Judgment : Dt.18.1.2018
Shri S. K. Verma, President
This is a complaint made by one Mrs. Dimple Jund, widow of Mandeep Kumar (Since deceased) insured of 2P, Garcha 1st Lane, P.S.-Gariahat, P.O.-Ballygunge, Kolkata-700 019 against The Manager (Claims) LICI, K. M. Division No.-II, 23A, 4x D.H.Road, P.S.-New Alipore, Kolkata-700 053, OP No.1, The Zonal Manager, LICI, EZO, 4, Chittaranjan Avenue, Kolkata-700 072, OP No.2 and The Senior Branch Manager, LICI, Kasba Branch, Gariahat Market Complex, A.B.Block- Kasba, Kolkata-700 019, OP No.3 praying for declaration of the letter of repudiation dt.16.3.2015 of the death claim of Rs.5,00,000/- is illegal and Complainant is entitled to death claim for Rs.5,00,000/- as made in the application as per death claim policy No.446903273 and for compensation of Rs.1,00,000/- for harassment and mental agony and litigation cost of Rs.20,000/-.
Facts in brief are that Complainant is the wife of deceased Mandeep Kumar and is nominee of the deceased assured Mandeep Kumar as per policy No.446903273 d.24.2.2012 for fifteen years and the proposal form was signed by the assured person on 1.6.2011.
At the time of obtaining the insurance policy the assured person was thoroughly checked up by the Inspector of the OPs along with medical checkup by Doctor who came with the Inspector and on being satisfied in all respects about the assured person Mandeep Kumar was issued on 24.2.2012. Assured person Mandeep Kumar was admitted into CMRI on 17.6.2013 and was discharged on 20.6.2013 wherefrom it will appear that the assured person known diabetic and no history of COPD, TB, Bronchial asthma, thyroid abnormality. The report was overall good except known diabetic.
Thereafter, the assured Mandeep Kumar went on or about December, 2013 to Asian Institute of Gastroenterology at Hyderabad for overall CT Scan of abdomen and that Institute reported dt.9.12.2013 without finding any wrong in the stomach. Again Mandeep Kumar took admission for further checkup of the abdominal problem from 13.12.2013 at Kothari Medical Centre at Ekbalpur for his medical treatment and was discharged on 25.12.2013. It appears from the said report that the assured person was a patient of alcoholic liver disease with esophageal varices and it was recorded in discharge summary that the condition was satisfactory on discharge of the patient. Assured person took admission in Fortis Hospital Ltd. on 23.5.2014 and discharged on 5.6.2014 under Dr. Shibabrata Banerjee. Assured person lastly took admission for his treatment on 8.6.2014 at Fortis Hospital Ltd. and continued his treatment till 12.6.2014. The assured person died on 12.6.204 and the declaration dt.18.8.2014 about the cause of death was made to signed by the brother of the Complainant declaring that the assured died out of multi organ failure at the instance of the OPs. The brother of the assured person Baldeb Kumar Jund put up a claim petition before the State Commission at Kolkata in respect of mediclaim policy wherein the certificate was issued by Dr. Shibabrata Banerjee of Fortis Hospital Ltd. that the assured person died out of heart failure and in the same certificate Dr. Sourav Pradhan certified that the death of the assured person is natural.
The inconsistent diagnosis report about the cause of death itself proves that all the certificates issued by Fortis Hospital Ltd. in order to suit the malafide purpose of the OPs. The copies of the death certificate issued by Fortis Hospital showing cause septic shock with multi organ failure dt.12.6.2014 as opined by Dr. Shibabrata Banerjee of Fortis Hospital and in the same certificate Dr. Sourav Pradhan opined that the death of the assured person was natural but nowhere it is mentioned that the assured person died out of chronic liver disease. Accordingly, the Complainant put up one death claim petition dt.24.2.2012 before the OPs as per demand of the OPs the Complainant submitted all documents of requirement as per letter dt.12.11.2014. From the receipt letter dt.1.11.2014 issued by OP No.1, it clearly indicates that the life assured person was suffering from chronic liver disease for the last one year though the death claim policy was taken on 24.2.2012. As such, at the time of death claim the assured person was not suffering from any type of disease. Such statement made by the OPs prove that the falsity of documents prepared by the OPs are all fabricated and manufactured for the purpose of rejecting the claim petition. OP No.1 vide its letter dt.16.3.2015 rejecting and repudiating the claim of the Complainant. So, Complainant filed this case.
