Sri. Apurba Kr. Ghosh ……….President
The Complainant has filed this case against the OP’s and prays for the following orders/reliefs :-
- Direction against the OPs no. 1 to 4 to pay a sum of Rs.15,00,000/- to the complainant along with 18% interest accrued thereon, on and from 23.07.2012 till its realization.
- Direction against the OPs no. 1 to 4 to pay a sum of Rs. 2,00,000/- to the complainant on account of mental pain, agony and continuous harassment and mental agony.
- Direction against the OPs 1 to 4 to pay a sum of Rs.1,00,000/- on account of punitive damages
- Direction against the OPs 1 to 4 to pay a sum of Rs. 25,000/- to the Complainant towards cost of litigation.
- Any other relief which the complainant is entitled.
BRIEF FACT OF THE COMPLAINT
1. The Complainant is a peace loving and law abiding citizen of India and the O.P. No. - 1 is a Corporate Body and it deals with and promotes Life Insurance business all ever in India under the name and style of Life Insurance Corporation of India and the O.P. No. 2 is the Branch Manager of the O.P. No.-1 for the Siliguri Branch-I and the O.P. No.-3 is the Divisional Manager of the O.P. No.-1 and the O.P. No.-4 is the Zonal Manager of the O.P. No.-1 for the Eastern Zonal Region and accordingly all the O.Ps are severally and jointly liable for the day to day works and affairs of the O.P. No.-1.
2. That the Proforma O.Ps are attended doctor of deceased insured viz. Sujit Kumar Roy.
3. That the deceased husband of the Complainant, Sujit Kumar Roy, during his lifetime, had insured himself with the O.P. No.-1 at the office of the O.P. No.-2 being Policy No.-457227142, under LIC'S Anmol Jeevan I Policy and the said policy was commenced on and from 21.03.2012 and total sum assured of the aforesaid policy was/is Rs.15,00,000/-and the said policy was/is valid for 25 years / yearly premium of the said policy was of Rs. 7677/-.
4. That deceased Sujit Sujit Kumar Roy, during his lifetime, had also insured his life with the O.P. No.-1, at the branch of the OP. No.-2, with two other separate policies one being No.-453676422 assured amount of Rs. 3,00,000 which commenced on 24.12.2004 and another being No.-453707423 sum assured of Rs.2,00,000/- which commenced on 06.03.2006 and in the morning of 29.05.2012 the insured Sujit Kumar Roy felt sudden weakness in whole body , he was taken to Mitra's Clinic and Nursing Home by the Proforma O.P. Nos.- 5 and 6 for admission and on the same day i.e. on 29.05.2012, at around 3 P.M.Sujit Kumar Roy died and at that time, the Pro-forma O.P. Nos.- 5 and 6 had disclosed that the cause of death was due to Cardio Respiratory Failure.
5. That being the nominee and wife of deceased insured of aforesaid three LIC policies, the Complainant has/had fulfilled all the formalities and duly submitted the claim forms with the O.P. No.-2 and the O.P. Nos.- 1 to 4 have directly paid a sum of Rs.1,64,289/- to the account of the Complainant, standing with the Bank of Baroda, Siliguri Branch being account No.-07800100007886 against the policy being no. 453707423 on account of deceased claim on 05.12.2012 and they have also deposited a sum of Rs. 2,62,108/- directly in the account of the Complainant, being account No.- 32360431188, standing with the S.B.I., Court Branch, Siliguri, on 23.07.2012, against the policy being No.-453676422.
6. That though the O.P. Nos. I to 4 have paid the policy assured amount in respect of two previous policies to the Complainant, in respect of death of insured Sujit Kumar Roy, without raising an objection, but surprisingly the O.P. Nos-1 to 4 illegally and malafidely, have started unnecessary lingering to make payment of Rs. 15,00,000/- as the same is a high amount.
7. That on several occasions, the Complainant has visited with the office of the O.P. Nos.-1 and 2 and sometimes with the office of the O.P. No.-3 for taking/setting the legal, valid and genuine claim amount of insured Sujit Kumar Roy with a request to settle the valid, legal and genuine claim of the Complainant but on 26.06.2013, the O.P. No.-3, by issuing a letter, has repudiated the legal, valid and genuine claim of the Complainant, without disclosing any cogent and valid reason therein and the said genuine claim of the Complainant was illegally repudiated on some flimsy, arbitrary, false and self contradictory grounds though the deceased insured never suffered from any alleged diseases and/or pre-existing diseases since the date of his death and thus the letter dated 26.06.2013 is illegal, arbitrary, false, self contradictory in the eye of law and no way binding upon the Complainant.
