1.                     The brief history of the case of the complainants are that their father Sri Kailash Chandra Sahoo was an employee under OHPC and during his service period, he had obtained Policy No.574072492 and 574072493 under Salary Saving Scheme along with 4 other policies and the subject policies were commenced from 11.4.2014 with monthly premium of Rs.525/- each for basic sum assured of Rs.1.00 lac and accidental benefit of sum assured Rs.1.00 lac under which the present complainants were declared as nominee.  It is submitted that the LA died on 29.12.2014 with a brief illness while he was on duty and the Ops settled claims under other policies but did not settle the claims under above two policies in spite of several approaches.  During last approach in the month of March, 2016, the OP.1 orally stated that the LA had undergone an operation prior to taking the subject policies and hence the claim is getting late for settlement but on contact to OP.2 it stated that the OP.1 is not forwarding the claims.  Thus alleging deficiency in service on the part of the Ops, the complainants filed the above cases praying the Forum to direct the Ops to pay the basic sum assured of Rs.1.00 lac and accident benefit for a sum assured of Rs.1.00 lac with vested bonus besides interest @ 18% p.a. from the date of death and to pay Rs.50, 000/- each towards compensation and costs to the complainants.

2.                     The Ops filed counter in joint for both the cases denying the allegations of the complainant with same and similar reply but admitted that the Policy No.574072492 and 574072493 were issued to late Kailash Ch. Sahoo with DOC 11.4.2014 and a sum assured of Rs.1.00 lac each with monthly premium of Rs.525/- and the complainants were nominees under the said policies.  It is contended that the death claims against other 4 policies have been settled under non early claim and as the present policies have come under early claim, the Ops made enquiries and found that the DLA has suppressed material facts regarding his past illness while answering question No.11 in the proposal form.  The Ops further contended that the DLA had undergone operation for Anterior Cervical Disc Fixation at Ayus Hospital, Bhubaneswar on 24.4.2013 and continued up to 06.05.2013 but he has answered “No” to all personal history.  Further the DLA was suffering from Diabetics and Hypertension prior to the DOC as per available report.   It is also further contended that due to violation of contract, the Ops have repudiated the claim on 12.9.2016.  Thus denying any deficiency in service on their part, the Ops prayed to dismiss the case of the complainants.

3.                     Both the parties have filed certain documents in support of their cases.  The complainants filed written arguments.  Heard from the Ops through their A/Rs and perused the materials available on record.

4.                     In the above cases, the insurance policies vide No.574072492 & 574072493 granted by the Ops with DOC 11.4.2014 with monthly premium of Rs.525/- each under SSS in favour of Kailash Ch. Sahoo and nominations of both the complainants respectively under the policies are all admitted facts.  It is not a disputed fact that the LA died while he was on duty in his office on 29.12.2014.  As ascertained the LA felt chest pain and within an hour or two, he succumbed to death without any treatment.  The prescription of local doctor dt.29.12.2014 also indicates that the LA died of heart attack and chest pain.  The complainants stated that their father had other 4 policies with the Ops and they submitted claim forms along with original policy bonds and necessary papers for settlement of claims including the present policies and the Ops have settled the death claim in respect of 4 policies but did not settle the claims under the present policies in spite of requests.

5.                     The Ops in their counter stated that the claim under the disputed policies come under early death claim category as the death of LA occurs within 3 years of DOC of the policies.  After receipt of claim forms and documents they conducted enquiry to know the bonafides of the claims and found that the DLA had suppressed material facts regarding his past illness while answering Question No.11 in the proposal form.  The Ops stated that the DLA had undergone operation for Anterior Cervical disc fixation at Ayush Hospital, Bhubaneswar on 24.4.13 and continued till 06.05.2013 but he has answered “No” to all personal history in the proposal form.  It is also further stated that the patient was suffering from diabetics and hypertension prior to DOC as per available report.

