Jharkhand

Bokaro

CC/18/111

Sri Sunny Kumar - Complainant(s)

Versus

Branch Manager, Life Insurance Corporation of India - Opp.Party(s)

S K Pandey

24 Mar 2022

ORDER

1. Complainant has filed this case with prayer for direction to O.Ps. to pay death claim to the complainant on account of the death of policy holder of policy No. 547409176 and to pay Rs. 2,00,000/- as compensation to the complainant.

 

2. Complainant’s case in brief is that mother of the complainant was Sona Devi who has taken LIC Policy on 10.02.2011 having policy No. 547409176 for sum assured Rs. 1,60,000/- and quarterly premium was Rs. 4000/-. Further case is that at the time of taking policy age of the insured was 53 years who was examined by the Medical Officer of the LIC, thereafter policy was issued. Further case is that on 10.12.2013 and 16.09.2014 due to nonpayment of the premium policy was lapsed but it was again revived after payment of all dues with interest etc. and at the time of revival mother of complainant was again examined by the Medical Officer of the LIC and it was found that she was fit for continuance of policy. Further case is that due to Cardio respiratory failure mother of the complainant died on 11.03.2015 thereafter, being nominee of the policy holder, complainant applied for payment of death claim but it was rejected on the ground that insured has suppressed material facts from the LIC regarding her previous illness. Hence it caused to file this case.

 

3.  As per W.S. of the O.Ps. case is not maintainable and complainant has made false, frivolous allegations before this Commission. Further reply is that the deceased has taken alleged policy on 11.02.2011 and complainant is recorded nominee of the policy bond. It is also reply that the deceased was examined by the Doctor of the LIC at the time of issuance of the policy and thereafter on its revival but said examination was only age related medical examination on the basis of personal statement as well as age of the deceased. Further reply is that in the personal statement Sona Devi has not disclosed her past illness history related with COPD, DM & HTN. Further reply is that as per medical book issued by Bokaro General Hospital (in short BGH) deceased was treated for COPD/HTN/DN since 14.10.2013 but it was suppressed at the time of revival of the policy in question. Hence due to suppression of material facts related to illness at the time of revival of the policy claim has been rejected which is lawful. Hence it is prayed to dismiss the case.

 

4.   As documentary evidence following documents have been filed on behalf of complainant:-

 

1. Photo copy of the Insurance policy.
2. Photo copy of death Certificate of Sona Devi.
3. Photo copy of claim rejection latter dt. 19.03.2016.
4. Photo copy of the claim rejection latter issued by Zonal Office on 29.12.2016.

5. On behalf of O.P. either on demand or suo moto by the complainant following papers have been filed:-

1. Photo copy of Medical Examiner’s confidential Report dt. 10.02.2011.
2. Photo copy of receipt dt. 16.09.2014.
3. Photo copy of revival view slip dt. 12.08.2014.
4. Photo copy of receipt dt. 19.08.2014.
5. Photo copy of receipt dt. 12.08.2014.
6. Photo copy of policy revival application dt. 12.08.2014.
7. Photo copy of Aadhar Card of the Sona Devi.
8. Photo copy of Medical Examiner’s confidential Report dt. 12.08.2014.
9. Photo copy of special Medical Report dt. 13.08.2014.

Photo copy of format by which ECG report of Sona Devi was recorded on 13.08.2014.

10. Photo copy of Medical book of the deceased Sona Devi   

maintained by the BGH.

11     Photo copy of death claim review slip prepared by the LIC.

12 Photo copy of investigation report prepared by LIC Officials in          

      respect to claim of the complainant.

 

6. Except above mentioned documents no any other evidence has been produced by any of the parties.
7. On basis of the pleadings of the parties we are of the opinion that only question for determination is whether repudiation of death claim by the O.P. is justified or not ? And whether complainant is entitled to get any relief or not?
8.  On careful perusal of the pleadings of the parties it is apparent that following facts are admitted facts in this case.

