The complainant Geeta Devi has filed this case for realization of Rs. 10 lacs/- as sum assured , Rs. 1 lacs/- for compensation for mental and physical harassment, Rs. 21,000/- as litigation cost with 18 % p.a. interest on the sought amount since date of death of L.A. till final payment.
The brief, facts of the case is that the complainant is wife of L.A. namely Jagadish Mahato and nominee of the insurance policy. The husband of complainant, Jagadish Mahato purchased a life insurance policy bearing No.0290959542 for sum assured of Rs. 10 lacs/- by paying Rs.10,831/- as premium. The further case of the complainant is that the insurance company has got medically examined Jagadish Mahato L.A. by its Dr. and thereafter issued the policy bond in the name of insured person. The risk coverage of the policy was from 24-02-2013. The further case is that on 03-11-2014, unfortunately the L.A. person Jagadish Mahato died at his residence due to diarrhea (vomiting & loose motion). The further case is that after death of L.A., the complainant filed death claim against the above policy with all relevant documents but the insurance company repudiated the claim the complainant on concocted and baseless ground.
The complainant has annexed the following documents with the complaint petition - photocopy of premium receipt annexure-1, photocopy of Death Certificate- annexure-2, photocopy of Income Tax Return for the assessment year 2013-14 & 2014-15 -annexure-3, photocopy of acknowledgement for assessment year 2013-2014 annexure-4, photocopy of Pan Card annexure-5, photocopy of certificate granted by Mukhiya, of Gram Panchayat Raj Piroi Shamshuddin regarding death of Jagdish Mahto annexure-6, photocopy of repudiation letter annexure-7
On issuance of notices, o.p appeared and filed their w.s. on 05-03-2019 with prayer to dismiss the complaint petition with exemplary cost. It has been mentioned in the w.s. that the complaint petition is false, frivolous, vexatious and an abuse of the process of this forum. It has been further mentioned that the present complaint does not raise any Consumer Dispute as defined under the Consumer Protection Act -1986 as there is no deficiency in service or negligence on the part of o.ps. It has been further mentioned that the complaint is not maintainable. It has been further mentioned that the complaint has concealed material fact as to his health condition in the proposal form. It has been further mentioned that the L.A. had concealed material facts as to pre-existing, liver, cronic kidney disorder therefore the claim of the complainant is based on a of policy which is void invalid and non enforceable due to suppression of material fact. It has been further mentioned that this forum has got no jurisdiction to entertain the present complaint as there is no deficiency in service or negligence on part of the o.ps. Issuance of insurance policy in the name of L.A. is an admitted fact. The copy of proposal form has been annexed as annexure-A. The copy of policy document including the first premium receipt, policy schedule and terms and condition has also been annexed as annexure-B. The o.ps have also annexed the declaration of good health submitted to the company by the deceased L.A. as annexure-C. The receiving of death claim intimation on 25-03-2015 from the complainant is also an admitted fact. The o.ps have annexed photocopy of death claim intimation dated 25-03-2015 and death certificates as annexure-C. It has been further mentioned that since the death of deceased L.A. had taken place within Short Span of approximately within 1 year 9 month from the date of commencement of policy, hence the company issued the process of claim investigation in order to verify the authenticity of the said claim. It has been further mentioned that it was revealed during enquiry that the documents submitted, by the nominee to validate her claim was faulty, and fraudulent. It has been further mentioned that it also came to the notice of the o.ps that the deceased L.A. was addicted to alcohol . It has been further mentioned that due to high consumption of alcohol, L.A was suffering from liver and kidney disorder and underwent treatment for the same. It has been further mentioned that L.A. had consulted Dr. B. Kumar M.B.B.S , BSC (honours) bearing registration no.Vol- 270/2019 on 18-06-2012, 08-07-2012 and 20-10-2012, for treatment of liver kidney disorder that is prior to proposal form and commencement of the subjected policy. The prescriptions issued by Dr. B.Kumar, has been annexed as annexure-E. photocopy of repudiation letter dated 29-05-2015 has also been annexed as annexure-F.
On behalf of complainant AW-1 Geeta Devi (complainant) has been examined.
On behalf of o.ps, o.p.w -1 Balram Kumar Patwa Zonal Head legal and compliance has been examined.
