The titled complainant Smt. Kuljit Kaur being the nominee/Legal Heir/Widow of the DLI (Deceased Life Insured) Late Sh. Jasbir Singh has filed the present complaint against the titled opposite parties (for short, the OP1-5 insurers) aggrieved/hurt at their arbitrary repudiation of her spouse's death-claim allegedly on flimsy considerations thus infringing her statutory consumer rights. She further pleads that her spouse during his life-time had purchased from the OP insurers Policy # 474017325 @ B.S. I. (Basic Sum Assured) of Rs.5.60 Lac on his life commencing on 19.03.2016 and has been paying all its premiums regularly till his hospitalization on 13.07.2017 and subsequent death on 27.07.2017.
2. As ill-luck would have it, the insured Jasbir Singh suffered stomach pain in July'2017 and to get the same medically checked-up he himself drove along with the complainant/his wife Kuljit Kaur to Guru Ram Dass Hospital, Vallah (Amritsar) on 13.07.2017 but had to be admitted there for medical treatment as he was diagnosed for Jaundice of Lever etc. Further, he did suffer from the Glucose Situation and his health further deteriorated and he succumbed to his illness in the Hospital itself, on 27.07.2017.
3. In due course of time, the complainant filed the requisite Death-claim with the OP insurers along with the requisite/requisitioned documents/papers and has been waiting for release of the claim-settlement sum when she received claim-rejection on 02.08.2018 stating therein forfeiture of policy along with all its accrued benefits etc on the grounds of deceit with the insurers by way of suppression of the pre-existing disease/ailments etc and then the Final Repudiation on 25.10.2018 hence the present consumer complaint seeking directives to the OP insurers to pay her the Sum Insured Rs.5.60 Lac with interest @ 18% PA besides Rs.50,000/- as cost of the present litigation, in the interest of justice.
4. The complainant has produced the herein listed documents in evidence in support of his present complaint. i) Duly Sworn-in Affidavit (Ex.CW1); ii) Copy of the Request/Reply by the complainant (Ex.C1) for claim-settlement; iii) Copies of the Premium Receipts (Ex.C2 to Ex.C4); iv) Copy of Death Certificate (Ex.C5); v) Copy of Aadhar ID 684084498674 (Ex.C6); vi) Copy of the Complainant Letter (Ex.C7) to the OP requesting release of Claim; vii) Copy of LIC letter (Ex.C8) seeking F-3816; viii) Copy of the Aadhar ID of the DLI (Ex.C9); ix) Copy of the Medical Attendant's Certificate (Ex.C10) on the LIC Format; x) Copy of the Bill (Ex.C11); xi) Copy of the Hospital Certificate (Ex.C12); xii) Copies of letters (Ex.C13 to Ex.C15) by the complainant; xiii) Copies of letters (Ex.C16 to Ex.C19) by the OP insurer to the SGRDC Hospital; xiv) Copy of LIC acknowledgment (Ex.C20); xv) Copy of Policy (Ex.C21); xvi) Complainant's Rebuttal to the OP written statement as well as her rejoinder + written arguments.
5. The titled opposite party LIC insurers (OP No.2 to 4), in response to the commission’s summons appeared through their counsel who filed the written reply stating therein the OP Insurers' version/pleadings and objections in order to achieve a successful prosecution of the OP defense. The OP insurers have admitted issuance of the related policy relying upon the information as provided by the DLI in the associated proposal-form in which the DLA/Proposer had stated that he (the DLA) had been in good health and had neither consulted any Medical Consultant/Hospital nor hospitalized for any medical-treatment/surgery etc. As the policy resulted into death-claim as duly filed by the complainant stating therein Form 3783 that the DLI had died on 27.07.2017 due to Liver ailment with duration of the illness at 15 days only along with Form 3784 only from the hospital authority sans any previous record. Thus, she was asked to file the Form 3816 through the hospital that she never submitted. So, the OP insurers themselves procured the Form 3816 by deputing their official to the Hospital and could get apprised of that the DLA has been suffering from General Weakness and Yellow Discoloration for 4-5 months; Swelling in B/L lower limbs for 15 days; Vomiting for 2 months; Loss of Appetite for 1 month and Chronic Alcoholism for the last 20 years at an intake of one Liquor Bottle per day prior to his hospitalization on 13.07.2017 and thus the death-claim was rejected on 02.08.2018 and the complainant's appeal was also rejected on 25.10.2018 by the competent authority. The OP insurers have further pleaded that the DLA had replied all his health related questions in affirmative in the related proposal form and had thus purchased the related policy by suppressing his true state of ill-health and the preexisting illness/ailment. Thus the death-claim under the policy was rightly repudiated on the ground of concealment of material fact regarding ill-health in the related proposal form at the time of purchase of the policy. The repudiation was duly conveyed with liberty to appeal before the ZO Claim Review Committee and the complainant did file her appeal that failed and as such she has exhausted the prescribed remedy and thus the present complaint need by dismissed on this count, alone.
