Punjab

Ludhiana

CC/14/546

Mill Anchal - Complainant(s)

Versus

LIC of India - Opp.Party(s)

Amrit

28 Apr 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                   C.C. No.546 of 08.08.2014                                                                                  Date of decision: 28/04/2015

Miss Anchal minor daughter of Late Sh.Umesh Kumar through her natural guardian Smt.Shanti Devi @ Sunita wife of Late Sh.Umesh Kumar resident of Bhagat Singh Colony, Street No.3, Sherpur, District Ludhiana.                                                                                                                                            ….Complainant

Versus

 

1.Life Insurance Corporation of India, Jeevan Prakash, Divisional Office, Urban Estate, Phase-I, Dugri, Ludhiana.

2.The Zonal Manager, LIC of India, Zonal Office, Jeevan Bharati, 124, Connaught Circus, New Delhi.

3.The Sr.Divisional Manager, The Insurance Ombudsman, SCO 101-103, Sector-17, Batra Building, Chandigarh.

4.Manvinder Partap Singh H.No.15116, Guru Arjan Dev Nagar, Near Military Camp, Ludhiana.

                                                                   ….. Opposite parties

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:    Sh.R.L.Ahuja, President.

                   Sh.Sat Paul Garg, Member.

                   Ms.Babita, Member.

                            

Present:       Sh.Amit Moldi, Adv. for complainant.

                   Sh.Rajeev Abhi, Adv. for OP1 and OP2.

                   OP3 and OP4 ex-parte.

 

ORDER

R.L.AHUJA, PRESIDENT.

1.                Present complaint under Section 12 of the Consumer Protection Act, 1986, amended upto date (hereinafter referred as to “Act”) has been filed by Miss Anchal minor daughter of Late Sh.Umesh Kumar through her natural guardian Smt.Shanti Devi @ Sunita wife of Late Sh.Umesh Kumar resident of Bhagat Singh Colony, Street No.3, Sherpur, District Ludhiana (hereinafter in short to be referred as ‘Complainant’) against Life Insurance Corporation of India, Jeevan Prakash, Divisional Office, Urban Estate, Phase-I, Dugri, Ludhiana and others(hereinafter in short to be referred as ‘OPs’) directing them to fulfill the death claim being policy holder of Ops company alongwith interest and to pay Rs.1 lakh as compensation on account of mental agony and harassment and other benefits to the complainant.

2.                 In brief, the case of the complainant is that the OP4 came to the house of complainant and allured Mr.Umesh Kumar father of the complainant and husband of Smt.Shanti @ Sunita to buy Life Insurance Policy namely “Jeevan Ankur” of OP1. Due to the said assurances and promises given by the OP4 on behalf of OP1 to OP3, Umesh Kumar agreed to buy the said policy and he bought the said policy of OP1 to OP3 through OP4 vide policy No.301935599, commencement date of which was 28.3.2012 and date of commencement of risk was 30.3.2012. Under the said policy death risk upto Rs.4 lakh was covered of Umesh Kumar, who appointed Miss Anchal his minor daughter as his nominee. Before issuing the said policy, Umesh Kumar undergone each and every medical test which are conducted by OP1 to OP3 properly and after confirming the health fitness of complainant, OP1 to OP2 issued the said policy to Umesh Kumar. Unfortunately, Umesh Kumar died on 4.4.2012, due to natural death and after his death, complainant immediately approached Ops and requested them to issue the death claim amount. Thereafter, OP1 to OP2 submitted the file alongwith original documents to Op1. Till date, despite repeated approaches made by the complainant, Ops failed to pay the death claim and refused to do so with false and baseless reasons vide letter dated 5.3.2013 issued to the complainant. Complainant also wrote letter dated 31.5.2013 to the Op3 and also served a registered notice dated 2.4.2014 upon the Ops calling upon them to make the payment of the death claim but despite receipt of the said notice, Ops failed to do the needful and gave false and baseless reply dated 21.4.2014 taking baseless and justified pleas. Such act and conduct of OPs is claimed to be deficiency in service on their part by the complainant. Hence, this complaint.

