The Complainant has filed this case alleging deficiency-in-service by the O.Ps, where O.P No.1 is the Managing Director-cum-Chief Executive Officer, Bajaj Allianz Life Insurance Company Ltd., Pune, O.P No.2 is the Claims Review Committee, Bajaj Allianz Life Insurance Company Ltd., Pune and O.P No.3 is the Regional Head, Bajaj Allianz Life Insurance Company Ltd., Balasore.

                    2. The case of the Complainant in brief is that the Complainant is the wife of Ram Chandra Das Adhikari, who had three Bajaj Allianz life insurance policies bearing Nos.0311700041, 0311619370 and 0313169162, date of commencement: 27.01.2014, 01.02.2014 and 11.03.2014 for sum assured of Rs.1.22 Lacs, Rs.2.50 Lacs and Rs.2.00 Lacs respectively, where policy term is 20 years for policy Nos.0311700041 and 0311619370 and for policy No.0313169162 is up to 73 years of age, in which his wife Smt. Gayatri Das Adhikari, the Complainant is the nominee. But, unfortunately, the policy holder Ram Chandra Das Adhikari died on 31.10.2014 due to cardio respiratory failure, while he was under treatment of Dr. S.R Jena. As such, the Complainant being the nominee of above said policies, 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 to the Complainant. Moreover, the Complainant received letters from O.P No.2 mentioning therein “the claim has been repudiated due to non-disclosure of material facts amounting to fraud”. On receipt of said letter, the Complainant had been to the Office of O.P No.3 and described about cause of death of her husband i.e. “failure of cardio respiratory”, as such her husband has neither suppressed any material facts nor submitted any false documents before the O.Ps at the time of commencement of said policies. Though the Complainant requested the O.Ps for payment of death claim of her husband, but the O.Ps did not pay any heed to it, causing mental agony and financial loss to the Complainant. Thus, the Complainant sent legal notices to the O.Ps on 21.09.2017 for deficiency of service by the O.Ps. Cause of action to file this case arose on 18.09.2017 and 21.09.2017. The Complainant has prayed for payment of death claim amount with interest along with compensation for mental agony and litigation cost.

                    3. Though sufficient opportunities were given to O.Ps No.1 and 2, but they have not appeared in this case. The O.Ps No.1 and 2 are set ex-parte.

                    4. Written version filed by the O.P No.3 through his Advocate denying on the point of maintainability, jurisdiction, limitation as well as its cause of action. The O.P No.3 has further submitted that as per the proposal dtd.22.01.2014, 25.01.2014 and 10.03.2014 submitted by the deceased insured Rama Chandra Das Adhikari, the policy certificate bearing No.0311700041, 0311619370 and 0313169162 are issued subject to its terms and conditions. All the information in the proposal form are duly declared and submitted by the deceased life assured before the O.P No.3, wherein the proposal form in column-22 (Declaration of Good Health), it is declared/ mentioned/ submitted by the deceased that he was not suffering from any disease including the Kidney disease as per column-22 (f) of the proposal form and considering the self declaration of the insured in good faith, the respective insurance policies were issued. Thereafter, on 08.03.2016 the Kontai Branch received the information with regard to death of the insured on 31.10.2014 due to “cardio respiratory failure” at his residence. Though, the insured has died on 31.10.2014, the death information submitted by the Complainant on 08.03.2016 is at inordinate delay. The insured has died on 31.10.2014 (i.e. within one year of taking policy) and thereby, the said claim comes under early claim category and thereby, necessary investigation was carried out by the insurance company by deputing an investigator, who has found that the deceased life assured had obtained the insurance policies with a false declaration with regard to his health. Therefore, the claim of the Complainant is not entertained as it is not within the scope and coverage of the policy, for which the death claim was repudiated as per provisions U/s.45 of the Insurance Act, 1938 for suppression of information at the time of taking policy. This fact of repudiation is also intimated to the Complainant vide letter dtd.25.03.2016. Moreover, during the course of investigation, the investigator has obtained the detail of case history with regard to the pre-existing disease of the deceased, for which he was undergoing treatment with Sparsh Hospitals & Critical Care (P) Ltd., Bhubaneswar on 03.12.2013 and discharge summary issued by the said Hospital reveals that the deceased was treated there for the disease “Chronic Renal failure”. Thus, it is ascertained that the deceased was suffering from critical disease prior to submission of proposal for insurance policy and he has knowingly/ mischievously suppressed the fact of suffering from Kidney disease prior to the commencement of policy, with an intention to defraud the insurance company. It is pertinent to mention here that while issuing the policy, the company underwrites the risk on the basis of the statements made in the proposal form and personal statement on the presumption that the statements so made are true in all respects. The insurance contract is based upon the principle of “Uberrimafides” i.e. “Utmost good faith”, wherein the proposer is required to make a full and fair disclosure of the material facts in the proposal form. As per Section-45 of Insurance Act, 1938, if there is a mis-statement of fact in the proposal form with regard to the material fact and the same has been fraudulently suppressed, the insurance company is at liberty to repudiate the claim. Thus, the claim of the Complainant being illegal and bears no merit, is liable to be dismissed with cost.

                    5. 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) Whether the case is barred by law of limitation ?

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

                    6. 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 3 Bajaj Allianz life insurance policies for sum assured of Rs.1.22 Lacs, Rs.2.50 Lacs and Rs.2.00 Lacs respectively. Out of 3 policies, the policy term is 20 years for 2 policies and the other one is up to 73 years of age of the policy holder. 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 after thorough scrutiny, it was repudiated by the O.Ps, 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, the O.Ps No.1 & 2 are set ex-parte as mentioned earlier and it has been argued on behalf of the O.P No.3 that at the time of submission of proposal form, the policy holder had given certain declaration according to column-22 regarding declaration of good health of the same form 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 Kontai Branch of the O.Ps received the death claim from the Complainant on 08.03.2016 and according to the Complainant, the death of the policy holder was due to cardio respiratory failure at his residence. 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-5 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-4. According to the O.P No.3, as it was an early death claim, necessary investigation was carried out by the insurance company by deputing an investigator, who has disclosed that the policy holder had pre-existing disease, for which he was undergoing treatment with Sparsh Hospitals & Critical Care (P) Ltd., Bhubaneswar on 03.12.2013 and discharge summary issued by the said Hospital reveals that the deceased was treated there for the disease Chronic Renal failure. So, it shows that the policy holder had suppressed material facts without disclosing the real fact. The O.P No.3 has filed xerox copies of such medical documents like treatment and follow-up card vide Annexure-V and discharge summary vide Annexure-VI. So, it has been argued on behalf of the O.P No.3 that at the time of submission of proposal form, the policy holder had very much knowledge about the pre-existing disease and he had suppressed the same for the reason best known to him. According to Section-45 of the Insurance Act-1938, if the policy holder has suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that the statement was false, the insurance company has right to repudiate the claim. So, even if the policy holder died due to cardio respiratory failure, he had pre-existing disease as per medical documents available in the case record, which was suppressed by the policy holder at the time of taking the policies. Further, it has been argued on behalf of the Complainant that the O.P No.3 has 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.P No.3 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 disease like Chronic Renal failure, for which he had under treatment at Sparsh Hospitals & Critical Care (P) Ltd., Bhubaneswar about one month 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.    

                    7. 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 ex-parte against the O.Ps No.1 & 2 and on contest against the O.P No.3, but in the peculiar circumstances without cost.  

                         Pronounced in the open Forum on this day i.e. the 31st day of January, 2019 given under my Signature & Seal of the Forum.