Hon'ble Mr. Haradhan Mukhopadhyay, President.
The brief facts of the case which led the Complainant to lodge the case before this Commission is that the Complainant Jyotsna Singha Sarkar’s deceased son namely Jiban Krishna Singha Sarkar had a Life Insurance Policy being LIC New Bima Gold Table-179 on 28.09.2010 through O.P.-1 CBR Branch with the following details:-
- Policy No. 456761706
- Date of Commencement 28.09.2010
- Maturity Date 28.09.2040
- Premium Amount Rs. 9,666/-
- Mode of Policy- Half Yearly
- Nominee of the Policy: Jyotshna Singha Sarkar
OPs being the Branch Manager of LIC India, Cooch Behar Branch, Dist- Cooch Behar, are the authorities with whom the said policy was invested. Subsequently, the said Jiban Krishna Singha Sarkar died on 28.07.2011 at Cooch Behar Subham Hospital Pvt. Ltd. on acute Pancreases and Multi-organ Failure. Thereafter, the Complainant submitted the aforesaid Policy claim along with the relevant documents before the O.P.-1 on 21.11.2011. After receiving the Policy, O.P.-2 issued a letter on 30.05.2014 (after twenty months from submitting the claim form) to the Complainant stating the repudiation of the said claim on the ground of misstatement and withholding the correct information and advised to submit a prayer for re-consideration of claim to the Zonal Office, Kolkata. Accordingly, the Complainant submitted a prayer to the Zonal Office and the Ombudsman, Kolkata for getting the insurance claim as per the instructions dated 30.05.2014. In the month of April, 2016 the Complainant received a letter from the Ombudsman, LIC dated 18.04.2016 stating inter-alia that the hearing of the said matter would take place on 30.05.2016 at 10.30. On 30.05.2016 the Complainant and her family members attended the said meeting for hearing having Complaint No. JNS/OMB/KOL-L-029-1415-1401 but she did not receive any answer at a subsequent stage from O.P.-1 or O.P.-2 despite several meeting with them. Therefore, the Complainant understood that the OP would not entertain the claim of the Complainant. Thus the act of the OPs regarding the said repudiation tantamounts to deficiency in service against which the Complainant sustained financial problem. The Complainant, therefore, prayed for an award of Rs. 2,00,000/- as death benefit of the deceased, Rs. 50,000/- as compensation for mental pain and agony and harassment, Rs. 50,000/- for deficiency in service and Rs. 10,000/- towards cost of the proceedings.
The OPs contested the case by filing written version on behalf of both the parties denying each and every allegation of the Complainant. The positive defence case of the Complainant in a few words is that the death claim was repudiated by the Divisional Office Dispute Redressal Committee on the ground of suppression of two previous policies No. 45A423363 of Rs. 50,000/- and Policy No. 450423271 of Rs. 60,000/- which were not disclosed by the proponent in the proposal form submitted for taking the Policy No. 456761706. The OPs informed the Complainant such decision of repudiation on 30.05.2014 and also informed her that if dissatisfied, she might apply to the Zonal Office Claim Dispute Redressal Committee (ZOCDRC) and the said ZOCDRC upheld the decision of the DODRC, which was duly informed to the Complainant by a letter on 24.11.2014. The deceased Life Assured i.e. the deceased son of the Complainant had given false statement to answer the Question No. 9 of the proposal form without disclosing the previous policies. They mentioned only one Policy after suppressing the other policies. So the question of deficiency in service does not arise at all. The deceased policy holder while signing the proposal form suppressed material facts. The Contract of Insurance is one resting upon good faith. Furnishing of incorrect information and deliberate false statement would make the Insurance Contract null and void. LICI always settles the death claim which are genuine in nature. It is pertinent to mention that the claim of other three policies of the Complainant vide Policy No. 4504423271 of Sum Assured Rs. 6,00,000/-, Policy No. 4504423363 for Rs. 50,000/- and Policy No. 450421992 for Rs. 3,50,000/- on the life of the deceased had been settled by LICI as there was no suppression of material facts. There is no cause of action in the present case. The OP, therefore, prayed for dismissal of this case.
On the basis of the pleadings of the parties and the questions involved in this case, this Commission wants to ascertain the following points:
Points for determination
- Whether the Complainant is a Consumer under the CP Act?
