District Consumer Disputes Redressal Forum Dumk
Complaint Case No- 01/2017
Date of filing Date of Admission Date of Order
18.01.2017 25.01.2017 27.04.2018
Wakil Ahmad S/o Late Gafur Mian, r/o-Village- Parsimla, P.O- Pahrudih, P.S- Masanjore, Subdivision and District- Dumka, Jharkhand
(Respresented By Mahadeo Mahato , Advocate)
………….. Complainant.
Versus
(i) The Manager Life Insurance Company Ltd. Nahar Park, Rampurhat Road,
Dumka, P.O + P.S – Dumka, Subdivision and District – Dumka, Pin – 814101.
(ii) The Chairman, Life Insurance Company Ltd. Yoga Kshema Jeevan Bima
Marg, P.B. No – 19953, Mumbai- 400021.
(iii) The Divisional Manager, Life Insurance Company Ltd. Bhagalpur, Jeevan
Prakash Zero Mail Road, Bhagalpur- 813210.
(Respresented by Bidyut Kumar Ambastta, Advocate )
………. Opposite Parties.
BEFORE:-
PRESIDENT:- Shri Ram Naresh Mishra
MEMBER :- Smt. Dr. Babita Kumari Agrawal
O R D E R
The instant complaint has been filed by the complainant Wakil Ahmadagainst the Opposite Parties i.e. Manager Life Insurance Company Ltd, Dumka, Chairman Life Insurance Company, Mumbai and Divisional Manager, Life Insurance Company Ltd. Bhagalpur U/S-12 of the Consumer Protection Act,1986 for illegally and arbitrarilynot settling thedeath Claim of life assured Gafur Main (Since deceased) who was insured vide Policy No.525456354 on 25.07.2011 for sum assured of Rs. 4,00,000/-(Four lac) in which the complainant stood as nominee, in gross negligency and deficiency in service and thereby causing mental tension, agony etc. to the complainant. The complainant has prayed to direct O.P’s to pay a sum of Rs.4,00,000/-(Four lac) towards Insurance claim amount, further direct to pay compensation of Rs.25,000/-(Twenty five thousand) and also to direct to pay a sum of Rs.10,000/- (Ten thousand) towards cost of the litigation. The complainant has also prayed to allow interest @12% p.a. on the awarded amount.
2. The brief facts of the case as revealed form the format of the complaint and the documents annexed therewith are as follows:-
That the father of the complainantGafur mian s/o ofLate Pana Mainresident of village- Parsimla, P.O.- Pahrudih, P.S.- Masanjore, District-Dumka was insured by the opposite party no.1 Life Insurance Company, Ltd Dumka Branch vide Policy No- 525456354 on 25.07.2011 for a sum assured of Rs.4,00,000/-(Four lac) in which the complainant stood as nominee.
The further case of the complainant is that the life assured Gafur main died on 02.11.2011 due to heart failure at the age of 50 years at his house at village- Parsimla when Dr. S. Pandey was called for at his house for treatment. Thereafter, complainant informed the death of the deceased to the local officer of the Insurance Company, who issued a claim form which was duly filled and signed by the complainant and submitted the same to the local office, Life Insurance Company of Dumka. The complainant after submission of the death claim waited for payment of assured amount and visited many a times to the local office of the LIC, where he was solaced that his claim was in process and it will be paid shortly. The O.P’s company subsequently sent a letter on 21.05.2014 asking him to deposit some documents which were not relevant and were also not possible to collect as the deceased Life assured never suffered from any chronic disease or Hypertension. The opposite parties through the said letter dated21.05.2014 requiredto submit documents relating to treatmentof hypertension, documents relating to chronic disease, Medical bills, Age proof of D.L.A., Income certificate and Ration card etc. The complainant replied to that letter stating that neither D.L.A. was suffering from any chronic disease or hypertension nor he was ever treated for the same. It is further stated that the Dr. S. Pandey, who attendedD.L.A. mentioned in his prescription that the D.L.A. was suffering from “CHD” which only means congestion of heart failure. The doctor in his certificate dated 23.06.2014 clearly mentioned meaning of “CHD” and it was replied to the Opposite party. It is also averred that the complainant visited many a times to the local office of the company and also sent Pleader’s notice on 31.01.2015 to the O.P’s but it was not replied and lastly on 09.01.2016 his death claim was denied. The complained lastly having no optionto filed this case before this forum on 18.01.2017 forthe redressal of hisngrievances.
