DATE OF DISPOSAL: 23.02.2021.

Dr. Aswini Kumar Mohapatra,President:

               The factual matrix of the case is that the complainant has filed this consumer complaint Under Section 12 of the Consumer Protection Act, 1986, alleging deficiency in service against the Opposite Party (in short the O.P.) and for redressal of his grievance before this Forum.  

               2. Briefly stated the case of the complainant is that being an innocent customer approached the O.P. to have a life Insurance Policy of his mother Chanchala Debi Mahapatra, w/o late Bipra Charana Mahapatra for an insured amount of Rs.20,00,000/- (Rupees Twenty lakhs) only. The O.P. offered the policies taking into consideration of the age, income and health condition of the insured (i.e. the mother of the complainant). On 30.05.2017 the complainant paid the premium of Rs.2,623/- for the insured amount of rupees twenty lakh for his mother through the HDFC Account No. 00040350005586 for Rs.20,00,000/- vide its policy No. P/700001/02/2018/000101 dated 02.06.2017 and provided the customer code No. as AA0005151746 in the said policy covering accidental and hospitalization care of the insured.  Unfortunately on 21.08.2017 at about 9.00 AM said insured Chanchala Debi Mahapatra while going towards the roof of the building by using   concreting steps, at that time her leg was suddenly slipped and she fell down from the steps as a result of which she  sustained grievous injuries on her head and leg. Thereafter she was shifted immediately by the complainant to the MKCG Medical Berhampur where the doctor on duty declared her as dead. The postmortem of the insured/deceased was conducted vide P.M.No.865/17 at F.M. & T Department of MKCG Medical College, Berhampur where the doctor has clearly mentioned that the deceased died due to head injury and its complications thereof. To corroborate all the above facts the B.N.Pur Police Station, Berhampur had submitted its final report in the U.D. Case No. 374/17 dated 23.09.2017 that “the cause of death of the deceased Chanchala Debi Mahapatra, aged about 69 years, W/O late Bipra Charana Mahapatra of Rath Sahi, Purushottampur P.S Dist: Ganjam is due to fall from height and there is no suspicious of any foul play exist”.  After the accidental demise of the mother of the complainant and soon after the obsequies of the deceased mother the complainant informed the insurance company over phone, regarding the accidental death of her mother and enquired about the procedure of claiming the death claim. Accordingly the O.P. advised the complainant to download the claim application form from the internet and proceed accordingly. As such the complainant after collecting all the related claim papers i.e. the police papers, death certificate and downloading the claim form etc. sent the same to the O.P. in speed post in the month of October 2017. Accordingly the O.P. issued a claim reference No. 0001718 to this complainant for future correspondence. In the month of November 2017 the O.P. sent an investigator who verified and enquired the matter thoroughly. After the verification of the investigator, the O.P. remained silent for so many days. But when the present complainant enquired about the position of the claim, the O.P. replied repeatedly that the process is going on and replied the complainant that the official work is in progress and he will get the claim amount within short period.  But after few days on 29.01.2018 the complainant received a letter of repudiation from the O.P. alleging the immaterial facts against the claim which is inadmissible by law. It is pertinent to  mention here that the mother of the complainant was in a sound health having income from house rent, pension amount and agricultural income totaling of about Rs.2,81,600/- per annum. The letter of repudiations date d 29.01.2018 sent by the O.P. is not tenable and against the law. With an ill intention and to avoid the payment of such claim, the O.P. sent the letter of inability to pay the claim wherein he has falsely alleges the allegations like ill health of insured, lesser income & other insurance policies and finally not having the faith on the police verification and police papers. These all allegations by the O.Ps are false and fabricated and are alleging only to avoid the payment of death claim to the complainant. From the above submissions it clearly reveals that the O.Ps is having the gross negligent which deems the deficiency in service on his part. As such the respondent is liable to pay the death claim insured amount to the complainant and also to compensate for the harassment, mental agony caused to the complainant. Alleging deficiency in service on the part of the O.P the complainant prayed to direct the O.P. to pay the complainant the insured claim amount of Rs.20,00,000/- along with an amount of penalty for his harassment and mental agony to the complainant in the best interest of justice.

