Orissa

Cuttak

CC/200/2021

Liza Sahoo - Complainant(s)

Versus

PNB Metlife India Insurance Co Ltd - Opp.Party(s)

S K Parida & associates

30 Sep 2022

ORDER

            IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

                                                                C.C.No.200/2021

Liza Sahoo

W/o:Late Ranjan Kumar Sahoo,

D/o Prasanta Kumar Sahoo

At-Choudwar Shankarpur,

Po/PS-Choudwar,Dist-Cuttack.                                                                ... Complainant.

            

                                                Vrs.

1.        Chairman, Claim Committee,

PNB Metlife India Insurance Co. Ltd,

First Floor, Techni Complex-1,

Techno Complex Complex,

Off Veer Sawarkar Fly Over,

Goregaon,West Mumbai,Maharastra-40062.

 

2.        Managing Director,

PNB Metlife India Insurance Co. Ltd,

Regd Office-Brigade Seshmahal,

5,Varivilassh Road,Basavanagudi,Bangalore-560004

 

3.         PNB Metlife India Insurance Company.

B.M.C Bhawani Mall,8 & 9 First Floor,

Block-1 & 2,Sahid Nagar,Bhubaneswar-751007,

Dist –Khurda.

 

4.         PNB Metlife India Insurance Co. Ltd,

First Floor, Gajanan Complex,

Dolamundai Road, PO-Buxibazar,

Dist-Cuttack-753001.                                                                                ..Opp. Parties.

 

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    25.11.2021

Date of Order:  30.09.2022

 

For the complainant:            Mr. S.K .Parida,Adv. & Associates.

For the O.P s.            :            Mr. S.K.Ruplal,Adv. & Associates.

Sri Debasish Nayak,President.  

            Case of the complainant as made out from the complaint petition in short is that the complainant is the widow of Late Ranjan Kumar Sahu who was the insurance policy holder under the scheme “Metlife Major illness premium Back cover” and had paid a sum of Rs.36,203/- on 12.4.16 vide payment reference no.195306535 and receipt no.C5640868.  The term of the said policy was for 10 years.  The complainant has further mentioned in her complaint petition that according to clause-2.1 , the insurance company is under obligation to pay the sum assured of Rs.15,00,000/- to the insured who is diagnosed and is suffering from any of the 35 critical illnesses.  The husband of the complainant was having high fever, myalgia and yellow discolouration of urine for which he was admitted to the Blue Wheel Hospital at Bhubaneswar on 8.1.21.  On 9.1.21 the husband of the complainant died as it was dictated that he was suffering from obstructive jaundice which comes under End stage liver disease as described at sl.no.8 Appendix ‘A’ and the cause of death was reflected to be “Cardio Pulmonary Arrest” with specific shock with Hepatopathy.  After collecting all the relevant documents the complainant had submitted her claim before the O.P’s Insurance Company but O.P no.1 through his letter dt.31.3.21 had communicated the complainant that her claim had been turned down.  The complainant had sent a pleader’s notice on 30.9.21 to the O.Ps and ultimately when she failed to get any positive response, she has to file this case claiming the insurance value of Rs.15,00,000/- alongwith a sum of Rs.35,00,000/- towards her mental agony and harassment.

            She has filed copies of several documents in order to prove her case.

2.         All the O.Ps have contested this case and have filed their written version jointly.  As per the written version of the O.Ps, the case is not maintainable as filed by the complainant.  According to them, the complainant and the O.Ps are to abide to the terms and conditions of the agreement as executed and thus, no claim made as per the stipulated terms and conditions can be accepted or granted.  They have relied upon a decision of our Hon’ble Ap;x Court as held in the case of Bharati Knitting Co. Vrs. DHL Worldwide Express Courier Division of Airfreight Ltd., published in AIR 1996 SC 2508.  According to the O.Ps, if critical illness is diagnosed after completion of the waiting period of 90 days and the insured survives until and atleast the completion of survival period of 30 days from the date of genuineness of the critical illness for which the company receives notice of the claim and that the critical illness has been confirmed in writing by the registered medical practitioner including the specialist which is acceptable to the same, then the policy is to be given effect to.  They have also relied upon a decision of Hon’ble Apex Court pas published in AIR 1996 SC 1644 in the case of General Assurance Society Ltd. Vrs. ChandMull Jain where it is held that no court can create a contract for the parties howsoever good it may. Thus, the O.Ps have claimed through their written version that there was no deficiency in their service and the complaint case as filed is liable to be rejected.

