1. Brief fact of the case of the Complainant is that her husband has opened 3 policies with O.P.No.1 vide (1) policy no. 571822815 for Rs. 1,25,000/-, (2) Policy no. 571817819 for Rs. 1,25,000/- and (3) policy no. 571818186 for Rs. 90,000/- and during the policy period, her husband was died on 10.08.2011 and after his death, being the legal heir / nominee, the Complainant submitted the claim application alongwith original policy bonds and other documents to the O.Ps for death claim of her late husband.  It is alleged that inspite of making payment, the O.Ps have repudiated the death claim vide their letter no. BDO/Claims/ dated 12.08.2014 stating that the policy holder was having diabetics, High B.P. and Asthma since last 7-8 years and letter no. BDO/Claims/Rep/JPR dated 24.03.2015 intimating that the policy holder was having Diabetes Miletus for 7 years, Hypertension for 3 years and Asthma for 7 years and the same were concealed in the proposal form before opening the policies.  It is also alleged that all the above mentioned policies were opened during the month of March, 2009 i.e. before 2 & half years from the date of death and the policy holder was never suffered from any diseases and the O.Ps have whimsically and arbitrarily  has repudiated the death claim of the policy holder.  Thus alleging deficiency in service on the part of O.Ps, Complainant has filed the present case claiming from the O.Ps to pay all the entitlements alongwith 24% interest from the date of claim till payment and Rs. 1,00,000/- towards compensation and Rs. 25,000/- towards cost of litigation to her.
    
2. On the other hand, the Opposite Parties appeared in this case, filed their joint written version admitting the issue of alleged insurance policies in favour of the deceased policy holder, have specifically denied that the insurance claim against all the above mentioned policies were repudiated on account of deceased policy holder having withheld material information regarding his health and disease at the time of effecting the assurance with them.  Also they have contended that since the death of the policy holder occurred within 3 years from the date of commencement of the above policies, as such they investigated into the genuineness of the cause of death and found that the deceased policy holder has suppressed the material fact of his suffering and treatment at the time of taking the policies.Further they have contended that the policy holder was suffering from Diabetes Miletus for 7 years, Hypertension for 3 years and Asthma for 7 years prior to death and also have contended that the policy no. 571822815 for Rs. 1,25,000/- was in lapsed condition, as such they have repudiated the death claims under all the policies and with other contentions, they have prayed to dismiss the case against them.

3. In the instant case, the Complainant has filed certain documents which were marked exhibits as C1, C2, C3, C4, C5, C6, C-7 and C8 for better clarification and the documents are :-

                         C1 -Xerox copy of correspondence made to O.P. No. 3

                           dated 03.08.2015,

C2 -Xerox copy of correspondence made to O.P. No. 2,

C3 - Copy of letter dated 12.08.2014 issued from the claim

department of O.P.No.2,

                      C4 - Copy of letter for repudiation of claim dated

                   C5 - Copy of policy contract,

                 C6 - Copy of proposal form,

                C7 -Copy of medical report of Gyana Ranjan Mohanty

                         issued by Deptt.of Cardiology of Apollo Hospital,

                  C8 - Copy of death certificate of Gyana Ranjan Mohanty

 to prove her case alongwith verdicts of Higher Forum, whereas the Opp. Parties did not choose to file any single documents to prove their contentions.  Heard from the parties through their respective A/Rs at length and perused the record and material documents available therein.       

4. In the instant case, there is no dispute regarding the issuance of 3 nos. of insurance policies in favour of deceased policy holder Gyana Ranjan Mohanty vide policy no. 571822815 for Rs. 1,25,000/-, policy no. 571817819 for Rs. 1,25,000/- and policy no. 571818186 for Rs. 90,000/- by the Opposite Parties.  There is also no dispute that during the policy period, the policy holder, husband of the Complainant was died and after his death, being the legal heir / nominee, the Complainant submitted the claim application and original policy bonds and other documents to the Opposite Parties for death claim of her late husband.  The allegations of the Complainant is that inspite of her submissions of relevant documents for settlement of death claim over the life of her late husband, the Opposite Parties have repudiated the death claim vide their letter no. BDO/Claims/ dated 12.08.2014 stating that the policy holder was having diabetics, High B.P. and Asthma since last 7-8 years and letter no. BDO/Claims/Rep/JPR dated 24.03.2015 intimating that the policy holder was having Diabetes Miletus for 7 years, Hypertension for 3 years and Asthma for 7 years and the same were concealed in the proposal form before opening the policies, whereas her deceased husband was never suffering from any diseases at any time prior to taking the insurance policies.  Whereas the Opposite Parties have strictly challenged the submissions of Complainant contending that the policy holder was having Diabetes Miletus for 7 years, Hypertension for 3 years and Asthma for 7 years and the same were concealed in the proposal form before opening the policies, as such they have repudiated the death claim vide their letter no. BDO/Claims/ dated 12.08.2014 and letter no. BDO/Claims/Rep/JPR dated 24.03.2015.  Further the Opposite Parties have contended that the policy no. 571822815 for Rs. 1,25,000/- was in lapsed condition, as such they have repudiated the death claims under all the policies on the point of suppression of material facts prior to taking the insurance policies.
    
5. So, now the question arose before us to decided that :
    
6. Whether the policy holder (deceased) was having the diseases like Diabetes Miletus for 7 years, Hypertension for 3 years and Asthma for 7 years at the time of submission of proposal form for obtaining insurance policies?
   
   a. Whether the policy no. 571822815 for Rs. 1,25,000/- was in lapsed condition at the time of death of policy holder?
   b. Whether the Complainant is entitled for the sum assured as per the insurance policies and other reliefs as claimed by her?

