Complaint No: 134 of 2019.

                                                          Date of Institution: 04.04.2019.

                                                                    Date of order: 26.12.2023.

Smt. Bindo Wd/o Viki Masih Son of Munshi Masih, resident of #214 Kahnuwan Road, Abadi Sagarpur Batala District Gurdaspur.

                                                                                                                                                                                      ....Complainant.     

                                                    VERSUS

1.       P.N.B. Met Life India Insurance Company, Regd. Office Brigade Seshamahal 5, Vani Vilas Road, Basavanagudi, Bangalore – 560004 W, through its Managing Director.

2.       The Chairman, Claims Committee, P.N.B. Met Life India Insurance Company, 1st Floor, Techniplex 1, Techniplex Complex, Off Veer Sawarkar Flyover, Goregaon. West Mumbai – 400062.

3.       P.N.B. Met Life India Insurance Company Ltd., Unit No. FUF 5-8 "Eiment Mall" Build on Property bearing No.10, Keneddy Avenue, Mall Road, Amritsar (PB) 143001, through, its Manager.

                                                                                                                                                                   ….Opposite Parties.

                                                         Complaint U/s 12 of the Consumer Protection Act.

Present: For the Complainant: Sh.Rahul Puri, Advocate.

              For the Opposite Parties: Sh.Vikas Sharma, Advocate. 

Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.

ORDER

Lalit Mohan Dogra, President.

          Smt. Bindo, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act, (here-in-after referred to as 'Act') against P.N.B. Met Life India Insurance Co. Etc. (here-in-after referred to as 'opposite parties).

2.       Briefly stated the case of the complainant is that husband of the complainant namely Viki Masih obtained an insurance policy bearing policy No. 21605420 dated 23.06.2015 in his name. It is pleaded that husband of the complainant was insured for a sum of Rs.13,89,120/- and she is the nominee of her husband. Her husband deposited premium of Rs.12,000/- with the opposite parties and the date of its maturity was 23.06.2045 and mode of payment of premium was quarterly. It is further pleaded that all the formalities were also completed by the duly authorized agent of the opposite parties in his office of opposite party No. 3 as the representative of the opposite parties No. 1 and 2 were sitting in the office of the opposite party No. 3. It is further pleaded that unfortunately, all of sudden husband of the complainant died on 02.07.2015 in natural death and information regarding his death was duly given to the opposite parties by the complainant. It is further pleaded that the complainant submitted her claim for payment of the insured amount alongwith all vested benefits to the opposite parties, but the opposite party No. 2 vide letter dated 29.11.2016 repudiated her claim on false and flimsy ground. It is further pleaded that observations raised by the opposite parties are totally false, imaginary, which has no legs to stand. It is further pleaded that husband of the complainant was hale and hearty. It is further pleaded that the husband of the complainant was medically examined by the agent / representative of the opposite parties before issuance of insurance policy. This decision of the opposite parties is liable to be set aside and the complainant is entitled to receive the amount of insurance policy. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in service on the part of the opposite parties.

          On this backdrop of facts, the complainant has alleged deficiency and negligence in service and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to honour the claim of the complainant and make the payment of insured amount immediately in terms of the Insurance policy. Besides the insurance amount, the complainant may also be awarded compensation to the tune of Rs.50,000/- on account mental agony, physical harassment and deficiency in service on the part of the opposite parties and litigation expenses to the tune of Rs.5000/- to the complainant, in the interest of justice.

3.       Upon notice, the opposite parties appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complaint is false, malicious, incorrect and with malafide intent and is nothing but an abuse of the process of the law. It is further pleaded that complaint filed by the complainant does not fall within the definition of a consumer dispute. It is pleaded that the answering opposite parties received the Death Claim Intimation from the complainant dated 15.9.2016 thereby intimating that the Person Insured died on 02.07.2015, which was duly acknowledged vide condolence letter dated 16.09.2016. The claim being an early claim, as the person insured died within a short span of only 9 days from the date of reinstatement of the policy, the opposite parties as per the procedure, carried out an investigation to settle the claim of the complainant. It is further pleaded that during the course of investigation and assessment of the claim, it was revealed to the opposite parties that the DLI (“Decreased Life Insured”) was suffering from Lung Cancer prior to the issuance of the policy. It is further pleaded that the DLI suppressed this material fact while submitting the proposal form and DLI expired only within a short span of 9 days from the date of issuance of the policy and others objections have also raised by the opposite parties. It is further pleaded that the DLI after completely understanding the terms and condition of our product had submitted the duly signed Proposal Form on 22.06.2015 and offered to pay Rs.12,420/- quarterly towards the initial premium against the Sum Assured of Rs.13,89,120/-. It is further pleaded that in the proposal form, there was a column wherein the DLI was required to provide answers with respect to his Medical History and the DLI replied that he was not suffering from any disease neither he was taking any medical treatment. It is further pleaded that upon receipt of the duly filled up proposal form and believing the information provided by the DLI to be true and correct, alongwith the initial premium, the opposite parties evaluated and processed the Proposal Form on the basis of the information furnished by Deceased Life Insured (DLI) and issued the policy bearing No. 21605420 with Risk Commencement date of 23.06.2015. It is further pleaded that the DLI was suffering from Lung Cancer prior to the issuance of the policy and as such the claim of the complainant has been rightly repudiated by the opposite parties. It is further pleaded that DLI was duly bound to disclose his correct medical condition in order to assess the risk factor that the opposite parties will bear upon the life of insured and any non- disclosure of same would vitiate the contract at the option of the opposite parties. It is further pleaded that the complainant being beneficiary/nominee under the said policy is bound by the contents stated by Deceased Life Insured (DLI) in the Proposal Form and cannot challenge the same. Lastly, the complaint of the complainant has been prayed to be dismissed.

