The complainant has filed this Complaint against the Opposite Party (herein after referred in short as OP) u/s 12 (2) of Consumer Protection Act, 1986 alleging deficiency in service against OP.

2.    The brief fact of the case is that the Complainant is permanent resident of Dharwad. The husband of the complainant deceased Basavaraj.S.Pattihal insured his life by purchasing insurance policy bearing No.697862309 from divisional office Dharwad and paid a premium of Rs 4187/- and nominated his wife (complainant) as a nominee to the said policy. On 16.05.2014 the husband of the complainant (Insured) died at KIMS Hubli. 

3.      Further complainant submits that the complainant claimed for the said insured amount she approached to the Hyderabad zonal office in-turn the said office replied that they have forwarded the claim details to the OPs office, The complainant approached the Ops office the officials of the Ops inform that within five days after consulting with their higher authorities they will inform her. Further complainant alleged that after laps of sufficient time the OP had not progressed the process of the claim the complainant approached the Ops office several times, but Op was postponing the process by stating one or the other reasons. On 24-02-2015 the OP sent a letter rejecting the claim, the complainant immediately approached Hubli branch the officials of said office refused to comment on it. After that complainant repeatedly approached the officials of Op to look into the matter but they refused to do so.

4.      Further complainant wrote a letter to zonal office Hyderabad and Mumbai to reconsider the matter but after 6 months i.e., 14.09.2015. The divisional office Dharwad informed the complainant that they are unable to revise the decision of rejection of the claim of the policy and further complainant submits that insured (Husband of the complainant) was healthy at the time of contract of life insurance and he had not withheld any information about his health the repudiation of claim is not just, hence complainant filed this complaint seeking relief to pay the sum assured along with 18% interest further prayed to order for reliefs as the Forum deems fit. 

5.  The predecessor on seat registered the Complaint and notice were ordered as such OP appeared through his advocate and filed their Vakalat and Written Version.

Brief facts of the Written Version of OP:

That the OP had denied the contents of the Complaint and further stated that the policy issued by the OP and number of the policy is admitted, and OP submitted that the documents which are produced before the forum as Annexure A and B that is the proposal form and policy bond  is admitted that the complainant is the nominee of Basavaraj.S.Pattihal, the complainant being a nominee submitted a claim form with necessary document.

6.      Further Op submit that the claim is an early claim the Op appointed an investigation officer to verify the cause of death and whether the claim is bonafide or not, the investigation officer revealed that the deceased (Proposal) suppress the information relating to his availment of Sikh leave from 30-07-2013 to 01-10-2013 total 64 days It reveals that the proposer suppressed the material fact while answering in a proposal form, after taking all information about the complainant OP states that Op had not made any deficiency in service, after going through the records and the materials fact of the case Op found that complainant was suffering from chronic synovitis in his left knee, hence he had taken leave for 64 days, hence this claim is rejected for suppressing the material facts, since OP prayed to dismiss the complaint.

7.     In the background of the above said pleadings, the Complainant filed his affidavit and produced photo copies of the document 7 in number, the documents produced are:

1. Photo copy of the LIC bond.

2. Photo copy of repudiation letter.

3. Legal notice.

4. Postal receipt and Postal acknowledgment.

5. Letter from LIC.

6. Photo copy of death certificate.

7. Photo copy of geological tree. 

8.      On the other hand, Op filed the Written Version one Sri. Hanumappa, The Manager, Legal and HP, LIC of India, Dharwad division. Filed Chief Affidavit and following documents had been filed on behalf of Op.

1. Certified copy of proposal
2. Certified copy of LIC bond.
3. Certified copy of complainant’s letter.
4. Certified copy of death certificate.
5. Certified copy of claim form.
6. Certified copy of claimant’s statements.
7. Certified copy of certificate by an employer.
8. Certified copy of letter by an employer along with leave detail.
9. Certified copy of fitness certificate.

       10. Certified copy of repudiation letters 4 in no.

9.      On perusal of above documents and arguments heard on both the sides, we conceived that the dispute is regarding the death claim of the complainant’s husband. The Op repudiated the claim as insured had suppressed the material facts. This being the pleadings, the points arises before us for adjudication are as follows:

Our Answer to the above Points are:-

Point No.1 – Affirmative,

Point No.2 – Partly Affirmative,

Point No.3 - As per the final order.

10.    On consideration of pleading, objection, evidence, documents and arguments of the parties, we answer the above points as under:

                        R E A S O N S

11.  POINT NO.1 and 2:  Since the Point No.1 and 2 are identical and to avoid the repetition of the fact we consider both the points together for discussion.

