Orissa

Jajapur

CC/37/2017

Mitanjali Sahu - Complainant(s)

Versus

The Branch Manager Claim Section HDFC Standard Life Insurance Co.Ltd. - Opp.Party(s)

Umakanta Sahu

30 May 2018

ORDER

IN  THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, JAJPUR.

                                                        Present:      1.Shri Jiban ballav Das , President

                                                                            2.Sri Pitabas Mohanty, Member,

                                                                            3.Miss Smita Ray, Lady Member.                                

                                             Dated the 30th day of  May,2018.

                                                      C.C.Case No.37 of 2017

Mitanjali Sahu    , W/O  Late Pradeep ku.Sahu

Vill.  Phajalpur , P.O/P.S. Korei   

Dist.- Jajpur .                                                                            …… ……....Complainant .                                                                   .                                    

                                                  (Versus)

1.The Branch Manager claim section H.D.F.C Standard Life  Insurance Co.Ltd,

    At/P.O.Jajpur Road , Dt.Jajpur

2.The Branch Manager, Standard Life  Insurance Co.Ltd, Corporate Registered Office

Lodha Excelus,13 th floor,A poilo Mills Compound, N.M Joshi Marg,

Mahalaxmi ,Mumbai .

                                                                                                                              ……………..Opp.Parties.                 

                                                                                                                            

For the Complainant:                                    Sri Umakanta Sahoo , Sammy Sahoo, Advocates ,

For the Opp.Parties : No.1 and 2                    Sri  B.K.Tripathy, S.Chakraborty,J.P.Mondal,, Advocates.

                                                                                                     Date of order:   30 .05.2018.

SHRI  JIBAN  BALLAV DAS , PRESIDENT  .

Deficiency in Insurance  service is the grievance of the complaint.

The fact relevant as per complaint petition  shortly are  that the petitioner husband has  opened a Insurance Policy bearing No. CPO00044 under the O.P  namely HDFC Life  Group Protect  a sum assured value of Rs. one lakh towards death benefit which has been commenced of membership on 29.07.15  and terminal date is  28.7.18 .  That while the policy was in force the  policy holder namely Pradeep ku Sahoo died on 08.12.15  leaving his wife  who   is also nominee of the said policy .

            That after death of policy holder the wife being the nominee of policy  placed her claim in time with all required documents which was accepted by the O.P and finally the O.P in order to avoid liability issued a letter dt. 04.4.16 repudiating  the claim stating  that the life assured was suffering from chronic  kidney disease, chronic liver disease with typell, diabetics mellifes  much prior to getting  policy which was not disclosed in the application form and declined in the application .

            It is   stated  that the  Insurance policy was opened when the policy holder was in healthy condition and after satisfying the same the policy was accepted and the husband of the complainant has paid premium regularly  but in order to avoid the same the O.P declined the claim of the petitioner and finally the O.P as per letter dt. 04.04.16 and  dt.30.12.2016 the claim of the petitioner has been denied  . The O.Ps  neglected to provide assistance  as per insurance benefit for which the petitioner suffered mental agony and harassment  and sustained damage of 1,30,000/- .Accordingly the petitioner knocked the door of this fora  with the prayer to direct   the O.Ps  to pay Insurance amount of Rs.  one lakh ,  cost Rs.  20,000/- for  mental agony and Rs. 10,000/- for harassment  totaling  Rs 1,30,000/- along with bank interest .

            The O.Ps after   appearance  through their learned  advocate  filed their written version  taking the following stands :-

That the Hon’ble forum has no jurisdiction to entertain , try and adjudicate the  claim . The complainant   has raised  issues , facts as well as law and it necessarily requires deposition of evidence and trials  and can be appropriately  done only by civil court .  Hence the proper forum to agitate the grievance before the Civil Court   . Therefore , the complaint is liable to be dismissed on this score alone .

1.That after accepting the above policy proposal the policy paper were dispatched to the customer, wherein terms and conditions of the policy are clearly stated. The mode ,method and frequency of payment of premium  were clearly mentioned in the policy  documents . In this  case policy no. CPO00044   was issued to Mr Pradeep  ku Sahoo who is one group term  policy on the basis of duly signed form for the purchase of HDFC standard Life Group Credit Protect plan “  having single premium Rs.998/-  for sum assured  of Rs . one lakh .The commencement of policy was 29.07.15 . The members information  Form ,LA has declared  that he has read  and understood the term and condition of the policy opted by signing the same . On the basis of the members information form and  the document submitted by the petitioner, the O.P  had  accepted the proposal and issued the aforesaid policy.  It is stated that the said policy question was  done securing the two wheeler loan from HDFC Bank  Ltd.   It is further stated that in this kind of policy holder  filed the Members information form , instead of proposal form . In members information Form, policy holder should answered “ short medical questioner about Health Details of member ,where the LA denied from any medical unfitness which was suppression of material facts .

