C.F. CASE No. : CC/2013/19 & CC/2012/81
ANALOGOUS JUDGEMENT
The judgment for the above two cases is to be written analogously vide order No. 17 dated 17.07.13 passed in case No. CC/2013/19.
COMPLAINANT : Kalyani Dutta,
W/o Late Khokon Dutta,
Vill. Bethuadahari (near forest)
P.O. Bethuadahari,
P.S. Nakashipara, Dist. Nadia
PIN - 741126
– Vs –
OPPOSITE PARTIES : 1) Divisional Manager,
LIC of India
Divisional Office – KSDO,
Jeevan Prabha,
DD-5, Sector – 1,
Salt Lake City, Kolkata – 700064
2) Branch Manager,
LIC of India,
Krishnagar Branch – II,
Padia Market Building,
R.N. Tagore Road,
P.O. Krishnagar, P.S. Kotwali,
Dist. Nadia, PIN – 741101
PRESENT : SHRI PRADIP KUMAR BANDYOPADHYAY, PRESIDENT
: SHRI SHYAMLAL SUKUL, MEMBER
: SMT REETA ROYCHAUDHURY MALAKAR, MEMBER
DATE OF DELIVERY
OF JUDGMENT : 30th August, 2013
- Consumer Case No. CC/2013/19
The case of the petitioner is, in brief, the complainant Kalyani Dutta, W/o Khokon Dutta has filed the instant case against Divisional Manger, LICI, Salt Lake City, Kolkata as OP No. 1 and Branch Manager, Krishnagar Branch II as OP No. 2. The deceased husband of complainant, Khokon Dutta purchased a policy (No. 426128020, table 180 term 10 years) through an agent of LICI for the assured sum of Rs. 50,000/-. The first premium of Rs. 10,000/- paid on 31.03.2007 and the second premium of Rs. 10,000/- was paid on 16.05.2008. The said policy was continued till the death of the policy holder. The present complainant being the widow of the deceased life assured (DLA) is the beneficiary. The DLA died on 22.11.2008 due to subacute stent thrombosis with cardio-genic shock and after his death the petitioner informed the LICI branch office and submitted form No. 3784 along with claim form No. B & B1. The petitioner after a few days went to the office of the OP No. 2 with a request to settle the claim, but on 16.03.12 OP No. 1 informed the complainant in writing that they are unable to honour the claim because the DLA, Khokon Dutta had a past history of inferior wall M1 2004 and he was a patient of IHD which was prior to the date of commencement of the policy and the facts were not disclosed in the proposal form dtd. 26.05.06. So according to the OP since there was suppression of material fact they were compelled to repudiate the claim of the petitioner as a beneficiary of the DLA. But OP No. 1 gave a liberty to the petitioner to send a representation within one month if she was dissatisfied with the repudiation to the zonal office. Accordingly the petitioner sent a letter to the Zonal Manager, LICI Eastern Zone, Hindusthan Building, Kolkata with a copy to OP No.1 for reconciliation of the claim. But the claim was not settled from that end too. The petitioner states that the cause of action arose on and from 16.03.2012 when OP No. 1 repudiated the claim after two years violating the IRDA regulations. In these circumstances, the petitioner prays for an order with a direction upon the OPs to make payment of the full sum insured of Rs. 50,000/- along with bonus and interest @ 10%. She also prays for litigation cost and compensation of Rs. 20,000/- for the loss and damages caused to her due to such repudiation of the claim.
(2) Consumer Case No. CC/2012/81
Almost the facts are same with case No.CC/2013/19. The only difference is that the DLA, Khokon Dutta took the policy (No. 425564038, table 174, term 20) on 25.05.06 for the sum assured of Rs. 1,00,000/- at a premium of Rs. 4,995/- . In this case the petitioner prays for an order with a direction upon the OPs to make the insured sum of Rs. 1,00,000/- with bonus and interest @ 18%. She also prays for litigation cost and compensation of Rs. 1,00,000/- for loss and damages caused to her due to the repudiation of the claim.
