DATE OF FILING: 06.11.2015
DATE OF DISPOSAL: 25.11.2017
Dr. N.Tuna Sahu, Presiding Member:
The complainant has filed this consumer dispute under Section 12 of the Consumer Protection Act 1986, alleging deficiency in insurance service against the Opposite Parties (in short the O.Ps) and for redressal of her grievance before this Forum.
2. Briefly stated the case of the complainant is that she is the widow and nominee of Late P.Satyanarayana Prusty. As per her complaint, her deceased husband obtained a L.I.C. policy bearing No.573480943 namely Jeevan Shree-1 on 08.08.2012 on payment of yearly premium of Rs.41,357/ for an assured sum of Rs.7,00,000/- with death benefits. The Medical Examiner, Dr. P. Das, MBBS, P.H.C., Sheragada examined the deceased regarding the health conditions of the deceased prior to taking of the insurance policy. After the policy bond was received from the O.P.No.1, the husband of the complainant suffered from ill health for which he was referred to the Hospital at Mumbai for better treatment. While the husband of the complainant was undergoing treatment at Hospital, Mumbai he died on 23.02.2013. After obtaining the death certificate from the competent authority, the complainant filed the claim application for Rs.7,00,000/- before the O.Ps towards assured money as per the terms and conditions of the policy bond. It is also mentioned in the complaint that the Manager (Claim) of the O.P.No.2 informed the complainant in his office Letter No.1125 dated 30.03.2015 intimating that the death claim has been admitted by the Competent Authority and further directed to submit the discharge voucher at their office at Aska Branch immediately for early settlement of the claim. Surprisingly the O.P.No.2 in his another letter on the same day i.e. on 30.03.2015 repudiated the claim on ground of suppress of previous disease. In the aforesaid letter dated 30.03.2015 the O.P.No.2 had intimated to submit the representation to the O.P.No.3 within three months for reconsideration of the claim and although the complainant submitted the representation immediately thereafter there was no response. When the O.Ps did not give any heed to the grievances of the complainant, she has filed this consumer dispute alleging deficiency in insurance service on the part of the O.Ps and prayed to direct the O.Ps to pay the assured sum of Rs.7,00,000/- towards death benefit along with Rs.30,000/- towards compensation for harassment and mental agony and Rs.10,000/- as cost of litigation in the best interest of justice.
3. Upon notice the O.Ps appeared through learned counsel Shri Bijaya Kumar Pattnaik, Advocate and filed version. In the written version/argument, it is stated that the allegations made in the complain petition are baseless, illegal, not convinced and not sustainable in the eyes of law. The complainant has no locus standi to file the present proceeding. The complaint is bad for non joinder of necessary party and is liable to be dismissed. The policy No. 573480943 was purchased by one P.Satyanarayan Prusty of Polasara, Dist: Ganjam. The Deceased Life Assured (For short, DLA) has nominated Smt. P.Usharani Prusty, the present complainant of this case as the nominee and the relationship mentioned as wife. The policy was procured through agent code No.0090158F but it is not a fact that the proposal form was entered/ filled up by the agent and the policy holder simply signed the same. So far as the Para No. 3 & 4 of the petition are concerned, there is no dispute relating to the contentions of the said paragraphs. In Para Nol.5 the DLA was examined by empanelled doctor of the LIC of India Sri P. Das, Sheragada but the DLA has suppressed the material facts of his ill health to question No. 5 (a), (b), (d) & (e). In para No. 6,7,9 & 10 of the complaint petition, the O.Ps do not want to dispute the contentions. As per the Medical Attendant’s certificate of Tata Memorial Hospital, Mumbai the disease and the duration of illness is approximately 10 months before death which is very much clear that the DLA was suffering from the disease (Metastasis right breast carcinoma) much before the commencement of the policy i.e. on 28.05.2012 taking the provisions of dating back, the premium deposited in August 2012 (in different dates) and he was died on 23.02.2013. Actually, the premiums deposited about before 6 months from the date of death. It is not a fact that the Manager (Claims) vide office Letter No.1125 dated 30.03.2015 intimated the complainant regarding admission of the claim under the policy in dispute and communicated the admission of other policy bearing No.572550030 on the life of the DLA and requested to submit the discharge voucher at our Aska Branch for the settlement of the death claim. The policy in dispute was repudiated on the grounds of suppression of material facts of ill health and the decision to this effect was communicated to the complainant vide office letter dated 30.03.2015 of LIC of India. The LIC of India had intimated the decision of repudiation vide office letter dated 30.03.2015 and also mentioned the details of authority to whom the representation can be made, if she is not satisfied with the decision within three months from receipt of the letter. The Zonal Office of the LIC of India has respondent to the appeal of the claimant vide their letter dated 5.2.2016. So far as Para No.14 of the petition is concerned, the O.Ps have no dispute. As the DLA was not well and was undergoing treatment much before inception of the policy in question and has suppressed the material facts of his ill health to defraud the corporation, the claim has been repudiated. So there is no question of deficiency of service and harassment. All the averments made therein the complaint are baseless, wrong and are emphatically denied. The complainant is not entitled to any relief whatsoever and is not entitle to claim and recover anything from the answering O.Ps in the light of what is stated above. Hence the O.Ps prayed to dismiss the complaint with costs after considering all the facts and circumstances of the case in the interest of justice.
