Orissa

Cuttak

CC/87/2015

Baijayanti Sahoo - Complainant(s)

Versus

The Secretary General,Governing Body of Insurance Council - Opp.Party(s)

R Biswal

05 Sep 2019

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL FORUM,CUTTACK.

        C.C No.87/2015

 

Baijayanti Sahoo,

W/O:Late Susanta Kumar Sahoo,

Plot No.306,Debananda Vihar Apartment,

Bamikhal,Bhubaneswar-751010.

At present:Baijayanti Sahoo,

At:Parida Sahi,PO:Arunodaya Market,

P.S:Badambadi, Cuttack-12.                                                                        … Complainant.

 

                Vrs.

 

1.         The Secretary General,

Governing Body of Insurance Council,

Jeevan Annexe,3^rd Floor(above MTNL),

S.V.Santacruz9w),Mumbai-400054.

 

2.         Amitabh Verma,Chief Operating Officer,

Birla Sun Life Insurance Company Ltd.,

One Indiabulls centre, Tower-1,15 & 16^th floor,

Jupiter mill compound,841,Senapati Bapat Marg,

Elphinstone Road,Mumbai-400013.

 

3.        Gadadhara Samantaray,Business Development Manager,

3^rd floor,Plot No.53/1384/1828,

Unit No.31,Laxmisagar,Bhubaneswar,Khurda District,

Orissa-751010.                                                                                        … Opp. Parties.

 

Present:               Sri Dhruba Charan Barik,LL.B. President.

Smt. Sarmistha Nath, Member (W).

 

Date of filing:     26.08.2015

Date of Order:   04.09.2019

 

For the complainant        :   Sri Raghunath Biswal,Adv. & Associates.

For the O.P.No.1              :                 None.

For O.Ps.2,3,4 & 5            :   Sri L.Sahoo,Adv. & Associates.

      

Sri Dhruba Charan Barik,President.

                The complainant has filed this case against the O.Ps alleging therein deficiency in service on their part and seeking appropriate relief against them in terms of her prayer in the consumer complaint.

1. The facts of the complainant’s case stated in brief are that the complainant happens to be the wife of Late Susanta Kumar Sahoo who was a businessman and social activist.  He was the Director of ‘IMAGE’ a renowned college of professional courses.  The deceased obtained an insurance policy from the O.P,Insurance Company under Birla Sun Life Insurance Company Ltd. BSLI  Company Vision Plan on 12.6.12 in the name of his daughter Sunena Sujayani.  The period of the said policy is 100 years and the date of maturity is 12.6.2112.  The annual policy premium was fixed at Rs.1,00,000.23p which was due to be paid on 12^th of every June.  The entire policy premium was payable for 16 years and the last premium is fixed for payment on 12.6.2027.

There was also a rider policy issued by the BSLI Company Ltd. in favour of the deceased and the benefits under the said rider policy were sent as in case of BSLIC Vision Plan.The above two policies were running simultaneously.The sum assured is Rs.13,53,110/- and the Guaranteed Survival Benefit(GSB in short) was Rs.16,87,328/- respectively.The BSLIC Ltd to float their policies more effectively in market, have introduced this rider policy system where an insurance policy is done for the insured for certain amount of premium, a rider will be introduced at the same time with the very negligible premium so that the rider will be covered under the same benefit like that of the policy for the insured.This rider policy forms part of the policy contract and shall be governed by the policy terms and conditions applicable to the policy for the insured.The rider policy will have the rider sum assured, rider term, the annual rider premium etc.It has been clearly mentioned in the policy details that the claim can be submitted against termination of the rider and in that event the claims applicable to the base policy holder would also be applicable to the rider.

The rider Late Susanta Kumar Sahoo was a healthy person but he died on 20.12.13 of Carsinomastomach which is otherwise known as stomach cancer at Hemalata Hospital and Research Centre,Bhubaneswar.According to the terms and conditions of the policy documents, after the rider was dead the amount due was supposed to be given to the complainant, the wife of the rider but the BSLI Company Ltd who are the O.Ps instead of paying the dues as per the terms and conditions of the policy, have changed the rider by virtue of an affidavit executed by the complainant at the instance of the O.Ps.It has been done with malafide intention to continue the rider policy for illegal gain.For that reason the insurance planning official’s denied to pay the rider claim of the deceased when such claim was made by the complainant.Even several representations made at regular intervals by the complainant to BSLI Company Ltd. for the said purpose did not evoke any response from them.They were sitting silent over the mater for a long period which has caused serious mental agony and harassment to the complainant.

It is stated that the complainant is entitled to Rs.5,0,000/- towards compensation for mental agony and harassment caused to her, Rs.13,53,110/- towards the rider claim, Rs.1,00,000/- towards the legal expenses which comes to Rs.19,53,110/- and the O.P,Insurance Company may be directed to pay the same in the interest of justice together with other reliefs as deemed fit and proper.

The complainant has filed photo copy of BSLI Company Ltd. Vision Insurance Plan, photo copy of death certificate of the deceased Susanta Kumar Sahoo, photo copy of the statement of the claimant, photo copy of the PAN card, Voter Identity card of the consumer/complainant and photo copy of the deed of relinquishment of the complainant in support of her case.They have been marked as Annexure-1 to 5 respectively.