8. That through the letter dated 26.06.2013 the O.P. No.-3 has suggested the Complainant to make a representation within a month for reconsideration of the claim of the Complainant with the O.P. No.-4 and on receipt of the said letter, the Complainant has made a representation with the O.P. No.-4 and the O.P. No.-4 has acknowledged receipt of the said representation but the O.P. No.-4 despite receiving that representation did not bother to make any response from his end .
9. That the Complainant is legally entitled to get back the assured sum of Rs.15,00,000/- along with the other benefits from the O.P. nos.- 1 to 4 and the aforesaid acts and conducts of the O.P. Nos.- 1 to 4, it is crystal clear that there is a great deficiency in service, latches and negligence on the part of the O.P. Nos.- 1 to 4 and thereby they are bound to pay adequate compensation to the Complainant, as the Complainant has suffered immense mental pain and agony and harassment, which are still now continuing.
10. That the cause of action, for this case, arose, firstly on 26.04.2013, when the repudiation letter was issued by the O.P. No.-3 and thereafter on 18.06.2013, when the O.P. No.-4 has issued the acknowledgement letter to the Complainant and thereafter each and every date/dates within the jurisdiction of this commission .
In support of the Complaint the Complainant has filed the following documents:-
1. Photocopy of Policy Schedule being No.-457227142 amounting Rs. 15,00,000/- standing in the name of deceased Sujit Kumar Roy.
2. Photocopy of the Burning Ghat Certificate of deceased Sujit Kumar Roy.
3. Photocopy of the death certificate of deceased Sujit Kumar Roy.
4. Photocopy of Policy Schedule being no.-453676422 amounting to Rs. 3,00,000/- standing in the name of deceased Sujit Kumar Roy.
5. Photocopy of Policy Schedule being No.-453707423 amounting to Rs. 2,00,000/- standing in the name of deceased Sujit Kumar Roy.
6. Photocopy of Medical Attendance Certificate in respect of Policy Nos.-453676422, 453707423 and 457227142 standing in the name of deceased Sujit Kumar Roy (10 pages).
7. Photocopy of Statement of Account of Bank of Baroda, standing in the name of the Complainant and deceased Sujit Kumar Roy (2 pages).
8. Photocopy of Statement of Account of State Bank of India, standing in the name of the Complainant (2 pages).
9. Photocopy of Death Claim application dated 21.08.2012 given by the Complainant.
10. Photocopy of repudiation letter dated 26.04.2013 issued by the O.Ps.
11. Photocopy of the letter dated 30.05.2013 issued by the Complainant to the O.P. No.-4.
12. Photocopy of acknowledgement letter dated 18.06.2013 issued by the O.P. No.-4 to the Complainant.
Notice was issued from this commission for serving the same on the Op’s . On receipt of notice the OP Life Insurance Corporation of India appears before this Commission, filed written version / denied all the material allegations of the Complainant. The OP’s have stated that the complaint is not maintainable in law or on facts / there was no cause of action to file this instant complaint against this Opposite Party and as such the same is liable to be dismissed / the present complaint is barred by principle of waiver, estoppels and acquiescence / the Complainant has filed this petition not in clean hand and she by deliberately suppressing the material facts has filed this case for wrongful gain / Complaint lodged by the Complainant is totally motivated, baseless, false, whimsical, unwanted, malicious and vexatious and she has brought false case by adopting false plea with a view to making her wrongful gain / the Complainant has no locus-standi to file the case against the Opposite Party. The Op has further stated in their written version that this Commission has no jurisdiction to entertain, try and adjudicate the instant case against the Opposite Party since no deficiency of service has taken place / the OP has stated that , the statements made in paragraph No. 1 of the petition are matter of record and the Complainant has to put strictest proof thereon and in respect of the statements made in para 2, the Opposite Party submits that Life Insurance Corporation of India, Siliguri Branch is a Corporate Body and it deals with and promotes Life Insurance Business all over India under the name and style of Life Insurance Corporation of India and the O.P. NO. 2 is the Branch Manager of O.P. No. 1 for Siliguri Branch-I and the O.P. No. 3 is the Divisional Manager of the O.P. No. 1 and the O.P. No. 4 is the Zonal Manager of O.P. No. 1 for the Eastern Zonal Region and he is unnecessarily included as O.P. No. 4 in this case. They have further stated in the W/V