Date of filing:-01/02/2017.
Date of Order:-12/09/2018.
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM(COURT)
B A R G A R H.
Consumer Complaint No. 61 of 2017.
Kalyani Hota , Wife of Late Krushna Chandra Hota, Resident of Kalinga Nagar, Brahmachari, W.No. 16, Bargarh, Po/Ps/Dist. Bargarh ..... ..... Complainant.
Vrs
The Branch Manager, ICICI Prudential Life Insurance, Bargarh At. Bandutikra chowk, Bargargh P.o/.P.s/Dist- Bargarh, Pin-768028.
The Associate Vice President Claims, ICICI Prudenrtial Life Insurance Company Ltd., Unit IA & 2A, Raheja Tipco Plaza, Ranisati Marg, Malad ( East ) Mumbai 400097 ..... .......Opposite Parties.
Counsel for the Parties:-
For the Complainant :- Sri M.K.Satpathy, Advocate with other Advocates.
For the Opposite Parties:- Sri D.D. Mishra, Advocate with other Advocates.
-: P R E S E N T :-
Sri Krishna Prasad Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Ajanta Subhadarsinee ..... ..... ..... ..... ..... M e m b e r (W).
Dt.12/09/2018. -: J U D G E M E N T:-
Presented by Sri Krishna Prasad Mishra, President:-
Brief Facts of the case :-
The Complainant has preferred to file the case pertaining to the deficiencies of service and unfair trade practice caused on the part of the Opposite Parties towards her as hereunder.
That the complainant is the wife of her deceased Husband who had purchased one Policy namely Suraksha LP Plan with the Opposite Parties being persuaded by the Opposite Party and one Dharmendra Pati an agent of the Opposite Parties as a good insurance plan, and being influenced by them the deceased husband of the Complainant purchased with a hope to secure his Life for five years and after completion of five years would get an amount of Rs. 3,50,000/-(Rupees three lakh fifty thousand)only against his premium amount of Rs.50,000/-(Rupees fifty thousand)only and in case of any mis happening in the mean while the same would be paid to his legal heirs by the Opposite Parties ,and paid an amount of Rs.50,000/- (Rupees fifty thousand)only as premium on Dtd. 29.07.2016 vide receipt No.F7218631 for the same P.A. against which policy bond was issued with him vide Policy No.20174146 .
Her further case is that during the subsistence of the coverage period of the same policy her deceased husband the insured person died of sudden heart attack on Dt.27.02.2017 .therefore the Complainant being the Nominee and also the legal heirs of her Husband placed her claim for the sum assured amount from the Opposite Parties with all relevant documents but to her surprise instead of paying her the same the Opposite Parties repudiated her claim which as per her, amounts to deficiencies of service coupled with unfair trade practice on their part. As such served them with a pleader Notice but they replied denying to pay the same legal money of the Complainant hence has filed the case before the forum with a prayer for a direction to the Opposite Parties to pay the sum assured amount Rs.3,50,000/-(Rupees three lakh fifty thousand)only along with an amount of Rs.50,000/-(Rupees fifty thousand)only as compensation towards her mental agony and physical harassment undergone by her with Litigation expenses .
And in support of her such case has relied on some following documents,
The Policy bond copy of the said Insurance,
The receipt issued by the Opposite Party against the payment of the premium amount.
and a copy of the pleader Notice with AD card.
And later on has also filed a notes of arguments supported by a decision of our State Forum reported in the Cuttack Law times ( CDC) and the provision of the Insurance act U/s 45 ,subsequently at the time of the final hearing of the case.
On perusal of the Complaint, its related documents and on hearing the Counsel of the Complainant the case was admitted as a genuine one and Notice was served on the Opposite Parties, in response to the same they appeared before the forum through their Advocate and filed their a voluminous version jointly.
The rival contentions of the Opposite Parties are all an Evasive one to the case of the Complainant, in it’s version initially they have challenged the maintainability of the case before the Forum amongst others that the Complainant has suppressed the materials facts of his previous ailments like obstructive jaundice with acute cholangitis with type IV Hilar Structure with Cholangio Carcinoma and was under the treatment from Dt.28.01.2014 to Dt. 04.03.2014 in the Asian Institute of Gastroenterology and in its support to repudiate the Claim has relied on the Apex Court of the Country reported in AIR 2008 424 in the case of P.C.Chacko and anr vrs Chairman, Life Insurance Corporation of India. And also has further made averments with regard to the suppression of the previous ailments if any on the part of the assured to disclose at the time of commencement of the Insurance query or else would be amounting to suppression of materials facts as it is based on the utmost good faith resulting to which the repudiation of the claim is justified in view of the decisions of the supreme court in different time.
