SRI BIJOY KUMAR DAS,PRESIDENT:-
Deficiency in service in respect of illegal repudiation of death claim of the Policy holder are the allegations arrayed against the Opp.Party.
2. Complaint Petition reveals that, Complainant’s wife namely Sabitri Das obtained a Life Insurance Policy under the Op-Insurance Company vide its Policy No. NP141609018188 and Its Plan No. UIN128N047V01 for a period of 15 years. The sum assured of the Policy was for Rs. 56,000/- and the Annual premium was for Rs. 5032/-. The risk and maturity date was covered form dt. 30/09/2016 to 28.09.2031. Complainant Gandharba Das being the husband of the Policy-holder was nominee of the policy. Unfortunately the policy holder Sabitri Das died on dt. 06.02.2017 at her residence and the deceased policy holder was examined by Dr. Ashok Kumar Nayak, Asst. Surgeon, dist. Hqrs, Hospital, Kendrpara, on the opinion of the Dr. Nayak the Policy holder died due to Heart attack. After the death of the policy holder, Complainant being the nominee lodged a claim before the Op-Insurance Company on completing all the official formalities. But on dt. 24.07.2017 the Op-Insurance Company repudiated the claim by intimating the complainant, that the deceased policy holder was suffering from Hepatomegaly as diagnosed. The Acts of the Op-Insurance Company, according to Complainant be treated as deficiency in service which caused financial loss and mental agony. The last cause of the action of the instant case arose on dt. 24.07.2017, when the claim was repudiated. In the complaint, it is prayed that a direction may be given to Op-Insurance Company to settle the claim to the tune of Rs. 56,000/- with other benefits and a compensation of Rs. 40,000/- be awarded in favour of the complainant.
3. On receipt of the Notice and on the direction of the Honbl’e State C.D.R. Commission in R.P.Case No. 70/2018 the written statement of Op-Insurance Company is accepted, wherein it is averred that one Sabitri Das obtained a Life Insurance Policy being No. NP141609018188 under the Plan “Sriram New ShriLife Plan” which commenced from dt. 28.03.2016 for a sum assured of Rs. 56,000/- for a term of 15 years with annual renewal premium of Rs. 5032/- and her spouse Mr. Gandharba Das was nominee of the Policy. It is also averred that on receipt of intimation of death of Policy holder by complainant on June-2017 and as the death claim was an early one the matter was investigated and it was noticed that Policy holder was suffering from pre-existing ailment, which was deliberately suppressed at the time of submitting the proposal. It was further averred that deceased policy holder was diagnosed with Hepatomegaly (Enlarged Liver) on dt. 31.08.2016. The pathological report of the Panda Diagnostic Centre, Cuttack gave the impression of “GALL BLADDER MASS WITH DILATED 1HBR & HEPATOMEGALLY” and the deceased Policy holder was under treatment for ‘obstructive jaundice’ by Dr. Purna Chandra Dash, Associated Professor of S.C.B. Medical College, Cuttack on dt. 31.08.2016. It is the case of the Op-Insurance Company that, as the contract of Insurance based on principle of ‘UBERRIMA FIDE’ or ‘Utmost good faith’, the deceased policy holder concealed material facts on proposal to avail the policy with an ulteriormotive to obtained the Life Insurance Policy, the claim is rightly repudiated by the Op and intimation has been given on dt. 24.07.2017, further on repudiating the claim on the above grounds, Op has not committed any deficiency in service as alleged by the complainant and the complaint is to be dismissed with exemplary cost.
4. Heard the arguments advanced by Ld. Counsels for the parties perused the documents field into the dispute. Complainant to substantiate his case filed Xerox copy of Non-ULIP Policy schedule, attested Xerox copy of claim Form ‘C’(4 sheets), death claim Form ‘A’ (2 sheets). On the otherhand Op-Insurance Company field attested copies of documents as described in the written statement.
The admitted facts of the case are that, Sabitri Das, W/o- Gandharba Das had taken a Life Insurance Policy of Op-Insurance Company bearing Policy No. NP141609018188. The sum assured of the policy was for Rs. 56,000/- and the annual premium amount was for Rs. 5032/-. Gandharab Das, husband of the policy holder was nominee of the policy. It is also admitted that the policy holder Sabitri Das died on dt. 06.02.2017 and a claim was lodged before the Op-Insurance Company by the husband-nominee Sri Gandharb Das. The claim of the complainant was repudiated and intimation of repudiation was given to the complainant vide letter dtd. 24.07.2017, the grounds of repudiation mentioned in the letter is the only ground of repudiating the claim.
