Haryana

StateCommission

CC/2/2014

Sita Gusain - Complainant(s)

Versus

Aegon religare Ins.co. - Opp.Party(s)

30 Jan 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA.

 

                                                Complaint No.02 of 2014

                                                       Date of Institution: 22.01.2014         Date of Decision: 30.01.2017

 

Sita Gusain aged 56 years W/o late Sh.Chander Singh Gusain R/o H.NO.730 Sector 23 NIT Faridabad 121001, (Haryana)

…..Complainant

 

Versus

 

1.      M/s Aegon Religare Life Insurance Co. ltd. Situated at Nomura, B-Wing, First Flor, Unit NO.102, Near D-Mark, Hirachandani Business Park, POWAI, Bumbai-400076, through its Managing Director & Chief Executive Officer.

2.      M/s Aegon Religare Life Insurance Co. Ltd. SCO-11, 2^nd Floor, Sector-14, Gurgaon-122001 (Haryana) through its Vice President.

          …..Opposite Parties

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                   Mrs.Urvashi Agnihotri, Member.                                    

For the parties:  Mr.G.D.Gupta and Mr. Munish Kapila, Advocates counsel for the complainant.

                             None for the opposite parties.

 

O R D E R

 

R.K.BISHNOI, JUDICIAL MEMBER :-

It is alleged by complainant that her son Harish Gusain obtained insurance policy NO.513013968557 issued on 06.02.2013 for sum assured of Rs. One crore. Before issuing insurance policy he was thoroughly checked by the physicians of insurance company i.e. opposite parties (O.Ps.).  He was not suffering from any ailment at that time. He was working with Honda Motorcycle Limited, Faridabad and was getting Rs.Five lacs per annum i.e. approximately Rs.41,670/- per month.  During the night of 17.05.2013 he suffered pain in abdomen and on 18.05.2013 he was taken to doctor. He was admitted in Fortis Escorts Hospital and Research Centre, Faridabad (In short “Fortis Hospital”) on that day because besides abdominal pain there was also vomiting.  He was diagnosed a case of acute pancreatitis and mild ascites.  Best available treatment was given to him, but, he breathed his last on  28.05.2013 at about 11.15 P.M.  Till 18.05.2013 they were not aware about his illness.   Claim was lodged with the O.Ps. and all the relevant documents were submitted, but, was not settled. Claim submitted with M/s Aviva Life Insurance Co. Ltd. (In short “Aviva Insurance”) under another policy and that company paid Rs.6,30,000/-.  There is deficiency in service on the part of the O.Ps. and they be directed to pay sum assured i.e. Rs.One crore alongwith interest @ 12% on the delayed payment (from when it is not mentioned) and cost of litigation or any other relief deemed fit.

2.      Lateron complainant filed an another copy of complaint on these very grounds on 22.01.2014 without any permission to file fresh complaint.

2.      O.Ps. filed reply controverting her averments and alleged that the complaint was beyond pecuniary jurisdiction of this commission because she has demanded Rs.One Crore besides interest and other damages, which goes beyond one crore.  It is also alleged that Deceased Life Assured (DLA) Harish Gusain was a known case of hypertention, Acute coronary Syndrome, Urinary Tract Infection (UTI) with Gastritis and Acute Severe Pancreatitis.  He received treatment from various hospital including NIMS Faridabad since 18.12.2012 to 18.12.2012, but, concealed this fact while obtaining insurance policy.  At Fortis Hospital he was diagnosed as case of acute severe Pancreatitis, septic shock, acute kidney injury-DM dialysis and Hypoxic encephalopathy.  Hypertention or High blood presume called arterial hypertension is a Chronic medical condition in which blood pressure in arteries is elevated.  In the proposal form he did not disclose about his condition and his answers were as under:-

“11(iii)         It is further stated that for the following queries the insured Mr. Harish Gusain had answered “NO” in the proposal form with regard  to policy No.513013968557, whereas the diseases which he had succumbed to, could not occur overnight.

Section 7. Medical Information

Question 1)         Have you ever been diagnosed with, received any treatment or been referred for investigation or tests for:

Questions 1A) High Blood Pressure, Chest Pain, Heart Attack, Heart Murmur, Shortness of Breath or any other heart condition?

Answer      No.

Question 1e.) Recurrent indigestion, ulcer, jaundice, hepatitis, cirrhosis, kidney failure, or any other disease of the liver, stomach, bowels, kidney bladder, reproductive system or urinary system?

Answer      No.

Question 2) With the last 5 years have you:

Question 2a) Undergone or currently undergoing any investigations such as ECG/X-ray and/or blood reports for other than routine or pre-employment health check up?

