This complainant case has been filed by the Complainant alleging claim of insurance policies. The Complainant has prayed for payment of claimed amount Rs. 6,55,000/- (Six lakh fifty five thousand only) including Principal amount Rs.5,25,000/-, Compensation Rs. 1,00,000/- and Cost of Litigation Rs. 30,000/-.
The case of the complainant in brief as made out in the format of complaint petition, synopsis thereof and the documents annexed therewith is as follows:-
The Complainant’s husband purchased three life insurance policy No. 0117443203, 0124562038 and 0066775691 in the benefits Bajaj Allianz New Unit gain, Fortune Plus and Capital gain unit respectively on 08.10.2009, 28.03.2009 and 14.09.2007, on completion of all formalities including medical examination, on payment of premium of Rs. 20,000/-, Rs.35,000/- and Rs.15,000/- for sum assured of Rs. 2,00,000/- (Two lakh), Rs.1,75,000/- (One lakh seventy five thousand) and Rs.1,50,000/- (One lakh fifty thousand) respectively. Unfortunately, the complainant husband Samuel Purty died on 11.11.2010. On submission of the death claim, the Opposite parties have denied the claim of the complainant saying that the policy holder has concealed the declaration of good health through the opposite party company has themselves conducted medical examination of the deceased life insurance through their own system. The Complainant old case no. 227/2011 was filed on 19.12.2011 and was admitted on 04.01.2012 at Ranchi Consumer Forum.
The Opposite Parties appeared on 03.04.12 and filed written statements on 25.08.2012. Further The Complainant and Opposite parties submitted their evidence on 13.02.2013 and 05.07.2013. In continuation of this case at Ranchi, the Opposite Parties and Complainant filed their argument on 19.11.2013 and 07.07.2014. Further Opposite parties filed additional evidence on 27.08.2014. On 29th July 2016, the learned counsels for both the sides were presented and during course of argument, it was decided to transfer the case under jurisdiction of Khunti district. Accordingly, in view of the memo no.354 dated 24.11.2015 of Hon’ble State Commission, this case was transferred to Khunti Consumer Forum on 13.09.2016. Since then hearing of this case is continued.
Case of O.Ps in brief as made out in the written version is as follows: The statement and evidence submitted by opposite parties dated 05.07.2013, 19.11.2013 & 27.08.2014 are similar in nature in reference to the arguments made in order of high court judgments coated by the opposite parties.
A Repudiation of death claim under policy number. 66775691 on the life of Late Mr. Samuel Purti was submitted by the complainant to reexamine the case before Opposite party. But based on the facts of the case the opposite party regret that Claims Review Committee has not found possible to reverse the earlier decision of repudiation.
The Opposite Party submitted written notes of arguments stating that a person Samuel Purti (now deceased) submitted three proposal Forms in the office of the Bajaj Life Insurance Company Ltd. (hereinafter referred as ‘the company’) for insurance on his own life. The proposal Forms were filled up and signed by the life assured on 08.01.2009, 28.03.2009 &14.09.2007 for sum assured Rs.2,00,000, Rs. 1,75,000/- & Rs. 1,50,000/- respectively. In the proposal Form, the life proposed declared his date of birth 23.08.1966. The complainant is the widow of the Late Samuel Purti and was made nominee in all the three policies. The life assured died on 11.11.2010, the complainant lodge her claim with the opposite party and the opposite party after conducting investigation repudiated the claim of the complainant on the ground that the life assured while filling up the revival form in respect of policy no.0066775691 suppressed the material facts regarding his health and the other two policies were lying in lapsed condition. In clause-14 of all the three proposal Forms the life proposed was required to give answer to certain question relating to his personal health. The life assured died on 11.11.2010 and in respect of policy No.0066775691, the policy had been revived on 24.09.2010 on the basis of facts as mentioned in the Declaration of Good health submitted by the life assured. However on receiving the claim intimation for the above said policy, the various investigation and the various medical certificates confirmed that the deceased life assured was under hospitalization/medical investigation/treatment during July 2010 for different hepatic disorder, splenomegaly and ascites with known case of alcoholic liver disease. These facts were known to the life assured prior to the revival of the policy and the same was deliberately concealed in the Declaration of good