The complainant has filed this application U/S 11 & 12 of Consumer Protection Act 1986 and praying for the following relief/order:

1. Direction against the OPs to make payment of insured sum of Rs. 19,41,940/- to the complainant together with other policy related benefits as well as interest.
2. Direction against the OP’s for making payment of Rs. 40,000/- to the complainant on account of damages and compensation for mental agony, harassment and sufferings.
3. Direction against the OPs to pay a sum of Rs. 10,000/- towards the cost of legal proceedings.
4. Any other relief or reliefs which the complainant is entitled  as per law.

BRIEF FACT OF THE COMPLAINT

1. The complainant is a housewife/ OP No. 1 is an insurance company engaged in the business of insuring lives/ OP 2 and 3 are the officials of OP 1 who are engaged for the purpose of forwarding and regulating the business operation of the OP 1 company in their respective capacities and position.
2. The husband of the complainant Mr. Subhra Biswas ( Now deceased) had taken PNB Metlife policy on his life with an intention to insure his life against any unforeseen event for a sum of Rs. 19,41,940/- for a term of 10 years being policy no. 21360514 w.e.f  27.07.2014 and purchased the same from the OP No. 1 / the complainant was made nominee under the said policy being no. 21360514 / the husband of the complainant has made a payment of Rs. 1,81,995/- only being the yearly premium under the said policy.
3. That Subhra Biswas  has died on 29.04.2015 due to cardio respiratory failure/ the complainant being the nominee under the policy being no. 21360514 on 24.06.2015 applied for insurance claim approached the OP 1 company for settlement of her legitimate claim but the OP repudiated the said  claim through a letter dated 17.09.2015 assigning false and fabricated reasons.
4.  That the complainant on several occasions contacted with the OP’s personally, requested/ persuaded them verbally to make arrangement for payment of the said amount but the OPs paid no heed and finding no other alternative the complainant served a legal notice dated 20.01.2016 to the OP’s through her lawyer but in spite of receiving the said lawyers notice they have failed to make an arrangement for settling the legitimate and the bona fide claim of the complainant.
5. That the OPs sent their reply thorough Ld advocate disclosing false, fabricated, baseless, motivated, unfounded allegations more or less mirroring the repudiation letter dated 17.09.2015.
6. That the complainant denies the allegations made in the said reply notice regarding the ailment of diabetes made in para 6 of the reply that the husband of the complainant never suppressed the fact of his said ailment of diabetes and he never suffered from diabetes and the allegation of the OP’s had been cooked up by them for the purpose of repudiation of the insurance claim made by the complainant.
7. That during the years 2014-15 the town of Siliguri and adjoining areas had suffered three major earthquakes and last of which struck the town four days prior to the death of late Subhra Biswas, due to the reason of that major earthquakes that Subhra Biswas became a sudden patient or sufferer of hyper-tension and that ailment was most common during the relevant period amongst most of the inhabitants of Siliguri who were struggling to find their way back to normal life.
8. That the acts and conducts of the O.P.s the Complainant has been suffering the serious mental pain and agony and passing her days with great difficulties which is clear from the conduct of the O.P.s that there was a great deficiency in service on the part of the O.P.s towards the Complainant and the said conduct of the O.P.s amounts to unfair trade practice in repudiating the claim of the Complainant.
9. That the cause of action of this case arose on 29.04.2015 when the husband of the complainant died and on 26.04.2015 when the application for claim in the prescribed form was submitted by the Complainant and on 17.09.2015 when the claim of the Complainant was repudiated on 20.01.2016 when the Lawyer’s notice was issued and on thereafter on each and every dates within the jurisdiction of this Commission.

In order to prove the case the complainant has filed the following documents:-

1. Photocopy of Policy certificate.
2. Photocopy of Death Certificate of Late Subhra Biswas.
3. Photocopy of Claim Application Form along with Doctors Certificate.
4. Photocopy of Claim repudiation letter dated 17.09.2015
5. Photocopy of Lawyers notice dated 20.01.2016 issued by the Ld. Advocate on behalf of the Complainant.
6. Photocopy of postal receipts along with A/D Cards,
7. Photocopy of reply dated 30.03.2016 issued by the Ld. Advocate of O.P. No. 01.

Notice was issued from this Commission upon the O.Ps which were duly served.

