Sh.Rajesh Kumar Sharma and Sh.Parbhat Bhushan Sharma complainants have filed this complaint U/s 12 of the Consumer Protection Act of 1986 against the opposite parties praying that opposite parties may kindly be directed to release the claim of their mother amounting to Rs.3,50,000/- along with interest at the rate of 18% per annum from the date of due till its actual realization. Complainants have further prayed that opposite parties may also be directed to pay compensation to the tune of Rs.50,000/- and litigation expenses for physical harassment and mental agony suffered by the them, in the interest of justice.   

2.       The case of the complainants in brief is that the deceased life assured Smt.Kailash Rani w/o Pritam Lal had taken the policy HDFC SL Pro Growth Flexi bearing No.18139938 on 05.02.2016 for sum assured Rs.3,50,000/- and the deceased deposited the installments to opposite party No.1 as settled between the parties at the time of purchasing the policy. It was pleaded that the above said deceased Smt.Kailash Rani had died on 08.10.2016 at Sri Hargobindpur, tehsil Batala and at the time of purchasing the policy in question she nominated the complainant No.1 as her nominee. Complainants had completed all the formalities after the death of above said deceased and also submitted all the relevant documents with the opposite party No.1 for disbursement of claim. It was further pleaded that complainant many times approached the opposite party No.1 and requested them for making the payment of the assured amount along with interest but opposite parties putting the matter pending with one pretext or the other. It was also pleaded that opposite parties issued a letter dated 24.01.2017 to the complainant No.1 by which they repudiated the claim of the complainants on the ground that the deceased life assured had not given the correct information regarding her age and her occupation at the time of purchasing the above said policy as the deceased life assured had declared her date of birth as 18.10.1950 as per her PAN Card whereas her age is more than 65 years at the time of purchasing the policy and occupation declared by the deceased at time of purchasing the policy as agriculture was false. As such opposite parties repudiated the claim of the complainants on false and flimsy grounds as deceased life assured had given the true and relevant information to the opposite parties at the time of purchasing the policy and repudiation of the claim vide letter dated 24.1.2017 by the opposite parties was illegal, & void and is not sustainable. It was next pleaded that the act of the opposite parties not to pay the insurance claim was illegal, null & void and opposite parties are bound to pay the insurance claim of the mother of the complainants and there was deficiency in service of the opposite parties in which they have withheld the insurance claim of the mother of the complainants as they approached the opposite parties many times for releasing of the insurance claim but the opposite parties refused to admit the claim of the complainants, hence this complaint.

3.       Notice of the complaint was issued to opposite parties who appeared through their counsel and filed its written reply by taking the preliminary objection that complainant has no cause of action to file the present complaint. That the complainant does not fall within the definition of consumer. That insurance was a contract between the two parties and both the complainants and the opposite parties bind with the terms and conditions of the policy. That the contract of insurance was based on utmost good faith and there was breach of utmost good faith as the relevant things had not been disclosed by the insured at the time of getting the policy. That there was no deficiency in services on the part of the opposite parties. It was stated that the policy was issued on the basis of proposal dated 12 January, 2016 made to the opposite party for purchase of HDFC SL Pro Growth-Flexi which was accepted on the basis of information provided in the proposal form. It was further stated that the statement of the death claim had been duly received and the life assured had declared her date of birth as 18.10.1995 and had produced Pan Card as proof of the same and on the basis of it life assured was 65 years at the time of death and even some questions had been wrongly answered. It was also pleaded that from the thorough investigation it has become clear that correct age of the life assured was higher than disclosed at the time of proposal and the detail regarding occupation and income disclosed in the application dated 12 January, 2016 was also found false from which it become clear that the life assured got the policy by concealing the true facts and as such there is no liability of the insurance company and letter dated 24 January, 2017 was duly sent in this regard. That complainant has not come to the court with clean hands and as such the present complaint is liable to be dismissed. On merits, it was stated that complainant may put strict proof regarding the death of deceased. It was also stated that complainant may get legal heir certificate or any other authenticated certificate regarding their relationship with the deceased. It was further stated that the letter dated 24.01.2017 was legal and valid and the facts stated in this letter were true and correct. All other averments made in the complaint have been denied and lastly prayed for dismissal of the complaint.     

4.      Counsel for the complainants had tendered into affidavit of complainant Ex.C1 along with documents Ex.C2 to Ex.C18 and closed the evidence on behalf of complainant.

