Smt.Sunita Rani, complainant has filed the present complaint against the titled opposite parties U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short, the C.P.Act.) in which she has prayed that the opposite parties be directed to pay the insured amount on account of death of her husband immediately in terms of the insurance policy in question alongwith interest @ 18% P.A. from the date of death till actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation besides the amount in question on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties alongwith Rs.5,000/- as litigation expenses, in the interest of justice.   

2.       The case of the complainant in brief is that her husband Tilak Raj obtained Life Insurance Policies from the opposite parties vide policy No.17661323 dated 5.6.2015, annual premium of Rs.14,550/-. Her husband was assured for Rs.1,05,001/-. He had also taken another policy No.17768549 dated 21.8.2015 with annual premium of Rs.53,000/- and maturity value of the same was Rs.5,81,000/- and she is his nominee in the said insurance policies. Unfortunately, her husband had expired on 2.2.2016 as natural death on account of Heart Attack. Before death he was hale and hearty and was not suffering from any kind of disease. He never remained under treatment at any point of time from any doctor/hospital before his death. Her husband was a retired employee from Cooperative Societies and was getting pension. Her husband had also obtained two other policies from the opposite parties in the name of his daughter-in-law namely Happy wife of Sandip Rai bearing Policy No.18102366 dated 30.12.2015 and 18108003 dated 31.12.2015. His son Sandip Rai went abroad i.e. Kuwait on 16.9.2015 after spending huge money who was forced to come back for performing last rites of the deceased. Similarly other son of the deceased went abroad on 30.6.2015. She informed the opposite parties regarding her husband death and also submitted the claim as per terms and conditions of the insurance policy but the opposite parties repudiated her claim with the false and imaginary observations.  The opposite parties after repudiating her claim have paid Rs.79,102/- to her which is totally inadequate much less than the actual due amount. Thus, there is deficiency in service on the part of the opposite parties. She also served a registered AD legal notice dated 14.6.2016 upon the opposite parties to make the payment of remaining amount of insurance policies to her but of no avail. Hence this complaint.

3.       Upon notice, the opposite parties appeared and filed the written reply through their counsel by taking the preliminary objections that the complainant has no cause of action to file the present complaint. There is no deficiency in service on the part of the opposite parties and the claim of the complainant has been repudiated as per terms and conditions of the policy. The deceased gave wrong answer to the question no.27, 38, 35 which provides regarding the suffering of any illness which the complainant has to disclose and the complainant answered in negative to all these questions and answered all the question in ‘No’. So, the deceased concealed material facts regarding his health at the time of getting policy and not disclosed the preexisting diseases. The company got investigated the matter and during investigation it was established that life assured was suffering from diabetes mellitus with Coronary Artery disease prior to the policy issuance which was not disclosed in the application dated 24 July, 2015 and this Ld.Forum has no territorial jurisdiction to try the present complaint. On merits, it was submitted that the policy no., date of policy and the premium of the policy and maturity value of the policy are matter of record and is as per documentary proof. The deceased concealed material facts regarding his health at the time of getting policy and as such due to concealment, the claim has been repudiated. It was further submitted that the amount of Rs.79,102/- i.e. the Fund Value has been duly paid. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Complainant tendered into evidence her own affidavit Ex.C1, alongwith other documents Ex.C2 to Ex.C10 and closed the evidence. 

5.       Counsel for the opposite parties tendered into evidence affidavit of Sh.Amit Khanna, Deputy  Manager (Legal) OP1, alongwith other documents Ex.OP2 to Ex.OP-60 and closed the evidence.

6.         We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contestants. We find that the present dispute has arisen on account of the impugned ‘repudiation’ (Ex.OP3) of 01.06.2016 of the insurance-claim pertaining to Policy # 17661323 (by the opposite party insurers, hereinafter for short ‘the OP’) as filed by the present complainant pertaining to the ‘death-claim’ of her late (demised) husband Tilak Raj, the DLA (deceased life assured). We observe that the one and the only prime eventful aspersion founding/supporting the repudiation of the impugned 'death claim' in question has been the intentional non-disclosure/concealment (by the DLA) of his alleged ill health and continuing (pre-existing) multiple diseases in his ‘personal-proposal/signed-application’ dated 29.04.2015 in the related ‘proposal for assurance’ duly accepted by the OP and policy issued on 05.06.2015. Further, the OP written reply as well as the OP affidavit Ex.OP1 are silent as to the fate of the DLA’s other policy # 17768549 of 21.08.2015 with however a mention of Payment of Fund Value of Rs.71,902/- on 01.06.2016 pertaining to Policy issued vide application dated 24.07.2015. The OP insurers have alleged that the DLA had been suffering from serious ailments prior to purchase of these policies but he had opted not to disclose the same in his related application/proposals filed to purchase the policies in question.

