ORDER NO. 20 DT. 13.09.2018
Brief facts of the case are that the husband of the complainant since deceased started a Life Insurance Policy being Policy No. 456302196 with the O.P. No. 1 Life Insurance Corporation of India, Malda Branch under the category of “WEALTH –P” of Rs. 100000/- and its quarterly premium was Rs. 5000/-. The said policy was /is valid on and from the date of commencement year 2010 to 23.03.2018 and the petitioner was nominated as the nominee of the said policy. During continuation of the said policy the husband of the petitioner died on 06.12.2011 at Malda Sadar Hospital and Medical College leaving behind the petitioner as widow and two sons viz. Souvil Pal, Sumon Pal and mother Sankari Bala Pal as his legal heirs and successors. After demise of husband the petitioner intimated the matter of death of her husband in writing to the O.P. No. 1 and requested to disburse the assured amount of Rs.100000/- as early as possible. Thereafter, the O.P. No. 1 issued a claim form to the petitioner which was duly filled up and submitted together with all required relevant documents and filled up “E-Form” to the O.P. No.1. Thereafter, the O.P. No.1 by a letter requested the petitioner to submit the medical treatment papers of her husband (life assured) of last three years from his death for early disbursement of the claim amount. The petitioner submitted some medical treatment papers to the O.P. No.1 but the P. Manager (Claims) of LICI by his letter dt.18.10.2012 being No. JDO Claims-457 requested the petitioner to clear the fact of death of the life assured. The petitioner sent a letter dt.24.11.12 to the O.P. No.1 and submitted affidavit in this regard. But the O.P. No.3 by a letter dt. 11.07.2014 repudiated the claim of the petitioner arbitrarily and without any cogent reason. The petitioner then submitted an appeal to the O.P. No.3 on 24.11.2014 but got no result.
Finding no other alternative the petitioner submitted an application to the insurance ombudsman being Complaint No. KOL.-L -029-1415-1327. During pendency of the said complaint the ombudsman deputed a mediator and the said mediator heard both sides but surprisingly directed the opposite parties to pay only NAV Value of Rs. 28187 to the petitioner but surprisingly the name of the insured was mentioned as Aliara Khatun of Jalpaiguri. The said act of the O.Ps and mediator were mala-fide and unfair trade practice for their personal gain. The petitioner intimated the said matter to the insurance ombudsmen but of no result.
The petitioner is legally entitled to get the sum assured of Rs. 100000 and accordingly the petitioner sent a demand notice to the O.P. No. 1 on 23.09.2016 which was duly received by the O.P. No.1 but he did not disburse any amount.
It has been asserted by the petitioner that the death of the insured person was a natural death but the O.Ps intentionally harassing the petitioner by taking unfair trade practice policy. Hence this case.
The opposite parties have entered appearance and contested the case by filing written version wherein the material averments made in the complaint have been denied and it has been contended inter alia that the present case is not maintainable. It has been contended by the O.Ps that the life-assured was suffering from various chronic disease before commencement of the policy but he suppressed those material facts at the time of signing of the proposal form and as such claim of the complainant was repudiated due to non-disclosure of material information regarding his health by the insured in the proposal form and the repudiation of claim of the complainant was on valid grounds. It has been further contended by the opposite parties that there is no cause of action for filing the present case and the present case is not maintainable and liable to be dismissed with cost.
In this case the complainant has submitted examination-in-chief supported by affidavit and she was cross-examined in full by the O.Ps. Complainant also submitted following documents by list.
- LIC Wealth Plus Policy Deed Policy No. 456302196 (Ext.-1)
- Death Certificate Santosh Ch. Paul Date of Death 06/12/11 (Ext.-2)
- LIC First Premium Receipt of Santosh Kr. Paul Rs. 5000/-
Policy No. 456302196 (Ext.-3)
- LIC Renewal Premium Receipt dt. 02.07.2010(Ext.-4)
- LIC Renewal Premium Receipt dt. 08.10.2010 (Ext.-5)
- LIC Renewal Premium Receipt dt. 03.12.2010 (Ext.-6)
- Legal Hair D.O. Dist. Order No. 114 dt. 10.01.2012 (Ext.-7)
- Letter to the Branch Manager LICI Br.-1 Malda Dt. 23.12.2011 (Ext.-8)
- Medical Attendant Certificate of LICI (Ext.-9)
10.Letter to the Supdt. Malda Dist. Hospital dt. 28.02.2012 (Ext.-10)
11)Letter to the Branch Manager LICI Malda Br.-1 dt. 06.07.2012 (Ext.-11)
12)Letter to the Manager Claims LIC of India dt. 05.03.2014 (Ext.-12)
13)Certificate by Employer by LIC of India Bombay Division Office Malda Branch I (Ext.-13)
14)Notice to Sefali Paul from LIC Jalpaiguri Divisional Office (Ext.-14)
15)Letter to the P. Manager (Claims) LIC of India Jalpaiguri Divisional Office (Ext.-15)
16)Affidavit of Sefali Paul by Notari Public Malda (Ext.-16)
17)Notice of LICI to Sefali Paul dt. 11.07.2014 (Ext.-17)
18)Notice of Claim Manager LICI to Sefali Paul dt. 24.11.2014 (Ext.-18)
19)Award Document of LIC Ombudsman K.B. Saha (Ext.-19)
20)Advocate’s Notice of Ranajit Saha to the Branch Manager LIC of India (Ext. -20)
The complainant submitted written notes of argument.
