benefits and pay the arrears of the benefits with interest @ 18% p.a. from the date when the amount became due and payable. The Insurance Company shall continue the benefits of his policy as per the terms of the policy and will pay consequential benefits that would arise as if the policy is in full force. The Insurance company shall pay additional Rs. 5,000/- by way of pain and suffering to the complainant and cost. ORDER We direct that the Insurance Company shall pay the arrears of the installments to the complainant with running interest @ 18% per annum from the date the installment became due till the date of payment and will also pay damages of Rs. 5,000/- as stated above and waive further premium keeping the policy in force and will give the consequential benefits as and when it arise as if the policy is in force. The Insurance company shall pay the cost which we quantify at Rs. 2000/-. Complaint allowed with costs.