Orissa

Rayagada

CC/19/2018

Smt. P. Sindhu Nair - Complainant(s)

Versus

The Branch Manager, LIC of India - Opp.Party(s)

Sri L.N Padhi

09 Jan 2020

ORDER

DISTRICT   CONSUMER DISPUTES REDRESSAL FORUM

POST  /  DIST: Rayagada,  STATE:  ODISHA,  Pin No. 765001.

                                                      ******************

C.C.case  No.       19         / 2018.                                    Date.   9      .01. 2020

P R E S E N T .

Dr. Aswini  Kumar  Mohapatra,                                     President

Sri Gadadhara  Sahu,                                                        Member.

Smt.Padmalaya  Mishra,.                                                 Member

Smt. P.Sindhu Nair, W/O: Late  A.Nagaraju  Nair, At/Po:Kolnara, Dist:Rayagada   (Odisha). 765 017,  .                                                                                                                                                                     …. Complainant.

Versus.

1. The   Branch  Manager, LIC of India, Rayagada
2. The Claims Manager, Berhampur Divisional office, Jeevan Prakash, Berhampur, Dist: Ganjam- 760010.
3. The Zonal Manager, LIC of India, East Central  Zonal offic, Jeevandeep building, 6^th. Floor, Exhibition road, Patna-800001.                             

… Opposite parties.

For the complainant: - Sri Pradeep Das, Advocate, Rayagada.

For the O.Ps:-    Sri  Sahedev Choudhury, Advocate, Rayagada.

 

2041079862166.  
2041079862167. 1,00,000/- towards policy No. 570965677  for which  the complainant  sought compensation  inter alia  for redressal of the grievances raised by the complainant.

         

The Back ground  facts in a nutshell  are that  the   husband of Complainant submitted the proposal form for insured of his own life through the authorized agent of the O.Ps. Life insurance plan namely Endowment annuity with profit and double accident benefits Assure (regular premium) bearing Policy No. 570965677  dtd.23.03.2005 for sum of Rs. 1, 00,000/- (Rupeees One  Lakhs)only  for the term of 20 years and to pay annual premium of Rs. 4,879/- (Rupees  four thousand  Eight Hundred seventy nine) only. But unfortunately on  Dt. 14.12.2013 the insurerd the (husband of the Complainant)  passed away in his village.  As the Complainant is the nominee of insured deceased, on claim of the Complainant for insured amount purchased policy by the deceased, the O.Ps  have  repudiated the claim of the complainant on the ground that the deceased has suppressed  about the fact that he was suffering was suffering from  Renal disease Mild Hepatomegally, mildly thickened urinary  blader wall with high  residual  urine volume  disease during  revival of policy on Dt. 22.2.2013. The O.Ps had repudiated the claim of the complainant on Dt. 15.7.2017. The allegation of the Complainant against the O.Ps that there is deficiency of service which caused mental agony and harassment. Hence this  C.C. case. Therefore  the Complainant  filed   C.C. case before the forum  and prayed for compensation and the insured amount with interest @ Rs. 9% from the date of claim till payment of the same.

 

On being noticed the O.Ps  appeared through their learned counsel and filed written version refuting allegation made against them.  The O.Ps   taking one and another pleas in the written version   sought to dismiss the complaint as it is not maintainable  under the C.P. Act, 1986. The facts which are not specifically admitted may be treated  as denial of the O.Ps. Hence the O.Ps    prays the forum to dismiss the case against  them  to meet the ends of justice.

 

Heard arguments from the learned counsel for the    O.Ps and from the complainant.    Perused the record, documents, written version  filed by the parties. 

This forum  examined the entire material on record  and given  a thoughtful consideration  to the  arguments  advanced  before us by  the  parties touching the points both on the facts  as well as on  law.

                                                         FINDINGS.

Undisputedly the Policy No. 570965677   was issued  by  the O.Ps in favour of the  D.L.A. Death life assured  Late A.Nagaraju Nair i.e. husband of the complainant ( copies of the bond is in the file  which is marked as Annexure-I).   The   above   policy   was   commenced  on   Dt.  23.03.2005  for a   sum  assured   of Rs.1, 00,000/- (Rupees one Lakhs)only   for the term of 20 years and to pay annual premium of Rs. 4,879/- (Rupees  four thousand  eight Hundred seventy  nine) only  under   Endoment annuity  with profit & double accident benefit (regular premium). Further there is no dispute that the insured has paid the premium upto the  March,2013 (copies of the  Renewal premium receipt  is in the file which are marked as  2 & 3) . The policy holder  died on Dt. 14.12.2013 at his residence  (copies of the  death certificate is in the file which  is marked as Annexure-4).

