Fact of the case of the Complainant in short is that O.P. no.3 came to the house of the Complainant and made proposal to purchase SBI Life Insurance Policy in the name of his wife Mira Goswami since deceased. As such, SBI Life Insurance Policy was purchased in the name of Mira Goswami, wife of Complainant and annual premium of Rs.50,000/- was paid O.P. no.1 & 2 Insurance Company.
On 20-03-2013 panel doctor of O.P. Insurance Co. examined the LIC Policy Holder i.e. Mira Goswami, wife of the Complainant and after being satisfied O.P. Insurance Co. issued LIC Policy bearing no.44053821306 in favour of Mira Goswami, wife of the Complainant.
On 13-09-2013 Mira Goswami policy holder suddenly suffered chest pain at her husband’s paternal residence at Dubrajpur situated under District - Bankura and she was admitted to B.S.M.C.H. at Bankura on 16-09-2013 where she died on 19-09-2013.
Thereafter, claim was submitted by Complainant / husband of the Policy Holder before the O.P. Insurance Co.; but Insurance Co. did not pay the same and subsequently repudiated the claim vide letter no.25-06-2014. So, this Complainant has filed this petition of complaint and prays for passing award directing O.Ps. insurance company to pay the assured amount of the LIC Policy to the tune of Rs.3,50,000/- with interest @ 18 % p.a. to Complainant and also prayed for Rs.1,00,000/- for compensation and 25,000/- as cost of litigation and other reliefs.
This case is being contested by the O.P. No.1 & 2 Insurance Co. by filing W.V. denying all allegations as made in the petition contending inter alia that this case is not maintainable as Complainant is not Consumer. No cause of action. Specific case of defence is that the LIC Policy holder Mira Goswami was suffering from serious illness long before the taking of case LIC Policy and she took the policy suppressing the fact of her pre-existing disease.
There was no deficiency in service. Complainant is not a Consumer. So, Complainant is not entitled to any relief in this case and case is liable to be dismissed.
In this case written argument has been filed on behalf of the O.P. no.1 & 2.
Points for Determination.
1) Is the Complaint maintainable ?
2) Whether the Complainant is entitled to the amount assured in the case SBI LIC Policy took in the name of Mira Goswami.
3) Whether there was any deficiency in service ?
4) Whether the Complainant is a Consumer as defined in the Consumer Protection Act, 1986.
5). Whether the Complainant is entitled to relief as prayed for.
Decisions with reasons.
In this case Ld. Advocate for the Complainant made argument by reiterating the fact as stated in the petition of complaint and also denied the contents of W.V. on the point of pre-existing decease as alleged by the O.P. no.1 & 2.
It also reveals from the written argument where O.P. no.1 & 2 has denied contents of petition of complaint and reiterated the fact as stated in their W.V.
We have carefully heard the submissions and perused the contents of written argument and the Xerox copy of documents. It appears that it is undisputed that Mira Goswami took a policy bearing no.44053821306 from the O.P. Insurance Co. on 05-03-2013, commencing from 20-03-2013 and the sum of Rs.3,50,000/- was assured, for a payment term of five-years and policy terms as eight-years.
The dispute is that the O.P. have claimed that the policy holder took the LIC Policy by fraud practice upon the O.P. Insurance Co.
In this regard Ld. Advocate for Complainant referred 2012(1) CPR page 236 (NC) where it has been observed by National Commission that onus of proving ground for repudiation of insurance claim lies heavily on Insurance Company.
It has also been observed by the Hon’ble National Commission reported in 2017 (2) CPR page 658 (NC) inter alia that pre-existing ailment must be proved by Insurance Company.
So, in view of observation of the National Commission we find that pre-existing of ailment of Mira Goswami before taking case LIC Policy must be proved by Insurance Company by adducing cogent evidence..
In this case we find from petition of complaint para – 4 where it is stated that the fact that panel doctor of O.P. Insurance Co. examined at length this LIC policy holder on 20-03-2013 and after being satisfied the case policy was issued.