The complainant has annexed the repudiation letter as annexure-7 and the same document has also been annexed on behalf of ops as annexure-f. The claim of the complainant has been repudiated by o.ps on the ground that the D.L.A has actively concealed of pre-reinstatement consultation /treatment taken for alcoholic liver disease, cronic kidney disease with alcoholism. The o.ps have raised this question in his w.s. and has stated that deceased L.A. submitted a declaration on dated 15-07-2014 for good health to the o.ps again reiterating that the deceased L.A. has not consumed alcohol in any form and that he has not previously or currently undergoing any medication or treatment. It has also been mentioned in the w.s. that it was revealed during the investigation that the document submitted by the nominee to validate his claim was faulty and fraudulent . It has also been mentioned that it also came to the notice of o.ps that the deceased L.A. was addicted to alcohol. It has been also mentioned that due to high consumption of alcohol, the L.A. was suffering from Liver and kidney disorder and underwent treatment for the same. The o.ps have annexed prescriptions note issued by Dr. B.Kumar MBBS as annexure-E.
Learned Lawyer for the complainant submits that there is no father’s name of patient on annexure-E., So it is not identified that the patient under gone treatment before Dr. B.Kumar on 18-06-2012 was D.L.A . He further submits that moreover neither Dr. nor surveyor have been examined on behalf of o.ps to prove the fact that the L.A. was suffering from liver and kidney disease. He has relied on the findings of case of PNB met Life Insurance Company V/s Veenita Devi decided on 24-09-2018 by National Consumer Disputes Redressal, Commission New Delhi.
The question of pre-existing disease has been raised on behalf of o.ps ,so the burden of proof lies on their sholder.
On behalf of o.ps, o.pw-1 Balram Kumar Patwa has been examined who is neither Dr. nor surveyor to prove the above fact. He is only zonal head legal and compliance who has only placed the fact on behalf of o.ps only. Photocopy of prescriptions of Dr. B.Kumar has been annexed as annexure-E.
The complainant has denied the above fact in her deposition and has stated that the L.A. never suffered either from liver /kidney disease neither got any treatment regarding said disease. No explanation has been offered on behalf of o.ps for examination of Dr. or surveyor. In the case of PNB Met Life Insurance Company V/s Vinita Devi decided on 24-09-2018 by Hon’ble National Consumer Dispute Redressal Commission New Delhi in para-4, Hon’ble National Commission has observed in para-8 of the order and the same is as follows-
“We rely on the judgment of this Commission titled Sushil Kumar Jain Vs. United India Insurance Co. Ltd. I (204 (NC) which has attained finality, wherein it is observed that the doctor’s prescriptions have to be substantiated by an affidavit of the said doctor, specially in the light of the fact that it is being disputed by the complainant. In the instant case the Insurance company has not produced the affidavit of the concerned doctor nor did the said doctor answer any interrogatory by way of evidence before the Fora below. At the cost of repetition, it is reiterated that the burden to prove that the life assured was suffering from any pre-existing disease lies with the Insurance Company and the Insurance Company had not filed any documentary evidence or affidavit of the treating doctor in support of their contention. Hence, we find force in the contention of the Counsel of the complainant that the insured was never treated by the said doctor Y.K. Thakur of Hazipur as the reports are not substantiated by any affidavit of evidence. In the light of this observation, we are of the considered view that the aspect of nexus between the kidney disease and heart attack is of no relevance in the instant case. The State Commission has rightly placed reliance on the prescription given by Dr. Mihir Chandra, in whose treatment the Insured was before his death and in the said prescription It is only stated that the insured had breathlessness and lost consciousness and thereafter died.”
As per observation of the N.C.D.R.C in the above case, the documentary evidence inform of affidavit of treating Dr. was to be filed but no affidavit of the treating Dr. has been filed on behalf of o.ps to prove the pre-existing disease Dr. has also not been examined. No explanation has been offered on behalf of o.ps for non examination of the Dr. to show the pre-existing liver disease and its treatment.
On Scrutiny of all the materials available on record and the decision referred above , we are of the opinion that there is deficiency on part of o.ps and the o.ps has repudiated the claim of the claimant of flimsy ground.
Accordingly, the complaint petition is allowed and the o.ps are directed to pay Rs. 10 lacs /- as sum assured with 7 % interest p.a from the date of filing of complaint petition that is on 26-10-2015, Rs. 20,000/- as physical and mental harassment and Rs. 10,000/- as litigation cost within two months from the date of order, /, on failure they shall be responsible to pay the above amount with 8 % p.a. interest till realization. Let a copy of this order be furnished to both the parties as per rule.
