Haryana

Fatehabad

CC/50/2015

Silochana - Complainant(s)

Versus

Birla sun life Insu. - Opp.Party(s)

Raviender Singh

13 Jun 2016

ORDER

BEFORE THE DISTT.CONSUMER DISPUTES REDRESSAL FORUM; FATEHABAD.

                                                          Complaint Case No.50 of 2015.                                                                 Date of Instt.: 25.03.2015.                                                                          Date of Decision: 23.06.2016.

Silochna wd/o Krishan, resident of village Bhuthan Kalan, Tehsil and District Fatehabad.                      

                                                                    ...Complainant

                              Versus

1.Birla Sun Life Insurance Company Ltd., on the upper side Canara Bank G.T. Road Fatehabad, through its Branch Manager.

2. Birla Sun Life Insurance Company Ltd., Claims Department, G Group Tech Park, 6^th Floor Cashar Vadavali Ghodeluder Road Thane West 400601 through its Authorized Person.

                                                                   ..Opposite Parties

          Complaint U/S 12 of the CP Act,1986              

Before:                  Sh. Raghbir Singh, President.                                                                     Sh.R.S.Panghal, Member.

Present:                 Sh. Ravinder Singh, Advocate for complainant.                                                  Sh.Ashish Goyal, Advocate for opposite parties.                            

ORDER

                    Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986.

2.                Briefly stated the facts of the present complaint are that husband of complainant namely Krishan got himself insured with the opposite parties vide policy No.005762844 for a sum assured of Rs.9,57,000/- (assured amount amended from Rs.5,50,000/- to Rs.9,57,000/) commencing from 20.9.2012 by making payment of premium to them. It is further averred that the insured was hale and hearty at the time of taking policy and there was no history of any disease prior to his death. The insured was also got medically checked up from the doctor by the opposite parties. It is further averred that insured died on 20.9.2012 during subsistence of the policy. The complainant who is nominee of the insured intimated the opposite parties regarding death of insured and requested to pay death claim. She completed all the formalities in this regard and also submitted all the documents alongwith original policy to the opposite parties and the officials of the ops assured the complainant that claim amount will be disbursed within short period. It is further averred that complainant requested the officials of ops many times for disbursement of claim but all in vain and ops have not paid the claim till today and wrongly repudiated the claim vide letter dated 31.10.2013 on the ground that the insured died before the issuance of the policy, which is wrong, false and concocted and improbable version of the opposite parties only to repudiate the genuine claim of the complainant. The opposite parties have harassed and humiliated the complainant by not paying the claim for which she is entitled to Rs.50,000/- as compensation for harassment and is also entitled to Rs.11,000/- as litigation expenses. Hence, this complaint.

3.                Upon notice, opposite parties appeared and resisted the complaint by filing written statement taking certain preliminary objections regarding maintainability; that complainant is not consumer as per provisions of the Consumer Protection Act and that complainant has not come to this Forum with clean hands and has concealed the material facts from this Forum. It has been submitted that on 20.9.2012, the answering opposite parties were in receipt of fully filled proposal form showing the same to be submitted by the husband of the complainant. The answering ops considering the information contained in the proposal form true and believing the same, had processed the case for issuance of the policy and on the basis of proposal form, the policy bearing No.5762844 on semi annual mode of Rs.15,457/- stands issued on 26.9.2012. In the month of May, 2013, the answering ops were in receipt of death claim intimation from the complainant and on perusal of the same, it has been revealed that the life assured shown to be passed away within a short span of three months i.e. 26.12.2012. Being an early claim, the answering opposite parties had processed the case for conducting necessary investigation and during investigation, it has been revealed that the husband of the complainant passed away on 26.7.2012 i.e. much prior to the applying for the policy and the proposal applied after the death of the life assured upon which the policy stands issued is the result of fraud so played by the complainant with the ops with a view to cause undue loss to the company and the relevant entry to that effect was found in the Anganwari Register. It has been further submitted that as the death of the life assured occurred much prior to the issuance of the policy, therefore on the date of applying for a policy no concluded contract came into existence and in view of the same, the claim of the complainant stands repudiated vide repudiation letter dated 31.3.2012. The falsity of the version of the complainant can barely be evident from the fact that complainant by impersonating some other person had got procured the policy by showing the annual income of the life assured as Rs.3.5 lacs approximately but during the course of investigation, it has been revealed that LA Krishan Kumar did not possess sufficient funds so as to bear the huge premium of Rs.31,000/- annually and life assured was labourer by profession and was having limited resources of income and was a member of BPL category. So from all corners, it is amply proved on the file that the policy in question stands purchased only with a view to defraud the ops. It has been further submitted that complainant just to give sanctity to her false version, had procured forged hospital record showing the death of the life assured occurred after the issuance of the policy in connivance with the concerned doctor and had also got managed death certificate of the life assured on the basis of false record so produced by the complainant from Life Line Hospital Gurgaon. During the course of investigation, it has been established that the entire record managed from the hospital authority, Gurgaon is forged one and life assured was never treated by that hospital and this fact is evident from the fact that there is no reference of the name of the life assured in the register maintained for the indoor patient nor the consent form bears the signature of the LA or any of his attendants, which itself is a mandatory one. Further, no test whatsoever has been performed by the hospital authority upon the LA especially in a situation, when the situation of the life assured was alleged to be so much critical. Even otherwise, the life assured was having no such financial backup to get his treatment from the hospital situated at Gurgaon and particularly in a situation when within the vicinity of Fatehabad District, there were many other cardio centres.

