IN THE COURT OF THE PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,KEONJHAR
CONSUMER COMPLAINT CASE NO. 36 of 2017
Sukumari Mukhi,aged about 47 years,
W/o Late Dhuna Mukhi of village-Indukholi Sahi,
Po- Keonjhar Bazara, P.S.-Town,
Dist.-Keonjahr,……………………………………….…...…..… Complainant
Versus
1.S.B.I Life Insurance ,State Bank of India,
Keonjhar Branch,At/Po- Keonjhargarh
P.s-Town, Dist-Keonjhar.
(Odisha) ………………………………………………..Opp.Parties
Present:
Smt. B.Giri, President (I/C)
Sri Bharat Bhusan Das (Member)
Advocate for complainant- Srinibas mukhi & Associates
Advocate for Op1 & Op2 - C.Hota & Associates
Date of hearing - 09.07.2019 Date of Order- 30.10.2019
B.Giri President (I/C)-
The case of the complainant in short is that complainant is the nominee and wife of deceased Dhuna Mukhi who was a policy holder of SBI life (Sarala Swadhar) bearing policy No—1J044317704 and the deceased become the policy holder on payment of RS 5000/-Five thousand) on 15.4.2016 for sum assured of Rs. 1,75,000/-for a term of 10 years and the policy holder died on 15.9.2016 i.e just after 5 months of commencement of the policy as such present complainant i.e the widow and nominee of deceased policy holder lodged claim for the sum assured amount of Rs. 1,75,000/-but the Op insurance company on 31.1.17 instead of payment of the total amount of sum assured amount only paid Rs 5000/-i.e the amount paid for 1st premium and when complainant enquired for such less payment the Op insurance company sent a reply of repudiation of claim stating the reason there in that the policy holder was suppressed his ailments at the time of taking policy and for such overt act complainant put a mental agony and met financial loss and hence this complaint for a direction to Ops to pay the sum assured amount of Rs 1,75,000/- and Rs. 25,000/-towards compensation for mental agony and Rs 10,000/-for financial loss and Rs 5000/- towards cost of litigation and in total Rs 2,15,000/- with interest.
In supported filed Xerox copies of policy paper, letter addressed to Op dt 18.02.2017,Death certificate of deceased policy holder, Advocate notice dt 07.08.2017, reply of legal notice dt 6.10.2017 SBI pass book of deceased policy holder and complainant.
After service of notice Op insurance company through his engaged counsel filed version stating that as the death claim was reported in very short span of time this Op has conducted enquiry in the matter and it was revealed that deceased life assured was suffering from chorionic obstructive pulmonary disease prior to the date and by suppressing his ailments in a fraudulent manner took the policy and also not disclosed that the DLA was also suffering from Dcm(Dilated cardio mylopathy,(COPD) (Chronic obstructive Pulmonary Disease) and IVC (Prominent Hepatic vein and in ferior vein cava) and hence complainant fraudulently suppressed the material facts and hence claim was repudiated as per terms and condition of the policy document as such not committed any deficiency in service and hence not liable for any compensation and complainant is not entitled for any relief.
And to prove its case relied upon the following documents.
1. Copy of the proposal form
2. Copy of the policy document
3. Copy of the investigation report
4. Copy of the discharge ticket of Rogikalyan samiti Hospital
5. Copy of the report dated 5.9.17
6. Copy of the Discharge certificate of SCB medical college and Hospital.
7. Copy of the USG report
8. Copy of the claim repudiation letter
9. Copy of the communication by the CRC
10. Copy of the legal notice
11. Copy of the reply to the legal notice
Perused the documents filed on behalf of parties. There is no dispute that deceased is a policy holder of Op insurance and who died after 5 month of taking his policy and the present petitioner is the widow and nominee of deceased policy holder and the claim of policy is repudiated by the Op.
So question remains that whether repudiation of claim by the Op insurance Co Ltd on the ground of suppression of ailment during taking of policy by policy holder is genuine or not ?
In this point the learned counsel for the complainant averred that Op Insurance company failed to give concrete evidence of such ailments that policy holder was actually suffering prior to execution of policy or thereafter.
On the other hand the learned. Counsel for the Op Insurance Company argued that the deceased life assured in short (DLA) had suppressed the material facts in the Proposal form and hence the policy was obtained fraudulently. Therefore claim has been duly repudiated as per the terms and condition of the policy and the same was communicated to the complainant on dt 1.2.2017 and this Op has paid the investment value of Rs 5,000/-in the Bank A/C of complainant on 31.01.2017 towards refund of premium as per the amended Insurance laws and Hence repudiation of claim by the Op is genuine.
After taking into consideration of argument extended by the parties and after gone through the final investigation report, Discharge ticket of Dist H.Q Hospital, Keonjhar, Requisition of pathological examination and Discharge certificate of SCB Medical college cuttack, USG report of abdomen by Department of Radio Diagonists. it is seen that prior to taking insurance coverage the deceased policy holder was suffering and was under treatment for Dilated cardio myopathy, Chronic obstructive pulmonary Disease and Bilateral Acute Renal Disease prior to date of commencement of policy and deceased policy holder did not disclose these illness against the specific questions related with the health in the proposal form through it the duty of policy holder to disclose every fact regarding his health, habits from the above discussion, We have no doubt that the deceased policy holder had suppressed the material facts in the proposal form as such it is clear that the policy was obtained fraudulently and repudiation of claim by the Op Insurance company after reviewed by the claim review committee of Op Insurance Company is genuine and Op has not committed any wrong by repudiating the death claim of the complainant.
On the above discussion we have no hesitation to hold that the action of insurance company can not be intimated as deficiency in service and hence the complaint petition filed by the complainant is dismissed accordingly but without cost.
The order pronounced in open forum today i.e on 30th day of Oct 2019 under my hand and seal.
Pronounced on 30th Oct .2019
I agree Dictated & Corrected by me.
( Sri B. B. Das) ( B. Giri)
Member (I/C.,President)
DCDRF,Keonjhar DCDRF,Keonjhar
