Smt.Harjit Kaur, complainant has 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 she has prayed that the opposite parties be directed to pay the amount as per terms and conditions of the policies i.e. double amount of the sum assured under the policies having nos.472820687, 472820686, 472949781 and 473071547 alongwith interest @ 12% per annum. Opposite parties be further directed to pay compensation, in the interest of justice.    

2.       The case of the complainant in brief is that she is widow of Charanjit Singh. Her husband died due to drowning under accident. The postmortem has been duly conducted. The deceased was in Army under Sikh Regiment and he died on 8.8.2011 in the area of District Gurdaspur. Report under Section 174 Cr.P.C. has been duly registered. She has further pleaded that during the lifetime of her husband he got four policies in his name from the opposite parties. The policy having no.473071547 of sum assured 2 lacs, policy no.472949781 having sum assured 5 lacs, policy no.472820687 having sum assured Rs.1,05,000/- and policy having no.472820686 having sum assured Rs.1,00,000/-. As per terms and conditions of these policies in case of accidental death the insured is entitled for double the amount of sum assured and she is nominee. She has next pleaded that during the subsistence of these policies her husband died in an accident due to drowning and as such she is entitled for the claims under the abovesaid policies i.e. the double of the sum assured as the deceased died in an accident due to drowning. The claim has been filed before the opposite parties by her and all the requisite formalities have been duly competed but the opposite parties has wrongly repudiated her genuine claim in all the policies on the ground that the insured gave wrong answers regarding his health at the time of filing the proposal.  Hence, the present complaint was preferred with the prayed relief as herein above.

3.       Upon notice, the opposite parties appeared and filed the written reply through their counsel by taking the preliminary objections that the present complaint is not maintainable as the deceased life assured Charanjit Singh had allegedly died due to drowning in a canal which cannot be termed as accidental death in the absence of any proof of any such accident. Thus the case of DLA is not covered under the Double Accident Benefit Clause contained in the policy bonds; the complainant is estopped to file the present complaint as there is no deficiency in service on the part of the opposite parties and the complainant is estopped by her own acts and conduct to file the present case as the complainant had filed appeal to the Claims Disputes Redressal Committee in respect of only two policies bearing Nos.472820686 and 472820687 against the repudiation of claim. The committee had admitted the claim on ex-gratia basis for sum assured as full and final settlement but the admitted claim of two policies has not been accepted by the complainant so far. On merits, it was submitted that the insured had given wrong answers regarding his health at the time of filing the proposals. The DLA while proposing for assurance in answer to relevant questions of the proposal Forms Clause (11) (a) to 11(e), had stated that he was in good health and neither consulted any Medical Practitioner/hospital for any ailment requiring treatment nor he was ever hospitalized or had undergone any operation etc. But these answers were wrong as the DLA was not in good health at the time of taking these policies. As per records, the DLA was kept in Low Medical category by his employer i.e. Indian Army for having received Gun Shot Wound and was disabled. As per battle Casualty Certificate issued by the Army, DLA was declared as “GSW lower Chest Wall and Multiple Sprinter injury Left Hand”. Further as per letter Ref.3404051/CS/A dated 27.2.2008 it reveals that DLA applied for claiming Ex-Gratia on the basis of disability Certificate, which shows that DLA was disabled prior to taking of LIC policies. Thus the opposite parties had repudiated the claims after carefully considering all the available facts. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Complainant tendered into evidence his own affidavit Ex.C1, alongwith other documents Ex.C2 to Ex.C28 and closed the evidence. 

5.       Counsel for the opposite parties tendered into evidence affidavit of Sh.Yogender Singh Sisodia Manager Legal L.I.C Ex.OP1 and of Munish Bhatia, Assistt. Admn. Officer LIC of India Ex.OPW-3/A alongwith other documents Ex.OP-2 to Ex.OP-29 & Ex.OP-12A and closed the evidence.