               2. Upon notice the O.P. filed written version through his advocate. It is stated that the averments in para-1& 2 to the effect that the complainant approached the O.P. for accidental insurance coverage of his mother one chanchala Devi Mahapatra for Rs.20,00,000/- in pursuance to which the O.P. issued the policy in favour of his mother taking into consideration of the ages, income and health condition are all false specifically denied and the complainant is put to strict proof of the same. The O.P. submits that in accordance to the name specified and indicated in the proposal form under heading “name of the person to be insured” the O.P. has issued the policy in favour of the person so named i.e. in favour of one  “Chachala Debi Mahapatra”. The said policy is annexed to this version as Annexure-A and be read as a part of the version. The O.P. further submits that by the recitals in the proposal form and Annexure-A, this complainant has no locus standi nor any right whatsoever to initiate the proceeding as because he is nether the nominee nor the beneficiary and the insured being one Chachala Debi Mahapatra and since the proceeding has been initiated on account of death of one ‘Chanchala Debi Mahapatra’ the same is misconceived and not tenable under the law. The present complaint is not relevant to this proceeding since those relate to one ‘Chanchala Debi Mahapatra’ with whom the O.P. has no privity of contract nor in whose favour annexure-A had been issued.   The said annexure-A is issued in favour of one Chachala Debi Mahapatra and since the beneficiary indicated in the policy is one Chanchala Debi Mahapatra as such this complainant has no locus standi to file this case. As per the intimation and claim records received from the insured it is observed that the insured Mrs. Chanchala Devi Mahapatra got hospitalized on 21.08.2017 in MKCG Medical College and Hospital and intimated a claim for the death of the insured. The averments in para-5 of the complaint are matter of records and needs no comments. The averments in para-6, 7,8 and 9 of the complaint are not admitted and denied. On scrutiny of claim records and to evaluate the genuineness of the claim, the claim was entrusted for verifications and the findings are follows:

On investigation, the O.P. was shocked to notice that the proposer/son- availed insurance policies not only from the O.P. Company but also from

a) M/s Royal Sundaram Alliance Insurance Co. Ltd. Vide policy           No.PADCB00001 for the sum insured of Rs.25 lakhs.

b) M/s ICICI Lombard General Insurance Co. ltd. Vide policy no.4111/EPP/131390880 dated 29.05.2017.

C) M/s National Insurance Company Ltd.

d) M/s The Oriental Insurance Company ltd.

In respect of the aged mother Mrs. Chanchala Devi Mahapatra aged 69 years who was sick and suffering from jaundice and other complications. The O.P. believed that it was a false and fabricated claim to mulct liability from insurers and as such the O.P. also advised to approach the Superintendent of police under Sec. 154 Cr.PC to lodge a complaint seeking re-investigation of the FIR and collusive final report and proceed against persons guilty of cognizable offences in accordance with law. The insured patient is a aged person who is suffering from jaundice and other complications and the opposites party also observed  from the pension book of the insured patient that in the year of 1989 the slab has been decreased from Rs.299.50 paisa to Rs.269.50 paisa. The deceased insured as pensioner had Rs.8,120/- per month after the demise of her husband and had no income status to avail such insurance cover and thus there was suppression of material fact to induce the insurer to issue a cover which is not enforceable. Her physical condition also suppressed at the time of availing the cover.  The death of the insured was suspected that due to her frail health and affliction to jaundice and its aftermath with other complications related to old age. The insured/complainant has not only taken the accident care policy from the O.P. also obtained from so many insurer makes disbelief against complainant. The averments in para-11 of the petition are all self serving and as are specifically denied to be true and the repudiation of the claim is justified on valid and logical considerations. As the reason mentioned in the above paragraphs the O.P. rejected the claim and the same was communicated to the insured vide dated 07.03.2018. The O.P. has also marked a copy of the repudiation to other insurance companies as above, so that they can jointly lodge the complaint with the police to establish the collusion and conspiracy indulged in by the insured/complainant. The petition is filed to avail death claim benefits arising on account of death of one Chanchala Debi Mahapatra. It is submitted that since the insurance policy is issued in favour of one “Chachala Debi Mahapatra” and not in favour of “Chanchala Debi Mahapatra” as such the petition as filed is not maintainable nor it gives any cause of action to the complainant to file the case. The complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the O.Ps with the intention for getting unlawful enrichment from the O.Ps who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India. As public money is held in trusts, the company must exercise abundant caution in dealing with the claims by applying all conditions correctly. The O.P. prays that the learned Forum will be pleased to dismiss the application as being frivolous, vexatious and direct the complaint to pay to the O.P. cost U/S 27 of the Act as the Forum deems fit. 

