Orissa

Sambalpur

CC/58/2017

Soumya Ranjan Kumbhar - Complainant(s)

Versus

1-The Divisional Manager,LIC of India - Opp.Party(s)

B.K. Purohit, B.Nayak & D. Shroff

27 Jul 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer.Case No.- 58/2017

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

 

Sri. Soumya Ranjan Kumbhar,

S/O- Ushat Kumbhar

R/O-Shanti Nagar, Po-Budharaja,

Dist-Sambalpur, Odisha-768004                                   …………..Complainant

 

Vrs.

1. The Divisional Manager, Life Insurance Corporation of India

Office at-“Jeevan Prakash” Ainthapali,

PO-Budharja, Sambalpur-768004

2. The Zonal Manager, Life Insurance Corporation of India

East Central Zone Office, “Jeevan Deep” office at-6^th floor,

Exhibition Road, Patna-800001                           ……….….Opp. Parties

Counsels:-

1. For the Complainant    :-            Sri. B.K.Purohit, Advocate & Associates.
2. For the O.P                    :-            Sri D.K.Bishi, Advocate & Associates.

DATE OF HEARING :04.07.2022 DATE OF JUDGEMENT : 27.07.2022

Presented by Dr. Ramakanta Satapathy, PRESIDENT:

1. The case of the Complainant is that Manas Ranjan Kumbhar, brother of the Complainant was issued with one JEEVAN SUGAM Policy No. 594643943 for sum assured Rs. 9,80,875/- plan/Term:813:10 and proposal No. 18464 dated 30.03.2013. The Complainant is the nominee in the policy. The life assured died on 21.07.2014 at V.S.S. Medical College (VIMSAR), Burla after payment of single premium Rs. 1.00lakh. A claim was lodged before O.P. No.1. The O.Ps repudiated the claim stating that the assured concealed the suffering from sickle cell disease since childhood alleging wrong answer made in question No. 11 of the proposal form.

The policy holder got married on 04.06.2014 and on 19.07.2022 died in VIMSAR when fell ill. The O.Ps settled the claim in policy No. 593893748, 593325771 and 591732557 but repudiated the present policy. The O.Ps send the policy bond without attaching a copy of proposal form to the policy holder. As usual practice the proposal form was filled up by the Agent, took the signature. In question No.11(i) during last assured did not consult any Medical petitioner for any type of ailment requiring treatment for more than one week, the answer was ‘No’. The life assured was never admitted in any Hospital or any Nursing Home for general check up, observation, treatment or operation. The life Assured was never suffering from diabetes, tuberculosis, high/low blood pressure, cancer epilepsy, hernia, hydrocele and leprosy. The life assured was having usual good state of health.

The Compulsory requirement at the time of proposal to be attached with Agent/CLIA confidential report/Moral Hazard report and proposal was accepted on payment of single premium of Rs. 1.00 lakh

On 30.08.2016 the Complainant made a representation dated 14.01.2017 to O.P. No.2 but not been answered by the O.Ps.

The repudiation made by the O.Ps are arbitrary and came before the Commission for Redressal.

2. The O.Ps in their version stated that the claim is not maintainable for suppression of facts, fraud and furnished wrong information. The issuing branch has not been made a party. The petition is barred by doctrine of estoppels & principles of waiver. The deceased policy holder deposited a single premium of Rs. 98,087/- and the complainant is the nominee. The date of death of life assured is 21.07.2014.

The Complainant has admitted of the pertaining to the reason of death of the deceased which is due to sickle cell. The deceased was very aware of his health condition and factum of suffering from the disease. The deceased suppressed the facts. In early claim case the O.Ps carry enquiry to verify genuineness of the payment. The representation of the Complainant disposed of on 12.07.2017 and Rs. 78,470/- has been paid to the claimant on 11.01.2017.

The O.Ps are not deficient in their service and the complaint is liable to be dismissed.

