Sri Shyamal Gupta, Member

This is a case over repudiation of Complainant’s insurance claim by the OP Insurance Company.

To narrate in brief, case of the Complainant is that his husband took an insurance policy having sum assured for an amount of Rs. 50,00,000/- from the OP Insurer on 22-06-2013.  Unfortunately, on 15-07-2013 Complainant’s husband had to be rushed to a nursing home, namely, Sankar Nursing Home with fever, where he died on the very same day at 9.30 p.m. due to cardio respiratory failure in a case of fever and convulsion.  On 12-09-2013, Complainant intimated the OP Insurance Company about such death of her husband.  However, the OP on 21-03-2014 repudiated her claim alleging that her husband was suffering from cancer.  It was further alleged that her husband was a construction worker and not an agriculturist as declared in the proposal form. Hence, this complaint.

On receipt of notice, OPs appeared before this Commission and submitted a WV denying inter alia all the material allegation of the complaint.  It is the case of the OPs that after receiving claim intimation, they carried out an investigation as per procedure.  During such investigation, it revealed that the Life Assured (LA) was a construction worker, which the LA suppressed while filling up the proposal form.  It also came to surface during such investigation that the LA was suffering from cancer.  Based on such information, they repudiated the claim.

The core issue that warrants my concentration whether the repudiation of Complainant’s claim was justified.  In other words, whether the Complainant is entitled to any relief.

Decision with reasons

The solitary piece of document that has been advanced from the side of the OPs to show material suppression of fact pertaining to condition of health of the DLA is the photocopy of a Certificate dated 16-07-2013 purported to have been issued by the Executive Assistant of Radhakantapur Gram Panchayat, Raidighi, Dist. South 24 Parganas.

Significantly, no effort whatsoever has been made from the side of the OP Insurance Company to prove this document following due procedure of law.  It is also noteworthy here that it is the undisputed position of this case that the Complainant gave due intimation about the demise of LA on 12-09-2013.  In such given circumstances, due investigation, if at all carried out by any Investigator, the same must have been done only after that day.  Therefore, question is bound to be raised while death intimation was given after nearly two months, how did the Investigator get hold of such a Certificate issued on the very next day following demise of the LA.  Alas, no Investigator has deposed before us to throw light in this regard.

It appears from the photocopy of ‘Statement – Death Claim (Non-Accidental)’ where Prodhan of Radhakantapur Gram Panchayat has put her signature as a witness that the LA was lastly suffering from ‘Fever & Convulsion’.  When the Prodhan of said Panchayat put her stamp of approval as to the claim of the Complainant that the LA died of fever and convulsion, one wonders, wherefrom the Executive Assistant of said Panchayat came to know that the LA was suffering from cancer.

Another intrigue fact of this case is that although the LA died in a nursing home, the Investigator concerned did not make any endeavour to examine the treating doctor and find out as to whether the LA was indeed suffering from cancer.  It is hardly believable that when the patient was rushed to the nursing home concerned, the treating doctor was not apprised of the past medical condition of the LA by the patient party or that the aid doctor did not notice anything suspicious.  In the death certificate, it was clearly mentioned that the LA died of Cardio Respiratory in a case of Fever and Convulsion. 

Also, it transpires from the ‘Doctor’s/Hospital Certificate’ on record that uncle of the LA, who briefed the treating doctor about past history of the patient, did not make any whisper before the treating doctor that the patient was suffering from cancer.  He merely said that the patient was suffering from fever for the last two days and from convulsion for the last two hours. 

Be it the various symptoms or the cause of death as mentioned in the Doctor’s/Hospital Certificate’, there is virtually nothing wherefrom it can be ascertained that the LA was suffering from cancer. 

Further, we cannot lose sight of the fact that had the LA been indeed suffering from cancer, then it would certainly not have escaped the notice of his neighbours. Most surprisingly, not a single statement from the neighbours of the DLA is placed on record to prove the veracity of the allegation of the OPs.

Last but not the least; the LA was invariably examined by the panel doctor of the OPs before issuance of the policy.  When a person gets seriously ill (and dies within a month of commencement of the policy), it is easier said than done to mask such infirm health from an experienced doctor.  There is nothing on record to show that the concerned doctor reported anything adverse about the health condition of the DLA. 

As regards the issue of alleged disparity in respect of the occupation of the DLA, it is clarified by the Complainant that her husband was an agriculturist and he used to pay tax to the Radhakantapur Gram Panchayat.  However, he also used to work as a construction worker on a temporary basis. In support of her claim, the Complainant submitted tax receipt, copy of Profit & Loss A/c, Computation of Total Income etc. 

In the light of my foregoing discussion, I have no qualms holding that the OPs have miserably failed to put forth any cogent document to justify repudiation of Complainant’s claim.  Merely because the LA died within a month of commencement of policy and the policy amount was quite substantial, it does not justify repudiation of Complainant’s claim on some fragile grounds.  The conduct of OPs is not at all appreciable.  Rather, it was a blatant misuse of the official position and a clear instant of deficiency in service.

There being enough merit with the complaint, the same is allowed.

Hence,

O R D E R E D

That CC/57/2015 be and the same is allowed on contest against the OPs.  The Complainant is entitled to get insurance benefit to the tune of Rs. 50,00,000/- from the OPs.  The OPs shall disburse the claim amount within 45 days hence, i.d., simple interest @ 9% p.a. shall accrue over the aforesaid amount from this day till full and final payment is made.