Renu Gangwar vs Aviva Life Insurance Company India Ltd.

THE main controversy in this case revolves round the question, "Whether, repudiation of the claim made by Smt. Renu Gangwar, the complainant, with Aviva Life Insurance Co. India Ltd., the OP, is valid -. Sh. Pankaj Kumar Gangwar, the husband of the complainant, expired during the subsistence of the insurance policy, "Aviva Life Shield Plus", issued by the OP. As per the policy, the life of the complainant''s husband was assured for a sum of Rs. 50.00 lakh only, along with an additional Accidental Death Benefit of an amount of Rs. 50.00 lakh. The said policy has been placed on record as Annexure C -1.

IN April, 2011, the insured went to Bareilly, Uttar Pradesh. On 23.4.2011, he slipped and fell down at Railway Station, due to which, he got injured. The insured was taken to District Hospital, namely, Maharana Pratap Jila Sanyukt Chikitsalay", where, he was examined by Emergency Medical Officer, vide copy of OPD ticket, dated 23.4.2011, is appended with the complaint as Annexure C -2. The insured got himself treated till 2.5.2011 by Dr. Rakesh Kumar, at Bareilly. The said Doctor issued Fitness Certificate, vide Annexure. C -3, dated 2.5.2011. On 3.5.2011, the deceased got himself examined at Swastit Hospital. He was advised to take further medicines, vide Annexure C -4. On 6.5.2011, the deceased arrived at Delhi and got himself examined at Dean Dayal Hospital, in Emergency Department. The medical prescription dated 6.5.2011 is annexed with the complaint as Annexure C -5. Unfortunately, the insured, passed away, in the night of 7.5.2011. His cremation took place at Kacchla, Badaun, on 8.5.2011. Copy of the Death Certificate, marked as Annexure C -6, has been placed on record.

THERE after, the relatives of the deceased came back to Delhi and Renu Gangwar, his wife, filed the claim before the OP, which was repudiated vide Annexure C -8. It is stated that the deceased had paid the premiums regularly. The present complaint petition was filed before this Commission, on 2.5.2013, with the following prayers: "1 Direct the opposite party to release the insurance claim in favour of complainant amounted to Rs. 1,00,00,000 (Rupees one crore only) along with interest of 24% per annum from the date of claim, till the realization of claim amount.

Pass an order of compensation in favour of complainant and against the opposite party for physical and mental harassment amounted to Rs. 10,00,000.

Grant the cost of present litigation in favour of complainant and against the opposite party amounted to Rs. 50,000.

Pass any other order as this Hon''ble Commission may deem fit according to facts and circumstances of the present case."

NOTICE was issued to the OP, vide order dated 18.11.2013, for 5.5.2014. The A/D Card was received back. On 5.5.2014, none appeared on behalf of OP, till 12.45 pm. Consequently, the O.P. was directed to be proceeded against ex parte, on the said date. The final arguments were heard on 7.10.2014. O.P. has not approached this Commission, till the pronouncement of this judgment. We have heard the Counsel for the complainant. The repudiation letter is crucial. The relevant portion of which runs, as follows: "As per the information procured by us during the course of claim evaluation, we have noted that the Cremation Certificate submitted by you, on the basis of which, Death Certificate has been issued, is forged. Also, we have noted that the Income Tax Return as per Article 9(c) of the standard terms and conditions:

Fraud: If the policy holder or the insured or the nominee or anyone acting for any of the or at their knowledge makes or advances any claim knowing it to be misleading, false, dishonest or fraudulent, in any respect, then, this policy shall be void and any benefit actually paid or potentially payable, shall be forfeited. Further, as per the information procured by us, during the course of claim evaluation, the deceased life assured had previous life insurance policies with ICICI Prudential and LIC amounting to Rs. 34 lacs, which were not disclosed to us, in the proposal form."

THE claim was repudiated on three prongs. First of all, it is stated that Death Certificate was ''fraud''. The case of the complainant is that her husband had expired. It appears that the body of deceased insured was taken to the River Bank of the Ganges at Kacchla Badaun by his relatives and they performed his cremation. His wife stayed at her house and did not attend the cremation ceremony. The relatives provided a slip of woods and deposited the same with Registrar of Birth and Death, MCD, which issued a Death Certificate. In addition, neighbours and relatives filed Affidavits, Exs. C -1, C -8 and C -9.

ANNEXURE C -2, Outer Patient Ticket issued by Maharana Pratap Jila Sayukt Chikitsalya, Bareilli, reveals that the deceased insured was advised complete rest for one week and "Tab -Dfe T -200 - 1BD, Tab -Crocin -1 TDS, Syrup -Katcid 2 - BF", were recommended. Annexure C -3, Certificate, dated 2.5.2011, issued by Dr. Rakesh Kumar, Bareilly, clearly goes to show the following: "Certified that Sh. Pankaj Kumar Gangwar, transporter in IBM., Gurgaon, was suffering for accidental injuries in his leg and was under my treatment from 25.4.2011 to 2.5.2011. He was advised complete rest during treatment.

Now he is fit to resume his duties w.e.f. 2.5.11, evening. His signature given below, duly attested by me.

Sd/ -(Dr. Rakesh Kumar)BAMS, ARSH (London)".

