DATE OF DISPOSAL: 26.09.2019.
Sri Karuna Kar Nayak, President.
The complainant Sumitra Rath has filed this consumer complaint Under Section 12 of the Consumer Protection Act, 1986, alleging deficiency in service against the Opposite Parties ( in short the O.Ps) and for redressal of her grievance before this Forum.
2. Briefly stated the case of the complainant is that the complainant is the nominee in the LIC policy bearing No.574006406 which commenced on 28.08.2015 and an amount of Rs.24,005/- was deposited against the said policy towards premium amount by the policy i.e. husband of the complainant. The proposal form has been duly verified and satisfied by the Department doctor of the O.Ps. While the matter stood thus the policy holder Arun Kumar Rath suffered from ailments and admitted in the MKCG Medical College and Hospital, Bramhapur on 13.5.2016. After treatment the policy holder Arun Kumar Rath died on same day, i.e. on 13.05.2016. The complainant being the nominee under the policy in question filed claim petition for payment of basic sum assured amounting to Rs.3,80,000/-. The O.P.No.1 in his office letter dated 20.12.2016 of the documents stating that the case is under consideration. The complainant on receipt of the said letter dated 20.12.2016 submitted all such documents including Medical Attendance Certificate and certificate of hospital treatment. Even after receiving all such documents as called for, the O.P.No.2 communicated of his letter dated 02.03.2017 repudiating the claim. In the afore-mentioned letter dated 02.03.2017 it has been advised to approach the O.P.No.3 if not satisfied. On receipt of the letter dated 02.03.2017 the complainant submitted his petition on 17.05.2017 to consider the case judiciously to the O.P.No.3. The complainant submitted reminder to the O.P.No.3 for consideration, but inspite of the same the O.P. did not took any steps till date. The complainant suffered from harassment inspite of submission of all documents as called for payment of the sum assured. Alleging deficiency in service on the part of the O.Ps the complainant prayed to direct the O.Ps to pay the basic sum assured of Rs.3,80,000/- with interest, compensation for harassment and mental agony of Rs.20,000/- and litigation cost of Rs.7,500/- in the best interest of justice.
3. As per prayer of the advocate for complainant the O.P.No.3 is deleted from the cause title on 09.01.2018.
4. Upon notice the O.P.No.1 & 2 filed written version through his advocate. It is stated that the averments made in the petition are all not true and correct and the petitioner is put to strict proof of such allegation which is not specifically admitted herein. The allegations made in Para 1 to 4 are based on records and the complainant is put strict of the same. The allegations made in Para-5 regarding medical verification have not been properly explained. No clinical/pathological test was conducted prior to issuance of the policy. Based on the information regarding health conditions provided by the life assured, the medical report was issued. Admittedly, Arun Kumar Rath availed a life insurance policy from these Opposite parties i.e. Life Insurance Corporation of India through its Polosora Branch vide policy No. 574006406 for a basic sum assured of Rs.3,80,000/- with accident benefit with a yearly premium of Rs.24,385/- and commencement of risk under the policy started from 30.09.2015. His wife i.e. the complainant is the nominee in the said policy. Subsequently, the death of the life assured on 13.05.2016, while undergoing treatment at MKCG Medical College, Bramhapur was intimated by his wife to these O.Ps. As the policy holder died within the period of one year from the commencement of the policy, the claim was classified as early claims and necessary investigation was conducted by these opposite parties. In this regard vide letter dated 20.12.2016 the O.Ps requested the nominee to comply certain requirements and provide treatment particulars of the deceased life assured from 01.08.2012 to 13.05.2016 i.e. the prescriptions, test reports, bed head ticket, case sheet, discharge summery report issued by the medical etc. But unfortunately the complainant could not comply and provided all relevant documents, except the bed head ticket and B and B1 forms to these opposite parties. However, on investigation and verification of the bed heard tickets and certificate of hospital treatment, it was observed that the life assured had undergone hydrocele operation 5 years back and was suffering from related health problem. By suppressing his earlier hydrocele ailment and by giving wrong/misleading information in the proposal form, the life assured had taken the policy. Admittedly the policy was taken by the life assured. At the time of taking the policies the deceased life assured has given the proposal form stating his health condition as good and he has not been suffering from any diseases. The deceased life assured had also clearly stated “no” to all the questions mentioned vide clause No. 11 (I to viii) and stated “good” to the question mentioned in 11)ix). Moreover, in the declaration given the policy proposal form, the life assured has stated that, the facts stated in the proposal form and answer given by him to the doctor are all