health submitted on 24.09.2010 for reviving the policy and in respect of two other policies it is submitted that the both policies were lying in lapsed condition since the month of September, 2010. The company appointed Zenith Surveillance an investigating agency to investigate into the cause leading to the claims under the policies as also to known the genuineity of the claims all the three policies. The Zenith Surveillance has submitted its Claim Report. In course of investigation, the investigating officer, visited various Medical Shops, Hospitals, consulted various persons and authorities and collected several medical documents. From the detailed report it will appear that the investigating officer consulted Dr. H.D. Sharan (MD), Gurunanak Hospital, Ranchi, who confirmed that LA was admitted in the hospital since 28.07.2010 to 03.08.2010 and was suffering from Alcoholic Liver Disease and Ascites. The opposite party after considering the entire fact and circumstance of the case decided to repudiate the claim on the ground of suppression of material facts relating to health in the proposal form with respect of policy no. 0066775691. Whereas the other two policies were lying in lapsed condition. According to the company, these facts were known to the life proposed from before, however, he knowingly did not disclose those facts in the proposal Form. The claimant was informed vide letter dated 10.08.2011 that her appeal had been re-examined by the claims Review Committee and after due consideration it was found that the decision of repudiation could not be reversed. The alcoholic lever disease is a serious and Fatal ailment. The opposite party, i.e, the insurer, has rightly repudiated the claim in accordance with the provisions of section 45 of the Insurance Act,1938 as interpreted by the Hon’ble Supreme Court in various decisions and hence no interference is required by the Learned Forum in the instant case. The instant case has been filled without any ground and even the repudiation has not been challenged by the complainant and hence the present case is fit to be dismissed with cost to the opposite party. The complaint petition is also not maintainable as the complainant has moved before this Learned Forum without availing the remedy of appeal as available to the complainant. At this stage the complaint case is fit to be dismissed on the ground alone.
In this case complainant filed following documents in support of her claim:-
- Premium receipt for the policy no. 0124562038 for Rs.1,75,000/-. Premium amount Rs.35,000/-.
- Premium receipt for the policy no. 0066775691 for Rs.1,50,000/-. Premium amount Rs.15,000/-.
- Premium receipt for the policy no. 0117443203 for Rs.2,00,000/-. Premium amount Rs.20,000/-.
- Policy of Policy No. 0117443203 issued by Bajaj Allianz Life Insurance Company Ltd.
- Policy of Policy No. 0124562038 issued by Bajaj Allianz Life Insurance Company in favor of Samuel Purty.
- Policy deposit receipt for the Policy No. 0066775691.
- Receipt of Rs.35,000 against Policy No. 0124562038.
- Medical Certificate issued by Dr. Manjhi, Civil Assistant Surgeon, Referral Hospital, Torpa.
- Death certificate of Samuel Purty issued by Government of Jharkhand, Department of Planning and Development.
- Repudiation of death claim under Policy no. 0066775691 on the life of Late Mr. Samuel Purty issued by Bajaj Allianz Life Insurance Company Ltd.
Besides the above documentary evidence the complainant has also produced herself for evidence in the court and she has filled her evidence on oath in support of her case.
Opposite party have also produced following documents in support of her case:-
- Copy of three proposal forms of Policy No. as Ext – 1,2 & 3 respectively
- Copy of report of Zenith Surveillance along with discharge summery of Guru Nanak hospital as Ext- 4.
- Copy of letter dated 10/08/2018 as Ext -5.
- Copy of revival form in respect to Policy No. 0066775691 as Ext-6.
Besides above documentary Exhibits opposite party has produced two witnesses in support of his case. They are – 1. Rakesh Kumar Srivastava (O.P. witness No.-1) and 2. Om Prakash upadhyay (O.P. witness no.2)
From perusal of record and documents submitted by the parties it is almost in settled position that deceased Samuel Purty has purchased 3 policies which are:-
- 0117443203 - Rs 2,00,000/-
- 0124562038 - Rs 1,75,000/-
- 0066775691 - Rs 1,50,000/-
From the Opposite Party Bajaj Allianz Life Insurance Company Limited in the benefits Bajaj Allianz New Unit Gain, Fortune Plus & Capital Gain Units respectively on 08/01/2009, 28/03/2009 and 14/09/2007 on completion of all formalities including medical examination on the payment of premium Rs.20,000/-, Rs.35,000/- and 15,000/- respectively.
