The titled complainant Sulakhan Singh was having his Bank A/c with the OP1 Bank and at their instance/recommendations he purchased the Metlife Money Back New Policy (Platinum) No.22155470 from the OP2 Insurers in the name of his wife Smt. Kuljit Kaur as Life Insured @ Sum Assured of Rs.5.0 Lac with an annual premium of Rs.48,255.68 p to be paid for 10 years valid w e from 31.03.2017. The Life Insured's Health Status along with her other requisitioned particulars were duly provided/disclosed to the titled opposite parties who had cross-checked the same prior to acceptance of the related proposal.

2.     Unfortunately, the complainant's wife was diagnosed suffering from a fast-developing Tumor and breathed her last on 17.02.2018 as she could not survive the related surgery at the PGI, Chandigarh. The OP2 insurers were duly informed of the insured's demise.     

3.    Having spent substantial funds on the tumor-surgery cum medical-treatment of his wife the complainant had been urgently in need of funds so he filed the insurance death-claim (of his wife) and requested the OP2 for an expeditious settlement. But, the OP2 insurers were delaying and deferring the claim-settlement, so the complainant got them served legal notice dated 27.07.2018 that was not even acknowledged/replied back and hence prompted the present complaint seeking directives to the OP2 insurers to pay his claim, in full, in terms of the related policy besides Rs.50,000/- as compensation and Rs.20,000/- as cost of litigation, in the interest of justice.

4.    The complainant in order to accomplish the successful prosecution of his complaint has also filed his i) Self-attested Affidavit (Ex.CW1) along with ii) copy of the Policy (Ex.C2); iii) Copy of Legal-notice (Ex.C3) with postal-receipts (Ex.C4 & Ex.C5) and Rejoinders to the OP.

5.       The titled opposite party Bank (the OP1 bank), in response to the commission’s summons appeared through their learned counsel who filed their written reply stating therein preliminary as well as other (on merits) objections as: The complaint pertains to the Dhianpur Branch of PNB (upon whom Legal Notice was served) but the title of the complaint has enjoined the Dhariwal Branch as the opposite party No.1. However, the services of the OP1 Bank were never hired for issues pertaining to the text of the complaint. The complainant had concealed the true facts regarding her previous brain tumor surgery at the time of purchase of the related policy that gets revealed in the letter dated 31.08.2018 The premium of Rs.48,255.66ps was refunded on 03.09.2018 as evidenced by the related bank-account statement. Further, the OP2 insurers are wrongly/in-correctly addressed in the title of the complaint. On merits, the above objections have been repeated along with denial of other contents of the complaint addressing these as incorrect and/or matter of records etc. The written reply is supported by Affidavit (Ex.OP1) Sanil Kumar, Br. Manager.

6.      The OP2 insurers were ordered to suffer ex-parte proceedings on 26.02.2019 however they were allowed to join the proceedings vide the State Commission Orders dated 20.09.2019.

7.      The OP2 insurers appeared through their counsel and filed the written reply raising therein their preliminary as well as other (on merits) objections as:

8.       The complainant has mentioned incorrect address of the OP2 upon the complaint with malafide intentions and thus misled and misguided the commission. The information as provided in the proposal forms dated 02.08.2016 & 16.03.2017 by the DLA (Deceased Life Assured) were established to be incorrect as per the medical documents procured during the investigations and thus the OP2 are within their rights to repudiate the related insurance-claim. The OP2 insurers have mentioned of the past treatments undergone by the DLA at PGI, Chandigarh and the K.D. Hospital, Amritsar and have also quoted nine nos of Apex Court Judgments to support and strengthen their resolve determining repudiation to the impugned insurance-claim. The D.L.A.'s replies, in negative, thus suppressing the pre-existing diseases in reply to the questionnaire accompanying the proposal form, as has also been re-produced in the written reply. Further, as the complicated questions of law as well as of fact are involved requiring voluminous evidence that are not feasible in summary trial as such the matter needs be relegated to the civil court. Lastly, the complaint has been sought to be dismissed with costs. Again, on merits, the OP insurers have categorically denied all the contents n allegations as put forth by the complainant in the present complaint except that specifically admitted during the course of the herein trial/proceedings. The written reply is supported by self-attested Affidavit (Ex.OPW2/A) of Sh. Kamal Sachdeva Dy. Manager along with other documents as: i) Ex.OP2/1–Policy Back Cover Document cum Terms & Conditions 31.05.2017; ii) Ex.OP2/2–Policy Welcome Letter 08.04.2017; iii)  Ex.OP2/3–Death-Claim of the DLI; iv) Ex.OP2/4–Prefecture Report Status – Final: Investigation Outcome: Negative; v) Ex.OP2/5 – PGI (OPD) Card 31.12.2016; vi) Ex.OP2/6 – Claim Decision Letter 31.08.2018. vii)    Written Arguments by the OP2 insurers.                     

9.       We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some of the documents ignored to be produced by the contesting litigants against the back-drop of the arguments/oral as well as written, as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen on account of the impugned ‘repudiation' of insurance death-claim pertaining to the insured DLA wife (Late Smt. Kuljit Kaur) of the complainant, by the OP2 insurers who allege non-disclosure of the pre-existing/continuing ailments etc by the DLA and/or the Complainant, at the time of insurance.

10.     We have minutely examined all the documents produced in evidence by the complainant and also by the OP insurers as produced and as collected by them during the course of their investigations and find that the insured's health status as well as all clinical and medical-examination reports were in the notice, knowledge and possession of the OP insurers at the time of insurance/policy-selling/pocketing of the fat premium etc and thus they are presently stopped to cause repudiation to the death-claim, in question, merely on the strength of photocopies of the alleged past medical-treatments sans any affidavit/deposition/statement of the treating doctors/hospital authorities etc. Further, there's no evidence of delivery (not even that of dispatch) of the OP2 insurers documents viz: Policy Document, Terms and Conditions and others etc; and, in the absence of cogent evidence the contents/allegations of suppression/non-disclosure of past ailments are not proved and cannot be relied upon since on the other hand complainant has satisfactorily proved the contents/allegations and non-resolve cum delay etc vide the documentary evidence. We observe the OP insurers' present role fully marred by an employ of unfair-practices  and unscrupulous exploitation of the innocent consumer and that amounts to an open play of deficiency in service at its full volume. We disapprove the OP insurers' acts of omissions as well as that of commissions, in totality. And, of course we do not concur with the logic of the herein impugned 'repudiation' of the death-claim and are inclined to examine the validity and legality of the same in the back-drop of the preceding and also the succeeding acts and events in the light of the facts on records and current law on the consumer proposition’s subject matter, in issue. We observe that the impugned repudiation of the insurance-claim has been the result of the OP insurers' resolve in their endeavor to somehow repudiate the same to cause and unfair and unjust loss to the complainant.       

11.     Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the intentional 'repudiation' by the OP insurers as ‘deficiency in service' and 'unfair-practices' at play and thus we partly allow this complaint and  ORDER the OP insurers to  pay the death-claim, in full, to the herein complainant, in terms of the related policy with interest @ 6% PA from the date of complaint till actually paid, in full, besides to pay Rs.15,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the aggregated amount shall attract an additional interest @ 3 % PA from the date of the orders till actually paid.  

12.      The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

13.      Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.                                                      

                                                          (Naveen Puri)

                                                                President.

ANNOUNCED:                                 (R.S.Sukhija)

OCT. 20, 2022.                                            Member.

YP.