This is a complaint U/s 12 of the Consumer Protection Act, 1986 with the prayer for direction upon O.P./ Insurance Company to pay the full sum assured of Rs.15,03,000/- with interest and for compensation of Rs.2,50,000/- for unnecessary harassment and also Rs25,000/- for litigation cost.
The case of the complainant in short is that the husband of the petitioner Late Uttam Kumar Roy while alive purchased one Life Insurance Policy of O.P./ Ins. Company Elite Assure Plan / LPPT 7, being policy No.00861804 . Sum Assured was Rs. 15,03,000/- for the term 30.03.15 to 30.03 36. O.P. No.2 is the corporate agent of O.P. No.1 and being satisfied by the M.O. and fit for purchasing the policy he submitted necessary documents i.e. voter card, PAN card, medical certificate as required by the O .P.s The present petitioner is the nominee of the policy . That O.P. No.1 arranged medical examination and being satisfied the policy was issued against deposit of required premium of Rs,1,40,821/- in the month of March 2015. The certificate was issued and the terms of the policy is 21 years and as per terms, 7 number of premium will be payable with sum assured Rs.15,03,000/-. Suddenly the husband of the petitioner died on 22.04.2015 due to cardiac respiratory failure when the policy was in force. The husband was in good health with no disease at all before inception of the policy. After demise of the husband the petitioner claimed the insured money following the policy. But O.Ps after enquiry only intended to pay the petition the premium amount which the petition did not agree. O.P. issued letter dt. 14.12 15 that O.Ps are unable to admit liability due to non disclosure of material facts . That sum assured under the policy is not payable and O.P refunded Rs.1,32,502/- as premium . Petitioner being deprived of legitimate value contacted the O.Ps but with no result. Cause of action arose on 14.12.15 when O./P. repudiated the claim . Therefore petitioner come up with the petition before this forum with above mentioned prayer.
O.Ps. appeared and contested the case by filing written version, where they categorically denied the allegations of the complainant. O.P. made a very elaborate written statement containing decision of National Commission and Hon’ble Supreme Court . That, the complaint is false, fabulous vexatious and abuse of the process . That, life assured had failed to disclose the material fact concerning his medical ailment in the proposal form . That he was suffering anemia and hypertension and taken treatment from C..C., Vellore in Feb, 2015 prior to purchase of the policy . That It was revealed during the course of investigation by the company that the insured procured the policy by misleading the company suppressing the material facts . Therefore the policy is void, ab-initio, illegal and not enforceable and liable to be dismissed. That the company validly repudiated the claim under clause No.17 for incorrect information and non disclosure. That sum assured was Rs.15,03,000/1- with annual premium of Rs.1.40,821/- having policy term and premium payment term as 21 years and seven years respectively was issued by the company to DLA on 30.03.2015 and the D.L.A died on 22.04.2015 i.e within 23 days . The company commenced an investigation by regulation 8(3) of the I.R.D.A Regulations 2002 for the genuineness of the claim through an indeepend3nt investigation agency Madox Advisory and Consultancy Private Ltd. That it was revealed that life assured was ill since past 4/5 months prior to his death. He was prescribed medicines for treatment of anemia and hypertension. But in the proposal form he answered ‘ no’ for questions on personal health. So u/s.45 of the Insurance Act the death claim was validly repudiated. That petitioner to deceive the forum to gain benefit and with unclean hands came before this Forum. Therefore O.P prays for dismissal of this case. What is relevant is that how far O.P has investigated the disease and treatment of the life insured to prove that the insured was suffering from anemia and hypertension prior to the purchase of the policy.