3. Havingreceived complaint petition filed by the complainant it was admitted on 25.01.2017 andnotice were issued upon the opposite parties, who appeared and contested the case by filling joint written version on 07.06.2017.
4. The opposite parties besides being taken preliminary objection’s such as maintainability and lack of cause of action for the case has admitted that the deceased life assured namely Gafur mian had taken a policy bearing no-525456354 for sum assured of Rs.4,00,000/-(Four lac) having yearly premium of Rs.29,612/-(Twenty nine thousand six hundred twelve) and the policy commenced on 25.07.2011 in which the complainant stood as nominee, who is the son of deceased life assured. The life assured died on 02.11.2011 and as such the policy could run only for three months. It is further stated that the claimant Wakil Ahmad submitted claim form “A”B”C”D” along with an affidivated statement of SafayatHussain with respect to the death of the deceased that the deceased life assured he died due to heart attack but DLA was never treated. It is further stated that after the perusal of the documents submitted by the claimant, Manager ((L &HPF) D.O. LIC, Bhagalpur sent a letter to the claimant to submit treatment papers for the last three years prior to July 2011, claim form B and B1 about last treatment, BHT and case history, Age proof ofD.L.A. and adult children of D.L.A.,Income proof of D.L.A, other policy details of D.L.A. and family members. It is further stated that claimant complied partially to that letter. It is asserted that as per prescription of Dr. S. Pandey and claim form “B” the D.L.A. was suffering from HTN with CHD, CVA, CVD Angina pectoris and was serious withheart disease and died in presence of Dr. S. Pandey on 2.11.2011.Thereupon as per the opinion ofDMR documents namely CT scan of Brain for CVA,CTMT,ECG and Echoquery reportfor “CHD” and anginapectoris, Age proof ofD.L.A., and elder children of DLA and other policy details of D.L.A. and family members were called forbut the claimant failed to submit anysuch documents. Thereafter severalletters i.e. on 10.09.2013, 21.05.2014, 23.03.2014, 26.01.2015, 24.03.2015 and 01.09.2015 were sent to the claimant but he did not submit the requisite documents hence, no claim arose infavour of claimant and also no case of negligency and deficiency in service is made out against the answering O. P’s, and hence prayed to dismiss the complainants.
5. The respective parties have adduced oral as well as documentary evidence in support of their case. The complainant in the support of his case led oral as well as documentery evicence. In oral evidence he has filed his own affidavited statements as C.W-1 Wakil Ahmad, besides he has adduced following documentary evidence:-
-
LIC, Bhagalpur to the complainant ,
Ext-2. Photocopy of death certificate of Gafur mian issued by
Panchyat Secretary Govt. of Jharkhand,
Ext-3. Photocopy of intimation of death ofD.L.A. Gafur
Ext-4. Photocopy of Medical attendants certificate filled in
Annexture-II ofclaim form B dated 02.05.2014
by Dr .S. Pandey;
Ext-5. Photocopy of reply to the letter dated 21.05.2014 of
complainant ;
Ext-6. Photocopy of letter dated 23.06.2014 issued by
Dr. S.Pandey regarding clearfication of the world”CHD”;
Ext-7. Photocopy of prescription dated 02.11.2011 issued by
Dr. S.Pandey;
Ext-8. Photocopyof Medical certificate issued by
Ext-9. Photocopy of claimants statements form A;
Ext-10. Photocopy of certificate of Identity form”C”;
Ext-11. Photocopy of pleader’snotice dated 31.01.2015;
Ext-12. Photocopy of voter I .D. card of D.L.A. of Gafur
Ext-13. Photocopy of Aadhar card & voter I.D.card of
Ext-14. Photocopy of Bank Passbook in the name of Wakil
On other hand no any oral evidence has been adduced on behalf of the oppositeparties, however it has adduced a documentary evidence asi.e. Photocopy of proposal form of D.L.A. Gafur mian, marked Ext “A”.