The main grievance of the complainant is that after death of  D.L.A.  death life assured  i.e. husband of the complainant  the O.Ps had  not  paid  the assured amount  and repdudiated the same on the grounds that the D.L.A had  suppressed of  disease during revival of the policy (copies of the  repudiated letter Dt.15.7.2017 issued by the O.P is in the file which is marked as Annexure-5) . Hence this  C.C. case.

The  O.Ps  in their written  version contended that the aforesaid policy has not completed 3(three) years  from the date of revival which  was 22.2.2013 to date of death of the life assured keeping in view of provisions of Section -45 of the Insurance Act, 1938.

In this connection  this forum relied citation it is held and reported  in CPR- 2009(2) page No. 406  where in the Hon’ble National Commission has observed  “Period of 3 years for purposes of Section-45 of life insurance Act,1938 has to be counted from the date of which policy was originally effected and not from the revival of policy”.

Again  the O.Ps   in their written version contended that the personal statement of Helth dated 11.2.2013, that the deceased life assured had answered the following questions as noted here in below .

QUESTIONS.                                                                                                           ANSWERS.

2(a)	Have you suffered from any illness/disease requiring treatment for a week or more ?	No.
4.	Are you at present in sound health ?	Yes.

 

The O.Ps further contended that the complainant  was suffering from  Renal disease Mild Hepatomegally, mildly thickened urinary  blader wall with high  residual  urine volume  disease during  revival of policy on Dt. 22.2.2013. Though this fact of suffering from the above disease  was known  to the death life assured he did not disclose the same at the time of revival of policy  on Dt. 22.2.2013.

In this connection this forum  relied citations which are mentioned here.

It is  held and reported in CPR- 2012 (2) Page No.220 where in the Hon’ble  State Commision, Rajstan  observed “Once accepting premium and having entered into agreement without verifying facts  insurance Company can not  wriggle out   of liability.”

Further it is held and report  in CPR-2014 (3) Page No. 1 the Hon’ble National Commission  where in observed  in para No.10   “ It will be unfortunate, if the insurance companies try to repudate genuine death claims on such technical and flimsy grounds. Most of the innocent insured  will be victims and the beneficiaries will be deprived of the fruits of life insurance. The complainant  was a illeterate  did not suppress any material fact with any fraudulent intention.  It is unfortunate that on one hand the LIC raises the voice of “Utmost good faith” but, in contrast, the faith will  be lost while not settling the genuine  claims for some or other reasons.   It is the exploitation of the policy holders.   The consumers are literally under  fear of dilemma that, whether, after death, the beneficiaries ever certainly get any  fruits from the  LIC….!  “

Again it is held and reported in CPR-2011(1) page No. 312 the Hon’ble   State commission, Raipur  where in observed  in para – 9  “The proposal for obtaining a new policy was in the month of February, 2007 and old policy was also revived  in the month of  December, 2006  much prior to the date of knowledge of sufferance of deceased  insured from cancer.  When deceased insured himself, was   not  knowing that he is patient of Cancer or that he is suffering  from some diseases, then  it   can not be expected from him  to mention all these things in the proposal form for obtaining a new  policy or in the proposal  form for revival   of the lapsed  insurance policy.”     

Further  it is held and reported in  CPR- 2012(1)  page No. 391 the Hon’ble National Commission where in  observed  “The insurance company must investigate health issues before issuing insurance  policy.”

Again  It is held  and reported  in C.P.R. 2012 (3) page No. 65 where  in the  hon’bleRajstan  State  Commision observed  “That a common man is not supposed to know all the  niceties and technicalities of law.  Once accepting  the premium and having entered into an agreement without  verifying the facts, the Insurance Company can not wriggle out of the  liability merely by saying that the  contract was made by  misrepresentation and concealment. The insurance policies should not be issued and  repudiated  in such a casual mechanical manner. The policy entails  the liability on both sides.  It is rather exploitation of the consumer and more or less fraud on the public. Such practice should be strongly  deprecated.”

Further It is held and reported  in C.P.R 2007(3) page No.93 where in the  hon’ble Chatisgarh  State Commission observed “That the claim repudiated on  the ground that insured suppressed material fact regarding ailments he was suffering would not  constitute  deficiency in service and cause of death would have no relevance to  non-disclosure of  such facts.  The proposal  or revival  form  have been filled  by the Agent of the O.P . The said proposal or revival form  was not filled by the  O.P. though extracted  some passages from it in their  written version.