On receipt of notice the OP No. 1, 2 & 3 appears before this Commission through Vokalatnama, filed their written version, denied all the material allegation of the complainant. In the written version the OPs have stated that O.P. No. 1 is a registered Office, O.P. no. 2 is a CEO, and O.P. no. 3 is a Branch Office of PNB MetLife India Ins. Co. Ltd. and they have denied all allegations contained in the complaint. The O.P.s have also stated that the Complainant has filed the present compliant  claiming sum assured of Rs. 19,41,940/- along with compensation of Rs. 40,000/- and cost of Rs. 10,000/- which exceeds the pecuniary jurisdiction of this commission u/s 11(1) of the C.P.Act,1986. They have also stated in the W/V that the complainant has filed this case with frivolous grounds with ill intention of making wrongful gain and  causing wrongful loss to the O.P.s by concealing the material facts and they are praying for dismissal of this case/with mala fide intention and vague allegation the complaint has been filed and there is no deficiency in service on the part of O.P.s which is not supported by any documentary evidence on the side of the Complainant. They also stated in the W/V that the complainant is not a consumer under the Consumer Protection Act and there is neither any deficiency in service as well as restrictive trade practice adopted by the O.P.s being established and for which the complaint is liable to be rejected. The O.P.s have also stated that the deceased life insured/DLI after completely understanding the Terms and conditions of the product Met Monthly Income Plan Pay had submitted the duly signed proposal form dated 26.07.2014 and offered to pay Rs. 1,81,995/ annually towards the initial premium against the sum assured of Rs. 19,41,940/- and the contents of the proposal form were explained to the DLI and he had given a declaration and furnished the information after fully understanding the contents thereof and after understanding the terms and conditions of the plan he applied for the said policy. It is also stated by the O.P.s that there was a column wherein the DLI was required to provide answers with respect to his medical history and DLI replied that he was not suffering from disease and neither he was taking any medical treatment and on receipt of duly filled in proposal form and believing the information provided by the DLI to be true and correct along with the initial premium the O.P. evaluated and pressed the proposal form on the basis of the information furnished by the DLI they issued the policy bearing no. 21360514 with risk commencement date of 27.07.2014 and the complainant was made nominee of the policy / policy documents were dispatched at the address of the deceased life insured which were duly delivered (Annexure O.P.-1).It is also stated by the O.P.s that the policy was issued by them relying upon the information provided in the proposal form regarding the various aspects including the personal, professional and other details and proposal form was duly signed by the DLI clearly had a provision for a declaration by the DLI / the DLI had fully understood the terms and conditions of the policy and agreed under the agreement if any untrue statement be contained in the application of the proposal form the policy contract shall be null and void and the money which had paid in respect thereof shall stand forfeited to PNB MetLife(LIC India vs. B. Chnadravathamma, AIR 1971,A.P.41). The O.P.s have further stated they received the death claim information dated 29.06.2015 from  the complainant thereby intimating the person insured died on 29.06.2015 which was duly acknowledged by the O.P. vide letter dated 30.06.2015.(Annexure O.P.-2series). They have also stated in the W/V that the person insured died within a short span of nine months. The O.P. as per the procedure carried out an investigation to settle the claim of the complainant as the claim being an early claim and during the course of the investigation as well as assessment of the claim it was revealed to the O.P.s that the DLI did not provide true and correct information while filling in the proposal form with respect to his medical history and it was revealed that the DLI was a known case of diabetes and HTN prior to the purchase of the insuring policy and the death certificate issued by Dr. A. B. Dutta Chowdhury clearly states that the DLI was suffering from diabetes and HTN but while he submitted the proposal form intentionally concealed the said material fact despite having specific question with respect to his medical history and thereby the DLI played fraud upon the O.P.s and induced the O.P’s. to issue the policy in his favour (Annexure O.P. 3 series). The O.P.s have also stated in the W.V that at the time of filling in the proposal form the DLI willfully misrepresented the O.P.s for availing the said policy though he was duty bound to answer the questions with regard to his health, occupation, habit of which he alone had personal knowledge. Thus the contract of insurance being of utmost good faith DLI was obliged to give full and right information on all matters which would influence the judgment of the insurer in determining whether he will accept the risk and if he would at what rate of premium and subject to what conditions and that’s why the O.P.s have rightly repudiated the claim of the complainant on the ground of providing false information with respect to his medical history at the time of filling in the proposal form based on which the policy was issued by the O.P. to him and the fact/grounds of repudiation was duly communicated to the complainant vide letter dated 17.09.2015(Annexure O.P.-4). The O.P.s have also referred one decision reported in (2009)8 SCC 316 in the case of Satwant Kaur Sandhu vs. New India Assurance Co. Ltd. as well as another decision of (1996)6 SCC 428 in United India Ins. Co. Ltd. vs. MKJ Corporation as well as decision of Modern Insulators Ltd. vs. Oriental Insurance Co. Ltd. (2000)2 SCC 734. It is further stated that the complainant has no cause of action in filing of this case/ case is not maintainable on law nor on facts / there cannot be any complaint on deficiency of service or unfair trade practice against the O.P. as made by the complainant and for which the complaint requires to be dismissed. The O.P.s have separately given answers to the contents of the complaint.

