IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,PURI

CONSUMER COMPLAINT NO. 207/2017

Present: Sri D.Moharana, President I/c

Ms. S.K.Rath,Member(W)

Smt. Sisindri Jamauna Patra,

W/o. Late Sisindri Nageswar Patra,

At- Erapali Bondiya Baraf, Shri Bihar,PS-Sea Beach, Dist-Puri. ..Complainant

Vrs.

1-M/s. R.M. Vishaka, M. D. & CEO,

India First Life Insurance Co.Ltd., 301, B-Wing,

The Qube, Infinity Park, Dindoshi Film City Road,

Malad(East) Mumbai-400097.

2- Branch Manager, Andhra Bank, Kacheri Road,

Puri Town, PO/Dist- Puri. …Opp.Parties

For the Complainant- Sri Sidhartha Sankar Pattnaik,Advocate & Associates .

For the Opp.Party No1- M/s. Panindia Legal, Advocate & Associates

For the Opposite Party No.2- Sri Debaprasad Das, Advocate & Associates

DATE OF FILING- 21.11.2017

DATE OF DISPOSAL-30.06.2020

O R D E R

Sri D. Moharana, President I/c

The present complainant is a widow of late Sisindri Nageswar Patra who died 5.12.2016 due to heart failure. Late Sisindri Nageswsar Patra during his life time had procured one life insurance policy under Jeevan Abhaya Double Plus bearing Policy No.G-0000538 with effect from 17.10.2016 from Opposite Party No.1 on payment of premium of Rs.1,746/- on yearly basis for the sum assured of Rs.5,00,000/-. He was also issued another life insurance policy under PMJBY insurance on payment of Rs.330/-. Both the policies were stood against Account No. 04581011000627779 and Member No.05978. After the death of the life assured Sisindri Nageswar Patra on 5.12.2016, the complainant being the nominee under the said policies, filed claim application with the opposite partty no.1 along with relevant documents which was received by opposite party no.1 on 31.01.2017. The opposite party no.1 vide its letter dated 31.3.2017 repudiated the claim of the complainant giving reason that the life assured was suffering from Haematuria and was under treatment for the same prior to his proposal for insurance. The opposite party no.1 also rejected the claim in another policy i.e. Pradhanmantri Jeevan Jyoti Bima Yojana vide its letter dated 7.6.2017 mentioning the same reason. The complainant, subsequently, represented to O.P No.1 submitting doctor's prescription about the treatment and supporting certificate of doctor for consideration. The O.P No.1 issued a letter on 3.7.2017 in favour of the complainant assuring her to esquire the matter on or before 13.7.2017, but did not turn up and rather asked through e-mail on 17.7.2017 for submission of Id proof,complete address and documents as required. The complainant submitted all requirement of the opposite party no.1, but despite all her efforts, the O.P No.1 turned down her claim and remained silent thereafter for which the complainant no other way out filed the present complaint under Sec.12 of the C.P. Act, 1986 claiming insured amount with compensation and cost of litigation. Hence, this case.

2- The opposite parties appeared through their learned counsels and filed their written version separately.

3- The opposite party no.1 in its written version has made preliminary objection regarding non-maintainability of the case on the grounds of cause of action and as far as the policy terms and conditions are concerned. Regarding the merits of the case, it is admitted that the deceased life assured Sisindri Nageswar Patra was a policy holder under Jeevan Abhaya Double Plus Plan vide Master Policy No. G0000538, Member No.05978, Certificate of Insurance No.0458101000062779 commencing from 17.10.2016 against payment of premium of Rs. 1,198/- for the sum assured of Rs.5,00,000/-. It is also admitted to have received the death claim intimation from the complainant on 31.01.2017 wherein it was mentioned the life assured had expired on 5.12.2016 due to heart failure. It is further contended that the death of the life insured was occurred within a period of 1 month and 18 days from the date of commencement of risk date, they have conducted investigation as per statutory provision under I.R.D.A Regulations, 2002. During the course of investigation, it is revealed that the life assured was under treatment for Heamaturia (presence of Red Blood Cells in Urine) at S.C.B. Medical College Hospital, Cuttack during 24 .11. 2015. The life assured had complaints of recurrent Haematuria ( 4-5 times in a year). It is also revealed from the medical documents that the life assured was also a known case of Lichen Spinulosus which may cause multiple patches of minute follicular papules each centred by a horny spine which may occur on any part of the body, which is also called “ keratosis spinulosa”. It is also revealed that the deceased life assured had not disclosed his past medical history which was material for the O.P to grant policy. It is also stated that the insurance is based on a foundation of utmost good faith i.e. principle of Uberrimae- fides and the life assured was the obligation to disclose all material facts prior to obtaining insurance policy. Thus, it is contended that the deceased life assured had knowingly and deliberately concealed the true facts about his past medical history. If he would have disclosed such material facts of his medical treatment, no insurance policy would have been issued in his favor. He had wrongly declared about his health in the health declaration form and obtained the policy wrongfully. Taking into account all such pre-existing disease of the deceased policy holder, the claim application made by the complainant was rejected as per terms and conditions of the policy in question. Thus, it is prayed for dismissal of the case as there is no ground or merit in the claim of the complainant.

