IN THE COURT OF THE PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,KEONJHAR
CONSUMER COMPLAINT CASE NO. 21 of 2018
Jadumani Behera,aged about 45 years
S/O-Late Ghasinath Behera
F/O-Late Namita Behera nominee of deceased policy holder
At/ Po/P.s- Telkoi
Dist-Keonjhar ,… ……….……….………………….…………...…..… Complainant
Versus
1.Branch Manager,
LIC of India, Keonjhar
Keonjhar Branch, At-Mandua, Po-Keonjhargarh,
P.S-Town, Dist-keonjhar
2. Divisional Manager,
Cuttack Divisional office
Jevan Prakash, P.O Box no-36
cuttack ,753001………………….……….……………………………..Opp. Parties
Present:
Smt. B.Giri, President (I/C)
Sri Bharat Bhusan Das (Member)
Advocate for complainant- G.N Gena
Advocate for Op1 & Op2 - T.K Mohapatra & P.K Jena
Date of hearing - 23.09.2019 Date of Order- 11.11.2019
B.Giri President (I/C)-
Briefly the facts raised to present complaint is that one Namita Behera had taken a jeevan saral LIC policy on payment of Rs 2,940/-as yearly premium against sum assured of Rs 62,500/-which commenced from 28.01.2011 to till maturity date i.e 28.01.2025 who suddenly fell ill and got admitted in Dist Head Quarter Hospital, Keonjhar for her treatment on 3.7.2013 with a complaint of stomach pain and the treating physician after administrating medicine diagonise that policy holder is suffering from SCD VOC and District Head quarter Hospital referred her to SCB Medical for better treatment but due to poverty the family members of the policy holder could not able to take her to SCB for better treatment as such on 4.7.2013 policy holder declared medically dead by the treating physician.
After funeral ceremony the present complainant who is father and nominee of the complainant filed claim before Ops who instead settling the claim delayed the grievance of the present complainant as such complainant filed complaint before LIC ombudsman on 13.8.2015 and awaited the decision of ombudsman for a long time and on 20.2.2018 could only became to knew that in the mean time ombudsman has already been rejected the complainant filed on behalf of the present complainant on a ground that it is not maintainable as per sec 13 (3) (a) of RPG Rule and finding no other alternative complainant filed this petition before this forum for redressal.
And to prove his case he filed and relied upon the following documents.
1.Xerox copy of policy Bond
2. Letter dt 20.2.2018 of insurance ombudsman addressed to complainant.
3.Corresspondence with ombudsman dot 8.8.2015
4. Letter dt 2.7.2015 of ombudsman addressed to complainant.
5. Letter dt 13.8.2015 of ombudsman
6. Correspondences of complainant with ombudsman dt 10.6.2015
7.Correspandence with Op1 and Op2 by the complainant - 2 sheets.
8.Letter of Op dt 31.3.2015 in the name of complainant regarding health querries.
9.Letter dt 8.8.2014 asking for all treatment particulars.
10.Letter of Op Branch Manager LIC dt 12/2013 regarding policy papers for settlement of claim.
11. Discharge ticket
12. Bed head ticket
13. Claimant statement
14. Medical Attendant statement
15. Certificate of Hospital treatment
16. Certificate of identity.
After notice the Ops appeared through their engaged advocate on 6.12.2018 and challenged the case of the complainant on the ground that there is no cause of action to bring this complaint against the Ops and the case is hopelessly barred by limitation and further submitted that the death claim was rightly repudiated on a ground that the deceased policy holder was suffering from sickle cell disease and veno occlusive crisis prior to taking policy which was suppressed by the policy holder and from Bed head of Dist Head quarter hospital, Keonjhar it could ascertain as such the death claim was repudiated and also intimated to the complainant and the repudiation of claim was also confirmed by ombudsman and hence this case be dismissed against these ops.
In support filed Bed Head ticket of District Head Qr Hospital, Keonjhar and receipt of Blood Bank,Keonjhar dt 3.7.13.
Heard both the counsels for the parties while the learned counsel for the complainant submitted that the repudiation of claim on the ground is illegal and improper the learned counsel for Ops submitted that by repudiating the death claim deceased policy holder on the said ground is not improper.