in respect of the statements made in para 3 of the petition that Life Insurance Corporation of India, Siliguri Branch Office No. 1 issued a Life Insurance Policy on the life of Sujit Kumar Roy being Policy No. 457227142 for a sum assured of Rs. 15,00,000/-, yearly premium of Rs. 7677/- and date of commencement of the policy was 21.03.2012 and it is not true that the policy was valid for 25 years , but the term of the policy was for 25 years / in respect of statements of para 4 is not true and this O.P. as the husband of the Complainant namely Sujit Kumar Roy during his life time obtained other two insurance policies bearing No. 453676422 for a sum assured of Rs. 3,00,000/- and 453707423 for a sum assured of Rs. 200000/- but actually the policy holder Sri Sujit Kumar Roy obtained other three insurance policies not two insurance policies and the other insurance policy No. is 456767305 for a sum assured of Rs. 6,00,000/-. When the policy holder Sri Sujit Kumar Roy submitted the proposal for sum assured of Rs. 15,00,000/- bearing Policy No. 457227142 he deliberately suppressed the Policy and his his proposal for a policy of Rs. 15,00,000/- would not have been accepted and he had to undergo some medical examinations before accepting the proposal of Rs. 15,00,000/-/ the statements made in para 5 of the Complaint is not true and the O.P has stated that the insured was suffering from G.B. Syndrome, Hypokalamic Paralysis and Ex. Chord Lesion vide prescription dated 29.04.2012 of Mitra's Clinic and Nursing Home, Siliguri wherein he was advised to undergo MRI of Cx. Spine (refer Page No. 6) and his admission in Mitra's Clinic and Nursing Home took place second time on 29.05.2012 when the insured died / they have also stated that the statements made in paragraph 6 is matter of record . That OP has further stated that the statements made in paragraph 7 , 8 , 9 & 10 of the Complaint are not true and as such this Opposite Party denies each and every allegations made in those paragraphs and stated that , two policies where claims were paid without objections were non-early claims where duration of the policies from the date of risk to date of death were more than 6 and 7 years old and LIC does not investigate such non-early claims where date of death takes place after duration of 3 (three) years or more from the date of risk of policies and whereas the Policy no. 457227142 resulted in early claim with risk date 21.03.2012 and insured died on 29.05.2012 i.e. just 2 months 8 days after commencement of risk and claim investigation are allotted in such Early Death Claims which have aroused within 2 years from the date of risk vide Circular Ref. CO/CRM/740/23 dated March, 31, 2009 and to complete investigation some time is required which should not be called lingering on our part due to high sum assured. It is also stated that while proposing for the last Policy the insured did not disclose that he had also purchased another policy No. 45675305 under LIC's Child Carrier Plan under which there was risk of 6 Lakhs sum assured and if the policy Holder disclosed that policy, his proposal for a policy of Rs. 15,00,000/- would not have been accepted, he had to undergo some medical examinations before accepting the proposal of Rs. 15,00,000/-. The OP has also stated in the W/V that they repudiated the claim vide letter dated 26.04.2013 and not 26.06.2013, informing therein that the claim was repudiated as because Life Assured Sujit Kumar Roy had given false statements in proposal question No. 11, a) to i) regarding status of his health and and the Life Assured admitted in Mitra's Clinic and Nursing Home, Siliguri on 29.05.2012 wherein in the Admission Sheet of Mitra's Clinic & Nursing Home, it is clearly mentioned that the patient was suffering from weakness of Limbs since 2/3 months and he has died within 2 months 8 days from the date of commencement of the policy but the policy holder did not disclose that he had weakness in limbs while he proposed for insurance of Rs. 15,00,000/- bearing Policy No. 45722142 and therefore the LICI has rightly repudiated this death claim and stated that the statements made in paragraph 11 is partly true and partly false, it is true that the O.P. No. 3 i.e. Divisional Office, Jalpaiguri has suggested the complainant to make representation vide their letter dated 26.04.2013 but not vide letter dated 26.06.2013 as given in the plaint and the statements made in paragraph 12 & 13 , 14 15 , 16 & 17 of the Complaint are not true and the complainant has to put strict proof thereof. and the Claimant is not entitled to get any claim against the said policy and LICI has rightly repudiated the claim.