THERE are other certificates which are not that relevant. The Certificate issued by the Deen Dayal Upadhyay Hospital, New Delhi, dated 6.5.2011, marked as Annexure C -5, runs as follows: "History: C/o. Pain in Rt. LumberReterGeneral Condition: InjuryPulse: 80 BPMBP 110/70H/of all 12 days backCVS ]P/A ] - - NADCNSjL/E ]

RA/in OPD No. 3

AdvOmk - Voveron 7.5mg. -instantTab Dikase - 1 BDTab Rantac - 150 mg.BD

Sd/ -".

AFTER the deceased insured''s visit to Deen Dayal Upadhyay Hospital, on 6.5.2011, no further history of the deceased insured has seen the light of the day. The fact that, how did the insured die, is surrounded by dallops of mystery. Prima facie, it is for the complainant and nobody else who has to carry the ball to show the cause of the death of the insured. In absence of any cogent and plausible evidence, the same does not begin to jell. It is not clear as to how the complainant died and under what circumstances and where (the place of his death). When he had expired, why his body was cremated at Kacchla Badaun, when he was residing at New Delhi?. The absence of his wife at the time of cremation, at Kacchla Badaun, causes a film of doubt over this story. The Post Mortem examination of the deceased was not conducted. The production of Post Mortem Report would have gone a long way to elicit the true picture. The absence of Post Mortem Report dampens the ardour of the complainant''s case. He was never admitted in the Deen Dayal Upadhyay Hospital. The Prescription Slip, dated 6.5.2011 issued by the Doctor of the Deen Dayal Upadhyay Hospital, Delhi, shows that he was only an outpatient. He was declared fit by Dr. Rakesh Kumar, on 2.5.2011. It, therefore, clearly goes to show that he did not pass away due to the above said accident/slip in the railway station. It is not clear, whether he died due to suicide or was murdered or there was some other cause. The complainant has failed to prove her prima facie evidence. It is also interesting to note that the person who prepared the English Translation of the Certificate issued by Dr. Rakesh Kumar, has tried to play a trick with this Commission. The Certificate/Report of Dr. Rakesh Kumar, dated 2.5.2011 dearly states "Now he is fit to resume his duties w.e.f. 2.5.2011, evening". However, the English translation (Typed copy, at page 10A) goes to show "Now he is first to xxxxx his duties w.e.f. 2.5.11 evening;". The words "fit to resume" are conspicuously missing. This is an attempt to pull the wool in the eyes of this Commission.

MOREOVER , the three affidavits produced by the complainant are of no relevance. Vijay Kumar Gupta, S/o. Sh. Raja Ram Gupta, is merely a neighbour. In his affidavit (Ex. C -7), he does not state, how did the insured expire.

NATHNO Singh, S/o. Sh. Bansi Lal, is a relative of the deceased insured. In his affidavit (Ex. C -8), he has not explained how he is related to the deceased insured. His evidence is hearsay evidence. Para No. 2 of his affidavit, runs as follows: "I say that in the night of 7.5.2011, Pankaj Kumar Gangwar expired and I was informed by his wife Renu Gangwar and she further intimated me that his relatives were willing that his cremation shall be held at Khachla Ghat, Badaun, Uttar Pradesh, accordingly I have attended his cremation at Khachla Ghat, Badaun, Uttar Pradesh on 8.5.2011."

No value can be pinned with his evidence.

Last witness, Lalu Singh Patel, S/o. Sh. Satender Singh, is the real brother of the deceased insured. He says that his brother, in the night of 7.5.2011, had expired and he being his real brother, had solemnized and attended his cremation which was held at Khachla Ghat, Badaun, Uttar Pradesh, on 8.5.2011. He does not disclose, why and how his brother died. He does not state why his brother was not cremated at Delhi. His statement is vague, evasive and leads this Commission, nowhere.

THE second objection raised in the repudiation letter is that Income Tax Return, as per Article 9(c) of the standard terms and conditions, was filed on 31.7.2011, i.e., after the expiry of the insured, who died in the night of 7.5.2011. The complainant has tried to rebut this objection by producing the certificate issued by Dinesh Kumar & Co., the Chartered Accountants. The said Certificate dated 29.9.2014, runs as follows: "To Whomsoever It May Concern

It is certified that I was handling the Income Tax Return filing work of late Sh. Pankaj Kumar Ganwar, since year 2007 and he was one of my clients. Lastly, I met with Mr. Pankaj Kumar Gangwar, on or before 20.4.2011 and taken his signature on ITR -45. After waiting for him in July, 2011, I allocated and found the information about his TDS from Income Tax website and accordingly assessed his Income Tax and have filed his Income Tax Return on 31.7.2011 in good faith as I was not aware about his health.

Sd/ -For Dinesh Kumar & Co.Prop.".

THE said certificate dated 29.9.2014, should have been produced before the Insurance Company, before the case of the complainant was considered, which was not done so. This is an after -thought and no value can be attached with this document. The Insurance Company did not get the opportunity to investigate this matter. The last objection which appears in the repudiation letter is that, the complainant had previous life insurance policies with ICICI Prudential and LIC of India, amounting to Rs. 34.00 lakh, which were not disclosed to the OP, in the proposal form. This fact is conspicuously missing in the proposal form dated 31.8.2009.

IN view of the facts and circumstances detailed above, this objection assumes importance. It may not be of considerable importance if read in isolation. The above said facts and circumstances rock the case to a dangerous extent. It is also not understood as to why the ''cremation'' was done in a ''hush -hush'' manner. The story of ''accident'' of the insured, is nothing, but a ruse to make sure that the claim of the complainant is accepted. Under these circumstances, we dismiss the complaint. No order as to costs.