Haryana

Yamunanagar

CC/219/2010

Ankit Mangla S/o satish Mangla - Complainant(s)

Versus

AEGON Religare Life Insurance Company Ltd. - Opp.Party(s)

Jitender Kumar

05 Dec 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR AT JAGADHARI

                                                                                          Complaint No. 219 of 2010.

                                                                                          Date of Institution: 12.03.2010       

                                                                                          Date of Decision: 05.12.2016

 

1. Ankit Mangla, aged about 25 years, S/o Sh. Satish Mangla,
2. Satish Mangla S/o Late Shri Onkar Dass, husband of deceased Sunita Mangla,
3. Ankush Mangla son of deceased Sunita Mangla,
4. Neha Mangla daughter of deceased Sunita Mangla,

All R/o H. No.1591/A Amar Vihar, Chhachhrauli Road, Jagadhri, Yamuna Nagar        

  …Complainant.

                                    Versus

1. AEGON Religare Life Insurance Company Limited, 2^nd Floor SCO 2417-2418, Sector-22C, Chandigarh, through its Branch Manager.
2. AEGON Religare Life Insurance Company Ltd, 2^nd Floor Paranjpe ‘B’ Scheme, Subhash Road, Near Garware House, vileparle (East), Mumbai-400057.
3. Lalit Mittal son of Shri Prem Mittal, Resident of 1882, Civil Lines, Jagadhri, District Yamuna Nagar.
4.  
5.                                                                                                  ...Respondents

 

BEFORE:         SH. ASHOK KUMAR GARG…………….. PRESIDENT.

                        SH. S.C.SHARMA………………………….MEMBER.

 

Present:           Sh. J.K Gupta, Advocate for complainant. No.1.

Sh. Parveen Rana, Advocate, for complainants No.2 to 4. (Impleaded       later on vide order dt. 17.10.2016)  

                        None for OP No.1 and 2

OP No.3 already ex parte vide orders dt. 21.05.2010

ORDER

 

1                         The present complaint has been filed under section 12 of the Consumer Protection Act. 1986.

2.                     Brief facts of the present complaint, as alleged by the complainants, are that mother of the complainant No.1 namely Smt. Sunita Mangla took a life Insurance Policy, vide policy No.081010045422 dated 17.10.2008 (policy schedule Annexure C-6) for a sum of Rs.10,00,000/- (10 Lakhs)  and a sum of Rs.5078.67/- (premium receipt Annexure C-5) was paid as premium to the ops no.1 &  2 insurance company through OP No.3. The mother of the complainant No.1 appointed the Complainant No.1 as Nominee to the aforesaid policy. Unfortunately, the mother of the complainant No.1 died on 09.07.2009. After that complainant lodged Insurance claim with OPs Company and all required documents such as claim form, death certificate and other relevant documents were submitted to the Ops Insurance Company on 23.09.2009. The complainant No.1 requested the OPs Insurance Company to entertain the claim of complainant No.1 on account of death of his mother, but the OPs Insurance Company did not entertain the claim of the complainant No.1 and kept on prolonging the same by putting off the matter either on the one pretext or the other. A registered AD legal notice was also served to the Ops Insurance Company on 02.02.2010 but the claim of the complainant has been wrongly repudiated on 06.02.2010 (Annexure R-7) by the OPs Insurance Company. Hence, this complaint.

3.                     Upon notice, OPs No.1 and 2 Insurance company appeared and filed its written statement jointly by taking some preliminary objections such as; this forum has no territorial jurisdiction to entertain and adjudicate the present complaint; complainant has concealed and suppressed the material and relevant facts of the case; the complaint is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified money  from the OPs and on merit it has been mentioned that the OPs were in receipt of proposal bearing No. 0017181 dated 08.10.2008 ( Annexure R-1) signed by Mrs. Sunita mangla. The said proposal was accepted by the OPs at standard (ordinary) rates of premium under non medical category without subjecting the life assured to a medical examination since no medical problem was stated by the life assured in the proposal form. The Life assured was issued a policy bearing No.081010045422 (Annexure R-2) for plain “Level Terms” for sum assured of Rs.10,00,000/- (Rs. Ten Lac) at the annual premium of Rs.5078/- per annum. As per nomination clause Mr. Ankit Mangal son of the deceased Smt. Sunita Mangla was nominated as nominee. Further it has been specifically mentioned in the proposal forms (Annexure R-1) under the clause “INSTRUCTION FOR COMPLETING THIS PROPOSAL FORM” that

“2. Insurance is a contract of utmost good faith which requires all material facts to be disclosed to the Insurance Company. In case any doubt as to whether a fact is material or not, the fact should be disclosed.”

