BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.472 of 2017

Date of Instt. 11.12.2017

Date of Decision: 05.03.2019

Smt. Sarla Devi aged about 54 years W/o late Shri Ram Lal, R/o House No.31, Mohalla Raika, Kapurthala.

..........Complainant

Versus

1. Life Insurance Corporation of India (LIC), Branch Office, Kapurthala Through its Branch Manager.

2. Life Insurance Corporation of India (LIC) Divisional Office, Jeevan Prakash, Model Town Road, Jalandhar through its Senior Divisional Manager.

3. Manager (Claims) Life Insurance Corporation of India (LIC), Divisional Office, Jeevan Parkash, Model Town Road, Jalandhar-144001.

4. Manager (CRM) Life Insurance Corporation of India (LIC), Divisional Office, Jeevan Parkash, Model Town Road, Jalandhar-144001.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Jyotsna (Member)

Present: Sh. K. C. Malhotra, Adv Counsel for the Complainant.

Sh. S. C. Sood, Adv Counsel for the OPs No.1 to 4.

Order

Karnail Singh (President)

1. This complaint has been presented by the complainant, wherein alleged that Ram Lal Kumar (since deceased) S/o Late Shri Mehar Chand husband of the complainant, while alive got his life insurance policy, bearing No.132498825 for sum assured Rs.7,50,000/- with OP No.1 through its authorized agent. The policy was under LIC's Jeevan Saral with Profits Plan No.165 for terms 13 years. The proposal dated 28.02.2013 was accepted at ordinary rate of premium as Standard Life. The risk of the policy commenced from 28.02.2013. The mode of payment of installment of premium was monthly under Salary Saving Scheme. The signature/thumb impression of the life assured on printed Proposal Form No.300 dated 28.02.2013 were taken in routine and mechanically on dotted lines on the proposal form filled in English by securing agent of OP No.1. The deceased life assured was illiterate not conversant with English language nor could read English and sign in English. The deceased life assured underwent through complete, comprehensive and careful medical check up by panel doctor of choice of OP No.1 at the time of submission of proposal form for own life insurance and additional special medical test reports relating to health profile were obtained. The panel medical examiner did not notice/observe an adverse feature of past history and habit or existence of any other complication and that panel doctor had examined the DLA in private and recorded true findings in his own hands on the eve of proposing for life insurance company. The risk of the life assured was accepted without raising any kind of objection as to details given in the proposal form and personal statement and these entire reports collected premium at a tabular rate of premium as standard life without any demur on the eve of proposing for life insurance and carefully and thoroughly scrutinized and verified before acceptance of the proposal. The DLA had healthy existence and normal physical conditions during his life time and was not harbouring and labouring under any disease or sickness when he sought insurance on his life under the policy subject matter of the complaint.

2. That deceased life assured was taken ill on 05.01.2015 and unfortunately expired on 10.01.2015 after short illness of 6 days. The death was natural. It was God's Will. The policy was alive on the date of death of the life assured and thereafter, the complainant being a wife and nominee of the deceased, lodged a claim with the OP No.1 for payment of sum assured with the accrued bonus and other benefits. The complainant completed and complied with all the requirements and then submitted the requisite prescribed claim forms, but the claim of the complainant has been repudiated, vide letter Ref: Claims/Death/Repd/No.152/72 dated 10.03.2017 by registered AD Post by OP No.2. The claim by death has been repudiated after expiry of two years from the date on which life insurance policy was effected. The claim was repudiated for concealment for pre-existing disease, but there was no fraud or deliberate misrepresentation by DLA.

3. That refusal to pay just rightful and genuine claim by OP No.1 is arbitrary, wrongful, malafide, perverse, capricious, unilateral, oppressive, unfounded and non-existing reasons, fiction speculation, doubt and suspicion in the absence and non available original basic record of the policy allegedly missing/untraceable and without any valid justification. The repudiation of the legitimate rightful bonafide and genuine claim by death of life insured is virtually deficiency in service and unfair trade practice on the part of the OP and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the insurance claim of Rs.7,50,000/- with interest @ 12% per annum + bonus from the date of death up to the date of actual payment and further OPs be directed to pay compensation for causing mental tension and agony to the complainant, to the tune of Rs.20,000/- and litigation expenses of Rs.10,000/-.

4. Notice of the complaint was given to the OPs and accordingly, all the OPs appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the complainant is estopped by her own act, conduct and acquiescence to file the present complaint and further alleged that Ram Lal Kumar concealed the material facts at the time of taking the insurance policy and further averred that the contract between the life assured and the OP is contract of faith, but the complainant has submitted Form No.3816 and 3784 which discloses the ailment of the life assured and as such, complaint is to be dismissed on this ground. It is further alleged that as per Form No.3816, it was observed by the doctor when assured was admitted in S. G. L. Charitable Hospital that the life assured was known case of COAD presented with Cough, Breathlessness and General Weakness. The life assured has taken the policy wrongly, even documents submitted by the complainant proves that the life assured was having the above said ailments. Non-disclosure of the above said ailments at the time of taking of the policy, the complaint is to be dismissed with cost. On merits, it is admitted that the deceased Ram Lal Kumar got the insurance policy for sum insured of Rs.7,50,000/-, but the life assured had given a wrong information in the proposal form and as such, the complainant is not entitled for the claim. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

5. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB along with some documents Ex.C-1 to Ex.C-5 and closed the evidence.

