SRI ASISH DEB , PRESIDENT

The short fact of the complaint case is that the complainant is the brother and nominee of the deceased Samsu Khatun. Samsu Khatun purchased a  Life Insurance Policy vide No. 459944447 from the OP, Tamluk Branch for the period from 20.05.2015 to 20.05.2035.  Said insured Samsu Khatun died on 26.07.2017 at Vivekananda Nursing Home, Mechogram, Ghatal Road, Purba Medinipur. The basic sum assured in the policy was Rs. 1,00,000/-. After demise of his sister the complainant had been to the office of the OP no. 1 and 2 to settle the claim but the Ops did not settle the claim.  The cause of action of this case arose on ands from 24.10.20187 when the Ops refused to settle the claim.

In the aforesaid circumstances, the complainant has been compelled to file this complaint case before this Ld. Forum praying for the reliefs as made in the complaint petition.

The complainant has filed all the relevant documents in support of her claim.

The OPs 1 and 2 have contested this case by filing a joint written version and denied all the material allegation of the complaint and prayed for dismissal of the claim application.

The specific deference of the Ops is that the insured took the policy on 20.05.2015. The insured died on 26.02.2017 due to Cardio Respiratory Failure ( CRF) in a case of gangrene in right  leg. During investigation of the death case of the insured,  it was found  from the Claim Form-B issued by Dr. Amit Kar, (Regd No. 60539) that the death was due to gangrene of right leg with type-2 DM and duration of illness is more than 12 months. As it is the early stages of investigation and the Ops have to come to the conclusion as to whether there was any suppression of fact of illness of the life assured, the Ops called for all the relevant papers from the complainant.  In reply the complainant only submitted some medical reports issued from various diagnostic centers.  The Ops called for the discharge summary on 22.12.2017 to ascertain the cause of death but till date  there is no response from the complainant/nominee. Under such circumstances, the Ops have prayed for dismissal of the complaint.

The points need be considered here is (1) whether the complaint case is maintainable and (2) whether the complainant is entitled to get the relief as prayed for.

 DECISION WITH REASONS.

All the points are taken up together for discussion for the sake of convenience and brevity.

Perused the complaint and the documents filed by the complainant in support of hhis case. Seen the questionnaires and reply thereto filed in record, the documents and heard the submission of the ld. Advocates for the parties. Considered.

The complainant has filed all the insurance documents.

Ld. advocate for the complainant has submitted that the proposer/life assured had no pre-existing disease before the date of the proposal/commencement of the risk/policy.  So, the complainant is entitled to get the reliefs as prayed for. On the other hand, the ld advocate for the Ops has vehemently resisted the said submission of the Ld. Advocate for the complainant and added that the life assured had suppressed some material facts at the time of taking the policy.  The policy holder died due to CRF in case of gangrene or right leg with type-II diabetes mellitus (DM)  and duration of illness was more than 12 months which will be revealed from the papers submitted by the Opposite Parties. As such the complaint is liable to be dismissed.

Having regards had to the facts and circumstances and keeping in view of the contentions raised by the parties, it appears from annexure A, the life insurance certificate the nominee of life assured Samsu Khatun is Samidul Khan. There is no disputes about it. Indisputably the OPs issued the policy certificate in favour of the life assured on 20.05.2015. The only dispute raised by the OPs is that the life assured had suppressed the material facts. In law, it is the onus of the Opposite Party to prove his/ their defence.  In the instant case the OPs have failed to prove by adducing any documentary evidence that the life assured/ proposer had been suffering from any disease as alleged at the time of commencement of the policy. I do not find any evidence on record to establish that the life assured had any disease on the date of commencement of the policy/ risk that is on 20.05.2015.

The Ops have failed to discharge their onus to establish their defense as alleged. Moreover, it is the norms on the part of the Insurer that before granting the policy certificate there would be a vigorous health check up of the proposer. Here, in this case the OPs did not conduct such health check up of the proposer or it would be presumed that they did it; due to lapse on the part of the OPs, if any in this respect no liability can be imposed upon the life assured.

In such circumstances the Insurer has fallen under the mischief of deficiency of service on their part to settle the claim in favour of the nominee/ claimant in due time.

Therefore, the complainant is entitled to get the reliefs within the meaning of provisions of the Consumer Protection Act, 1986.

Both the points are accordingly disposed of in favour of the complainant.

Hence, it is

O R D E R E D

That CC/ 202 of 2018 be and the same is allowed on contest against both the OPs i,e, the Life Insurance Corporation of India.

The Opposite Parties are directed to pay Rs. 100000/- + simple interest @ 9 % per annum to the complainant from the date of knowledge of death of the Life assured i,e, 26.07.2017 till full realization, Rs. 5000/- towards compensation or damage and Rs. 1000/- as cost of litigation within one month from the date of this order, in default the complainant will be at liberty to execute this order through the Provisions of law.

Let copy of this judgment be supplied to the parties free of cost.