DATE OF FILING: 26.03.2013.
DATE OF DISPOSAL: 25.05.2017
Dr. N.Tuna Sahu, Presiding Member:
The complainant has filed this consumer dispute under section 12 of the Consumer Protection Act, 1986 alleging deficiency in insurance service against the Opposite Parties ( in short the O.Ps) and for redressal of his grievances before this Forum.
2. The brief fact of the case of the complainant is that his mother deceased Hema Pradhan procured a policy from the O.P. Bajaj Allianz insurance company in the name and style Alliance Invest Gain Economy. As per the complaint, at the time of obtaining the policy, the deceased policy holder submitted all required documents in respect of her age, income, residential proof etc as desired by the O.Ps and after verification of the aforesaid documents the O.Ps issued a policy bearing No.0193680197 in favour of the deceased policy holder. The deceased policy holder also paid a sum of Rs.36,370/- towards annual regular premium for a basic sum assured of Rs.5,00,000/- under the policy and the term of the policy was for 15 years. The present complainant was kept as nominee of the said policy. While the policy was in force, the policy holder died on 16.1.2011 due to ‘Cerebral Malaria’. It is also stated that the nominee of policy intimated the death of deceased policy holder by obtaining death certificate from U.G.P.H.C. Khallikote and claimed assured sum under the policy along with enclosing all relevant documents but the O.P. rejected the claim without going through the documents the reason best know to them. The complainant issued a legal notice to the Claims Review Committee to consider the genuine claim of the complainant but the Review Committee again rejected the claim without any reason thereof. When the O.Ps did not give any heed to the grievances of the complainant, he filed this complaint with a prayer to direct the O.Ps to pay an assured sum of Rs.5,00,000/- along with accrued bonus and to pay Rs.1,00,000/- towards damage, mental agony and to grant such other reliefs as deems fit in the best interest of justice.
3. Notice issued against all the O.Ps. The O.Ps appeared through their learned counsel Mr. Sriharsh Prasad Das, Advocate and Associates on 26.8.2013 and filed written version on 5.5.2014 and also filed his written argument on 2.6.2014. In the written version/argument it is averred that the allegations in the complaint are all not true and correct as such he is put to strict proof of the same and the allegations which are not specifically admitted deemed to be denied in toto. It is admitted that the mother of the complainant was a policy holder who had deposited a sum of Rs. 36,370/- towards premium for a policy bearing No. 0193680197 with O.Ps Company for an assured sum of Rs.5,00,000/- under the policy. It is also contended that the mother of the complainant was suffering from some incurable disease and it was suppressed by her and other family members during obtaining of the said policy. Just after two months of the commencement of the policy in question the complainant submitted all relevant medical treatment papers claiming the death benefit of said policy but on scrutiny of the medical papers submitted by the complainant it was ascertained that the mother of the complainant was suffering from some chronic incurable disease prior to the commencement of the said policy. It is also contended that due to suppression of the fact of chronic incurable disease prior to commencement of policy and understatement of the age by 15 years along with submitting the fake documents for the death claim, the company held that the nominee of the policy holder is not entitled to get the sum assured. It is further stated that the complainant being aggrieved with the letter of repudiation referred to the claim Review Committee and the Claims Review Committee also confirmed the previous order of repudiation. Thereafter, the complainant has come with this case with ill intention to harass the O.Ps. It is also stated the complainant has violated the policy conditions submitting fake documents and was suffering from incurable chronic disease. Due to suppression of material fact regarding her health and by understatement of age by 15 years and by submitting fake documents she was procured the policy, so the complainant is not entitled to the claim amount under the policy. Hence, the O.Ps prayed to dismiss the case in the best interests of justice.