4. On the date of hearing we have heard the learned counsel for the complainant and the learned counsel for the O.Ps are found absent on repeated calls. In fact the learned counsel for the O.Ps were directed to remain present without fail for final hearing of the consumer dispute but in spite of the directions on dated 26.07.2017 and 04.09.2017 respectively the O.Ps failed to represent their case. We, therefore, decided to dispose of the case on merit on hearing the learned counsel for the complainant and going through the materials placed on the case record.
5. On merit and on perusal of the documents we find that in this case the present complainant is the widow and nominee of deceased policy holder P. Satya Narayan Prusty who had insured his life with O.Ps vide policy No.573480943 on payment of Rs.38,080/- towards annual premium for an assured sum of Rs.7,00,000/- under plan term 162-25-16 dated 28.05.2012. During the course of hearing the learned counsel for the complainant submitted that when the policy was in force the deceased policy holder while undergoing treatment at Mumbai Hospital all of sudden died due to sickness on dated 22.02.2013. After death of the deceased policy holder the nominee widow complainant submitted the death claim before O.P.No.2 who in his letter dated 30.03.2015 informed the complainant that her claim is admitted by the competent authority and directed her to submit the discharge voucher at Aska Branch Office immediately for settlement of the claim. However on 30.03.2015 in another letter bearing No.REF.BDO/Claims/Rep/Aska of O.P.No.2 repudiated the claim of the complainant on the plea of suppression of material fact. It is also a fact placed on record that prior to the present claim, the O.P. Insurance Company had settled another five policies of the complainant vide policy Numbers 580507150, 571004604, 571004603, 572565037, and 572550030 respectively. The learned counsel for the complainant has also filed a number of decisions of Hon’ble National Commission in support of his argument reported in 2014(3) CPR 1 (NC) in the case of Abdul Latheef & Ors versus Life Insurnce Corporation of India, in the case of Manager, Bajaj Allianz Life Insurance Co. Ltd & Ors versus Mrs. Raj Kumar R/o Baran reported in 2014(CPR) 178 (NC), in the case of Oriental Insurance Co. Ltd versus Itrawati and Anr reported in 2014(3) CPR 131 (NC), and in the case of M/s Kamboj Ultra Sound & Diagnostice Pvt. Ltd reported in 2014 (3 ) CPR 732 (NC) respectively and prayed to direct the O.Ps to settle the claim of the complaint with cost and compensation.
6. On the contrary, as per the written arguments of the learned counsel for the O.Ps, the deceased policy holder was suffering from metastasis right breast carcinoma prior to taking of the policy and he was undergoing treatment at Tata Memorial Hospital, Mumbai. In fact, as per the death certificate the deceased was died at Mumuai. It is also submitted that insurance policy is issued on good faith and the deceased policy holder suppressing the previous disease obtained the insurance policy fraudulently to defraud the insurance company. Due to suppression of previous disease by the deceased policy holder the insurance company has rightly repudiated the claim of the complainant and there is no deficiency in service on part of the O.Ps hence the complaint of the complainant may be dismissed with cost.
7. We have heard the above submissions and thoughtfully considered the same. We have also gone through the materials submitted by both parties in support of their case placed on the case record. In view of the above submissions and considering the fact and circumstances of the case, the issues that are crop up for our consideration as to - (i) whether in this case there was suppression of material disease by the deceased policy holder prior to taking of the insurance policy in dispute? And (ii) whether in this case the nominee widow complainant is entitled for the claim amount along with cost and compensation, if any?