The  complainant  submitted  during the course of hearing    that  at the time of revival of the L.I.C. policy   the  policy  holder  was  free  from any  physical disease and  was also  mentally sound.

Again It is held and reported  in C.P.R. 2012 (4) page No. 231 wherein the hon’ble  National Commission observed “ That   pre-existing  disease must be proved in documentary evidence. In the present  case the O.P.  should have  produced  some  concrete evidence in support of its  case. The examination of  doctor who checked  the patient, prior to the obtaining  of the policy in question, some treatment papers, some prescriptions etc. should have been produced . There is no evidence  which may  go to show that he had ever consulted  the doctor for taking treatment to the said disease.”

Further this forum perused the case law  in the instant case. It is held and reported in  CPC- 1991, page -540 the  Hon’ble  Hariyana State  Commission held that when ever there is any delay or dilatoriness in finalizing  the insurance claim, the same would be tantamount to a  deficiency  in service and thus comes squarely within the  purview of Consumer Forum.  Once it is held that default or negligence in the  settlement of an insurance claim is a deficiency  in service then an arbitrary  or mischievous  rejection  of an insurance claim  would patently  be a default  within its larger  meaning. On principle , it would   seem  some what manifest that the mere repudiation of the insurance claim cannot itself operate  as a  jurisdiction bar for redressel forums under the Act.  This is further  made it clear and  it is held and reported  in CPR-1991(2), page No.18  the Hon’ble National Commission  clearly defines  the mere unilateral  rejection of an insured parties  claimed by the insurer does not  per  se  operate as jurisdictional bar to seek redressal before  the forums under the Act. It is on the strength of the  above decision  the instant case is admitted by this forum.

In the present  case it is not disputed by the O.P. that the policy of the deceased  covers the risk from  Dt. 23.3.2005 vide their policy  No.570965677. On perusal of the records, this forum found  that there was concluded contract of insurance between   the insurer and the  insured  as on the date which the  insured had  desired  to take the policy i.e. on Dt. 23.3.2005. The O.Ps.  have not  disputed the health condition of the insured  on Dt. 22.2.2013(Date of revival of policy ) which was then satisfactory.  There was, therefore, no question of his having made false  statement.  In this context  there  was, therefore  no suppression of any   material fact by the deceased.  Therefore the dictum of “Suppression veri  suggestionfalsi” can not be said to apply. 

Again   it is held and reported in AIR SC 1991 page No. 392  in the case of  LIC of India Vrs. Srimati  G.M.Channabasamma  where in the Hon’ble  Supreme Court observed  “ That in a case where the complainant proves that there was valid  insurance  and the insured has expired during the  pendency of the   valid   insurance the burden to prove that there was any   mis statement in the proposal  form is upon the insurance company. Not  only the insurance company  has the burden  to prove that the deceased was suffering from ailment but the  O.P. shall have to prove that the deceased knew that he was  suffering from ailment and he had made false statement to the question raised   by the  O.P. in the proposal form. The proposal   and the  date of risk of the  insured in this case has been accepted  by the O.P. from  Dt.23.3.2005 without taking a second look, at  type of replies  furnished, but the  crunch came, the O.P. has sought  to take shelter   behind such reply, using therein that the insured  suppressed material fact   in the proposal form as a handi stick to beat the complainant  out of the benefits under the policy.  The burden lies on the  O.P. to substantiate its allegation when the  claim of the  insured is not settled  on the ground suppressed material information.

In view of the order passed by the Hon’ble National Commission and  Apex Court  this forum  allow this case  in  part.

In view of the above discussion relating to the above case and  In Res-IPSA-Loquiture  as well as  in the light of the settled legal position  discussed  as above referring citations  which is Aliane Juris. Hence  we allow the above complaint petition  in part.

Hence  to  meet the  ends of justice, the following order is passed.                                                                                                              

ORDER.

            In resultant the complaint petition stands  allowed  in  part  on  contest against  the O.P. 

The O.Ps  are ordered  to pay the sum assured  of  LIC policy No. 570965677 together  with accrued bonus      to the complainant.   Parties are left to bear their own cost.

The OPs ordered to make compliance the aforesaid Order within  3(three) months  from the  date of  receipt  of this  order  failing which  an interest  @ Rs.9% per annum  would  accrue on the sum  assured   amount . from  the  date of  repudiation  i.e. on Dt. 15.07.2017  till  realization.

Dictated and corrected by me. Pronounced on this         9 ^th.   Day of    January,   2020.

 

 Member.                                                            Member.                                                             President