               3. On the date of final hearing advocates for complainant and advocate for O.P. are present. Heard arguments from the Ld. Counsel for the complainant and from the O.P. Perused the records, documents filed by the parties. This Commission examined the entire materials on record and given a thought and consideration to the arguments advanced before us by the parties touching the points both on facts as well as law.

It is admitted fact that the insured had purchased the life insurance policy from O.Ps on 30.05.2017 it is not in dispute that the insured expired on dated 21.08.2017 within 3 months of commencement of the policy. It is also not in dispute whether the insured had suppressed material facts like pre-existing disease and make false statement of negative of any other policies obtained as mentioned in the claimed repudiation letter issued by the O.Ps on dated 29.01.2018 and the name of the insured is in dispute.

               It is reveals from the record that the proposal form was offered for a life insurance policy of M/s Star Health and Allied Insurance & Co. in the name of the deceased mother of the complainant wife of late Bipina Chandra Mohapatra in which the complainant was the nominee of the said policy covering residential and hospitalization care of insured. The O.P. accepted it calculating the amount of premium considering the age health condition and income of the insured after receiving the premium amount issued the policy vide No. P/70000/02/2018/000101 dated 02.06.2017. Due to leg slip the insured fell down on the concrete stair case while going to the roof of the house on 21.08.2017 due to such accident she sustained grievous injury on head and leg for her treatment immediately she was shifted to MKCG Medical Hospital Berhampur the doctor on duty had examined and declared her dead. The incident was reported at the P.S. in time and the concerned police registered U.D. case No. 374/23.09.2017 and submitted final report after completion of investigation basing on  the local inquiry and postmortem report wherein the Medical Officer opined that the deceased died due to head injury and its complication thereof caused by hard and blunt force impact . There is no suspicious or any foul play in support of his case the complainant has filed Xerox copy of health policy No.P/700001/02/2018/000101(Annexure-1 four sheets) , certified copy of postmortem report and the copy of the final form of UDGR 576/17 (Annexure-3 eight sheets), copy of Mail receipt of premium by the O.P. (Annexue-2 one sheet) Annexure-4 three sheets relates to repudiation of the claim of the complainant. Annexure-5 relates to death certificate of the insured   since onus lies on the O.Ps to prove the pre-existing disease of the insurer being suppressed which was the sole ground of their repudiation of the claim to prove their contains the O.Ps must have to adduce evidence except a mere written version the O.Ps had not adducing any evidence to substantiate their case. Further the O.Ps submitted that the present complaint is no way relates to chanchala devi Mohapatra with whom the O.Ps have no privity of contract nor in whose favour annexure—had been issued. That annexure issued infavour of the Chanchala devi Mohapatra to prove the contention of the written version the O.P. have to prove by adducing evidence relating to these two names are two different persons. In contrary the complainant submitted that Chanchala devi Mohapatra is the correct name of the insured. Accordingly mentioned in the proposal form but deliberately the O.Ps had issued annexure-I- by mis-spelling the name in place of the correct name and submitted that both the names are belongs to one and same person. The said statement and evidence filed by the complainant is supported by an affidavit sworn by the complainant.

