The Complainant has filed this case alleging deficiency-in-service by the O.Ps, where O.P No.1 is the Competent Authority, AVIVA Life Insurance Company India Ltd., Gurgaon, O.P No.2 is the Claims Review Committee, AVIVA Life Insurance Company India Ltd., Gurgaon, O.P No.3 is the Branch Manager, AVIVA Life Insurance, Balasore and O.P No.4 is Mr. Barun Kumar Jena, AVIVA Life Insurance Agent, Hiranandapur, Nampo, Balasore.

                    2. The case of the Complainant in brief is that the Complainant is the wife and nominee of the Policy holder namely Late Ramachandra Das Adhikari vide Policy No.10108345 (Policy Name- AVIVA Dhan Samruddhi) under the O.Ps-Insurance Company. The policy holder had deposited a sum of Rs.48,485/- (Rupees Forty Eight Thousand Four Hundred Eighty Five) only on dtd.06.03.2014 as premium. The sum assured for the policy is Rs.7,70,000/- (Rupees Seven Lakhs Seventy Thousand) only, policy premium term- 10 years, Due date of last payment of regular premium- 06.03.2023, policy term- 20 years, maturity date- 06.03.2034 and annualized premium is Rs.47,032/- (Rupees Forty Seven Thousand Thirty Two) only. The O.P No.4 had verified the original documents of the policy holder regarding age proof, identity, address proof and also verified the health condition through the Doctor and filled up the proposal form vide No. NUP 16622876 and thereafter, confirmed the policy bond, which was issued in favour of the policy holder vide Policy No.10108345. But, unfortunately the policy holder died on 31.10.2014 due to “Cardio Respiratory Failure”, while he was undergoing treatment by Dr. S.R Jena. Thereafter, the Complainant filed death claim of her husband along with all necessary and relevant documents before the O.Ps, but the O.Ps intentionally had not paid the death claim amount of the policy holder to the Complainant. After receiving of a decline letter dtd.10.08.2015 from O.P No.2, the Complainant/ nominee came to know about the rejection of death claim of her husband vide Policy No.10108345 that due to “non disclosure of material facts with respect to medical history is a violation of the terms & conditions of the insurance policy and gives the O.Ps the right to repudiate the claim”. Thereafter, the Complainant/ nominee had visited the Office of the O.P No.3 and approached to settle the insurance policy and said that her husband had died due to failure of Cardio Respiratory as per Doctor’s report. Moreover, her husband (the policy holder) had not either suppressed any material facts or submitted any false documents before the O.Ps at the time of commencement of the above said policy on dtd.03.03.2014. But, the O.Ps did not consider her request and also refused to pay the death claim amount to the Complainant/ nominee since huge death claim amount is involved in this case. Due to non-payment of death claim amount of her husband, the Complainant sent legal notice to the O.Ps through her Advocate on dtd.17.10.2015. Thus, the Complainant sustained mental agony, harassment and financial loss due to non-payment of death claim amount of her husband by the O.Ps, which amounts to deficiency of service on the part of the O.Ps. The Complainant has prayed for directing the O.Ps for payment/ release of death claim amount of Rs.7,70,000/- (Rupees Seven Lakhs Seventy Thousand) only with interest along with compensation for mental agony, harassment and financial loss as well as litigation cost.

                    3. Written version filed by the O.Ps through their Advocate denied on the point of maintainability as well as its cause of action. The O.Ps have further submitted that the deceased life insured/ DLI had submitted the duly signed proposal form bearing No. NUP 16622876 for a “AVIVA Dhan Samruddhi Life Insurance Policy” on dtd.03.03.2014, whereby he was required to pay an annualized premium of Rs.48,485/- (Rupees Forty Eight Thousand Four Hundred Eighty Five) only for a sum assured of Rs.7,70,000/- (Rupees Seven Lakhs Seventy Thousand) only. It is also submitted that the DLI had mentioned ‘No’ against the specific questions asked in the Clause 6.2 of the Health and Activity section of the proposal form for the policy. On the basis of the said proposal form and upon receipt of the initial premium amount, the “AVIVA Dhan Samruddhi Life Insurance Policy” bearing No.10108345 was issued by the O.Ps to the Complainant with effective date of coverage being 06.03.2014. Further, the O.Ps have received a death claim form on dtd.09.07.2015 from the Complainant, raising a claim due to the death of the DLI on dtd.31.10.2014. Thereafter on dtd.10.07.2015, the O.Ps informed the Complainant by a letter that for processing the claim at the earliest, the alcohol questionnaire, liver questionnaire and other relevant documents were required for claim evaluation. The O.Ps by a letter dtd.10.08.2015 informed the Complainant that the claim raised could not be accepted and was liable to be repudiated due to non-disclosure of the fact that the DLI had been suffering from kidney related ailments even before applying for the policy and was under treatment for the same and also he was hospitalised prior to signing of the proposal form, as evident from the hospital records dtd.03.12.2013. So, the Complainant has not approached the Forum with clean hands and there has been no misrepresentation, concealment of facts, negligence or deficiency in service on the part of the O.Ps. Hence, the case of the Complainant is liable to be dismissed with cost.

