SRI JIBAN KRUSHNA BEHERA, MEMBER (I/C)
The Complainant has filed this complaint petition, U/s-12 of C.P.A.-1986, (here-in- after called as the “Act”) alleging a “deficiency-in-service” against the Opp. Parties, who are the Life Insurance Corporation of India located at different places.
2. The factual matrix of this case is that one Malatilata Sashini, the deceased wife of the complainant, had purchased one policy from the LIC of India on dt.28.12.2000 vide policy No.583468080 wherein the complainant was the nominee. Said policy was a money back policy which has been duly matured after completion of its tenure. The deceased used to receive Rs.10,000/- in every five years. After 15 years, OP No.3 asked the deceased to open a fresh policy in her name to which she opened a new policy bearing No.597072784 on dt.28.1.2016 for a sum of Rs.1,00,000/- and used to pay the premium amount. In the meantime, deceased died on dt.11.2.2016 while underwent treatment at SCB & MCH, Cuttack. The treating doctor has fraudulently reported the cause of her death was due to heart problem, but, in fact, she has never affected by any kind of heart disease till her death. It is further stated that at the time of opening of policy, the deceased was quite well and healthy and has not affected by any kind of diseases and after proper medical check-up and compliance of all formalities, OP No.3 had duly accepted her as the policy holder.
It is also the case of the complainant that he, being the nominee, is entitled to get the insured amount, death benefit with interest. But the Ops have denied to disburse the claim of the complainant for which he suffered harassment, unnecessary expenditure and mental agony.
The cause of action for filing the case arose on dt.26.11.2018, when the Ops denied to disburse the claim amount of the complainant. Hence, this case.
To substantiate his case, the complainant has relied on the following documents, which are placed in the record, as mentioned hereunder-
- Photocopy of burial certificate.
- Photocopy of death certificate of the deceased wife of complainant.
- Photocopy of claimant’s statement.
- Photocopy of claimant’s statement.
- Photocopy of claim form.
- Photocopy of proposal form.
3. In the present case, Ops were made their appearance and filed their joint written version. In their written version, the Ops have not only challenged the cause of action to file the present case but also emphatically stated that the case is not maintainable. They have denied the allegations made in the complaint petition. The Ops have stated, inter alia, that on receipt of intimation from the complainant regarding the death of assured Malatilata Sashini, they issued claim form and on receipt of claim form along with other relevant documents, it came to know that the deceased died on dt.11.2.2016 only 13 days after purchasing of the policy in question. On being asked, the complainant failed to produce the medical papers. On verification of the medical records as well as bed head ticket from SCB MCH, Cuttack, they came to know that the deceased assured was admitted there on dt.11.2.2016 for treatment of cancer cervix (Stage IV) and the same was a known case of cancer prior to proposal of insurance. It is further stated that at the time of admission for treatment, the deceased assured was quite unable to walk due to breathing problem for 10 days. The deceased assured has sufficient knowledge that she was suffering from cancer at the time of giving proposal for purchase of policy and at that time she had intentionally concealed and suppressed the said fact of suffering from cancer and she had obtained the insurance policy with a false declaration with regard to her health. Therefore, after thorough verification, the Ops have constrained to repudiate the claim of the complainant. Thus, the Ops have not committed deficiency in service, as alleged by the complainant. In the above premises, Ops have prayed to dismiss the case with cost.
To substantiate their case, the Ops have relied on the following documents, which are placed in the record, as mentioned hereunder-
- Photocopy of proposal form.
- Photocopy of bed head ticket in respect of the deceased assured.
- Photocopy of policy bond.
- Photocopy of repudiation letter dt. 28.6.2018.
4. In view of the above averments of parties, the points for determination in this case are as follows:-
(i) Whether the complainant is a consumer or not?
(ii) Whether the complainant has cause of action to file this case?
(iii) Whether this consumer case is maintainable?
(iv) Whether there is any deficiency in service on the part of the OPs?
(v) Whether the complainant is entitled to get the relief, as sought for?
(vi) To what other relief(s), the Complainant is entitled to?
F I N D I N G S
5. First of all it is to be determined as to whether the complainant is a consumer or not. From the averments made in the pleadings of both the parties so also from the documents produced by the parties, it is clear that the complainant is the nominee of his deceased assured wife, who purchased the policy bond from the Ops. The deceased wife of the complainant died on dt.11.2.2016, as reflected vide Annexure-2. From the above, it is clear that the complainant is covered under the definition of a consumer as defined under the provisions of the Consumer Protection Act, 1986.
