The titled complainant Sh.Harbaksh Singh being the nominee/Legal Heir/Widower of the DLI (Deceased Life Insured) Late Smt. Harinder Kaur has filed  the present complaint against the titled opposite parties (for short, the OP1-2 insurers) aggrieved hurt at their arbitrary rejection of his spouse's death-claim allegedly on flimsy considerations thus infringing his statutory consumer rights. He further pleads that he during the life-time of his spouse had purchased from the OP insurers Policy # 118764390 @ S.I. (Sum Insured) of Rs.2.0 Lac on her life. Though, most unfortunate it had been, Harinder Kaur died of her natural death on 30.09.2018 and the related death claim was duly filed with the OP insurers for its payment in terms of the related policy.

2.        However, the OP insurers have been delaying/deferring the requisite settlement/resolve of the DLI death-claim and hence the complainant has filed the present consumer complaint seeking directives to pay him Rs.2.0 Lac being the Policy's Sum Insured besides Rs.50,000/- as compensation for having caused physical/mental harassment along with any other relief as deemed fit.

3.        The complainant has produced the herein listed documents in evidence in support of her present complaint. i) Duly Sworn-in Affidavit (Ex.CW-1) along with copy of Aadhar Ex.C4; ii) Copy of the related Insurance (Ex.C1) LIC Policy; iii) Copy of the related Death Certificate (ExC2); iv) Copy of the Noor Hospital Treatment (Ex.C3) on the prescribed LIC format.          

4.       The titled opposite party insurers (OP1 & OP2), in response to the commission’s summons appeared through their counsel who filed the written reply stating therein the OP Insurers' version/pleadings and objections in order to achieve a successful prosecution of the OP defense. The OP insurers have admitted issuance of the related policy relying upon the information as provided in the associated proposal-form (22.08.2018) in which the DLI/ Proposer had stated the DLI to be in good health and had neither consulted any Medical Consultant/Hospital nor hospitalized for any medical-treatment/surgery etc. As the policy resulted into death-claim on 30.09.2018 as submitted on 01.12.2018 it revealed in Form 3816 (Certificate of Hospital Treatment) was admitted in Noor Hospital, Qadian on 08.07.2018 to 11.07.2018 due to generalized skin-infection with fever and had previously undertaken the OPD (Out Patient Department) treatment. Thus the death-claim under the policy 118764390 was repudiated on the ground of concealment of material fact regarding ill-health in the related proposal form at the time of purchase of the policy. The repudiation was duly conveyed on 31.01.2019 with liberty to appeal before the ZO Claim Review Committee, New Delhi but the complainant filed the present complaint without exhausting the available/prescribed remedy and thus need by dismissed on this count, alone. The complainant could also have approached the Insurance Ombudsman. 

5.        The OP insurers have further elaborated and emphasized the issue of concealment of prior continuing ailments by the DLI that itself warrants 'forfeiture' of the policy. Also on merits, the OP have pleaded/responded on the same grounds, as above, and have finally prayed for the dismissal of the complaint with litigation costs, in their favor; and have also  produced the duly Sworn-in Affidavit (Ex.OP1/A) of Sh. Virsa Singh Manager (Legal) along with the herein listed documents in evidence, in support of prosecution of defense;  i) Ex.OP1 - Copy of Repudiation dated 31.01.2019; ii) Ex.OP2 - Copy of the related Policy; iii) Ex.OP3 - Copy of Proposal Form; iv) Ex.OP4 - Copy of Certificate of Identity/Cremation; v) Ex.OP5 - Copy of the Policy Status Report; vi) Ex.OP6 - Copy of Accrued Policy Benefits; vii) Ex.OP7 - Copy Claimant Statement; viii) Ex.OP8- Copy Certificate Hospital Treatment; ix) Ex.OP9 - Copy of Death Certificate; x) Ex.OP10 - Copy of OPD Prescription 08.07.2018; xi) Ex.OP11 – Copy of the Complainant's Request for release of the death-claim of Policy; and xii) the written arguments in which the OP insurers have also quoted/referred to many of the subject-related senior court judgments that we are bound to respectfully peruse during the course of the present adjudication.

6.        We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some of the documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We observe that the present dispute has arisen on account of the impugned ‘repudiation' of insurance death-claim pertaining to the insured DLA spouse (Late Smt.Harinder Kaur) of the complainant, by the OP1,2 insurers who allege non-disclosure of the prior-existing/continuing Generalized Skin-infection ailments by the DLI at the time of insurance.

7.        We have minutely examined all the documents produced in evidence by the complainant and also by the OP insurers as produced and as collected by them during the course of their investigations and find that the insured's health status as well as all clinical and medical-examination reports were in the notice, knowledge and possession of the OP insurers at the time of insurance/policy-selling through their agent Nishan Singh Bajwa with Agency Code 01737136 6337047 and thus they are presently stopped to cause repudiation to the death-claim, in question. Moreover, the ailments like Skin/Fever etc are quite common and as these present no bar to policy-selling so these should also pose no bar to claim-settlements etc. We observe the OP insurers' present role fully marred by an employ of unfair-practices and unscrupulous exploitation of the innocent consumer and that amounts to an open display of deficiency in services at its full volume. We disapprove the OP insurers' acts of omissions as well as that of commissions, in totality. And, of course we do not concur with the logic of the herein impugned 'repudiation' of the death-claim and are inclined to examine the validity and legality of the same in the back-drop of the preceding and also the succeeding acts and events in the light of the facts on records and current law on the consumer proposition’s subject matter, in issue. We observe that the impugned repudiation of the insurance-claim has been the result of the OP insurers' resolve in their endeavor to somehow repudiate the same to cause and unfair and unjust loss to the complainant. 

8.       Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the intentional 'repudiation' by the OP insurers as ‘deficiency in service' and an employ of 'unfair-practice' and thus ORDER the OP insurers to pay the death-claim, in full, to the herein complainant, in terms of the policy with interest @ 6% PA from the date of complaint till actually paid, in full, besides to pay Rs.25,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the aggregated amount shall attract an additional interest @ 3 % PA from the date of the orders till actually paid.

9.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

10.      Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.                                                                

                                                          (Naveen Puri)

                                                                President.

ANNOUNCED:                                  (R.S.Sukhija)

OCT. 26, 2022.                                            Member.

YP.