DR. S. M. KANTIKAR, MEMBER

1.       The above said cross Appeals have been filed under Section 19 of the Consumer Protection Act, 1986 against the impugned order dated 30.09.2014 passed by U. P. State Consumer Disputes Redressal Commission, Lucknow (in short, ‘the State Commission’) in Complaint Case No. 64 of 2013.  By the said order, the State Commission allowed the complaint of the complainant and directed the OP to pay Rs.26,13,623/-  to the complainant. 

2.       The brief facts for the disposal of both appeals are that the complainants, Ms. Sunita and the complainant’s husband, Shri Bijender Singh had taken housing loan for the sum of Rs.26,13,623/- from PNB Housing Finance Limited/OP-3 on 31.5.2011.  In pursuance of the internal arrangement with the TATA AIG Life Insurance Company/Opposite Party No. 1 and 2, the OP 3 financer purchased a policy of insurance covering the risk of the life of the Borrower/Late Brijendra Singh.  The total tenure of the policy was 10 years i.e. till 30.5.2021.  Unfortunately, her husband died on 25.7.2011 by heart-attack.  The death intimation was given to OP-2 and OP-3 on 3.9.2011.  The OP 2/insurance company neither settled the claim nor informed about progress despite several reminders/letters were sent by the complainant.  Thereafter, two legal notices were also served to the OPs but the claim was repudiated by OP on 19.3.2013.  Hence, aggrieved by the repudiation, the complainant filed a complaint before the State Commission, U.P. 

3.       After due service of notice, the OPs did not file written statement and OPs abstained from the proceedings.  Therefore, the State Commission allowed the complaint ex parte and directed the OPs 1 and 2 to pay Rs.26,13,623/- along with interest @ 9% per annum from 3.5.2012.  It allowed Rs.2,00,000/- as punitive damage and Rs.15,000/- as costs.

4.       Being aggrieved by the order of State Commission, OPs 1 and 2 filed first appeal No. 1432 of 2014 for dismissal of complaint whereas first appeal No. 1163 of 2014 was filed by Ms. Sunita, the complainant for enhancement of the compensation.

5.       We have heard learned counsel for both the parties.  Learned counsel for OPs 1 and 2 submitted that there was delay of 8 days in filing the appeal (FA No. 1432 of 2014).  The delay is condoned for the reasons stated in the application for condonation of delay.  Learned counsel further argued on merits that on receipt of death claim from the complainant, the matter was assigned by OPs to the investigating agency, which submitted report inter alia alleging that deceased was having medical history prior to the inception of the policy and he was suffering from kidney disease.  He had also taken treatment from Yashoda Hospital in Meerut.  The Sanjivni Diagnostic Center, which was located in front of the house of the deceased, had helped the deceased during treatment of kidney disease.  Also, the records of Astha Blood bank situated at Baraut proves that in July, 2011, the blood bank had sent blood to Kidney Hospital, Meerut in the name of deceased.  The counsel further stated that the deceased was not CGHS beneficiary.  He had taken treatment and benefits under CGHS in the name of Shri Ravindra Singh, a constable working in Delhi Police.  Thus, deceased was hiding his identity and his previous medical history about his health condition at the time of inception of the policy.  Therefore, on the basis of investigation report, the claim was repudiated.  The OP also sought information through RTI application from CGHS office as well as Delhi Police.  As per RTI information from the Deputy Commissioner’s office, Delhi, it was stated that Shri Ravindra Singh was a constable in Delhi Police and he was suffering from neck problem.  Similarly, RTI information from Chief Medical Officer, Ghaziabad Wellness Centre revealed that Shri. Ravindra Singh took treatment from Nephrologist, Cardiologist and Gastroenterologist.  Thus, it proves that the deceased was residing with his real brother, Ravindra Singh in the same house.  The complainant in connivance with Shri Ravindra Singh and deceased has tried to conceal the material fact of the previous illness and also misrepresented about the treatment taken in the name of Shri Ravindra Singh under CGHS.  The counsel further submitted that the OPs have also lodged the criminal complaint against the complainant and other persons involved, for the alleged fraud.     

6.       Learned counsel for the complainant submitted that claim was lodged with the financer/bank as well as with the insurance company by means of two separate letters dated 3.9.2011 and 2.1.2012.  The claim in view of the Regulation 8(3) of the IRDA (Policy Holders Interests) Regulations, 2002, should have been decided by the opposite party Nos. 1 and 2 within a period of 30 days and not more than 6 months i.e. latest by March, 2012.   Thus, it was an utter disregard of the statutory provisions; the opposite party nos. 1 and 2 repudiated the claim on 19.3.2013, which took 2 years and three months to take decision in this matter.  Learned counsel further submitted that since the loan was secured by OP 3/Financier under the policy taken from OPs 1 and 2.  There was no cooperation from the bank as a financier but it threatened the complainant by a letter in June, 2013 to clear the outstanding dues, otherwise, the recovery proceedings would be initiated. 

7.       We have given our thoughtful consideration to the arguments advanced before us by the learned counsel for both the parties and also carefully examined the material placed on record, including the orders passed by the State Commission.  The basic issue involved in the present matter is whether the insured, Brijendra Singh suffered from any kidney disease etc. prior to submitting the proposal form for obtaining the policy and whether there has been any concealment of any material fact on his part.

8.       While passing the impugned order, the State Commission identified the issue correctly and stated as follows:

“A crucial question for determination is that whether in the instant case there was impersonation or fraud committed by the insured and whether any material fact regarding the treatment of kidney disease prior to the proposal of policy have been concealed by the insured.”

9.       A perusal of the impugned order reveals that although the State Commission identified the crucial issue as stated above but they have not given any finding on the same, rather the State Commission passed their judgment based on the IRDA Regulations 2002 only, saying that the insurance company had indulged in deficiency in service in not deciding the claim within the time laid down in the Regulations.  It was the duty of the State Commission to have examined the entire evidence on record and then give a clear-cut finding on the question, whether there was any impersonation or fraud committed by the insured in any manner.

10.     Further, it has been stated that the insured had taken treatment in Ghaziabad impersonating himself as Ravindra Singh and enjoyed the benefits under the Central Government Health Scheme (CGHS) in the name of Ravindra Singh.  The information obtained under the Right to Information Act reveals that Ravindra Singh was a constable in Delhi Police and was suffering from neck problem only.  The State Commission should have examined the relevant medical record available at the places, where the treatment was taken in order to find out whether it was Brijendra Singh, who had taken the treatment or it was Ravindra Singh.  It is, therefore, necessary that the matter be thrashed out in detail to bring out, whether there has been an act of fraud on the part of the insured.  It is evident from the facts recorded above that the order of the State Commission has not taken into account the crucial issue involved in the matter and decided the case, based on technical aspects only.  The order passed by the State Commission is, therefore, perverse in the eyes of law and the same is hereby set aside.

11.     Both these first appeals are disposed of with the directions that the matter shall be re-heard and decided by the State Commission, after affording an opportunity to both the parties to lead further evidence, if any in their favour.  The parties have been directed to appear before the State Commission for further proceedings on 15.12.2017.  There shall be no order as to costs.