It is admitted position that the insured Samuel Purty died on 11/11/2010 due to illness. After the death of the insured his wife Bipai Purty approached the Insurance Company for death claim of her husband under the above mentioned polices but the claims made under above polices were repudiated by the Insurance company on the ground that at the time of death Policy No. 0117443203 & 0124562038 were lying in lapsed condition and Policy No. 0066775691 was repudiated on the grounds of suppression of material facts relating to health.
Aggrieved by the decision of Insurance Company wife of deceased, Bipai purty approached this Forum for direction to the opposite party (Insurance Company) to make payment of death benefits of the deceased husband against the policies cited above with interest and cost of litigation and compensation for harassment.
Now the question before the Forum is to decide weather-
- The case of complainant is barred by limitation?
- The case of complainant is not maintainable because she has not approached the appellate authority of the complainant?
- The policy no.0117443203 & 0124562038 were lying in lapsed condition at the time of death of the deceased?
- The deceased at the time of revival of the policy no. 0066775691, supraised material facts and relating to health ?
- The complainant is entitled to get relief claim or not?
F I N D I N G S
Issue no.1- Barred by limitations or not
Though the O.P has taken the plea that the case of complainant is barred by limitation, yet neither any oral nor any documentary has been bought by the O.P in support of its claim. Further records speaks that wife of deceases Bipai Purty approached the Insurance Company for the claim without any inordinate delay. Hence this issue is decided negatively.
Issue no.2- Complain maintainable or not
One of the grounds taken by the Insurance Company is that the present case of the complainant is not maintainable before the forum as she has not approached the appellate authority of the Insurance Company. But Ext- 5 filed by the Insurance Company itself make it clear that appeal of the complainant was re-examined by the claim review committee. Hence the above plea of the O.P is not acceptable at all. Accordingly this issue is decided negatively.
Issue no.3- Policy No. 0117443203 and 0124562038 lapsed or not at the time of death of the deceased
There is no dispute on the point that above two policies were purchased by deceased Samuel Purty on 08/01/2009 & 28/03/2009 respectively. The date of death of Samuel purty i.e. 11/11/2010 is also not in dispute.
O.P in his show-cause, in evidence on oath, as well as in written argument has clearly inserted that at the time of the life assured the above mentioned polices were lying in lapsed condition.
From perusal of statement given by Bipai Purty on oath dated 12/02/2013, we find that she had not denied the above contention of the opposite parties. She is silent at the point that the Policy no. 0117443203 & 124562038 were lying in lapsed condition.
Further from the perusal of the written argument filed by the complainant Bipai Purty dated 07/07/2014, I find that again in her written argument Bipai Purty had not denied the statement of the OP that above mentioned two policies were lying in lapsed condition.
Further from the perusal of the document filed by the complainant Bipai Purty with her statement on oath we find that no receipt have been filed by her to show that second premium for Policy no 0117443203 & 0124562038 was ever paid. Though from the perusal of the Policy documents it transfires that these policies were annually paid.
In view of the discussion made here in above, I came to the conclusion that the policy no. 0117443203 & 0124562038 were not in continuation at the time of death of Samuel Purty, hence this issue is decided against the claimant Bipai Purty.
Issue no.4 – Weather material facts relating to health suppressed by the life assured at the time of revival of Policy no-066775691
From perusal of show cause, statement of witness no- 1&2 as well as written argument filed by the opposite party, I find that the opposite party has denied the claim of the claimant against the Policy no. 0066775691 on the ground that at the time of the revival of the said Policy i.e., on 24/09/2010 deceased Samuel Purty had conceived material facts regarding his good health.
In para 7 of the statement given by the opposite party’s witness no-1 Rakesh Kumar Shrivastava, it has been deposed that the Policy no 0066775691 was revived on 24/09/2010 on the basis of facts mentioned in the declaration of good health submitted by the life assured. However on reviving the claim for the said policy, the various investigation and various medical certificates confirmed that deceased (life assured) was under hospitalization, medical investigation, treatment since July 2010 for different hepatic disorder, splenomegaly and Ascites with known case of alcoholic liver disease. These facts were known to the life assured prior to the revival of the policy and the same was deliberately concealed in the declaration of good health submitted on 24.09.2010 for reviving the policy.