The complaint is field for illegal repudiation of the claim by the Op- Insurance Company. It is the case of the complainant that, the deceased policy holder died on account of Heart-stroke as opined and examined by the Dr. Ashok Kumar Nayak, M.O. Dist. Hqrs. Hospital, Kendrapara and the Op-Insurance without considering the cause of death illegally repudiated the claim of the complainant. On the contrary, the defence pleas of Op-Insurance Company on repudiation claim related to principle of ‘UBERRIMA GIDE’ in a contact of Insurance. It is the further plea of the Op that, though the deceased policy holder Sabitri Das was under treatment of Dr. P.C.Dash of S.C.B.Medical College, Cuttack for ‘obstructive Jaundice’ and the pathological report of Panda Diagnostic Centre, Cuttack, the Policy holder was having “GALL BLADDER MASS WITH DILATED 1HBR & HEPATOMEGALLY”, which was within the knowledge of the policy-holder prior to filing the proposal of Life- Insurance with an ulteriormotive. As the Policy holder was willfully concealed her pre-existing disease, the Op- Insurance Company rightly repudiated the claim.
Considering the facts and position of law we had gone through the attested copies of Pathological report of deceased Policy holder Sabitri Das. The Pathological report including the ultrasound report of Panda Diagnostic Centre dtd. 31.08.2016 reveals that, the deceased policy-holder was suffering from “XXXX HEPATOMEGALLY XXXX” equally the treatment prescription of Dr. P.C.Dash, Associated Professor of Dept. of Medicine, S.C.B. Medical College, Cuttack, on the same date i.e, 31.08.2016 while examining the deceased policy holder opined that, the patient is suffering from “obstructive jaundice’. Now, it is clear that the Policy holder was suffering certain ailments prior to filing of the proposal Form. The attested Xerox copy of proposal Form reveals that the proposal was signed by the deceased policy holder on dt. 29.09.2016 in the presence of the witness. The column No. 9(3) of personal Medical History of the Life to be assured discloses that the deceased-policy-holder on the date of filing of the proposal Form was free from any diseases as answered by her.The documents presented before us reveal that the deceased policy-holder has suppressed material facts like suffering from any pre-existing disease by not disclosing the true facts about her health condition and availed the Life Insurance Policy with an uleteriormotive. The documents relied on and field by the Op is supported by affidavit of Branch Manager of Op-Insurance Company in their written statement. We are of the opinion that, the Pathological report and treatment prescription of Dr. P.C.Dash of S.C.B. Medical College, Cuttack dtd. 31.08.2016 are credible evidence of pre-existing disease persist with the deceased policy-holder Sabitri Das prior to filing of proposal of Life Insurance. Ld Counsel for complainant argued that, the cause of death of the Policy holder as detected by Dr. Ashok Kumar Nayak of Dist. Hqrs. Hospital, Kendrapara can’t be disbelieved, when the Policy holder is examined by a qualified Doctor who opined the cause of death due to “Cardiac arrest due to myocardial Infaraction” and the claim lodged by the complainant to avail the Insurance benefits are in accordance with the terms and conditions of the Policy and the repudiation of claim is illegal. In this point, we are of the opinion that, the ground of repudiation of claim by the Op is based on suppression of material facts like concealment of any pre-existing disease while submitting the proposal form of Insurance Policy by the Policy-holder and not for the reason of death of the Policy-holder. The position of law in this regard is very clear, the Honbl’e National Commission and Honbl’e Apex Court in a number of decisions observed that if a Policy of Life is obtained through concealing the material facts, which affects the prudent insurer to accept the proposal, the Insurance Company has right to assail the claim. we rely on a decision of Honbl’e National Commission reported in 2016(4) CPR765(NC) in case of SBI Insurance Company Ltd. vrs Nirmal Singh, where Honbl’e national Commission observed that, the Insurance Company has every right to repudiate the claim on suppression of pre-existing disease while submitting the proposal. Accordingly, in the present dispute the Op-Insurance Company has rightly repudiated the claim and has committed no deficiency in service as alleged.
Having observations reflected above, the complainant is dismissed without any cost.
Pronounced in the open Court, this the 20th day of April,2019.
I, agree.
Sd/- Sd/-
MEMBER PRESIDENT