6. We have heard the argument of both the parties and gone to therecords along with the materials & documents attached therein.
7. The only point for discussion it whether the complainant is entitled to get the relief claimed?
F I N D I N G S
8. That admitted position of the case is that the D.L.A. namely Gafur mian had taken a policy for sum assured for Rs.4,00,000/-(Four lac) commencing on 25.07.2011 in which the complainant stood as nominee. The life assured died on 02.11.2011 and thereupon nominee Wakil Ahmad submitted claim form A, B, C and an affidavited statement of Safayat Hussain in support of the death of the deceased life assured stating that the life assured died of heart attack and he was not treated earlier. It is also anadmitted fact that the Divisional Manager LIC, Bhagalpur, after perusal of the submitted papers asked the complainant to submit treatment papers for the last three years prior to Jully2011, claimform B and B1, Papers of treatment for the last three yerars, B.H.T case history, Age proof of D.L.A. and his adult children, income Proof of D.L.A and other policy details of D.L.A and his family members. It is further admitted fact that claimants partially complied to the said letterby submitting income proof and claim form ‘B’ duly filled by Dr. S. Pandey as well as the death certificate issued by same doctor. It is also admitted fact that opposite parties furtherrequired to submitCT scan of brain for CVA,CTMT,EGC andEchoquery report for CHD and Angina pectoris , Age proof of D.L.A. and also elder children and other policy of D.L.A. and his family member. However, the claimant could not submit any thing as per the said requirement. It is claimed by O.P’s that no claim arise arose at the end ofLIC, In this connection the complainant has asserted in para 3&4 of his complain petition, that he submitted all the required documents and he was continuously visiting opposite parties local office at Dumka. He received letter dated 21.05.2014 whereby O.P.L.I.C. asked some more documents which were neither relevant not possible to collect as the D.L.A was not suffering from any chronic disease of Hypartension. In reply to the letter dated 21.05.2014 claimant submitted reply letter slating that the D.L.A was neither treated not suffering from anychronicdiseaseor hypertension. It is further asserted that the complainant in support of his version sent letter of Dr. S. Pandey dated 23.06.2014, in which the said doctor clearly said that themeaning of CHD is congestion of heart failure. It has been asserted by the complainant that claim of the O. P’sthat they sent letters dated 10.09.2013, 23.08.2014, 28.01.2015, 24.03.2015 and 01.09.2015 are entirely wrongrather only one letter dated 21.05.2014 was received in which O.P’s demanded certain documents which complainant could notsubmit as D.L.A. was not suffering from any such disease.
9. Ext-1 is the letter dated 21.05.2014 of the O.P’s which shows that demand made for submitting age proof of D.L.A. and adult children of D.L.A., Income proof and all the documents prior to 02.11.2011relating to treatment of hypertension and chronic heart disease ofDLA along his test reports and medical bills.Ext-2 is the death certificate of .D.L.A . Ext-9 and Ext-10 are the claim forms No- “B”and “C”respectively and from their perusal it appears that they are related to the medical attendants certificate issued by Dr. S. Pandey in which in Para4, 5 it is clearly stated that the patient was not suffering from any deceased previously and the patient died of congestion of heart failure. It is also mentioned that no other disease was found at the time of death of the patient except closing of valve. In para-11 doctor has further mentionedthat the patient was not suffering from Angina pectoris and CHD from previously. Ext-5 is the letter of the claimant Wakil Ahmad in reply to the letter dated 21.05.2014 of the O.P’s LIC in which he has clearly mentioned that hisfather was not suffering from either Hypertension or chronic heart disease from before 02.11.2011. Ext-6 is the letterof Dr. S. Pandey to the Claim Manager Divisional office LIC, Bhagalpurdated 23.06.2014in which he has clearly mentioned that in the death prescription of the deceased GafurMian he has mentioned “CHD” which means congestion ofheart failure but it does not mean chronic heart disease. Further the claimant has filed his Pleaders notice dated 31.01.2115 sent to the opposite parties where in he has clearly mentioned that Life assured Gafur Mian died on 02.11.2011 and then he submitted claim forms, along with all documents but even after lapse of three years his claim was not settled by them. But the Opposite parties have not replied to this notice and this shows that the questionraised by O.P’s.haveno leg to stand. All the requisite papers were submitted and queries were explained and querry as furtheralleged been made at page-3 of the show-cause have not been brought on the record and even if such documents were required it were clearly irrelevant and uncalled for as the complainant and the doctor who attended the deceased at the time of his death have clearly stated that the D.L.A. Gafur mian was not suffering from any disease from before his death on 02.11.2011. In this connection it is settled Principal of Law that one who alleges or claims about existence of any fact should lead evidence in support thereof, but the opposite parties LIC did not adduce any document to show that prior to the death of the Life assured he was suffering from any chronic heart disease or hypertension.
