MR. NAYANANANDA DASH,MEMBER
The C.C. case is about non-release of death claim benefit to the nominee of the insurance policy, when the policy holder has expired and the nominee has submitted the requisite documents to the LIC .
2. Brief facts of the case is such that one Mr. Karim Khan of Vill-Nageswarpur, PO-Tilottamadeipur of Ps/Dist-Kendrapara had made two policy with LIC, one bearing No.598067155 on dtd.12.10.2010 with table No.802 and another bearing No.548010630 with table No.91 with a total sum assured of Rs.1,15,000/-. Unfortunately, Karim Khan expired on dtd.28.06.2012 while being treated at Health care Hospital in Kendrapara for tumor operation, policy holder died on heart attack. As soon as the news of death of Karim Khan was spread outside,there was mob violence and public disturbance attacking the hospital and the miscreants set fire the hospital premises and there was severe loss of valuable documents including vital documents related to treatment particular of patients due to fire. This incident was reported widely in the newspapers. Karim Khan’s medical reports and documents got burnt with this incident. The complainant was the nominee of the two policies made by Karim Khan and the complainant applied before the OP-Insurance Company for the death benefit of the two policies. As per advice of the OP-Insurance company the complainant applied in the proper form along with original policy bond and other related documents. But the OP-Insurance Company have not settled the death claim benefits by not releasing the sum assured inspite of repeated requests and has adopted a dilatory tactics which gives mental agony to the complainant and hence the complainant has filed this case.
3. On Being noticed, the OP-Insurance company appeared and submitted the written version formally denying the allegations and submitted their point of view. According to OP-Insurance Company there was creation of the two policies as mentioned in the complaint petition. But the OP-Insurance Company’s only plea in countering the allegation on written statement is that after the death of Karim Khan, the complainant has not submitted the necessary documents and inspite of repeated reminders by OP-Insurance Company, the complainant has not submitted those and instead filed the case.
4. Upon Notice, Op No.3 Health Care Hospital, Kendrapara appeared through their Ld. Counsel and filed written statement who impleaded as a party in the later stage of the proceeding. The written statement of Op No.3 reveals that Complainant’s deceased husband was admitted to the Hospital for treatment of ‘Tumor’ and died on dt. 28/06/2012 at 9.30 A.M. on death of the Policy Holder general public agitated near the Hospital, burnt and destroyed some relevant documents related to the treatment of Karim Khan, the deceased Policy holder. It is also averred that the treating doctor of Op No.3, Hospital filled up the L.I.C. papers produce by the complainant on the opinion of the treating doctor the cause of death is heart attack during operation of ‘Tumour’ and handed over the said paper to the Complainant for its submission before Insurance- Corp., accordingly the Op No.3 has no latches and the Complaint be dismissed against Op No.3, Hospital.
5. Heard, the arguments advanced by ld. Counsels by Complainant and Ld. Counsels of Op- Insurance Company and case of the Op No.3 on merit, gone through the Complaint, written statements and documents filed by Complainant as per the list. The fact reveals from the complaint petition and written statement of OPs that one Karim Khan, husband of the complainant was a policy holder under LIC, having two(2) nos. of policies bearing No.598067155 and another policy bearing No.598070630 under different schemes having a total sum assured of Rs.1,15,000/-The policy holder Karim Khan died on dtd. 28.06.2012 at Health care Hospital, Kendrapara, when under treatment for operation of tumor and the policy holder died on ‘heart attack’ as stated by the treating doctor of OP No.3,Hospital. It is also a fact that complainant was the nominee of the deceased policy holder in the said 2 policies in capacity of ‘wife’. It is further a fact that though the deceased policy holder died on dtd.28.06.12, her death claim as per the policy has not settled yet.