The Opposite Party No.2 in its written version has denied all allegations and contended that there is no cause of action or locu-standi to file the case against him. It is, however, stated that the husband of the complainant viz. Sisindri Nageswar Patra had a S.B. Account bearing No.045810100062779 with their bank. As per government policy, he had insured for the untime death under Jeevan Abhaya Double Plus and under PMJBY scheme. Accordingly, insurance premium of Rs.1,277/- and Rs.330/- was debited from deceased account on 17.10.2016 and on 18.10.2016 respectively and the same were credited to the account of O.P No.1. Therefore, the bank has no role or liability for insurance claim as claimed by the complainant for which the case is liable to be dismissed against him.

4- We have gone through the case in detail and perused the case record and documents filed by both the parties. From the above submissions of both the parties, it is clear that the husband of the complainant had insured his life with the Opp. Party No.1 through Opp. Party No.2, being an S.B account holder with the bank. The O.P No.1 has also not denied to have issued policy bearing No.G0000538 , Member No.05978 and insurance certificate No.045810100062779. The risk period was commenced from 17.10.2016 for the sum assured of Rs.5,00,000/-. It is also not dispute that the life assured had died on 5.12.2016 while the policy was in force. However, the claim filed by the complainant was being repudiated by the O.P No.1 due to non-disclosure of health history and pre-disease. The Opposite Party No.1 has repudiated the claim basically when they revealed that the life assured was under treatment for Heamaturia at S.C.B. Medical College and Hospital, Cuttack in the month of November, 24, 2015 for the complaints of recurrent Haematuria and treated 4-5 times in a year. It is found from the report that the deceased had been treated in the SCB Medical College, Cuttack as per the attestation made by the Superintendent of SCB Medical College, Cuttack in 2015. Even though, it is held that the disease haematoma is suppressed by the deceased Insurer at the time of enterting into the policy but there is no report or any other documentary evidence of his death due to haematoma and the disease haematoma can lead to heart failure and can not be recovered at all. There is no scrap of paper that the deseased died due to haematoma rather the deseased died due to heart failure as raised by the learned counsel for the complainant and in that support, he has also filed a certificate regarding the cause of death of deseased is due to failure of the heart. It is also admission of the O.P- insurance company that the disease Heamaturia relating to kidney disease. So, it is crystal clear that the deceased died not for kidney failure but for heart failure. On the other hand, the learned counsel for the complainant submitted that the husband of the complainant had died of heart failure and the life assured had never undergone treatment for any disease. The Opposite party No.1 was time and again directed to submit substantial evidence to prove their submissions and despite several opportunities, the O.P No.1 failed to file a piece of paper before us to come to the conclusion that the life assured had any pre-existing diseases . At the belated stage the O.Ps filed written argument along with some documents. The principle of law clearly envisaged that onus lies on the party who claims pre-existing disease of the life assured. In this case, particularly the O.P No.1 has failed to substantiate that the life assured had any pre- existing disease. In absence of any documentary evidence, we are not inclined to accept the contentions and pleas, whatsoever, made by the O.P No.1 to reject the claim of the complainant. Hence, the repudiation of claim made by the O.P No.1 is totally injustice. Therefore, the complainant will be entitled for the claim against life insured by her husband viz. Sisindri Nageswar Patra.. Hence, it is ordered that:-

O R D E R

The case of the complainant is allowed against Opposite Parties on contest. The Opposite Party No.1 is directed to pay the sum assured of Rs.5,00,000/- against Policy No.G0000538, Member No. 05978 and Certificate of Insurance No. 045810100062779 stands in the name of late Sisindri Nageswar Patra to the complainant within 30 days from the date of receipt of this order. In the event of non-compliance of the order within the stipulated time, the amount would carry interest at the rate of 6 % p . a from the date of disposal of the case. There is no order against O.P No.2. The case is disposed of accordingly with an order of Rs. 2000/- towards cost of litigation to be paid by the O.P No.1 to the complainant within the above period.

Dictated and corrected by me on this 30th day of June ,2020

Sd/-S.K.Rath Sd/-D.Moharana

I AGREE( MEMBER) PRESIDENT I/C