7.  For better clarification in regard to the first point, we have carefully gone through the material documents available in the record and found that though the Opposite Parties raised their voice on the point existing of diseases prior to taking the insurance policies, as claimed by them, but miserably failed to produce any supportive documents / any medical report to that effect.  Whereas the Complainant has filed the documents like exhibits C1, C2, C5, C6 & C7 which clearly indicates that the claim of Complainant regarding non existence of any diseases, as claimed by the Opposite Parties, with her husband / deceased policy holder.  Further we have gone through the documents filed the Complainant marked as exhibit C7 i.e. medical report of Gyana Ranjan Mohanty (deceased policy holder) issued by the Deptt. of Cardiology, Apollo Hospital, Bhubaneswar, which does not reveals any kind of diseases that the deceased policy holder was having like Diabetes Miletus for 7 years, Hypertension for 3 years and Asthma for 7 years prior to his death.  As such we feel that without any cogent evidence on medical report/ opinion, the plea of Opposite Parties cannot be accepted and will not do at any angle.  In this regard, the Complainant has filed a decision of Hon’ble State Commission, New Delhi reported in 2013(1) CPR 150, the case between Narayan Chimandas Bhambhani Vrs OrientalInsurance Co. Ltd & Ors, where in Hon’ble State Commission, New Delhi has held that “Once Insurance Company has accepted proposal it cannot go behind the same even if proposal is in violation of criteria mentioned in the insurance policy”.Further in the case between New India Assurance Co. Ltd Vrs Mohinder Kaur, Hon’ble National Commission has held that “Pre-existing disease must be proved by proper medical report”.Also in the case between Kamala Devi Vrs LIC of India & others, Hon’ble NationalCommission has held that “ Plea of suppression of pre-existing ailment must be  proved by cogent evidence”. As such without any cogent evidence from any medical expert, the plea of Opposite Parties regarding pre-existing disease of the deceased policy holder is not sustainable in the eye of law.Hence from the above discussions and as per the verdicts of the Higher Commission, we are not inclined to accept the versions of Opposite Parties and accordingly the answer goes in favour of the Complainant.
    
8. Now coming to the second point regarding lapse of policy no. 571822815 for Rs. 1,25,000/-, we have carefully gone through the counter version of the Opposite Parties and complaint petition the Complainant.  The contentions of Opposite Parties is that at the time of death of the policy holder, the policy no. 571822815 for Rs. 1,25,000/- was in lapsed condition, as such no death claim can be settled and also they have disputed the date of death of the policy holder, but they have not filed any single document to that effect.  Whereas, the Complainant has filed the document like copy of death certificate of policy holder marked as Ext. C8, which reveals that the date of death of Gyana Ranjan Mohanty (policy holder) was mentioned as 11.08.2011 and the same was issued by the Registrar, Births & Deaths, Bhubaneswar Municipal Corporation on 17.09.2011. Hence, it can be safely concluded that the date of death of policy holder is 11.08.2011. Further, the policy no. 571822815 for Rs. 1,25,000/- was issued on 22.09.2009 and the First Unpaid Premium (FUP) was occurred on 09/2011 after two years of his death, whereas the date of death of policy holder as revealed from the Ext. C8 is 11.08.2011, it is prima facie evident that the said policy became lapsed one month after the death of policy holder.In other way, it can be said that the death of policy holder was occurred prior to one month of lapse of said policy. As such in our view, the said policy was in force as on the date of death of policy holder and plea of O.P. disputing the date of the death is having no merit and accordingly, the answer goes in favour of the Complainant.
    
9. As per the discussions made in the foregoing paras, the answer of point no. 3 also goes in favour of the Complainant.
    
10. As per the discussions made in the foregoing pars, in our view, the Opposite Parties without going through the documents filed by the Complainant and without any proper medical verification have arbitrarily repudiated the death claim of the deceased policy holder in favour of the Complainant and have tried to play hide and seek game with the emotions of the Complainant, which they should not do at all.  Further, it is also seen from the documents filed by the Complainant i.e. Ext. C1, C2, C3 & C4 that the Complainant has moved from pillar to post to get her legitimate rights over the death claim of her deceased husband, leaving behind her emotions, her children’s future and non settling the above death claims the Opposite Parties have compelled the Complainant and her children to pass through drastic condition like financially, physically and socially, and in our view, this is a grave negligence and deficiency in service on the part of the Opposite Parties which they were not supposed to do, for which the Complainant was compelled to file the case incurring some expenses, as such she is entitled some compensation and costs.  Considering her suffering and mental agony, we feel an amount of Rs. 25,000/- towards compensation and Rs. 10,000/- towards costs of litigation will meet the end of justice.  Hence this order.

ORDER

        The complaint petition is allowed in part.  The Opposite Parties jointly and severally are liable to settle all the death claims of the life assured under all the policies i.e. (1) policy no. 571822815 for Rs. 1,25,000/-, (2) Policy no. 571817819 for Rs. 1,25,000/- and (3) policy no. 571818186 for Rs. 90,000/- in total Rs. 3,40,000/- in favour of the Complainant alongwith Rs. 25,000/- and Rs. 10,000/- towards compensation and costs of litigation, within 30 days from receipt of this order, failing which, the total insured amount of Rs. 3,40,000/- shall carry interest @ 6% p.a. from the date of filing of death claim by the Complainant till payment. 

Pronounced in the Forum on this the 29^th day of March, 2018.

        Issue free copy to the parties concerned.