The Complainant has filed this case alleging deficiency-in-service by the O.Ps, where O.P No.1 is the Competent Authority, MAX Life Insurance Co. Ltd., Gurgaon, O.P No.2 is the Claims Support Unit, Max Life Insurance Company Limited, Gurgaon and O.P No.3 is the Branch Manager, MAX Life Insurance Company Limited, Balasore.

                    2. The case of the Complainant in brief is that the Complainant is the wife and nominee of Late Ram Chandra Das Adhikari, who had a MAX life insurance policy bearing No.201966363, date of commencement is on 03.03.2014 for a term of 20 years with initial yearly premium of Rs.38,643.29 ps. (Rupees Thirty eight thousand six hundred forty three and twenty nine paisa) only, maturing on 03.03.2034 for sum assured of Rs.4.50 Lacs (Rupees Four lakhs fifty thousand) only, which was issued on 08.03.2014. But, unfortunately the policy holder died on 31.10.2014 due to “Cardio Respiratory Failure”, while he was under treatment of Dr. S.R Jena. Thereafter, the Complainant filed death claim of her husband along with necessary/ relevant documents before the O.Ps, but the O.Ps intentionally had not paid any death claim amount of the husband of the Complainant to the Complainant. On receipt of a letter dtd.30.11.2015 from the O.P No.2, the Complainant came to know about the rejection of death claim of her husband, which reads as “we are declining the death claim against the above mentioned policy for reasons of material medical non-disclosure of kidney disease”. Accordingly, the Complainant had written a letter to O.P No.2 with a request for payment of death claim amount of her husband stating there in that the allegation made by O.P No.2 is totally false and fabricated on the basis of report by Dr. S.R Jana. Moreover, her husband has not either suppressed any material facts or submitted any false documents before the O.Ps at the time of commencement of above said policy. The O.Ps did not consider her request 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 notices to the O.Ps through her Advocate on 12.05.2016. Thus, the Complainant sustained mental agony, harassment and financial loss on account of non-payment of death claim amount of her husband by the O.Ps. The Complainant has prayed for payment/ release of death claim amount 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 denying on the point of maintainability as well as its cause of action. The O.Ps have further submitted that Late Ram Chandra Das Adhikari (the deceased life insured/ DLI) has submitted the duly signed proposal form of Max Life Gain Premier policy bearing No.201966363 on 03.03.2014 and offered to pay Rs.37,485/- (Rupees Thirty seven thousand four hundred eighty five) only annually towards the initial premium against the sum assured of Rs.4.50 Lacs (Rupees Four lakhs fifty thousand) only, where the Complainant is the nominee under the same policy. It is also submitted that the contents of the proposal form were explained to the DLI and he had given a declaration stating that he has furnished the information after fully understanding the contents thereof and also after understanding all the terms and conditions of the policy, he had applied for the policy and has made true and accurate disclosure of all the facts and has not withheld any information. It is further submitted that in the proposal form at page-3, there was a column wherein the DLI was required to provide details with respect to his health/ medical conditions, where he replied as “No” with reference to the question regarding Kidney or bladder disorder, stones, prostate disorder or gynaecological disorder. The said policy was issued by the O.Ps relying upon the information provided in the proposal form. The DLI had fully understood the terms and conditions of the policy and further agreed under the agreement therein that if any untrue statement be contained in the application/ proposal form, the policy contract shall be null and void and the moneys which have paid in respect thereof shall stands forfeited to Max India Life insurance. Accordingly, the DLI has paid one premium only. On receipt of death claim intimation dtd.24.06.2015 from the Complainant intimating the person insured had expired/ died on 31.10.2014 due to Cardio Respiratory failure as acknowledged by the O.Ps dtd.01.07.2015. The claim being an early claim, the O.Ps as per the procedure carried out an investigation to settle the claim of the Complainant. During the course of investigation and assessment of the claim, it was revealed to the O.Ps that the DLI did not provide true and correct information while filing up the proposal form and cheated the O.Ps by providing false information and obtained the insurance policy. It was revealed to the O.Ps that the DLI was suffering from kidney disease prior to the signing of the proposal form. As per the medical documents of Nightingale Hospital, Kolkata, it was revealed that the DLI was suffering from kidney disease since December, 2013 and underwent dialysis since December, 2013 i.e. prior to signing the proposal form. Even after being aware of the fact that the DLI was suffering from such a chronic disease, he induced the O.Ps to issue the policy in his favour to get the undue advantage out of the same and provided false information in the proposal form. The DLI misrepresented before the O.Ps by providing false/ wrong information as to the material facts and thus played fraud upon the O.Ps and induced them to issue the insurance policy in