Smt.Paramjit Kaur and others, complainants have 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 they have prayed that the opposite parties be directed to pay Rs.10,00,000/- to them as well as to Chamkaur Singh alongwith interest @ 24% per annum from the date of due till its realization as a insurance claim of deceased Gurnam Singh alongwith compensation for illegally harassment by the opposite parties to them and also mental agony or any other relief may be granted to them as this Hon’ble Forum deem fit, in the interest of justice.   

2.       The case of the complainant in brief is that her husband Sh.Gurnam Singh deceased had taken policy bearing No.473806328 on 28.10.2013 for Rs.10,00,000/- and deposited the installment of Rs.37,595/- to the opposite party no.1 and she is nominee of her husband. The opposite parties medically examined the Gurnam Singh before issuing policy from their authorized doctors. Gurnam Singh died on 6.5.2014 and information regarding the same was given to the opposite party no.1. They completed all the formalities of the opposite parties after the death of Gurnam Singh for getting sum assured amount from the opposite parties. Even submitted all the relevant documents to the opposite parties for disbursement of claim and also submitted one cancelled cheque on the demand of the opposite parties.  They many times approached  the opposite parties and requested them to make the payment of Rs.10,00,000/- alongwith interest to them as insurance claim of deceased Gurnam Singh but they put the matter pending with one pretext or the other. They have next pleaded that the opposite parties issued letter bearing No.Claims/Repd No.1855/1081 dated 31.03.2017 to them and alleged in the letter that complainants are not entitled for the insurance claim as policy holder suppressed the material facts at the time of taking policy and they are not entitled for the insurance claim of the insurance policy and also alleged that he remained admitted in the Hospital from 21.2.2014 to 26.2.2014 and taking ALD, Chronic Alcohol, the DLA was drinking daily since past. This fact is totally wrong as the deceased never taken liquor as alleged by the opposite parties and he never remained ill as alleged in the abovesaid letter by the opposite parties. The deceased never remained ill and if there is any document regarding the illness of the deceased Gurnam Singh i.e. illegal, null and void. Moreover, the deceased Gurnam Singh never taken Alcohol and he was follower of Radha Swami Dera Beas and Gurnam Singh had died in his house at village Machrai.  They have approached to the opposite party no.3 and requested the opposite party no.3 to make the payment of insurance claim to her but they refused to make the payment of insurance claim. Thus, there is deficiency in service on the part of the opposite parties.  Hence this complaint.   

3.       Upon notice, the opposite parties appeared and filed the written reply through their counsel by taking the preliminary objections that Gurnam Singh, an agriculturist purchased Insurance policy bearing No.473806328 for a sum assured Rs.10,00,000/-, Table-Term 14-16 with date of commencement 28.10.2013. While proposing for assurance, in answer to relevant questions of the proposal form 11(a)-11(I) DT.20.11.2013, the Deceased Life Assured had stated that he was in good health and he never used alcohol drinks/narcotics/drugs etc, nor he consulted any medical practitioner or underwent any medical treatment. The proposal was accepted on Non Medical Basis and no medical examination was conducted by LIC at the time of proposal. The policy resulted into death claim on 06.05.2014 within one year of the date of insurance and the claim was lodged by the wife of the deceased life assured, who is the ‘Nominee’ under the policy. The claim being early was investigated and it is revealed that the deceased life assured was not keeping good health and used Alcohol frequently and suffering from Liver Infection. The deceased life assured remain admitted at Sri Guru Ram Das Charitable Hospital, Amritsar for more than 20 days in December 2013 to February, 2014. He was not keeping good health and sober habits before the proposal of insurance and the policy has run for only 5 months and it is evident that these material facts were not disclosed by the deceased life assured while making the proposal and in this way he suppressed the material fact of his ill health and alcoholic habit, which was only in his exclusive knowledge and by providing incorrect information deliberately regarding his ill health. The claim has been repudiated by the competent authority, on the recommendations of the standing committee since the deliberate miss-statement was making in this case and material facts had been suppressed. The claimant was intimated accordingly vide registered letter dated 31.03.2017 and even suggested to make representation to higher offices of the LIC, but they filed this complaint instead.  On merits, the same facts have been reiterated which have been taken in preliminary objections and prayed for dismissal of the complaint.

4.       Counsel for the complainants has tendered into evidence affidavit of Smt.Paramjit Kaur Ex.C1, alongwith other documents Ex.C2 to Ex.C5 and closed the evidence. 

5.       Counsel for the opposite parties tendered into evidence affidavit of Sh.Rajinder Kumar Manager (Legal) LIC of India Ex.OP-1 alongwith documents Ex.OP-2 to Ex.OP-6 and closed the evidence.

