ORDER

(Passed on  19/09/2019)

PER SHRI.ATUL D.ALSI, PRESIDENT.

            The complainant has filed this complaint U/s 12 of the Consumer Protection Act,1986 against repudiation of her insurance claim and praying for assured amount of Rs.5 lacs alongwith 18% interest besides compensation and cost of proceeding.

2.      The facts in short giving rise to this petition are that the complainant is the mother of deceased Sandeep Ramdas Ramteke, who used to work as a labour in WCL, Chandrapur. During his lifetime, on 8/3/2013, said Sandeep had insured himself with OP No.2 by obtaining life insurance policy bearing No.973921331 on 8/3/2013 for a sum assured Rs.5 lac and its monthly premium of Rs.2158/- used to be deducted from his salary and remitted to OP No.2 regularly. However on 30/6/2013, said Sandeep died. The complainant being nominee and heir, raised insurance claim but the Ops avoided to honour the claim. On the contrary, on 5/4/2014, the OP issued a questionaair to her so also sought some documents from her. Accordingly she complied all the requisite formalities. However, inspite of that, the OPs repudiated her claim by their letter. Hence the complainant issued legal notice dated 3/12/2015 to the OPs. through her advocate. In its reply, the OP No.1 intimated that they would revert back as soon as necessary information is received from OP No.2. However, the OPs did not comply.  Hence, the complainant has filed this complaint.

3.      The complaint is admitted and notices were served on the OPs. The OP No.1 and 2 filed their joint reply to the complaint. Both the OPs in their reply admitted that they had issued term insurance life insurance policy bearing No.973921331 on 8/3/2013 for a sum assured Rs.5 lac and its monthly premium of Rs.2158/- used to be deducted from his salary and remitted to OP No.2 regularly. However on 30/6/2013, said Sandeep suddenly died. The complainant being nominee and heir, raised insurance claim but the Ops repudiated her claim vide letter dated 5/4/2014 for the reason of suppression of material fact by the DLA while filling the proposal form for obtaining the policy, and the said repudiation has been affirmed by the Central Office Claim Disputes Redressal Committee of the OPs. Said DLA while filling the proposal form for obtaining said insurance cover, had concealed material information regarding his medical history.  Said Sandeep died on 30/6/2013.  As the death of the insured occurred within one year of initiation of the insurance cover, the OP No.2 initiated an investigation in the matter.  From the investigation, it came up from the discharge summary of Nagrale Heart Care & Maternity Centre, that the DLA had taken treatment at Nagrale Heart Care & Maternity Centre, for Enteric fever for the period 10/12/2012 to 11/12/2012 and again for Anaemia for the period 20/2/2013 to 23/2/2013. In the meantime also, he was on sick leave for a considerable period. These facts are evident from the prescriptions, Discharge Summary and medical certificates issued by Dr.Nagrale of Nagrale Heart Care & Maternity Centre and the leave record of DLA. The complainant concealed this fact while filling the proposal form and answered the specific querries vide Q.Nos.11(c), & 11(i) regarding antecedents of medical history in the negative. The principal cause of death as per medical record is acute anaemia for which the DLA had undergone medical treatment prior to obtaining the policy. Hence the insurance contract is vitiated from said suppression of material fact of earlier ailment. It is a breach of utmost faith which is condition precedent to the contract of insurance and fulfillment of which is compulsory. Since the very base of contract is fallacious and false, the contract has become void and hence the claim thereunder has been rightly repudiated by the OP No.2. Therefore the petition deserves to be dismissed with cost.

4.      Counsel for the complainant argued that the suppression of material facts has not been proved by the OP by adducing appropriate evidence and hence repudiation of insurance claim amounts to deficiency in service.

5.        Counsel for the OP No.1 & 2 argued that deceased life assured had underwent medical treatment at Nagrale Heart Care & Maternity Centre, and these facts are evident from the prescriptions, Discharge Summary and medical certificates issued by Dr.Nagrale of Nagrale Heart Care & Maternity Centre, Chandrapur. However, this fact was suppressed by the DLI while filling proposal form which amounts to suppression of material fact and hence the repudiation of insurance claim is proper.  Hence the petition deserves to be dismissed.

6. We have gone through the complaint, written versions filed by OP No.1 and 2, affidavit, documents and WNA filed by the parties. We have also heard the oral arguments advanced by parties.

                    Points                                                                           Finding

1. Whether the complainant is a Consumer  of Op Nos.1 & 2?     Yes

2.  Whether  there is deficiency in service on the part of

   OP No.1&2?                                               Yes

3.  What order ?                                                                  As per final order..

                                                          REASONING

As to issue No.1

7.      Admittedly, the complainant’s deceased son Sandeep being the Insured and after his demice, the complainant being legal heir and nominee under the said policy are the consumer of OPs. within the meaning of Section 2(1)(D) and the services as promised are the services within the meaning of section 2(1)(d)(ii) of CP act. and hence the issue is decided accordingly.

As to issue No.2

8.         The dispute is regarding repudiation of insurance claim by OP No.2 vide repudiation letter dated 26/6/2014 for the reason of suppression of material fact of taking treatment for Anaemia from 20/2/2013 to 23/2/2013 at Nagrale Heart Care & Maternity Centre, for Anaemia, at the time of submission of proposal for the policy. However this contention of previous treatment has not been proved by the OP by adducing evidence on affidavit of the treating doctor Mr.Nagrale with treatment papers. As the burden of proof and defense lies on the shoulder of O.P. mere statement without evidence can not be accepted as existence of fact. When the previous treatment has not been proved there can not be any suppression of material fact. Hence the rejection of insurance claim by OP is not proper. Hence the complainant is entitled to the assured amount  under the policy alongwith compensation for mental agony and cost of litigation, and hence, the issue is decided accordingly.

As to issue No.3

9.     In view of our observation supra, we pass the following order..

Final order

  1. The Complaint is partly allowed.

2. The OP Nos 1&.2 shall jointly and severally pay the assured amount of   

   Rs.5 lac under the policy bearing No.973921331 to the complainant  

   alongwith interest @9% p.a. thereon from the date of admission of this  

   complaint i.e.3/3/2016 till realization.

3. The OP Nos 1&.2 shall jointly and severally pay to the complainants an

   amount of Rs.10,000/- towards compensation for physical and mental

   agony and further Rs.5,000/- towards cost of litigation.

4. Copy of the order be furnished to both the parties free of cost.

(Smt.Kalpana Jangade (Kute)  (Smt.Kirti Vaidya (Gadgil)  (Shri.Atul D.Alsi)

               Member                                    Member                      President