Present (1) Nisha Nath Ojha,
District & Sessions Judge (Retd.) President
(2) Smt. Karishma Mandal,
Member
(3) Anil Kumar Singh
Member
Date of Order : 30.06.2018
Nisha Nath Ojha
- In the instant case the Complainant has sought for following reliefs against the Opposite party:-
- To direct the opposite parties to quash/set aside the repudiation order dated 18.10.2011 ( annexure – 8) and part of letter dated 21.02.2012 ( annexure – 12) by which the repudiation of claim for death benefit made through repudiation order dated 18.10.2011 ( annexure – 8) has been confirmed.
- To direct the opposite parties to make payment of the insured amount/assured amount of Rs. 10,00,000/- minus Rs. 2,26,713/- already paid to the complainant on 21.02.2012.
- To direct the opposite parties to pay Rs. 1,00,000/- for harassment and mental agony to the complainant.
- To direct the opposite parties to pay Rs. 40,000/- as litigation cost.
- The facts of this case lies in a narrow compass which is as follows:-
The complainant has asserted that her mother Late Smt. Sadhana Sinha was the principal of the Army School, Danapur Cantonment, Patna. The opposite parties after medical examination has accepted the consideration amount i.e. single premium of Rs. 2,00,000/- on 28.01.2009 from mother of the complainant and her life was assured for the period of 5 (five) years for Rs. 10,00,000/- vide annexure – 1 and 2. In the insurance policy the complainant was made nominee in the event of death of policy holder.
The further case of the complainant that mother of the complainant i.e. policy holder died natural death on 25.01.2011 at her residence at Danapur Cantonment, Patna. That after death of mother of the complainant during the continuance of the policy the complainant submitted necessary documents to opposite party no. 2 intimating about the death of her mother and for payment of assured amount as will appear from annexure – 2, 3 and 4.
It is further case of the complainant that the opposite parties through opposite party no. 2 acknowledge receipt of death claim by complainant vide annexure – 6 and as per demand of the opposite parties the claimant has also submitted medical prescription, record of her mother which she received during period April 2006 to November 2008. Opposite parties instead of paying the insured amount have rejected the claim of the complainant vide rejection order dated 18.10.2011 vide annexure – 8 on the ground of non – discloser of diagnosis of Ca of breast in April 2006 and subsequently treatment April 2006 to November 2008.
The grievance of the complainant is that the opposite parties had insured the life of her mother after thorough medical examination and all the medical prescription /records were submitted to opposite parties on demand for settling the claim but instead of selling the claim, it was rejected in arbitrating manner.
The complainant has further stated that the mother of the complainant was declared fit in 2008 whereasthe policy is taken in 2009 when she was totally medically fit and she has died a natural death on 25.01.2011 due to Cardio Respiratory Arrest as will appear from annexure – 3.
After the rejection of the claim of the complainant vide annexure – 8 the complainant filed a representation to opposite party no. 5, claim review committee, mentioning all the relevant facts as will appear from annexure – 9.
The grievance of the complainant is that despite paying the entire assured amount of Rs. 10,00,000/-, the complainant was asked to submit certain details and documents which was done by the complainant as will appear from annexure – 11 and the claim review committee vide annexure – 12 has affirm the rejection of the opposite parties (annexure – 8) and has issued annexure – 12 whereby and where under it has decided to admit the said claim for account value amount of Rs. 2,26,713/- under the policy and the aforesaid amount was credited in account of complainant vide NEFT.
The complainant has challenged the aforesaid order of the opposite parties containing in annexure – 8 and 12 on the ground that the aforesaid order is arbitrary as her mother had not misrepresented or suppressed any fact relating to her medical record etc. and her consideration amount was accepted after thorough medical examination.
On behalf of opposite parties a written statement has been filed. in Para – 12 of which the following facts have been asserted, “that the life assured died within a period of two years from the date of risk under the policy due to ‘Breast Cancer’. After getting death intimation from the complainant, the opposite parties started investigation in the matter under the rights conferred upon the insurance companies under Section 45 of the insurance act, 1938 (quoted by the complainant in paragraph – 6 at page – 10 of the complaint petition) and found that the life assured was suffering from breast cancer and had got treatment for the same during the period 2006-2008. The wound had been operated and the life assured had been discharged as fit by the Army Hospital. This fact which was well within the knowledge of the life assured, had been suppressed by her in the proposal form at the time of proposal. It had also been found that the complainant was an old patient of hypertension and diabetes mellitus and was under treatment at the time of proposal. This fact had also been suppressed by the proposer in the proposal form.”
In Para – 14 of written statement it has been asserted by opposite parties that as per annexure – 3 the life assured has died due to Carcinoma Breast ( B/L) opted with metastasis and as such the claim of the complainant has rightly been rejected vide annexure – 8.
On behalf of complainant reply to written statement has been filed stating therein that after thorough medical examination and due consideration of all aspects of the matter, the opposite party no. 5 accepted the consideration amount and as such the policy was issued.
It is the case of the complainant that mother of the complainant was completely cured from Carcinoma Breast after her treatment in Army Hospital Research and referral, Delhi Cantonment from April 2006 to November 2008.
Heard the learned counsel for the parties.
The insurance policy is admitted. It is also admitted by the parties that the insured died during continuance of the policy. It has been asserted by the complainant that her mother was found fit and free from Carcinoma as far back in 2008 and after 1 (one) year her life was insured. It is also not denied by the opposite parties that the complainant’s mother was insured without medical examination on their part.
In our opinion when the complainant’s mother was examined by the Doctor of the opposite parties prior to accepting the premium amount. Hence, the complainant cannot be punished for any later development because the very fact that at the time of issuing policy certificate the mother of the complainant was medically fit. Even from the careful perusal of annexure – 3 it is clear that the complainant’s mother has died due to Cardio Respiratory Arrest besides Carcinoma Breast (B/L) OPTD with metastasis.
It goes without saying that after admitting the complainant’s mother to the insurance after proper medical examination and thereafter rejecting the claim of the complainant after later development the opposite parties have committed deficiency in service.
Therefore we direct the opposite parties to pay the rest insured amount to the complainant after adjusting the already paid amount of Rs. 2,26,713/- i.e. Rs. 10,00,000 - Rs. 2,26,713 = Rs. 7,73,287/- ( Rs. Seven Lac Seventy Three Thousand Two Hundred Eighty Seven only ) within the period of two months from the date of receipt of this order or certified copy of this order failing which opposite parties will pay 10% interest on the above said amount ofRs. 7,73,287/- ( Rs. Seven Lac Seventy Three Thousand Two Hundred Eighty Seven only ) till its final payment.
Opposite parties are further directed to pay Rs. 50,000/- ( Rs. Fifty Thousand only ) to the complainant by way of compensation and litigation costs within the period of two months.
Accordingly this complaint stands allowed to the extent referred above.
Member Member(f) President