7.       Somehow, we have been inclined to examine the validity & legality of the impugned repudiation (of the related insurance death-claim) in the back-drop of proceeding and also the succeeding acts & events in the light of the facts on records and current law on insurance vis-à-vis consumer subject matter, in issue. We find that the related 2 nos of insurance policies were admittedly issued on the strength of the DLA applications/proposals as of 24.07.2015 and 29.04.2015 whereas the Investigation Report Ex.OP2 clearly states that the DLA’s CAG was first time done on 26.11.2015 as a follow up measure to his clinical first time tests done on 10.11.2015 & 13.11.2015 and was hospitalized for his medical treatment with effect from 07.12.2015 to 10.12.2015. There has been no other evidence on records to prove that the DLA could have any occasion to learn of his ‘ailments’ prior to his applying for purchase of the policies. Moreover, it has been placed on records that he underwent medical examinations etc before issuance of the LIPs in question. The other evidence of ‘Old case of CAD’ on the records is Ex.OP6 ‘Death Claim Intimation’ where Doctor’ Post Death Certificate dated 10.03.2016 states the illness diagnosed on DOD (02.02.2016) as: Old case of Cad etc.; and naturally so, as CAG done on 26.11.2015 shall be certainly addressed as ‘old case’ on 02.02.2016/ 10.03.2016. Last and Further, page ‘6’ (last 2 lines) of Ex.OP2 (Investigation Report) mention that medical records of LA got from the Amandeep Hospital (on 07.12.2015) shows Type two DM since last 18 months i.e., one year prior of the date of policy. This clearly shows that upon admission on that date 07.12.2015 the information was recorded as provided by some attendant of the DLA patient as it has not been a part of the Doctor’s Certificate and duly supported by the affidavit, as requisite.

8.       Thus, the OP insurers have failed to prove through some cogent evidence, it’s lone/prime allegation of non-disclosure of pre-existing disease/ aliment etc and also of the DLA’s knowledge of his latent DMA etc and that in turn proves adoption of unfair trade practice to turn down an otherwise a valid insurance claim. The other documentary evidence as produced/ exhibited by the OP insurers undoubtedly proves the DLA’s post-insurance ‘hospitalization’ and subsequent death on 02.02.2016 but it surely stands apart as ‘not proved’ that the DLA had the knowledge of his ‘existing’ ailments that he concealed at the time of purchase of the Policy in question. There has been no evidence on records of prior-insurance ‘medical-treatment’ of the DLA for any of disease/ailment, of whatsoever. We find that the OP insurers here have arbitrarily repudiated the present claim merely on the ‘presumption’ that the DLA had the knowledge of his ‘ailments’ at the time of purchase of ‘insurance’ since he was hospitalized soon after said ‘purchase’ and he intentionally concealed the material information that was material to disclose. To remove all ambiguity, it may be clarified here that an ‘insurance claim’ and for that matter any ‘issue’ can be neither legally ‘favored’ nor legally ‘ousted’ on the basis of mere ‘presumption’ how strong it might appear to be. We further find that the present policy in question was purchased through the services of insures Agent carrying his name/ signatures on policy and confidential report etc; hence it is understood that all the DLA’s information in totality was fully available in the hands of the OP insurers’ Representative/Agent and thus the OP’s are estopped from taking the plea of non-disclosure etc. Moreover, section 45(3) of the Insurance Act, 1938 (as amended up to date) bars repudiation of Policy on account of mis-statement(s) and/or suppression of fact(s) that are within the knowledge of the insurers.  The OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial reviews and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law.   

9.       In the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s impugned repudiation of the death claim being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’. Thus, we ORDER the OP insurers to pay the impugned ‘insurance claim’ pertaining to both the Policies in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9% PA from the date of  filing of this complaint till actually paid.

10.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                      (Naveen Puri)

                                                                                      President     

ANNOUNCED:                                                               (Jagdeep Kaur)

February,16 2017.                                                        Member.

*MK*