4.                On merits, it has been submitted that even on the basis of false information, the policy in question has commenced on 26.9.2012 and not on 20.9.2012 and even if the pleadings of the complainant be perused, then no concluded contract came into existence on the date of death of the life assured. It has been further submitted that as per the sum assured demanded in the proposal form, there is no requirement to get the proposer medically examined and it is on account of the same, the proposer was not medically examined and if it be so, then the real face of the complainant and their forgery be catched at the very first moment and ops would not issue the policy in question. The other pleas taken in the preliminary objections have been reiterated, the contents of the complaint have been denied and prayer for dismissal of the complaint has been made.

5.                The parties then led their respective evidence by way of affidavits and documents. The complainant has tendered into evidence her affidavit as Ex.C1 and repudiation letter dated 31.10.2013 as Ex.C2. On the other hand, the opposite parties have tendered into evidence affidavit of Ms. Aakriti Manocha, Assistant Manager Legal as Annexure RW1/A and documents as Annexures R1 to R5.

6.                Heard. The counsel for the complainant reiterated the averments made in the complaint and prayed for its acceptance whereas the counsels for OPs reiterated the averments made in the reply and prayed for dismissal of the complaint.

7.                From the proposal form placed on file by the opposite parties as Annexure R1, it is evident that a proposal for taking the health secure plan in the name of Krishan (since deceased) was made on 20.9.2012. The sum assured in the said proposal form is mentioned as Rs.9,57,000/- and annual premium of Rs.29,000/- in two installments of Rs.14,500/- each was to be paid to the opposite parties by the life assured. The pay term of the premium was five years and last premium was to be paid on 26.3.2017. In the column No.9 of payment details, it is mentioned that initial premium of Rs.15,457/- was to be paid by the life assured and the complainant has alleged that her husband paid the said amount of initial premium to the opposite parties. The policy has been issued on 26.9.2012 as is evident through first premium receipt Annexure R3. The complainant is nominee in the said policy. According to the complainant, on 25.12.2012,  her husband suddenly started experiencing chest pain at workplace from where he was taken to Gurgaon Hospital where he expired on 26.12.2012 due to heart attack but the opposite parties have wrongly repudiated the genuine claim of the complainant on the ground that her husband Krishan had died much prior to the application for obtaining insurance policy which is not correct. The opposite parties in the reply besides reiterating their above said stand that in the investigation, it was revealed that husband of the complainant passed away on 26.7.2012 i.e. much prior to the applying for the policy have also averred that complainant by impersonating some other person had got procured the policy by showing the annual income of the life assured as Rs.3.5 lacs but during the course of investigation, it was revealed that Krishan life assured did not possess sufficient funds so as to bear the premium amount and he was simply a labourer. In the proposal form Annexure R1 the occupation/ business of Krishan (since deceased) is mentioned as agriculturist and his annual income has been shown as Rs.3,50,000/-. In this very document, the name of agent of the opposite parties is mentioned as Mukesh Kumar with his code number as BF 8714.  In the instant case, it appears that the proposal was made through agent.  On Annexure R1,  we find the signatures of agent Mukesh Kumar and specified person code and license No. on the first and last pages of the proposal.  A close scrutiny of the proposal form would reveal  even the columns were filled up by the agent. It is manifest that the proposal was routed through the agent of the opposite parties. The photograph of the life assured is also pasted on the proposal form and there are also signatures of Krishan Kumar on the proposal form. So, it cannot be said that representative/ agent of the opposite parties was not aware about the fact that proposer was not Krishan Kumar and some other person. There is no plea on behalf of the opposite parties that the agent was not acting on their behalf.  The opposite parties also ought to have made thorough enquiry and necessary investigation before issuance of policy irrespective of the amount involved. Had the preliminary investigation been conducted by the opposite parties, such complications would not have arisen. Without doing so, when they have issued the policy, now they cannot turn round and contend that fraud has been committed upon them.