            It is submitted  that the allegation  made by the complainant  is false and fabricated . It is submitted that after receiving the death intimation , the O.Ps  received the claim documents from the petitioner and further requested to submit medical records and other relevant documents to proceed the process of claim of the petitioner on behalf of LA.  It is stated that after going through all the documents  it was observed from the medical report which was done by the petitioner at the time of treatment and suppressed that deceased LA was suffering from Chronic kidney Disease, chronic Liver Disease with Type of 11 , Diabetic mellitus much prior to the policy issuance which was not disclosed  in declaration  ( mandatory as per law )  at the time of purchase of the policy . In the fact and circumstances of  the case , it is respectfully  submitted that the Forum would be pleases  to dismiss  the instant case with exemplary cost  .

            On the date of hearing we heard the argument from the learned advocate of  both the parties . After perusal of the record and documents in details  we are inclined to  decide the dispute as per  our observation given  below :-

1It is undisputed fact that the husband of the petitioner is a  policy holder of the O.P and  during enforcement of policy period the LA was died .

2. It is also undisputed fact that the O.Ps have repudiated the claim of  the petitioner on the ground of   suppression of material facts ( pre-existing disease and treatment ) . It is also a fact that as per broucher supplied by the O.Ps against the above Insurance policy such disease which are raised by the O.Ps are also cover under the policy  .  In such situation we are of considered view that the onus  having lies with the O.Ps  to prove the same by reliable cogent evidence that prior to submission of proposal form the DLA was suffering with pre existing ailment  as per observation of appellate forum

            2008(3)-CPR-53(Rajsthan) ( Mumini  vrs L.I.C of India & Others)

2005(2) CPR-528-Odisha (D.M.L.I.C Vrs. Surendranath Samal )

2005-CTJ-1008-N.C(Surinder Kaurd & Others Vrs L.I.C of India )

AIR-1991-SC-392( LIC of India Vrs. Smt G.M.Chennabasemna )

In the present  case the O.Ps have not filed any documentary  evidence prior to    accepting the proposal form ,  the O.Ps  have examined the health of the petitioner . Accordingly we are inclined  to follow the observation of Andhra Pradesh ,State Commission reported in 2014 (4) CLT-115-Hyderabad ( B.M L.I.C & Others Vrs. Pasupulet Bhagya Laxmi & Others)  wherein it is held that

“ Insurance claim (life Repudiation on the ground that insured suppressed the material information with regard to health – Held - when the policy was issued by the Insurance company with utmost good faith, the same yardstick has to be applied while settling the claims also - The LIC ought to have made thorough enquiry, investigation or necessary medical health check – ups before issuance of policy irrespective of the amount involved- without doing so, when they have issued the policy, now they cannot turn round and contend that they need not pay any amount as there was suppression of material information with regard to his health - All these discreet enquiries, investigations and health check-ups etc. ought to have been made before issuance of the policy itself - Having issued the policy they cannot repudiate the claim on the ground or the other - The Insurance company failed to establish that the life assured had taken treatment prior to obtaining the policy as stated supra, nor could prove the nexus between the alleged treatment and the cause of death-Appeal dismissed.”

                        We have been observing that a number of cases, the Insurance companies are issuing policies basing on the statements made by the proposer in utmost good faith but when it comes to settlement of claims, they start examining the matter under the microscope”.

                        In view of the above narrated analysis as well as owing to the above observations of Appellant Forums and in absence of any documentary proof, cogent and valid evidence  regarding pre-existing ailment prior to submitting proposal form , it is crystal clear  that the O.Ps. have issued the Insurance policy to the  insured without medical examination at the time of accepting the proposal form and subsequently  have repudiated the Insurance claim of the complainant  on the pretext of pre-existing ailment  which is  only malafide ,arbitrary on the part of  the O.Ps. and  such plea /stand is not sustainable in the eye of law. Accordingly the interest of justice will be best served in case this dispute will be allowed in favour of the complainant.

 Hence this order.

                                               

In the net result the dispute is allowed against the O.P. The o.ps are directed to pay the insurance claim of the petitioner Rs .one lakh   within one month  after receipt of this order ,failing which the ops are liable to pay 9% interest on the above awarded amount from the date of filing of the present dispute till its realization .

                        This order is pronounced in the open Forum on this the 30th  day of  May,2018. under my hand and seal of the Forum.                                                                                             

 

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