          On merits, the opposite parties have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.

4.       Learned counsel for the complainant has tendered into evidence affidavit of Smt. Bindo, (Complainant) as Ex.C-1 alongwith other documents as Ex.C-2 to Ex.C-12.

5.       Learned counsel for the opposite parties has tendered into evidence affidavit of Sh. Rajeev Sharma, (Senior Manager - Legal, P.N.B. MetLife India Insurance Co. Ltd., Bangalore) as Ex.OPW-1/A alongwith other documents as Ex.OP-1 to Ex.OP-11.

6.     Written arguments filed by both the parties.

7.       The present complaint was remanded to this Commission vide order dated 19.03.2019 by the Hon'ble State Consumer Disputes Redressal Commission, Punjab Chandigarh to decide the matter afresh after going through the vital documents on record. Opposite parties have placed on record documents and we have gone through the documents.

8.       Counsel for the complainant has argued that husband of the complainant namely Vicky Masih had purchased insurance policy and was insured for Rs.13,89,120/-. However, unfortunately husband of the complainant died on 02.07.2015 on account of natural death and intimation was given to the opposite parties. However, opposite parties wrongfully repudiated the claim vide letter dated 29.11.2016 on false and flimsy grounds. Repudiation of the claim by the opposite parties amounts to deficiency in service on the part of the opposite parties.

9.       Counsel for the opposite parties has argued that policy of insurance is admitted. However, there is column in the proposal form wherein the DLI was required to provide answers in respect of his medical history and the DLI replied that he was not suffering from any disease neither he was taking any medical treatment. The insured person died on 02.07.2015 and the claim being earlier claim i.e. within short span of 9 days from the date of reinstatement of policy and opposite parties carried out investigation to settle the claim and it was revealed that DLI was suffering from lung cancer prior to issuance of the policy and DLI suppressed this material fact while submitting the proposal form. Counsel for the opposite parties has also referred to the record i.e. admission certificate issued by the Civil Hospital Batala as per which Vicky Masih was admitted in the said Hospital on 19.02.2015 in emergency condition and thereafter referred to Guru Nanak Hospital Amritsar on 21.02.2015 and was suffering from Asthmatic, Consolidation, Right Lung with Hepatitis SOL. Copy of the said record is Ex.OP-10 and Ex.OP-11.

10.     We have heard the Ld. counsels for the parties and gone through the record.

11.     It is admitted fact that late Vicky Masih submitted the duly signed proposal form on 22.06.2015 and offered to pay Rs.12,420/- to the opposite parties and life insurance policy bearing No.21605420 with risk commencement date 23.06.2015 was issued. It is further admitted fact that complainant is nominee of the said policy. It further admitted fact that after issuance of the policy the insured person died on 02.07.2015 within a short span of 9 days from the date of reinstatement of the policy. It is further admitted fact that the opposite parties have repudiated the claim of the complainant vide letter dated 29.11.2016.

12.     To prove her case complainant has placed on record her duly sworn affidavit Ex.C1, copy of legal notice Ex.C2, copy of first premium receipt Ex.C3, copy of policy document Ex.C4, copy of welcome letter Ex.C5, copy of list of ombudsman Ex.C6, copy of proposal form Ex.C7, copy of death certificate Ex.C8, copy of intimation letter Ex.C9, copy of repudiation letter Ex.C10 and postal receipt Ex.C11 and also tendered into evidence copy of letter of Senior Medical Officer Civil Hospital Batala Ex.C12 whereas opposite parties have placed on record affidavit of Rajeev Sharma Sr. Manager Legal Ex.OPW-1/A, copy of declaration form Ex.OP-1, copy of claim intimation Ex.OP-3, copy of detail regarding policy Ex.OP-3, copy of repudiation letter Ex.OP-4, copy of policy issued by Bajaj Allianz Ex.OP-5, copy of proposal form Ex.OP-6, copy of Pan Card Ex.OP-7, copy of Key Features of the Plan Ex.OP-8, copy of claim notes and decisions Ex.OP-9 and copies of admission record of Vicky Masih Ex.OP-10 and Ex.OP-11.

