SRI BIJOY KUMAR DAS,PRESIDENT:-
Allegation of deficiency in service in respect of illegal repudiation of claim of the Complainant on RPLI Policy are the allegations arrayed against the Opp.Parties.
2. Complaint, in brief reveals that, Complainant’s wife namely Gitanjali Jena insured her life under Rural Postal Life Insurance Policy bearing No. R-OR-EA-751735 for a sum assured of Rs. 1 lakh and the quarterly premium was fixed to Rs. 1088/-. Complainant’s wife Policy holder died on 18.02.2015 sustaining chest pain while she was on the way for medical treatment and on the advise of villagers/relatives the dead body was cremated in village burial ground without taking to the Hospital. Complainant received a certificate of cause of death from the local ‘Sarapanch’ and after arranging necessary documents i.e, Death Certificate, Legal heir certificate etc. lodged the Insurance claim on 29.08.2016 before Op No.3 Supt. of Post offices (North Division), Cuttack, but Ops vide their letter No. R-OR-EA-751735 dtd. 11.02.2017 informed the claimant-Complainant that his claim has been denied as premium has not paid in time, and death occurred within 3 months of taking of the Policy. Complainant also obtained certain information regarding non-settlement of claim under RTI and an appeal has been preferred before 1st appellate authority for more information. The cause of action of the instant case arose on 11.09.2017, when the Petitioner filed an appeal before the concerned authority vide letter No. PG/CKN/RTI-34/2017. In the complaint, it is prayed that a direction may be given to Ops for settlement of claim of the complainant with a sum assured of Rs. 1 lakh along with 12% interest and Rs. 25,000/- as compensation for mental agony.
3. Being Noticed Ops appeared through their Ld. Counsel and field joint written version into the dispute submitting the facts that, Complainant’s wife Late Gitanjali Jena was obtained a Rural Postal Life Insurance Policy (RPLI) with a sum assured of Rs. 1 Lakh and a quarterly premium of Rs. 1088/-. The proposal was accepted on dt. 17.11.2014 and her Policy No. is R-OR-EA-751735. The 2nd and last premium was deposited on dt. 16.02.2015 and the Policy holder died on dt. 18.02.2015. It is averred that under Rule-53 of RPLI Rules-2011 as the Policy holder dies within 3 years from the acceptance of Policy, the claim of the complainant needed a thorough enquiry, specifically to know whether the Policy-holder has obtained the Policy by suppressing the material facts of any pre-existing disease. In the written version, Ops also challenge the place of deposit of premiums and after completion of Departmental enquiry, the claim was rejected by Op No.4 with the reason that the premium was not paid in time and the Policy bond was delivered irregularly, death occurred within 3 months and the cause of death etc. It is also averred that claimant-complainant in his representation addressed to Deputy Divisional Manager (PLI) clearly mention that his wife expired on dt. 18.02.2015 due to pain in chest during taking her to Hospital, which creates ambiguity. But on enquiry, neighbourers of complainant’s village opined that the Policy-holder died due to head reeling, while sitting in her bed, Further, the claimant supported the version of neighbourer on the written statement on dt. 05.05.2016 countering his earlier statements dtd. 23.06.15. In the written statement, Ops also raised questions on the irregular delivery of Regd. letter containing Policy Bond and premium receipt Book which is delivered after the death of insured, and on examination of the allegations blames the complainant for indulging in foul play without disclosing the true fact about the cause of the death of Policy-holder. It is further averred that, the Op-Dept. has been acted and providing service to the citizens since-long with all sincerity and responsibility. Hence, the question of deficiency in service does not arise at all and compensation and cost claimed by the complainant is imaginary and as Ops have not committed any deficiency in service.
4. Heard the authorized representative of complainant and Ld. Counsel for Ops, perused the documents field into the dispute by the parties. Complainant to support his case filed original premium payment receipt dtd. 15.11.2014 & 16.02.2015, Xerox copy of Policy Bond, Attested Xerox copy of letter dt. 29.10.2016 addressed to DDM(PLI), attested Xerox copies of Op-Deptt. Letter dtd. 17.10.2017, 11.02.2017 and17.08.2017, copy of RTI application, Xerox copy of death certificate of Policy holder, Legal heir certificate, attested copy of indemnity Bond, attested Xerox copy of certificate of ‘Sarapanch’ of TALASANGA G.P. and attested Xerox copy of letter addressed to Sarapanch by the complainant. Op-Dept. filed documents as per the written version,which are marked as Annexure R-1 to R-11.The admitted facts of the case are that Complainant’s wife namely Gitanjali Jena obtained a Rural Postal Life Insurance Policy(RPLI) bearing No. R-OR-EA-751735 with a sum assured of Rs. 1 Lakh. The proposal of Insurance was accepted by the Op-Deptt. and policy bond was issued in favour of the deceased policy holder. It is also admitted that, Policy holder Gitanjali Jena died on 18.02.2015, prior to her death 2(two) quarterly premiums were paid on 15.11.2014 and 16.02.2015. It is further admitted that without any medical treatment/Hospitalization the Policy-holder died and the complainant being the husband of the deceased policy holder lodged claim before the Op-Authorities for availing the Insurance benefits of the Policy and his claim was rejected by the Op-Authorities. On question of rejection of claim, the pleas of the Ops are that, Complainant by suppressing material facts violated the very principle of Insurance contract has made an attempt to get the financial benefits derived from the Policy. In order to substantiate the suppression of material facts, Ops relied on contradictory statement of Complainant-the husband of the deceased Policy holder regarding cause and place of death of the insurant alognwith the written statement of neighbourers of the complainant(Annexure R/5 to R/10). Apart from these pleas of suppression of material facts Op-Deptt. takes further plea of rejection of claim on grounds that as the premium was not paid in time and the Policy