SRI JIBAN KRUSHNA BEHERA, MEMBER (I/C)
The Complainant has filed this complaint petition, U/s-35 of C.P.A.-2019, (here-in- after called as the “Act”) alleging a “deficiency-in-service” against the Opp. Parties, who are the Postal Authorities located at different places.
2. The factual matrix of this case is that the deceased wife of the complainant namely Sasmita Panda had purchased one policy i.e. RPLI on 4.3.2019 vide policy No.0000002931202 for a sum assured of Rs.2,00,000/- from the Ops in which the complainant was the nominee. The deceased paid the first annual premium of Rs.16,630/- on the same day and obtained policy bond on 29.3.2019. The deceased died on 18.5.2020 at about 9.30 AM in FM MCH, Balasore while underwent treatment there and post mortem was conducted there. But, the post mortem report reveals that the deceased was died due to cardiac arrest. Thereafter, the complainant applied for the death claim before OP No.2, but the same was rejected. On being aggrieved, the complainant appealed before OP No.1 on 7.6.2021, but the same was also rejected. Thus, the complainant sent legal notice against the Ops on 29.4.2022 and as the Ops did not take any action, the complainant was constrained to file the present case with the reliefs, as sought for in the complaint petition.
To substantiate his case, the complainant has relied on the following documents, which are placed in the record, as mentioned hereunder-
- Photocopy of Policy bond.
- Photocopy of letter dated 29.3.2019 for acceptance of premium.
- Photocopy of OPD prescription.
- Photocopy of medico legal FIR.
- Photocopy of Police information for medico legal death.
- Photocopy of death certificate of the deceased wife of the complainant.
- Photocopy of Aadhaar card of the deceased.
- Photocopy of letter dated 13.4.2021 declining of claim request.
- Photocopy of letter dated 7.6.21 sent to OP No.1.
- Photocopy of reply of OP No.1 dated 27.7.21 to complainant.
- Photocopy of legal notice dated 29.4.2022 & track consignment.
3. In the present case, Ops were made their appearance and filed their joint written version. In their written version, the Ops have not only challenged the cause of action to file the present case but also emphatically stated that the case is not maintainable. They have denied the allegations made in the complaint petition. The Ops have stated, inter alia, that after the death of his deceased wife, the complainant submitted claim form along with relevant documents mentioning the cause of death of his wife as cardiac arrest, but he did not provide any information with regard to prior disease of his wife. The wife of the complainant died within three years from the commencement of the policy. On verification of the medical records and on collection of evidence, the Ops came to know that the deceased assured was suffering from asthma since last five years. The deceased assured has sufficient knowledge that she was suffering from asthma at the time of giving proposal for purchase of policy and at that time she had intentionally concealed and suppressed the said fact of suffering from asthma and she had obtained the insurance policy with a false declaration with regard to her health. Therefore, after thorough verification, the Ops have constrained to repudiate the claim of the complainant. Thus, the Ops have not committed deficiency in service, as alleged by the complainant. In the above premises, Ops have prayed to dismiss the case with cost.
To substantiate their case, the Ops have relied on the following documents, which are placed in the record, as mentioned hereunder-
- Photocopy of proposal form.
- Photocopy of final report of a case of unnatural or sudden death.
- Photocopy of statement of the complainant.
- Photocopy of statement of Satyasadhan Chakraborty.
- Photocopy of statement of Lalit Kumar Panda.
- Photocopy of letter dated 13.4.2021 for repudiation of claim.
- Photocopy of letter dated 27.7.2021 of OP No.1 sent to complainant.
4. In view of the above averments of parties, the points for determination in this case are as follows:-
(i) Whether the complainant is a consumer or not?
(ii) Whether the complainant has cause of action to file this case?
(iii) Whether this consumer case is maintainable?
(iv) Whether there is any deficiency in service on the part of the OPs?
(v) Whether the complainant is entitled to get the relief, as sought for?
(vi) To what other relief(s), the Complainant is entitled to?
F I N D I N G S
5. First of all it is to be determined as to whether the complainant is a consumer or not. From the averments made in the pleadings of both the parties so also from the documents produced by the parties, it is clear that the complainant is the nominee of his deceased assured wife, who purchased the policy bond from the Ops. The deceased wife of the complainant died on 18.5.2020, as reflected vide Annexure-5 & 6. From the above, it is clear that the complainant is covered under the definition of a consumer as defined under the provisions of the Consumer Protection Act, 2019.
6. Before delve into the merits of the case, it is required to be decided how far the complainant is able to prove his case with regard to the cause of action and maintainability of the case.
