DATE OF DISPOSAL: 09.12.2024
PER: SRI SATISH KUMAR PANIGRAHI, PRESIDENT(I/C)
The factual matrix of the case is that the complainant has filed this consumer complaint Under Section 12 of the Consumer Protection Act, 1986, alleging deficiency in service against the Opposite Party (in short the O.P.) and for redressal of his grievance before this Commission.
2. The husband of the complainant Pemi Debraj during his lifetime insured with SBI Life Insurance Co. ltd being encouraged and induced by the agent of the O.Ps on dated 11.09.2013. The agent Mr. Soumya Ranjan Sahoo of the O.Ps prepared the proposal form by ascertaining the relevant facts and document s such as Voter ID Card, Pan Card and Income Tax Return and existing policies of other companies and at his instant the insured Pemi Debaraj put his signature at relevant column of the proposal form. The insured also appointed his wife Smt. Pemi Jagiama herein referred to the complainant as his nominee. The agent also collected the first premium amount of Rs.10,088/- and submitted the proposal form together with the required documents before the O.P.No.2 onwards transmission to the O.P.No.1. The O.P.No.1 on scrutiny of the documents and the proposal form alongwith the premium directed the insured to face Medical examination and pursuant to the direction, the insured appeared before Nidan Diagnostic Centre Berhampur and was found to be fit. After receipt of the Medical reports, the O.P.No.1 accepted the proposal as well as the premium and issued the policy bond No. 09011180507 covering the risk dated 20.09.2013 and sent the original policy bond by the O.P.No.1 through speed post by enclosing the Xerox copy of the proposal form. The insured after receipt of the original policy bond and proposal form when he came to know that the fact of previous policy made by him has not been correctly filled up and answered in negative in column No.11 of the proposal form he however informed to the Regional Director, Bhubaneswar of the O.P.No.1 about the fact of previous policies made by him with the HDFC life Insurance Co. ltd and ING Vysya Life Insurance Co. Ltd. Describing the policy numbers of the said respective Life Insurance Companies on dated 07.10.2013. The mode of the payment of premium is semi-annual and the next due date of payment of the premium was on 20th March 2014. The O.Ps after receipt of the letter dated 07.11.2013 did not make further query/objection about the insurance made by the insured. While the policy was inforce, the insured husband of the complainant suffered from fever and was carried to MKCG Medical College and hospital, Berhampur on dated 04.12.2013 for treatment but he was not admitted as the indoor patient. When the insured was not recovered from fever, the complainant with the assistance of her relatives carried her insured husband to Sriram Hospital, Berhampur for better treatment on dated 11.12.2013. The doctors of the said hospital after conducting all types of pathological tests admitted the insured husband of the complainant as indoor patient on the same day for treatment due to suffering from complicated malaria. When the condition of the patient was not improved the treating doctor of the said hospital advised the complainant and her relatives to shift him to a higher centre for further better treatment. Accordingly the treating doctor of the said hospital issued discharge certificate on dated 14.12.2013 at about 10.15 A.M. The complainant and her relatives carried her ailing husband to their village Kirtipur to arrange money and man power to take her ailing husband to a higher centre on same day i.e. on 14.12.2013. In course of busy in arrangement of money and man power, the insured husband of the complainant was unfortunately died on the same day at about 11.10 A.M. The local A.N.M. informed the fact of death of the insured to the Registrar of Birth and Death CHC Keluapalli where the death of the insured has been registered. The complainant claimed Rs.6,00,000/- before the O.P.No.2 by enclosing the related documents together with treatment papers, death certificates, original policy bond on darted 26.08.2014. The O.P.No.1 without taking into consideration of the facts and related documents out rightly rejected the claim on the ground that the insured has suppressed the fact of previous policy made with other companies at the time of submission of proposal form and communicated the rejection order vide their reference No.64854/OPS/14/CL/D/105341 dated 04.03.2015. The complainant being aggrieved preferred review before the Review Committee of O.P.No.1 on dated 20.04.2015 by enclosing the related documents. But the Claims Review Committee of the O.Ps did not take any action to reconsider the grievance of the complainant. When the O.P.No.1 did not consider the claim, the complainant approached before the Arbitrator of the Insurance Company here-in-after called the Insurance Ombudsman on dated 28.05.2015. The Insurance Ombudsman registered a complaint vide reference No. BHU-1-041-1516-2013 dated 08.06.2015 and directed the complainant for submission of facts in brief. The Insurance Ombudsman in course of hearing did not take into consideration of material facts and documents confirmed the rejection order of the O.P.No.1. The order of the Insurance Ombudsman is highly illegal, perverse and is not sustainable. The insured Pemi Debaraj was a business man and an income tax assesses. In order to avail income tax rebate he insured with different Life Insurance Companies during his life time. He had got taxable gross income out of his business and was capable to pay the premium amount towards the insurance policies made by him with different Life Insurance Companies by paying premium and to get income tax rebate. Rejection of claim by the O.P.No.1 on the ground that the insured has suppressed the previous fact of insurance is completely arbitrary, illegal and to deprive the complainant to get the legitimate claim. The complainant being the nominee of the deceased insured is a consumer and non settlement of the claim by the O.Ps amounts to deficiency in service. Alleging deficiency in service on the part of the O.Ps the complainant prayed to direct the O.,Ps to settle the policy bond No.09011180507 of Rs.6,00,000/- with 12% interest, compensation of Rs.50,000/- and litigation cost of Rs.10,000/- in the best interests of justice.