The sum and substances of the contention of the Opposite Parties so far as his versions and the evidence in the form of an Affidavit filed by the Opposite Party No.1(one) is that the Complainant is not entitled to any claim rather the same is liable to be dismissed in liminee on the ground of the suppression of materials facts by the insured and in support of their such contentions have relied on a numbers of decisions of the Apex court of the Country which is mentioned below in details, besides that also the learned counsels of the Opposite Parties has vehemently argued out the case in their support and pressed to dismiss the case in view of such references and the provision of the Insurance Act U/s 45 and the physical verification by their agencies from the neighbors of the Complainant, the Medical report collected from different treatment agencies and also from the working place of the Deceased husband of the Complainant , the insured. And in support of his such arguments has filed a voluminous amounts of Documents in relation to the case to justify his contention of repudiation of the claim of the complainant. Which are enumerated below in details ,
1, Annexure 1 to 12 along with many other documents such as follows:-
Copy of the proposal form exhibit R-1 Dt.31.07.2016.
Copy of death Claim intimation , Exhibit R-2. Dt.01.05.2017.
Copy of investigation report with copy of affidavit of investigator Ex-R-3.
Copy of essentialities certificate by Asian institute of gastroenterology prior to policy. Ex-R-4. Dt.28.03.2014.
Copy of Essentiality certificate by Asian Institute of Gastroenterology Ex-R-5 Dt.04.03.2014.
Copy of VSS Medical College ticket Ex-R-6 Dt.08.12.2014.
Copy of PTBD (SEMS) report from Asian Institute of Gastroenterology also mention as indications,Ex-R-7.
Copy of Repudiation Ex-R-8.Dt08.02.2016,05.11.2016.
Copy of letter of his Decease Ex-R-9,dt.02.03.2017.
Copy of beneficiary ,Ex-10 ,Dt.04.03.2014.and 03.03.2014.
Copy of repudiation Letter Ex-11. Dt.30.06.2017.
Copy of Legal Notices Ex-R-12,dt.20.10.2017.and 07.11.2017.
Having gone through the complaint, the documents filed by her and the version, the evidence and the oral and written submissions of the learned counsels of the respective Parties the Following points for the proper adjudication of the case have cropped up before us as follows :-
Whether the case is maintainable in the Forum ?
Whether the Opposite parties are deficient in rendering service to the Complainant ?
Whether the Complainant is entitled to the reliefs sought for by her ?
Firstly while considering the point as to whether the case is maintainable in the Forum under the Consumer Protection Act 1986, after vividly verifying the materials available in the record it reveals therein that the deceased insured person has genuinely paid the amount of Rs.50,000/-(Rupees fifty thousand)only vide the receipt No.F7218631 on Dt.29.07.2016 and the proposal was accepted by the Insurer Opposite Party issued him with a policy Bond vide policy No. 20174146, under the Suraksha LB plan ,and during the subsistence of the policy the deceased has died on Dt.27.02.2017 after seven months of the commencement of the said policy due to heart stroke ,so it is obvious upon the Complainant to claim for the sum assured amount of her husband wherein she was placed as nominee, and as the insured deceased person has paid the premium amount with due receipt of the Opposite Party and has also has issued him with the policy Bond ,he is a bona fide consumer and any dispute in between the claimant and the Opposite Party is a consumer dispute , therefore in our prudent view it is a genuine case , as such is very much maintainable in the present forum so our opinion is expressed in favor of the Complainant.
Secondly with regard to the point as to whether the Opposite Parties is deficient in rendering service to the Complainant, delving deep in to the facts and Laws relating to the case as the materials available in the record, we scrutinized the same placed by the Complainant and the voluminous versions along with its supporting documents and the oral arguments and the written notes of arguments with utmost care, in the process it came to our Notice that the Complainant has paid the premium amount as above mentioned and the acceptance of the same proposal by the Opposite Parties. But in its versions they have bluntly denied to have caused any deficiencies in rendering service to the Complainant or committing unfair trade practice on the ground as mentioned therein in their version as has suppressed the materials facts by the insured against the query made at the time of presentation of the same before the Opposite Parties, during the course of arguments the learned counsel for the Opposite Parties also vehemently pressed before the forum agitating the materials where the Complainant has filled up the proposal of the insurer in denying to have under gone with any ailments before, but at the time of the claim of the same it has been investigated from different angel from different medical agencies and the working place of the deceased insured and being sure of his suppression the materials facts as true have repudiated the claim, but in answering the points, the learned counsel have also vehemently pressed with a submission that much prior to the submission of the proposal he had some ailments with him and had undergone treatment for the same and was quite healthy at the time of submission of the proposal and also has claimed the attendance of the deceased was regular in his school and vehemently argued that the pledged investigation made by the Opposite Parties are done in the absence of the Complainant and hence is not tenable in the eye of law, in support of his claim has also relied on a decision of our own state commission reported in the year 2006 pressing thereby to substantiate his point as by the time of the submission he was not suffering from any decease and has died of heart failure suddenly which has got no relation to his earlier ailments, hence is entitled to the sum assured amount.