- Whether the Complainant suppressed the material facts deliberately?
- Whether the repudiation of the claim by the OP Company tantamounts to deficiency in service?
- Whether the Complainant is entitled to get the relief as prayed for?
- To what other relief if any the Complainant is entitled to get?
Decision with reasons
Point-1:-
It is an undisputed fact that the Complainant Smt. Jyotshna Singha Sarkar is the mother of the insured Jiban Krishna Singha Sarkar having LIC Policy No. 456761706 from LIC of India, Cooch Behar Branch for Sum Assured of Rs. 2,00,000/-, and the Policy Commencement Date 28.09.2010 under Table and Term 179-20 in which the mother Jyotshna Singha Sarkar was the nominee under the said policy.
The relation between the deceased Jiban Krishna Singha Sarkar and the nominee Smt. Jyotsna Singha Sarkar and the OP LICI fulfilled all the criteria for being a Consumer and Service Provider/Seller under the C.P. Act.
Regard being also had to the fact that the OP did not deny that the Complainant is not a Consumer under the C.P. Act.
Thus after assessing the pleadings of the parties and the evidence on record, I am of the view that the Complainant is a Consumer under the C.P. Act. Accordingly, Point-1 is decided on behalf of the Complainant.
Point-2:-
The Complainant claimed that the insured Jiban Krishna Singha Sarkar died on 28.07.2011 at Cooch Behar Subham Hospital Pvt. Ltd. on Acute Pancreases and Multi-organ Failure which is an admitted fact. It is also admitted that the Complainant submitted the aforesaid Policy Claim to the O.P.-1 on 21.11.2011. The evidence on record further goes to show that the Complainant submitted Policy Claim to the OP against which O.P.-2 issued a letter dated 30.05.2014 to the Complainant by repudiating the aforesaid claim on the ground of misstatement and withholding correct information and also advised to submit a prayer for re-consideration of claim to the Zonal Office, Kolkata.
The main defence plea of the OP LICI is that the Complainant suppressed material facts by not disclosing the two other insurance policies vide Policy No. 45A423363 for Rs. 5,00,000/- and Policy No. 450423271 for Rs. 6,00,000/- which were not submitted for taking the Policy No. in dispute.
The OPs in order to strengthen their defence filed the Proposal Form of the disputed policy in the name of deceased Jiban Krishna Singha Sarkar where from it is revealed that the Complainant disclosed only one previous Policy No. 450421992 but the said document clearly disclosed that the Complainant/the deceased did not disclose about the aforesaid other two policies.
Accordingly, the defence plea of material suppression of fact by the Complainant and/or the deceased Jiban Krishna Singha Sarkar being the insured appears to be willful and discretionary.
Ld. Advocate for the Complainant argued that the burden of proof about the suppression of facts lies upon the OP LIC. Even if there was mistake in the insurance Contract, the OP cannot escape from the liability of payment of final amount.
After assessing the entire evidence on record, it transpires that the OP apart from filing the Certified Copy of the Proposal Form for the disputed LIC Policy bearing No. 456761706, also cross-examined the Complainant by putting questionnaires before the Commission on 08.11.2019 wherein the following two questionnaires were submitted:-
Questionnaires
- Whether the deceased Jiban Krishna Singha Sarkar had two other previous LICI policies bearing No. 450423363 (DOC- 28.03.2010) for Rs. 5,00,000/- and another Policy No. 450423271 (DOC- 12.03.2010) for Rs. 6,00,000/-?
- Whether Deceased Life Assured (DLA) Jiban Krishna Singha Sarkar disclosed such fact in Column-9 of the Proposal Form?
After assessing the entire case record it transpires that the OP submitted the said questionnaires on 08.11.2019 but the Complainant did not file any reply to the said questionnaires at any point of time of the hearing of the case. In other words, the Complainant preferred not to file the said reply to the questionnaires.
After perusing the said proposal form it is found that in Para-9 of the said form except one Policy No. 450421992, the Complainant or the deceased Assured Jiban Krishna Singha Sarkar did not disclose about the other two policies. Thus the defence plea of suppression of material facts by the Complainant and/or her son deceased Jiban Krishna Singha Sarkar stands well proved beyond all reasonable doubt.
Accordingly, the defendant/OP duly discharged their onus of disproving the Complainant’s plea and substantiating the defence plea.
