For Complainant : Sri Ashok Mishra, Advocate and associates.
For OP No.1 to 3 : Sri M. Ravindra, Advocate & associates. -x-
1. The brief history of the case of the complainant is that she is the widow of late Khetra Mohan Madala and Khetra Mohan during his life time had obtained an insurance policy from the Ops vide Policy No.573309997 commencing from 20.07.2014 for a sum assured of Rs.15, 30,000/- under which the present complainant was nominee. It is submitted that during existence of the policy, the policy holder died on 08.05.2015 due to Cardiac Arrest i.e. heart failure at Visakhapatnam and the complainant being the nominee submitted claim application before the OP.2 along with relevant documents but the OP.3 vide its letter dt.15.05.2018 repudiated the claim stating that the deceased Khetra Mohan was under treatment from 13.09.2012 to 16.09.2012 for some ailments. The complainant further submitted that the death of the deceased was natural and one investigating agency has submitted report that the deceased had no previous critical ailment for which other insurance claims of the deceased have been settled. Thus alleging deficiency in service on the part of the Ops she filed this case praying the Forum to direct the Ops to settle the claim as per sum assured of Rs.15, 30,000/- and to pay Rs.2, 15,000/- towards compensation and cost to the complainant.
2. The Ops filed counter in joint admitting the policy issued in favour of Khetra Mohan Madala who was the late husband of the present complainant. It is contended that the death of the policy holder was not natural and the allegation that the Ops did not settle the claim intentionally is not true. The Ops contended that while availing the policy the Life Assured had given wrong information regarding his health condition and on verification of medical papers of the DLA it was found that he was undergoing treatment from 13.09.2012 to 16.09.2012 at Sidhartha Hospital, Visakhapatnam for various illness and the DLA was continuously under treatment in the said hospital for various illness including Acute Respiratory Distress Syndrome (ARDS) even after taking the policy. It is also further contended that the policy is basing upon false information given by the life assured and hence they rightly repudiated the claim of the complainant. Thus denying any deficiency in service on their part the Ops prayed to dismiss the case of the complainant.
3. Both the parties have filed certain documents in support of their respective cases. The Ops filed affidavit. Heard from the parties through their respective A/Rs and perused the materials available on record.
4. In this case it is admitted facts that the husband of the complainant during his life time had obtained LIC policy from the Ops vide Policy No.573309997 commencing from 20.07.2014 for a sum assured of Rs.15, 30,000/- with yearly mode of premium of Rs.1, 25,283/- and the life assured died on 08.05.2015 due to cardiac arrest in Sidharth Hospital at Visakhapatnam. The complainant submitted claim application before the LIC, Jeypore and as per advice of Divisional Office of LIC, Berhmapur, the complainant has submitted relevant documents. The case of the complainant is that the Divisional Office, Berhampur on 15.05.2018 i.e. after a long interval has repudiated the claim on the ground that the LA was treated from 13.09.2012 to 16.09.2012 at Sidharth Hospital, VSP which is prior to taking policy for various types of illness and he was continuously under treatment in the same hospital even after taking the policy but the fact of his sufferings prior to taking policy was not disclosed at the time of taking the policy. It is found that in support of repudiation letter dt.15.05.2018, the Ops have supplied the relevant treatment papers to the complainant obtaining from Said hospital and also Ops have filed the same papers in support of their case.
5. We have carefully examined the relevant papers. The policy of the LA, Khetra Mohan Madala was commenced from 20.07.2014 and the Ops have stated that the complainant was under treatment from 13.09.2012 to 16.09.2012 at Sidharth Hospital. It is found that no Medical Record/Sheet in the name of LA has been filed by the Ops. In this medical paper so filed by the OPs, Registration No., Age, Sex, Religion, Home Address and other details are to be recorded in order to know the patient. The Ops have only filed the Progress Note of the said hospital where in no such information is available. This is a prescription type document for outdoor patients and no treatment details are available in that paper. Provisional Diagnosis, final diagnosis or date of admission and date of discharge are also not available in that document which has been relied by the Ops in support of their case that the LA was under treatment prior to taking the present policy. However, on perusal of that prescription which does not bear the name of any patient it was found that only 3 medicines have been prescribed for 4 days i.e. from 13.09.2012 to 16.09.2012. The medicines are Ciproflex, Zincovit and Atarax. As ascertained, Ciproflex is an antibiotic, Zincovit is a multi-vitamin and Atarax is an antielergic medicine. Those medicines are very common and can hardly be prescribed to any major disease. However, the Ops at para-3 of their counter stated that as per information gathered by them, the LA was treated from 13.09.2012 to 16.09.2012 at Sidharth Hospital for various illnesses. The Ops therefore, neither filed any authentic document in the name of LA nor disclosed the name of any disease for which the LA was under treatment in the said hospital prior to taking the policy.
6. From the above discussions we have no scope to rely or believe on the medical paper submitted by the Ops claiming treatment of LA in the Sidhartha Hospital from 13.09.2012 to 16.09.2012. Further the said paper does not indicate any kind of evidence that the said paper is issued in favour of the LA, Sri Madala. Except that paper, no such other papers is filed by the OPs in support of their case that the LA was treated at any hospital for any serious illnesses prior to taking the policy.
