1. The brief fact of the case of complainant is that he being the nominee and beneficiary on the life insurance policy obtained by his late brother Tapas Kumar Bagchi under salary saving scheme bearing policy no. 1Z6226355906 with premium of Rs. 22,885/- for sum assured of Rs. 6,50,000/-.  It is alleged that during the valid period of insurance policy, his brother (policy holder) died on 11.06.2021 and thereafter he lodged the death claim of his brother with the O.P. alongwith all the relevant documents and during investigation by the concerned investigator, he submitted all the documents which was acknowledged by the O.P. vide their letter no. 01.09.2021, but on April, 2022 the O.P. repudiate the insurance claim of his brother vide their letter no. 07.12.2021 on the ground of suppression of preexisting disease.It is also alleged that without his knowledge, the O.P. remitted an amount of Rs. 22,123.49 only into account of complainant instead of settling the death claim, thus showing deficiency in service on the part of O.P. he filed this case claiming the total sum assured of Rs. 6,50,000/- and also to pay Rs. 2,00,000/- and Rs. 50,000/- towards compensation and cost of litigation.

2. The O.P. appeared through their Ld. Counsel, filed their counter version admitting the issuance of alleged insurance policy in favour of deceased policy holder and they have repudiated the death claim in the month of April, 2022 vide their letter dated 07.12.2021, but denied the allegations contending that since the deceased life assured committed a breach of the principle of Utmost Good Faith by suppressing the material fact that he was suffering from Diabetes Mellitus, Digestive disorder, Liver disease and Anaemia and was taking treatment for the same prior to date of applying for insurance policy, they have repudiated the insurance claim on the ground of suppression of preexisting disease, thus showing their no deficiency in service, they prayed to dismiss the case.

3. Parties have filed their respective documents in support of their submission.  Heard from the parties at length.  Perused the case record and material available therein.

4. In the instant case, issuance of alleged policy bearing no. 1Z6226355906 with premium of Rs. 22,885/- for sum assured of Rs. 6,50,000/- is an admitted fact.  It is also an admitted fact that the death claim of policy holder was repudiated by the O.P. The allegation of complainant is that his deceased brother (DLA) had no pre existing disease at the material time of obtaining the proposal form by the O.P. but the O.P. has repudiated the death claim, is not justified.  Whereas the contention of O.P. is that the deceased policy holder had suppressed the material fact of preexisting disease prior to obtaining the alleged insurance policy.  Now the question arose to decide that

1. whether the deceased policy holder was having preexisting disease at the time of obtaining the insurance policy,
2. whether repudiation of death claim is justified,
3. whether complainant is entitled for death claim alongwith compensation and cost.

5. Coming to first point, we have gone through the documents filed by the O.P. and ascertained that the medical reports of deceased policy holder shows that he was underwent treatment for Diabetes Mellitus, Digestive disorder, liver disease and Anemia on different occasions, but all those documents does not disclose / reflect that alleged diseases were continuing since the date of treatment till the date of obtaining the insurance policy.  Further the medical documents filed by the O.Ps also do not disclose that the alleged diseases were chronic in nature and as per all the diseases were on periodical treatment basis.  Further it is ascertained from the investigation report filed by the O.P. i.e “claimants statement – death claim” which is investigated by one Sri Sandeep Mohanty on behalf of M/s Total Claims Solutions clearly shows that the deceased policy holder was suffering from Fever, Headache for two days i.e. 10.06.2021 & 11.06.2021 and was also treated under the medical supervision of Dr. Prafulla Kumar Behera, DHH, Malkangiri.  If the O.P.  had any doubt or suspect regarding the preexisting disease of the policy holder, than they could have obtained the certificate / consent of Dr. Behera who was treating the deceased policy holder just before the death of the deceased, but without obtaining the said certificate or any consent of Dr. Behera, the O.P. has filed such medical documents which do not disclose anything about disease which caused the death of policy holder.  
   