Answer      No.

Question 2b)  Attended or been advised to attend hospital or clinic as an inpatient or outpatient or undergone any surgery or waiting for any form of treatment to start.

Answer      No.

Question 4) Do you  currently have or had in the past any other medical condition, illness, diseases, disorders, disability, surgery or treatment or are currently intending to seek any medical advice which is not mentioned above?

Answer      No.”

He was suffering from serious ailment as mentioned in para No.11 sub para (i) and (vii) of reply which cannot develop overnight.  Due to concealment of previous ailment her claim was repudiated.

3.      Both the parties have led evidence.

4.      None appeared on behalf of the opposite parties since three dates.  Even on this date nobody appeared on their behalf till 3.00 P.M.  The appeal  is pending since the year 2014. There was no ground to wait any more and arguments of complainant’s counsels are heard.

5.      Learned counsels for complainant vehemently argued that there is no evidence on the file to show that he was suffering from any ailment at the time of obtaining insurance policy. He was properly checked by the doctors of O.Ps. and no abnormality was found which is clear from the perusal of Ex.C-1. Had he been suffering from this ailment the same must have been mentioned by the doctors of O.Ps.  As per death Ex.C-8 he died natural death. There was no nexus in between disease and death on the basis of which claim was repudiated vide letter dated 03.09.2013, copy of which is Ex.C-11.  Even otherwise Aviva Insurance has already granted compensation of Rs.6,30,000/- in other insurance policy which is clear from the perusal of Ex.C-10. So O.ps. be directed to give sum assured i.e. Rs.One crore. He placed reliance upon opinion of Hon’ble Punjab and Haryana High Court expressed in IFFCO TOKIO General Insurance Company Ltd. Vs. Permanent Lok Adalat (Public Utility Services), 2012 (11) R.C.R. (Civil) 901.

6.      This argument is devoid of any force.  It is well settled preposition of law that life insurance is a contract of utmost good faith and uberrima fides and complainant should have disclosed true facts. In case of concealment of any fact policy will be void as opined by Hon’ble National Commission in Kokilaben Narendrabhai Patel Vs. Life Insurance Corporation of India 2010 CTJ  920 (CP) (NCDRC). Relevant head note is reproduced  as under:-

“Insurance-Deficiency in service- Consumer Protection Act, 1986-Section 2(I) (g)- Section 2(I) (o)-Insured died due to heart attack- His wife nominated to receive the insured amount in the event of his premature death-  Repudiation of her claim-Allegedly correct answers not given by the deceased regarding his health in the proposal form- Complaint by his wife allowed by the District Forum-State Commission accepted the appeal and set aside the order passed by the Forum-Hence, the present revision petition-Admittedly the insured suffered from Enteric fever eleven months prior to the taking of the policy-Further, for getting it treated, he even took leave for seventeen days-These two facts not disclosed by him in the proposal form-Non-disclosure thereof was clearly a material fact having a bearing on the risk involved-Repudiation of the claim fully justified-View taken by the Sate Commission upheld-Revision Dismissed.”

          Another  opinion by Hon’ble National Commission in The Marketing Manager, LIC of India Versus Smt. S.Vijaya, CPC (1995 (1) 341 is as under:-

“Insurance Claim-Complainant’s husband had taken a life insurance policy for Rs.30,000/- who dies due to illness- The claim was repudiated on the ground that the deceased had suppressed the fact that he was already suffering from Circhsis of liver-This fact was revealed from the record of the Hospital-Repudiation of claim justified-Order of State Commission giving relief the respondent set aside.”

 

When proposal form Ex.C-2 was submitted, DLA did not disclose about previous ailment, as mentioned in reply. Whereas according to record of NIMS Hospital (colly) DLA was admitted there on 18.12.2012 and was discharged on 21.12.2012 with following ailment:-

“ HT with ACS with Enteric with Backache with UTI  with Gastritis.”

                   As per ultrasound report dated 18.12.2012 liver was increased in size. This record shows that DLA was aware about ailment on 18.12.2012 and was suspecting an untoward incident at any time. Due to this reason he obtained policy of one crore from different company, whereas previously he obtained policy of Rs.6,30,000/- from Aviva Insurance. Change of insurance company and huge increase in insurance amount casts cloud over his intentions. Complainant cannot derive any benefit from the cited case law because in that case insurance company was in a dominant position whereas in the present case DLA obtained second insurance policy with malafide intention, so complainant is not entitled for any compensation and the complaint is hereby dismissed.

 

January 30th, 2017

Mr.Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench

S.K.