Order no. 18 Date : 16.04.2021
COMPLAINT CASE NO. – CC/155/2019
DEBJANI RANA
W/O LATE GOUTAM RANA
VILL – BARATALAYA, P.O. – TAJPUR
P.S. – NANDIGRAM
DIST. – PURBA MEDINIPUR, PIN – 721 656.
………………….. COMPLAINANT
Vs.
- EXIDE LIFE INSURANCE COMPANY LTD.
J.P. TECHNO PARK, 1ST FLOOR
NO.- 3/1, MILLERS ROAD, BANGALORE – 560 001.
- EXIDE LIFE INSURANCE COMPANY LTD.
3RD FLOOR, 4, MANGO LANE
SURRENDRA MOHAN GHOSH SARANI
NEAR CTC HEAD OFFICE
KOLKATA – 700 069.
………..…….….. OPPOSITE PARTIES
PRESENT — SRI SWADES RANJAN RAY
President
SRI SADANANDA SARKAR
Member
JUDGEMENT
Date – 16.04.2021
SRI SWADES RANJAN RAY
President
Facts of this case in short, is that the husband of the complainant, Goutam Rana expired on 20.10.2016 at Nil Ratan Sircar Medical College and Hospital, Kolkata. That after demise of Goutam Rana, complainant came to know that her husband purchased a Life Insurance policy vide No. 03238672 from Exide Life Insurance Company Ltd. for the period from 16.12.2015 to 16.12.2039.
That the policy holder Goutam Rana, husband of the complainant, received the policy deed after purchasing the policy for the basic sum assured of ₹9,97,777/- (Rupees nine lakh ninety Seven thousand seven hundred and seventy seven only) with guaranteed death benefit of ₹12,06,210/-(Rupees twelve lakh six thousand two hundred and ten only). After death of her husband Goutam Rana, the complainant went to the office of O.P. No.-1 and O.P. No.-2 and submitted all the relevant papers to settle the claim. But all her efforts are in vain.
That the O.P. No.-1 and O.P. No.-2 are not diligent rather negligent to render the service of the complainant as such complainant claiming the compensation that the complainant has not any source of income at this stage. She required death benefits of the claim from O.P. No.-1 and O.P. No.-2.
That the complainant faces loss which has caused by the O.P. No.-1 and O.P. No.-2 and unfair acts and deficiency of service all the O.P. No.-1 and O.P. No.-2 resulting loss of ₹12,06,210/- (Rupees twelve lakh six thousand two hundred and ten only) plus interest from the death of Goutam Rana along with litigation cost.
Cause of action arises on and from 22.06.2017 when O.P. No.-1 refused to make payment of compensation.
O.P. No.-2 appeared and contested this case by filing Written Version. In W/V O.P.s denied the material allegation made against them. It is the case of the O.P.s that complainant suppressing the material facts and this case filed on vexatious and frivolous ground. It is the case of the O.P.s that Goutam Rana deceased, husband of complainant submitted a proposal form dt. 07.12.2015 with the insurance company (O.P.s) opting for life insurance product named as Exide Life Guaranteed Income Insurance Plan. The premium opted by the life assured was on annual basis and the premium payable was ₹1,20,621/- (Rupees one lakh twenty thousand six hundred and twenty one only) plus applicable taxes for a premium paying tenure of 24 years for a sum assured of ₹9,97,777/- (Rupees nine lakh ninety Seven thousand seven hundred and seventy seven only) with maturity date being 16.12.2039 (policy term 24 years) and a guaranteed death benefit being ₹12,06,210/- (Rupees twelve lakh six thousand two hundred and ten only). That the O.P. (Insurance Company) trusting that the details furnished by the deceased Goutam Rana would be true and correct with respect to the concerned policy. That the O.P. (Insurance Company) received death claim intimation from the complainant on 12.01.2017, informing that life assured has died on 20.10.2016 and the reason of death mentioned on the claim form was as Meningoencephalitis.