8.                Now, we see whether the opposite parties have rightly repudiated the claim of the complainant on the above said ground that life assured was not alive at the time of proposal or issuance of policy or not? To substantiate their plea that Krishan had already expired on 26.7.2012 i.e. much prior to applying for the policy have relied upon investigation report Annexure R4 wherein it is mentioned that as per the Anganwari register, Mr. Krishan had already expired on 26.7.2012. The opposite parties have also placed on file three Photostat copies of one document alleging an extract from the register of Anganbadi but all these three Photostat copies are so black that it can hardly be read. Though all the three Photostat copies of this document are almost not readable, but if we minutely read this document (all the three copies) we see that name of Krishan son of Parsa Ram with date 26.7.2012 is mentioned and word “Achanak” (suddenly) is also mentioned in this document. In this document names of other several persons besides the name of Krishan are mentioned but from the said document it is not clear that same is extract of the register of Anganwari. The investigator has annexed the said document with his report which has been placed on file by the opposite parties. According to the learned counsel for the opposite parties, the said document has been prepared by a public servant while discharging his/her official duty and therefore, same is a public document to which presumption of truth is attached and reliance can easily be placed on this document. Learned counsel for the opposite parties also contended that in Consumer Forums, documents are filed in the form of photo copies of the documents and the above said document being a public document is perse admissible in evidence. In support of his contentions, he has relied upon the observations of Hon’ble National Commission in case titled as ICICI Bank Ltd. Vs. Pushpa Chandran & Ors. Decided on 17 October, 2014. There is no dispute with the law and the fact that documents are filed in the form of photo copies in the Forums, but the photocopy should be clear and visible. The opposite parties are relying upon a document which is almost black and not visible. The photocopies can be relied upon when the original document cannot be easily produced or not possible to be produced. The opposite parties could have taken a legible copy of the register of Aganwari by visiting the said office or could have summoned the record of Aganwari but the opposite parties have failed to do so. The opposite parties have not tried to collect any authentic evidence in support of their contentions and have merely relied upon a document submitted by the Investigator. Even from the above said photocopies of said document it is not clear that to which authority the said document belongs. The photostat copies also do not bear any signatures and stamp of issuing authority/ official. Even the affidavit of the Investigator who conducted the investigation and attached the said document with his report has not been placed on file. The opposite parties have not proved the date of death of Krishan being 26.7.2012 by any cogent and reliable evidence and the abovesaid document in this regard cannot be read into evidence. In this regard we are also fortified with the observations of the Hon’ble Punjab & Haryana High Court in case titled as Surinder Kaur Vs. Mehal Singh & others, 2014 (I) RCR (Civil) page 467 wherein it has been held that “In cases where the photostat copy is itself suspicious it should not be relied upon. Unless the Court is satisfied that the Photostat copy is genuine and accurate it should not be read in evidence.  