5.       Counsel for the opposite parties had tendered into evidence affidavit of Sh.Arpit Higgins Manager (Legal) Ex.OP-1,2/1 along with documents Ex.OP1,2/2 to Ex.OP1,2/13 and closed the evidence on behalf of opposite parties.         

6.       We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contesting clients.                   

7.       We find that the present dispute has arisen on account of the impugned ‘repudiation’ (Ex.C4 & Ex.OP1,2/2) of 24.01.2017 of the death-claim pertaining to the deceased mother of the complainant on the grounds of incorrect declaration of her DOB (Date of Birth) by her on 05.02.2016 at the time of purchase of the related life policy. The opposite party 2 and 3 insurers here, (hereinafter for short ‘the OP insurers’) have duly admitted the impugned repudiation through their written statement and the accompanying affidavit (Ex.OP1,2/1) deposing therein that the DLA (Deceased Life Assured) was not entitled to purchase the life-policy (in question) on account of her advanced age that she somehow suppressed vide her false declaration and thus the related policy turned void abinitio and as such the complainant has not been eligible to the policy’s benefits etc.                    

8.       We find that the complainant has successfully proved the contents of his allegation-contented complaint pertaining to purchase of the life-policy and the natural death of DLA along with the subsequent filing of the related claim with its repudiation etc vide evidentiary documents exhibited here as: Ex.C1 affidavit of complainant and documents Ex.C2 to Ex.C18. The OP insurers, in rebuttal, have filed its lone affidavit Ex.OP1,2/1 accompanied by other documents exhibited here as: Ex.OP1,2/2 to Ex.OP1,2/13 to prove its responding rebuttals along with the fresh claim of false declaration of ‘age – DOB’ by the DLA. We find that the ‘onus of proof’ lay heavily upon the OP insurers since the DLA’s false ‘age’ declaration was alleged by them but somehow they failed to prove the same through some definite or other acceptable evidence. We further observe that the OP insurers did neither produce their investigator’s ‘deposition’ nor the ‘declaration’ alleged to be false and incorrect. The document Ex.OP1,2/13 does not mention full particulars (including age) of the applicant (DLA) nor the false age-proof has been produced herein to substantiate the grave charge of ‘suppression’ of material facts to facilitate the purchase of the related policy. Thus, we find that the OP insurers have repudiated the ‘claim’ arbitrarily and on ‘non-existent’ charges.                                                            

9.       Further, we find that the OP insurers have not proved the very ‘delivery’ or even communication of the related Policy along with its applicable ‘terms’ etc to the insured complainant that has been vital under the circumstances. Even, its very dispatch (of the Policy etc) has not been attempted to be proved, either. And as such the OP insurers are presently barred from availing any benefit of the ‘undisclosed’ terms of the related contact of insurance and that in turn also proves adoption of ‘unfair trade practice’ to turn down an otherwise a routine claim. To remove all ambiguity, it may be clarified here that an ‘insurance claim’ and for that matter any ‘issue’ can be neither legally ‘favored’ nor legally ‘ousted’ on the basis of mere ‘presumptions’ how strong these might appear to be. We further find that the present policy in question was purchased through the services of the OP insures’ agents and thus it had been their duty to clearly disclose and make the insured understand all the applicable ‘terms’ of the Policy but no such agent’s declaration/deposition has been put forth during the present proceedings. We are further strengthened in our above legal proposition by virtue of the orders (31.03.2011) of the honorable State Commission Punjab in FA # 537 of 2008.

10.     Lastly, the OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial reviews and thus need be taken with due application of mind and not arbitrarily and these should also be of speaking nature duly explaining the reason and logic of the decision as to how the same has been reached. All the facts in issue need be appreciated while awarding sanctity to the current applicable law. The duty of settlement of insurance claims shall not be, in routine, delegated to the investigators/consultants who shall simply provide assistance on issues of facts pertaining to investigations etc. The insurance-contract has been between insured and the insurers and the consultants/investigators shall not manage the issue of settlement including its ‘repudiation’.                                               

11.     In the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s impugned repudiation being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’ etc. Thus, we partly allow this complaint and ORDER the OP insurers to pay the impugned ‘insurance claim’ in full to the present complainant (pertaining to the Policy in question) with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.    

12.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to records.

                             (Naveen Puri)

                                                                                                President.

ANNOUNCED:                                                            (Jagdeep Kaur)

JULY 20, 2018.                                                                        Member               

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