As the death of life assured has taken place within a period of 10 months from the death of commencement of policy (20.10.2016) an internal or external investigation was conducted as per the routine business practice of the O.P.s and it was found that life assured has suppressed / not disclosed that he was a chronic alcoholic and he was suffering the disease Meningoencephalitis from the medical report issued by N.R.S. Hospital, Department of Health and Family Welfare, Government of West Bengal. It is stated in the clinical notes that life assured had a history of alcohol from past 20 years, apparently had stopped the consuming only since last 8 days of his admission to the hospital. From the medical reports it is clear that life assured was a chronic alcoholic and was also suffering from the disease namely Meningoencephalitis much before obtaining the policy from the O.P. (Insurance company). Hence, Life assured (Goutam Rana) has deliberately with-held the above material facts which amounts to violation of the policy terms.
With the information as per section 45 is essential for claiming benefit under the policy by suppressing the fact in the proposal from the life assured (Goutam Rana) has intentionally misguided and influenced the decision of O.P. (Insurance Company) to issue the policy. That the O.P. (Insurance Company) has fulfilled the terms and conditions and obligation of the policy whereas complainant suppressing the material facts in respect of the policy, therefore, O.P. (Insurance Company) rightly repudiated the claim of the complainant vide letter dt. 22.06.2017.
It is the further case of the O.P.s that as per section 4.4.3.1, the O.P. (Insurance Company) transfer the guaranteed surrender value for a sum of ₹24,124.65 (Rupees twenty four thousand one hundred twenty four and sixty five paise only) and the same was transferred in favour of the account of the complainant vide transaction id. CITIN17793604750 dt. 22.06.2017.
That the complainant files this case before this Commission by suppressing the factual aspect and on frivolous baseless ground and the O.P.s never committed any deficiency of service and unfair trade practice while dealing with the case of the complainant. Hence, O.P. (Insurance Company) rightly repudiated the claim of the complainant and complaint case is liable to be dismissed.
Points for decision:
- Whether complainant has any cause of action to file this case or not?
- Whether O.P. is a guilty of deficiency of service or not?
- Whether complainant is unable to get any relief / reliefs as prayed for or not?
Decision with reason:
All these points taken together for sake of convenience and brevity.
I have carefully perused the complaint, Written Version and the Brief Notes of Argument (BNA) of complainant and the O.P.s.
It is the only case of the complainant that her husband Goutam Rana expired at N.R.S. Medical College and Hospital who was admitted on 10.10.2016 at 01.28 p.m. and expired on 20.10.2016 at 11.30 p.m., and her husband purchased a life insurance policy vide no. 03238672 from Exide Life Insurance Company for the period from 16.12.2015 to 16.12.2039. As per terms of the policy Debjani Rana wife of deceased Goutam Rana entitled for basic sum assured of ₹9,97,777/- (Rupees nine lakh ninety Seven thousand seven hundred and seventy seven only) with guaranteed death benefit of ₹12,06,210/- (Rupees twelve lakh six thousand two hundred and ten only). The O.P. refused to give the benefit as per terms of the insurance policy.
On the other hand, the only case of the O.P. insurance company that deceased Goutam Rana suppressed the material facts at the time of purchasing the insurance policy referring the treatment sheet (bed head tickets) wherein it was mentioned the cause of death was Meningoencephalitis and chronic alcoholic, which was completely suppressed by the deceased Goutam Rana. According to Ld. Counsel for the O.P. insurance company that the person who is chronic alcoholic, it is presumed that the said person consumed alcohol for a long period i.e. after year after year. Due to chronic alcoholic habits, deceased Goutam Rana suffers from Meningoencephalitis. So, deceased Goutam Rana violated the terms and conditions of the insurance policy by suppressing this facts. As a result of which Goutam Rana would not get any insurance benefit.
According to O.P.s the deceased Goutam Rana was a chronic alcoholic i.e. he was a habitual drunker. But it cannot be said that the person who is a habitual drunker or chronic alcoholic always suffer Meningoencephalitis.
The term Meningoencephalitis means an inflammation of the brain, its surrounding protective membranes can be caused by bacteria, viruses, fungi and protozoan or as secondary sequel of other inflammation like aids.