6. Similarly, counsel for the OPs tendered into evidence affidavit of Sh. Parvathy Krishanan, Manager as Ex.OW1/A and affidavit of Dr. Damanjit Singh as Ex.OW2/B along with some documents Ex.O-1 to Ex.O-5 and then closed the evidence.

7. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also scanned the case file very minutely.

8. In this complaint, the factum in regard to obtaining insurance policy by deceased Ram Lal Kumar is not in dispute rather the risk of the policy commenced from 28.02.2013 and filling of proposal form on 28.02.2013, is also not denied by OP in response to para No.1 of the complaint. It is also not denied that a claim was submitted by the complainant on the occasion of the death of her husband deceased life assured Ram Lal Kumar, but the dispute started only after the repudiation of the claim, vide letter dated 10.03.2017 Ex.C-1 and the said letter is challenged by the complainant on various grounds and accordingly, we have analyze all factors and also gone through the said letter dated 10.03.2017 for repudiation of the claim of the complainant and find that the main plea taken in the said repudiation letter dated 10.03.2017 is only that the deceased has suppressed the material facts in regard to his previous ailment at the time of inception of the policy and due to that reason, the claim has been repudiated and further in the said repudiation letter, the question put and thereof answer given by the assured, is incorporated in the said repudiation letter by taking from proposal form and admittedly in these questions, the deceased assured given reply that he was never diagnoses nor any problem to him prior to inception of the policy, but it is very strained to read these questions and answer in the repudiation letter, when the OP itself denied the copy of proposal form to the complainant while it was demanded under RTI Act and copy of the reply given by the OP in response to RTI Act is available on the file Ex.C-5, wherein question No.5 itself clear that the complainant sought the proposal form along with its medical examination report, but the OP gave a reply the document is missing in the branch, it is very strained to read this reply of the OP, because the OP is a very big insurance corporation in India and running a huge business and if such like important document of the any insured person during the alive period of that insurance policy. It shows that the document has been intentionally got missed by the OP just to deprive the complainant from eating the fruits of the insurance policy.

9. First of all, if we accept the version of the OP that there is some concealment and mis-statement made by the deceased insured at the time of taking the policy, then it is bounded duty upon the OP to produce on the file original proposal form, where-from we can ascertain what answer has been actually given by the deceased insured at the time of filling the said proposal form and in the absence of the original proposal form, we cannot accept that the answer alleged by the OP in the repudiation letter is correct version as filled in the proposal form or not. So, in the absence of the proposal form, the plea taken by the OP that the deceased insured has concealed the previous ailment, is not acceptable.

10. Furthermore, the complainant alleged in Para No.1 that he got insurance on 28.02.2013 and on the same day proposal form was filled and risk of the policy commenced from 28.02.2013 and in reply to para No.1 of the complaint, the OP has not denied. So, it means the dates given by the complainant are virtually true and correct and acceptable to both the parties. If the insurance was commenced on 28.02.2013, thereafter it is the duty of the OPs to produce on the file some documentary medical evidence showing that the deceased insured was having some critical ailment prior to 28.02.2013, but in order to give answer or meet out this query, the counsel for the OP referred affidavit Ex.OW2/B of Dr. Damanjit Singh, M. D. (Medicine), wherein he stated that Form No.3816 and information was provided by patient Ram Lal himself, the form is correct, but simply bringing on the file any information is not sufficient until any treatment was not taken by the deceased insured and moreover, the said Dr. Damanjit Singh in his affidavit did not disclose on which date the patient Ram Lal Kumar himself provided information whether prior to taking insurance policy or after that. Further, the document referred by the learned counsel for the OP is Ex.O-2 Medical Attendant's Certificate issued by SGL Charitable Hospital, Garha Road, Jalandhar and in this certificate, no where mentioned that the deceased insured Ram Lal Kumar was diagnosed prior to 28.02.2013 and any critical disease was observed. Similarly, the OP has referred a certificate of hospital treatment Ex.O-3 issued by SGL Charitable Hospital, but again in this certificate it is not observed by the doctor that the deceased insured was having any critical problem prior to inception of the policy, the next document referred by learned counsel for the OP is a Claimant's Statement Ex.O-4, but again from this document nothing is proved that deceased Ram Lal Kumar was having some medical problem prior to taking of the policy. Then coming to an other document referred by learned counsel for the OP i.e. Ex.O-5, wherein the admission into the hospital have been mentioned 07.12.2014 of Ram Lal Kumar, but again, if we considered this document, then say without any hesitation that the admission of the complainant in the hospital on 07.12.2014 is after the obtaining of insurance policy i.e. 28.02.2013. So, from all documents, it is clearly established that there is not even iota of document produced on the file by the OP where-from we can assess that the complainant was ailing any serious problem prior to inception of the policy and he was taking a treatment of that ailment, if so, then we conclude that the OP has wrongly and illegally repudiated the claim of the complainant and thus, the said repudiation letter dated 10.03.2017 is set-aside and further hold that the complainant is entitled for the relief claimed.

11. As an upshot of our above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay the insured amount of Rs.7,50,000/- with interest @ 9% per annum from the date of repudiation of claim i.e. 10.03.2017, till realization and further OPs are directed to pay compensation for harassing the complainant, to the tune of Rs.15,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Jyotsna Karnail Singh

05.03.2019 Member President