JUDGMENT

            The complainant has filed this complaint u/sec. 12 of the Consumer Protection Act – 1986 against the OP alleging deficiency in service in not settling the claim of the first policy amount of Rs.1,30,000/- and second policy amount of Rs.8,00,000/-.  Hence prays for relief to settle the policy claim with bonus of Rs.1,30,000/- of first policy and Rs.8,00,000/- of second policy along with compensation of Rs.25,000/- for physical and mental agony and Rs.25,000/- for deficiency in service and Rs.10,000/- for litigation and miscellaneous expenses.

             Brief averments of the Complaint are;

            2.  That the complainant’s son had made a policy during his life time in the branch of OP Company.  The policy number of the first policy is 15537095 and the total sum assured is Rs.1,30,000/- and it had a yearly premium of Rs.8,690/- and the policy was issued on 29-10-2012.   The policy number of the second policy is 15535559 and the sum assured is Rs.8,00,000/- and it had a yearly premium of Rs.2,994/-.  The policy was issued on 28-10-2012.  The nominee in these two policies is the complainant.

            The complainant further alleged that on 11-05-2013 the complainant’s son died due to Heart attack in his own village Shriram Nagar Gangavathi taluk.  The complainant after getting the knowledge of the policy informed about the policy to the OP branch and then submitted the policy claim along with the related documents to the OP branch.   The complainant further alleged that the OP branch had posted a letter to the complainant on 11-12-2014 stating that the policy amount cannot be paid because the policy holder was suffering from Tuberculosis and Retro viral disease due to this reason this policies have been rejected.

            The complainant further alleged that her son was physically and mentally fit and healthy and he did not suffer with any of these diseases at the time of issuing the policies.  The OP instead of settling the claim is giving silly reasons and the policy claims have been rejected and hence filed this complaint praying for settling the policy claim of 1^st policy of Rs.1,30,000/- and 2^nd policy of Rs.8,00,000/- along with compensation of Rs.25,000/- for physical and mental agony and Rs.25,000/- for deficiency in service and Rs.10,000/- for litigation and miscellaneous expenses as prayed above.   

            3.  The Fora after admitting the complaint, a notice was issued by the Fora to OP and the said notice is served upon the OP.  The OP has failed to appear before the Fora on the date of appearance and hence was placed as exparte and the case was posted for complainant evidence.

            4.  During the evidence of the complainant, the complainant in support of her case has got examined herself as PW1 and got marked the documents as Ex.A.1 to Ex.A.6 and closed her side of evidence.

            5.  Heard the argument of counsel for the complainant and perused the records.

            6.  From the above pleadings, now the points that arise for our consideration are;

POINTS

1.  Whether the complainant proves that there is deficiency in service in not settling the policy amount after the death of her son?

2. Whether the complainant is entitled for any relief sought for?

3. What order?

7.  Our findings on the above points are as under;

Point No. 1 :  In Affirmative

Point No. 2 :   In Affirmative

Point No. 3:   As per final Order for the following.

REASONS

8.  POINT No. 1and 2:  As these issues are interconnected each other, hence they are taken together for common discussion to avoid repetition of facts, evidence documents and arguments.

            9.  On perusal of the pleadings, evidence coupled with the documents of respective parties on record.  It is the case of the complainant alleging deficiency in service in not settling the claim of the policy amount of 1^st policy of Rs. 1,30,000/- and 2^nd policy of Rs.8,00,000/-.  There is no dispute regarding that the complainant’s son Prasad during his life time had obtained two policies by name HDFC life with a policy No. 15537095 which was issued on 29^th October 2012 with a premium of Rs.8,690/- annually and the sum assured amount is Rs. 1,30,000/- and another policy by name HDFC Life with a policy No. 15535559 which was issued on 28^th October 2012 with a premium of Rs.2,994/- annually and the sum assured amount is Rs.8,00,000/-.  There is also no dispute that the premium of the policy is not paid on 11-05-2013 the complainant son died due to Heart attack in his village Shriram Nagar Gangavathi taluk leaving the complainant as a nominee in the policies.  Being a beneficiary in the policy, the complainant approached and claimed for assured amount and submitted the claim form and necessary documents.  Till today the OP has not settled the claim.  Hence the complainant alleged deficiency in service. 

            10.  To prove the case of the complainant, the PW1 has reiterated the complaint averments in her examination in chief and in support of her case she has produced the policy documents which has been marked as Ex.A.1 and Ex.A.2.  It is admitted that these two policies were issued by OP after going through the proposal form.  These policies were issued to the complainant’s son at the time of making the policies.  She has further averred that the policies contain the details of the sum assured and the premium to be paid i.e. Ex.A.1 and Ex.A.2.  Ex.A.1 and Ex.A.2 clearly reveals that these two policies are issued in the name of the complainant’s son during his life time and the premium was paid and the policies are commenced from 29^th October 2012 and 28^th October 2012.