3.                Upon notice of the complaint, Op1 and OP2 were duly served and appeared through their counsel Sh.Rajeev Abhi, Advocate and filed their written reply, whereas, despite service through notice, OP4 failed to appear and was proceeded against ex-parte vide order dated 19.9.2014, whereas, written reply on behalf of OP3 was received by post.

4.                OP1 and OP2 filed the written reply, in which, they have taken up certain preliminary objections that the present complaint is barred under Section 26 of the Consumer Protection Act; the present complaint is not maintainable as the policy in question has run for only four days from FPR since the life assured under the policy namely Umesh Kumar expired on 4.4.2012. It is very early death claim. The life assured Umesh Kumar had submitted a proposal for his life assurance with the answering Ops on 8.3.2012. The life assured had signed personal statement on 10.3.2012 at the time of his medical examination and the first premium was paid on 30.3.2012. Immediately on the receipt of the claim, it was duly registered, entertained and processed. The complainant was called upon to submit the documents in respect of the claim lodged regarding the death of Umesh Kumar. The complainant had submitted the following documents i.e.

a)form No.3783(R) claim form A i.e. Annexure I “claimant’s statement”.

b)Annexure II form No.3784(R), claim form B i.e. Medical attendant’s certificate.

c)Form No.3787 (Revised), Claim form E i.e. certificate of employer.

d)Claim Form no.3816 signed by the doctor of ESIC Hospital, Bharat Nagar, Ludhiana.

e)Form No.3816.

Sh.Sanjay Mohan, branch Manager, Branch Haibowal, Ludhiana of LIC of India was called upon to make the enquiry regarding the claim under policy No.301935599, who had made thorough enquiry and thereafter, submitted his claim enquiry report clearly stating that the deceased was admitted in ESIC Hospital, Ludhiana on 21.3.2012 and died on 4.4.2012 and the proposal under the said policy was completed when the life assured was admitted in the hospital and as such, the claim seems not to be genuine, since the date of proposal is 8.3.2012, date of medical report is 10.3.2012, date of inward office is 22.3.2012, date of U/W decision is 28.3.2012, date of completion of proposal is 30.3.2012 and the date of FPR issued is 4.4.2012. The policy holder as such was admitted in the hospital on the date of completion of policy proposal. Sh.Umesh Kumar had also died on 4.4.2012. After the receipt of the abovesaid documents and after scrutinizing the documents placed on the claim file, it is evident that the life assured Sh.Umesh Kumar had died milliary kochi’s with snopd added infection and he was suffering from this disease since one month and was admitted in ESIC Hospital, Bharat Nagar, Ludhiana on 21.3.2012. As per form 3787, the life assured Umesh Kumar lastly attended his duties on 21.3.2012 and thereafter, admitted in ESIC Hospital, Ludhiana on account of cough, breathlessness etc., and died on 4.4.2012. The proposal of assurance as such was completed when the life assured was admitted in the hospital and the life assured Umesh Kumar was suffering from the disease prior to the date of proposal but he did not disclose this fact in the proposal form. After the scrutinizing the documents placed in the claim file and after applying the mind by the officials of the answering Ops in terms of the insurance policy, the claim of the complainant was repudiated as ‘No Claim’ vide letter dated 5.3.2012 on the grounds that the deceased had withheld correct information regarding his health at the time of effecting insurance with the answering Ops since in the proposal for insurance dated 8.3.2012 and personal statement signed by the deceased insured on 10.3.2012 at the time of his medical examination he had answered the following questions as under:-

	Questions	Answer
11(a)	During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week?	No
b)	Have you ever been admitted to any hospital or nursing home for general check up observation, treatment or operation?	No
c)	Have you remained absent from place or work on grounds of health during the last 5 years?	NO
d)	Are you suffering from or have you ever suffered from ailments, pertaining to liver, stomach, heart, lungs, kidney, brain or nervous system?	No
e)	Are you suffering from or have you ever suffered from diabetes, tuberculosis, high blood pressure, low blood pressure, cancer, epilepsy, hernia, hydrocele, leprosy or any other disease?	No
f)	What has been your usual state of health?	Good

 