bond was delivered irregularly, and as the insurant died within 3 months of taking the Policy suspicion was raised and the matter was investigated by the authorities accordingly claim was rejected. Before discussing the case on merit we must define the word “suppression of material fact’ Honbl’e Apex Court and Hon’ble National Commission defining the word ‘material fact’ opines that the term “material fact” is not define in Act and, therefore, it has been understood and explained by the courts in general terms to mean as any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether he would like to accept the risk. Any fact which goes to the root of the Contract of Insurance and has a bearing on the risk involved would be “material”. Hence, it is clear that any fact which is suppressed by the Policy holder with an evil intention to avail Life Insurance Policy by keeping the insurance authorities in dark on point of accepting the proposal/risk and on determining the premium. In this case it is also clear that under Rule-53 of Postal Life Insurance Rules-2011 a thorough inquiry was conducted by the Op-authorities and it is no where disclosed that the deceased policy holder was having any type of pre-existing disease, which was suppressed prior to submission and acceptance of the proposal of the said policy inspite of a detail departmental enquiry, it is also clear that not a single evidence has been placed before this Forum by the Ops to substantiate their plea of suppression of material facts by the proposer-Policy holder to avail the policy with an ulterior motive and keep the insurer Postal Authorities on dark to accept the proposal/risk. It is legally also clear that the ‘onus’ lies with the OP-Authorities to prove that the policy holder suppressed material facts of pre-existing disease. The further pleas of Ops on non-payment of premium amount in time and irregular delivery of policy bond according to us are not suppression of any material facts as defined earlier. In this dispute, the last premium was paid on dtd.16.02.2015 and on point of deposit of premium on another branch office of Ops and irregular delivery of policy bond, the acceptance of premium amount and delivery of policy bond are the duties of the employee of the Op-Deptt.,for which policy-holder can not be blamed as same are internal matter of OP-Deptt.. It is also not accepted by this Forum that the irregular delivery of policy bond is a good ground for rejection of claim.
The Op-Deptt.’s other plea for rejection of the claim is that as the Policy holder died within 3 years of taking the Policy and the cause and place of death creates ambiguity. In support of the plea, Ops file written statement of neighbourers of complainant and complainant’s 2(two) written statements(Annexure-R-5 to R-10). The Annexures reveal that the deceased policy holder died when she was seating on the bed and due to head-reeling fell down and died. The written statement of complainant(Annexure R-11) is similar to the statement of neighbourers but his earlier letter dtd. Nil (Annexure R-6) reveals that the policy holder died due to chest in pain and on the way to the medical she expired. The Authorized representative of complainant submits that the written statement of the neighbourers can not be taken into consideration as the written statement of Baikuntha Pal and Sri Biswaranjan Jena(Annexure R-7 & R-9) reveals that they have no direct knowledge or witness to the cause of death of policy holder, both the gentleman’s version be treated as ‘here say’ evidence and the written statement of Subhasini Jena(Annexure-R-8) reveals that she was present in the time of occur rence on dtd.18.02.2015 by supporting the versions of other 2 neighbourers, in this aspect Authorised representative submits that, the statement of Subhasini Jena can not be believed as there was a family enemity between Subhasini Jena and deceased policy holder. In connection to the written statement of complainant dtd. 05.05.2016(Annexure R-11), it is stated that the statement of complainant was taken under coercion and complainant’s wife Geetanjali Jena deceased policy holder in fact died on account of chest in pain. The authorized representative also pointed figure towards the disputed inspection, it is submitted that the written statements of witness(Annexure R-7 & R-9) are collected on one day i.e. on dtd.25.02.2016, but the written statement of complainant is procured on dtd.05.05.2016 almost about 3 months of collecting the informations from the neighbourers of complainant, and it is alleged that the inspection itself is disputed, controversial and not in accordance with the law. It is also the submission of the complainant that in the absence of the report of the enquiring officer the total plea of the Ops lost its credibility.. In this aspect, we are of the opinion that, there may be a minor lapses on part of complainant-claimant regarding statement in connection to cause of death of his wife and the complainant has not examined the neighbourers and such statements are filed without any affidavit, including the report/affidavit of Inquiring Officer. These defence pleas can not be taken as granted and can not be a sole ground for rejection of the claim, if the double statement of complainant-claimant which were addressed and deposed on different dates is a fact, then the rejection of claim in its totality can not be accepted and is bad in eye of law and the rejection letter dtd. 11.02.2017 has to be withdrawn and the settlement of claim is to be award in a non-standard basis.
Having observations reflected above, it is directed that OP-authorities shall settle the claim of the complainant-claimant by deducting 25 per cent (twenty-five) of the sum assured bearing Policy No R-OR-EA-751735. It is further directed that Ops shall pay 6% simple rate of interest per annum calculating from the date of lodging the claim i.e, dtd. 29.08.2016 till its date of realization alongwith Rs.500/-(Rupees Five hundred) as cost of litigation. The directions are to be carried out within one month of receipt of this order, failing which action will be initiated against the Ops under the provisions of C.P.Act,1986.
Complaint is allowed in part with cost.
Pronounced in the open Court, this 26th day of December,2018.
I, agree.
Sd/- Sd/-
MEMBER PRESIDENT
