Policy terms ‘not given upfront’: Kerala man wins Rs 2.8 lakh payout from insurance firm

“The case on hand is a special case with peculiar circumstances, unlike the normal cases against rejection of claim on the basis of the terms and conditions of the policy. There is no proof before this commission to show that the handbook containing the terms and conditions of the policy was handed over to the complainant before the acceptance of the proposal form of the complainant,” the August 20 order read.

No idea of terms and conditions

The complainant claimed that representatives of the insurance company approached him and persuaded him to take its Life Guaranteed Income Pro policy, following which he took the policy in favour of his daughter. He paid the first annual premium, including GST, of Rs 3.09 lakh on February 22, 2022.

The complainant submitted that although he had asked for the handbook containing the policy’s terms and conditions, it was handed over to him only three months after he had made the premium payment. He alleged that the terms and conditions governing the policy had not been communicated to him in advance.

The man subsequently suffered a stroke, which caused difficulty in walking, speaking and understanding, besides paralysis or numbness in his face, arm and leg. He claimed that, as a result of his health condition and because he was the sole earning member of his family, he was unable to continue paying the premiums.

He further submitted that he had undergone treatment and surgery and remained on medication, while substantial amounts were required for his medical expenses. He, therefore, requested the insurer to discontinue the policy and refund the premium already paid.

However, the insurer allegedly replied that there was no provision for refund of the premium if the policy was surrendered at that stage. Aggrieved, the man approached the commission, where he was represented by advocates Ajitha V K Nair and Sachin V L.

‘Peculiar case’

The commission described the matter as “a special case with peculiar circumstances”, distinguishing it from ordinary cases involving rejection of insurance claims based on policy terms and conditions.

It noted that there was no proof that the handbook containing the policy terms and conditions had been handed over to the complainant before he accepted the proposal form. The commission also noted that the complainant had raised the same grievance regarding non-issuance of the handbook before the insurance ombudsman.

The commission pointed out that the insurer had entered appearance through counsel after receiving notice but had failed to file a written version responding to the complainant’s allegations.

The commission nevertheless held that the insurer had incurred GST, documentation and agent-commission expenses while issuing the policy and was therefore entitled to retain Rs 35,000 from the amount paid by the complainant.

Based on the evidence placed before it, the commission held that the complainant had suffered mental agony and financial loss due to the insurer’s conduct. The commission directed the officials of the insurance company to jointly and severally refund Rs 2.74 lakh, along with Rs 10,000 as compensation and Rs 3,000 being the cost of these proceedings, to the complainant within 30 days.

Takeaway

This ruling highlights that an insurance company has a responsibility to provide the policy handbook containing the terms and conditions to the policyholder before accepting the proposal form, enabling the consumer to make an informed decision.

For consumer-related grievances, individuals can contact the consumer helpline in their respective states and Union territories (Kerala: 1800-425-1550) or call the National Consumer Helpline at 1915 for assistance.

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