(Passed this on 07th January, 2017)
Shri. S.P. Muley, President –
1. By this complaint the complainant has alleged that the Opposite Parties by repudiating the insurance claim have made deficiency in their service.
2. The OPs are Bajaj Allianz Life Insurance Company Ltd and its Head and Branch offices. The complainant is the widow of the deceased insured, Kailash Kothari. The deceased had taken ¨Unit Gain Plus¨ policy from the OPs on 23/6/2006 and thereby the OPs assured his life risk for a sum of Rs. 75,000/-. The complainant was a nominee under the policy. Thereafter the deceased took another policy from the OPs to cover his risk for the period from 7/3/2007 to 7/3/2027 for a sum assured Rs.2,00,000/-. In that policy also the complainant was a nominee. Only policy schedule was supplied both the times.
3. During validity of the policies, the deceased suddenly died of natural cause on 3/7/2007. The complainant thereafter made a claim to the OPs. About 4 months after the death of the deceased, the OPs by letter dated 14/12/2007 repudiated her claim on the ground of non disclosure of material facts regarding his pre existing disease. The complainant informed the OPs that the deceased had no previous history of ailment and was not treated for any disease prior to his death. Therefore she requested to reconsider the decision. But for over 3 years nothing was communicated to her. Then on 31/5/2011 she was informed that reconsideration of the decision was not possible. When her persistent efforts to get insurance claim could not bear fruits, she has lodged this complaint and has claimed insurance claim of Rs.2,75,000/- under two policies with 18% interest along with compensation and cost.
4. The OPs have filed reply at Ex.10 and admitted two policies taken by the deceased. However, it is denied that during subsistance of the policies the deceased died a natural death. Admitting that the complainant had given claim form, it is stated that after due investigation it was found that there was breach of terms and conditions as fact regarding pre existing disease of the deceased was not disclosed. Therefore the claim was rightly repudiated. It is denied that for considerable period nothing was communicated to her about decision on the claim or on reconsideration of earlier decision. It is further stated that the complainant filled in death claim form by suppressing material facts. The deceased had history of Chronic Obstructive Airways disease and Bronchitis since 2002-03. But it was not disclosed while submitting proposal form for policies. Hence, it is submitted to dismiss the complaint.
5. We have heard Ld. Counsels for both the parties. Perused documents and notes of arguments. Thereupon we record our findings and reason as under.
FINDINGS AND REASONS
6. The foremost question is whether the deceased died natural death or due to any complications arising from pre existing disease. It is not disputed that he died during subsistence of the policies and in both the policies the complainant was shown as nominee. The OPs have filed on record the copy of medical certificate issued by Dr. Suneel Deshpande, who has noted in it that the deceased had Bronchitis and treatment was going on since 21/10/2002. The copy of proposal form signed by the deceased, is also placed on record. In the form, queries regarding any previous or current treatment for any diseases or conditions were answered in the negative. Thus it can be said that the deceased had been suffering from Bronchitis, but he did not disclose it in the proposal form. Alleging such concealment as breach of terms and conditions, the claim was repudiated. Reliance is placed on a decision in P.J. Chacko v/s Chairman, LIC AIR 2008 SC 424.
7. The deceased died on 3/7/2007 and in the death claim cause of death is mentioned as ¨Natural sudden death¨ at home. About nature of illness, it is specifically mentioned as not applicable. These documents filed by the OPs confirm that the deceased did not die of any complications from Bronchitis or due to obstructive airways disease as alleged by the OPs. The death certificate issued by the same doctor also confirmed that death was due to natural cause and it was sudden death. The OPs have not disputed the death certificate or cause of death. Thus there is no document or evidence to show his death has any co relation with his pre existing disease. The exclusion clause, which excludes pre existing diseases from policy coverage, will not come into play if cause of death is not co related with pre existing disease. Suppression of pre existing diseases can be a ground to repudiate the insurance claim if it has direct or indirect bearing on the cause of death. We do not find such possibility in the present case from the documents. As such, we are unable to accept the ground of repudiation, which must be held to be unjustifiable.
8. The Ld counsel for the OPs also pointed out discrepancy in the income of the deceased. In the letter (document no.8) filed by the complainant, income of the deceased is stated to be Rs.5000/- p.m. But in the proposal form Rs.1 lakh annual income was mentioned. This is also alleged to be suppression of fact. However, we fail to understand what difference it made in the proposal. It is nobodyś case that the insurance policy depends on income of an insured. We do not think it has any adverse effect on the deceasedś policy.
9. Ld counsel for the complainant further alleged that when the complainant, being dis satisfied with repudiation, wrote a letter to the OPs for reconsideration of decision, reply was sent on 31/5/2011 (document no.13). By reply letter it was intimated to her that on receipt of her letter, the claim of policies on the life of late Mr. Pedda Abbulu K. was re examined. Ld counsel has rightly alleged that the OPs without application of mind based their opinion upon documents of another person failed to reverse their erroneous decision. It is tried to explain by the OPs that that was a typographic error of name of the insured and therefore should be overlooked. In fact, it was brought ot their notice in the complaint itself, but no attempt was made to rectify the same. Be that as it may, we are convinced that the death of the insured deceased was a natural death and has nothing to do with his pre existing disease or it was not a cause for his death. Therefore the complainant is entitled to claim death benefits under the policies. The OPs have made deficiency in service by repudiating her claim on erroneous ground. Hence, we allow the complaint and pass the following order.
ORDER
- The complaint is partly allowed.
- The OP are directed to pay, jointly and severally, a sum of Rs.2,75,000/- with 9% p.a. interest from date of receipt of the claim, to the complainant
- The OPs are further directed to pay, jointly and severally, compensation of Rs. 10,000/- for physical and mental agony and litigation cost Rs.5000/- to the complainant.
- The OPs shall comply the order within 30 days from date of the order.
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