            11.  As per Ex.A.3 and Ex.A.4 the statement of Death Claim and the Doctor’s Certificate, on perusal of these two exhibits i.e. Ex.A.3 and Ex.A.4 it is clearly reveals that the complainant’s son died due to heart attack while giving emergency treatment to Myocardial Infarction.  Ex.A.5 is the Death Certificate issued by Chief Registrar of Births and Deaths.  As per Ex.A.6 the claim repudiation letter given by OP on perusal of it, it is crystal clear that the OP has rejected the claim stating that the DLA was suffering from Tuberculosis and Retroviral Disease prior to the issuance of the policy and this was known to them from investigation.  To prove the disease, the OP has not appeared before this Fora and has not produced any cogent evidence.  Therefore the contention which was taken by the OP in their claim repudiation letter is vague and is not justifiable one.

            12.  At the time of issuing the policy it becomes the duty of the Insurance agent to verify and see that the medical examination is done.  However in the personal medical details it is clear that the DLA has mentioned ‘No’ to the details of the disease given.  This is clear in the Ex.A.6 that he was not suffering from any disease as suggested by OP in his claim repudiation letter.

            13.  The counsel for the complainant has relied on the citation which has been passed by our Hon’ble Supreme Court of India in IV (2011) CPJ 6 (SC) – P.Vankat Naidu V/s Life Insurance Corporation of India & Anr., -

“Consumer Protection Act, 1986 – Sections (\2(1)(g), 14(1)(d), 23 – Insurance (Life) – Suppression of material facts – Pre-existing disease – Forum allowed complaint – State Commission dismissed appeal – National Commission allowed revision – Hence special leave to appeal – Contention, deceased suppressed information relating to his illness – Not accepted – Respondents did not produce any tangible evidence to prove that deceased withheld information about his hospitalization and treatment – Order of National Commission set aside.”           

            14.  The facts and circumstances of the case in hand and circumstances of the said citation is same and applicable in this case.  Their lordships have held that the contention, deceased suppressed information relating to the illness is not accepted and the respondents did not produce any tangible evidence to prove that DLA has withheld the information about his hospitalization and treatment.  Therefore, in the light of principle laid down by their lordships in the afore said citation more specifically with respect to suppressed information relating to his illness, it is crystal clear that the DLA has mentioned as ‘No’ in the personal medical details.  Therefore, it can be presumed that the complainant’s son (DLA) was not suffering from the disease and his death was caused due to heart attack.

            15.  The complainant has also relied upon another citation, which has been passed by our Hon’ble National Consumer Disputes Redressal Commission, New Delhi reported in 1986 – 2015 (2) Consumer 48 (NS) – LIC of India V/s Saurabh Agarwal , wherein it is held thus;

“A) Life Insurance – Claim filed – rejected on the ground of suppression of pre-disease – complaint filed – allowed – hence, the petition – no linking in the medical certificate that the insured was suffering from cancer – the investigator of the LIC did not take the trouble to investigate the case properly and made allegations in a clumsy way – revision petition dismissed.

B) Life Insurance – the life insured died during the policy in operation.  Her nominee filed the claim, which was rejected on the ground that she had suppressed the material fact that she was ailing with cancer – the death certificate goes to show that the insured died due to polycystic Ovary Syndrome, which is a type of cancer or ovary.  However, there is nothing on the record to show that she was aware that she was suffering from this ailment.  It was not in her knowledge and cannot be said to be a suppression of pre-disease – petition dismissed.”

            16.  The facts and circumstances of the case in hand and circumstances of the said citation is same and applicable in this case. 

17.  The OP has not appeared before this Fora to answer any of the allegations made by the complainant and have not shown any reasons for repudiation of the claim of the complainant.  Therefore, it can be presumed that there is deficiency in service in not settling the claim.

            18.  From the arguments submitted by the learned counsel, we are of the opinion that the DLA has not given or suppressed information relating to his illness to the OP.  Hence the OP is not supposed to repudiate the claim of the complainant because the onus lies on the OP Company to establish that the DLA has suppressed material facts regarding his illness.  In the absence of such evidence, we found a deficiency in service on the part OP in not settling the claim.  As such the OP is liable to pay the sum assured amount to the complainant.

            19.  The OP Company is also liable to pay compensation of Rs.5,000/- for deficiency in service along with litigation expenses of Rs.1,500/- to the complainant.  Hence in the light of above observations we constrained to hold point No.1 and 2 in affirmative.

20.  POINT No. 3 :- In view of above discussion and findings we proceed to pass the following;

ORDER

1. The complaint is partly allowed.

2. OP is directed to pay sum assured of the first policy of Rs.1,30,000/- (Rupees one lakh and thirty thousand only) and Rs.8,00,000/- (Rupees eight lakh only) of the second policy along with Rs.5,000/- (Rupees five thousand only) towards compensation for deficiency in service and Rs.1,500/- (Rupees one thousand five hundred only) towards litigation expenses to the complainant within one month from the date of receipt of this order.  Failing which 12% p.a. interest will be charged from the date of filing of complaint till realization.

3. Send the free copies of this order to both parties.

// ANNEXURE //

List of Documents Exhibited for the Complainant.

Witnesses examined for the Complainant / Respondent.