Further it has been deposed that the company appointed Zenith Surveillance, an investigating agency to investigate. The report of the said investigating agency has been filed by the opposite party as Ext. 4 series. From perusal of the discharge summery of Guru Nanak Hospital and Research Center submitted by the said agency, it appears that Samuel Purty was admitted in the said hospital from 28/07/2010 to 03/08/2010. Further from perusal of the other documents of Ext. 4 series it appears that during the aforesaid period Samuel Purty was getting treated for liver diseases.
From perusal of the record we find that though the opposite party has not filed any specific document that during the revival of Policy no. 0066775691 any separate declaration made by the claimant Samuel Purty regarding his good health. But Ext. 6 filed by the opposite party shows that on 24/09/2010 in revival form in clause 1 (a) a specific question was asked that “have you suffered from any illness/disease requiring treatment for a weak or more” to which the deceased answered negatively.
From perusal of the written argument filed by the complainant on 07/07/2014 we find that the facts regarding the illness and treatment of deceased Samuel Purty as alleged by the O.P has not been denied. Further from the documents submitted by the Claimant Bipai Purty in her evidence on oath, we find that she has herself filed the certificate dated 09/11/2010 of Doctor Manjhi showing that deceased Samuel Purty was suffering from Infective Hepatitis leading to Jaundice and was under his treatment and bed rest from 01/09/2010 to 09/11/2010.
Ext. 6 is revival form of Policy no.066775691 and during the revival of the said policy i.e., on 24/09/2010 the decease Samuel Purty has denied from suffering from any illness/disease requiring treatment for a week or more.
From the evidence and show cause filed by the Claimant Bipai Purty, I find that it is her case that at the time of accepting the proposal and issuing the Policy No. 0066775691 the life assured was of good health and thorough medical examination was done. Therefore the insurance company cannot deny claim of the said policy on the ground of subsequent illness.
Here it is worth mentioning that policy no. 0066775691 was not in continuance since it was purchased on 14/09/2007 rather it was lapsed and was revived on 24/09/2010. Therefore the declaration of good health and medical examination of the deceased made at the time of issuance of policy no.0066775691 was of no use. Rather the vital fact to look into is as at the time of revival of said policy any fact regarding health of deceased was concealed or not.
From the discussion made herein above and from perusal the documents filed by the parties, I find that, there is no dispute on the point that just before the revival and even during the revival of the said policy, the deceased was getting medical treatment and was also hospitalized. But at the time of the revival of the said policy, this fact was not disclosed by the deceased Samuel Purty, rather concealed by denying that he was not getting any treatment.
It is well established principle that if a policy is taken on revive by suppressing preexisting material fact like preexisting disease then the insurance is not liable to pay the amount insured under the policy.
The Opposite parties has relied upon two judgments of National Consumer Disputes Redressal Commission, New Delhi.
- HDFC Standard life insurance company limited –Versus- Smt. Jaya Laxmi
- LIC life insurance corporation of India limited –Versus- Smt. M. Bhavani
In the first case the order of District Consumer Forum as well as State Consumer Dispute Redressal Commission was set aside and it was ordered “We agree that in view of the two documents which are on files the Insure suppressed the facts that he consumed alcohol in the relevant issuance form and also there is credible medical evidence of his being an alcoholic. There are numerous judgments of apex court and also of this commission that since the insurance policy is a contract entered between the two parties in atmost good faith, any violation of its terms and conditions by the insuree entitles an insurance company to repudiate the claim”
In the second case also it has been observed that if any material fact like preexisting decease is intentionally suppressed than the Insurance Company is not liable to pay the amount insured under the policy.
From the discussion made here in above we came to the conclusion that at the time of revival of the Policy no.0066775691 the material facts regarding pre existing health condition was deliberately suppressed by deceased Samuel Purty. Hence this issue is decided against the Claimant Bipai purty.
Issue no. 5 - Weather Claimant entitled to get relief claimed or not?
In view of the decision arrived at while deciding the issue no.3 and 4, we hereby conclude and decide that claimant is not entitled to get any relief as claimed by her. Hence this issue decided against the Claimant Bipai Purty. Accordingly, it is therefore
O R D E R E D
That Complainant Case no. 02/2016 is dismissed on context without any cost.
