Per:  Akatha.H.D.  

JUDGMENT

            This is the complaint filed by the complainant u/s 12 of the Consumer Protection Act – 1986 against the OP alleging deficiency in service in not settling the claim of the policy amount of Rs.7,50,000/-. Hence, prays for the relief to settle the policy claim of Rs.7,50,000/- along with compensation of Rs.50,000/- towards deficiency in service and Rs.10,000/- towards miscellaneous and litigation expenses.  

             Brief averments of the Complaint are as under;

            2.  That the complainant’s husband late Naganagouda S/o Naganagouda Patil had made a policy during his life time in the bank of the OP Company. The policy number is 140114024020. The total sum assured of the policy amount is Rs.7,50,000/- and it had a yearly premium of Rs.77,317/-. The policy was issued on 06.02.2014. The nominee in the policy is the complainant.

3.         The complainant further alleged that on 12.08.2014 the complainant husband died due to Heart Attack in his home town Yaradona. After getting the knowledge of the policy, the complainant informed about the policy to the OP Branch and they submitted the Claim Form and other necessary documents to the OP-Branch.

4.         The complainant further alleged that on 31.07.2015 a letter was sent to the complainant by OP stating that the policy amount cannot be paid because at the time of issuing the policy he was suffering from diabetics and hypertension, hence the policy claim has been rejected. 

5.         The complainant further alleged that at the time of making the policy the complainant husband was physically and mentally in good health. The OP instead of settling the claim is giving silly reasons stating that his health conditions were not good at the time of making the policy and hence filed their complaint praying for settling the policy claim amount of Rs.7,50,000/- along with compensation of Rs.50,000/- towards deficiency in service and Rs.10,000/- towards litigation expenses and miscellaneous charges as prayed above.

            6.         This Forum after admitting the complaint, the notice was issued to the OP and the said notice was served upon the OP. The OP failed to appear before the Forum on the date of appearance and hence he was placed as Exparte and the said case was posted for complainant evidence.

            7.         On the basis of the above pleadings, the following points have been framed:

POINTS

1.  Whether the complainant proves that there is deficiency in service in not settling the Life Insurance Policy claim after the death of her husband?
2. Whether the complainant proves that she is entitled for any relief sought for?

3. What order?

8.     To prove the case of the complainant, the complainant herself examined as PW1 and she got marked documents as per Ex.A.1 to Ex.A.5 and closed their side evidence. 

9.   Heard the Arguments.

10.  Our findings on the above points are as under;

Point No. 1 :   In the Affirmative,

Point No. 2 :  In the Affirmative

                  Point No. 3 :  As per final Order for the following

REASONS

11.  POINT No. 1 and 2:  As these issues are interconnected each other, hence they are taken together for common discussion to avoid repetition of facts, evidence, documents and arguments.

12.  On perusal of the pleadings, evidence coupled with the documents of complainant, it is the case of the complainant alleging deficiency in service in not settling the claim of the policy amount of Rs.7,50,000/- There is no dispute regarding that the complainant’s husband Sri.Naganagouda Patil during his life time had obtained a policy plan by name “AEGON Religare Guaranteed Growth life insurance plan”  with a policy No.140114024020 which commences from 06.02.2014 with a premium amount of Rs.77,317/- yearly and the sum assured amount is of Rs.7,50,000/-. There is also no dispute that the premium towards the policy is not paid. On 12.08.2014, the complainant husband died due to Heart Attack in Yaradona, Tq: Gangavathi, leaving the complainant as legal heir and a nominee in the policy. Being a beneficiary in the policy the complainant approved and claimed for assured amount and submitted the Claim Form and necessary documents, but till today the OP so far has not settled the claim. Hence, the complainant alleges deficiency in service.

13.       To prove the case of the complainant the PW-1 has reiterated the complainant averments in his Examination in Chief and in support of her case. She has produced the documents pertains to the policy i.e. policy bond. The said policy bond is marked as EX A2. EX A2 clearly reveals that the name of the complainant husband in the policy bond has been duly entered and the details of the policy and its yearly premium. She has further averred that after the death of her husband she submitted the claim form along with necessary documents to the OP-Branch, but the OP Company gave a letter stating that they have decided to repudiate the liability under the policy an amount of the deceased having withheld correct information regarding his health. The said claim repudiation is marked as EX A1. On perusal of EX A1, it is crystal clear that the OP has rejected the claim stating that DLA has suppressed about his ill health in the proposal form prior to the issuance of the policy and this was known to them from investigation. To prove that the DLA has suppressed that his health was not in good condition, the OP has not appeared before this Forum and has not produced any cogent evidence. Therefore, the contention which was taken by the OP in their claim repudiation letter is vague and is not justifiable one. The OP has failed to prove that the DLA assured has obtained the Insurance Policy by suppressing the material fact except putting suggestion.  

14.       As per EX A4, it is the death certificate issued by Chief Registrar of Birth and Death and EX A3 is the death claim. Hence it reveals that the complainant has died.