4. On the date of hearing of the consumer dispute the learned counsel for the complainant as well as for the O.Ps are present and submitted orally before this Forum. During the course of hearing we have also gone through the complaint, written argument of the parties and also verified the vital documents placed on the case record. During the course of argument the learned counsel for the complainant contended that the deceased policy holder obtained a policy on payment of Rs.36,370/- towards premium for an assured sum of Rs.5,00,000/-. The present complainant was nominated as nominee of the said policy by the deceased life assured. During the policy was in force, the mother of the complainant died on 16.1.2011 due to ‘Cerebral Malaria’. Accordingly, the U.G.P.H.C. Khallikote issued the death certificate and the complainant also submitted the claim form along with death certificate and together documents to get the insurance claim. However, the O.Ps repudiated the claim of the complainant on the ground of suppression of material fact relating to the health of the deceased. The complainant redressed his grievance before Claim Review Committee but the O.Ps did not consider the claim of the complainant and harassed the complainant. So the complainant filed this case with a prayer to direct he O.Ps to pay Rs.5,00,000/- along with other benefits and Rs.1,00,000/- towards compensation towards damage, mental agony and to grant other relief as deem fit in the best interest of justice.
Per contra, the learned counsel for the O.Ps contended that admittedly the mother of the complainant deceased life assured Hema Pradhan had made a policy bearing No.0193680197 for a term of 15 years on payment of Rs.36,370/- towards premium for a sum assured of Rs.5,00,000/- and the policy was commenced from the date 11.12.2010. However, the deceased policy holder was died on 16.1.2011 due to “Cerebral Malaria”. It is also contended that the complainant also submitted the death certificate of deceased policy holder to substantiate his claim but the O.Ps repudiated the claim on the ground of suppression of material facts relating to age and disease. The complainant’s deceased mother did it deliberately to obtain policy and to get the insurance benefit. Since the complainant’s mother obtained the policy by suppressing the material facts relating to her age by understatement of 15 years by submitting fake documents and by suppressing incurable diseases, the O.Ps repudiated the claim of the complainant which is just and proper. Therefore there is no deficiency in service on the part of the O.Ps hence the O.Ps prayed to dismiss the case in the best interest of justice.
5. We have heard the above submissions made by the learned counsels for both sides and have also thoughtfully considered the contentions made by parties to this dispute. We have also perused the pleadings and verified the material documents placed on the case record. Considering the above submission of the parties, the Forum is to decide whether the deceased life assured suppressed material facts relating to her age and pre-existing incurable disease at the time of taking the policy?
6. We perused the vital documents like policy bond, premium receipt and death certificate, voter card submitted by the complainant and the repudiation letter and investigation report of the O.Ps placed on the case record. On perusal of documents, it reveals that the deceased policy holder took the policy on payment of Rs.36,370/- towards policy premium for an assured sum of Rs.5,00,000/- which was commenced on 11.12.2010. It is also not in dispute that the present complainant is the nominee of the aforesaid policy as nominated by the deceased life assured. As per Death Certificate placed on case record issued by Registrar of Births and Deaths and Medical Officer-In-charge, U.G.P.H.C. Khallikote (Gm), the deceased policy holder Hema Pradhan was died on 16.1.2011 i.e. just after one month and 5 days of commencement of policy in dispute due to high fever namely cerebral malaria. According to policy documents, the deceased life assured obtained the policy from the O.Ps by submitting copy of voter card as her proof of age and identity. The policy document discloses that her date of birth is 01.01.1955 and at the time of procuring the said policy she was a woman of 55 years old and accordingly the age of the deceased life assured was admitted by the O.Ps. The medical attendant certificate collected from concerned hospital certified by the Medical Officer, CHC-II, Balugaon, Dist-Khurda submitted by the O.Ps placed on the case record discloses that the primary cause of death of deceased life assured was due to high fever like cerebral malaria. However, it is contended by the O.Ps that the mother of the complainant was suppressed her age by 15 years and she was suffering from chronic incurable disease prior to taking of the policy in dispute. The O.Ps in their letter dated 16.7.2012 repudiated the claim on the ground of understatement of age by 15 years by the