The answering Ops have reasons to believe that about 15 days before the life assured proposed for the above policy, he was suffering from cough and breathlessness and milliary kochi’s for which he consulted a medical man and had taken treatment from him/hospital. He did not, however, disclose these facts in proposal/personal statement. Instead he gave false answering therein as stated above. The deceased life assured died on 4.4.2012 due to milliary kochi’s. The life assured Umesh Kumar had made incorrect statements and withheld information from the answering Ops regarding his health at the time of effecting the assurance and hence, in terms of the policy contract and the declaration contained in the forms of proposal for assurance and personal statement, the answering Ops had rightly repudiated the claim as the answering Ops are not liable for any payment under the above policy and all money that have been paid in consequence thereof belong to the answering Ops.
The complainant received the said letter and filed an appeal before the Zonal Office Claims Disputes Redressal Committee of LIC of India, who examined the facts of the case and decided to upheld the decision of repudiation of the claim a/c Umesh Kumar under the policy in question vide their letter dated 30.10.2013 and had called upon the Sr.Divisional Manager, LIC of India to convey the decision to the complainant. The Sr.Divisional Manager of LIC Of India vide their letter dated 23.11.2013 had conveyed the decision of Zonal Office Claims Review Committee of LIC of India to the widow of the life assured namely Shanti Devi vide their letter dated 23.11.2013. Further, took the preliminary objections that the complainant is estopped by her own act and conduct from filing the present complaint since the complainant is not coming to the Hon’ble Forum with clean hands and she has concealed the material facts from this Hon’ble Forum and the present complaint is not maintainable since complicated question of law and facts are involved which requires elaborate evidence, both oral and documentary and it is only the Civil Court of competent jurisdiction who can try and decide the present complaint and the complaint cannot be decided by this Hon’ble Forum in a summary manner. Further, the present complaint is not maintainable since all the legal heirs of deceased Umesh Kumar are not impleaded as parties to the present complaint. On merits, it is submitted that the life assured Umesh Kumar of his own had approached the OP4 for obtaining the policy in question. Further, the facts regarding obtaining of insurance policy in question for a sum of Rs.4 lakh and its commencement, lodging of claim and repudiation of the same are not denied. Further, it is submitted that the life assured was not subject to any medical test. The insurance policy was issued on utmost good faith as per the personal statement signed by the deceased life assured Umesh Kumar on 10.3.2012 at the time of his medical examination. The life assured Umesh Kumar suffered from fever, cough, breathlessness and milliary kochi’s prior to the date of proposal but did not disclose this fact before medical examiner for taking the insurance policy. Otherwise, similar pleas were taken as taken in the preliminary objections and at the end, denying any deficiency in service on the part of answering OPs and all other allegations of the complainant being wrong and incorrect, answering OPs prayed for dismissal of the complaint with costs.

5.                In the written reply filed by OP3 which was received by post by this office on 29.10.2014, it has been submitted that it has been directed by the Hon’ble Ombudsman to inform this office that the offices of Ombudsman at different locations in the country have been set up by the Central Government u/s 114 of the Insurance Act, 1938, for redressal of grievances of insuring public. Ombudsman are not party to the dispute between the insured and insurer. The insuring public has an option of lodging a complaint with the Ombudsman or the concerned Consumer Forum/Courts having jurisdiction. The Insurance Ombudsman thus provides a parallel mechanism for resolution of disputes between the insurer and the insured. Therefore, Ombudsman, being an independent authority and not being a party to the dispute, cannot be impleaded as a party in the proceedings before any Redressal Forum.

6.                Learned counsel for the complainant in order to support the case of the complainant, tendered into evidence by placing on record affidavit of Smt.Shanti Devi @ Sunita complainant as Ex.CA, in which, she has reiterated all the allegations made by her in the complaint. Further, learned counsel for the complainant has relied upon documents Ex.C1 to Ex.C15.