            They have stressed upon the condition as per the policy as availed by the deceased husband of the complainant referring to clause-2.1 of the terms and conditions as regards to critical illness policy, which states that the insured has to revive atleast till the completion of the revival period of 30 days from the date of diagnosis of the deceased. The deceased husband of the complainant was made on 8.1.21 and he died on 9.1.21 thereby disentitling the complainant to avail the benefits of the policy since because the deceased had not survived for 30 days after the disease of the deceased was diagnosed.  Thus, it is the prayer of the O.Ps that the complainant is not entitled to any of the reliefs and the complaint petition is liable to be rejected.

            The O.Ps have filed copies of several documents in order to prove their case.

3.         Keeping in mind the averments as made in the complaint petition with contents of the written version of the contesting O.P, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

            ii.         Whether there was deficiency in service on the part of the O.Ps?

            iii.        Whether the complainant is entitled to the reliefs as claimed?

Issue no.ii.

            Issue no.ii being the pertinent issue is taken up first for consideration here in this case.

            Admittedly the deceased husband of the complainant had undertaken the policy “Metlife Major Illness Premium Back Cover”, for which he had paid premium of Rs.36,203/- and that he had died on 9.1.21 being diagnosed of critical illness.  It is the contention of the O.Ps that since because the deceased husband of the complainant who was diagnosed of critical illness on 8.1.21 had died on 9.1.21 without surviving for atleast a period of 30 days with effect from 8.1.21, this is a violative of the provisions U/S-5 part-B of the policy conditions which disentitles the claim as made by the complainant.

            While perusing, the copies of documents as filed by the O.Ps alongwith their written version and while scrutinizing those, it is noticed that while filling up the proposal form, the deceased husband of the complainant namely Ranjan Kumar Sahu was assisted in doing so by the agent of the O.Ps namely Swarna Mayee Panda having agent code no.60085810 with mobile no.7205959262.  As it appears further from the said proposal form vide Annexure-A, of the deceased Ranjan Kumar Sahu dt.26.4.2016 vide Annexure-B, it reflects the name of such agent Swarna Mayee Panda with the said agent code and said mobile number.  Thus, one thing comes to the mind that if the authorised agent of the O.Ps was assisting the deceased Ranjan Kumar Sahu in filling up the proposal form enabling him to be insured, nowhere it is found that the said authorised agent had infact explained the terms and conditions of such policy to the deceased Ranjan Kumar Sahu and if knowing those properly, the said Ranjan Kumar Sahu had entered into the agreement and had thus executed the policy thereafter.  In absence of such, it can never be concluded here arbitrarily that since because the deceased Ranjan Kumar Sahu had given his signature to the proposal form he knew all the terms and conditions of the said policy and being fully aware he had executed the said agreement.  Thus, the rider which the O.Ps now have raised, drawing attention of this Commission which had enabled them to revoke the policy claim when made was definitely not within the knowledge of the deceased Ranjan Kumar Sahu nor in the knowledge of the present claimant/complainant Liza Sahu.  Thus, the agreement so executed do not appear to be a genuine one, rather, had been fraudulently executed behind the knowledge of the insured deceased Ranjan Kumar Sahu.  Accordingly, this Commission has no hesitation to hold here that infact there was deficiency in service on the part of the O.Ps.  Hence this issue goes against the O.Ps of this case.

Issues no.i & iii.

            When the claim of the complainant was disallowed by the O.Ps, by filing this case, it appears to be quite maintainable and the complainant is also entitled to the reliefs as claimed by her.  Hence it is so ordered;

                                                   

  ORDER

            The case is decreed on contest against all the O.Ps who are found to be jointly and severally liable here in this case.The O.Ps are thus directed to pay the nominee/complainant for the deceased insured, who was the husband of the complainant of this case, the insured amount together with interest thereon @ 9% per annum with effect from 9.1.21 till the total amount is quantified.  The O.Ps are further directed to pay a sum of Rs.3,00,000/- to the complainant towards her mental agony and harassment as caused to her and further to meet her litigation expenses to the tune of Rs.30,000/-. This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on the 30^th day of   September,2022 under the seal and signature of this Commission.           

                                                                                                                               

              Sri Debasish Nayak

                                                                                                          President

                       

                                                                                                                                      Sri Sibananda Mohanty

                                                                                                             Member