Delhi

East Delhi

CC/767/2012

Sh. J.C. Mehta - Complainant(s)

Versus

Bajaj Allianz Life Insurance - Opp.Party(s)

30 Nov 2012

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT OF NCT OF DELHI

                                                   CONVIENIENT SHOPPING CENTRE, SAINI ENCLAVE: DELHI-92

 

CC. NO-767/12

In the matter of:
Sh. J.C. Mehta

S/o Sh.Ghanshyam Das Mehta,

E-275, East of Kailash,

New Delhi-110065                                  

Complainant

 

Vs

 

Bajaj Allianz Life Insurance Company Ltd.

(A Company Incorporated under the Companies Act, 1956)

And having its office at:

601,6^th Floor, 17, Sachdeva Corporate Tower,

Karkardooma Community Center,

Karkardooma,

Delhi-110032.

 

                                                                                                                  Opposite Party

 

                                                                                     DATE OF ADMISSION-03/10/2012

                                                                                 DATE OF ORDER        -01/09/2015

 

ORDER

 

SH. N.A.ZAIDI, PRESIDENT

This complaint has been filed with the allegation that the complainant son Sh. Sumit Mehta was insured by the Respondent vide policy No.97765432 dated 10/05/2008 for a sum of Rs.5,00,000/- of which the maturity dated was 28/04/2018. He was examined by the respondent company doctor and he was not suffering any disease. He died on 27/07/2008 due to heart attack. The information was given to the respondent for final claim on 13/03/2009 with all the relevant documents.  On 12/05/2009 respondent asked the complainant to submit the indemnity Bond on Rs.100/-which was accordingly submitted but the claim was repudiated on 06/07/2009. The claimant took the matter of repudiation to the review committee. It is submitted that the stone was removed laproscopically more than 3 years prior to Sh. Sumit Mehta’s death. He was in sound cardiac health. He did not die due to kidney failure. No reply was given by the respondent of the communication dated 19/09/2010 and the review committee, maintained the decision of the repudiation of the claim vide its letter dated 07/12/10. The other insurance company of which detailed has been given in Para 8 of the complaint have promptly paid the amount of insurance under their policies. The Ombudsman asked the complainant to once again submit the claim to the respondent for reconsideration. The respondent did not reply and when complaint was made to the Ombudsman they rejected the claim on 11/11/2011. The rejection was wholly unjustified. The complainant has prayed for the payment of the insured amount with 15% interest and Rs.50,000/- for mental harassment and suffering and Rs.10,000/- for the cost of litigation.

            Respondents were served and Mr. Sanjeev Nirwani (adv.) took notice on behalf of the OP but no written statement filed and case proceeded exparte.

            We have heard the Ld. Counsel for the complainant and perused the record.

            This is evident from the documents on record that the complainant is the son of Sh.Sumit Mehta, who was insured for the Sum of Rs.5,00,000/- on premium of Rs.10,000/- per year, date of maturity was 28/04/2018. The complainant has illegally mentioned that the claims has been repudiated on the ground of concealment in the proposal form is their letter dated 06/07/2009, the claim was repudiated on the ground that the deceased was diagnosed of left Ureter calculus at ultraviolet junction and DJ stenting was performed on 22/02/2005. They have further mentioned that, “Had these facts been disclosed the company would not have covered the risk for the policy on the same terms and conditions”. The complainant have specifically mentioned in the complaint that before issuance of the policy the deceased Sh. Sumit Mehta was examined by the Doctor of the OP company and it is after proper medical checkup, the OP agreed to insured the deceased. The complainant have further alleged that the cause of death of Sh. Sumit was not related to the calculus stone which was removed on 22/02/205 but it was the cardiac arrest as has been certified by Sethi Medical Centre in their death certificate dated 27/07/2008. Question arises as to whether none mentioning of operation got done on 27/02/2005 amount to suppression of facts. This has been contended on behalf of the complainant that between 2005 and May 2008, there was no disease to the deceased as such he has not committed any mischief by not mentioning their earlier operation, secondly he was examined by the Doctors of the OP and they found no disease, in short the cause of death was not connected with the earlier disease for which he was operated in 2005. Reliance has been placed on LIC of India Vs Smt. Surekha Ramesh Rao Manker, Revision Petition No. 2837/2007 decided on 03/11/2011, where in the Hon’ble National Commission in the similar circumstances have ruled that the cause of death has no relationship what so ever with the decease earlier suffered by the complainant  and death has no connection with the earlier disease. In these circumstances none mentioning of earlier disease could not be said to be a suppression of fact. From the record it is not proved that the urinary problem (Ureter Calculus) has in any way contributed to the Heart Attack further the allegation of the complainant in Para 8 that the insurance companies have disbursed the claim of the complainant on the same facts. Taking the cause of death as cardiac arrest, the details have been mentioned in Para 8 of the complaint.

 In view of these facts on record, we are of the view that repudiation by the respondent is wholly unjustified and illegal. OMBUDSMAN is supposing to check the malpractice of the insurance companies and they are also behaving in the same manner and are not examining the fact legally and logically.  It creates a serious doubt upon the independent functioning of the OMBUDSMAN. Rejection by the OMBUDSMAN is surprising, when this fact before him that other insurance company have already passed the claim. The OMBUDSMAN has not applied his mind at all in rejecting the claim. The Hon’ble Justice Sh. V.B. Gupta in the matter of Life Insurance Corporation vs. Sh. Anand Kumar have observed, taking into consideration, Judgment of the Hon’ble Supreme Court in Bhag Singh & ors Vs Union Territory of Chandigarh, (1985) 3 SCC that unwarranted litigation by the governments/statutory authorities basically stem from the two general baseless assumptions by their officers.

1. That all the claim should be viewed as illegal and should be resisted and fought up to the highest court of the land.
2. If taking the decision on an issued could be avoided, then it is prudent not to decide the issue and let the aggrieved party approach the Court and secures the decision.

This clearly applies to the facts of this case. The officer of the insurance company and OMBUDSMAN both have acted in the above manner as pointed out by Hon’ble Justice Gupta. This is sufficient for imposing the hefty penalty upon the OP for denying the legitimate claim and making the complainant to run from one court to another court, such officers not only cause harassment to the claimant but they also cause loss to the insurance company as it is burdened with litigation cost, the interest which they have to pay for the delayed disbursement and the penalty imposed. This is public money of which the insurance company is custodian. No official or officer can be permitted to flout the rules and causes loss to the organization, such loss should be recovered from their personal take away.

We allow this complaint. The OP is directed to pay to the complainant the entire amount under the policy with 15% interest there on from the date of filing the complainant till it is finally paid. We further award the compensation of Rs.50,000/- to the complainant on account of mental pain, harassment etc, this shall also include the cost of litigation. If this amount is not paid to the complainant within 45 days from the date of this order the complainant shall be entitled for 18% interest till it is finally paid. As has been observed above the interest and compensation is to be recovered by the insurance company from the personal pay of the officers responsible of the rejection of this claim and this shall not be taken as the excuse for non compliance of the order within 45 days as directed above.

Copy of this order be served upon both the parties.

 

 

SUBHASH GUPTA                            POONAM MALHOTRA             N.A.ZAIDI

     MEMBER                                            MEMBER                                 PRESIDENT