On receipt of notice the Pro- OP No-5 & 6 appears through vokalatnama , filed their written versions , denied all the material allegations of the Complainant and they have stated that the said Pro- OP’s are not involved with any disputes of the Complainant and other OP’s . By filling W/V both the Pro- OP No-5 & 6 praying for dismissal of this case against them .
Having heard the Ld. advocate of both the side and on perusal of the complaint, written version as well as documents filed by the parties the following points are taken to be considered/decided by this Commission.
POINTS FOR CONSIDERATION
- Whether the complainant is a consumer as per the provision of C.P. Act. ?
- Whether the case is maintainable in its present form and prayer under the provision of the C.P. Act. ?
- Whether there is any cause of action to file this case by the complainant?
- Whether there was deficiency in service on the part of the OP as alleged by the complainant?
- Is the complainant has able to prove this case and entitled to get any relief as prayed for?
DECISION WITH REASONS
All the points are taken up together for discussion to avoid unnecessary repetition and for the sake of convenience and brevity of this case.
The complainant was given opportunity to prove the case against the OP’s. In order to prove the case the complainant has adduced written evidence in the form of an affidavit. In the written evidence the complainant has corroborated all the statements made in the plaint/ she specifically stated in her evidence on which day her husband Sujit Kumar Roy had insured himself with the OP no. 1 and purchased the policy under the name & style Anmol Jeevan-I Policy. She also stated that, her husband purchased the policy which was commenced on and from 21.03.2012 of which total sum was assured of Rs. 15 Lakhs being policy No. 457227142 and yearly premium was of Rs. 7,677/-. She also corroborated the plaint who stated that, her husband had also insured himself during his lifetime with the OP no. 1 at the branch of the OP no. 2 with two other policies being in no. 453767422 For sum assured Rs. 3,00,000/- which was commenced 24.12.2004 and policy being in NO. 453707423 for sum assured Rs. 2,00,000/- was commenced on 06.03.2006 . She further stated in her evidence that after death of her husband the OP no. 1 to 4 have paid the entire benefits for those two policies but they did not make any payment in respect of policy No. 457227142 of Rs. 15 lakhs and she visited the office of the OP’s No. 1 to 4 on several occasions and also sent legal/demand notice. But on 26.06.2013 the OP no. 3 without making payment for that policy had repudiated the claim of the complainant without assigning valid reasons.
At the time of argument Ld. Advocate of the complainant has stated that the complainant has been able to prove the case against the OP no. 1 to 4 and she is entitled to get the relief as prayed for. He also argued that, the evidence adduced by the complainant as well as the documents filed on her behalf has not been challenged by the OP’s NO. 1 to 4 either through counter evidence or through cross-examination. It is further argument of the complainant that, her claim is genuine, valid and legal in respect of that policy and the OP has failed to produce any single document to show that the insured had not disclosed regarding his earlier policy in the proposal form and the OP’s have failed to prove their said plea. Ld. Advocate of the complainant has also argued that, the OP’s have failed to produce any evidence in support of their plea that the insured was suffering from G.B. Syndrome, Hypokalamic Paralysis and Exchhord Lesion vie prescription dated 29.04.2012. At the time of argument Ld. Advocate of the complainant referred decisions of (i) CPJ Vol-II, 2014, page No. 3B (ii) CPJ Vol- III- 2014, page NO. 582 NC. (iii) CPJ Vol-II, 2022, page No. 245 (NC), (v) CPJ, Vol- III page No. 340 (vi) CJP, Vol-IV, 2006, Page No. 213(NC). By referring the decisions Ld. Advocate of the Complainant argued that, mere non discloser of any material fact is also not the grounds for repudiation of claim.
Ld. Advocate of the OP during argument submits that, they have already filed written notes of argument and stated everything and the complainant has not been able to prove the case against the OP and the husband of the complainant by practicing fraud and by suppressing material facts obtained the said policy in question by deception. He further argued that, the husband of the complainant did not disclose the third policy being in No. 456767305 prior to taking policy NO. 457227142 and had he disclosed the said policy details then some additional medical requirement could have been called for or the policy might have been rejected or declined or extra premium could be called for or any lien could be imposed as per norms. He also argued that, the claim of the complainant was rightly repudiated as the policy was procured by her husband by use of falsehood and suppression of necessary facts is fraud and thereby the complainant is not entitled to get any relief as prayed for.