At the time of issuing the policy it becomes the duty of the insurance as to verify and see that the particulars are filled correctly and even the Medical Examination is also conducted by the Company itself before accepting the policy and look after all the documents and medical test and then issue the policy to the insurer but not blindly issue the policy just to reach the target of the Company in making insurance policies. When the mistake is made by the insurance agent without verifying the medical tests of the insurer, now they cannot deny the claim by saying that the DLA has not disclosed the material facts regarding his health conditions. So here the question of suppression the health condition of DLA is no way applicable as per the suggestions made by OP in their claim repudiation letter.

15.       The counsel for the complainant has relied on the citations reported in CPJ IV (2011) Page 6 Supreme Court of India, P.Vankat Naidu V/s Life Insurance Corporation of India & Anr., the LIC contended that the complainant there in was not entitled to insurance amount. At the time of taking policy, the insured has suppressed the facts relating to his illness. In paragraph – 7, the Supreme Court observed as follows:

7.  Since the respondents had come out with the case that the deceased die not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegations. However, as found by the District Forum and the State Commission, the respondents did not produce any tangible evidence to prove that the deceased had with held information about his hospitalization and treatment. Therefore, the National Commission was not justified in interfering with the concurrent findings recorded by the District Forum and the State Commission by making a wild guesswork that the deceased had suppressed the facts relation to the illness.”   

The counsel for the complainant has also relied upon the citations reported in 2006 (3) CPR 74 (NC), LIC of India V/s K.Purushothama the Important points reads as under:

“The insured cannot be said to have provided incorrect and false information regarding the insurance policy held by her husband in the facts of the case and State Commission rightly ordered for settlement of the claim of complainant with other benefits in accordance with law.

     Consumer Protection Act, 1986 – Section 21 (b) – Revision against order of State Commission directing LIC to settle the claim – claim under house wife policy – LIC refused to settle on ground of false declaration in proposal form, concealment of disease and violation of underwriting manual – National Commission finding proposal was filled by LIC agent – Medical examiner, of LIC signed it and underwriting manual was confidential – Held: insured cannot be blamed – order by State Commission is correct – Revision dismissed.”

In 2006 (2) CPR 195 Mangej Kanwar V/s Life Insurance Corporation of India & Anr., the important point reads as under:

 Repudiation of insurance claim cannot be made merely on ground of non-mentioning of chest disease in declaration form especially when death occurred due to heart attack.

Consumer Protection Act, 1986 – section 2 (1) (g) and 15 – Insurance – repudiation of claim – death of insured due to heart attack – non-mentioning of T.B. in declaration form – not amounts to suppression of material fact – no nexus between cause of death and T.B. – Repudiation of claim, not justified.”

The facts and circumstances of the case in hand and circumstances of the said citations is same and applicable in this case.

16.       Therefore, in the light of the principle laid down by the hardship in the aforesaid citations more specifically with respect to false declaration in proposal form concealments of disease that insured cannot be blamed. Therefore, it can be presumed that the complainant’s husband has not suppressed any material fact.

17.       The OP had not appeared before this Forum to answer any of the allegations made by the complainant and have not shown any reasons for repudiation of the claim of the complainant. Therefore, it can be presumed that there is deficiency in service in not settling the claim.

18.       From the arguments submitted by the learned counsel we are of the opinion that DLA has not given or suppressed information relating to the disease as alleged by the OP. Hence, the OP is not suppressed to repudiate the claim of the complainant because the onus lies on the OP-Company to establish that DLA has suppressed material facts regarding his disease. In the absence of such evidence, we found a deficiency in service on part of OP in not settling the claim. As such, the OP is liable to pay the sum assured amount to the complainant.

19.       On the contrary as per the oral evidence coupled with the documentary evidence, the complainant has proved the deficiency in service on part of OP in not settling the policy claim amount and the said fact has been clearly discloses in EX A1 to EX A3 which are the claim repudiation, policy bond and Death Claim which have been already discussed supra. Hence, in the light of above observations the complainant has proved the deficiency in service on part of OP. Hence, in the light of above observations, we constrained to hold Point No.1 and 2 in the affirmative.

20.  POINT No. 3 :-  In view of the above discussion and findings, we proceed to pass the following;

ORDER

1. The complaint filed by the complainant is hereby partly allowed.
2. The OP is directed to pay Sum Assured of the policy of Rs.7,50,000/- (Rupees seven lakh fifty thousand) along with Rs.3,000/- (Rupees three thousand) towards compensation for deficiency in service and Rs.1,500/- (Rupees one thousand five hundred) towards litigation expenses and Rs.2,000/- (Rupees two thousand) towards physical and mental agony to the complainant within one month from the date of receipt of this order, failing which 12% p.a. interest will be charged from the date of filing of the complaint, till realization.

3. Send the free copies of this order to both parties.

Dictated to the Stenographer, transcribed, typed by him, typescript, corrected by me and then pronounced in the Open Forum on 31^st day of May, 2016.

// ANNEXURE //

List of Documents Exhibited for the Complainant.

Witnesses examined for the Complainant / Respondent.