1. That Sona Devi has obtained insurance policy on 10.02.2011 vide policy No. 547409176.
2. That at the time of proposal for the LIC policy age of the Sona Devi was 53 years.
3. That at the time of opening of the policy apart from declaration by the Sona Devi she was also examined by the Medical Officer of the LIC and at that time she was found quite fit and healthy for the purpose of issuance of policy.
4. That after full satisfaction by the O.P. (LIC) above mentioned policy was issued.
5. That premium for the policy was Rs. 4000/- per quarter which was paid regularly till before 10.12.2013.
6. That sum assured under policy was Rs. 1,60,000/-.
7. That On 10.12.2013 and 16.09.2014 due to nonpayment of  the premium in time policy was lapsed.
8. That again on request of the Sona Devi original policy No. 547409176 was revived twice.
9. That at the time of revival of the LIC Policy Sona Devi was repeatedly examined by the Medical Officers of the LIC.
10. That at the time of revival of the LIC Policy pathological tests and ECG was also done by the LIC to insure regarding good health and eligibility of the Sona Devi for revival of the policy.
11. That complainant Sunny Kumar is nominee of the said policy.
12. That Sona Devi died on 11.03.2015.

9. In light of above mentioned admitted facts we would like to examine the claim of the complainant. It is important to note here that sum assured is Rs. 1,60,000/- and till death deceased has deposited about Rs. 69,000/- in the office of the O.Ps. as premium as well as revival cost etc. Another important fact is that there is no case regarding issuance of fresh policy rather in this case original policy No. 547409176 has been revived. In this way the policy which was opened on 10.02.2011 was continuing till death of the insured. There is no any evidence either oral or documentary to show that on the date of opening of the policy deceased was suffering with any vital illness. If for the sake of argument the contention of the O.P. that deceased was diagnosed on 24.10.2013 regarding illness related to COPD/HTN/DM, then also it is apparent that prior to 24.10.2013 there was no such illness. It is also important to note here that on the first date of revival of the insurance policy i.e. on 10.12.2013 more than 2 years period was expired from first day of the opening of the insurance policy.
10.  Taking the case with another angle  it is apparent from the papers submitted by the O.Ps. that at the time of revival of insurance policy Sona Devi was examined by the Medical Officer of the LIC who also conducted ECG and got other pathological test to satisfy that she is fit for renewal of the policy. Hence contrary to it O.Ps. cannot be allowed to say some things else.
11.  On perusal of the copy of death claim review sheet prepared by the O.Ps. it appears that the first examining officer of the LIC found the claim genuine and forwarded it to his Senior officer for further processing. NOTES & DECISIONS SHEET prepared by the office of the O.Ps. shows that by same sheet claim related to late Sona Devi was examined in respect to two insurance policies one is policy No. 547409176 issued on 10.02.2011 and another is policy No. 548211422 issued on 28.03.2013 but surprisingly the claim in respect to second policy has been allowed mentioning therein that “ we do not have any evidence on record which can prove that the I.A. had been suffering from ill health prior to the commencement of this policy so benefit of doubt may be given in this case”. In this paper at the beginning of the notes it has been mentioned that “ as per the report of I.O., the claim seems to  be genuine”. In this way it is apparent that for the claim of the LIC policy of same deceased LIC has adopted dual stander and the claim of the policy which was opened more than two years earlier has been refused but the claim on the policy which was opened after more than two years period of the first policy  has been allowed finding no any defect or suppression of material fact related to any illness. In this way the rejection of the claim on previous policy appears to be arbitrary and unlawful.
12.   On behalf of  complainant reliance has been placed on the principles laid down by the Hon’ble Orisa High Court reported in A.I.R. 1993 Orisa 103, Hon’ble Rajashthan High Court reported in 2006 A.C.J. 241 & 2006 A.C.J. 100. Facts and circumstances of above noted cases are different from the facts and circumstances of present case as indicated above hence those principles are not helpful for  the purpose of this case.
13.   In light of above discussion taking the matter as a whole it is apparent that there is no justification of the O.Ps. in rejection of the claim and there is apparent deficiency in service by the O.Ps. hence complainant is entitled to get relief as claimed.
14. Accordingly, the prayer made by the complainant is being allowed in the following manner:-

O.P. No.1 and 2 are directed to pay Rs. 1,60,000/-(Rs. one lac and sixty thousand) with all other accrued benefit on the policy No. 547409176 within 60 days from today to the complainant, failing which they shall pay interest thereon @ 10% per annum from 04.09.2018 till realization of the money. Further O.P. No.1 &2 are directed to pay compensation of Rs. 10,000/- within 60 days from today.