Orissa

Rayagada

CC/21/2021

Smt. P. Laxmi - Complainant(s)

Versus

M/s Birla Sunlife Insurance Co, Ltd., - Opp.Party(s)

Sri D.Ravi Prasad

18 Dec 2021

ORDER

DISTRICT   CONSUMER DISPUTES  REDRESSAL COMMISSION, RAYAGADA,

AT:  KASTURI NAGAR, Ist.  LANE,   L.I.C. OFFICE     BACK,PO/DIST: RAYAGADA, STATE:  ODISHA, PIN NO.765001,.E-mail- dcdrfrgda@gmail.com

…

 

C.C.CASE  NO.__21_______/2021                                      Date.     17   .12.  2021.

 

P R E S E N T .

 

Sri   Gopal   Krishna   Rath,                                               President.

Smt.Padmalaya  Mishra,.                                                 Member

 

Smt. P.Laxmi, W/O: Late P.Gopal  Rao,  Resident  of  Rohit Colony, 8^th. Lane,  Sastri  Nagar,    Po/Dist:Rayagada. (Odisha) 765   001.       ….  Complainant.

Versus.

 

1.The Manager, Birla Sunlife Insurance Co. Lt., Claims Department, G crop Tech  park,  6^th. Floor,  Kesar Wadavali, Ghodbunder Road, Thane- 400 601.

 

2.The Manager, M/S. Birla Sunlife Insurance Co. Ltd., Regd. Office, One India bulls  Centre, Tower1, 15^th.  And 16^th. Floor, Jupiter Mill Compound,841, Senapati   Bapt  Marg,  Elphinstone Road,   Mumbai-400 013.

3. Mr. Subudhi Santunu Kumar, Advisor Birla Sunlife Insurance Co. Ltd. , Rayagada  Branch, Mobile No. 9777065631, Om Mobile phone sales and service, Near Sarala  Junction, Po/Dist: Rayagada.      …Opposite  Parties.

                                                                                                                       

For the Complainant:- Sri  D.Ravi  Prasad, Advocate, Rayagada.

For the  O.P s:-  Set  exparte.

 

JUDGEMENT

The  crux of the case is that  the above named complainant alleging deficiency in service  against  afore mentioned O.Ps    for  non receipt of death claim towards  policy  No. 005586412 sum assured  amount a sum of Rs.4,48,000/-  from the  O.Ps  for which  the complainant  sought for redressal of the grievances raised by the complainant. 

Upon  Notice, the O.Ps    put in their appearance and filed  written version in which  they refuting allegation made against them.  The O.Ps    taking one and another pleas in the written version   sought to dismiss the complaint as it is not maintainable  under the C.P. Act,  The facts which are not specifically admitted may be treated  as denial of the O.P.   Hence the O.Ps prays the forum to dismiss the case against  them  to meet the ends of justice.

Heard arguments from the learned counsels for the    O.P    and from the complainant.    Perused the record, documents, written version  filed by the parties. 

This commission   examined the entire material on record  and given  a thoughtful consideration  to the  arguments  advanced  before us by  the  parties touching the points both on the facts  as well as on  law.

      FINDINGS.

Undisputedly the Policy No. 005586412   was issued  by  the O.Ps in favour of the  D.L.A. Death life assured  Late P. Gopal Rao, i.e. husband of the complainant ( copies of the bond is in the file  which is marked as Annexure-I).   The   above   policy   was   commenced  on   Dt.  30.05.2012  for a   sum  assured   of Rs.4,48,000/- (Rupees Four  Lakhs  forty eight thousnd)only   for the term of 5(five) years and to pay half yearly  premium of Rs. 16,448/- (Rupees  sixteen thousand  four Hundred forty eight) only   for the period from 30.5.2012  to 30.11.2012 under   BSLI wealth secure-fund coverage and BSLI wealth secure LCV- whole life  pay 05 coverage policy. Further there is no dispute that the insured has paid the premium upto the  November 2012 (copies of the   premium receipt  is in the file which are marked as  2 ) . The policy holder  died on Dt. 30.06.2012 at his residence  (copies of the  death certificate is in the file which  is marked as Annexure-3).

The main grievance of the complainant is that after death of  D.L.A.  death life assured  i.e. husband of the complainant  the O.Ps had  not  paid  the assured amount  and repdudiated the same on the grounds that the D.L.A had  suppressed of  disease during filled up proposal form of the policy (copies of the  repudiated letter Dt.30.11.2012 issued by the O.P is available  in the file which is marked as Annexure-4) . Hence this  C.C. case.