3. The O.Ps filed written version/written argument through his advocate. It is stated that the complainant has availed a policy from O.P. in which the complainant is the nominee. Basing on the particulars furnished by the proposer in the proposal form the policies are being issued with utmost good faith. Prior to availing the policy they are giving a declaration regarding the facts started in the proposal form are all true and if later any mis statement would be detected the policy would be void abinitio. In the instant case the deceased policy holder has availed the policy by suppressing his earlier policies obtained from other companies as per communication obtained from other firms i.e. from Exide Life and HDFC life which was revealed during investigation of the death claim. Thus the policy obtained by way of miss statements furnished earlier at the time of taking the policy. There is a specific point No.11 which asks for any other policies obtained by the policy holder to which the policy holder answered in negative. Moreover the deceased policy holder did not disclose that the matter was earlier heard before the OMBUDSMAN which awarded as dismissed. This hits the principles of RES JUDICATA. In this case the deceased policy holder has suppressed in both the counts i.e. obtaining other policies from other firms and the matter was heard earlier with the same issued and between same parties. If he would have disclosed the facts of availing the other policies, this policy would not have been issued. As the deceased policy holder had obtained the policy by suppressing the material facts and in a fraudulent manner, the company has rightly repudiated the death claim of the complainant basing the declaration given in the proposal form. Hence the O.Ps prayed to dismiss the case with cost.
4. On the date of hearing both parties are present. We heard argument from both sides at length. We perused the complaint petition, written version, written argument and documents available in the case record.
5. On foregoing discussion, in our considered view the O.Ps. have issued the policy in favour of the DLA after getting confirmation from all corners and assured the DLA in terms of policy contract. It tantamount that, the O.Ps have issued said policy after full and final satisfaction of clauses required to issue a life insurance policy to the DLA Pemi Debaraj. After elaborately adduced documents available in case record, it comes to table that, the complainant has disclosed the fact about other two insurance policies in the complaint and in a letter issued to the Regional office of the O.P. and review committee for consideration which were filed in Annexure-2 and Annexure-7 as well. Therefore the complainant has not suppressed any material fact to the O.Ps. Secondly, the order of the Ombudsman does not attract the principle of resjudicata. The law is well settled in catena of cases that, adjudication of grievance of the insured by the Ombudsman is very limited to administrative cause only but not otherwise. So it cannot be said that the order of the Insurance Ombudsman attracts the principle of resjudicata.
On analysis of the evidence and documents of both the parties the O.P. failed to bring any evidences to the case record that the complainant has approached the Commission in clean hand. Therefore, the O.Ps are liable to pay the life assured amount to the nominee. Hence there is deficiency in service rendered by the O.Ps by repudiating the claim made by the nominee violating their own assured contract policy and not considered the Annexue-2 and 7 which was issued prior to this complaint.
6. The Commission relied the principles laid down by the Hon’ble National Commission that “Once proposal is accepted and policy is issued LIC is liable for payment of claim” 2011 (4) C.P.R LIC of India verses Prabhasa Ranjan Nayak. Further Hon’ble National Commission, New Delhi in Life Insurance Corporation of India versus Pariapally Sujatha & ors 2009 (4) CPR 326 held that, “Death claim cannot be repudiated by LIC without any tangible evidence”. As such the Commission fixed the liability upon the O.Ps.
In the light of the above principles of law, the Commission allowed the case on contest in the interest of the justice.
In the result, the complainants’ case is allowed against O.Ps. The O.Ps who are jointly and severally liable are directed to settle the policy bond No. 09011180507 of Rs.6,00,000/- of Pemi Debaraj with interest at the rate of 6% per annum from the date of filling of the case i.e. 02.02.2016 in favour of the nominee/complainant together with pay litigation cost of Rs.7,500/- to the complainant within 45 days of receipt of this order. In the event of non-compliance of the Order, the Complainant is at liberty to recover the entire dues at the rate of 09% interest per annum till its actual date of realization and rights to take appropriate steps in accordance to the Consumer Protection Act, 2019.
This case is disposed of accordingly.
The Judgment be uploaded on the www.confonet.nic.in for the perusal of the parties.
A certified copy of this Judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986. A copy of this order be also sent to the Secretary, State Consumer Disputes Redressal Commission, Odisha, Cuttack for information.
The file is to be consigned to the record room along with a copy of this Judgment.
Pronounced on 09 December 2024.
