Date: 11-08-2015

By: Sri Santi Prosad Roy, Member

Corrected by Sri Kamal De, President

Case of the Complainant, in short, is that her husband took a Group Janata Personal Accident Insurance Policy being no. 4751220001799/E No. 47-30834 from the OP Insurance Company through the OP No. 2, which was valid from 01-06-2000 to 31-05-2015.  During currency of the said policy, her husband met a road accident on 16-03-2012 and he succumbed to injury on 01-04-2012 and a Police Case in this regard was registered by Tamluk P.S. being no. 119/2012 dated 21-03-2012.  Subsequently, she submitted her claim to the OP Insurance Policy on 26-11-2012 and on 16-01-2013, she submitted requisite documents, viz., Xerox copy of death certificate, Income Certificate, photocopy of insurance certificate and also followed up the matter with the OPs regularly, but to no avail.  Hence, the instant case.

Case of the OP Insurance Company is that neither the GTFS, nor the Complainant, despite repeated requests, has submitted documentary proof regarding the status of certificate holder.  In view of the order of the Hon’ble High Court, Calcutta dated 16-03-2006, whereby the Hon’ble Court restrained the OP No. 2 from collecting any premium from the category of “Friends”, it became necessary for them to verify the status of the deceased policyholder and accordingly, repeated requests were made to both of them, but none of them came clean on the matter.  In absence of any documentary proof to substantiate the status of the deceased policyholder, save and except one simpliciter certificate from the OP No. 2 declaring the deceased policyholder as one of their “Fieldworkers”, they were not in a position to settle the claim of the Complainant.  That apart, from the written statement of the Complainant it transpires that the deceased Sk. Abdul Odud was a hawker by profession and he had no connection with the GTFS as an Investor or Agent or Fieldworker.  In such circumstances, the Complainant is not entitled to any insurance benefit.

Case of the OP No. 2 is that by virtue of a MoU dated 30-12-1998 signed by and between the OP Insurance Company and the OP No. 2, they used to collect premiums from the proposers and remit the same to the OP Insurance Company.  In terms of the said Mou, the OP Insurance Company is solely responsible for settlement of every insurance claim.  They have no financial liability whatsoever in this regard.  Still they provided all due cooperation to the Complainant to facilitate settlement of her bona fide claim. 

Point that stands out for decision is whether the Complainant is entitled to get insurance claim, or not.

Decision with reasons

Ld. Advocate for the Complainant has submitted that her husband, during his lifetime, took an insurance policy from the OP Insurance Company through the OP No. 2 after paying due premium thereof.  Her husband died of a road accident on 01-04-2012.  So, she staked her claim with the OP Insurance Company and submitted all the necessary documents to satisfy the need of the OP Insurance Company.  However, in a brazen display of insensitivity, the OP Insurance Company refused to settle her bona fide claim.  Finding no other alternative, she has filed the instant complaint case.

Ld. Advocate for the OP Insurance Company has submitted that by its solemn order dated 16-03-2006, the Hon’ble High Court, Calcutta in W.P. No. 2343/2002 directed the OP No. 2 not to collect any premium from the category of “Friends”.  Therefore, when the instant claim was submitted by the Complainant, as an abandon precaution, they asked both the GTFS as well as the Complainant to furnish documentary proof to establish the status of the deceased policyholder.  However, none of them has complied with said request of the OP Insurance Company.  As such, it tied their hands in the matter of settlement of the claim of the Complainant.  In support of his contention, the Ld. Advocate has referred to a decision of the Hon’ble High Court, Calcutta in W.P. No. 1740 (W) of 2012, another decision of Hon’ble State Commission, W.B. in FA/311/2012, a decision of Ld. District Forum, Siliguri in C.C. No. 82/S/2012 and a decision of Ld. District Forum, Unit II, Kolkata in C. C. No. 216/2012.

We have carefully gone through the rival contentions of the Ld. Advocates of respective parties and perused the materials on record thoroughly.

Undisputedly, the policy in question was issued by the OP Insurance Company on 01-06-2000 and the policyholder died on 01-04-2012.  There can be no two opinions as to the fact that accidental insurance policy is having several resemblances of a life insurance policy which is designed to cover the insured, in case one dies of accident. In terms of Sec. 45 of the Insurance Act, 1938, no life insurance policy can be called into question on grounds of misstatement or wrong disclosure after two years of the policy coming into force.  Against this backdrop, the OP Insurance Company has got no right whatsoever to call in question the status of the deceased policyholder after almost 12 years since the policy came into existence.  It bears mentioning here that the said Section of the Insurance Act notwithstanding allows the Insurance Company to call in question an insurance policy, it comes with a string, i.e., this can be done provided an Insurer is able to show that such statement was on a material matter or suppressed facts which was material to disclose and that it was fraudulently made by the policyholder and that the policyholder had full knowledge of it.  It is clear from the above that the onus of proving a statement false rests with the Insurer and nobody else.  However, the OP Insurance Company has not come up with even a single piece of document to corroborate their apprehension.  In our considered opinion, simply on the basis of suspicion, they cannot withhold a claim. On the other hand, the OP No. 2 in unequivocal terms confirmed vide its certificate dated 13-02-2014 that the deceased policyholder was one of their “Fieldworkers”. 

