Jharkhand

Bokaro

CC/16/95

Smt. Basanti Devi - Complainant(s)

Versus

The Divisional Manager, Life Insurance Corporation of India - Opp.Party(s)

Annu Mishra

22 Feb 2022

ORDER

1. Complainant has filed this case with prayer for direction to O.Ps. to pay insured amount (Rs. 250000/- + 100000+ 100000) = Rs. 4,50,000/- on account of death of insured late Hari Narayan with 18% interest and for payment of Rs.20,000/- and Rs. 10,000/-  as compensation and litigation cost respectively to the complainant.
2. Complainant’s case in brief is that the husband of the complainant was late Hari Narayan S/o Late Ramnath, Resident of 4 NOS. Bermo, Qr. No. 275, M- Type, P.O.- Jaridih Bazar, P.S.- Gandhi Nagar, Dist.- Bokaro who purchased total 7 LIC policies bearing no. 548290870, 548290869, 548290868, 548290867, 548295813, 549810067 and 549010088 in which complainant has been shown nominee. Further case is that suddenly the husband of the complainant died on 13.02.2015 at Regional Hospital, Kargali due to Cardio Respiratory failure on which complainant made claim with the O.P. Life Insurance Corporation for payment of insured amount. Further case is that the LIC has paid the insured amount of above mentioned first four policies but refused to make payment of last three policies vide repudiation letter dt. 15.02.2016 on the ground that the insured was suffering with chronic alcoholism and diabetic foot wound and did not disclose these facts in proposal and gave false answers. Further case is that the claim of the complainant is genuine but it has been wrongly repudiated hence  a legal notice was issued having no impact, therefore, case has been filed before this Commission with above mentioned reliefs.
3.     O.Ps. appeared and they have filed joint written statement. The contents of para 1,2,4,5 of the complaint petition  have been admitted by the O.Ps. In respect to contents of para 8 of the complaint petition there is no comment hence it will be treated as admitted fact. It is reply of the O.Ps. that as per Medical attendant’s Certificate dt. 07.04.2015 signed by the Medical Superintendent Regional Hospital, Kargali the deceased was regularly treated since long ago and symptoms of the illness were breathlessness, gasping condition and he was suffering from IDDM, Several Anemia, Diabetic Ulcer & Associated disease who died on 13.02.2015 at 12:45 P.M. due to Hyperglycemia & Acute obstruction long disease as IDDM etc. Further reply is that out of 7 policies taken by the deceased death claim for basic sum assured in respect to 4 policies has been admitted and payment has been made in favour of recorded nominee because those policies were taken before the occurrence of the above diseases. So far, the claim of the remaining three policies is concerned those policies have been taken after occurrence of disease to which decease has not disclosed in the proposal papers hence, on the ground of suppression of material fact claim has been repudiated, hence repudiation is not on the basis of assumption rather it is based on some investigations and papers and rejection has been made after proper scrutiny of the documents filed by the complainant and complainant is not entitle to get any relief.
4.    In support of the case both parties have filed photo copy of the following  documents.
5.    On behalf of the complainant following documents have been filed :-

1. Photo copy of the attested copy of policy proposal paper related to policy No. 548295813
2. Photo copy of the attested copy of policy proposal paper related to policy No. 549010088 which is being used for two policies.
3. Copy of status report related to policy No. 549010088.
4. Photo copy of Medical Attendant’s Certificate dt. 07.04.2015.
5.  Photo copy of requisition dt. 20.08.2015 issued by the LIC in the name of the complainant.
6. Photo copy of account statement of the savings bank account of the complainant related to Bank of India.
7. Photo copy of claim repudiation letter dt. 15.02.2016.
8. Photo copy of Death Certificate.
9. Photo copy of Legal Notice.
10. Photo copy of Photo Medical Card issued by The Central Coalfields Ltd. having entry from the year 2003 till February 2015.

6. On behalf of the O.Ps. photo copy of following documents have been produced:-

1. Photo copy of Medical Attendant’s Certificate dt. 07.04.2015.
2. Photo copy of Medical Certificate of the cause of death of the deceased.

c. Photo copy of the Certificate by employer showing absence      of the deceased from duty since February 2012 to February 2015.

D. Photo copy of the policy paper and status report related to policy No. 548290867.

E. Photo copy of the policy paper and status report related to policy No. 548290869.

F Photo copy of the policy paper and status report related to policy No. 548290870.

G Photo copy of the status report related to policy No. 548290868.

H Photo copy of the status report related to policy No. 548295813.

I Photo copy of the status report related to policy No. 549010087.

7. On careful perusal of the pleadings of the parties it appears that purchase of 7 policies by the deceased is admitted fact. Another admitted fact is that deceased died on 13.02.2015. It is also admitted fact that in respect to 4 policies claim of the complainant has been accepted by the O.Ps.
8.  Only question for decision by this Commission is that whether repudiation of the claim of the complainant by the O.Ps. is justified or nor ? And whether complainant is entitled to get relief as prayed ?
9. At this place for the sake of convenience we would like to mention here about all the polices taken by the deceased from the O.P. and their details in following table:-

 

Sl.no.	Policies No.	Sum assured	Date of commencement	Status of Claim
1	548290667	1,00,000/-	16-08-2012	Allowed
2	548290668	50,000/-	16-08-2012	Allowed
3	548290669	50,000/-	16-08-2012	Allowed
4	548290670	50,000/-	16-08-2012	Allowed
5	548295813	2,50,000/-	26-04-2013	Rejected
6	549010087	1,00,000/-	28-02-2014	Rejected
7	549010088	1,00,000/-	28-02-2014	Rejected

 

10. The above table shows that policies at serial No. 1 to 4 have commenced on 16.08.2012 and on that very day deceased was having no complain or illness as it is apparent from para 7 of the W.S. Rest of three policies have been taken on 26.04.2013 and 28.02.2014 within short period from the first four policies. No where it has been mentioned in the W.S. that from which period or from which date alleged disease have occurred about which claim has been repudiated.
11.   In support of the objection Learned counsel O.P. placed reliance on the Orders passed by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi in connection with Revision Petition No. 1327/2008, 2025/2011, 2482/2008, 1883/2015, 4250/2012, 1863/2014, 1001/2011, 1991/2011, 470/2013 and 2996/2015. In our opinion the facts and circumstances of above mentioned cases are different from the facts and circumstance of the present case, hence principle lead down in the above noted cases are not helpful for the O.Ps.
12.  Since on the same set of papers O.Ps. have accepted/allowed the claim of the complainant in respect to first four policies and there is no specific period or date denoting the disease from which deceased was alleged to be suffered hence here in this case the principle of ‘Estoppel’  will be applicable against the O.Ps. and they will be stopped from saying or doing against the Act to which they have already done. Therefore, we are of the opinion that there is deficiency in service by the O.Ps. Insurance Co. and claim of the complainant is liable to allowed.
13. Accordingly, the prayer made by the complainant is being allowed in the following manner:-

O.P. No.1 and 2 are directed to pay Rs. 4,50,000/-(Rs. four lac fifty thousand) only to the complainant as claim amount within 60 days from today, failing which they shall pay interest thereon @ 10% per annum from 26.08.2016 (i.e. the date of filing of the case)  till realization of the money. Further O.P. No.1 &2 are directed to pay compensation of Rs. 10,000/- and litigation cost of Rs. 5000/- within 60 days from today.