SRI JIBAN KRUSHNA BEHERA, MEMBER (I/C)
The complainant has filed this complaint petition, U/s-12 of the Consumer Protection Act, 1986 (here-in-after called as the “Act”) alleging deficiency-in-service against the Ops, who are the authorities of Life Insurance Corporation of India, but located in different places.
2. The case of the complainant, in a nutshell, is that in the year 2005, her deceased husband namely Karunakar Mohanty had purchased two policies bearing No.583115224 & 585999079 from the Ops and the complainant was the nominee in the above policies. While the aforesaid polices were in force, her husband died on 1.9.2005. After the death of her husband, the complainant applied for the death benefits in writing along with all relevant documents before the OP No.2, who settled the death benefit and released the entire claim in respect of Policy No. 583115224, but, surprisingly, the Ops had repudiated the death claim in respect of the Policy No.585999079 on 29.6.2006. It is stated that at the time of purchase of the above policy in question, her deceased husband was healthy and hearty and on recommendation of the treating physician the Ops have accepted the proposal for the policy and the premium and had issued with the policy bond. The life assured, during his life time, had never defaulted in making payment of the premium. When the Ops have disbursed the claim in respect of other policy, they have no right to repudiate the claim of the complainant on the baseless grounds and such action of the Ops clearly attributes a case of deficiency in service against them.
The cause of action for filing of the case arise on 29.6.2006, when the Ops repudiated the death claim of the complainant. Therefore, finding no other way out, the complainant was constrained to file the present case against the Ops with the prayer, as stated in the complaint petition. Hence, the case.
To substantiate her case, the complainant relied upon the following documents, which are placed in the record-
- Photocopy of policy certificate.
- Photocopy of letter issued by complainant to OP No.1 dated 4.4.2006.
- Photocopy of letter issued by OP No.1 to complainant dated 29.6.20
3. The Ops, in their written version, challenging the averments made in the complaint petition, have stated that the complainant has no cause of action to file the present case and the case is not maintainable. The Ops have stated, inter alia, that the life assured Karunakar Mohanty submitted proposal on 20.6.2005 and on the basis of proposal form and the medical examination report, they issued policy bearing No.585999079 on 20.6.2005. The life assured died on 1.9.2005, just after 2 months and 11 days from the date of issue of the policy bond. On receipt of the claim submitted by the complainant, the Ops enquired about the matter and found that the life assured was under the treatment in Panda Medical Centre, Telenga Penth, Cuttack from 11.10.2004 to 26.11.2004 for brain tumour. Thus, the life assured, knowing very well that he will die very soon and without disclosing his past suffering, had proposed for the policy. Hence, the Ops have rightly repudiated the claim of the complainant and no deficiency in service attributes against them. In the above facts and circumstances, the Ops have prayed to dismiss the case with cost.
In order to substantiate its case, the Ops relied upon the following documents, which are placed in the record-
- Photocopy of proposal form submitted by the complainant.
- Photocopy of policy certificate.
- Photocopy of letter issued by Panda Medical Centre to OP No.1.
4. In view of the above averments of both the parties, the points for determination in this case are as follows:-
- Whether the complainant is a consumer as per C.P Act?
- Whether there is any cause of action to file this case?
- Whether the present case is maintainable?
- Whether there is any deficiency of service on the part of the Ops towards the complainant?
- To what other relief(s), the complainant is entitled to?
F I N D I N G S
5. So far as the point No.(i) & (ii) are concerned, first of all, it is seen that the deceased life assured husband of the complainant had purchased two Insurance policies from the Ops for bearing No.583115224 & 585999079 on 20.6.2005 and the complainant was the nominee in both the policies. It is not disputed that the deceased husband of the complainant died on 1.9.2005. After the death of her husband, the complainant claimed death claim of her deceased life assured husband and the Ops have settled the claim in respect of policy No.583115224, but repudiated the claim in respect of the disputed policy No.585999079 on the ground that the life assured has not supplied the true state of affair with regard to his suffering from brain tumour at the time of submission of proposal form. In the present scenario, whether the complainant is entitled to the death benefit of her deceased life assured husband or not is required to be discussed later on, but from the above discussion, it is held that the complainant is a consumer and she has cause of action to file the present case.
6. In order to arrive at a definite conclusion, it is required to be decided as to whether the case is maintainable and whether there is any deficiency of service on the part of the Ops. It is an admitted fact that the deceased husband of the complainant had purchased the disputed policy for a sum assured of Rs.50,000/- from the Ops on 20.6.2005. It is also an admitted fact that the husband of the complainant died on 1.9.2005. It is the claim of the complainant that at the time of submission of proposal form, her deceased husband was in a fit condition having no disease and was also underwent medical checkup by the doctor recommended by the Ops and after being satisfied the Ops have accepted the proposal for the policy in question so also the premium and issued the policy certificate vide Annexure-1. So, repudiation of the claim of the complainant on the ground that her deceased husband deliberately suppressed the material information regarding the health and occupation is totally baseless and prejudicial to the interest of the complainant. Further, when the Ops have settled the death benefit in respect of the other policy, what prevented them in settling the claim in respect of the disputed policy. Therefore, non-settlement & repudiation of the claim of the complainant in respect of the disputed policy casts a serious deficiency in service on the part of the Ops.
7. On the other hand, it is the claim of the Ops that deceased life assured Karunakar Mohanty submitted proposal on 20.6.2005 and on the basis of proposal form and the medical examination report, they issued policy bearing No.585999079 on 20.6.2005. The life assured died on 1.9.2005, just after 2 months and 11 days from the date of issue of the policy bond in question. On receipt of the claim submitted by the complainant, the Ops enquired about the matter and found that the life assured was under the treatment in Panda Medical Centre, Telenga Penth, Cuttack from 11.10.2004 to 26.11.2004 for suffering from brain tumour. Thus, the life assured, knowing very well that he will die very soon and without disclosing his past suffering, had proposed for the policy. Thus, the Ops have rightly repudiated the claim of the complainant and no deficiency in service attributes against them.
8. From the above discussions, it is found that the deceased husband of the complainant had purchased the disputed policy from the Ops for a sum of Rs.50,000/- on 20.6.2005. On 1.9.2005 he died just after 2 months and 11 days from the date of issue of the policy bond. From the proposal form vide Annexure-A, it is seen that the life assured did not disclose the pre-existing disease or ailments intentionally prior to inception of the policy in question at the time of proposal. The deceased life assured husband of the complainant had supplied wrong and false information with regards to the personal history in Serial No.11 of the proposal Form knowing very well that these were false and incorrect. Thus, the deceased life assured husband of the complainant has intentionally and fraudulently concealed the true state of affairs regarding his health at the time of proposal for insurance. It is, therefore, held that the ailments from which the life assured was suffering is prior to the date of proposal for which the Ops did not accept the risk on the health of the life assured. Had the deceased life assured husband of the complainant 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 in his favour 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 he 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 life assured husband of the complainant had also supplied a false declaration that the information supplied by him 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 the Ops have not committed any deficiency in service in repudiating the claim of the complainant. Therefore, the case of the complainant is not maintainable. Consequently, the complainant is not entitled to any relief what-so-ever as claimed in her complaint.
Hence, it is ordered: –
O R D E R
The complaint of the complainant be and the same is dismissed on contest against the Ops. In the facts and circumstances, no order as to costs.
Pronounced in the open court of this Commission, this the 3rd day of June, 2024 under signature & seal of the Commission.
