Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 89.
Instituted on : 14.06.2013.
Decided on : 19.08.2016.
Mrs. Krishna Devi wife of Late Sh. Jaipal resident of village-Ladhot, Tehsil and District Rohtak.
………..Complainant.
Vs.
- Birla Sun Life Insurance Co. Ltd. Claims Department “G Corp Tech Park” 6th Floor, Kasar Wadavali, Ghodbunder Road, Thane-400 601(through its Incharge).
- Birla Sun Life Insurance co. Ltd., Near LIC Office, Subhash Road, Rohtak(Through its Manager).
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.JOGINDER KUMAR JAKHAR, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
SH. VED PAL, MEMBER.
Present: Sh.Yogender Singh, Advocate for the complainant.
Sh.Rajesh Sharma, Advocate for the opposite parties.
ORDER
SH. JOGINDER KUMAR JAKHAR, PRESIDENT :
1. The present complaint has been filed by the complainant with the averments that husband of the complainant had obtained policy No.005533018 for a sum of Rs.350500/- from the opposite party and the complainant was appointed as nominee of the policy holder. It is averred that the husband of the complainant died on 03.04.2012. It is averred that after the death of her husband complainant filed the claim with the opposite parties and submitted all the required documents with the opposite parties but the opposite parties flatly refused to disburse the claim amount of the complainant. Complainant also served a legal notice but to no effect. It is averred that the act of opposite parties of repudiating the genuine claim of the complainant is illegal and amounts to deficiency in service. As such it is prayed that opposite parties may kindly be directed to pay a sum of Rs.350500/- alongwith interest, compensation and litigation expenses to the complainant.
2. On notice opposite parties appeared and filed their written reply submitting therein that the life assured passed away on dated 03.04.2012 and the answering opposite parties came to know about the same after the receipt of claim form from the complainant and being an early death i.e. within 4 days from the date of commencement of policy, the opposite parties had got investigated the matter and on investigation it came to know that the life assured was suffering from cancer much prior to entering into proposal form in favour of the opposite parties were regularly taking treatment from PGIMS, Rohtak. It is averred that under the said registration papers it is clearly recorded that the DLA was diagnosed of MOV Stage IV on 30.09.2011 i.e. much prior to the issuance of the policy in question. It is averred that on account of concealment of fact the opposite party company has repudiated the claim of the complainant and the same was duly communicated to the complainant. It is averred that there is no deficiency in service on the part of opposite parties and the claim of the complainant has rightly been repudiated. Opposite parties prayed for dismissal of complaint with costs.
3. Both the parties led evidence in support of their case.
4. Complainant in her evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C9 and has closed her evidence. On the other hand ld. Counsel for the opposite parties has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R6 and has closed his evidence.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case insurance and death of life assured is not disputed. After the death of life assured complainant filed the claim with the opposite parties but the opposite parties vide their letter Ex.R6 had repudiated the claim on the ground that the life assured was suffering from Cancer(Metastasis of unknown origin) and had undergone treatment for the same prior to policy issuance. To prove its contention, opposite parties have placed on record copy of investigation report Ex.R4 and photocopy of C.R. No.986004.
7. After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite parties on the ground of concealment of pre-existing disease. But to prove its contention, opposite party has placed on record copy of investigation report Ex.R4 and photocopy of C.R Ex.R5 only. But neither the report of investigator is supported with affidavit nor the medical record of PGIMS is supported with the affidavit of the doctor who treated the life assured for the alleged disease. Hence in the absence of cogent and convincing evidence opposite parties have failed to prove the fact that life assured was suffering from cancer at the time of proposal for the policy. In this regard reliance has been placed upon the law cited in II(2013)CPJ 60 titled Life Insurance Corporation of India & Anr. Vs. Raj Kumar Sharma whereby it is held that: “Neither inquiry officer was examined nor his affidavit had been tendered into evidence by appellant to prove that LA was suffering from peptic ulcer at the time of filling the proposal form-Evidence of inquiry officer was withheld for unknown reasons-In repudiation letter no name and identity of person is disclosed from whom ‘LA’ had taken treatment and no proof to this effect was produced-Appellant had failed to prove that LA suffering with peptic ulcer and she had deliberately made wrong report/answer to agent at the time of filling proposal form-Repudiation not justified” , as per 2001(3)CLT633 Joginder Kaur & Others Vs. Life Insurance Corporation of India & another Hon’ble Punjab State Commission, Chandigarh has held that: “OP failed to lead direct evidence to prove that the life assured was suffering from any prior ailment or disease-Merely producing copy of hospital record/medical certificate as evidence does not mean that the contents thereof are necessarily true-it would not be acted upon or relied upon unless the writer thereof is subjected to examination and cross examination before the District Forum-The mere fact that the death occurred only after 11 months of taking the Insurance Policy is not a suspicious circumstances to deny the relief to the complainants-Order of District Forum dismissing the complaint set aside”, as per as per 2007(1)CPC 471 titled Life Insurance Corporation of India & Anr. Vs. Asha Singh Hon’ble National Commission has held that: “There was no evidence on record that deceased was suffering from any cardiac problem or other ailment which was within his knowledge-Repudiation of claim by OP is not in accordance with Section 45 of Insurance Act. Order of state Commission allowing claim upheld”. In view of the aforesaid law which are fully applicable on the facts and circumstances of the case, it is observed that the repudiation of claim by the opposite parties is illegal and unjustified and the complainant is entitled for the claim as per policy.
8. In view of the facts and circumstances of the case it is observed that opposite parties shall pay the amount of Rs.350500/-(Rupees three lac fifty thousand and five hundred only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 14.06.2013 till its actual realization, other benefits under the policy, if any and shall also pay an amount of Rs.3500/-(Rupees three thousand five hundred only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the awarded amount shall carry interest @ 12% p.a. from the date of decision. Complaint is allowed accordingly.
9. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
19.08.2016.
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Joginder Kumar Jakhar, President
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Komal Khanna, Member.
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Ved Pal, Member.
