SRI JIBAN KRUSHNA BEHERA, MEMBER (I/C)
The Complainant has filed this complaint petition, U/s-35 of C.P.Act-2019, (here-in- after called as the “Act”) alleging deficiency in services by the Ops, where Ops are the authorities of Shriram Life Insurance Company Limited located in different places.
2. The case of the complainant, in a nutshell, is that she is the wife of deceased life assured Kanduru Charan Sethi who purchased two insurance policies bearing No.NN011909253765 and NN011909253339 each for sum assured of Rs.2,30,000/- covering 10 years under the Ops wherein the complainant was the nominee. The life assured Kanduru Charan Sethi had deposited Rs.24,782/- as annual premium on 28.9.2019. Unfortunately, the life assured died at the age of 45 years on 11.11.2019 due to cardiac arrest. After the death of her deceased husband, the complainant claimed the death benefits before the OP No.1 and submitted all relevant documents. The Ops have received the documents, but they intentionally did not settle her claim. The complainant had also requested the Ops several times for settlement of the death claim of her deceased husband, but they turned a deaf ear to it. Finding no other way out, the complainant sent legal notice against the Ops for settlement of her claim, still then the Ops are silent over the matter leaving the complainant to suffer harassment and mental agony. The above acts of the Ops clearly shows their deficiency in service in the settlement of the matter. Hence, the complainant was constrained to file the present with the reliefs stated in her complaint.
To substantiate her case, the complainant relied upon the following documents, which are placed in the record-
- Photocopy of premium receipts.
- Photocopy of death certificate of life assured.
- Photocopy of claim form A, B & C.
- Photocopy of certificate issued by local Sarpanch.
- Photocopy of legal notice.
- Photocopy of reply letter.
- Photocopy of Aadhar Card.
- Photocopy of PAN card.
- Photocopy of Bank Pass Book.
3. In the present case, on receipt of notice, the Ops were made their appearance and filed a joint written version, but the same was not accepted as the Ops have filed their written version beyond the statutory period. But during the course of hearing of this case, the learned counsel for the Ops relied upon the following documents which are placed in the case record.
- Photocopy of Policy Schedule.
- Photocopy of Proposal Form.
- Photocopy of death certificate of life assured.
- Photocopy of Claim form-B.
- Photocopy of claim investigation report.
- Photocopy of repudiation letter dated 21.5.2021.
4. In view of the above averments of both the parties, the points for determination in this case are as follows:-
- Whether the complainant is a consumer as per C.P Act, 2019?
- Whether there is any cause of action to file this case?
- Whether the present case is maintainable?
- Whether there is any deficiency of service on the part of the Ops towards the complainant?
- To what other relief(s), the complainant is entitled to?
F I N D I N G S
5. So far as the issue as to whether the complainant is a consumer or not is concerned, first of all, it is to be seen how far the complainant has proved herself to be a consumer under the Ops. On perusal of documents submitted on behalf of both the parties, it is clearly made out that the deceased husband of the complainant had purchased the Shriram Life Insurance policies from the Ops for a sum assured of Rs.2,30,000.00 bearing Policy Nos. .NN011909253765 and NN011909253339 by paying first premium amount of Rs.24,782/-. It is also made out that the complainant, being the wife of deceased life assured, stood as the nominee in both the policies. Her life assured husband died due to cardiac arrest, as stated by the complainant. So, being the nominee, the complainant made her application before the Ops claiming death benefit of her deceased life assured husband which was turned down for which she filed the present case. From the above discussion, it is held that the complainant is a consumer, as required under the Act.
6. As regards the cause of action, it is alleged by the complainant that the denial for settlement of her claim and repudiation of the claim due to sad demise of her deceased life assured husband violating her legitimate right gave rise to a cause of action to file case against the Ops. On the other hand, learned counsel for the Ops submitted that it is the learned Commission who has ample jurisdiction to decide with regard to the cause of action. From the above submissions and on perusal of the documents, this Commission is of the considered opinion that the complainant has cause of action to file the present case.
7. In order to arrive at a definite conclusion, it is required to be decided as to whether the case is maintainable and whether there is any deficiency of service on the part of the Ops towards the complainant. It is argued on behalf of the complainant that the complainant is the wife of deceased life assured Kanduru Charan Sethi who purchased two insurance policies bearing No.NN011909253765 and NN011909253339 each for sum assured of Rs.2,30,000/- under the Ops and the complainant was the nominee in both the policies. It is further argued that the life assured Kanduru Charan Sethi deposited Rs.24,782/- as annual premium on 28.9.2019, but unfortunately, he died on 11.11.2019 due to cardiac arrest and after the death of her deceased life assured husband, she claimed the death benefits before the OP No.1 and submitted all relevant documents which were received by the Ops, but intentionally did not settle her claim. It is also argued that the complainant requested the Ops time and again for settlement of the death claim of her deceased husband, but they turned a deaf ear, for which she served legal notice against the Ops for the purpose, but the Ops remained silent over the matter leaving the complainant to suffer harassment and mental agony. Thus a case of deficiency in service is clearly attributed against the Ops.