   Further as per the O.P’s document i.e. SBI Final Investigation Report wherein column A. Discreet Investigation Checks under (1) (a) reveals that “a. Life Assured – As per enquiries, LA was not suffering from any disease” from which it is also evident that the life assured was not having any preexisting disease, as per local enquiries being submitted by the O.P., which may be a cause for the death of life assured. As such without any cogent evidence, the plea of O.P. regarding pre-existing disease is not sustainable in the eye of law, as in the case between Usha Happa Vrs LIC of India and another, Hon’ble National Commission has held that “allegation of suppression of material fact has to be proved by cogent evidence”.  Hence it is can be safely concluded that the O.P. have miserably failed to establish their plea regarding suppression of material facts by the policy holder, so also the medical report of concerned Doctor produced by the O.P, failed to prove that the policy holder (deceased) had the alleged diseases at the material time of submit the proposal form or on the date of issuance of the alleged insurance policy.
   
   Since there is no cogent evidence that the DLA was having preexisting disease at the time of obtaining insurance policy and there is lots of lacuna in the investigation report done the concerned investigator, we do not think that the deceased life assured was having preexisting disease at the material time of obtaining the insurance policy.Accordingly, the answer goes in favour of the complainant.

6. Coming to the second point, we verified the counter version and the documents filed by the parties.  As per settled law it is the mandatory provision of any insurance company to obtain the health status of the proposer prior to issue of any life insurance policy.  But the instant case the O.P. in the line 4 para no. 6 of their counter version has admitted that “ x x x x x x The insurance cover was granted on non –medical basis.  It is humbly submitted that the medical tests are not mandatory for issuing a policy in all cases and whether a medical test is required to be conducted depends mainly on the age of the life to be assured, sum assured, term, details of personal history etc. and in the instant case, the insurance cover was granted on non – medical basis.  Whether a medical test has to be conducted in a given case depends entirely at the description of the insurer. x x x x x”.  From the above submission, it is clearly evident that the O.P. issues the insurance policy as per their own interest but not as per the requirement of the insured.  If the alleged policy is issued on non medical basis, then why and how the O.P. repudiate the death claim on the DLA, is a matter of surprise.  It is also feels that the O.P. do not obtain any medical test report where they think that no claim will be raised up in future and in our view, the same is not justified and not in accordance with the provisions of insurance law and also the medical jurisprudence emphasizes about the role of the insurer and their empanelled doctor during obtaining the proposal form, accepting the form, issuance of any insurance policy related to life and health.Without going through such provisions and guidelines, the repudiation of death claim of DLA, in our view, is not justified.
   
   Further medical jurisprudence emphasizes that “while examining a person for obtaining life insurance, there is often a set proforma issued by the life insurance companies which requests for height, weight, blood pressure, pulse rate, and urine analysis.  The applicant for life insurance cannot sue a medical practitioner if he incorrectly gives wrong information to the insurance company which leads to the rejection of the policy.  However, the medical practitioner has a duty of contract to the insurance company who is paying the fee to be conscientious and accurate.  Therefore, these examinations should not be performed in a casual manner.” 
   
   Further catena of verdicts of higher courts are also cited that after issuance of insurance policy, if the policy holder suffered any medical illness, then it cannot be said that he had suppressed the material facts.In the case between LIC of India Vrs Pankaj Pandey, Hon’ble National Commission also held the same view.Hence considering the above observation, we think, repudiation of death claim of insured (DLA), is not justified. Accordingly, the answer goes in favour of complainant.

7. Coming to the third point, as per discussions and observation made in foregoing paras, the complainant is entitled the death claim alongwith compensation and costs.

8. As per the discussions made in the foregoing pars, in our view, the O.P. have not properly and carefully gone through the medical certificate / documents obtained from the different medical and have tried to play hide and seek game with the emotions of the complainant, which they should not do at all and the said act of O.P. makes the complainant suffering from mental agony and physical harassment, which compelled the complainant to file the case incurring some expenses, as such he is entitled some compensation and costs. Considering his suffering and mental agony, we feel an amount of Rs. 50,000/- towards and compensation and Rs. 5,000 towards costs of litigation will meet the end of justice.Hence this order.

                                                                                                               ORDER

          The complaint petition is allowed on part.  The O.P. is herewith directed to settle the death claim of Rs. 6,50,000/- in favour of the complainant alongwith Rs. 50,000/- and Rs. 5,000/- to the complainant towards compensation and costs of litigation within 45 days from receipt of this order, failing which, the sum assured of Rs. 6,50,000/- shall carry interest @ 10% p.a. from the date of order till payment.    

Pronounced in the open Court on this the 30^th day of August, 2022. Issue free copy to the parties concerned.