In the case in hand, complainant alleges that inspite of production of original policy bond and relevant documents, Ops did not settle the claim of the complainant. On the other hand contesting OP-LIC of India countered the allegations by taking the plea that as the complainant on several information did not submit the necessary documents like claim form A,B,B-1 etc. and other relevant documents for which the OP-Insurance Company could not proceed with the insurance claim. Complainant to substantiate her case filed documents before this Forum and according to Complaint those documents were deposited before the Op-Insurance Company for settlement of the claim, and filed attested Xerox copies of status report of 2 policies and also filed documents as per the list on the date of argument which includes original claim application, claim form-A, claim form-B, Claim form-B-1, Form C.R. and on intimation letter of OP-Corporation dtd. 26.03.2016 addressed to complainant along with attested Xerox copy of bank passbook, voter I.card, legal heir certificate, death certificate and policy table. The filing of original documents before this Forum is a mystery neither the complainant in her petition nor the OP-Insurance company whispered a single sentence regarding return/possession of original documents, which are required for consideration of the claim. The settle principle of law that evidence must be taken into consideration in corroboration with pleadings. When the Complaint Petition is silent regarding possession of those documents, when the same was produced before the Op-Insurance Company, then as per the law the said documents lacks the evidentiary value. But for the shake of argument for the moment we, believe that, those documents were produced before the Op-Insurance Company for settlement, and on scrutiny of those documents it is noticed that the intimation letter addressed to complainant on dtd.26.03.2016 by Sr.Divisional Manager of OP-Corporation reveals that certain quarries have to be complied by the complainant, and the claim Form-A is a incomplete one, which is to be filled in by the complainant-claimant for consideration of the claim.
In this circumstances, assuming that the documents presented before the OP-Corpon. for settlement of insurance claim and basing on those documents OP-Corpn. has to consider the claim of the complainant and can this Forum allowed the prayer of the complainant by directing the OP-Insurance Company to settle the claim of the complainant by releasing the sum assured in favour of the complainant/claimant ? The Answer is ‘no’. To settle or repudiation of a claim, Application Form complete in all respect alongwith other documents is to be produced before the insurance authorities, in addition to that official formalities are to completed including the investigation etc. as per the provisions of the Insurance Act to consider the claim. Complainant in her complaint states that the original policy bond was produced before OP-Corpn. for settlement of claim, and on the written statement of OP-Corpn. though averred that complainant has submitted different forms alongwith relevant documents, but silent about submission of original policy, hence, it is presumed that the original policy bond of deceased policy holder Karim Khan is in custody of OP-Corpn., which has not been returned to the complainant-claimant Any decision in the circumstances directing the OP-Insurance Company to settle the claim will be miscarriage of justice. More so the complaint petition does not disclose the date of submission of claim Application Form before OP-Corpn., when the policy holder died on dtd.28.06.2012, on the otherhand, the OP-Corpn. in their written statement discloses that inspite of repeated requests complainant did not submit the documents required for consideration of the claim. In the circumstances, this Forum finds that except the written version, no correspondence of letters or formal intimation in support of the acknowledgement to complainant regarding production of documents is filed by the OP-Corpn. for better appreciation of the fact by this Forum. Simultaneously, the plea of destruction of treatment particulars as revealed from the complainant and written version of OP No.3 is no way relevant to the present dispute at this stage. Equally, it is a fact that OP No.3,Hospital is no way responsible for settlement of the claim. and OP-Corpn. can not be treated as deficient in service as alleged by the complainant.
The next point of determination is How the grievance of the complainant, who is a young widow lost her husband in her early age will be redressed ?
In our opinion, the complainant will resubmit the fresh claim Application form-A along with other claim Forms filling the same in complete in all respect and as per the instructions mentioned in the claim Application Form. Complainant may take the documents in original filed before this Forum as per the list for her submission or reference by substituting the attested Xerox copies as these documents carries the signature of Treating Doctor and witness etc.. It is further observed and directed that OP-Corpn. will consider the claim Application Forms on its submission sympathetically, if any minor latches/discrepancies found in filing the claim Form same to be ignored on the instance of complainant/claimant.
Considering the facts and position of law involved in the dispute we direct that the complainant has to resubmit a fresh claim application forms required for consideration of the claim along with other relevant documents, within 15 (fifteen days) from the date of the order, and on receipt of the fresh claim application forms, the OP-Corpn. will consider the claim as per the provisions and will intimate the complainant within 45 days from the date of receipt of the claim application forms. The process is to be completed within 60(sixty) days from the date of the order.
Accordingly, the complaint is allowed in part without any cost on contest against OP-Corpn. and on merit against OP No.3,Hospital.
Pronounced in the open Court, this the 20th day of June, 2017.