Having heard the Ld. Advocate of both the parties and on perusal of the entire record it is admitted fact by both the parties that, the husband of the complainant had insured himself with the OP No. 1 at the office of the OP no. 2 and policy certificate was issued in his favour where sum assured of the policy No. 457227142 was of Rs. 15 lakhs.
It is also admitted fact by both the parties that, the said policy was commenced on and from 21.03.2012.
It is also admitted by both the parties that, the tenure of that policy was for 25 years.
It is further admitted by both the parties that, the OP’s No. 1 to 4 have already paid the death benefit in respect of two other policies being in No. 453676422 & policy No. 453707423.
It is further admitted fact by both the parties that the husband of the complainant has died and after his death the complainant raised claim with the OP’s no. 1 to 4 in respect of the policy No. 457227142 but the same had been repudiated.
Only dispute in this case is that the OP’s are claiming that the husband of the complainant obtained the said policy by suppressing the previous policy.
Now let us see how for the complainant has been able to prove the case against the OP’s No. 1 to 4 or not?
The complainant herself in her written evidence as well as in the written notes of argument has specifically stated that her husband during his life time obtained that police where sum assured is of Rs. 15 lakhs. The complainant herself not only has filed written evidence in support of her complaint but also filed some documents before this Commission including the policy certificate. That evidence of the complainant has not been challenged by the OP’s. The OP’s No. 1 to 4 neither files any written evidence to falsify the case of the complaint, nor they cross examined the complainant through putting of questionnaires or otherwise before this Commission. It is also not complained on the side of OP’s No. 1 to 4 as to why they accepted the proposal form of the policy in question without any medical report & whey they issued policy certificate in favour of the husband of the complainant and when the proposal of that the deceased insured was accepted by the OP’s it can safely be presumed that, they have waived their right.
The OP’s No. 1 to 4 have also taken plea that, the husband of the complainant was suffering from G.B. Syndrome Hypokalamine paralysis and Ex chord Lesion vide prescription dated 29.04.2012 of Mitra clinic and Nursing Home. But these OP’s NO. 1 to 4 have neither adduce any evidence by the attending doctor in this regard , nor they produce any documentary evidence before this commission to prove the plea taken by them and thereby it is clearly presumed that the plea of the OP’s regarding pre-existing decease of the insured (husband of the complainant) are not tenable.
The OP’s have also failed to produce any evidence either oral or documentary to prove the case that the husband of the complainant was suffering from any illness prior to his death for a long period. On the other hand the OP’s have already paid the entire benefits to the complainant in respect of two other policies which were lying in the name of husband of the complainant and they also did not repudiate these claims of the complainant.
In the case in hand it is not proved on the side of the Op’s that the insured had not disclosed the material fact prior to obtaining the policy certificate. More Over it is settled provisions of law that, non disclosure of facts relating to earlier policy is not material fact and repudiation of claim will be treated as deficiency in service vide decisions of CJP, Volume- III, 2014, Page 582 (NC) & CPJ, Volume- II, 2022, page 245 (NC).
Considering the unchallenged evidence of the complainant we are of the view that, the complainant has been able to prove the case against the OP’s and OP’s No. 1 to 4 are jointly and severally liable to pay the awarded amount.
Hence,
ORDERED
That the instant consumer case being no. 67/2015 is hereby allowed on contest against the OP’s and Pro-OP’s but in part.
OP’s no. 1 to 4 are directed to pay jointly as well as severally a sum of Rs. 15,00,000/- ( Rupees Fifteen Lakhs) only to the complainant along with interest @ 3% per annum with effect from 23.07.2012 till realization of the entire amount.
The OP’s No. 1 to 4 are also directed to pay a sum of Rs. 50,000/- (Rupees Fifty Thousand) only to the complainant on account of causing mental pain, agony and continuous harassment.
The OP’s No. 1 to 4 are also directed to pay a sum of Rs. 10,000/- (Rupees Ten Thousand) only to the complainant towards cost of legal proceedings and the OP’s No. 1 to 4 are further directed to pay a sum of Rs. 10,000/-(Rupees Ten Thousand) only in the Consumer Legal Aid Account of this Commission.
The OP’s No. 1 to 4 are directed to pay the awarded amount within 45 days from this day failing which the complainant will have the liberty to take proper steps against them as per law.
Let a copy of this order be given to the complainant free of cost.