2. The O.P No.1 represents the Secretary General of the office of the Governing Body of Insurance Council( in short GBIC).  In the written version filed by O.P.1 it is stated that this office of GBIC does not deal with or entertain any type of complaint received from the insured customers.  If any such complaint is required to be filed, it is to be filed before the Insurance under the Redressal of Public Grievances Rules,1998.  As such the office of O.P.1 has nothing to do with the complaints made by the complainant.  It is accordingly prayed that O.P.1 may be exempted from being a party to this case.
3. O.Ps,2,3,4 & 5 have jointly filed their written version and contested the case.   At the outset, it is contended that the case is not maintainable both in fact and law.  There is no cause of action to file the case and there is no deficiency in service on the part of O.Ps in any manner.  It is further stated that the deceased has suppressed the material fact with regard to his medical history and disclosure of the disease he was suffering from.  Because of such deliberate concealment of the material information in the proposal form by the deceased, the deceased had denied the answering O.Ps the opportunity to assess the risk under the said proposal in a prudent manner.  The said policy issued to the deceased was an outcome of fraud and misrepresentation because of the deliberate concealment of the material information with regard to the pre-existing disease of the deceased and as such the claim of the complainant is not acceptable.

It is pertinent to mention here that there are two policies i.e. policy bearing No.005611057 and 005611058 issued on 12.6.12 in the name of the policy owner Susanta Kumar sahoo under which the claim was repudiated but the complainant has mentioned only about one policy i.e. Policy No005611057issued in favour of Sunena Sujayani.A copy of the application form and illustrations filed in this case have been marked as Annexure-A. Annexure-B is the copy of the terms and conditions of the said policy.The O.Ps have also filed photo copy of death claim intimation, claimants statement and death certificate of the deceased which have been marked as Annexure-C series.A copy of the investigation report along with affidavit has been filed and marked as Annexure-D series.Annexure-E is the copy of the repudiation letter dt.30.11.13 of the claim made by the complainant. O.Ps,2,3,4 & 5 have jointly filed an affidavit in support of their stand.

In view of the above, it is prayed that the consumer complaint is devoid of merit and accordingly be dismissed.

4. We have heard the learned counsels from both the sides and gone through the case records and annexures filed by both the parties.
5. The death claim of the complainant was repudiated by the O.Ps on the ground that the deceased was suffering from pre-existing disease and that such material fact was deliberately suppressed by the deceased while filing the proposal form.  This is tantamount to violation of the terms and conditions of the policy and has resulted in repudiation of the claim.  Contrary to it the learned counsel for the complainant has fairly argued that there was no material suppression of any pre-existing disease especially when there was no medical examination conducted by the competent authority of the deceased before the proposal form was filed.  It is an admitted fact that the deceased signed the proposal form on 25.5.2012 for obtaining the insurance policy without there being any prior medical examination conducted of him.  There is also no specific mention of the disease carcinoma found in the proposal form that he was suffering from.  Subsequently the proposal form was accepted and rider policy No.005611057 was issued on 12.6.2012 in his name.  When the death claim was made by the complainant the matter was investigated into at the level of O.Ps and photo copy of the detailed investigation report has been filed which has been marked as Annexure-D.  It is revealed from Annexure-D that Endoscopy and USC test of the deceased w as done at Nilachal Hospital,Bhubaneswar on 17.3.12.  Specimen was taken from the gastric tumor for biopsy test at Lilabati Hospital,Mumbai on 24.3.12.  The diagnosis report reveals that the deceased was given 3 courses of chemotherapy on 29.3.12.  The deceased was admitted to Hemalata Cancer Hospital,Bhubaneswsar for treatment on 15.2.13 and lastly expired in the same hospital on 20.2.13 i.e. after lapses of 8 months and 13 days of issuance of policy.  There is absolutely no counter made to it by the learned counsel for the complainant.

The learned advocate for the complainant has further argued that medical examination of the deceased before submission of the proposal form and acceptance of the premium by the O.P is compulsory and the O.Ps have failed to comply with the same.In this connection he has relied upon a decision of the Hon’ble Apex Court reported in (2018) 1 SC eJ 457(D. Srinibas Vrs. SBI Life Insurance Company Ltd. and others).On perusal of the said decision, it is found that medical examination of the proposer is compulsory prior to accepting the premium if the proposer was willing to undertake the medical examination.It has been categorically held that if the premium is accepted by the O.P without such medical examination being conducted then it is held that the O.P has waived the conditions precedent of holding medical examination.But the facts and circumstances of the case of the parties here are quite different.There was no whisper about the fact that the deceased was ever willing to undergo medical examination prior to filing the proposal form.With due respect, it is held that the observation of the Hon’ble Apex court in the facts and circumstances of the case is not applicable to the case in hand.On the other hand the learned counsel for the O.Ps has advanced his argument that in the prayer portion, the complainant has made prayer to get the total benefit amounting to Rs.19,00,000/- approximately along with interest calculated on it.No specific calculation has been made for this purpose, rather it is stated that if the interest component would be added, it would exceed Rs.20,00,000/-, which is beyond the pecuniary jurisdiction of this Forum.That apart it has been further submitted by the learned advocate for the O.P that although two policies have been repudiated yet claim has been made for the benefit of one policy i.e. policy bearing No. 005611057 meant for the deceased.In that view of the matter it is stated that the claim made by the complainant is not tenable under law on the ground of pecuniary jurisdiction.There is no effective counter made to it by the learned counsel for the complainant.

From the above discussion, it is held that the complainant has failed to prove deficiency in service on the part of the O.Ps in any manner.Hence ordered;

                                                                   ORDER

The case of the complainant be and the same is dismissed on contest against the O.Ps.

                    Typed to dictation, corrected and pronounced by the Hon’ble President in the Open Court on this the 5^th day of September,2019  under the seal and signature of this Forum.

                                                                                                                                                  

    (   Sri D.C.Barik )

                                                                                                                      President.

                                                             

                                                                                                              (Smt. Sarmistha Nath)

                           Member(W)