The complainant Smt. Madhu Bala, the holder of Aadhar (Ex.C2) and the nominee/Legal Heir/Widow of Late Sh. Bharat Bhushan has filed  the present complaint against the titled opposite parties (for short, the OP1-2 insurers) being hurt at the repudiation (Ex.C1) of her husband's death-claim allegedly on flimsy and arbitrary considerations thus infringing her statutory consumer rights. She proceeds to explain that her late husband Bharat Bhushan had been the statutory consumer of the OP insurers having purchased/invested in Money Back Policy (Ex.C14) in Accidental Insurance Policy (Ex.C15) on 02.07.2012, in Personal Accidental Policy (Ex.C16) on 29.03.2013 and in Smart Wealth Builder (Ex.C13) @ a premium of Rs.1,50,000/- paid on 31.01.2017. However, Bharat Bhushan the insured suffered a massive heart attack on 15.05.2017 and died (Ex.C3) on his way to the hospital.

2.        The OP insurers were duly intimated of the insured's demise and as requisite the death-claim was filed along with the necessary documents etc. However, the death-claim was unceremoniously repudiated (Ex.C1) on 11.10.2017 on the flimsy grounds that the DLI had not correctly answered/disclosed his existing/continuing ailment of diabetes & others  to question 13 (iv) of the proposal form regarding his past hospitalizations, operation, tests investigations and medical-treatments etc and the repudiation was further upheld (Ex.C4). Further, the complainant has pertinently stated here that the DLI was made to undergo clinical tests many a times as well as medical examinations by the em-paneled physicians of the OP insurers and thus his health status was very well in their notice and knowledge and the insurance covers were provided post clearance from the OP medical quarters and the proposal form was only signed by the DLI at the instance of the OP2 Branch Manager as has been the practice continuing since the purchase of the policies in the past, too.

3.     As the complainant has been presently living alone @ her meager pension after the death of her husband with her only son having already met an unnatural death in the year 2015 and daughter having got married 11 years ago and thus she had requested the OP insurers vide her application (Ex.C5) mailed through India Post (Ex.C6) requisitioning all the documents pertaining to the related policy. But the OP insurers refused Ex.C7 to Ex.C9 to provide the results/reports pertaining to the DLI clinical tests and medical examinations etc. on the pretext of confidentiality in spite the complainant's protests (Ex.C11 & Ex.C12) alongwith written arguments.

4.        Lastly, the complainant has stated that the OP insurers in their endeavor to escape their legal liability to pay her the amount of the impugned death-claim (to the tune of the Sum-Assured @ Rs.1.5 Lac) have foxily credited her account with Rs.1.50 Lac the amount of premium paid by her late husband at the time of purchase of the policy. However, she has been willing and prepared to return the same back as and when requisite.              

5.        The complainant having realized her failure to move the OP insurers to review the impugned repudiation has filed the present complaint accompanied by her duly sworn out affidavit Ex.CW1/A seeking directives to the opposite parties to pay her the insured sum of Rs.15 Lac with interest @ 18 % PA from the date of death of the insured besides Rs.1.0 Lac as compensation in addition to any other relief that the forum may deem fit.

6.       The titled opposite party insurers (OP1 & OP2), 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 post self-introduction as well as description of their business activities exhausting the first three full paragraphs.

7.       The DLA (Deceased Life Assured) had two live-cum-active policies at the time of his death on 15.05.2017. The OP insurers have already paid the death-claim amounting to sum of Rs.111,778/- as per the one policy eligible for the death-claim-payment. However, the death-claim pertaining to the second policy, in question, has been repudiated as the DLA was suffering from Diabetes Mellifluous Type-II, Diabetic Foot prior to submission of the related proposal but here he had suppressed the same in violation of terms of the policy and that legally justifies the so-called impugned repudiation.

8.       Further, the OP1 office has been at Mumbai and the Managing Director has no involvement in the co.'s day to day operations thus he has been unjustifiably arrayed as an opposite party No.1. Moreover, insurance has been a contract of utmost good faith between the two parties and any such non-disclosure mars the mutual faith and warrants rejection/repudiation of the relating benefits that blossom in good-faith, only. The OP insurers have also addressed this non-disclosure as playing fraud upon them and that in turn nullifies the insurance contract void ab-initio by virtue of S-17 of the Contract Act, 1972; and, thus the complaint deserves dismissal on this very count, alone.

9.       The OP insurers have further narrated and discussed the 'Brief Facts of the Case' in the next 26 paragraphs annexed with Annexure-A to Annexure-M (in alphabetic order) as have been placed on record for perusal and consideration as and when found requisite.

10.     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.

11.     The policies as referred to in the complaint have different dates of commencement ranging from 20.03.2006 to 07.02.2017 and the insured's health status has also been in the process of change. The ailments of Diabetes and Diabetic Foot has been in the very notice/knowledge of the complainant as he has been availing reimbursements for its medical-treatment. Further, the medical examinations do not depict the factual status/position of the ailments/diseases during the course of medications so the clinical-test results as well as those of the medical examinations are to be weighed along with the other evidences on records. The plaintiff is not to take advantages/benefits of the defendant's weakness in his defense and has to win a decree on the strength and merits of his own case.

12.     Lastly, the OP insurers have quoted/ referred to many of the subject-related senior court judgments that we are bound to respectfully peruse during the course of the present adjudication. The OP also put forth the full-fledged interpretation of the policy document along with notes on Fraud, Summary Proceedings and Compassion duly supported as well as strengthened by quotes cum references of superior court verdicts. Finally, the insurers have sought dismissal of the complaint being bereft of merit and also for want of cause of action, in the interest of justice, equity and fair play.

13.     The OP insurers in support of their version and pleadings in defense have produced the following documents in evidence:

Ex.OP1 – Affidavit by the Asst. Vice President Legal Neelam Singh;

Ex.OP2 – Common ULIP Proposal Form;

Ex.OP3 – Medical Examination form;

Ex.OP4 – Welcome Letter;

Ex.OP5 – Claimant Statement;

Ex.OP6 - Delivery Letter dated 29.06.2017;

Ex.OP7 – Claim Investigation Report;

Ex.OP8 - Doctor Certificate (Discharge) 01.07.2017;

Ex.OP9 – GND Hospital, ASR (Certificate);

Ex.OP10 – RSD Hospital, Shahpurkandi (Certificate);

Ex.OP11, Ex.OP12 & Ex.OP13 – Medical Reimbursement Certificate;

Ex.OP14 – Prescription and Medicine Cash-memos;

Ex.OP15 & Ex.OP16 – Death Claims.

14.     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 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 husband (Late Sh. Bharat Bhushan) of the complainant, by the OP1,2 insurers who allege non-disclosure of the pre-existing/continuing ailments of Diabetes and Diabetic Foot   by the complainant at the time of insurance.

15.     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 of Rs.1.50 Lac and thus they are presently stopped to cause repudiation to the death-claim, in question. Moreover, the ailments like diabetes etc are quite common and these present no bar to policy-selling so these should also pose no bar to claim-settlements etc. 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.                 

16.     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 ORDER the OP insurers to pay the death-claim, in full, mius amount already received if any, to the herein widow 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.                        

17.      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.

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

                                                           (Naveen Puri)

                                                                 President.

ANNOUNCED:                                (B.S.Matharu)

SEP. 16, 2022.                                            Member.

YP.