However on perusal of records and submission made by the learned counsel for parties the following material questions stood before us for proper adjudication of the present case,
1. Whether the complaint petition is barred by limitation.
2. Whether this forum empower to adjudicate the matter which was earlier decided by the ombudsman.
3. Whether repudiation of claim by the Op insurance Company on the ground stated there in is right and proper and if not what relief can be granted to complainant.
As regards to limitation the learned. Counsel for the Ops submitted that the case is hope lesely barred by time as the claim was repudiated since 31.3.2015 and this complaint having been filed much after two years. On the other hand counsel for the complainant submitted that as the matter was continuing and the order of ombudsman came to the knowledge of this complaint on 20.2.18 only after receipt of information called through RTI application and hence the cause of action is continuing and this complaint filed before this forum within limitation period from last cause of action and hence it can not be said that the complaint has been field after limitation period and we also found gravity on the submission made on behalf of the complainant and hence we held that the complaint filed can not be said that beyond limitation period
On the point of disputed raised by Op that matter can not be adjudicated by this forum as it has already been adjudicated by ombudsman is a question to be decided.
In this point the learned counsel for the Op submitted that after cremation of the deceased policy holder the nominee is the present complainant filed claim before Op and as the matter delayed the complainant approached to ombudsman and the ombudsman also rejected the claim on the self same ground taken by Op stating that as per sec 13 (3) of RPG Rule the present complaint is not maintainable and on the other side the learned. Counsel for complainant submitted that even through the matter decided by ombudsman this forum has ample power to adjudicate the matter and in support relied upon a decision which clearly says ombudsman is not a court as such this forum can sit over the order of ombudsman. Kamaleswari Prasad singh Vr National Insurance Co Ltd(NCDRC P747),Satram singh vr NI co Ltd. Order passed on 6th jan 2015(SCDRC Punjab complaint No 6 of 2014 para 25).
In this decision Hon’ble NCDRC consider various provision of rules and was pleased to hold in case of Kameshwari Prasad Singh Vr NI co Ltd 2005(1) CPJ 107(NC) in para 8,10,11,12 that ombudsman order is binding to insurance company but not binding to complainant and subject to adjudication by the fora constituted under CP Act.
The most important point left for our consideration is that repudiation of claim by the Op LIC on a ground that policy holder was suffering from SCD & VOC since her birth and only stands on Bed Head ticked of D.H.H, Keonjhar.
On perusal of said document it is seen that on 03.07.2013, 7:30 AM the deceased policy holder get admitted in the hospital with a complaint of pain in abdomen and the treating physician after administration of certain medicine could diagonise that the deceased policy holder was suffering from SCD & VOC but no where in the Bed Head ticket of D.H.H, Keonjhar it is mentioned that the policy holder was suffering said diseases since her birth and hence argument made by Op on the said ground can not be relied upon and further the learned counsel for the complainant led us through medical attendance certificate duly signed by medical officer where it is clearly mentioned in para 4 (c)(d)(e)(f) that she admitted with a complaint of abdomen pain and she had been suffering from these disease just before two days before her death. it is also ascertain from certificate of hospital treatment in para 2 (b) where treating doctor clearly stated that the duration of the complaint is before 1 day and Op is also failed to prove its case that the deceased was suffering from SCD since her birth and hence repudiation of claim on the ground that suppression of ailment during taking of insurance policy is not correct and this plea has been taken by Op Insurance Company is just to avoid their liability and to harass the complainant mentally and physically.
Under these facts and circumstances we have no hesitation to direct the Ops to pay the complainant the total sum assured amount of RS 62,500/-with 8% interest there on from the date of filing this case i.e 03.07.2018 to till realisation to meet the compensation for mental agony and harassment caused to complainant and further to pay Rs 2000/-towards cost of litigation within 30 days of receipt of this order failing which the entire amount will carry 10% interest till realization. The case is accordingly disposed off.
The order pronounced in open forum today i.e on 11.11.2019 under my hand and seal.
Pronounced on 11th Nov 2019
I agree I agree
( Sri B. B. Das) ( Smt B. Giri)
Member (I/C.,President)
DCDRF,Keonjhar DCDRF,Keonjhar
Dictated & Corrected by
(Smt B. Giri )
I/C (President)
DCDRF, Keonjhar