7.                On the contrary, learned counsel for the OP1 and OP2 in order to rebut the evidence of complainant, adduced evidence by placing on record affidavit Ex.RA of Sh.Parvinder Kumar, its Manager(Claims), in which, he has reiterated all the contents of written reply filed by OP1 and OP2 and refuted the case of the complainant. Further, learned counsel for the OP1 and OP2 has tendered into evidence affidavit Ex.RB of Sh.Sanjay Mohan, Branch Manger at Haibowal, Ludhiana, in which, he has proved the enquiry report as Ex.R12. Further, learned counsel for the OPs has proved on record the documents Ex.R1 to Ex.R31.

8.                When the case was fixed for evidence of OP3, OP3 failed to appear despite sending intimation through registered post on 11.3.2015, as such, OP3 was proceeded against ex-parte vide order dated 26.3.2015 by this Forum.

9.                We have heard the learned counsel for the complainant as well as learned counsel for the OP1 and OP2.

10.              Learned counsel for the complainant has contended that it is proved fact on record that deceased/life assured Mr.UMesh Kumar, who was the father of Miss Anchal and husband of Smt.Shanti Devi @ Sunita i.e. present complainants, had purchased the insurance policy in question i.e.”Jeevan Ankur” having policy No.301935599 from OP1 to OP3 through OP4 and the commencement date of the said policy was 28.3.2012 and date of commencement of risk was 30.3.2012 and said policy covered the death risk upto Rs.4 lakh of Mr.Umesh Kumar, who had appointed Miss Anchal his minor daughter as his nominee. Further, it has been contended that before issuing the said policy, deceased Mr.Umesh Kumar had undergone each and every medical tests which were got conducted by OP1 to OP3 properly and after confirming the health fitness of complainant, OP1 to OP2 had issued the abovesaid policy to Mr.Umesh Kumar. Unfortunately, Mr. Umesh Kumar died on 4.4.2012, due to natural death and after his death, complainant had immediately approached Ops and death claim was lodged with them. However, the same was repudiated by the Ops on illegal and arbitrary grounds by the OP1 to OP3.

11.              On the other hand, learned counsel for the OP1 and OP2 has filed the written arguments, in which, he has reiterated all the contents of written reply filed by the OP1 and OP2 and it has been specifically submitted under the head “Points of Arguments” that the insurance policy was issued on utmost good faith as per the personal statement signed by the deceased life assured Umesh Kumar on 8.3.2012 i.e. Proposal for insurance on own life and on 10.3.2012 at the time of his medical examination i.e. medical examiner’s confidential report. The life assured was not subject to any medical test as the insurance policies are issued on utmost good faith and as per the proposal form and personal statement duly signed by the deceased at the time of obtaining the insurance policy. The life assured Umesh Kumar suffered from fever, cough, breathlessness and milliary kochi’s with snopod added infection prior to the date of proposal but did not disclose this fact before medical examiner for taking the insurance policy and in the proposal form. The life assured was duty bound to disclose all the diseases suffered by him at the time of submission of the proposal form dated 8.3.2012 and signing the personal statement dated 10.3.2012 wrongly typed in the letter dated 5.3.2013 as 8.3.2013 and 10.3.2013 in the letter of repudiation dated 5.3.2013. The policy in question has run for only four days from FPR since the life assured under the policy namely Umesh Kumar expired on 4.4.2012. The claim of the complainant was repudiated vide letter dated 5.3.2012 on the grounds that all the answers given in the proposal form dated 8.3.2012 and personal statement signed by the deceased on 10.3.2012 at the time of his medical examination were false as 15 days before he proposed for the abovesaid policy he suffered from fever, cough, breathlessness and milliary kochi’s with snopod added infection, for which, he had consulted a medical main and had taken the treatment from the hospital but he did not disclose this fact in the proposal form and personal statement instead had given false answer therein and had die don 4.4.2012 due to milliary kochi’s with snopod added infection. The claim was repudiated for reasonable and probable cause and on the grounds which are legal, valid and enforceable and there is no deficiency in service on the part of the OP1 to OP3. Further, learned counsel for the OP1 and OP2 has made reference of all the relevant documents produced by the OPs in their evidence and he has also relied upon judgments titled as LIC of India vs. Neelam Sharma-IV(2014)CPJ-658(N.C.); Shakuntala vs. LIC of India-III(2014)CPJ-517(N.C.); Devamma vs. LIC of India-II(2014)CPJ-3(N.C.); Paramjit Kaur vs. LIC of India-IV(2014)CPJ-132(N.C.) and Laxmi Devi vs. Oriental Insurance Co.Ltd.-Iv(2012)CPJ-483(N.C.).