8. To adjudicate the first issue in dispute as framed above, we would like to say that in this case the deceased policy holder obtained the policy on 28.05.2012 for an assured sum of Rs.7,00,000/- on payment of Rs.38,080/- towards annual premium which is not at all in dispute. It is also a fact beyond any doubt or dispute that prior to issue of the aforesaid insurance policy the penal doctor of LIC, Dr. P. Das, Medical Examiner, P.H.C., Sheragada had examined the health conditions of the deceased policy holder and certified to issue the policy in favour of the deceased. However, the deceased policy holder unfortunately died on 23.02.2013 at Mumbai while under treatment as is evident from the death certificate issued on 22.03.2013 by the Municipal Corporation of Greater Mumbai placed on the case record. In this connection, we would like to view that there is no doubt that this is an early claim made by the nominee complainant since the deceased policy holder was died only after seven months of commencement of the policy in dispute. But as per contentions of the learned counsel for the O.Ps, we are not convinced that there was suppression of material fact, since there is no documentary evidence placed on record to prove the same. The learned counsel for the O.Ps though pleaded that the deceased policy holder was suffering from ‘Metastasis right breast carcinoma’ much before the commencement of the policy but failed to substantiate his contentions with documentary evidence since the onus probandi heavily lies on the O.Ps to prove that there was suppression of previous disease by the deceased policy holder. Besides, it is also a fact that when the claim was intimated to the O.P.No.2, the said O.P. as per his office letter dated 30.03.2015 informed to have admitted the claim of the complainant but on the same day vide Letter No.REF:BDO/ Claims/Rep/Aska dated 30/03/2015 repudiated the claim on the ground of suppression of previous disease. Similarly, as per written argument of the learned counsel for the O.Ps the claim of the complainant was repudiated due to suppression of material disease prior to taking of the policy in dispute and it was specifically submitted by the learned counsel that as per the medical attendance certificate of Tata Memorial Hospital, Mumbai the disease and duration of illness was approximately 10 months before death which is very much clear that the DLA was suffering from the disease (metastasis right breast carcinoma) much before the commencement of the policy. However, on perusal of case record we could not find a single scrap of paper in support of his pleadings which miserably failed to corroborate his arguments. On our query to produce the documentary evidence of treatment, the learned counsel for the O.Ps failed to produce any treatment paper except the death certificate which is also filed by the complainant. The learned counsel though pleaded that the Diseased Life Assured was suppressed material disease prior to taking of the policy but he failed to produce any documentary evidence thereof except the death certificate. It is also a fact that the learned counsel for the O.Ps has not filed any report of treatment of the diseased policy holder hence we feel that there is no force in the argument of learned counsel for the O.Ps. In view of the foregoing discussions and deliberations, we are not convinced to accept the arguments of the learned counsel for the O.Ps that there was suppression of disease by the deceased policy holder since the pleadings are not supported with documentary evidence. That apart, it is also a fact not in dispute that the panel doctor of LIC, Dr. P. Das, Medical Examiner, P.H.C., Sheragada had examined the health conditions of the deceased policy holder prior to taking of the policy from the insurance company. We are of the considered view that when prior to issuance of the policy by O.Ps, if the panel doctor of LIC had examined the health conditions of deceased policy holder, the insurer can’t repudiate the claim of the complainant on the ground of suppression of previous disease. In the light of foregoing discussions, when the learned counsel for the O.Ps failed to prove his case with documentary evidence, the complainant is entitled to get assured claim amount of Rs.7,00,000/- along with interest. Our finding is fortified with the decision of Hon’ble National Commission in the case of Life Insurance Corporation of India versus Smt. Chandra Baghrecha reported in IV 2003 CPJ 16 (NC) where it was held that ‘in case if the policy was issued by insurer after examination of health conditions of deceased policy holder by the panel medical examiner, the O.P. insurance company is liable to settle the claim of complainant’. We have also gone through the citations filed by the learned counsel for the complaint placed on the case record as discussed above and on going through the same we find that the said citations are not applicable to this case due to distinguished factual differences of those cases to that of the present case in hand hence we are not inclined to accept the same.
9. With regards second issue as framed above, we would like to view that in this case the complainant has prayed for a sum of Rs.30,000/- towards compensation and Rs.10,000/- for cost of litigation. On perusal of the complaint and arguments of the learned counsel for complainant we find that the complainant has not prayed for interest on the claim amount hence we are not inclined to direct the O.P. insurance company to pay interest on the claim amount. Similarly, in this case we are convinced that the complainant is entitled for cost of litigation to be paid by the O.Ps since the complainant has hired the services of a professional Advocate to file his case in this Forum and has incurred expenses towards payment of court fee and other incidental expenses to asset her right. Accordingly, we feel that a sum of Rs.2,000/- only will be just and proper towards cost of litigation to be paid by the O.Ps to the complainant. However, since the complainant has not prayed for interest on the claim amount and only prayed to direct the O.Ps to pay Rs.30,000/- towards compensation for harassment and mental agony, we are constrained to award an amount of Rs.5,000/- as compensation for harassment of complainant due to delayed settlement of the death claim. In a sequel to the above discussions, deliberation and considering the fact and circumstances of the case we allowed the case of the complainant against the O.Ps who are jointly and severally liable to pay assured claim amount of Rs.7,00,000/- to the complainant along with compensation and cost of litigation as discussed above.
10. In the result, we direct the Opposite Parties who are jointly and severally liable to pay the assured claim amount of Rs.7,00,000/- (Rupees Seven Lakhs) only to the complainant along with Rs.5,000/- only towards compensation and Rs.2,000/- only for cost of litigation. The above order shall be complied by the O.Ps within 45 days from the date of receipt of this order failing which the complainant is at liberty to recover the aforesaid amounts under Section 25/27 of the Consumer Protection Act, 1986. The consumer complaint of the complainant is disposed of accordingly.
11. The order is pronounced on this day of 25th November 2017 under the signature and seal of this Forum. The office is directed to supply copy of order to the parties free of cost and a copy of same be sent to the server of