12.    The husband of the complainant Basava S Pattihal insured his life with OP bearing Policy No.697862309 commencing from 05.12.2013, on 16.05.2014 the insured died in KIMS Hospital, Hubli.

13.    The complainant being the nominee of the deceased insured submitted the Claim Form to claim the insured amount, this is the undisputed fact.

14.    On 24.02.2015, the OP informed the complainant that the claim had been rejected by stating the reason that the deceased withheld the correct information regarding his health at the time of taking the insurance with us, the learned counsel for OP submitted that the deceased/insured has suppressed the material fact regarding his health. On perusal of the documents on record Proposal Form produced by OP as Document No.1 in which the details of the personal history had been filled by the deceased on the basis of which OP had rejected the claim. But the learned counsel for complainant strongly objected the argument of the OP and submitted that the deceased was in sound health prior to his death. The documents produced by the OP serially numbered as 09 issued by the employer of the deceased stated that the insured was on leave from 30.07.2013 to 01.10.2013 and 09.04.2014 to 16.05.2014 due to the illness, but at the same time while scanning the document NO.1 District Hospital Dharwad had issued the fitness certificate that the deceased is found fit to resume his duties from 02.10.2013 by this.  It is very much clear that the insured deceased was in sound health and was not suffering from any pre-existing decease. The deceased was on leave for above said period due to the knee pain as submitted by the OP himself and said that this is a chronic synovitis, which had not been certified by any medical officers that the knee pain is a chronic synovitis. There is no medical report that the death had actually occurred due to chronic synovitis. There is no medical report or diagnostic report or prescription on relating line of treatment had been filed.

15.    In the other cases which resembles this case, the OP produce their Confidential Report while depending their cases, but the OP had failed to produce the same. In this case which clears that the Confidential Report of the OP is not in their favour, moreover the OP had failed to produce the medical document to prove that the death of the insured is due to chronic synovitis. Hence, the OP had utterly failed to prove that the deceased insured had suppressed the material fact regarding his health while obtaining the policy. Here the learned counsel for the complainant filed four citations regarding the suppression of material facts. In the case CPJ 2008 296, CPJ 2008 279, CPJ 597 205 and CPJ 662 2005. In all these cases it is clear that merely mentioning some reason Insurance Company is not supposed to repudiate the claim.

III( 2015) CPJ 16(UP)

UTTAR PRADESH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, LUCKNOW

Mr.A.K.Bose, Presiding Member & Mr.Sanjai Kumar, Member

LIFE INSURANCE CO. LTD. & ANR.

                                      -Appellants/Respondent

Versus

RAM DAS JATAV

- Respondent / Appellants

Appeal Nos. 395 and 357 of 1999- Decided on 25.5.2015

Consumer Protection Act, 1986- Sections 2(1)(g), 15- Insurance(Life)- Death claim- Allegedly dog bite took place prior to obtaining of policy- Claim repudiated- Deficiency in service- District Forum allowed complaint- Hence appeal- No medical report that death and actually occurred due to Hydrophobia/ dog bite- No medical report or diagnostic report or even prescription relating to line of treatment has been filed- Insured had given all answers at time of proposal and LIC failed to specify as to which answer was given by way of concealment – claim repudiated without any reliable documentary/medical evidence, purely on basis of certain oral statements given by illiterate persons – Repudiation not justified.

16.    If the deceased have been treated for any pre-existing decease the OP have obtain a Medical Certificate from the treated doctor. Even the OP had failed to obtain the cause of death certificate which would have considerily be obtained the KIMS, Hubli. It clears that OP had failed to prove their defence. Since, the repudiation of claim is unjust and unlawful.  Hence, the complainant is liable for Sum assured along with the interest. Hence, we answer the Point No.1 in affirmative and Point No.2 in partly affirmative. 

17.  POINT No.3:  For the reasons and discussion made above and finding on the above points, we proceed to pass following:  

//ORDER//

1. This complaint is partially allowed.
2.  Op is directed to pay the sum assured of Rs.10,00,000/-( Rupees Ten Lakh only) along with the interest @ 6% per annum from the date of filing of this complaint to the complainant.
3. Further Op is directed to pay Rs.5,000/- (Rupees Five thousand only) towards mental agony and harassment and Rs.1,000/-( Rupees One thousand only)  towards litigation charges.
4. Further Op is directed to comply this order within a period of 45 days from the date of this order, failing which the Op is liable to pay interest at 9% p.a., till realization.
5. Send a copy of this order to both parties free of cost.

(Dictated to the Stenographer, transcribed by her, corrected and then pronounced by me in the Open Court 06^nd day of Dec., 2016)