This fact has not been denied in the W.V. by the O.P. Insurance Co.
It has been observed by the Hon’ble National Commission reported in 2014 (3) Consumer Law Today page 49 (NC) inter alia that “Consumer Protection Act, 1986 Section 2(1)(g) – Insurance claim – Pre-existing decease – Repudiation – On the ground that at the time of Proposal Form filled by insured he was suffering from Blood Cancer – Held – Usually, the authorised doctor of the Insurance Co. examined the insured assesses the fitness and, after complete satisfaction, the policy will be issued – Therefore we feel the O.P. was wrong in repudiating the claim of complainant.”
In view of the above observation of the Hon’ble National Commission it appears to us that no evidence have been adduced either documentary or oral by the O.P. Insurance Co. to prove the pre-existing decease of the policy holder namely Mira Goswami. Moreover, authorised doctor of the O.P. insurance co. examined the insured and assessed her fitness and after being complete satisfaction the case policy was issued. So, in view of the above observation of the Hon’ble National Commission we hold that the O.P. insurance co. was wrong in repudiating the claim of the Complainant.
We also hold that the claim of the Complainant in respect of case insurance policy stood in the name of the wife Mira Goswami after her death is a bona fide insurance claim of Complainant. It has been observed by the Hon’ble National Commission reported in 2017 (2) CPR page 9 (NC) that bona fide insurance co. claim cannot be repudiated by Insurance Co.
In view of the above observation of the Hon’ble National Commission we hold that this O.P. no.1 & 2 were wrong in repudiating the bona fide insurance claim of the Complainant.
In this case, contesting O.Ps. have claimed that the Complainant is not a Consumer; but we find that the Complainant has made insurance claim in respect of assured value of LIC policy issued by O.P. no.1 & 2 LIC Company in favour of his wife after the death of his wife. So, we find that repudiation of claim by any insurance co. after receiving its premium in respect of the insurance policy can be said that complainant being legal heirs of his LIC Policy holder can submit his claim and he can be termed as Consumer as per section 2(1)(d) of C.P. Act, 1986 being a consumer.
We hold that Complainant is a Consumer as defined in Consumer Protection Act, 1986.
In view of the above facts & circumstances and discussions made above we hold that Complainant is entitled to get an award in respect of Rs.3,50,000/- i.e. assured value of the case insurance policy.
Considering the materials on record if simple interest @ 8 % p.a. upon insured value from the date of passing of this Judgement is awarded then none would be prejudiced.
We do not like to award any amount as compensation as we awarded simple interest upon the sum assured in insurance policy involved in this case; but we like to award Rs.4,000/- as cost of litigation for interest of justice.
In the result this Complaint succeeds.
We find O.P. no.3 has no role in the matter of repudiation of case insurance claim.
So, we find no cause of action against O.P. no.3.
So, we hold that this Complaint is liable to be dismissed against O.P. no.3 as we find no cause of action against O.P. no.3.
Hence, it is
Ordered
That the Complaint Case no.112 of 2014 be and same is hereby allowed on contest against O.P. no.1 & 2 ; but dismissed against O.P. no.3 exparte.
O.P. no.1 & 2 are hereby directed to pay to the tune of Rs.3,50,000/- i.e. sum assured in case LIC policy no. 44053821306 stood in the name of Mira Goswami since deceased to this Complainant along with simple interest @ 8% p.a. from this date till it’s full realization by thirty (30) days from this day.
O.P. no.1 & 2 are also further directed to pay Rs.4,000/- to Complainant as Litigation Cost.
O.Ps. are directed to pay the amount awarded above to Complainant by 30-days from the date of receipt of copy of Judgement; failing which Complainant is at liberty to realize the same with due course of law.
Complaint is dismissed in respect of other relief / prayer made by Complainant in the petition of complaint.
Let a plain copy of this Judgement be supplied to the parties free of cost.
