DATE OF FILING: 5.12.2012.
DATE OF DISPOSAL: 16.3.2016.
Miss S.L.Pattnaik, President:
Alleging deficiency in service against the Opposite Parties (In short O.Ps)this complaint case was filed by the complainant claiming the insured amount of Rs. 2,00,000/- (Rupees two lakh) only towards the policy alongwith compensation of Rs.50,000/-(Rupees fifty thousand) only towards harassment , mental agony and litigation expenses to the extent of Rs.10,000/-(Rupees ten thousand) only in the interest of natural justice.
2. Brief facts of the case of the complainant was that her deceased husband late Swapneswar Pradhan had obtained an insurance policy bearing No. 572855745 for a sum of Rs.2,00,000/- (Rupees two lakh) only commenced from dated 28.8.2009 for a term of 22 years and date of maturity is 28.8.2031 on payment of premium from the Opposite Party Insurance Company and the complainant was the nominee in the said policy. During the subsistence of the said policy, the insured died on dt.22.9.2010 at Gooty Railway station in heart attack while returning from Prasanti Nilayam to Berhampur alongwith his family in Prasanti Express train. The complainant with much difficulty brought the dead body of her husband from Gooty Railway Station of Andhrapradesh. After obtaining all the necessary papers, the complainant being the nominee lodged a claim against this policy with the Opposite Parties alongwith relevant documents as per the requirement of O.Ps in different times but the said claim was repudiated by the O.P.No.3 on dt.29.10.2011 on the ground that the deceased had made incorrect statement and withheld the material information regarding his health and his previous insurance policy No. 572855039 at the time of effecting this insurance policy. According to the complainant there was no suppression of material fact on the part of the deceased who’s taking the policy as (i) Policy No.572855039 and the policy No. 572855745 has been originated from the one and the same agent of the Opposite Party. (ii) the agent of Opposite Party (iv) policy condition. Hence even repudiation was illegal unlawful and un-constitutional and same amounts to deficiency of service, as even being aggrieved the complainant filed this case claiming the amount under the policy and compensation etc. In token of evidence, the complainant filed the following documents.
(i) Xerox copy of first premium receipt No. 2565330.
(ii) Xerox copy of premium receipt No.0812881.
(iii) Xerox copy of Renewal receipt No. 0961761
(iv) Xerox copy of death certificate.
(v) Xerox copy of Legal Heir Certificate.
(vi) Xerox copy of final report of Railway police station, Gooty.
(vii) Xerox copy of LIC L.No. 58P dated 3.12.2010.
(viii) Xerox copy of LIC L.No. 58 P dated 28.12.2010.
(ix) Xerox copy of LIC L.No. 58P dt.5.1.2011.
(x) Xerox copy of LIC L.No.58P dated 14.3.2011.
(xi) Xerox copy of LIC L.No. 58P dated. 26.3.2011. (3 Nos)
(xii) Xerox copy of letter dt.8.9.2011 of LIC of India.
(xiii)Xerox copy of letter dated 29.10.2011 of LIC of India.
(xiv) Xerox copy of LIC OF INDIA why is a life insurance claim repudiated?.
(xv) Xerox copy of suryamani pradahn addressed to Zonal Manager, LIC of India,East Cental zonal office dt.28.11.2011.
(xvi) Xerox copy of Suryamani Pradhan letter dt.14.2.12 addressed to the Zonal Manager, LIC of India, East Central Zonal Office.
(xvii) Xerox copy of letter No. 58 P dt.17.3.2012 of LIC of India.
(xviii) Xerox copy of letter of Suryamani pradhan to the Chairman, LIC of India, CO Claims Review Committee, Central office, Yogakshema.
3. Upon notices being served, the O.Ps have appeared through their learned counsel and the written version was submitted by Opposite Parties while admitting the policy, deposit of premium and death of the insured, during the validity period the O.Ps rebutting other allegations made in the complaint on the grounds that the Deceased Life Assured (DLA) had taken two policies vide No. 572855039 dated 24.12.2009 and No.572855745 dated 31.12.2009. The DLA did not mention the previous proposal number in the proposal form submitted on 31.12.2009. He had not disclosed the same the SUC would have been called for and the policy would have been underwritten at Divisional under writing section. The under writing decision of the Opposite parties would have been affected, if the second proposal would have been allowed on modified terms on declined. Since the D.L.A. with deliberate intention had suppressed the above fact, while giving reply to question No.9 in the proposal form. Hence the policy No. 572855039 is admitted for BSA + Bonus less dues favoring to the nominee and the policy No. 572855745 is repudiated for previous insurance.
4. Further the O.Ps submitted that the complainant had made an application to the Zonal Manager, LIC of India, Berhampur and after proper enquiry of the facts, the Zonal Manager rightly upheld the repudiation which has been communicated to the complainant on 17.3.2012. The complainant has not submitted the Legal heir certificates, police reports, affidavit, F.I.R, P.I.R., P.M.R., P.F.R. and English version of the report etc. and the reports from the different hospitals the Super specialist Hospital at Puttaparthy, MKCG Medical colleges Hospital, Berhampur before the concerned Branch while submitting the claim form for settlement of the policy amount in her favour.