his favour. Thus, the claim 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, both the Parties have filed certain documents as per list. Perused the documents filed. It has been argued on behalf of the Complainant that Ram Chandra Das Adhikari was the policy holder of MAX life insurance policy bearing No.201966363, date of commencement is on 03.03.2014 for a term of 20 years with initial yearly premium of Rs.38,643.29 ps. (Rupees Thirty eight thousand six hundred forty three and twenty nine paisa) only, maturing on 03.03.2034 for sum assured of Rs.4.50 Lacs (Rupees Four lakhs fifty thousand) only, which was issued on 08.03.2014. However, this fact has not been disputed by the O.Ps. Further, the policy holder died on 31.10.2014 due to cardio respiratory failure. The Complainant being the nominee, has submitted the death claim of her husband along with relevant documents before the O.Ps, but the O.Ps had not paid any death claim amount of her husband to the Complainant. After receipt of a letter dtd.30.11.2015 from the O.P No.2, the Complainant came to know about the rejection of death claim of her husband, which reads as “we are declining the death claim against the above mentioned policy for reasons of material medical non-disclosure of kidney disease”. As such the Complainant had written a letter to O.P No.2 for payment of death claim amount of her husband stating there in that the allegation made by O.P No.2 is totally false and fabricated on the basis of report by Dr. S.R Jana, but the O.Ps did not pay any heed to it, for which the Complainant sent legal notices to the O.Ps. But, when the death claim was not settled after issuance of legal notices to the O.Ps, the Complainant has been compelled to file this case in this Forum praying for necessary relief as mentioned in the pleading. On the other hand, it has been argued on behalf of the O.Ps that at the time of submission of proposal form at page-3, the policy holder had given details with respect to his health/ medical conditions, where he replied as “No” with reference to the question regarding Kidney or bladder disorder, stones, prostate disorder or gynaecological disorder and the O.Ps believed the same as true and correct in good faith and also the O.Ps have issued insurance policy certificates to the policy holder. But, the policy holder died on 31.10.2014 and the O.Ps received the death claim from the Complainant on 24.06.2015 and according to the Complainant, the death of the policy holder was due to cardio respiratory failure. In support of such cardio respiratory failure, the Complainant submitted one xerox copy of handwritten medical certificate of Dr. S.R Jana of Purba Medinipur vide Annexure-7 and according to it, the policy holder died due to Ac. Cardio Respiratory failure. The Complainant has also filed xerox copy of death certificate of the policy holder vide Annexure-6. According to the O.Ps, as it was an early death claim, necessary investigation was carried out, where the O.Ps have found that the policy holder had pre-existing kidney disease, for which he underwent dialysis on 11.12.2013 and on 06.02.2014 at Nightingale Hospital, Kolkata. So, it shows that the policy holder had suppressed material facts without disclosing the fact. In support of it, the O.Ps have filed xerox copies of such medical documents like dialysis report on dtd.11.12.2013 and on dtd.06.02.2014. So, it has been argued on behalf of the O.Ps that at the time of submission of proposal form, the policy holder had very much knowledge about the pre-existing kidney disease and he had suppressed the same for the reason best known to him. So, even if the policy holder died due to cardio respiratory failure, he had pre-existing kidney disease as per medical documents available in the case record, which was suppressed by the policy holder at the time of taking the policy. Further, it has been argued on behalf of the Complainant that the O.Ps have not medically checked the policy holder after filing of the proposal form by him. To reply it, it has been argued on behalf of the O.Ps that the insurance company in good faith, believed the statement of the proposal form submitted by the policy holder to be true. But, subsequently, from the medical documents, it was found that he had pre-existing kidney disease, for which he had underwent dialysis at Nightingale Hospital, Kolkata about 2.5 months before filing of the proposal form. So, it shows that he had intentionally and fraudulently suppressed the material facts regarding his good health before the insurance company, for which the insurance company has rightly repudiated the death claim of the Complainant.   

                    6. So, now on careful consideration of all the materials available in the case record and hearing both the sides, I found no reasonable ground to differ in the opinion of the insurance company regarding repudiation of the death claim of the Complainant and the insurance company has rightly repudiated the death claim, for which the Complainant is not entitled for any relief as prayed for and accordingly, this Consumer case is liable to be dismissed. Hence, Ordered:-

                                                     O R D E R

                         The Consumer case is dismissed on contest against the O.Ps, but in the peculiar circumstances without cost.  

                         Pronounced in the open Forum on this day i.e. the 29th day of March, 2019 given under my Signature & Seal of the Forum.