It is claimed by the OP Insurance Company that the Complainant made a written statement wherefrom it transpires that the deceased policyholder was a hawker by profession and he had no association with the OP No. 2.  Most surprisingly, the same has not been filed before this Forum by the OP Insurer for some obscure reasons.  That apart, it is not the case of the OP Insurance Company that the job of a “Fieldworker” is a whole-time job.  That being so, even for the sake of argument, if we assume that the deceased policyholder was indeed a hawker by profession, it cannot be a stumbling block to pursue other professions and such an alibi is no good ground to withhold an insurance claim under the GJPA policy. 

As stated hereinabove, the OP Insurer raised such question when a peril has arisen.  We are of view that being the sole issuer of the insurance policy in question, it was the bounden duty of the OP Insurer to satisfy themselves about the antecedents of the policyholder.  They cannot be oblivious of the virtue of striking while the iron is hot. Issuance of a policy invariably denotes that the same has been issued upon proper scrutiny of the particulars embedded in a proposal form.  It is futile to cry foul over it at a later stage.  In this regard, it may not be out of the place to state that in terms of Section 19 of the Contract Act, 1872, a contract would not be voidable even if such consent was caused by misrepresentation or by silence, fraudulent within the meaning of Section 17, if the party whose consent was so caused had the means of discovering the truth with ordinary diligence.  The OP Insurer could have easily ascertained the status of each and every policyholder under the GJPA scheme in the wake of the solemn order passed by the Hon’ble Court in the matter of GJPA scheme.  Negligence on the part of the Insurer cannot be a cogent ground to deny a claim.  In the instant case, the GJPA policy in question has not been cancelled by the Insurer till the date of occurrence of peril.  As such, they cannot shy away at this stage to settle the claim of the Complainant on the basis of some unfounded suspicion.  One really wonders, if an Insurer can accept premium from a prospective policy without asking a single question in good faith, why they cannot repose same degree of “good faith” whenever a claim is filed.  The arbitrary action on the part of the OP Insurer clearly demonstrate gross deficiency in service on their part.

Last but not the least, we do appreciate that one aspires to avail of an Insurance Policy to fulfill certain specific purpose(s).  Had the OP Insurer been diligent enough to verify the status of the Insurer when the proposal form was received by them, they could have refused to issue the Policy in favour of the proposer in case he did not fit into the bill and in that case, the policyholder, since deceased, could have approached some other Insurer for this purpose.  While it is the sacrosanct right of every Insurer to tune the terms and conditions of policy as it so pleases within the broad framework penciled by the Insurance Regulator, i.e., the IRDA, as also that of the Insurance Act, it has got no right or authority to stand in the way of a prospective policyholder fulfilling one’s insurance need by taking a lackadaisical approach at the time of issuance of a policy. There is no dispute as to the accidental death of the policyholder.  So, the OP Insurer must settle the insurance claim.        

We are of view, in the light of our foregoing discussion, that the OP Insurance Company has miserably failed to drive home its viewpoint and they cannot legally call in question the status of the deceased policyholder after the lapse of nearly 12 years from the date of issuance of the policy in question, more so, the Insurance Company admittedly issued the policy in favour of the deceased husband of the Complainant.  It also appears from the Certificate of GTFS Company that the deceased worked as a “Field Worker” under the said organization as such, he is not also coming under the exempted category.

In the result, the complaint case succeeds.

Hence,

ORDERED

That the C. C. No. 19/2015 be and the same is allowed on contest against the OP Nos. 1&3 and dismissed on contest against the OP No. 2.  The OP Nos. 1&3 are jointly and severally liable to pay Rs. 1,00,000/- as insurance benefit to the Complainant together with interest @ 9% p.a. over the aforesaid amount from the date of filing of instant complaint case, i.e., 24-02-2015 till full and final payment is made along with litigation cost to the tune of Rs. 5,000/- within 40 days from the date of this order, i. d., the Complainant is at liberty to take recourse to appropriate legal steps against the OP Nos. 1&3.