true. However, being an early claim (claim arising within two years from the date of commencement of the policy), on verification it was found that, the deceased life assured has undergone hydrocele operation and was suffering from related ailments and subsequently referred to the MKCG Medical college Hospital, Bramhapur for treatment of complicacies arising out of the above ailment. So, it is clear that the deceased life assured by suppressing material facts regarding his illness and treatment, has taken the aforesaid policy. So these O.Ps have repudiated the death claim arising out of the policies and intimated the same to the nominee vide its letter dated 03.11.2017. So nothing is payable under this policy. The contract of insurance is a contract of UBERRIMA FIDES, i.e. contract of utmost good faith. In this case the policy holder has by deliberately suppressing his health condition taken this policy and these opposite parties on detection of the same has rightly repudiated the claim. No medical examination was required to be conducted since the coverage of insurance is granted on the basis of self declaration of good health only. The health condition of a policy holder is a material condition in the contract of insurance and as the material condition was suppressed, these O.Ps have rightly repudiated the claim. The Life Insurance Corporation of India is the Trustee of Policy holder’s money. So, all the claims are dealt carefully by its officers. It requires collection of information from various sources like Hospitals, co-villagers, policy holders etc., which requires time. Hence, there is no deficiency in service of these O.Ps in this case nor they have caused any mental agony or hardship to the complainant. Rather the life assured tried to defraud the Corporation, which was detected with proof. This case involves complex question of facts, evidence and law. Hence, this Hon’ble Forum has no jurisdiction to try the same and the matter can be properly adjudicated in the Civil Court, where it is pending. The petition is barred by limitation and the same has not been properly valued. The complaint is not maintainable due to non-joinder and mis-joinder of the parties. Hence the O.P.No.1 & 2 prayed to dismiss the case with exemplary cost in the interest of justice.
5. On the date of final hearing of the consumer complaint, the learned counsels for both parties are present. We heard argument at length from both parties and perused the complaint petition, written version, written argument and documents placed on the case record. It reveals from the materials on record that the complainant’s husband Arun Kumar Rath was the policy holders of LIC of India vide policy No.574006406 through Polosara Branch. It also reveals that the basic sum assured of the policy is Rs.3,80,000/- with accident benefit with an annual premium of Rs.24,385/- and the said policy of complainant’s husband commenced from 30.09.2015. Further, it reveals that the complainant’s husband expired on 13.05.2016 during the force of policy while undergoing treatment at MKCG Medical College and Hospital, Bramhapur. The complainant being the nominee of the said policy applied for getting the claim amount of her deceased husband and submitted all the relevant documents to the O.Ps but O.P.No.2 repudiated the complainant’s claim on 02.03.2017 due to suppression of material facts that the complainant answered as ‘No’ in the proposal form to the question of the LIC of India as follows:
Questions Answers.
(i)During the last five years did you consult a Medical
Practitioner for any ailment requiring treatment
For more than a week? No.
(ii)Have you ever been admitted to any hospital or
Nursing home for general check-up, observation, treatment
Or operation? No
(iv) Are you suffering from or have you ever suffered from
Diabetes, Tuberculosis, High Blood pressure, Low Blood
Pressure, cancer, Epilepsy, Hernia, Hydrocele, Leprosy or
any other diseases? No.
(ix) What has been your usual state of health? GOOD.
After careful consideration, we hold that for the aforesaid technical grounds the repudiation of complainant’s claim by O.Ps would not be accepted. Because law is well settled in case of ICICI Prudential Life Insurance Company Limited versus Smt. Bimal Kanta Kharab reported in 2013 (1) CPR 160 wherein the Hon’ble National CDR Commission, New Delhi has hold that “Death claim can not be repudiated on technical grounds”.
In the result, complainant’s case is partly allowed against the O.Ps who are jointly and severally liable as such they are directed to pay the sum assured amount of Rs.3,80,000/- bearing policy No. 574006406 alongwith Rs.2000/- towards cost of litigation to the complainant. The aforesaid order shall be complied by the O.Ps within 45 days from the date of receipt of this order failing which all the dues shall carry 12% interest per annum till final payment is made. The case of the complainant is disposed of accordingly. No order as to compensation.
The order is pronounced on this day of 26th September 2019 under the signature and seal of this Forum. The office is directed to supply copy of order to the parties free of cost and a copy of same be sent to the server of www.confonet.nic.in for posting in internet and thereafter the file be consigned to record room.