In case No. CC/2013/19, the OP in his written version denied all the allegations of the petitioner. According to them the instance case is not maintainable and also barred by limitation. Moreover, they had denied the fact of getting the second premium of Rs. 10,000/- from the petitioner. They also did not admit that the petitioner took money plus plan and also the fact that it was a unit linked plan. The main reason behind the repudiation of the claim was suppression of material fact by not disclosing the disease in the proposal form by the policy holder. The OPs repudiated the claim mainly on the basis of the certificate issued by BM Birla Heart Research Centre, where the Hospital Superintendent, Dr. Soma Bhattacharya noted that the policy holder was a known patient of IHD & he had a past history of inferior wall M1 from 2004 and expired in the Hospital on 22.11.2008. The OPs’ submission, in a nutshell, is that they have rightly repudiated the claim and so they are not deficient in their services. Hence, the OPs pray for dismissal of the suit.
Herein case No. CC/2012/81 the OPs denied all the allegations of the petitioner in the same line as in case CC/2013/19.
The parties did not adduce any evidence but only moved their cases on the basis of their documents. The documents submitted by the petitioner are as follows:-
- Policy Certificate
- Death Certificate
- Premium Receipt
- Letter of Repudiation
- Letter given to the Divisional & Zonal Manager of LICI dtd. 13.04.12
- IRDA Regulation, 2002
Documents submitted by the OP are as follows:-
- Proposal Form
- Medical Attendance Certificate (Claim Form B)
- Certificate of medical treatment (Claim Form B1)
- Medical certificate of cause of death issued by BM Birla Heart Research Centre.
From the pleadings of both sides and the documents submitted by them we
Frame the following issues.
Point No. 1) Whether the complainant is a consumer?
Point No. 2) Whether the OPs suffer from deficiency in service?
Point No. 3) Whether the complainant is entitled to get the reliefs as prayed for?
DECISIONS WITH REASONS
All the issues are taken up together for the sake of convenience and brevity.
The petitioner is a consumer under the OPs as being the beneficiary of the deceased policy holder as per Section 2(d)(ii) of the Consumer Protection Act, 1986.
The OP repudiated the claim on the basis of the Medical Attendance Certificate, Dr. Soma Bhattacharya. Dr. Bhattacharya mentioned that he was a known patient of IHD and had a inferior wall M1 from December, 2004. From this the OP deduced that the deceased policy holder Khokan Dutta deliberately concealed this fact while taking the policy. So his beneficiary is not entitled to get the claim. But the OP while issuing the policy did not have a medical check-up of the deceased policy holder without proper examination they issued the policy. The OPs also did not file any document to prove that the disease at all existed in 2004. The Hospital Superintendent made the noting only on the basis of the petitioner’s submission but not on the basis of the any previous prescriptions or documents. Hence, we are of the view that the OPs Insurance Company has not rightly repudiated the claim or rather the repudiation is devoid of merit. Now, let us discuss this point in the light of Section 45 of Insurance Act and somehow the judgments passed by the Hon'ble National Commission.
In 2012 (3) CPR 46 (NC), wherein Hon'ble National Commission reported the Insurance Company is bound to prove the grounds of repudiation of insurance claim. Here also of the view that the Insurance Company could not prove the proper ground of repudiation.
In 2012(1) CPR 391 (NC) wherein the Hon'ble National Commission reported that the Insurance Company must investigate health issues before issuing Insurance Policy. In our present cases LICI has relied entirely on the record of treatment on the period 21.11.2008 to 22.11.08 for repudiation of the claim under a policy taken more than 5 years prior to this period. The OP LICI could not point to any other evidence which could show that the deceased suffered from this ailment when the proposal for insurance was made. So, the question of disentitlement of the insurance policy as per Section 45 of the Insurance Act, on the ground of concealment / suppression does not arise in these cases, because the OP has failed to prove by producing evidence that the insured was treated for the same disease in near proximity of the time when the insurance policy was obtained. Hence, the OPs are deficient in the services and they are liable to pay compensation the petitioner.
Hence,
Ordered,
That the cases, CC/2013/19 & CC/2012/81 are allowed on contest with cost.
The OPs, LICI are directed to refund the insured of sum assured of Rs. 50,000/- & Rs. 1,00,000/- and accrued bonus along with a compensation of Rs. 2,000/- in case CC/2013/19 & Rs. 2,000/- in case No. CC/2012/81 and litigation cost of Rs. 2,000/- each in both cases to the complainant within a period of one month since this date of passing the judgment, in default, the decretal amount will carry interest @ 7% till the date of repudiation of the full payment.
Let a copy of this judgment be delivered to the parties free of cost.