In furtherance to our observation on the reference made by the learned advocate for the Opposite Parties. that in view of the Section 45 of the insurance act the case is rightly repudiated by them, in this context, we enquired in the process of hearing, that whether the Opposite Parties has taken any steps to ascertain the fact of the previous ailments of the deceased insured before acceptance of the proposal by the Opposite Parties. Because it is mandatory on their part as per the provision of the law relating to the case, in reply to the same we were impressed with the contention that for small amount of the insurance it is not mandatory to ascertain the same but it is accepted on the basis of good faith but no materials was supplied with us to take a positive view on that, so in this regard the principle of the good faith which the Opposite Parties claims to have accepted the plan of the deceased would also apply to the case of the complainant to which the Opposite Parties have admitted in their version in the paragraphs No.29(twenty nine) and also in view of the established principle of Law of contract the parties to any agreement or contract is supposed to have equal right facilities and reasonable opportunity to the same,furthermore the averments made by the Opposite Parties in its version that the fact of his prior ailments have been ascertained by them from the Asian Hospital but they did not agree to supply them with a copy thereof ,so later on they got it confirmed with help of the application through R.T.I. And also they have made averment that they have got it confirmed from the letter of the Block education officer that in last four years he was suffering from some fatal decease like cholangia Carcinoma which is a bile duct cancer but no written report from any expert has been filed and has admitted that however he was discharged from the Hospital with a stable condition, from where it can be safely inferred that by the time of the commencement of the said policy the Complainant was free from any such decease and the cause of death is not proved to be the consequence of the earliar decease by any expert as has claimed by the Opposite Parties further more it is found from para 15 of the version of the Opposite Parties that the proposal was received by them on Dt.29.07.2016 and their risk commencement has started from Dt.12.09.2016 without assigning any reason for such belated commencement of the risk period, so by this time they could have ascertained the decease undergone by the insured prior to the date of the acceptance of the same but they have not taken any care to that effect therefore taking the entire episode of the case of the Complainant and the Opposite Parties it was the prime duty of the Opposite Parties to get it confirm with regard to his health condition as have taken care to ascertain the alleged decease at the time of settlement of the claim and it is pertinent to mention here that they have received an extra amount of Rs.1,876/-(Rupees one thousand eight hundred seventy six)only as has been cited in the para.15 of their version though the premium amount was only Rs.50,000/-(Rupees fifty thousand)only ,which it self speaks the negative attitude on their part .
Further more it is also found from the document filed by the Opposite Parties relating to the provision of the Insurance Act u/s 41 wherein it is clearly stated that if an insurance policy is repudiated then it is mandatory on their part to refund the premium amount to the insured within 90(ninety) days from such repudiation to which also they have failed to comply, which clearly reveals their attitude and also it reveals from their version that though it is admitted by them, in furtherance to our such view the report of the M.Ramanujan the Apex Authority of the SEBI on the Advice of the reserve bank of India has clearly clarified with regard to the clarity and transparency of the financial and Insurance institutions in explaining the agreement and the terms and conditions embodied in the same in a clear manner to the lay man like the deceased insured , but as per him it is often seen the same is not maintained in most of the cases , which has also happened in this case as it is clearly stated by the Complainant in it’s complaint that her husband being persuaded by the Opposite Party No.1(one) and one of his agent ,has purchased the policy with a good faith , which has not being disputed by the Opposite Parties in any part of their version .
Furthermore with regard to the contention made by the learned counsel for the Complainant on the point of the filling of the claim form submitted by her before the Opposite Parties wherein she has given her tick mark on the table of the other decease which is contradictory to her claim wherein she has claimed that the death of decease was caused by heart failure with the support of the death report wherein it is opined the cause of death as heart stroke, in this regard it is pertinently clear from her signature on the same form where from it can be safely presumed that she being an illiterate lady is quite unaware of the language and the same might be wrong because it clearly reveals that the form has been filled up by somebody else other than the Complainant but for such an incident it cannot be held to be a genuine ground for repudiation of the claim of a widow rustic village lady , and in view of the aim and objective of the provisions. Since it is a benevolent provision to safe guard the interest of the Consumer, so it is a clear cut case of un-fair trade practice coupled with deficiencies of service on the part of the Opposite Parties and in our view the Citations filed by the Learned counsels for the Opposite Parties is not applicable as those are in a different footing having no similarity with the case in hand .And hence our consensus opinion is expressed in favor of the Complainant.
Thirdly with regard to the issues as to whether the Complainant is entitled to the reliefs as has sought for and both the Opposite Parties are jointly and severally liable, as we have already discussed in details in our foregoing paragraphs and have expressed our opinion in favor of the Complainant. Now it is obvious on our part to express our opinion in her favor, thus our order follows.
O R D E R.
Hence the Opposite Parties are directed to pay to the Complainant sum assured amount of Rs. 3,50,000/-(Rupees three lakh fifty thousand)only with interest @ 9%(nine percent) per annum from the date of filing of the case till date of Order and also further directed to pay an amount of Rs.5,000/-(Rupees five thousand) only towards her mental agony and physical harassment and Rs.2,000/-(Rupees two thousand)only against litigation expenses within thirty days from the date of receipt of the order , in default of which the entire amount would accrue an interest @ 12 %(twelve percent) per annum till the actual realization of the amounts. Accordingly the same is pronounced in the open forum and the case is disposed off to-day i.e. on Dt.12/09/2018.
Typed to my dictation
and corrected by me.
( Sri Krishna Prasad Mishra)
P r e s i d e n t.
I agree,
( Ajanta Subhadarsinee)
M e m b e r (W)