On the side of the O.Ps. no evidence adduced. The O.P. submitted Xerox copy of certain documents without having any list. O.P. submitted written notes of argument.
::POINTS FOR DECISION::
- Whether the case of the complainant barred by limitation?
- Whether there is any deficiency of service on the part of the O.Ps.?
- Whether the complainant is entitled to get relief /reliefs as prayed for?
::DECISION WITH REASONS::
Point No.1
It is admitted fact that the complainant is a ‘Consumer’ within the definition u/s 2 1(d) of the C.P. Act, 1986. The O.Ps. have raised a point that the complaint case is barred by limitation on the plea that the claim of the complainant was repudiated on 11.07.2014 but the complainant filed the present case on 25.01.2017 i.e. after lapse of two years and accordingly u/s 24 A of the C.P. Act, 1986 the case of the complainant is barred by limitation.
On scrutiny of the record as well as documents submitted on the side of the parties we find that the claim of the complainant was repudiated by the O.Ps. on 11.07.2014 and thereafter the complainant further made her appeal to the O.Ps but the O.Ps by their letter dt. 24.11.2014 rejected the prayer of the complainant and advised her to refer the matter to the Insurance Ombudsman. Accordingly, the complainant referred the matter to the Insurance Ombudsman being Complainant No. KOL–L /029/1415-1327 and both the complainant and the O.Ps were present before the mediator Mr. K.B. Saha deputed by the Insurance Ombudsman and the mediator heard both sides and thereafter directed the O.Ps to pay only NAV value of Rs. 28187/- to the complainant and by their decision being Award No. IO/KOL/A/LI/0043 dt. 2016-17 and the date of award/order was on 20.05.2016. The complainant has filed the present case on 25.01.2017 that is well within the limitation period of 2 years. So the present case is well maintainable and not barred by limitation. This issue is accordingly decided in favour of the complainant.
Point Nos. 2 & 3
Both the issues are taken up together for the sake of convenience and brevity of discussion.
It is admitted position that the husband of the complainant during his lifetime opened a policy being No. 456302196 with LICI, Malda Br.-1, Malda. in the category “Wealth –P” of Rs. 100000/- (Rupees One Lakh Only)and premium was fixed at Rs. 5000/- per quarter. The said policy was valid on and from its commencement dt. 23.03.2010 to 23.03.2018 and the present petitioner was the nominee of the said policy.
This is also admitted position that during continuation of the policy the husband of the petitioner died on 06.12.2011 at Malda Sadar Hospital and Medical College leaving behind the petitioner as his wife and his two sons and the aged mother as his legal heirs.
It is also admitted position that after demise of her husband the petitioner intimated the matter to the O.Ps and requested to disburse the sum assured amount of Rs. 100000/- in her favour and as per direction of the O.Ps submitted filled up claim form along with all required documents including filled up ‘E’ Form and medical papers of the deceased, Santosh Paul to the O.P. No.1 and thereafter, as per letter dt. 18.10.2012 of ‘P’ Manager (Claims) of LICI the petitioner clarified the death of her husband by an affidavit.
It is the case of the complainant that the O.Ps without showing any cogent reason illegally and arbitrarily repudiated the claim of the petitioner vide their letter dt. 11.07.2014. The petitioner then submitted an appeal to the O.P. No.1 but she got no result.
The further case of the petitioner is that finding no other alternative she preferred an application before the Insurance Ombudsmen, Kolkata being advised by the O.Ps vide their letter dt. 24.11.2014 and both parties appeared before the mediator Mr. K. B. Saha appointed by the Ombudsman and after hearing both parties the mediator awarded NAV Value of Rs. 28187/- instead of claim amount of Rs. 100000/- and mentioned the insured name as Aliara Khatun, Jalpaiguri. The said act of opposite parties and the mediator was mala- fide and unfair trade practice for their illegal gain.