6.         We analytically observe with the judicial precision and find that the OP insurers have arbitrarily repudiated (vide Ex.OP2) the complainant’s insurance death-claim for Rs 10.00 Lac on the pretext that the BHT (Bed Head Ticket) of Sri Guru Ram Dass Hospital, Amritsar; indicates that the DLA (Deceased Life Assured) remained admitted there with effect from 21.02.2014 to 26.02.2014 and has been a chronic alcoholic, daily-consuming since past 3-4 months. It shall be pertinent here to note that the DLA on 20.11.2013 had declared in the related proposal to be in good health not suffering from any kind of disease/ ailment etc and since then there had been no evidence of any pre-existing disease and somehow he had to be hospitalized on 21.02.2014 and as such there has been no adverse health-evidence against him, on records.

7.       The OP insurers have alleged in their duly deposed written reply (affidavit Ex.OP1) that the DLA’s proposal for one Rs.10 Lac Sum Assured Policy (w.e. from 28.10.2013) was accepted at his self- declaration on non-medical basis but was later investigated at his death on 06.05.2014 and that revealed (Ex.OP1) his post-insurance hospitalization in the month of February’ 2014 with history of liver-dysfunction due to alcoholism etc. The OP insurers have also produced Claim Enquiry Report (Ex.OP3/OP4) and the related Hospital Record (Ex.OP5/OP6) that is however not supported by any first-hand deposition and is thus a mere hearsay evidence indicating post-policy hospitalization with hearsay history of alcoholism etc and that in the absence of any cogent evidence merely amounts to bald statements, only. The complainant, on the other hand, has successfully and satisfactorily proved her contented complaints vide her duly deposed affidavit Ex.C1 and the supporting documents exhibited here as: Ex.C2 to Ex.C5  

8.       We find further that the purchase and validity of the related policy have been duly admitted along with the factum of receipt of its premium and resultant enforceability in law. Somehow, the OP insurers have failed to produce the treating doctor’s affidavit, discharge summary, treatment history and medicine/ surgery schedule etc to prove their allegation of pre-existing disease/ ailment etc for reasons best known to them alone and that addresses its repudiation as arbitrary, unethical and for the sake of some collateral considerations. The OP insurers have based their above repudiation decision solely on presumptions and hearsay evidences and the same are not admissible in judicial adjudicatory. Further, there has been no documentary evidence made available and/or produced on the records of the present proceedings proving the presence knowledge/symptoms of the ‘ailment’ (prior to the date of policy) as pre-existing and resulting into the DLA’s untimely demise for which the present insurance claim stood preferred.

9.       Thus, the alleged misrepresentation/concealment/non-disclosure of material facts etc do not stand proved. In such like repudiations the o. n. p. (onus of proof) always lay heavily upon the insurers but here they have miserably failed to legally discharge the same successfully. We are strengthened in our above proposition by virtue of the valuable comments as made out by the honorable Punjab State Commission in the FA # 537 of 2008 titled: LIC of India vs. Priya Sharma & ors., as: “…. in this case, there is no evidence on record to prove that the deceased life assured was suffering from any pre-existing disease at the time of purchasing the policy. …. There is no evidence to prove that the deceased was ever admitted or took any treatment from any hospital or the doctor regarding the alleged pre-existing disease. …”.  The honorable National Consumer Commission has further elaborated the legal proposition in RP # 218 of 2008 titled United India Insurance Co. Ltd., vs. Anumolu Rama Krishan as: “7… Even if Respondent was suffering from these diseases which admittedly do not occur overnight, it is both possible and plausible that he was unaware of it since these can be ‘silent diseases’ and a person suffering from them may not even be aware until the condition aggravates and overt symptoms appear….”.

10.     In the light of the all above, we are of the considered opinion that the OP insurers have blatantly bruised the consumer rights of the present complainant by employing ‘unfair trade practice’ amounting to ‘deficiency in service’ (on their part) and that lines them up for an adverse statutory award under the applicable Consumer Protection Act’ 1986. We, therefore,  partly allow the present complaint and thus ORDER the OP insurers to pay the impugned ‘insurance claim’ for the full insured amount of the related Policy as per its governing ‘terms’ (to its full benefits) strictly in accordance with the IRDA guidelines on ‘settlement of claims’ favoring the complainant besides to pay her Rs.10,000/- as cost and compensation within 30 days of receipt of the copy of the present orders otherwise the aggregate award amount shall attract interest @ 9% PA from the date of the orders till actual payment.

11.     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)

May 28,2018.                                                               Member               

*MK*