6.                     In this case the policies were commenced from 11.4.2014 and the LA died on 29.12.2014 due to heart attack at his work place as reported by Medical Officer, Project Dispensary, Bariniput vide Ticket No.4068 dt.29.12.2014.  There is no dispute regarding the fact that the complainants became late in filing claim forms.  As per averments of the complainants, the Ops did not take any interest to settle the claim for which these cases have been filed on 01.6.2016.  It is seen that after receipt of notice from this Forum, the Ops woke up and repudiated the claims on the life of K. C. Sahoo on 12.9.2016 i.e. after 3 months from the date of filing of these cases.  The Ops have no where stated that they have sent the copy of their repudiation letter to the complainants.  In the above circumstances, we do not understand as to why the Ops did not enquire into the bonafides of the claims within a reasonable period.  No explanation has been advanced by the Ops to that effect.  It is seen that after 20 months of death of LA the Ops repudiated the claims that to after filing of present disputes before this Forum.  Such inordinate delay of 20 months for repudiation by Ops without serving its copy on the complainants in our opinion is bad in law and amounts deficiency in service.

7.                     The prescription slip filed by the Ops show that the LA was suffering from diabetics and hypertension but the said report is not clear about the quantum of diabetics and hypertension suffered by the LA.  As per expert opinion, diabetics and high blood pressure are not serious diseases and they are part of ordinary stress and strain.

8.                     The Ops stated that the DLA had undergone operation for Anterior Cervical disc fixation at Ayush Hospital, Bhubaneswar on 24.4.2013 and continued up to 06.05.2013 but he answered ”No” to all personal history in the proposal form.  On perusal of said prescription it was ascertained that the DLA was suffering from Waist pain and had undergone operation prior to one year of the commencement of the policies.  The LA was also performing its duties in his office and has never consulted the doctor after such operation.  Hence he was fit and fine and ready to work after operation.   As he was fit and regularly attending his duties, the LA did not feel that he suppressed the fact of such past illness at the time of proposal.

9.                     The law has laid down certain parameters for cancellation of insurance policy in a case covered U/s.45 of Insurance Act.  The important parameter is that whether the suppression or concealment was fraudulently made by the policy holder and he was aware at the time of making the statement that it was false or if suppressed fact which it was material to disclose.  Section-45 of Insurance Act is applicable only in case of deliberate concealment of facts/frauds by the policy holder.  In this case, the LA had undergone operation one year before the taking of policy and the LA died of Acute Myocardial infarction.  Heart failure has no nexus with diabetics and hypertension also.

10.                   The Ops have relied the decision of Hon’ble National Commission in case of LIC of India Vrs. Ramamoni Patra and another reported in CJ 122 (2016).  With due respect to the said verdict, we are of the view that the above referred case is not squarely applicable to the present cases in hand and the subject matter and circumstances of the above case is totally different from the present cases.  In the above referred case the LA had taken the policy on 09.7.1994 and admitted to hospital on 12.7.1994 for Infective Hepatitis.

11.                   In view of above facts and circumstances, it was ascertained that the repudiation of claim is not legally warranted in the present cases and such repudiation of claims by Ops after 20 months of death and that to after filing of present cases is without application of mind and amounts to deficiency in service.  Hence the complainants are entitled for death benefit of their father as nominees under the policies.  In the cases, the sum assured is Rs.1, 00,000/- under each policy with accident benefit of sum assured of Rs.1, 00,000/-.  Due to non settlement of claims, the complainants suffered and as such entitled for interest @ 9% p.a. from the date of filing of this case on the amount so settled.  We are not inclined to grant any compensation in favour of the complainants except Rs.2000/- in each case.

12.                   Hence ordered that the complaint petition is allowed in part and the Ops being jointly and severally liable are directed to settle the death claims under each policy at Rs.1, 00,000/- along with accident benefits besides bonus etc. with interest @ 9% p.a.on such settled amounts from the date of filing of these cases (01.06.2016) and to pay Rs.2000/- each towards costs in favour of the complainants within 30 days from the date of communication of this order.

(to dict.)