STATE CONSUMER DISPUTE REDRESSAL COMMISSION
BIHAR, PATNA
Appeal No. 67 of 2018
Aditya Birla Sunlife Insurance Company Limited, 16th Floor, One India Bulls Centre, Tower-1, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai
… Appellant/ Ori. Opposite Party
Versus
Radhika Devi, W/o- Mr. Pramod Kumar Singh, Resident of Village- Talwan Bigha, PS- Dehri, PO- Pahleja, District- Rohtas, Bihar- 821308
…. Respondent/ Ori. Complainant
Counsel for the appellant: Adv. Anil Kumar
Counsel for the Respondent: Adv. Rabindra Kumar
Before,
Hon’ble Mr. Justice Sanjay Kumar, President
Mr. Ram Prawesh Das, Member
Dated 05.01.2023
As per Sanjay Kumar, President.
O r d e r
Present appeal has been filed on behalf of appellant / Opposite Party Aditya Birla Sun Life Insurance Company for setting aside the order dated 28.11.2017 passed by the Ld. District Consumer Disputes Redressal Forum, Sasaram in Complaint Case no. 06 of 2014 allowing the complaint case and directing the appellant to pay Rs. 19,00,000/- (Ninteen lacs) to the complainant as well as Rs. 10,000/- as compensation for mental harassment and Rs. 5,000/- as litigation cost within two months from the date of passing of the order failing which interest @10% p.a shall become payable.
Case of complainant is that her deceased husband had purchased an insurance policy on 28.06.2012 and had paid Rs. 6,914/- as annual premium amount from the insurance company in which she was nominee. However, unfortunately, her husband died on 20.12.2012 while being carried to hospital after he complained of severe stomach pain. He died while being carried to hospital at the young age of 39 years. She filed a claim before the insurance company for payment of sum assured amount of Rs. 19,00,000/- (Nineteen lacs) however, same was repudiated by the insurance company.
On filing claim by the complainant insurance company appointed an investigator who submitted a report that deceased was chronic patient of hepatitis and he suppressed this information while filling the insurance proposal form and on this ground her claim was repudiated by letter dated 16.01.2013, against which she approached the District Forum for redressal of her grievances.
Notices were issued to opposite party- insurance company and they filed their written statement stating therein that the policy holder had concealed that he was suffering from serious disease and he was on medication and was being treated for hepatitis and he suppressed this material facts at the time of filling of insurance proposal form and as such her claim was repudiated.
Insurance company had appointed an investigator to investigate the claim of complainant and cause of death of insured. The investigator submitted his report stating therein that deceased was suffering from serious disease on the date of filling the proposal form and it was suppressed and concealed at the time of filling of insurance proposal form.
It was further stated that life assured expired within five months twenty one days of insurance of policy. Appellant had conducted statutory investigation under clause 8(3) of the Insurance Regulatory and development authority Regulations 2002. During investigation the appellant company came to know about past medical history of the life assured which was deliberately suppressed.
In memo of appeal appellant has enclosed prescription of Dr. Chitranjan Sharma, practicing in Gaya town who had treated deceased on 15.05.2012 and had advised bed rest from 15.05.2012 to 20.06.2012 and had also prescribed some medicines and thereafter, on 20.06.2012 referred him for further treatment. He issued a certificate dated 07.05.2013 to this effect.
It is to be establish by the insurance company that insured was suffering from some serious disease at the time of filling of the proposal form which he deliberately suppressed and cause of death was such pre-existing disease which insurance company has miserably failed to establish. The insurance company has placed a prescription of medical practitioner at Gaya and has given no explanation as to how said prescription came in their possession. It is equally intriguing that complainant and deceased were residing in Rohtas and for medical treatment deceased will go to Gaya which is situated far away whereas better medical facilities are available in Rohtas as well as Banaras. The medical prescription also does not inspire confidence about its genuinity and correctness and does not indicates that deceased was being treated for hepatitis. Deceased died at the young age of 30. The insurance company has failed to establish that any material fact was suppressed by the deceased. The investigator affidavit has been enclosed as annexure-F to the memo of appeal which itself is quite vague and uncertain on basis of which no opinion can be formed with respect to health condition of deceased and is being reproduced as hereunder:
“ Affidavit of Manoj Pandey, S/o- Shri Ramani Mohan Pandey, aged 42, Occupation: Claim Investigator having its office as Zenith Surveillance, Dr. C.K. Shahi Complex, Court Road, Deoghar- 814112 (Jharkhand).
I Manoj Pandey, partner, Zenith Surveillance, the above named deponent do hereby solemnly declare and affirm as under:
1. The we have been retained by the B.S.L.I Company Ltd. (hereinafter referred to as the “Insurance Company”) to enquire into the genuiness of claim arising on the death on 20.12.2012 of Pramod Kumar Singh who is the life assured (hereinafter referred to as the “Life Assured”) under policy numbered 005642996 issued by the company.
2. That after investigation BSLI provided us copy of some medical documents collected by other investigation agency that on verification with the concerned doctor found to be genuine and got attested.
3. That I further state that my above statement is true and correct to the best of my knowledge and belief and nothing has been concealed there in.
Medical certificate issued by doctor indicating that insured was suffering from hepatitis and jaundice is not credible. No affidavit of said doctor nor of investigating officer submitted to prove authenticity of medical certificate. Medical certificate is of no help to the insurance company.
Burden to prove undeclared pre-existing disease is upon appellant and they are required to discharge this burden by producing cogent evidence. Appellant has failed to prove that deceased was suffering from any pre-existing disease. Pre-existing disease means disease for which insured had been hospitalized or undergone operation in near proximity to the insurance policy.
This Commission does not find any error or infirmity in the order under appeal and as such is not inclined to interfere in the order passed by the District Consumer Forum, Rohtas at Sasaram and accordingly this appeal is dismissed.
(Ram Prawesh Das) (Sanjay Kumar,J)
Member President
Md. Fariduzzama