                    4. In view of the above averments of both the Parties, the points for determination of this case are as follows:-

(i) Whether this Consumer case is maintainable as per Law ?

(ii) Whether there is any cause of action to file this case ?

(iii) To what relief the Complainant is entitled for ?

                    5. In order to substantiate their claim, the Complainant has filed certain documents as per list, whereas the O.Ps have not filed any documents in their support. Perused the documents filed. It has been argued on behalf of the Complainant that she is the nominee of the Policy holder/ her husband Late Ramachandra Das Adhikari vide Policy No.10108345 (AVIVA Dhan Samruddhi) having important particulars of the policy as follows:- sum assured is Rs.7,70,000/- (Rupees Seven Lakhs Seventy Thousand) only, premium payment term- 10 years, policy term- 20 years, policy start date- 06.03.2014, Date of maturity- 06.03.2034, last premium payment date- 06.03.2023 and annualized premium is Rs.48,485/- (Rupees Forty Eight Thousand Four Hundred Eighty Five) only as disclosed in Annexure-5. The policy holder had deposited the first premium of Rs.48,485/- (Rupees Forty Eight Thousand Four Hundred Eighty Five) only on 06.03.2014 vide Annexure-3. He died on 31.10.2014 due to “Cardio Respiratory Failure” vide Annexure-7. After his death, when the Complainant filed the death claim, the O.Ps did not co-operate and repudiated the claim vide Annexure-1 on the ground of non-disclosure of material facts with respect to medical history is a violation of the terms & conditions of the insurance policy. The Annexure-1 discloses that the deceased Mr. Ram Chandra Das was diagnosed with chronic renal failure prior to proposal and was taking continuous treatment for the said disease since December, 2013 prior to signing of the proposal form dtd.03.03.2014 and in the proposal form, the answer regarding having Diabetes, Kidney or Liver problem is “No”. So, when the O.Ps have repudiated the claim of the Complainant, she came to the Forum for necessary relief regarding payment/ release of death claim amount with interest along with compensation and litigation cost. The Complainant has filed the documents vide Annexure-1 to Annexure-11. Perused the same carefully. On the other hand, it has been argued on behalf of the O.Ps that they have repudiated the claim of the Complainant due to non-disclosure of the fact that the DLI had been suffering from kidney related ailments even before applying for the policy and was under treatment for the same and also he was hospitalised prior to signing of the proposal form, as evident from the hospital records dtd.03.12.2013 and in the pleading, it has been mentioned that the O.Ps have filed documents vide Annexure-OP-1 to Annexure-OP-5. But, strangely enough after thorough search of the record, it is found that no such documents has been filed by the O.Ps for the reason best known to them. Either it is the negligence or suppression of facts on the part of the O.Ps, which should be viewed seriously as it is an insurance matter. The Complainant is a nominee of the policy holder and it is undisputed. So, I found no reason when the O.Ps have suppressed all the material documents, how they have repudiated the claim, which amounts to suppression of facts or negligence on the part of the O.Ps as mentioned earlier.

                    6. So, now on careful consideration of all the materials available in the case record and after hearing both the sides, this Forum come to the conclusion that it is a fit case that the Complainant is entitled for death claim of the policy for an amount of Rs.7,70,000/- (Rupees Seven Lakhs Seventy Thousand) only with interest @ 9% per annum from the date of filing of death claim by the Complainant before the O.Ps along with compensation of Rs.10,000/- (Rupees Ten Thousand) only and litigation cost of Rs.2,000/- (Rupees Two Thousand) only within 60 days of receipt of this order and all the O.Ps are jointly and severally liable for the same, failing which it will carry interest @ 9% per annum for the total amount including compensation and litigation cost from the date of order till realization, which will meet the ends of justice in this case. Hence, ordered:-

                                                     O R D E R

                         The Consumer case is allowed on contest against the O.Ps with cost. The O.Ps are jointly and severally directed for payment of death claim amount of Rs.7,70,000/- (Rupees Seven Lakhs Seventy Thousand) only for the Policy No.10108345 (AVIVA Dhan Samruddhi) with interest @ 9% per annum from the date of filing of death claim by the Complainant before the O.Ps along with compensation of Rs.10,000/- (Rupees Ten Thousand) only and litigation cost of Rs.2,000/- (Rupees Two Thousand) only within 60 days of receipt of this order, failing which it will carry interest @ 9% per annum for the total amount including compensation and litigation cost from the date of order till realization. In case of failure by the O.Ps to comply the order within the stipulated time frame, the Complainant is at liberty to realise the same amount from the O.Ps as per law.

                         Pronounced in the open Forum on this day i.e. the 11th day of March, 2020 given under my Signature & Seal of the Forum.