The complainant Sri Ashok Kr Singh has filed this complaint petition against Branch Manager, Future Generally India, Life Insurance Company Ltd., Muzaffarpur and one another (o.p) for realization of Rs. 2,00,000/- as sum assured with interest within the time fixed by a court, Rs.50000/- for physical and mental agony and any other relief or reliefs to which the application be found entitled may be granted in his favour.
The brief, facts of the case is that the complainant had an insurance policy bearing policy No.-01195642 in the name of his wife Kanti Devi, of Future Generalli India L.I.C Ltd. Muzaffarpur for Rs. 2 lacs/- (sum assured). The further case is that insured Kanti Devi paid premium amount Rs. 9800/- on 22-02-2014. The further case is that after submission of policy proposal form, necessary inquiry and medical test of the insured (deceased) had been completed by the doctors and thereafter policy has been accepted by the o.p. no.-1. The further case is that on 22-06-2014 insured smt. Kanti Devi died due to diarrhea and vomiting. After death of the insured complainant made written complaint to the o.p no.-1 regarding the death of his wife smt. Kanti Devi and demand insured amount on 02-09-2014 as per terms of the policy but the o.p no.-1 refused to make payment on the ground of diabetes, thereafter the application sent a legal notice to the o.ps and demanded insured amount but after receiving said notice, o.p no.-2, claims review committee sent a reply letter dated 30-06-2015 and assured that the matter has been put before the claim review committee but no payment has been made to the complainant till filing of the complaint petition.
The complainant has filed the following documents with the complaint petition- Photocopy of certificate regarding death of late Kanti Devi –annexure-1, photocopy of Death certificate issued by Directorate of studies and evaluation - annexure-2, photocopy of receipt of receiving Rs. 9800/- annexure-3, photocopy of legal notice annexure- 4& 5, photocopy of letter of complainant to future general India Life Insurance annexure-6, photocopy of repudiation letter annexure-7.
On issuance of notices, o.ps. appeared and filed their w.s. on 24-05-2016 with prayer to dismiss the complaint petition with exemplary cost. It has been further mentioned in the w.s. that present complaint is false, frivolous, and vexatious and an abuse of the process of the forum. It has been further mentioned that the complainant has not disclosed any cause of action to proceed against the o.ps. It has been further mentioned complaint does not raise any “Consumer Dispute” as defined under the Consumer Protection Act-1986. It has been further mentioned that the present complaint is not maintainable. The claim of the complainant is based on a policy which is void ab-intio, invalid and unenforceable, due to suppression of material facts. Thereafter, present complaint is liable to be dismissed. It has been further mentioned that the L.A. had failed to disclose the material fact concerning her medical ailments in the proposal form. The Life Assured had failed to disclose that she had been suffering from diabetes and was under treatment for the same even prior to the application for the policy, as revealed during death claim investigation. Thus, the life assured with malafide intention deceived the company and availed the said policy by suppression of material facts. It has been further mentioned that this forum has got no jurisdiction to entertain the present complaint It has been further mentioned that there has been no deficiency of service or negligence on the part of the o.ps. Issuance of policy bearing No.- 01195642 in the name of L.A. Kanti Devi, in which complainant is nominee, is an admitted fact. The complainant has annexed the photocopy of proposal form as annexure-W/1. They have also annexed photocopies of policy schedule first premium receipt and future Generali Assurance Plus terms & condition as annexure-W/2. Receiving of death claim intimation on 03-09-2014, is also an admitted fact . The o.ps have also annexed photocopy of death claim as annexure- W/3. It has been further mentioned that since the L.A. had passed away within a mear span of 3 months and 25 days from the date of commencement of policy hence as permitted by regulation 8 (3) of the IRDA under protection of policy holders’ interest Regulations, 2002, the company commenced an investigation into the genuineness of the claim, and the said investigation agency revealed to the company that the life assured was suffering from diabetes prior to the date of application for the policy and had been diagnosed with an undergoing treatment for the same. It has been further mentioned that the said investigation agency had procured a prescription from one Dr. Mihir Chandra dated 21-09-2013, which is approximately 5 months prior to the date of application for the subject policy, and which categorically substantiates that the Life Assured had been diagnosed with and undergoing treatment for diabetes. The o.ps. have annexed the investigation report as annexure W/4. They have also annexed photocopy of prescriptions dated 21-09-2013 of Dr. Mihir Chandra as annexure-W/5. It has been further mentioned that since L.A. had suppressed the material facts of diabetes hence the claim was repudiated vide letter no. 13-03-2015. A copy of the claim repudiation letter has been annexed as annexure-W/6.
The complainant has examined Ashok Kumar Singh (complainant ) as AW-1 and Vinod Kr as Aw2.
None has been examined on behalf of the o.ps
The o.ps company have repudiated the claim of complainant on the ground that insured was suffering from poor control diabetes Mellitus and was under medication for the same. The complainant has annexed the repudiation letter as annexure-7, whereas the same has been annexed on behalf of o.ps as annexure w/6. This fact has been raised on behalf of o.ps so burden to prove the same lies on them. The o.ps have annexed the photocopy of death claim investigation report as annexure W/4. and prescription of Dr. Mihir Chandra as annexure-W/5. No investigation report has been filed on behalf of o.ps to show that on the basis of the same Dr. reached on conclusion that Kanti Devi was suffering from disabilities. Neither investigator nor Dr. has been examined on behalf of o.ps to prove that the D.L.A was suffering from diabetes prior to the filing of the proposal form. In the case of PNB Met Life Insurance V/s Veenita Devi first appeal No.-1045/2017, the Hon’ble N.C.D.R.C New Delhi has observed on 24-09-2018 that “ Doctor’s prescriptions have to be substantiate by an affidavit of the said Dr, specially in the light of the fact that it is being disputed by the complainant. In the instant Case the Insurance case has not produced the affidavit of the concerned doctor nor did the said doctor answer any interrogatory by way of evidence before the fora below. At the cost of repetition, it is reiterated the that the burden to prove that the L.A was suffering from any pre-existing disease lies with the insurance company and the Insurance company had not filed any documentary evidence or Affidavit of the treating doctor in support of their contention. Hence we find forced in the contention of the counsel of the complainant that the insured was never treated by said Dr. Y.K. Thakur of Hajipur as the reports are not substantiated by any affidavit of evidence.” On the other hand the complainant Ashok Kr. Singh has examined himself as aw-1 on the affidavit and he has denied the fact that his wife was suffering from any disease prior to filing of proposal form in para-12 of his examination- in -chief. He has further stated in para-13 of his examination in chief that his wife was physically healthy and she had no treatment /disease at the time on filing of insurance proposal form. The complainant has also filed photocopy of death certificate granted by Dr. Vijay Kr. Singh as annexure-1 who has mentioned in the certificate that L.A. Kanti Devi died due to diarrhea and vomiting on 22-06-2014. The same has not been challenged on behalf of o.ps.
On the basis of above discussions we are of the considered opinion that the o.ps have been failed to establish the ground of repudiation that the L.A Kanti devi was suffering from diabetes prior to the filing of proposal form and as such there is deficiency on their part. So, the complaint is liable to be accepted.
In the circumstances the complaint petition is allowed with direction to o.ps to pay Rs. 2,00,000/- as sum assured with 7 % interest p.a from the date of filing of complaint petition that is on 31-07-2015, Rs. 20,000/- as physical and mental harassment and Rs. 10,000/- as litigation cost within two months from the date of order, /, on failure they shall be responsible to pay the above amount with 8 % p.a. interest till realization. Let a copy of this order be furnished to both the parties as per rule.