8. On the other hand, it is submitted on behalf of the Ops that the life assured submitted the proposal form after being satisfied with the terms and conditions mentioned therein so also the information supplied therein are also verified by the life assured stating to be true and correct. It is further submitted that life assured died on 11.11.2019 i.e. after one month and 14 days from the date of commencement of the policies dated 28.9.2019. On receipt of the death intimation of the life assured, Ops have entrusted the investigator to ascertain the veracity of the claim advanced by the nominee and after completion of investigation, Investigator submitted his report which itself reflected that the life assured was suffering from Carcinoma Colon with Liver Metastasis which means cancer spread to liver and was under regular treatment. Further, in the claim forms submitted by the nominee/complainant accompanied with Form-B, a document submitted by doctor Susantha Maharana, who has lastly treated the deceased life assured before his death, the concerned doctor has opined that the exact cause of death of the life assured was due to Carcinoma Colon with Liver Metastasis which was previously diagnosed and was undergoing treatment at AIIMS, Bhubaneswar and Chemotherapy Unit at DHH, Balasore and the deceased life assured has been suffering from this disease for about six months before his death. But the deceased life assured has not supplied the above information which required to be supplied at the time of submission of proposal form in appropriate column, thereby the deceased life assured has suppressed the material facts while purchased the life insurance policies and does not come to this Commission in clean hand. Considering the above factors, the Ops have repudiated the claim of the complainant. Further, the policy bond is an agreement between the life assured and the insurance company and it was executed in good faith, but the life assured, as in the present case, has violated the terms and conditions of the policy bond by suppressing the material facts intentionally. Therefore, in the present case, deficiency in service on the part of the Ops, as alleged by the complainant, does not arise at all.
9. On a meticulous scrutiny of the case of the parties and on perusal of the documents produced on behalf of both the parties as well as on hearing from both the sides, it is found that the complainant has filed this case claiming that the Ops have not settled the death claim of her deceased life assured husband, who had purchased two insurance policies bearing No.NN011909253765 and NN011909253339 from the Ops. But interestingly, the complainant has not filed either the photocopy or the original policy bonds in respect of the aforesaid insurance policies, which are very crucial to decide the fate of this case. On the other hand, it is the case of the Ops that the deceased life assured was suffering from Carcinoma Colon with Liver Metastasis that means cancer spread to liver. Further, in the claim forms submitted by the nominee/complainant accompanied with Form-B, a document submitted by doctor Susantha Maharana, who has lastly treated the deceased life assured before his death, the concerned doctor has opined that the exact cause of death of the life assured was due to Carcinoma Colon with Liver Metastasis which was previously diagnosed and was undergoing treatment at AIIMS, Bhubaneswar and Chemotherapy Unit at DHH, Balasore and the deceased life assured has been suffering from this disease for about six months before his death. The deceased life assured has not supplied the above information, which required to be supplied, at the time of submission of proposal form in appropriate column. The deceased life assured has suppressed the material facts while purchasing the life insurance policies. Thus, the complainant has not come to this Commission in clean hand. Considering the above factors, the Ops have repudiated the claim of the complainant. Further, the policy bond is an agreement between the life assured and the insurance company and it was executed in good faith, but the life assured, as in the present case, has violated the terms and conditions of the policy bond by suppressing the material facts intentionally. In this connection, on perusal of Annexure- B, the proposal forms, it is found that the deceased life assured has not supplied the correct and true information, as required under Serial No.14(k). From the above, it is presumed that the deceased life assured was quite healthy and was not suffered from any kind of diseases. In case it is held to be true, but on perusal of Annexure-D, the Claim Form–B, Medical Attendant’s Certificate issued by Dr. Susanta Maharana, Consultant Medicine (J.D.), DHH, Balasore, it is seen that the cause of death of the deceased life assured is mentioned due to Carcinoma Colon with Liver Metastasis. It was not ascertained after the death of the deceased life assured, rather, it was previously diagnosed and undergoing treatment at AIIMS, Bhubaneswar and Chemotherapy Unit at DHH, Balasore and surprisingly the deceased life assured has been suffering from this disease since about six months. That apart, the deceased life assured had purchased the insurance policies in question on 28.9.2019 and he died on 11.11.2019 i.e. after 44 days of purchasing of the policy bonds.
10. From the above discussions, it is held that the complainant did not disclose the pre-existing disease or ailments intentionally prior to inception of the policies in question at the time of proposal. The deceased life assured had supplied wrong and false information in proposal Form knowing very well that these were false and incorrect. Thus, the deceased life assured has intentionally and fraudulently concealed the true state of affairs regarding his health at the time of proposal for insurance on 28.9.2019. It is, therefore, held that the ailments from which the deceased life assured was suffering is prior to the date of proposal for which the Ops did not accept the risk on his health. Had the life assured disclosed the true facts and information at the time of proposal for insurance, the risk under the policy in question would not have been accepted by the Ops and the policies in question would not have been issued to him or would have been issued on different terms and conditions. In all the contract of insurance, the proposer is bound to make full disclosure of all the material facts and nor merely those, which he thinks material, misrepresentation, non-disclosure or fraud in any document leading to acceptance of the risk automatically discharges the insurer from all liabilities under the contract. Hence, it is observed that the contract of insurance is null and void.
11. From the above discussions, it is held that there is no deficiency of service on the part of the Ops in repudiating the claim of the complainant and the complaint of the complainant is not maintainable. Therefore, the complainant is not entitled to any other reliefs what-so-ever, as sought for.
Hence, it is ordered: –
O R D E R
The complaint of the complainant be and the same is dismissed on contest against the Ops. In the facts and circumstances, no order as to cost.
Pronounced in the open court of this Commission, this the 29th day of April, 2024 under signature & seal of the commission.