The case of the O.Ps on the other hand is that the life assured, Santosh Kr. Paul (deceased) at the time of starting of the policy withheld material information regarding his health and in the proposal form dt. 23.03.2010 he had totally suppressed all material information regarding his illness but on enquiry it was found that before he proposed for the above policy he was suffering from disease for which he was admitted to police hospital, Malda on and from 02.04.2008 to 14.04.2008 i.e. 12 days for knee pain and hypertension and again admitted to Kolkata Police Hospital for treatment of urinary track infection from 27.05.2008 to 07.06.2008 i.e. for 13 days and again he availed commuted leave on the medical ground for 48 days ( 08.06.2008 to 25.06.2008 ) and it is evident that the deceased life assured was not in sound health at the time of signing the proposal form but he has not disclosed the above facts in his proposal form instead he gave false answer therein and deliberately gave misstatement regarding his health at the time of effecting his assurance.
In the instant case on the side of the O.Ps not a single medical paper / prescription of medical practitioner of Police Hospital or any other doctor has been submitted to show that the deceased was suffering from chronic disease before starting of the policy on 23.03.2010. O.Ps collected ‘E’ Form from the employer of the deceased who was in police service and from the said ‘E’ form (Ext. – 13) we find that the deceased took leave on three occasions during the year 2008. In the first occasion he took leave from 02.04.08 to 14.04.08 for a period of 13 days and then he took leave from 27.05.2008 to 07.06.2008 for 12 days and thereafter he took leave from 08.06.2008 to 25.07.2008 for 48 days. It further appears from the said ‘E’ Form that the life assured died on 06.12.2011 being suffered from chronic renal failure and before death he attended office till 30.10.2011. From the contents of the said ‘E’ Form we do not find any material to hold that the deceased was suffering from serious ailments and he suppressed that fact at the time of starting of the policy on 23.03.2010. The Discharge Certificates issued from the Police Hospital, Malda and Kolkata Police Hospital dt. 14.04.2008 and 07.06.2008 respectively (submitted from the side of the opposite parties) disclosed that the life assured was suffering from right ankle pain and Urinary Track Infection for certain period during the year 2008 but there is not a single medical paper or document to hold that the deceased was suffering from any serious chronic disease / ailment and due to such disease he was abstained from attending office for a prolong period during the last 5 years from the date of opening of the policy on 23.03.2010.
It is pertinent to mention that the deceased started insurance policy on 23.03.2010 and that time he was 54 years old but it is surprising that the O.Ps. did not think it necessary to perform thorough medical checkup of the insured to ascertain whether he was suffering from any prolonged disease on the contrary the O.Ps. through their agent encouraged and allured the life assured (deceased) to open a policy for their illegal gain and this is nothing but unfair trade practice on the part of the O.Ps.
In this case duly signed proposal form of the insured and the terms and conditions in respect of opening of the policy by the insured are not furnished by the opposite parties.
Considering the facts and circumstances of the case with regard to the materials and evidence on record submitted by the parties we are constraint to hold that the life assured was not suffering from any serious disease for a prolonged period before commencement of the insurance policy or that he suppressed any such information regarding his health at the time of starting of the policy. In this case onus is upon the opposite parties to establish by sufficient cogent evidence that the life assured was suffering from any critical disease and he was under medical treatment of any medical practitioner for a long period before commencement of the policy. Under such circumstances we are of the view that the O.Ps illegally and arbitrarily repudiated the claim of the complainant on the plea that the life assured was suffering from prolonged critical disease at the time of starting of the policy and he allegedly suppressed the said fact for receiving the policy in his name. We further like to mention that primary cause of death of life assured was chronic renal failure and the disease was first observed on 05.12.2011 and he died on 06.12.2011 as appears from the ‘B’ Form(Ext.-9) issued by the Malda District Hospital where the deceased breathed his last.
In view of above findings we are of the view that repudiation of the claim of the complainant by the opposite parties certainly comes within the definition of deficiency of service and accordingly, the complainant is entitled to get Rs.100000/- sum assured death claim together with interest till realization of the amount from the opposite parties and she is further entitled a sum of Rs.10000/- for mental agony and harassment and litigation cost of Rs. 5000/- from the opposite parties.
Both the points are accordingly decided in favour of the complainant.
In the result, the claim case succeeds.
Proper fee paid
Hence, ordered
that Complaint Case No.02/2017 be and the same is allowed on contest with cost against the O.P. Nos. 1, 2 and 3
O.P. Nos. 1, 2 and 3 are hereby directed to pay the sum assured of Rs. 100000/- together with interest up to date to the complainant within 45 days from the date of passing this order.
O.P. Nos. 1, 2 and 3 are further directed to pay a sum of Rs. 10000/- for mental agony and harassment caused to the complainant within 45 days from the date of passing this order
O.P. Nos. 1, 2 and 3 are further directed to pay a sum of Rs. 5000/- to the complainant towards litigation cost within 45 days from the date of passing this order. Failing which the awarded amount of Rs. 110000/- will be carried over 9% interest till its realization and the complainant will be at liberty to put the decree in execution if the order of the Forum are not being complies with
Let a copy of the order be handed over to the parties free of cost.
