(Passed on 07/10/2022)

Passed by Shri Atul D. Alsi, Hon’ble President 

1.         Complainants  filed  complaint case against the repudiation of insurance claim for the reason of suppression of material  facts and thereby  claiming  compensation  under three insurance  policies  amounted  to Rs. 13,00,000/- along with  compensation  and cost  Rs. 35,000/-.

2.         Story in short,  the complainant  No. 1 Wife and complainant Nos. 2,3&4 are daughters and son of deceased Chhedu Zuri Kaithal who purchased  three insurance policies  under  the plan of New Endowment  Policy  bearing No. 979237520 on 09/06/2016 for the  premium  of Rs. 1105/- for the   insured  amount of Rs. 2,00,000/-. The second policy  New Jeevan Anand  bearing  No. 979239070 on 15/12/2016 for the  monthly premium of Rs. 2775/- for sum assured of Rs. 10,00,000/- and the third insurance  policy  name  as Jeevan  Rakshak bearing  No. 979263752  purchased on  28/03/2015 for  monthly premium of Rs. 445/- for the  sum assured  of Rs. 1,00,000/- .

3.         Deceased was serving at W.C.L. at Chandrapur but on 13/01/2018 the Chhedu Zuri Kaithal was died. The premium of policies were paid from salary and the amount has been deducted in the month of December-2017. The complainants thereafter submitted insurance claim with relevant documents but the O.P.No. 1 has repudiated the claim   for the reason of suppression of ongoing treatment  at  Dr. Suresh  Kolhe  Hospital, Ghugus, District  Chandrapur and  therefore in proposal  form the  insured  has submitted  false  information  to the  question  Nos. 11-a to 11-i of the proposal. The complainant  issued legal  notice  through  advocate  Mr. Yogesh  Itankar on 14/10/2019 for  payment of insurance  claim but O.P. did not  complied the notice.  Therefore, rejection of claim under policy for the reason stated in the repudiation letter without material evidence does amount to deficiency on service. Therefore, complaint is filed.

4          The O.P. Nos. 1&2 filed reply and denied  allegations  against it and submitted that  the deceased purchased  three policies  out of which  the third policy  bearing  No. 979263752  the insurance claim has been paid  to the complainants. The deceased submitted false information for the proposal submitted for the policy bearing No.  979239070 on 10/12/2016 in respect of question bearing No. 11-a, during the last five years did you consult medical practitioner for any ailments requiring treatment for more than a week. It is submitted in reply that the deceased was under treatment at Dr. Kolhe Hospital from 19/03/2014 to 18/04/2014 for Enteric Fever. The deceased was died within period of two years from inception of policy.  Therefore,  for early  claim  the investigation  was conducted by the O.P. and found  that  as per  report  from W.C.L. Medical Department , Mungoli dated 12/02/2014 the deceased  was  under  treatment  for  Alcoholic  Gastritis  from 02/03/2014 to 07/03/2016 as per  medical  service  card issued by W.C.L. Hospital.  The O.P. submitted in reply that the deceased was under medical leave for several days from 2013 to 2018.  As per Insurance Act,  Section 45 the insurance  contract  is based  on utmost good faith  as per  policy  term the suppression of  medical treatment   or  disease   in  proposal form of policy  does amount to breach of  terms and  condition of policy  and  terms utmost  good faith. Therefore, the O.P.Nos. 1&2 has rightly rejected the insurance claim of deceased. Hence, the complaint deserves to be dismissed with cost.

5.         Counsel for the complainant argued  that  the O.P. has  filed  medical  papers  without  examination  or  affidavit  of concerned  doctor’s to prove the defence on record.  Therefore, rejection of insurance claim does amount to deficiency in service.

6.         The counsel for the  O.P. argued that  the suppression of  medical treatment  for the period  from 02/03/2014 to 07/03/2016 for Alcoholic Gastritis at W.C.L. Hospital  and medical treatment  of Dr. Kolhe at Kolhe Hospital  from 19/03/2014 to 18/04/2014 for  Enteric Fever. In proposal form  for the question  No. 11-a to 11-j does  amount  to suppression of material facts and breach  of  terms and conditions  of policy, if the deceased has submitted correct information  about  treatment  at the time of  proposal   the O.P. might  have  conducted  proper  medical  examination   which  right  to  issue  or deny  the  policy.  Therefore, the rejection of insurance claim under policies does not amount to deficiency  in service.

REASONING

7          The basic issues as per repudiation letter are denial of insurance claim is suppression of material facts in respect of health conditions at the time of proposal in the year 10/12/2016. After  the death of  insured  within  two years, the O.P. conducted  the investigation  of the claim and found that the  deceased was  under medical treatment  and therefore,  the fact submitted  in the  proposal  form  are  false and therefore,  denied  the claims. The O.P. did not  submitted  treatment  papers  with  certified  copies  with appropriate  evidence  of Doctor  on  affidavit to prove  its  contention.  The burden of proof lies    who alleges and want judgment of that point.  The Consumer Forum is  not  the  expert in medical field  to read  the  medical  terminology , therefore,  it is  necessary  to  prove  the  type of  disease , treatment  and relation  with death  the O.P. ought   to adduce  proper  and  reliable  evidence  to prove  its defence  of medical treatment,  therefore,  the contentions  of the O.P.  cannot be accepted.  The O.P. has disbursed the claim of third policy  plan Jeevan  Rakshak bearing  No. 979263752  of Rs. 1,00,000/- in favour of the complainants.  Therefore, the complainants are entitled  for the  claim under  the  two policies  bearing  No. 979237520 of Rs. 2,00,000/- and  another  policy  bearing  No. 979239070 of Rs. 10,00,000/- along with  benefits, if any, in favour of the complainants  with  interest at the rate of 7% p.a. for  the completion of  45 days  from the date  of  judgment  till  its realization  along with  compensation  for  physical and mental torture  amounted to Rs. 20,000/- along with cost of litigation  Rs. 10,000/- as per  following  order.

ORDER

i.          The complaint  No. CC/19/162 is partly allowed.

ii.          The O.P. Nos. 1&2  are  directed to pay to the complainants claim amount  under  the  policy bearing  No. 979237520 of Rs. 2,00,000/- and  another  policy  bearing  No. 979239070 of Rs. 10,00,000/- along with  benefits, if any, in favour of the complainants  with  interest at the rate of 7% p.a. from  the completion of  45 days  from the date  of  judgment  till  its realization.

iii.         No order is passed in respect of policy  bearing No. 979263752 as O.P. has already  settled the insurance  claim.      

iv.        The O.P. Nos. 1&2 are further directed to pay to the complainant compensation of Rs. 20,000/- towards physical and mental torture and cost of litigation  Rs. 10,000/-

v.         Copy of order  be furnished to both the parties free of cost.