deceased life assured and on the contrary on perusal of case record we found that the deceased policy holder was submitted a copy of voter card with respect to her age proof which is beyond dispute or doubt. It is also a fact that the complainant’s claim was rejected by the Claim Review Committee on the ground of suppression of age by 15 years and submission of fake documents of age proof during the issuance of insurance policy. In that view of the case, in our considered opinion we would like say that there is nothing placed on the case record to prove that the deceased life assured was suppressed her age and incurable disease at the time of taking the insurance policy in dispute since the O.Ps miserably failed to substantiate the claim of suppression of material facts by the deceased life assured relating to her age and previous disease. We have also carefully gone through the written and oral arguments of the O.Ps but we do not find there is any substantial case has been pleaded in defence in discarding the claim of the complainant. We also find that the investigation carried out by the investigator did not inspire confidence and the investigation did not disclose the suppression of pre-existing incurable disease. The report of the investigator discloses that the deceased life assured was died due to cerebral malaria which is not an incurable pre-existing disease and the investigator’s report strengthens by corroborating the case of the complainant that the deceased was died due cerebral malaria. We would, therefore, like to view that it was wrong to say that the deceased life assured has suppressed incurable disease and understated her age by 15 years during taking of the policy in dispute. In our considered view, the O.P. insurance company is liable for deficiency in insurance service due to arbitrarily repudiating the claim of the complainant. The O.P. insurance company failed to produce any reliable and convincing documentary evidence to prove that the deceased was suffering from incurable disease and has understated her age by 15 years. It is also corroborated from the case record that there was no understatement of age by the deceased life assured since there is nothing placed on the case record to hold otherwise.
7. With regard to the claim of the complainant, we would like to say that the as per the policy conditions the nominee complainant is entitled for Rs.5,00,000/- as minimum death benefit under the aforesaid policy and on maturity he is entitled to basic sum assured plus accrued bonus. In the present case, the complainant is entitled only for minimum death benefit and not entitled for any accrued bonus under the policy since this is not a case of maturity of policy. Hence, we are not hesitate to direct the O.Ps to pay Rs.5,00,000/- towards the insurance claim of the nominee complainant under the aforesaid policy. In this case, the nominee complainant has also prayed for payment of Rs.1,00,000/- towards damage, mentally agony and to grant other relief as the Hon’ble Forum deems fit in the best interest of the justice. On this point, we would like to say that the complainant has not submitted any cogent and convincing documentary evidence to prove that he has incurred a loss of Rs.1,00,000/- towards damage and mental agony so we are not inclined to accept the claim of the complainant and not inclined to award any compensation but convinced to direct the O.Ps to pay Rs.3,000/- towards cost of litigation since the nominee complainant has hired the services of an advocate to proceed with his case. Since the O.Ps without any substance has wrongly and arbitrarily repudiated the insurance claim of the nominee complainant, the nominee complainant is entitled for interest on the claim amount and the same is quantified at the rate of 6% per annum from the date of filing of this complaint petition in this Forum which is also liable to be paid by the O.Ps. In the light of the aforesaid discussion and considering the fact and circumstances of the case, we partially allowed the claim of the complainant against all O.Ps.
8. Resultantly, the O.Ps who jointly and severally liable are directed to pay Rs.5,00,000/- to the nominee complainant towards minimum death benefit under the aforesaid policy along with interest @6% per annum from the date of filing of this complaint in this Forum i.e. from 26.3.2013 till on the date of actual payment. The O.Ps are also directed to pay Rs.3,000/- to the nominee complainant towards cost of litigation. The above orders shall be complied by the O.Ps within two months from the date of receipt of the order, failing which the complainant is at liberty to recover the same under Section 25/27 of the Consumer Protection Act, 1986. The consumer dispute of the complainant is disposed of accordingly.
9. The order is pronounced on this 25th day of May 2017 under the signature and seal of this Forum. The office is directed to furnish copy of this order to the parties free of cost as per rules. A copy of the order be sent to the server of
