ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
The complainant is the nominee and the wife of the deceased Lt. Mohamad Murtja. The deceased had taken a policy namely Reliance cash flow plan from OP No. 1 for a sum insured amount of Rs.1,00,000/- for the period from 14.1.2014 – 14.1.2029 by paying a premium amount of Rs.9,684/- OP No. 2 is the service provider of OP No. 1.
That on 18.1.2013 the husband of the complainant fell sick and had expired on the very next date i.e. 19.1.2013. The complainant submitted the claim form alongwih all the original documents to OP No. 1 on 4.3.2013.
OP No. 1 repudiated the claim of the complainant vide repudiation letter dated 31.7.2013, the reason given for repudiation is as under:-
On a review of documents collected during the investigation of your claim, we understand that late Md. Murtaja was hospitalized and treated for tuberculosis since last two years.
The complainant had therefore approached this Forum for redressal of her grievance as the insurance co. and the TPA have not settled the claim. It amounts to deficiency an amount of Rs.1,00,000/- alongwith an interest @ 18% p.a., Rs.50,000/- as compensation for pain harassment and mental agony and Rs.20,000/- litigation charges.
The insurance company has contested the complaint and has filed its reply. The insurance company has stated in its reply that DLA was suffering from tuberculosis from last two years and was taking treatment from Safdarjung Hospital, Lala Ram Swaroop TB Hospital (Mehrauli) much prior to the signing of the proposal form i.e. 31.12.2013. Hence, it is crystal clear that DLA had a history of pre-existing disease and the said fact was mala-fidely concealed by the DLA at the time of issuance of the said policy. The counsel for the Insurance company pleaded that the complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine.
The complainant has filed rejoinder to the reply filed by insurance company and has reiterated the facts as pleaded in the complaint.
The complainant has filed evidence by way of his affidavit. She has relied upon the documents Ex-CW1/A to Ex-CW1/E mentioned in her affidavit dated 17.4.2015.
Sh. Rajesh Chouhan, A.R. of the Insurance Company has filed affidavit. He has relied upon the documents Ex-OPPOSITE PARTY NO. -1 to Ex-OP7.
We have heard Ld. Counsel for the parties and have examined the record.
The counsel for the OP has pleaded that the DLA was suffering from a pre-existing deceased and he had concealed this fact at the time of filling the proposal form, and as the claim being an early claim, the OP company got an investigation of the aforesaid claim through SRK investigation services Pvt. Ltd. The copies of the investigation report is annexed as Ex-4 alongwith the affidavit of investigation as Ex-5, which clearly shows that theclaim was rightly repudiated by the OP on the ground of pre-existing disease i.e. “Tuberculosis” . The counsel for the OP thus pleaded for dismissal of the complaint.
We are however not convinced with the contention of the counsel for the OP as the above said report filed by the investigation is not authentic. The investigator has filed his report without annexing any medical report/medical record of the deceased. The report of the investigator is also not accompanied by his affidavit.
Thus, the insurance company has failed to placed on record any documents to confirm that the patient was suffering from a pre-existing disease before taking the policy. It has further failed to prove the fact that the complainant had made a false statement about the state of his health before the purchase of th policy.
The claim was repudiated vide communication dated 31.7.2013. The denial of the claim was not according to the terms and conditions of the policy. It caused deficiency in service due to which the complainant suffered harassment, pain and mental agony. On account of such deficiency in services, we allow the complaint with the following direction to the insurance company to comply with:-
- To pay to the complainant a sum of Rs.1,00,000/- with interest @ 10% p.a. for the date of letter of repudiation dated 31.7.2013 till the realization of the amount.
- To pay to the complainant a sum of Rs.10,000/- as compensation for causing harassment, pain and mental agony.
- To pay to the complainant a sum of Rs.5,000/- as litigation charges.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule. File be consigned to record room.
Announced in open sitting of the Forum on.....................
(NIPUR CHANDNA) (DR. VIKRAM DABAS) (RAKESH KAPOOR) MEMBER MEMBER PRESIDENT