7. In absence of any cogent evidence in support of the case of the Ops, it can be safely concluded that the LA was not being treated at any hospital prior to taking the policy. In the above premises, the citations filed by the Ops in support of their case have no relevancy in this case to be considered. In the same manner, we further come to the conclusion that the answers to the questions given by the LA in the proposal form dt.20.07.2014 regarding his state of health are all true and correct.
8. While coming to the other aspect of the case, it is seen that the LA had proposed a policy for a sum assured of Rs.15, 30,000/- and the yearly premium of Rs.1, 25,263/-. It was a very big policy and the Ops before proposal must have examined the health condition of the proposer by a competent doctor but they are not showing the medically examined report in this case. If they have not conducted any medical examination regarding health status of the proposer, they have committed a wrong. In our opinion, doctor’s advice in such a huge policy is necessarily required. If they hide the doctor’s certificate or omit to do so, they cannot escape from the liabilities.
9. It is seen from the record that the complainant had obtained some other life insurance policies from other Companies. One of them is policy No.21542621 dt.29.03.2015 obtained from PNB MET LIC Ltd. The concerned insurance Company after receiving the claim application from the complainant had engaged Total Transparency Investigation Pvt. Ltd. as investigator. The said investigating agency has given an elaborate report containing 6 pages in which it is stated that after a thorough enquiry from different angles they come to the conclusion that the LA had not suffered from any critical illness in the past. The Agency further observed that on 07.05.2015 all of a sudden, the LA suffered from severe chest paid and his health condition got worsened. Immediately LA’s family called for a local Pharmacist who examined the LA and advised to take the LA to a higher centre. Thereafter LA was shifted to Sidhartha Hospital, VSP and was admitted for one day and on 08.05.2015 the LA could not recuperate from his illness and died in the said hospital.
10. While processing the claim application, the present Ops could have taken the final investigation report of Total Transparency Investigation Pvt. Ltd. dt.23.09.2015. The learned Advocate for the complainant submitted that as SA of the polcy under PNB MET was Rs.68.00 lacs, a Consumer Complaint No.79/2016 was filed before the Hon’ble State Commission, Odisha, Cuttack and due to non filing of counter by PNB MET LIC Ltd., the case went against the said Insurance Company. The Insurance Co. preferred F.A. No.1733/2017 against the order of the Hon’ble State Commission before the Hon’ble National Commission and the order of the State Commission was up held by the Hon’ble National Commission. Then the said Insurance Co. went to Hon’ble Supreme Court of India where the case is pending for disposal. As per directions of the Hon’ble Supreme Court, the said Insurance Co. has paid Rs.20, 000/- to the complainant as cost before admission of the case.
11. Further the LA had two other insurance policies with Star Union Dai-ichi LIC Co. one is for a SA of Rs.10, 00, 000/- and other is for a SA of Rs.3, 00,000/- and the said Insurance Co. has settled the claims under both the policies in favour of the complainant vide Claim Id.501741 SOL-ID 01570 and BOICBD/2014-15/33 SOL-ID01570 Mumbai (Maharastra) respectively. The complainant submitted that the claims under both the policies have been settled by the said Insurance Co. in favour of the complainant-nominee.
12. From the above discussions it was ascertained that the complainant-nominee has also received claim amounts under above policies. In our opinion, the present Ops at the time of processing the claim must have a cursory look to the other policies of the DLA if obtained from any Company at any point of time during his life time. Their status must be read before repudiation of the claim otherwise the repudiation would be mechanical and not based on proper application of mind besides thorough investigation.
13. The Ops in their counter stated that the LA was under treatment in the same hospital for various illnesses including Acute Respiratory Distress Syndrome (ARDS). On verification of case record of the hospital it was found that on 07.05.2015 when the LA was admitted in Sidhartha Hospital doctor’s final diagnosis was “Fever with ARDS”. It is an admitted fact and also revealed from the investigation report that the LA suffered severe chest pain on 07.05.2015 all of a sudden and his health condition got worsened for which he was shifted to Sidhartha Hospital, VSP. The LA died on 08.05.2015 due to Cardiac Arrest. Dr. Raj Kumar Panda of said hospital who is the attending physician issued certificate stating that the immediate cause of death is “Cardiac Arrest”. This certificate has been obtained by Max LIC Ltd. under whom the LA had a policy bearing No.253238265.
14. From the above discussions, we come to the conclusion that the DLA died on account of Cardiac Arrest which was found only two days prior to the date of death. This disease was not prevailing when the proposal form was filed. No treatment paper or proof of his treatment in the year 2012 has been filed. Further other Insurance Companies have settled the claim of the complainant without any objection after conducting due enquiry and investigation but the Ops in this case have repudiated the claim on 15.05.2015 without proper evidence. In our opinion, the conduct of the Ops in repudiating the claim amounts to unfair trade practice and deficiency in service on their part due to which the complainant suffered harassment, inconvenience and mental torture. Therefore, the complainant would be entitled to get the SA of Rs.15, 30,000/- with other benefits under the policy and interest besides cost of this litigation.
15. Hence ordered that the complaint petition is allowed in part and the Ops 2 & 3 being jointly and severally liable are directed to pay the SA of Rs.15, 30,000/- plus benefits attached to the policy with interest @ 9% p.a. from the date of repudiation i.e.15.05.2018 and to pay Rs.5000/- towards cost of this litigation to the complainant within 30 days from the date of communication of this order. No compensation is allowed since the interest is paid in this case.
(to dict.)