9.                Further more, during investigation the Investigator recorded the statement of Silochna statement who stated that on 25.12.2012, her husband suddenly started having chest pain at workplace from where he was taken to Gurgaon Hospital. Her husband died due to heart attack in Life Care Hospital at Gurgaon on 26.12.2012. There is also a certificate of Sarpanch of Gram Panchayat of village Bhuthan Kalan (Fatehabad) placed on file to the effect that Krishan Kumar son of Parsa Ram resident of village Bhuthan Kalan expired on 26.12.2012 due to heart attack in Life Care Hospital, Manesar (Gurgaon) and he was cremated on the same day in the cremation ground of the village in his presence. He has also certified that Krishan was doing the work of massion. There is also a certificate in this regard placed on file of five other co-villagers who have certified the date of death of Krishan as 26.12.2012. The Investigator also took treatment record of Life Care Hospital, Gurgaon at the time of investigation. The admission sheet of that hospital reveals that Krishan son of Sh. Parsa Ram was admitted in the said hospital on 25.12.2012 at 5.00 p.m. and he died on 26.12.2012 at 7.00 a.m. due to heart failure. Learned counsel for the opposite parties contended that villagers have certified the death of Krishan on 26.12.2012 in order to favour the complainant and the record of the above said hospital is false and fabricated. The treatment mentioned in the record also raises doubt because the patient is allegedly shown to have suffered heart pain and died due to heart failure but one of the injections mentioned in the treatment chart are for some other disease i.e. calculi (stone) and not for heart problem. However, we see no substance in the contentions of learned counsel for the opposite parties. First of all, a qualified doctor of such a reputed hospital will not prepare false and forged treatment record knowing well the consequences thereof as if forgery is proved besides criminal liability even the licence of the hospital is cancelled. Such a reputed hospital and its doctors work for treatments of a patient and not for preparing false treatment record. Secondly, the treatment given by the doctor shows that same has been given for heart problem and some medicines/ injections have been given to relieve the pain which can also be given if a patient is suffering from pain of calculi (stone). This is also contention of the opposite parties that no test has been performed upon the patient despite the fact that his position was critical and it proves that whole treatment record is false and has been prepared in collusion with the complainant. But we see no substance in this contention because it seems that Investigator at his own has recorded that no investigations were done whereas in the hospital record it is mentioned that CBC, ECG chest, x-ray, USG were conducted. Moreover, the opposite parties have not proved on record by any expert evidence to prove that treatment as mentioned in the record is not for heart disease. The patient was taken to Gurgaon for treatment by his attendants as there is hope in the mind of the family members that if he is taken to a hospital in big city with better facilities then he can be saved. From the documents placed on file, it is manifestly clear that Krishan life assured died on 26.12.2012 in Life Care Hospital, Gurgaon and accordingly his death certificate was issued by PHC Kasan (Gurgaon) as placed on file. The opposite parties have failed to prove on record that deceased life assured actually died on 26.7.2012 and not on 26.12.2012. So the contentions put forth by the opposite parties are baseless and repelled.

10.               Learned counsel for the opposite parties has also contended that life assured was having ration card of BPL category and was not in position to pay the huge premium of more than Rs.30,000/- and this fact also raises doubt about taking of the policy in question. However, there is no substance in the contention of learned counsel for the opposite parties. It has also come on record that deceased was doing the work of massion and it is well known that a massion earns sufficient income from this field. It is also very well known that ration card of BPL category is got prepared for availing subsidy and other benefits of various schemes of the Government and there is general tendency that in order to get these types of facilities, BPL cards are got issued.

11.                   Since the proposal was made on 20.9.2012, policy has been issued on 26.9.2012 and it is proved on record that deceased life assured died on 26.12.2012, therefore, it cannot be said that no concluded contract came into existence. The repudiation of the claim of the complainant by the opposite parties is not justified.

12.                   Thus, as a sequel to our above discussion, we allow the present complaint and direct the opposite parties to make payment of claim/insured amount of Rs.9,57,000/- to the complainant alongwith interest @6% per annum from the date of filing of present complaint till actual realization within a period of one month, failing which the complainant will be at liberty to initiate legal proceedings against the opposite parties. A copy of this order be supplied to both the parties free of costs.  File be consigned after due compliance.

Announced in open Forum.                                                    

Dated: 23.06.2016.

                                                                       (Raghbir Singh)                                                                                                          President,                (Ranbir Singh Panghal)                                     Distt.Consumer Disputes                Member.                                                      Redressal Forum, Fatehabad.