DECISION WITH REASONS
O.P has submitted a written argument which is kept in the record . Petitioner has been examined as P.W.1 . One Sreemaya Athikkat is examined as O.P.W. 1 on behalf of Ins. Company
Giving due consideration to the contents of the complaint petition, documentary evidence on record, hearing, argument advanced by the lawyers of both sides, the Ld. Forum has come to the findings as follows: -
Petitioner stated in the complaint petition and also deposed as P.W.-1 that her husband purchased the policy No.00861804, sum assured Rs.15,03,000/- and policy term for the period 30.03.15 to 30.03.36 .The policy paper has been filed . The husband died on 22.04 2015 due to cardiac respiratory failure. He has no previous ailments. For such sudden death during subsistence of the policy entitled the petitioner to claim the policy amount as a nominee of the deceased. The nomination paper was also filed. The death certificate is also filed.
It is the suggestion of the O.P that the deceased was suffering from severe ailments of anemia and hypertension, was undergoing treatment in the month of February 2015 and suppressed the material facts at the time of purchasing the policy. Therefore O.P. repudiated the claim on this ground only. O.P.W.1 also deposed accordingly.
It is the case of the petitioner that before granting the policy her husband was medically examined by Doctor of O.Ps and was found fit. O.P cited various decisions of Hon’ble National Commission as well as of Hon’ble Apex Court regarding suppression of material facts and breach of condition of policy. To prove these facts burden lies heavily on Insurance Company by adducing evidence, by examining treating doctors, by producing original documents of treatment and by linking the serious illness of the deceased with the fact of death by cardiac failure. But these are very much lacking in our case. We can refer here the judgement of National Commission as reported in 2014(3) CPR 401 (N.C.) SBI Life Vs. Harbindar Kaur . Moreover the disease mentioned hypertension and anemia is not a serious disease now a day in our present day life style. Ld. lawyer for the petitioner cited the decision as reported in 1(2011) CPJ 128, judgement of Hon’ble National Commission as reported in 2012(2) CPR 231 (N.C) and the decision reported in II(2006) CPJ 206 in this regard.
The Insurance policy should not be issued and repudiated in a casual and mechanical manner. The Ins. Co. is supposed to verify all facts mentioned in the proposal form before issuing policy. Agent of the company is required to explain all details and conditions in the Insurance policy. We have already noted that the policy of the deceased was only granted after his health was examined by the medical officer of the Insurer. When complainant put forward her claim O.P started reinvestigation of the disease of the deceased. But there is no documentary evidence put forward by the O.P. of any such reinvestigation. Nobody came forward to depose in this regard. Therefore the O.P/Ins. Co. cannot repudiate the claim of the petitioner in such a casual manner. O.P/Ins. Co, failed to prove by sufficient oral and documentary evidence that the petitioner was suffering from any mortal disease at the time of purchasing the policy, or that he suppressed these materials facts or did not disclose such facts in the proposal Form. On the other hand, petitioner has been able to prove her case successfully that her husband Uttam Kumar Roy died during subsistence of the policy due to sudden cardiac respiratory failure and she is entitled to get the death benefit under the policy.
Therefore we find there is a gross negligence on the part of the O.P/Insurance Company that it wrongly repudiated the claim by intimating the repudiation showing grounds and reason on the ground of non disclosure of material facts. We therefore find deficiency in service on the part of the Insurance Company. Therefore, the complainant is entitled to relief from O.P./ Insurance Company in the light of our above discussion.
Fees paid is correct. Hence, it is
ORDERED,
That the consumer complaint being No. CC-14/2016 be and the same succeeds on contest.
The O.P/Insurance Company is directed to pay the sum assured of Rs.15,03,000/- after deducting the payment of Rs.1,32,502/- if already refunded to the petitioner as premium money against the death claim. We direct the O.P/Insurance Company to pay the said amount with interest at the rate of 7% from the dead of death of deceased i.e on 22.04.2015. Further we direct the O.P. to pay Rs.5000/- as compensation for harassment and mental pain and Rs. 2000/- as litigation cost. Entire amount be paid within one month from this day, lest interest to be imposed at the rate of 9% per annum till full realization . Let copies of this order be supplied to the parties free of cost.