The O.Ps   in their repudiation letter Dt. 30.11.2012  had submitted that  the above  policy  was issued  on the basis of an application for insurance dated. 19^th. May, 2012 by  the complainant  (the  Death life assured) on his own life.  In the said application for insurance, the life assured  had replied   in the negative to questions numbered  11(B), (C), (iii), (E) and 14(i), (a), (b), (ii) (f) in the application for insurance.  Further  the O.Ps in their repudiation letter had mentioned that  the  Death  life assured  was diagnosed to be suffering from Esophagitis and Gastritis for which   he  had  under  gone  investigation and treatment prior to his application for insurance and that  the aforesaid  replied  in the application  for  insurance and in the  Medical  Examiner’s report  are false.  The O.Ps further mentioned  that  had the death life assured  replied to the aforesaid  questions in the application for insurance and MER  truthfully and correctly, the company would not  have issued the policy at all.

During  the course of  hearing the learned counsel for the complainant  relied   citations of the Hon’ble   National Commission  which  are  mentioned here under.

It is held and reported  in  CPJ 2014 (3)  page No. 340  in the case of  National India Assurance  Co. Ltd., Vrs. Rakesh  Kumar  where in  the  Hon’ble  National   Commission   observed “That the people can  live for months, rather years, without having  any knowledge  that they have any  disease it’s often discovered accidentally after routine check-ups, it  cannot be stated to be the  concealment  and the repudiation is not justified.”

In this connection this  District Commission relied citations which are mentioned here.

It is  held and reported in CPR- 2012 (2) Page No.220 where in the Hon’ble  State Commision, Rajstan  observed “Once accepting premium and having entered into agreement without verifying facts  insurance Company can not  wriggle out   of liability.”

Further it is held and report  in CPR-2014 (3) Page No. 1 the Hon’ble National Commission  where in observed  in para No.10   “ It will be unfortunate, if the insurance companies try to repudate genuine death claims on such technical and flimsy grounds. Most of the innocent insured  will be victims and the beneficiaries will be deprived of the fruits of life insurance. The complainant  was a illeterate  did not suppress any material fact with any fraudulent intention.  It is unfortunate that on one hand the LIC raises the voice of “Utmost good faith” but, in contrast, the faith will  be lost while not settling the genuine  claims for some or other reasons.   It is the exploitation of the policy holders.   The consumers are literally under  fear of dilemma that, whether, after death, the beneficiaries ever certainly get any  fruits from the  LIC….!  “

Again it is held and reported in CPR-2011(1) page No. 312 the Hon’ble   State commission, Raipur  where in observed  in para – 9  “The proposal for obtaining a new policy was in the month of February, 2007 and old policy was also revived  in the month of  December, 2006  much prior to the date of knowledge of sufferance of deceased  insured from cancer.  When deceased insured himself, was   not  knowing that he is patient of Cancer or that he is suffering  from some diseases, then  it   can not be expected from him  to mention all these things in the proposal form for obtaining a new  policy or in the proposal  form for revival   of the lapsed  insurance policy.”     

Further  it is held and reported in  CPR- 2012(1)  page No. 391 the Hon’ble National Commission where in  observed  “The insurance company must investigate health issues before issuing insurance  policy.”

Again  It is held  and reported  in C.P.R. 2012 (3) page No. 65 where  in the  hon’bleRajstan  State  Commision observed  “That a common man is not supposed to know all the  niceties and technicalities of law.  Once accepting  the premium and having entered into an agreement without  verifying the facts, the Insurance Company can not wriggle out of the  liability merely by saying that the  contract was made by  misrepresentation and concealment. The insurance policies should not be issued and  repudiated  in such a casual mechanical manner. The policy entails  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.”

Further It is held and reported  in C.P.R 2007(3) page No.93 where in the  hon’ble Chatisgarh  State Commission observed “That the claim repudiated on  the ground that insured suppressed material fact regarding ailments he was suffering would not  constitute  deficiency in service and cause of death would have no relevance to  non-disclosure of  such facts.  The proposal  or revival  form  have been filled  by the Agent of the O.P . The said proposal or revival form  was not filled by the  O.P. though extracted  some passages from it in their  written version.

The  complainant  submitted  during the course of hearing    that  at the time of opening  of the L.I.C. policy   the  policy  holder  was  free  from any  physical disease and  was also  mentally sound.