12.              We have heard the rival contention of learned counsel for the complainant and have also gone through the written arguments alongwith judgments filed by the learned counsel for the OP1 and OP2 during the course of arguments and have also perused the record on the file very carefully.

13.              Perusal of the record reveals that it is an admitted fact between the parties that deceased/life assured Mr.Umesh Kumar, who was the father of Miss Anchal and husband of Smt.Shanti Devi @ Sunita i.e. present complainants, had purchased the insurance policy in question i.e.”Jeevan Ankur” having policy No.301935599 Ex.C1 from OP1 to OP3 through OP4 which was commenced from 28.3.2012 and date of commencement of risk was 30.3.2012 and said policy covered the death risk upto Rs.4 lakh of Mr.Umesh Kumar. Further, it is a proved fact on record that unfortunately, Mr.Umesh Kumar died on 4.4.2012.

14.              The bone of contention between the parties is qua the issuance of the policy during the period when the said Umesh Kumar was admitted in the ESIC Hospital at Ludhiana.

15.              Perusal of the Proposal Form Ex.R1 reveals that same was filled up on 28.2.2012 and medical of the deceased/assured Umesh Kumar was got conducted by the Ops through their doctor namely Sh.Amit Modgil on 10.3.2012 Ex.R2, who had declared that deceased Umesh Kumar was not suffering from any disease and thereafter, the policy in question Ex.C1 was issued by the OP1 to Op3.

16.              Perusal of the copy of claim enquiry report Ex.R12 reveals that cause of death was reported as Cough and Fever and it was also reported that DLA was working as Tool Fitter in Embay Automobiles Pvt. Ltd. for last 2 years and he was covered under the ESI Scheme. He died in the ESI Hospital, Bharat Nagar Chowk, Ludhiana, where he was admitted since 21.3.2012. Perusal of the copy of repudiation letter dated 21.4.2014 Ex.R29 reveals that deceased/life assured was suffering from Milliary Kochi’s, for which, he had taken treatment in the hospital before the commencement of the policy, that is, 28.3.2012. He did not, however, disclose these facts in his proposal/personal statement. As the life assured was suffering from the disease before the commencement of the policy which was not disclosed by her deceased husband, the competent authority has rightly repudiated the claim under the abovesaid policy.

17.              Perusal of the whole evidence of the Op1 and OP2 reveals that on one side, doctor of the Ops had duly examined the deceased on 10.3.2012 finding no disease on the person of the deceased and the proposal of insurance of the deceased was processed and ultimately policy in question was issued on 28.3.2012 w.e.f.30.3.2012 and thereafter, the deceased/life assured Umesh Kumar was died on 4.4.2012. So, under these circumstances, it will be in the fitness of things that if the present complaint is partly allowed with the specific directions to the Ops to re-open and re-examine the death claim case of the complainant qua the death of Mr.Umesh Kumar and decide a fresh after taking into consideration all the facts and thereafter, to settle and pay the claim of the complainant as per the terms and conditions of the insurance policy in question.

18.             In view of the above discussion, by partly allowing this complaint, we hereby direct the Ops to re-open and re-examine the death claim case of the complainant qua the death of Mr.Umesh Kumar and decide a fresh after taking into consideration all the facts and thereafter, to settle and pay the claim of the complainant as per the terms and conditions of the insurance policy in question. Further, Ops are directed to pay Rs.5000/-(Five thousand only) as compensation to the complainant on account of mental pain, agony and suffered by her and Rs.2000/-(Two thousand only) as litigation costs to the complainant. Order be complied within 30 days from the date of receipt of copy of this order. Copy of order be supplied to the parties free of costs. File be completed and consigned to record room.

 

   (Babita)                       (Sat Paul Garg)              (R.L.Ahuja)

   Member                      Member                        President.   

Announced in Open Forum

Dated:28.04.2015

Gurpreet Sharma.