6.       We have carefully examined the documents/evidence produced on record along with that ignored to be produced to support/prove their respective ‘claims’ as pleaded by the present litigants in the light of the arguments as put forth by the learned counsels, while adjudicating the present complaint. The present dispute gets multiplicatively complex at the face of OP insurers’ ex-gracious settlement of one claim pertaining to 2 nos. of LIC policies and flat ‘repudiation’ of the second claim pertaining to the other 2 nos. of LIC policies against the complainant’s demand of ‘double-benefit’ as applicable to the ‘accidental-death’ claims. We find that the OP insurers had first repudiated both death claims (pertaining to 4 policies) on account of two counts: i) the DLA’s (Deceased Life Assured) false ‘personal statement’ regarding his health as recorded on the related ‘proposal-forms’ of all these policies; and ii) the OP insurers treating the DLA’s ‘death by drowning’ as a suspected case of ‘suicide’ i.e., being neither ‘natural’ nor ‘accidental’; but later on settled one claim as on ex-gracious basis pertaining to 2 policies, only. However, the complainant had always preferred her two ‘claims’ to be settled on ‘merit’ basis never opting (as per records) for an ‘ex-gracious’ settlement. We have closely examined the related proposal forms along with the other accompanying documents and find that the first two (# 6247 & 6248) exhibited as: Ex.OP3 & Ex.OP5 pertaining to the policy nos. 472820686 & 472820687; both are dated 28.11.2008 with no photographs of DLA affixed (as requisite) and apparently filled up in an apparently ‘casual’ manner under the assistance and guidance of the LIC agent Shivnandan Singh (code: 2257). There is variance (between the two) of 5 Kg in weight (at column 12.a) as requisioned to be indicated in the above two formats (of same date) in ‘exact’ terms of height in ‘cm’ & weight in ‘Kg’ and that also shows ‘callousness’ in its ‘subsequent’ scrutiny and acceptance. Further, ‘S/C’ has been indicated as have been ‘submitted’ in response to ‘Nature of Age proof submitted’ (in both the formats) but the same has not been produced ‘on records’ by the OP insurers as was desired for the sake of ‘clarity’ and ‘transparency’ etc. The abbreviation ‘S/C’ indicates ‘submission’ of the Army Service Certificate and that over-rules suppression of information on the DLA’s past health history of gun-shot injuries etc at the time of purchase of the LIC policies. Somehow, we are inclined to examine the validity & legality of the impugned repudiation (of the related insurance claims) in the back-drop precedent and also the succeeding acts & events in the light of the facts on records and current law on insurance vis-à-vis consumer subject matter, in issue. We find that the OP insurers have failed to produce any cogent evidence of the alleged suppression at the face of ‘active’ assistance of its own agent(s)/representative(s) rendering guidance to the complainant and ignoring the available medical history of the DLA (as available on his Service Card) and in its absence all the allegations amount nothing more than ‘bald’ statements. We find that the information as available and/ or as not made available on the proposal forms have been jotted down on the active & specific guidance of the agent(s)/ representatives (of the OP insurers) who know the exact terms and conditions of various insurance plans and manage the ‘replies’ to various ‘queries’ on the application proposal formats. Under the circumstances, what reliability can be placed on the personal statement of health on such like proposal Form upon which the very repudiation of the impugned Claims have been based by the OP LIC insurers. And, above all why the innocent complainants/ beneficiaries need be made to suffer for of the unholy nexus (even if there has been, any) between the DLA and the LIC Agent/representatives. Thus, we set aside the impugned ‘repudiation’ based upon the ‘suppression’ of past health history of the DLA since the same was available on the service card submitted along with proposal-applications of all the four policies but were knowingly ignored by the agent representatives of the OP insurers for collateral reasons such as ensuring sure-business to meet sales targets etc. Also, the other available intra-office communiqués and consumer-advisories clearly exhibit the said delayed repudiations (followed by ex-gracious settlement) have reached OP insurers with a wavering mind at the face un-sure pieces of evidences with doubtful acceptability. Moreover, section 45(3) of the Insurance Act, 1938 (as amended up to date) bars repudiation of Policy on account of mis-statement(s) and/or suppression of fact(s) that are within the knowledge of the insurers.  The OP must realize that their administrative decisions in settling insurance claims are open to judicial reviews and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law. The second part of impugned ‘repudiation’ has been based upon still a worse ‘footing’ i.e., suspicion and hearsay evidence. The OP insurers’ internal investigation Reports Ex.OP12 & Ex.OP13 surprisingly state that the DLA’s death by drowning has been a suspected case of ‘suicide’ and was not an ‘accidental death’ as per the verbal wordings of the interviewees who somehow have been reluctant to present written statements etc. However, the PMR (Post Mortem Report) confirms DLA’s death by drowning that shall legally amount to be an ‘accidental-death’ unless, otherwise countered by some other ‘cogent’ evidence confirming suicide, murder etc. But, a mere ‘suspicion’ shall not take place of ‘evidence’. Further copies of the Army Medical Board and other copies Ex.OP25 to Ex.OP29 prove the Gun Shot injuries caused to the DLA in the counter insurgency Rakshak Operation but that does not evidence its ‘suppression’ to OP insurers as already discussed above, in detail.

7.       In the light of the all above, we set aside the OP insurer’s impugned repudiations of the complainant’s claims being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’ and thus, we ORDER the OP insurers to pay the impugned ‘insurance claims’ pertaining to the related 4 nos. of Policies in question with full accruals along with the double benefits as applicable in case of ‘accidental-deaths’ etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9% PA form the date of filing of the complaint till actually paid.

8.       Copy of the order be communicated to the parties free of charges. File is ordered to be consigned to the record room. 

                 (Naveen Puri)

                                                                                     President.

ANNOUNCED:                                                            (Jagdeep Kaur)

April 21,2016.                                                             Member               

*MK*