And under the head “Declaration in the proposal forms duly submitted by the Life Assured, it was duly declared by Life assured that all the questions are given truthfully and same will become basis to issue the policy to the deceased life assured. It is further stated that text of section 45 was duly reproduced in the proposal form itself. It has been further mentioned that right from proposal stage, it was always made abundantly clear to the Decease Life Assured that truthful answers to questions in proposal form are of immense importance for accepting life insurance proposal of the deceased life assured and obligation of disclosing true fact continue even after signing of the proposal from and before acceptance of risk by the Ops company. Further it has also been submitted that Life Assured deliberately misled the Ops Company by concealing/misrepresenting material information and furnishing false replies while filing up the proposal form as the life assured had not disclosed the full complete and correct facts regarding her heath and medical history. In this connection it is submitted that in the proposal form for insurance signed by the Life Assured on 08.10.2008 (Annexure R-1) the relevant question in the proposal form were answered as follows:

Q. No.	Questions	Answers
1(a)	Raised BP, raised Lipids, Angina, Heart Attach (myocardial infarction), chest pain, hear murmur, STROKE, shortness of breath, palitations, Rheumatic fever or any other disease or abnormality of heart pulse or arteries?	No.
1(1)	Epilepsy, head injury, multiple sclerosis, cerebral palsy, paralysis, tremors, Numbness, double vision, dizzy or fainting spells?	No.
2.	Have you during the last 5 years. Suffered from an ailment/injury/accident requiring treatment/ hospitalization for more than a week? Undergone or advised to undergone or are currently undergoing any form of medical treatment? Consulted any doctor or other health practitioner except for common cold/influenza lasting for less than 4 days? Undergone investigation or test such as blood test, x ray, or ECG etc. been on any medication prescribed by a medical practitioner or on special diet or alternative medicine?	No. No No No No
3.	Have you ever or are you currently suffering from any illness, impairment or disability or any surgery not mentioned above?	No.

                       

          It has been further mentioned that from the records obtained during the claims processing, it was found that the deceased Life assured was admitted to  Sir Ganga Ram Hospital, New Delhi on 29.12.2007 and discharged on 02.03.2008 (discharge summary Annexure R-3) before the proposal date of 08.10.2008) during her hospitalization of  64 days,  she was diagnosed with the “Brainstem Stoke”  whereas the said material facts was suppressed by the deceased Life assured while filling up the proposal form on 08.10.2008,which was despite of the fact that material fact occurred before the date of proposal form. Further again life assured admitted  for 17 days  from 02.07.2008 to 18.07.2008 (discharge summary Annexure R-4)  i.e. before the proposal date 08.10.2008) in Sir Ganga Ram Hospital, clearly provides that the deceased life assured was follow up case of “Brainstem stroke”  was admitted with case of rashes on back and skin. Opinion was taken and diagnosed to have multiple tinea lesions over back on buttock which clearly shows the bed ridden state of health of the deceased/ life assured.  The deceased life assured was again admitted for 19 days i.e. from 12.10.2008 and discharged on 31.10.2008(discharge summary Annexure R-5) and as per the discharge summary of said dates again clearly proves that the deceased life assured was follow up case of brain stem stroke, bedridden admitted with case of increased secretion and also had 2 episodes of loosening of body, brought to SGRH casualty. The life assured was again admitted for 44 days to Sir Ganga Ram Hospital, Delhi on 13.04.2009 and discharged on 25.05.2009 (discharge summary Annexure R-6) as follow up case of brain stem stroke with quadriparesis, tracheostomised from October, 2008 with history of recurrent chests infection, Gastrointestinal Reflux Disease (GERD) with Hiatus Hernia on medication, admitted with increased secretion from tracheotomy tube and further care.   .                        Further  OP no.1 & 2 submits that from the documents on record i.e. proposal form Annexure R-1, it is clearly evident that the deceased Life Assured had applied for insurance policy on 08.10.2008 wherein she reported no adversaries in her health and whereas as per the documents on record i.e. discharge summary Annexure R-3, the deceased life assured was confirmed case of Brainstem stoke from 29.12.2007 much before the date of filing up the proposal and since then she has been on regular treatment for the same as much as condition was worsen to the state that deceased Life assured became bed ridden which resulted in rashes on back and had been on regular treatment for Brainstem Stoke since 29.12.2007 and had been in hospital for even more than 81 days before filing up the proposal. Had this medical history of the deceased life assured known to the OPs at the proposal stage, the OPs would not have issued the insurance policy in question. The OPs has been led to issue the policy by suppression of material facts. Life assured has suppressed the material facts from the OPs while entering into the contract of insurance the specific questions were asked under Question 9(a) clearly required the deceased life assured to disclose inter alia about the stoke if any suffered and further question 2(a) to (e) and 3 were question specifically call for information regarding the undergoing any tests, investigations, awaiting results of any tests or investigations or have ever been advised to undergo any test, investigations or surgery or been hospitalized for general check up, observation, treatment or surgery and further specific question was also asked about the past or present treatment or hospitalization but despite of fact that the Life assured had undergone the treatment for the “brainstem stoke” 29.12.2007 had suppressed this material fact from the OPs while procuring the insurance policy.