C.W-1 Wakil Ahmad, the complainant himself in his statements on oath as well as in his cross examination clearly stated that his father died on 02.11.2011 and then, he submits claim froms along with all documents but vide letter dated 21.05.2014 O.P’s demanded some unnecessary papers like hypertension, Chronic disease, Children’s birth details etc. and lastly death claim of his father was not psettled . The opposite parties have not led any evidence in support of their case for not settling the death claim of the claimant.
10. The learned Counsel for the complainant in support of his case has relied upon following rulings:-
- 2012(4) CPR Page 231(NC) in which the Hon’ble NCDRC New. Delhi held” Repudiation of death claim on the ground that insured had suppressed material fact that he was suffering from heart ailment…….There is no evidence which may go to show that insured had ever consulted doctor for taking treatment for the said disease Revision petition dismissed.
- 2017 (2) CPR page 688 (NC) in which Hon’ble NCDRC New Delhi held “ Allegation of concealment of the material information about health condition on the part of decease is not established from the record –complainant is entitled to get sum assured…………’'
- 2012(3) CPR page 65 in which Hon’ble Rajasthan State Consumer Disputes Redressal Commission, Jaipur held “Once accepting premium and having entered into an agreement without verifying facts Insurance Company cannot wriggle out of liability merely by saying that contract was made by misrepresentation and concealment.
These ruling fully support the case of the complainant. Where as the opposite Party Parties have not replied to the to the law points raised by learned counsel for the complainant.
11. Consideration the aforesaid facts, circumstances, evidence and the principal of law settled by the Hon’ble Court’s in the above rulings we find that the complainant /claimants furnished all required documents to the opposite parties/ LIC after the death of life assured Gafur Mian and had also explained meaning of the medical terminology but the death claim of the D.L.A. was neither settled nor payment was made by the Insurance Company. Besides it did not give any repudiation letter to the complainant thus, we find that the opposite parties/ Life Insurance Company has acted arbitrarily, despotic and capricious manner which amounted to negligency and deficiency in service and therefore liable for the reliefs claimed by the complainant.
It is therefore,
O R D E R E D
That the complainant’s case be and the same is allowed on contest with cost against the O.P’s (L.I.C. of India) and hence, the O.P’s (L.I.C of India) is directed to make payment of sum assured of Rs. 4,00,000/-( Four lac) along with interest 12% p.a. from the date of death of life assured Gafur Mian i.e. 02.11.2011 till its payment, further the O.P’s(L.I.C. of India) directed to make payment of compensation of Rs.25,000/-(Twenty five thousand) for the mental tension, agony etc. caused to complainant as well as make payment of Rs.5,000/-(Five thousand) towards cost of litigation to the complainant.
The order must be complied within one month from the date of receipt of this order failing which necessary legal action will be taken against opposite Parties ( L I C of India).
The office is directed to furnish copy of the order to the parties or their concerned Advocates free of cost.
This case, is thus, stands disposed off.