6. Before delve into the merits of the case, it is required to be decided how far the complainant is able to prove his case with regard to the cause of action and maintainability of the case. Learned counsel for the complainant urged that deceased wife of the complainant namely Malatilata Sashini had purchased one money back policy bond from the LIC of India on 28.12.2000 vide policy No.583468080 wherein the complainant was the nominee. The deceased used to receive Rs.10,000/- in every interval of five years. After 15 years, OP No.3 asked the deceased to open a fresh policy in her name to which she opened a new policy bearing No.597072784 on dt.28.1.2016 for a sum of Rs.1,00,000/-. Deceased died on dt.11.2.2016 while underwent treatment at SCB & MCH, Cuttack. The treating doctor has fraudulently reported the cause of her death was due to heart problem, but, in fact, she has never affected by any kind of heart disease till her death. It is further submitted that at the time of opening of policy, the deceased was quite hell and healthy and has not affected by any kind of diseases and after proper medical check up and compliance of all formalities, OP No.3 had duly accepted her as the policy holder. Thus, the complainant, being the nominee, is entitled to get the insured amount, death benefit with interest. But the Ops have denied to disburse the claim of the complainant for which he suffered harassment, unnecessary expenditure and mental agony.
7. On the other hand, learned counsel for the Ops submitted that on receipt of claim form along with other relevant documents, it came to know that the deceased died on dt.11.2.2016 only 13 days after purchasing of the policy in question. The complainant failed to produce the medical papers. But, on verification of the medical records as well as bed head ticket from SCB MCH, Cuttack, the Ops came to know that the deceased assured was admitted there on dt.11.2.2016 for treatment of cancer cervix (Stage IV) and the same was a known case of cancer prior to proposal of insurance. It is further submitted that at the time of admission for treatment, the deceased assured was quite unable to walk due to breathing problem for 10 days. The deceased assured has sufficient knowledge that she was suffering from cancer at the time of giving proposal for purchase of policy bond and at that time she had intentionally concealed and suppressed the said fact of suffering from cancer and she had obtained the insurance policy with a false declaration with regard to her health. Therefore, after thorough verification, the Ops have constrained to repudiate the claim of the complainant. Thus, the Ops have not committed deficiency in service, as alleged by the complainant.
8. From the above rival submissions, it is found that the deceased wife of the complainant had purchased Insurance policy from the Ops on 28.1.2016 and admittedly she died on dt.11.2.2016 in SCB MCH, Cuttack while underwent treatment and the cause of death as reflected from Annexure-1 is due to heart problem. It is claimed by the complainant that his deceased wife has not suffered any kind of heart problem and at the time of giving proposal for policy bond she was hell and hearty. In this connection, the complainant has not produced a single document that his deceased wife was not suffered any kind of diseases and she was hell and healthy prior to her death. On the other hand, from Annexure-B, the bed head ticket of the deceased assured, it is clear that at the time of treatment in SCB MCH, Cuttack, the deceased was suffering from cancer (stage IV) and she suffered breathing problem and unable to walk and not eating since 10 days. The complainant has not stated a single word that his deceased wife was suffering from cancer at the time of giving proposal for purchase of policy bond. All on a sudden one cannot suffer cancer stage-IV. That apart, the complainant has not at all agitated any claim that the medical papers submitted on behalf of the Ops are all false and fake. Thus, the complainant has intentionally and fraudulently concealed the true state of affairs regarding the health of his deceased wife at the time of proposal for insurance on dt.28.1.2016. It is, therefore, held that the ailments from which the deceased wife of the complainant was suffering is prior to the date of proposal for which the Ops did not accept the risk on the health of the deceased. Had the deceased assured disclosed the true facts and information at the time of proposal for insurance, the risk under the policy in question would not have been accepted by the Ops and the policy in question would not have been issued to his deceased wife or would have been issued on different terms and conditions. In all the contract of insurance, the proposer is bound to make full disclosure of all the material facts and nor merely those, which she thinks material, misrepresentation, non-disclosure or fraud in any document leading to acceptance of the risk automatically discharges the insurer from all liabilities under the contract. On the other hand, the deceased wife of the complainant had also supplied a false declaration that the information supplied by her are all true, accurate and complete and correct in all respects. Hence, it is observed that the contract of insurance is null and void. From the above discussions, it is held that there is no deficiency of service on the part of the Ops. Consequently, the complainant has no cause of action to file the case and the case is not maintainable. Therefore, the complainant is not entitled to any reliefs what-so-ever as sought for in this case.
Hence, it is ordered –
O R D E R
The case of the complainant be and the same is dismissed on contest against OPs. But in the peculiar facts & circumstances, no order as to costs.
Pronounced in the open Court of this Commission on this day i.e. the 09th day of January, 2024 given under my Signature & Seal of the commission.