Having heard the Ld. Advocate of the complainant and O.P.s and on perusal of the Complaint, as well as documents filed by the complainant, written version of the O.P.s, the following points are to be decided by this Commission.

Points for consideration

1. Whether the complainant is a consumer?
2. Whether the case is maintainable under the C.P. Act?
3. Whether there is any deficiency in service on the part of the O.P. as alleged by the Complainant?
4. Is the Complainant entitled to get any award and relief as prayed for as per the prayer of his Complaint?

                            Decision with Reasons

All the points are taken up together for discussion to avoid unnecessary repetition and for sake of convenience and brevity of this case.

In order to prove the case the Complainant has filed Written Deposition in Chief in the form an Affidavit wherein the Complainant has categorically stated and corroborated the contents of the Complaint. In the written deposition the complainant has stated on which day the husband of the Complainant purchased the PNB MetLife Insurance Policy being no. 21360514. The complainant has also corroborated that her husband purchased the policy with an intention to insure his life against any unforeseen events or contingency for a sum of Rs. 19,41,940/- for a term of ten years commenced on 27.07.2014 from the O.P. no. 01. In the deposition the complainant has also stated that her husband gave a sum of Rs. 1,81,995/- being the first yearly premium under the policy and she also stated that her husband Subhra Biswas died on 29.06.2015 due to cardio respiratory failure. The complainant in her written deposition in the form of an affidavit further stated that on 24.06.2015 she made a claim of settlement amount in respect of the policy which was repudiated by the O.P.s and intimate the same vide letter dated 17.09.2015. The Complainant has further corroborated that she sent legal notice dated 20.01.2016 to the O.P.s for settlement of the claim but the O.P.s on receipt of notice made a reply which is more or less mirroring the repudiation letter dated 17.09.2015 .

By filing the evidence in the form of an affidavit the complainant has stated that, she has been able to prove this case against the OP’s and she is entitled to get the relief as prayed for.  

To  falsify the case of the complainant the OP’s have  filed written evidence in the form of an affidavit. in the written deposition the Op’s have corroborated their written version and has stated that by suppressing the fact the policy was purchased from the OP No1 and for which they have right by repudiated the death claim.

Ld advocate of the op’s have also filed several documents which are treated as Annexure –OP-1 to Annexure –OP-4.

 At the time of hearing of argument Ld. advocate of the complainant submits that, they have already filed written notes of argument and stated everything there. He also argued that, the complainant has been able to prove her case against the Op’s and the complainant is entitled to get the relief as prayed for. He further argued that the OP’s have illegally repudiated the bona fide claim of the complainant with mala fide and ill motive to cause loss and injury to the complainant. He further argued that, this commission has pecuniary jurisdiction to entertain this case vide section 11 (1) of the Consumer Protection Act 1986 as the value of the services in respect of which there has been a deficiency in service on the part of the OP’s amounting to a sum of Rs. 19,41,940/- and compensation of Rs. 50,000/- together are within the pecuniary jurisdiction of this commission. He also argued that, the documents which the op’s have filed with their written version and thereafter are full of contradiction and lacunae and the certificate of Dr. A.B. Dutta chowdhury of Deshbandhu Para, Siliguri dated 25.08 2015 is a purported physician statement and  nowhere in the said statement has it been mentioned that the DLI was under treatment by whom and for how long or for what duration the DLI had been suffering from the said disease or what medication he has been taking for the said diseases. It is further argument of the Ld advocate of the complainant that, the OP’s have failed to produce any valid documents or evidence to support their claim of DLI having  medical history of diabetes and Hypertension.

It is also argument of the LD advocate of the complainant that the said Dr. A.B. Dutta Chowdhury has neither been examined before this commission nor any affidavit stating the entire medical history of the DLI has been filed by him nor the said physician statement has ever been exhibited by him on dock and that’s why the said physician statement has  no value or importance in this case.