Learned counsel for the complainant urged that deceased wife of the complainant namely Sasmita Panda had purchased one policy i.e. RPLI on 4.3.2019 vide policy No.0000002931202 for a sum assured of Rs.2,00,000/- from the Ops in which the complainant was the nominee. On depositing of the first annual premium of Rs.16,630/-, the deceased obtained policy bond on 29.3.2019 from the Ops. It is further submitted that the deceased died on 18.5.2020 while undergoing treatment in FM MCH, Balasore. Post mortem report reveals that the deceased was died due to cardiac arrest. So, the complainant submitted claim form along with all relevant documents before OP No.2, but the same was rejected. Thereafter, the complainant made an appeal before OP No.1 on 7.6.2021, but the same was also rejected. The complainant, being the nominee, is entitled to get the insured amount, death benefit with interest. But the Ops have denied to disburse the claim of the complainant for which he suffered harassment, unnecessary expenditure and mental agony. The above acts of the Ops clearly established that they are guilty for deficiency in service.
7. On the other hand, learned counsel for the Ops submitted that on receipt of claim form along with other relevant documents, it came to know that the deceased died on 18.5.2020, one year after purchasing of the policy in question. On verification of the medical records as well as the police papers and on proper investigation, the Ops came to know that the life assured was suffering from asthma since long and always feeling difficult to do any work and her respiratory system is not functioning properly and the same was a known case of asthma prior to proposal of insurance. It is further submitted that the life assured has sufficient knowledge that she was suffering from asthma at the time of giving proposal for purchase of policy bond and at that time she had intentionally concealed and suppressed the said fact of suffering from asthma and she had obtained the insurance policy with a false declaration with regard to her health. Therefore, after thorough verification, the Ops have constrained to repudiate the claim of the complainant. Thus, the Ops have not committed deficiency in service, as alleged by the complainant.
8. From the above rival submissions, it is found that the deceased wife of the complainant had purchased Insurance policy from the Ops on 4.3.2019 and admittedly she died on 18.5.2020. It is alleged by the Ops that the life assured was suffering from asthma since long and that the life assured has sufficient knowledge that she was suffering from asthma at the time of giving proposal for purchase of policy bond and at that time she had intentionally concealed and suppressed the said fact of suffering from asthma and she had obtained the insurance policy with a false declaration with regard to her health. In this connection, it is to be decided as to whether the information mentioned in Annexure-A is true or not. On a bare scrutiny of Annexure-A, it is found that the information supplied and written therein is not the handwriting of life assured, rather, it has been filled up by one Susanta Malik, BPM of Pandasuni, agent Code No.D600520381. It is also seen from the said proposal form that the life assured had only signed in the place where it is required. Similarly, in Serial No.11 of said proposal form, the information supplied are also filled up by said Susanta Malik and not the life assured herself. In total, Annexure-A seems to have been prepared by the agent of Ops. The Ops have not assigned any endorsement that it has been prepared to their best knowledge. It is the prevailing practice that one cannot directly purchased an insurance bond, rather, through an agent. The life assured has no direct communication with the Ops. The agent played a vital role between the Ops and the life assured. Further, it is the plea of the Ops that the life assured and the Ops are bound by the terms of the bond and the Ops have taken decision as per the terms of the bond and rules and regulation. In this regard, on perusal of Annexure-1 as well as Annexure-A, nowhere it is found that the terms and condition of the proposal form were read over and explained to the life assured and understanding the terms and conditions of the policy bond so also the rules and regulations, the life assured put his signatures. That apart, the agent who is a mediator between the life assured and Ops has also not supplied any endorsement that the terms and conditions of the policy bond so also the rules and regulations are explained to the life assured, who understanding the same to be true has put her signatures in his presence. Not a single document is filed by the Ops to satisfy the Commission that all those were in the knowledge of the life assured. From the above discussion, the claim of the Ops in this regard sounds no good.
9. Further, it is the claim of the Ops that the life assured died due to asthma which has been substantially corroborated by the witnesses examined by the postal authority. On perusal of the Annexure-C, D & E, the statement of the witnesses, it is made out that life assured was suffering from asthma, but she died due to heart attack. Not a single document is filed on behalf of the Ops that the life assured was suffering from severe asthma. Rather, from Col-3 of Annexure-B meant for known or probable cause of death as result of enquiry, it is found that the cause of death of the deceased occurred due to ante mortem in nature and abnormal findings of heart are consistent with accelimyocardial infarction that means the life assured died due to heart attack. Heart attack is not a long standing disease, rather it occurs suddenly. Myocardial infarction is otherwise known as heart attack, occurs when blood flow decreases or stops in one of the coronary arteries of the heart, leading to tissue death in the heart muscle. The most common symptom is chest pain or discomfort, which may radiate into the shoulder, arm, back, neck, or jaw. Myocardial infarction can cause complications such as heart failure, irregular heartbeat, cardiogenic shock or cardiac arrest. The underlying mechanism is usually the complete blockage of a coronary artery due to the rupture of an atherosclerotic plaque. Its risk factors include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet and excessive alcohol intake. On the other hand, asthma is a respiratory condition characterized by inflammation of the airways, leading to symptoms like wheezing, shortness of breath and coughing. Myocardial infarction occurs when blood flow to a part of the heart muscle is blocked, usually due to a blood clot. That apart, in the postmortem report vide Annexure-5 series, the doctor who conducted autopsy over the dead body of life assured has also opined that the death is due to complications arising from acute myocardial infarction. In this connection, the Ops have failed to establish that the life assured died due to severe asthma attack or cardiac asthma. Therefore, this Commission is of the considered opinion that the life assured died due to sudden heart attack and not by asthma.