                         OPs further submits that insurance is a long term contract and OPs has to take health and other relevant details of the Life Assured into consideration before arriving at a decision to accept the risk under the proposal and for taking said decision of underwriting the life of life assured true status of health is underlying factor to arrive out the decision to issue the policy or not. It is stated that had the life assured disclosed her correct health Insurance is a contract of “utmost good faith” and from the documents on record it is clearly evident that there has been a clear breach of this by the Life assured. In view of suppression of material facts by the deceased Life Assured in her proposal for insurance, the claim under the said policy was  repudiated due to non disclosure and suppression of material information by the deceased vide letter dated 06.02.2010. A legal notice dated 02.02.2010 (Annexure R-80 was received which was replied vide letter dated 26.02.2010 (Annexure R-9). It is also mentioned that the Insurance Act postulates repudiation of such policy within a period of two(2) years by reason of the aforementioned provision, a period of limitation of two year had, thus, been specified and on expiry thereof the policy was not capable of being called in question, inter alia on the ground that certain facts have been suppressed which were material to disclose or that it was fraudulently been made by the policyholder or that the policy holder knew at the time of making it that statement was false, statute, therefore, itself provides for the limitation for valid repudiation of an insurance policy and in present case the life assured died within period of 9 months from the date of taking policy thus the decision of OPs to declare the policy as null and void is fully justified and same cannot be termed as deficiency in services rendered by the OPs. The insurance policy may serve purpose of social security but then same should not be obtained with a fraudulent act by the life assured .Thus the present complaint under C.P. Act is gross abuse of process of law and in the present complaint there can not be any dispute as to veracity of documents produced by the OPs and lastly prayed for dismissal of the complaint.

4.                     Complainant failed to adduce any evidence, hence, his evidence was closed by Court Order dated 24.12.2014. However, at the time of filing of complaint, complainant placed on file his short Affidavit as Annexure CX and some photocopies of documents:- Legal notice as Annexure C- 1, Postal receipts as Annexure C-2,  Application form for death claim as Annexure C-3, Proposal form as Annexure C- 4, Premium receipt as Annexure C-.5, Policy schedule as Annexure C-6 and forwarding letter of sending policy as Annexure C-7  in support of his complaint.

5.                     On the other hand Ops also failed to adduce any evidence, hence the, evidence of the ops company was closed by Court Order dated 27.05.2015. However, at the time of filing the written statement, OPs company filed some photocopies of documents: - Proposal form as Annexure R-1, Insurance policy schedule as Annexure R.-2, Discharge summary for the  period 29.12.2007 to 02.03.2008 as Annexure R- 3, Discharge summary for the  period 02.07.2008 to 18.07..2008 as Annexure R- 4 , Discharge summary for the  period 12.10.2008 to 31.10.2008 as Annexure R- 5 , Discharge summary for the  period 13.04.2007 to 25.05.2009 as Annexure R- 6 , Repudiation letter dated 06.02.2010 as Annexure- 7, legal notice as Annexure R-.8, reply to the legal notice dated as Annexure R- 9 in support of his reply.  

6.                     We have heard the counsels of complainants and have gone through the pleadings as well as documents placed on the file very carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OPs failed to appear but as the case pertains to the year 2010, hence we have no option except to decide the case on merit.