13.     Perusal of file shows that proposal form Ex.OP-1 has been duly filled and it is signed by the insured Vicky Masih at the relevant columns and the insured had submitted declaration regarding his good health. The claim has been mainly repudiated by the opposite parties on the ground that the insured person was already suffering from lung cancer when he purchased the policy of insurance and the insured had deliberately concealed the said fact while purchasing the policy of insurance. The opposite parties have brought on record another policy of insurance purchased by the insured person from Bajaj Allianz Insurance Company copy of which is Ex.OP-5 and have also relied upon documents Ex.OP-10 and Ex.OP-11 as per which the insured remained admitted at Civil Hospital Batala from 19.02.2015 to 21.02.2015 and on 21.02.2015 the insured was referred to Guru Nanak Hospital Amritsar as per the record and to rebut the said evidence counsel for the complainant has placed on record information obtained under RTI Ex.C12 as per which it is mentioned that as per the record and the available investigations patient was diagnosed to be suffering from Consolidation Right Lung with Heptic SOL ? Metastasis for which patient was given conservative treatment. It is further mentioned that patient was having cancer or not cannot be confirmed or commented upon with the available record. We are of the view that only admission in hospital on 19.02.2015 to 21.02.2015 does not prove that the insured was suffering from lung cancer. Moreover, the opposite parties have not been able to explain that why the record of Guru Nanak Hospital Amritsar was not summoned to prove on record the alleged disease. Moreover, the opposite parties have not examined any such doctor who has given his opinion in the admission record Ex.OP-10 and Ex.OP-11 and in the absence of any such affidavit of the doctor to prove this fact that the insured was suffering from lung cancer or that remained admitted for said treatment in the hospital is not prove on record.

14.     We have placed reliance upon judgment of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2014(3) C.P.J. 13 : 2014(87) R.C.R.(Civil) 264 wherein it was held as under:-

          "Insurance Company failed to produce any evidence to show that appellant was suffering from said disease at the time of taking policy - No affidavit of any doctor or person who recorded history of patient".

15.     The matter regarding the repudiation of such claims on the ground of concealment of illness recently came up for consideration before the Hon'ble Supreme Court in the case of Life Insurance Corporation of India & Ors. V. Smt. Asha Goel & Anr., 1(2001) SLT 89=2001 Supreme Court 549. The Hon'ble Supreme Court held in para 12 as under:-     

          "12.Coming to the question of scope of repudiation of claim of         the insured or nominee by the Corporation, the provision of       Section 45 of the Insurance Act is of relevance in the matter.        The section provides, inter alia, that no policy of the life          insurance effected after the coming into force of this Act shall,        after expiry of two years from the date on which it was          effected, be called in question by an insurer on the ground that         a statement made in the proposal for insurance or in any  report of a medical officer, or referee, or friend of the insured,      or in any other document leading to the issue of the policy,      was inaccurate or false, unless the insurer shows that such    statement was on a material matter or suppressed fact which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time          of making it that the statement was false or that is suppressed       facts which it was material to disclose. The proviso, which       deals with proof of age of the insured, is not relevant for the   purpose of the present proceeding. On a fair reading of the          section it is clear that it is restrictive in nature. It lays down      three conditions for applicability of the second part of the       section namely: (a) the statement must be on a material matter       or must suppress facts which it was material to disclose; (b)     the suppression must be fraudulently made by the policy      holder; and (c) the policy holder must have known at the time   of making the statement that it was false or that it suppressed facts which it was material to disclose. Mere inaccuracy of     (or) falsity in respect of some recitals or items in the proof is        on the insurer to establish these circumstances and unless the insurer is above to do so there is no question of the policy   being avoided on ground of mis-statement of facts. The    contracts of insurance including the contract of life assurance           are contracts uberrimae fides and every fact of material must     be disclosed, otherwise there is good ground for rescission of     the contract. The duty to disclose material facts continues        right up to the conclusion of the contract and also implies           any material alteration in the character of the risk, which may     take place between the proposal and its acceptance. If there     are any mis-statements or suppression of material facts, the     policy can be called in question. For determination of the       question whether there has been suppression of any material   facts it may be necessary to also examine whether the      suppression           relates to a fact, which is in the exclusive          knowledge of the   person intending to take the policy and it    could not be ascertained by reasonable enquiry by a prudent   person".

We are of the view that insurance companies are only interested in procuring business this way or the other but at the time of the settlement they find one excuse or the other some of which are totally ignorable. We are of view that mere production of admission register and indoor patient department register Ex.OP-10 and Ex.OP-11 in no way prove this fact that deceased was suffering from lung cancer at the time of purchasing of the policy of insurance. We are further of the view that the early death of the insured cannot be a ground of repudiating the claim without any authentic medical record on the file. Accordingly, we are of the view that repudiation of the claim by the opposite parties is totally unjustified and without any reasonable cause.

16.     Accordingly, present complaint is partly allowed and opposite parties are directed to pay the sum assured of Rs.13,89,120/- to the complainant being nominee alongwith interest @ 9% P.A. from the date of this order till realization. Compliance of this order be made within 30 days from the date of receipt of copy of this order.      

17.      The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

18.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.  

                               (Lalit Mohan Dogra)

                                                                         President   

Announced:                                          (B.S.Matharu)

Dec. 26, 2023                                                Member

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