10. The Ops have further claimed that on a thorough enquiry made by the Postal authorities, the claim of the life assured was denied vide Annexure-F & G. Section 53 of the Post Office Life Insurance Rules, 2011 deals with this situation which is reproduced as under:
“53. Settlement of early death claims- Cases of early death i.e. before completion of 3 years from the date of Acceptance of a policy will be investigated thoroughly to enquire if the insurant while submitting the proposal had suppressed material information which otherwise would not have allowed the proponent to be eligible for PLI/RPLI and it should be examined whether insurant was suffering from any disease prior to taking of a policy, whether there was any deliberate attempt on the part of marketing staff to insure sub-standard life or to cause loss to fund and whether the cause of death had any relation to the disease. The Postmaster General after satisfying himself may sanction death claim.”
In this context, this Commission, considering all the factors mentioned in the Rules, 2011, has already held that the life assured has died due to heart attack and not by asthma. But the Ops have failed to produce any document before this Commission to satisfy that they had enquired about the real fact as to whether there was any deliberate attempt on the part of marketing staff to insure sub-standard life or to cause loss to fund, as provided in the said Rules, 2011. Further, on perusal of the order dated 27.7.2021 passed by the Appellate Authority i.e. Chief Postmaster General, Odisha Circle, Bhubaneswar vide Annexure-G, it is found that the Appellate Authority has totally ignored the medical certificate issued by the concerned doctor in respect of the life assured without assigning any cogent and concrete evidence, but only believing the statement of the husband of life assured, the claim of the complainant declined. In this regard, on perusal of the statement of the husband of the life assured namely Santosh Kumar Panda vide Annexure-C, it is found that he has stated “his wife was suffering from Asthma prior to five years”. But the Investigating Officer-cum-Superintendent of Post Offices, Balasore Division, Balasore, who examined him, has not attempted to clarify as to whether the life assured has been suffering from Asthma since five years or as to whether on the date of proposal she was suffering Asthma. Similarly, one Lalit Kumar Panda has stated in his statement vide Annexure-E that the life assured was not suffering from any disease at the time of her death. In this connection, the Appellate Authority i.e. Deputy Divisional Manager (PLI), Office of the Chief PMG, Odisha Circle, Bhubaneswar while passing his report has casts four points to arrive his conclusion and out of the four points No.1 point is “The reason mentioned that the insurant has been suffering from Asthma since last five years is fictitious.” The very word “has been suffering” attributes a different meaning i.e. continuous process of suffering Asthma by the life assured on the date of proposal. But it is mentioned here that the husband of the life assured has not at all stated in his statement that his wife i.e. life assured has been suffering from Asthma since five years, rather, he has stated that his wife was suffering from Asthma prior to five years. That apart, the Appellate Authority has not stated a single line in his finding that the cause of death of the life assured had any relation to the disease, as required under Section 53 of POLI Rules, 2011. Without approaching a definite conclusion as to whether the life assured has been suffering Asthma on the date of proposal or the life assured has already been cured from it, the Appellate Authority reached its conclusion in a different angle and not taken into account the medical certificate issued by the doctor so also the medical papers, the finding passed by the Investigating Officer vide Annexure-F and the Appellate Authority vide Annexure-G create a room of doubt on the veracity of the enquiry conducted by the Postal Authority and therefore, Annexure-F & G have got no sanctity at all and thus are not accepted.
11. From the above analysis made in the foregoing paragraphs, this Commission is of the considered view that the Ops have committed deficiency in service in repudiating the claim of the complainant. Thus, it is held that the complainant has cause of action to file the present case and the case is maintainable. Consequently, the complainant is entitled to get the reliefs, as sought for, in the complaint petition.
Hence, it is ordered -
O R D E R
The case of the complainant be and the same is allowed on contest against the O.Ps. The O.Ps are hereby directed to release the death benefits under RPLI Scheme in respect of Policy No. 0000002931202 in favour of the complainant with interest @ 9% PA from the date of death of the life assured till its actual disbursement along with Rs.10,000/- towards compensation for mental agony and litigation cost, within 45 days of this order, failing which the complainant is at liberty to realise the same through the process of law.
Pronounced in the open court of this Commission, this the 04th day of March, 2024 under my signature & seal of the commission.