OP filed written version. OP No.1 has denied all the allegations of the complaint and prayed for dismissal of the complaint. In addition, OP No.1 has stated that assured person Mandeep Kumar during his lifetime had been suffering from different types of serious diseases and he was a habitual drunker, a patient of alcoholic lever diseases with esophageal various and practically chronic liver diseases at least for a period of last 12 years. Actually, the cause of death of the assured person was septic shock with multi organ failure due to chronic liver diseases as clearly ventilated from the death certificate issued by Fortis Hospital Ltd. So, this OP has prayed for dismissal of the complaint petition.
Decision with reasons
Complainant filed affidavit-in-chief to which OP filed questionnaire to which Complainant filed affidavit-in-reply. Similarly, OP filed evidence to which Complainant filed questionnaire to which OPs filed affidavit-in-reply.
Main point for determination is whether Complainant is entitled to the reliefs as prayed for.
In this regard Complainant has prayed for declaration that the letter of repudiation dt.16.3.2015 is illegal. Consumer Forum does not have jurisdiction to pass any declaratory decree and so the prayer (a) of the Complainant cannot be allowed. As per prayer (b) Complainant has prayed for death claim for Rs.5,00,000/- as made in the complaint as per death claim policy. On perusal of the copy of the policy, it appears that this Jiban Anand Policy was in the name of Mandeep Kumar and Complainant is his wife. Complainant has filed copies of discharge summary as well as the other papers of different hospitals where he was treated and from where different types of reports were received. The copy of death certificate is also filed which reveals that the cause of the death is mentioned as chronic liver disease and septic shock with multi organ failure.
Amidst different versions of the medical report, it is clear that the deceased purchased a policy in 2012 and the policy is Jiban Anand for profit and accident benefits. OPs have claimed that since the death took place due to multi organ failure and lever disease they are not liable to pay the death benefit. However, we are of the view that Life Insurance Policies are purchased by the citizens for securing the eventuality and the miseries which may take place after the death of policy holder. The heirs of the policy holders are entitled to the benefit of policy in the event of death of the policy holder. So far as the report of different doctors are concerned, this may vary, but the report of Dr. after death cannot be said that the policy holder died due to chronic lever disease and multi organ failure. Furthermore, it can be opined that the multi organ failure and lever disease on a pre-existing background before the deceased purchased the policy. Admittedly the doctors of the OPs examined the insured and on being satisfied fixed the premium and thereafter issued the policy. If, OP’s contention is accepted, it can be said that the doctors who examined the insured before insurance of the police were incompetent and could not detect that the insured had pre-existing lever disease and there was of multi organ failure. These two reasons causes can develop even after the purchase of the policy i.e. between the period of purchase of policy and death of the deceased for which a person purchases the insurance policies.
Complainant has referred ruling decisions reported in 2012 3 CPJ equivalent to 2012(4) of CLJ 624 wherein it has been made clear that on the basis of surmise and conjecture the policy bills cannot be repudiated. There are other decisions also in this regard.
So, we are of the view that the complainant is entitled to death benefit as per the policy No.446903273.
Complainant has also prayed for compensation of Rs.1,00,000/- and litigation cost ofRs.20,000/-.
In this regard, we are of the view that if compensation of Rs.20,000/- and litigation cost of Rs.5,000/- are awarded, object of the justice would be served.
Hence,
ordered
CC/149/2017 and the same is allowed in part on contest. OPs are directed to pay death benefit to the Complainant as per policy and also compensation of Rs.20,000/- and litigation cost of Rs.10,000/- within two months of this order, in default the total amount shall carry interest @ 10%p.a. from the date of this order till realization.