It is also argument of the Ld advocate of the complainant that, the report which was submitted by the investigator conducted by the OP’s is in complete contradiction with their own claim of the DLI suffering from Diabetes and HTN prior to issuance of policy as the report of the investigator states that LA had “ only problem of HTN and since last one year he was under treatment and the physician statement of Dr. A.B. Dutta Chowdhury was clearly a manufactured document Ld advocate of the complainant referred decisions of LIC of India-Vs-Joginder Kaur and  Ors(2005)2 CLT 299 & Smt Champa Bhagat Singh Pardeshi-Vs-HDFC standard Life Insurance Company before the Maharashtra state Consumer Disputes Redressal commission and the Decision of LIC of India-Vs-Dr. P.S. Agarwal reported in (2005) I CLT 494 and LIC of India-Vs- Sudha Jain reported in(2007) 2 CPJ 452.

 Ld. advocate of the OP’s during argument submits that the complainant has failed to proved its case against the OP’s and she is not entitled to get any relief. He also argued that, they have already filed their written notes of argument and stated everything to falsify the case of the complainant. In the WNA as well as during oral argument Ld advocate of the OP’s has stated that, this commission has no pecuniary Jurisdiction to entertain the instant case as the complainant has filed this case claiming a sum assured of Rs. 19, 41,940/- plus interest along with compensation of Rs. 40,000/- and cost of Rs.10, 000/- and that’s why this complainant is liable to be dismissed for want of jurisdiction vide section 11(1) of the Consumer Protection Act 1986.

 It is further argument of the OP’s that, the Complainant has filed this case on some false allegation for wrongful gain of her own and for causing wrongful loss of the OPs and for causing wrongful laws of the OP’s and this case is liable to be dismissed. It is further argument of the OPs that, the averments made in the complaint are vague , baseless and with mala fide intend and the allegations are baseless on the questions of deficiency in services and in support of such allegation the complainant did not furnished any documentary evidence. It is also argument of the Ld advocate of the OP’s that, the complaint filed by the complainant does not fall within the definition of Consumer Dispute as there is neither any unfair trade practice adopted by the OPs nor the deficiency in service is established by the complainant against the OPs as the statement made in the complaint are baseless, false, frivolous. It is further argument of the OP’s that at the time of filling up the proposal from the DLI has stated that, he has furnished the information after fully understanding the contents thereof and also understanding the terms and conditions of the plan he had applied for and made true and accurate disclosure of all the facts and has not with held any information but the DLI did not provide true and correct information while filling up the proposal form with respect to his medical history and he suppressed that he was suffering from diabetes and HTN prior to issuance policy. He also argued that the DLI was suffering from diabetes and HTN which is clearly reveals from the death certificate which was issued by Dr. A.B. Dutta Chowdhury and the DLI intentionally concealed the said ailments while filling up  the proposal form and the DLI played fraud upon the OPs to induce them for issuing policy in his favour. Further argument is that, the OP’s have rightly repudiated the claim of the complainant on the grounds of providing false information as to material facts with respect to medical history of the DLI at the time of filling up of the proposal from on the basis of which the policy was issued. Ld advocate of the OP’s referred decisions reported in (2009) 8 SCC 316 and decision reported in (1996) 6 SCC 428 and decision reported in (2000) 2 SCC 734. By referring those decisions Ld. Advocate of the OP’s argued that the complainant has failed to prove her case and she is not entitled to get any relief as prayed for.

            Having heard the Ld. Advocate of both the sides and on perusal of the evidence of the parties as well as on perusal of the documents annexed by them, it is admitted fact by both the parties that, the husband of the complainant namely Subhra Biswas had purchased PNB Metlife Policy for a sum of Rs. 19,41,940/- from the OP No. 1 Company for a term of 10 years being Policy No. 21360514 Commenced on 27/07/2014.

            It is also admitted fact that the complainant was made nominee of that policy being in No. 21360514 by her husband Subhra Biswas.

            It is further admitted fact by both the parties that the said Subhra Biswas  made a payment of Rs. 1,81,995/- being the first yearly premium.

            It is also admitted fact by both the parties that the said policy holder Subhra Biswas died on 29/04/2015.

            It is further admitted fact by both the parties that the complainant being the nominee of that policy approached the OP No. 1 Company on 24/06/2015 for settlement of her claim and submitted the duly filled up prescribed form which was repudiated by the OP’s which was intimated through letter dated 17/09/2015.