So far as the question as to deliberate suppression of fact is concerned, regard being had again to the said document being the Proposal Form wherein it is found that the Complainant. Insured deceased Jiban Krishna Singha Sarkar had disclosed about only one policy. It means that they had prior knowledge about the other two policies but despite having their knowledge and information, they did not disclose it. Therefore, it is evident from the direct evidence like the document itself and the circumstantial evidence, it is crystal clear that the Complaiannt and/or the insured Jiban Krishna Singha Sarkar deliberately suppressed material fact of not disclosing the other two policies.
Accordingly, Point No.-2 is answered against the Complainant.
Point No.-3 & 4:-
Both the Point No. 3 & 4 are taken up together for discussion for having inter-link with each other and convenience and brevity.
It is the admitted position that the OP LICI repudiated the final claim of the Complainant on the ground of suppression of material fact. Previously we have ascertained that the Complainant/Insured Jiban Krishna Singha Sarkar suppressed material facts deliberately which led the OPs to repudiate the claim.
It is also the defence plea that despite repudiation of the said claim of the Complainant, she was given a further opportunity through their letter dated 24.11.2014 to the Complainant stating inter-alia that she might prefer an appeal to the Insurance Ombudsman within a period of three months from the date of receipt of the said letter. However, the said decision appears to have been upheld by the said superior authority.
Hence this case is filed.
In the given facts and circumstances, it would therefore be not justified to hold that the Complainant was not given opportunity for redressal of their grievance.
Ld. Counsel for the Complainant further argued that even if there is mistake in the insurance Contract, yet the entire claim can not be repudiated.
Ld. Advocate for the Complainant in order to strengthen his argument relied upon a decision reported in Civil Appeal No. 4245 of 2015 wherein it was held that the death of insured due to heart disease and myo-cardial infarction had nothing to do with his lumbar spondylitis. Since the alleged concealment was not justified.
The case law does not apply here in as much as there is hell and heaven difference between the factual aspects of the two cases.
Ld. Counsel for the Complainant further referred to a decision reported in AIR 2008 Delhi 29 wherein it was ruled that the insurance claim cannot be denied on the ground of these lifestyle deceases that are so common. The person insured may suffer consequences in terms of the reduced claims.
In the case in hand, the claim was repudiated due to suppression of material facts whereas in the reported case law the deceased had some other issues. SO the case law does not apply here.
Another case law referred to by the Ld. Advocate for the Complainant reported in Appeal (Civil) 4186-87 of 1988 before the Hon’ble Supreme Court in which it was opined inter-alia that mere inaccuracy or falsity in respect of some recitals in the Proposal is not sufficient. The burden of proof is on the insurer to establish these circumstances.
The said case law does not come to the help of the Complainant in as much as in the instant case the OP Insurance Company duly discharged their burden of proof by evidence on affidavit and documentary evidence.
On the contrary, Ld. Defence Counsel relied upon a decision reported in Revision Petition No. 1573 of 2012 by National Consumer Disputes Redressal Commission, New Delhi wherein it was decided inter-alia that obtaining the last policy without disclosing the earlier policy, the insured did not act with utmost good faith, therefore, the Insurance Company was within its right to repudiate the claim under the Policy and in doing so it did not commit any deficiency in service falling within the ambit of Section 21D of the C.P. Act.
The said case law squarely applies here.
The OPs also proved the other policies in the name of the insured Jiban Krishna Singha Sarkar bearing No. 450423271 for Rs. 6,00,000/- and 450423363 for Rs. 5,00,000/- and 450421992 which were disposed of as claim settled.
Thus having assessed the entire evidence on record reasonable inference can be drawn that the OP’s decision for repudiation of the claim of the Complainant is proper, justified and bonafide.
Accordingly, in the light of the discussion made herein above and the observation made in the foregoing paragraphs, the Commission comes to the finding that the Complainant failed to establish the claim up to the hilt.
In the result, the Complaint Case fails.
Hence, it is
Ordered
That the Complaint Case be and the same is dismissed on contest without cost.
Let plain copy of this order be supplied to the parties concerned by hand/by post forthwith, free of cost for information and necessary action, if any.
The copy of the Final Order is also available in the official Website www.confonet.nic.in.
Dictated and corrected by me.