7                      After hearing at length, we are of the considered view that the claim of the complainants has been rightly repudiated by the Ops no. 1 & 2 Insurance company vide letter dated 06.02.2010 (Annexure R-7)  due to non disclosure and suppression of material information by the deceased life assured as the deceased Life assured was admitted to  Sir Ganga Ram Hospital, New Delhi on 29.12.2007 and discharged on 02.03.2008 (discharge summary Annexure R-3) before the proposal date of 08.10.2008) during her hospitalization of  64 days,  she was diagnosed with the “Brainstem Stoke”  whereas the said material facts were suppressed by the deceased Life assured while filling up the proposal form on 08.10.2008, which was despite of the fact that material fact occurred before the date of proposal form. Further again life assured admitted  for 17 days  from 02.07.2008 to 18.07.2008 (discharge summary Annexure R-4)  i.e. before the proposal date 08.10.2008) in Sir Ganga Ram Hospital, clearly proves that the deceased life assured was follow up case of “Brainstem stroke”  was admitted with case of rashes on back and skin. The deceased life assured was again admitted for 19 days i.e. from 12.10.2008 and discharged on 31.10.2008(discharge summary Annexure R-5) . The life assured was again admitted for 44 days to Sir Ganga Ram Hospital, Delhi on 13.04.2009 and discharged on 25.05.2009 (discharge summary Annexure R-6) as follow up case   of brain stem stroke with quadriparesis, tracheostomised from October, 2008         with history of recurrent chests infection, Gastrointestinal Reflux Disease            (GERD) with Hiatus Hernia on medication, admitted with increased secretion from tracheotomy tube and further care.  

8.                           Further  from the perusal of  proposal form Annexure R-1, it is clearly evident that the deceased Life Assured had applied for insurance policy on 08.10.2008 wherein she reported no adversaries in her health and whereas as per the documents on record i.e. discharge summary Annexure R-3 to Annexure R-6  the deceased life assured was confirmed case of Brainstem stoke from 29.12.2007 much before the date of filing up the proposal and since then she has been on regular treatment for the same as much as condition was worsen to the state that deceased Life assured became bed ridden which resulted in rashes on back and had been on regular treatment for Brainstem Stoke since 29.12.2007 and had been in hospital for even more than 81 days before filing up the proposal. Had this medical history of the deceased life assured known to the OPs at the proposal stage, the OPs would not have issued the insurance policy in question. The OPs has been led to issue the policy by suppression of material facts. Life assured has suppressed the material facts from the OPs while entering into the contract of insurance the specific questions were asked under Question 9(a) clearly required the deceased life assured to disclose inter alia about the stoke if any suffered and further question 2(A) to (E) and 3 were question specifically calling for information regarding undergoing any tests, investigations, awaiting results of any tests or investigations or have ever been advised to undergo any test, investigations or surgery or been hospitalized for general check up, observation, treatment or surgery and further specific question was also asked about the past or present treatment or hospitalization.

9.                        The insurance is a long term contract and OPs insurance company has right to take health and other relevant details of the Life Assured into consideration before arriving at a decision to accept the risk under the proposal. In present case the life assured died within period of 9 months from the date of taking policy thus the decision of OPs to declare the policy as null and void is fully justified and same cannot be termed as deficiency in services rendered by the OPs. The insurance policy may serve purpose of social security but then same should not be obtained with a fraudulent act by the life assured.  It has been well settled that health Insurance is a contract of “utmost good faith” and from the documents on record i.e. discharge summary of hospital Sir Ganga Ram Delhi Annexure R-3 to Annexure R-6, it is clearly evident that Life assured has suppressed the material facts from the OPs Insurance Company while entering into the contract of insurance.  It is not disputed that the claim is paid by any insurance company out of the common pool of funds belonging to all policy holders of the OPs and Insurance Company has to check the genuineness of a claim before honouring it. The insurance company cannot do injustice to genuine policyholder by allowing ingenious and false claims. By concealing material facts at the time of proposal, the OPs were denied of the opportunity to assess the risk under the proposal. It was primary duty of the Life Assured to disclose all facts truly and correctly in the proposal form. The OPs were led to issue the policy by suppression of material facts.

10.                   Resultantly, In the circumstances noted above, we are of the considered opinion that in view of non disclosure and suppression of material facts by the deceased Life Assured in her proposal form, the claim under the said policy was rightly repudiated vide letter dated 06.02.2010 (Annexure R-7) by the ops insurance company hence, there is no deficiency in service or unfair trade practice on the part of Ops. Hence, the present complaint is hereby dismissed with no order as to cost. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Pronounced in open Court:  05.12.2016.

                                                                                          (ASHOK KUMAR GARG)

                                                                                           PRESIDENT

                                                                                           DCDRF Yamuna Nagar

 

                                          (S.C.SHARMA)

                                                 MEMBER