            Only dispute between the parties is that the complainant in her complaint, evidence-in-chief as well as in her written notes of argument has stated that her husband has died on 29/04/2015 due to cardio respiratory failure. On the other hand the OP’s in their written version, evidence-in-chief, written notes of argument has claimed that, the death was due to sufferings from Diabetes and HTN.

            Now let us see how far the complainant has been able to prove her case and entitled to get the relief as prayed  for or how far the OP’s have been able to falsify the case of the complainant by producing evidence or not.

            In the complaint, written evidence and in the written notes of argument the complainant has stated that her husband Subhra Biswas has died due to Cardio respiratory failure and she also stated that, during the years 2014-15 the town of Siliguri and adjoining areas had suffered the major earthquakes, the last of which struck the town 4 days prior to the death of Subhra Biswas and for the reason of those major earthquakes that Subhra Biswas became a sudden patient of hypertension. But to falsify the said claim of the complainant the OP’s have referred the death certificate which was issued by Dr. A. B. Dutta Chowdhury and by referring that certificate the OP’s have claimed that the death of Subhra Biswas was not due to Cardio respiratory failure but due to long suffering of Diabetes and HTN.

            From careful perusal of the documents of the OP’s we did not find anything/documents as to who was the doctor under whom that Subhra Biswas was treated prior to his death. The OP’s have also not filed any documents to prove how long Subhra Biswas was treated prior to his death and also fails to produce as to what medications were prescribed for that disease of Diabetes and HTN.

            From the record it is also not explained on the side of the OP’s as to what evidence they have produced before this Commission either oral or documentary to support their claim of that Subhra Biswas having a medical history of Diabetes and Hypertension.

            Moreover, though the OP’s have referred the certificate issued by Dr. A. B. Dutta Chowdhury to substantiate their claim of the disease Diabetes & HTN of that Subhra Biswas but the OP’s have not filed any Affidavit sworn By Dr. A. B. Dutta Chowdhury stating entire medical history of that Subhra Biswas, nor has been examined before this Commission as a witness of the OP’s.

On the other hand, the summary of investigation which was conducted by the OP’s it reflects that the investigator in the report clearly stated that on being asked about the past treatment history of that Subhra Biswas but the Dr. A.B. Dutta Chowdhury told that LA had only problem of HTN and since last one year he was under his treatment and the investigators requested that Doctor for providing for patient illness and treatment record but  that doctor told that he had no record of patient treatment and he filed the physician statement.

 From the said summary of investigation submitted by the investigator of the OP’s and the death certificate  which was issued  by Dr. A.B. Dutta Chowdhury we find that both are contradictory version of the other and the OP’s have failed to explain the said discrepancy before us by producing either oral or documentary evidence. Mere claim of having diabetes and HTN by the OP’s does not ipso-facto proves by the statement of a physician since the doctor has not been examined before this commission on dock.

It is also needless to mention here that only one physician statement/death certificate cannot be considered for concluding that the policy holder was suffering from the said disease of diabetes and there is no other cogent evidence produced by the OP’s on record to proved that the deceased Subhra Biswas had suffered from such disease of diabetes.

 Considering all we are of the view that that the complainant has been able to prove her case against the OPs and also proves that there was deficiency in service as well as restrictive on the part of the OPs towards the complainant who deliberately did not disburse the claim amount of the complainant.

Hence,

O r d e r e d

That the instant Consumer Case being No. 88/2016 be and the same is allowed on contest against the OPs but in part.

The OPs are jointly and severally liable to pay the awarded amount.

The OPs are directed to pay a sum of Rs. 19,41,940/- (Rupees Nineteen Lakh Forty One Thousand Nine Hundred and Forty) only to the complainant.

The OPs are also directed to pay a sum of Rs. 10,000/- (Rupees Ten Thousand) only to the complainant on account of compensation for mental agony, harassment as well as deficiency in service caused by the OPs towards the complainant.

The OPs are further directed to pay a sum of Rs. 10,000/-(Rupees Ten Thousand)  only to the complainant towards cost of legal proceedings.

The OPs are further directed to pay a sum of Rs. 10,000/-(Rupees Ten Thousand)  only in the Consumer Legal Aid Account of This Commission.

The OPs are directed to pay interest @ 4% per annum to the complainant on the awarded amount, with effect from the date of filing of this case till making payment of the entire amount.

The OPs are directed to pay the awarded amount within 45 days from this day failing which they will have to pay interest @ 7% per annum and in that case the complainant will have the liberty to take proper steps against the OPs.

Let a copy of this order be given to the parties free of cost.