               To prove the case the complainant submitted the related documents of insurance policy and produced medical report, death report, receipt of the premium deposited the copy of policy bond and the letter of repudiation but on the other hand except written version O.P. neither filed any documentary evidence nor any affidavit in support of their case.  

 The O.Ps in their written version contended that the complainant has suppressed material information and attempted to mislead the Forum by giving incorrect information. In this connection this Commission cited the decision of the Apex Court which are mentioned here under:

   It is held and reported in C.P.R. 2021 (3) page 65 wherein the Hon’ble Rajastan State Commission, observed that a common man is not supposed to know all the niceties and technicalities of law. Once accepting the premium and having entered in to  an agreement  without verifying the facts the Insurance Company can not  wriggle out of liabilities mearly by saying the contract was made by mis-representation and concealment the insurance policies should not be issued and repudiated in such a casual mechanical manner the policy entitles the liability on both sides. It is rather exploitation of the consumer and more or less fraud on the public such practice should be strongly deprecated. In another case it is held and reported in C.P.R. 2006 Page 207 the Hon’ble State Commission, New Delhi there observed C.P. Act, 1986 Section 2(1)(g) and 15 insurance – repudiate of claim- wrong statement. Second policy obtained by suppressing the factum of earlier policy – concealment of earlier policy not outs from taking benefit under second policy- repudiation of claim is not justified.  

               The object of obtaining of any Insurance Policy is mainly to protect the interest of the surviving legal heirs for looking after their needs for this purpose the materials and the most important fact which is relevant is the state of health of the person and the treatment obtained by him in the past for any serious diseases which during the subsistence of the policy would have been responsible for his death. However the contention of the counsel for the O.P. that the income of the insured has also to be taken into consideration as it should be commensurate with the sum insured does not find favour with us as it is no concerned of the insurer to see. As to how much income insured having and whether insured is in position to pay the premium or not. Any person who obtained insurance policy becomes entitled to its benefits in his capacity as insured and it is immaterial whether the insured contributes to the installments himself or pay the premium from any other sources the insurance policy can not be placed on the same pedestal as they became transaction.

From the record it is seen that, undisputedly the complainant had availed the insurance policy and the O.Ps  with proper verification accepted it without any objection or comment relating to the suppression of material facts while accepting the proposal and also not submitted any material evidence to prove their case relating to other insurance policies and the source of information relied after investigation while to meet the claim amount to be honoured, repudiated the claim without assigning reason or any cogent evidence not also exhibited any documentary evidence at the time of argument to substantiate their claim without any documentary evidence to prove the suppression of the material facts.  Repudiation of the claim of assured amount by the O.Ps is amounts to deficiency in service and unfair trade practice. We rely the decisions “Once proposal is accepted and policy is issued LIC is liable for payment of claim” 2011 (4)CPR LIC of India verses Prabhasa Ranjan Nayak. Further rejection or acceptance of insurance policy proposal must be expressly communicated to the proposer N.C. D.P. 278 CPR N.Venkateswarulu versus the BPM and other 2011 (4) CPR 278 (N.C.)  

               On foregoing discussion as well as settled principles of law, the complaint petition is allowed in part against the O.P. The O.P. is directed to settle the insurance claim of the deceased policy holder Chanchala Devi Mahapatra as permissible by the terms and conditions of the policy under the agreement vide policy No.P/700001/02/2018/000101 in favour of the complainant. The O.P. is directed to make compliance the aforesaid order within two months from the date of receipt of this order failing which all the dues shall carry an interest @9% per annum on the settled amount from the date of default till realization of the same. In peculiar facts and circumstances of this case there is no order as to cost and compensation.  

               The order is pronounced on this day of 23rd February 2021 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