5. Further the O.P. submitted that the averments made in the complaint petition of the complainant are baseless, wrong and is emphatically denied. The complainant is not entitled for any relief whatsoever and is not entitled to claim and recover anything from the Opposite Party No.1. In the light of what is stated above. The complaint petition is not maintainable and is beyond the jurisdiction of this Hon’ble Forum and is liable to be dismissed summarily. Hence prayed that such case against the complainant need to be dismissed as the complainant is not entitled to get any relief as sought for.
The O.P. furnished the following documents in support of his case.
(a) Xerox copy of policy No. 572855745 dt. 28.8.2009.
(b)Xerox copy of policy No. 572855039 dt.28.11.2009.
In support of their case, the O.Ps also filed the decision of Hon’ble National Commission, New Delhi in Revision petition No. 382 and 383/2011 which is attached in the case record.
6. We heard the argument from both sides at length, gone through the whole record and documents. From the pleadings of the parties, the following issues arise for considerations are:-
(i)Whether the Life Insurance Corporation was justified in repudiating the claim of the complainant on the basis of suppression of material facts?
(ii) Whether there is any deficiency in service on the part of the Opposite parties? If so, whether they are liable to pay the insurance amount and the compensation as prayed for?
(iii) To what relief the complainant is entitled?
7. ISSUE NOS. (i), (ii) and (iii):- There is no dispute regarding to the policy taken by the deceased husband of the complainant and also there is caused during the valid period of insurance policy. So admitted fact need not be proved. But the only dispute is that the O.Ps repudiated the insurance claim vide letter dated 29.10.2011on the ground that the deceased had made incorrect statement and withheld medical information regarding his health and also withheld the information relating to the question No. 9 of the proposed form about the existence of another previous policy No. 572855039 for sum assured of Rs.2,00,000/- under plan term 14-21.
8. Generally before issuing a policy to a insured, the LIC authorized doctors medically examined a insured and if affirmed that the answer to all the question of the proposal form are correct, then the LIC would issue policy in favour of the policy holder. On perusal of the proposal form, we found that in the instant case the authorized doctor of the LIC had examined the assured before she was given the insurance policy and the doctor has given the certificate and also the doctor did not notice anything wrong with the assured. If the deceased was suffering from any pre-existing disease, certainly the doctor of the LIC who have examined the assured before taking the insurance policy would have noticed that the assured is suffering from any disease. Even if the proposer was suffering from any disease, the doctor of the LIC who had examined her before issuance of policy would have certainly found it out. So here onus to prove that the policy holder was suffering from a pre-existing disease as per settled law is on the opposite parties. In the instant case the O.P. had not produced any credible documentary evidence/ expert medical opinion in support of its case.
9. We perused the policy bond and found that the policy was issued with the risk commencing from 28.8.2009 and the life assured died on 22.9.2010. The allegation of O.Ps that the life assured had suppressed the material information regarding his health at the time of purchase of policy is not sustainable, because the O.P. failed to produce the previous medical records to substantiate their allegation. A layman how could know about the origin of a disease. So it is difficult to hold that life assured knew about his sufferings and he suppressed that fact at the time of purchase of policy. On this point we rely on the decision of Hon’ble State Commission, Odisha, Cuttack reported in 2013(1) OLR (CSR) 773 in the case of Senior Divisional Manager, New India Assurance Company ltd. Bhubaneswar versus Naba Kishore Patra and another where Hon’ble State Commission has held that, “even if the insured was suffering from Rheumatic heart disease, it can not be presumed that she was aware of such disease by the time of filing in the proposal form in absence of any positive evidence to that effect. “
10. Further learned counsel for the O.Ps submits that since the contract of insurance is based on the principle of utmost good faith, it is the responsibility of the policy holder to disclose all information regarding her health and habits on this point, We rely on the decision reported in AIR 2000 SC 1014 in M/s Modern Insultors ltd. Versus Oriental Insurance Company, where Hon’ble court held that, “it is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non disclosure of the facts which the parties knew. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agent to disclose all material facts in their knowledge since obligation of good faith applies to both equally.
11. So the contention that the insurance company rightly repudiated the claim of complainant as the deceased had suppressed the material facts regarding his health condition as well as non-disclosure of previous policy is not sustainable. So the decision filed by O.Ps does not hold good relating to the instant case.
12. Admittedly, the deceased had paid premium in the said policy and as such as per the terms of the policy, the O.Ps are bound to pay the insured amount refused to make payment amounts to deficiency in service. The O.Ps are also liable to pay the compensation for causing mental agony and harassment to the complainant.
In the result, we allow the case of the complainant and direct the Opposite Parties who are jointly and severally liable to pay assured amount of Rs.2,00,000/- (Rupees Two lakhs)only to the complainant/nominee in respect of the policy bearing No. 572855745 with interest @6% (six percent) per annum from the date of filing of the case i.e. on 5.12.2012 till its actual payment. The Opposite Parties is also directed to pay a sum of Rs.2000/- (Rupees two thousand) only towards cost of litigation to the complainant. The above amount has to be paid by the Opposite Parties within 60 days from the date of receipt of this order failing which the entire amount shall carry interest at the rate of 9% (nine percent) per annum till the date of actual realization of the amount. The case is disposed of accordingly.
Order is pronounced in the open Forum today on 16th March 2016.
Copies of the order be supplied to the parties free of cost.