Again It is held and reported  in C.P.R. 2012 (4) page No. 231 wherein the hon’ble  National Commission observed “ That   pre-existing  disease must be proved in documentary evidence. In the present  case the O.P.  should have  produced  some  concrete evidence in support of its  case. The examination of  doctor who checked  the patient, prior to the obtaining  of the policy in question, some treatment papers, some prescriptions etc. should have been produced . There is no evidence  which may  go to show that he had ever consulted  the doctor for taking treatment to the said disease.”

Further this District Commission  perused the case law  in the instant case. It is held and reported in  CPC- 1991, page -540 the  Hon’ble  Hariyana State  Commission held that when ever there is any delay or dilatoriness in finalizing  the insurance claim, the same would be tantamount to a  deficiency  in service and thus comes squarely within the  purview of Consumer Forum.  Once it is held that default or negligence in the  settlement of an insurance claim is a deficiency  in service then an arbitrary  or mischievous  rejection  of an insurance claim  would patently  be a default  within its larger  meaning. On principle , it would   seem  some what manifest that the mere repudiation of the insurance claim cannot itself operate  as a  jurisdiction bar for redressel forums under the Act.  This is further  made it clear and  it is held and reported  in CPR-1991(2), page No.18  the Hon’ble National Commission  clearly defines  the mere unilateral  rejection of an insured parties  claimed by the insurer does not  per  se  operate as jurisdictional bar to seek redressal before  the forums under the Act. It is on the strength of the  above decision  the instant case is admitted by this forum.

In the present  case it is not disputed by the O.P. that the policy of the deceased  covers the risk from  Dt. 30.5.2012 vide their policy  No.005586412. On perusal of the records, this District  commission  found  that there was concluded contract of insurance between   the insurer and the  insured  as on the date which the  insured had  desired  to take the policy i.e. on Dt. 30.05.2012. The O.Ps.  have not  disputed the health condition of the insured  on Dt. 30.5.2012(Date of   taking  of policy ) which was then satisfactory.  There was, therefore, no question of his having made false  statement.  In this context  there  was, therefore  no suppression of any   material fact by the deceased.  Therefore the dictum of “Suppression veri  suggestionfalsi” can not be said to apply. 

Again   it is held and reported in AIR SC 1991 page No. 392  in the case of  LIC of India Vrs. Srimati  G.M.Channabasamma  where in the Hon’ble  Supreme Court observed  “ That in a case where the complainant proves that there was valid  insurance  and the insured has expired during the  pendency of the   valid   insurance the burden to prove that there was any   mis statement in the proposal  form is upon the insurance company. Not  only the insurance company  has the burden  to prove that the deceased was suffering from ailment but the  O.P. shall have to prove that the deceased knew that he was  suffering from ailment and he had made false statement to the question raised   by the  O.P. in the proposal form. The proposal   and the  date of risk of the  insured in this case has been accepted  by the O.P. from  Dt.30.5.2012 without taking a second look, at  type of replies  furnished, but the  crunch came, the O.P. has sought  to take shelter   behind such reply, using therein that the insured  suppressed material fact   in the proposal form as a handi stick to beat the complainant  out of the benefits under the policy.  The burden lies on the  O.P. to substantiate its allegation when the  claim of the  insured is not settled  on the ground suppressed material information.

In view of the order passed by the Hon’ble National Commission and  Apex Court  this  commission  allow this case  in  part.

In view of the above discussion relating to the above case and  In Res-IPSA-Loquiture  as well as  in the light of the settled legal position  discussed  as above referring citations  which is Aliane Juris. Hence  we allow the above complaint petition  in part.

Hence  to  meet the  ends of justice, the following order is passed.                                                                                                              

ORDER.

            In resultant the complaint petition stands  allowed  in  part  on  exparte against  the O.P. 

The O.Ps  are ordered  to pay the sum assured  of  LIC policy No. 005586412 together  with accrued  bonus      to the complainant.   Parties are left to bear their own cost.

The OPs ordered to make compliance the aforesaid Order within  45(forty five) days   from the  date of  receipt  of this  order  failing which  an interest  @ Rs.9% per annum  would  accrue on the sum  assured   amount . from  the  date of  repudiation  i.e. on Dt. 30.11.2012  till  realization.

Dictated and corrected by me. Pronounced on this     17      ^th.   Day of    December ,   2021.

Member.                                                             President