3. Perused the documents filed by the Complainant and O.P.s. The following issues are framed:-
103606587.  

1. Is there any deficiency in service of the O.Ps repudiating the claim of the Complainant?
2. What relief the complainant is entitled for?

Issue No.1 Is there any deficiency in service of the O.Ps repudiating the claim of the Complainant?

          It is the admitted case of the Complainant that the life assured issued with ‘JEEVAN SUGAM’ policy No. 594643943 S.A Rs. 9,80,875/- the life assured paid Rs. 98,087/- to the O.Ps to-wards premium. The assured died in VIMSAR, Burla due to sickle cell disease on 21.07.2011 since suffering from childhood.

          The Complainant contented that Annexures D,E, & F policy No. 593893748,593325771, 591732557 have been settled by the O.Ps and paid the claim. The O.Ps in reply stated that whenever there is an early claim within the period of three years from the date of commencement of the policy the concerned issuing branch has to forward the claim application to the divisional office for settlement but in the case of non-early claim (more than the period of three years) the branch office has the authority to settle the claim instead of sending to the Divisional office. In the present case as the claim is written period of three years accordingly the claim application has been forwarded to the Division al office for necessary enquiry and proper step. Here a question arises the branch officers of the O.Ps not making proper enquiries and settling the came? While granting/Allowing the claimas in policy No. 593893748, 593325771 and 591732557 whether proper enquiries are not made?

          A branch office is an unit of the O.P. officers and action of the officers are action of life Insurance Corporation. I am not inclined to go to the questions made in proposal form and answer given by the life assured. It is nothing but a stereotype formality of the O.P. Corporation and to get business will take signatures and premium from the ‘consumer’. At the time of settlement of claim, the negativities will be agitated and repudiation will be made. One Dr. Sudhanshu Sekhar Panda, M.B.B.S, M.S (General Surgery) Medical Examiner code No. 293-600457 Modipara, Sambalpur has examined the proposer. Relying on the statement of the proposer only if medical examination is made and certificate given by the panel doctor then conclusion can be drawn that at the proposal stage medical examination is a mere formality. The entire insurance business rest on the proposal, which is the basis of an agreement. The O.Ps cannot taken the benefits from both the side. The earlier three claims are settled as it was found suitable for the corporation. The present claim could not be settled as the claim is Rs. 9,80,875/-

          The O.Ps have pleaded that the Complainant suppressed material facts, deceitfully furnished wrong information as well as declaration, committed fraud. The language used are a disrespect to a consumer. The other side of the coin is that the agent who brought the proposal whether properly enquired and filed up the form? Whether the medical examination made by the doctor in proposal form is proper? The O.Ps have not enquired at all about the life assured, received the premium of Rs. 98,087/- to enlarge its business. The O.Ps are vigilant at the time of disbursement but not care at the time of receipt. The O.Ps while repudiating the claim should have examined the three policies settled and cannot throw mud to the Branch only as they are part and parcel of the system.

          The procedures adopted by the O.Ps are not proper as a result in three policies claim allowed and this policy was repudiated. The O.Ps are deficient in their service as settling the claim/non-settling the claim they have not applied their mind properly.

          The issue is answered in favour of the Complainant.

Issue No.2What relief the complainant is entitled for?

          As discussed earlier the Complainant is entitled for the claim for the deficient service of the O.Ps. Accordingly, it is ordered:

ORDER

          The Complaint is allowed on contest. The O.Ps are directed to pay the sum assured amount of Rs. 9,80,875/- after deducting Rs. 78,470/- amount paid to the Complainant along with 7% interest P.A. from the day of death of the life assured i.e. 21.07.2017 within one month from the day of receipt of this order, failing which the amount will carry 12% interest P.A. till realisation. No order as to compensation in the circumstances of the case. The O.Ps are directed to pay Rs. 20,000/- litigation expenses within 30 days failing which the amount will carry 12% interest P.A. till realisation.

          Order pronounced in open court on this 27^th day of July 2022.

          Supply free copies to the parties.