6. The complainant could also have approached the Insurance Ombudsman. The OP insurers have further elaborated/emphasized the subject/issue of concealment of prior continuing ailments by the DLA that itself warrants 'forfeiture' of the policy. Also on merits, the OP have pleaded/responded on the same grounds, as above, and have finally addressed the complaint as false, frivolous, vexatious, baseless sans merit and have prayed for its dismissal with litigation costs, in their favor; and have also produced i) the duly Sworn-in Affidavit (Ex.OP1/A) of Sh.Virsa Singh Manager Legal Divisional Office, Amritsar; along with the herein listed documents in evidence, in support of prosecution of their defense; ii) Ex.OP1- Copy of the Rejection Letter (02.08.2018); iii) Ex.OP2- Copy of the SGRD Hospital Indoor Admit Slip; iv) Ex.OP3 to Ex.OP7– OP insurers letters to the Hospital; v) Ex.OP8– Copy of the OP Letter to the complainant; vi) Ex.OP9– Copy of the OP insurers letter to the complainant; vii) Ex.OP10 & Ex.OP11– Copies of policy status report and its calculations; viii) Ex.OP12– Copy of the Claimant's Statement; ix) Ex.OP13- Copy of the Certificate of Identity and Burial; x) Ex.OP14– Copy of the Medical Attendant's Certificate; xi) Ex.OP15– Copy of the DLI Death Certificate; xii) Ex.OP16– Copy of the related Policy;
7. Opposite party No.1 did not appear despite the service of notice and was proceeded against exparte vide order dated 02.07.2019.
8. We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some of the documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We observe that the present dispute has arisen on account of the impugned ‘repudiation' of insurance death-claim pertaining to the insured DLA spouse (Late Sh. Jasbir Singh) of the complainant, by the OP insurers who allege non-disclosure of prior-existing/continuing ailments by the DLA at the time of insurance.
9. We have minutely examined all the documents produced in evidence by the complainant and also by the OP insurers as produced and as collected by them during the course of their investigations and find that the insured's health status as well as preexisting disease, if any should have been and were in the notice and knowledge of the OP insurers at the time of insurance/policy-selling through their recorded agent Tajinder Singh Agency Code 22695101816340047 and thus they are presently stopped to cause repudiation to the death-claim, in question. Moreover, the no ailment as at present has been proved to be preexisting and as these present no bar to policy-selling so these should also pose no bar to claim-settlements etc. We observe the OP insurers' present role fully marred by an employ of unfair-practices and unscrupulous exploitation of the innocent consumer and that amounts to an open display of deficiency in services at its full volume. We disapprove the OP insurers' acts of omissions as well as that of commissions, in totality.
10. Moreover, the information as contained (gathered from the hospital) in the Form 3816 has been only the hearsay information as got from the DLA patient's attendant may be of some value during medical treatment of the patient but has decidedly no legal value in the absence of any first hand deposition of the treating physician. And, of course we do not concur with the logic of the herein impugned 'repudiation' of the death-claim and are inclined to examine the validity and legality of the same in the back-drop of the preceding and also the succeeding acts and events in the light of the facts on records and current law on the consumer proposition’s subject matter, in issue. We observe that the impugned repudiation of the insurance-claim has been the result of the OP insurers' resolve in their endeavor to somehow repudiate the same to cause and unfair and unjust loss to the complainant.
11. Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the intentional 'repudiation' by the OP insurers as ‘deficiency in service' and an employ of 'unfair-practice' and thus we partly allow this complaint and ORDER the OP insurers to pay the death-claim, in full, to the herein widow complainant, in terms of the policy Sum Insured of Rs.5.60 Lac with full accrued benefits, if any, and interest @ 7% PA from the date of complaint till actually paid, in full, besides to pay Rs.20,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the aggregated amount shall attract an additional interest @ 3 % PA from the date of the orders till actually paid.
12. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
13. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (B.S.Matharu)
JAN. 12, 2023. Member.
YP.