In the W/V as well as in BNA, insurance company did not explain or failed to explain the reason of Meningoencephalitis. As per medical journal — (from Google encyclopedia) the cause for Meningoencephalitis either (i) various bacterial infection (ii) viral infection (iii) protozoan infection. The said medical journal never made any conclusion that the person who is chronic alcoholic or a drunker should have suffered Meningoencephalitis. The O.P. insurance company took only plea on the basis of bed head ticket wherein doctor mentioned as a case history — chronic alcoholic and Meningoencephalitis. From this observation, in my view, it is difficult for the Commission to come into a conclusion that chronic alcoholic or consuming alcohol was the cause of Meningoencephalitis. O.P. insurance company did not make any prayer for taking expert opinion regarding on this point. It is very difficult for the Commission to presume that due to consuming of alcohol the deceased Goutam Rana suffered from Meningoencephalitis. Another point taken by the O.P. that deceased Goutam Rana suffering from Meningoencephalitis for a long period which was suppressed at the time of entering insurance policy. Now the question before this Commission whether a person suffering from Meningoencephalitis can survive for a indefinite long period that is year after year. According to medical journal published in Google encyclopedia that the Meningoencephalitis is a very serious disease which caused serious headaque, vomiting, fever, unconsciousness and speech problem. In my view, a man cannot be survived for a long period who is suffering such type of serious disease. So the plea taken by the O.P. insurance company that the deceased Goutam Rana suffering Meningoencephalitis much before obtaining policy, it is difficult to believe. In my view, on this point, opinion of expert is required. But in this instant case the O.P. insurance company did not provide any expert opinion or did not make any prayer for sending the matter for obtaining expert opinion on this point.
The plea taken by the O.P. insurance company, the person who is a chronic alcoholic, in my view, may suffer Meningoencephalitis as immunity power of that person is very weak. In this regard, it cannot be said or it cannot be presumed that chronic alcoholic must or shall be suffered from Meningoencephalitis. On this point, in my view, should be cleared by the medical expert of the N.R.S. Medical college and Hospital who made this note — i.e. Meningoencephalitis and chronic alcoholic. But O.P. failed to take step in this regard. So court should not always act as an expert of all experts when the subject matter is a specialized subject, it should be cleared by the expert of that subject. And if the O.P. took opinion from that doctor who gave this note whether due to consuming alcohol for a long period would only caused of Meningoencephalitis in case of deceased Goutam Rana and from the medical journal (Google encyclopedia) it can be easily presumed that unless or until a person attacked or suffered from various bacteria, virus or protozoan infection in brain than only caused Meningoencephalitis otherwise not.
Hence, in my view, consuming alcohol will not be the sole cause for Meningoencephalitis.
It appears from the death certificate issued by the Doctor of N.R.S. Medical Collage and Hospital, wherein it was mentioned the cause of death due to Meningoencephalitis. I have carefully perused the bed head ticket wherein I do not get any finding that the cause of Meningoencephalitis was due to consuming alcohol for a long period. Moreover, O.P. has failed to submit any medical study or expert opinion or did not make any prayer for ascertaining the above fact by the concerned department of N.R.S. Medical Collage and Hospital.
O.P. has failed to submit any medical study or expert opinion that the person may carry disease of Meningoencephalitis year after year and deceased Goutam Rana carried the above disease long before the purchasing the insurance policy and as such deceased Goutam Rana suppressed the suffering of Meningoencephalitis at the time of purchase of mediclaim policy.
Hence, I am unable to agree with the plea taken by the O.P. insurance company.
Hence, in my view, complainant able to prove his case and denying claim of complainant cause deficiency of service on the part of O.P.s.
Hence, in my view, complainant has sufficient cause of action to file this case and will entitle to get relief as prayed for.
In the result, this complaint case succeeds.
Court fee paid correct.
Hence,
It is
O R D E R E D
that this complaint case be and the same is allowed on contest against O.P. No.-1 and O.P. No.-2.
O.P. No.-1 and O.P. No.-2 are jointly or severally liable to pay the guaranteed death benefit of ₹12,06,210/- (Rupees twelve lakh six thousand two hundred and ten only) with a interest @ 5% from the date of filing of this case i.e. 14.06.2019 till the date of realization and Complainant is also entitled to get litigation cost of ₹10,000/- (Rupees ten thousand only) in default liberty given to the complainant to file execution case for realization of the same.
No order with regard to mental plain and agony, as there is no such prayer.
Hence this complaint case is disposed of accordingly.
Let a copy of this judgement be handed over to all the parties at free of cost.
