BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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            Shyam Sunder Gupta RH-08, Sukh Niwas, Plot No. 62, Sector­-14, Vashi Navi Mumbai, Mumbai

…Complainant

                                      V E R S U S

1.         Aviva Life Insurance Co. India Ltd., SCO No-180-181-182, Sector 9-C, Madhya Marg, Chandigarh-160017, through its Manager.

2.         Aviva Life Insurance Co. India Ltd., Aviva Tower, Sector Road, Opp Golf Course, DLF Phase V, Sector 43, Gurgaon-122 003, Haryana. through its Director,

                                                ……Opposite Parties

CORAM:     SH.P.D.GOEL                                    PRESIDENT

                   SH.RAJINDER SINGH GILL              MEMBER

                   DR.(MRS) MADANJIT KAUR SAHOTA  MEMBER

Argued by:    Ms.Jaimini Tiwar, Proxy Counsel for Sh.Varun Chawla, Counsel                     for the complainant.

                        Sh.Jaipal Singh, Counsel for the OPs.

PER P.D.GOEL,PRESIDENT

1.                     Briefly stated, the facts of the case are that the wife of the complainant Late Smt.Sucheta Gupta took a life insurance policy "Aviva Dhan Vridhi" TDW 3056026 from OP No.1 with date of commencement 17.12.2010 and date of maturity 17.12.2030. It has been further stated the premium payable was Rs.50,270/- annually and the sum assured was Rs.4,50,000/-. As per the policy, if the life assured died before the date of maturity, then nominee will get sum assured of Rs.4,50,000/- along with vested bonus and if life assured survives on the date of maturity, life assured will get sum assured of Rs.4,50,000/­- along with vested bonus. At the time of taking the policy, the agent of the OPs filled the proposal form, which was only signed by the deceased. It has been further stated that the wife of the complainant expired on 23.02.2011 and intimation in this regard was given to OP No.1. The claim was lodged with OP No.1 and the original policy bond along with other papers, as demanded by the OPs were submitted. The complainant approached the OP No.1 several times for settlement of the claim but the insurance company lingered the matter on one pretext or the other. Thereafter, the OPs vide letter dated 27.4.2011 rejected the claim of the complainant on flimsy grounds that the life assured was suffering from Hypertension for the last 10-12 years. Despite repeated requests and visits, the OPs wrongly rejected the genuine claim, which amounts to deficiency in service. Hence, this complaint.

2.                     OPs No.1 & 2 filed the joint reply, wherein, it took the preliminary objections vis-vis maintainability and jurisdiction. On merits, it has been admitted that the wife of the complainant was insured with the OPs and in the proposal form the deceased life assured stated that she is not suffering from any of such deceases i.e. High Blood Pressure, Angina, heart attack, stroke or any other disorder of heart circulation. The wife of the complainant expired on 23.2.2011 and from the medical records of the deceased, it is clear that she was suffering from hypertension and was also under treatment from last 10-12 years. It has been further pleaded that in the certificate dated 14.4.2011 issued by Dr.G.M.Joshi, family doctor of the deceased, it has been mentioned that deceased was known case of hypertension for the last 12 years. Thus, the claim of the complainant was rightly rejected by the OPs. Denying all the material allegations of the complainant and pleading that there has been no deficiency in service on their part and prayer for dismissal of the complaint has been made.  

3.                     Parties led evidence in support of their contentions.

4.                     We have heard the proxy Counsel for the complainant and the learned Counsel for the OPs and have also perused the record. 

5.                     The wife of the complainant Late Smt.Sucheta Gupta took Aviva Dhan Vridhi Policy bearing No. TDW-3056026 from the OPs for a period of 20 years and the premium payable was Rs.50,270/- annually and the sum assured was Rs.4,50,000/-. It is the case of the complainant that at the time of taking the policy, Smt.Sucheta was hale and hearty. However, unfortunately she died on 23.2.2011. The complainant lodged the claim with the OPs after completing all the formalities but the OPs repudiated the claim vide letter dated 27.4.2011 on the ground of pre-existing disease – Annexure  C-1.

6.                     OPs have raised the plea that the L.A. was suffering from hypertension and was also under treatment from last 10-12 years but the L.A. had concealed these material facts at the time of taking the insurance policy and therefore, the claim of the L.A. was rightly repudiated vide letter dated 27.4.2011 on the ground of pre-existing disease. All the other allegations of the complainant has been denied and prayer for dismissal of the complainant is made. 

7.                     Now the only point which call determination from this Forum is whether the L.A. was guilty of concealing the material facts regarding his health. The answer to this is in negative.

8.                     The repudiation letter dated 27.04.2011 is Annexure C-1 qua which the claim had been denied by the OPs on the ground that the L.A. had concealed material facts regarding his health and taking treatment for hypertension from last 10-12 years i.e. prior to taking the insurance policy. To prove that the L.A had concealed the facts with regard to treatment for hypertension, the OPs have placed reliance upon the Annexure F which is a certificate dated 14.4.2011 issued by family doctor of the deceased, wherein, it has been stated that the wife of the complainant Mrs.Sucheta Gupta was known case of hypertension for the last 10-12 years.  Admittedly, the OPs have produced on record the certificate issued by Dr.Gautam.M.Joshi dated  14.4.2011 – Annexure F  but they have failed to support the said certificate with the affidavit of Dr.Gautam.M.Joshi. Thus, it looses its evidential value.

9.                     It is settled proposition of law that the policy holder is not supposed to disclose normal wear and tear of human life at the time of obtaining the policy. It is always on the insurer to prove concealment of pre-existing disease at the time of obtaining the policy. The ‘Disease’ means a serious derangement of health or chronic deep-seated disease frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon.  Further the Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of ‘pre-existing disease’ for repudiation of the insurance claim. Reliance placed on Oriental Insurance Co. Ltd. Vs. Mohinder Singh (Dr.) reported in IV(2008) CPJ 511 and Lakhwinder Singh and Anr. Vs. United India Insurance Co. Ltd. and Others reported in II(2010) CPJ 265 decided by our own Hon’ble State Commission. 

10.                   Besides this, the repudiation of the claim cannot be stated to be legal as the proposal for issuance of the insurance policy was accepted by the OPs after due examination by its doctors.  Had the L.A. was suffering from any pre-existing disease, the doctors on the panel of the Ops would have certainly declared the L.A. unfit for obtaining the insurance policy. Annexure – F, referred to above, is not sufficient to prove on record that the L.A. was suffering from any pre-existing disease. In this case, the OP had not been able to establish the concealment by leading proper and cogent evidence. Reliance placed on LIC of India and others Vs. Harbans Kaur, 2010(1) CLT (NC).

11.                   As a result of the above discussion, this complaint is accepted with a direction to the OPs to pay the sum assured (Rs.4,50,000/-) along with all benefits to the complainant under the policy in question along with compensation of Rs.50,000/- for mental agony and harassment and Rs.10,000/- as costs of litigation.

12.                   This order be complied with by the OPs within one month from the date of receipt of its certified copy, failing which, OPs shall be liable to refund the awarded amount to the complainant along with interest @ 12% p.a. from the date of repudiation i.e. 27.04.2011 till its realization besides Rs.10,000/- as litigation expenses.

13.                   The certified copies of this order be sent to the parties free of charge. The file be consigned.