| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 354 of 07-12-2017. Decided on : 9-02-2022 Shavinder Kaur Wd/o Mahinder Singh, aged about 46 years R/o H. No. 0, Village Bare Ke Hussaini Wala, Ferozepur. ........Complainant Versus Aviva Life Insurance Co. India Ltd., 1st Floor, 2089, The Mall, Bathinda, through its Branch Manager Managing Director of Aviva Life Insurance Co. India Ltd., Aviva Tower, Sector Road, Opposite Golf Course, DLF Phase-V, Sector 43, Gurgaon 122003 (Haryana)
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member. Smt. Paramjeet Kaur, Member Present For the complainant : Sh.Rohit Romana, Advocate For opposite parties : Sh. Varun Gupta, Advocate. ORDER Kanwar Sandeep Singh, President The complainant Shavinder Kaur (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Aviva Life Insurance Company India Limited & another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that in year 2014, husband of the complainant namely Mahinder Singh purchased one Life Insurance Policy from opposite parties and deposited requisite premium for Sum Assured Rs.8,30,000/-. Accordingly, the opposite parties issued policy No.10172791 but no terms and conditions ever issued to the complainant or nominee. In the above said insurance policy, the complainant was appointed as nominee by her husband. It is alleged that unfortunately, husband of the complainant was died a natural death on 05.11.2014. Intimation regarding death of the insured was given to the opposite party. Thereafter, the complainant being nominee in the aforesaid insurance policy, lodged an insurance claim of Rs.8,30,000/- and submitted all the original documents required by the opposite party for settlement of claim. The officials of the opposite party assured the complainant that her lawful claim shall be settled at the earliest. The information was given to the opposite party through its representative, who visited the house of the complainant. The complainant presented all the necessary documents to substantiate the death of Insured Mahinder Singh. The representative who visited the house of the complainant took all the documents such as original death certificate, documents pertaining to policy claim etc., with an assurance that the claim will be settled at the earliest and the documents will be returned. It is also alleged that the complainant is a simple rustic villager and is neither educated nor conversant with English language. The officials of the opposite party used to take all the documents on the pretext that they are helping the complainant and soon her claim will be settled. Thus believing upon the assurance of the officials of the opposite party, the complainant very innocently handed over all the documents received or asked by the officials of the opposite party. The complainant alleged that she made repeated requests to the opposite party to settle her claim but till date neither the claim was settled nor any response was received by the complainant on his requests and hence the complainant was forced to file the present complaint. It is further alleged that the representative of the opposite party took all the documents from the complainant under the veil of settling the claim and now the complainant does not have any document pertaining to the insurance policy, claim etc., The acts of the opposite party are totally arbitrary, Illegal and unjustified under the provisions and guidelines laid down by the law and Apex Court and Commissions. The factum of death and reasons leading to the death of the insured Mahinder Singh was very much inquired and also in the notice of the officials concerned of the opposite party but due to malafide intention of the company and its officials, the claim of the complainant has been wrongly withheld, to deprive the complainant from his lawful claim. The complainant alleged that the opposite party is deficient in providing proper services and used illegal trade practice while withholding the genuine and legal claim of the complainant. After filing the claim by complainant, the investigator visited the complainant and demanded his palm to be greased in order to pass the claim and when the complainant refused to oblige to the illegal request of the investigator, the investigator openly said he will make sure that the claim of the complainant will not get passed. The investigator in connivance with the officials of the opposite party withheld the claim of the complainant. The complainant further alleged that the opposite party intentionally harassing the helpless and rustic complainant by over delaying and withholding the claim on flimsy and un-sustainable reasons, and forcing innocent people like complainant to run from pillar to post in getting replies in the claim filed, causing great mental torture and distress. to the complainant. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to settle the claim of the complainant and make payment of Rs. 8,30,000/- with interest and pay Rs. 1,00,000/- as compensation for mental torture and agony besides Rs. 25,000/- as litigation expenses. Upon notice, the opposite parties appeared through counsel and contested the complaint by filing written reply. In joint written reply, the opposite parties raised preliminary objections that the complaint is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this Commission. In fact, the Complainant has suppressed material facts from this Commission. It has been pleaded that the opposite party received proposal/application form bearing No.NUP-16669144 duly filled and signed by decesed life assured seeking insurance on his life under "Aviva Dhan Samruddhi Plan". On the basis of information and declarations provided in the said Application Form, the Company issued the Policy bearing No.10172791 :- Policy Details | Particulars | Policy No. | 10172791 | Proposal No. | NUP16669144 | Name of Policy | Aviva Dhan Samruddhi | Name of policy holder | Mr. Mohinder Singh | Name of Life Insured and relationship with policy holder | Mr. Mahinder Singh | Date of Proposal Form | 09/10/14 | Commencement date of policy | 27/10/14 | Sum Assured | Rs. 8,30,000/- | Premium amount | Rs. 56,522/- | Premium Frequency | Half yearly | Nominee and relationship | Shavinder Kaur | Premium amount paid till date | Rs. 30,227/- |
That the opposite party, after receipt of duly filled proposal forms along with the other requisite documents and the amount of first Semi-annual premium deposited, issued the subject Policy. Copy of proposal form along with the policy documents bearing No.10172791 was sent to the Deceased Life Assured. That the Deceased Life Assured had himself opted for semi-annual premium which clearly indicated in the proposal form. The complainant had also signed a Benefit illustration after fully understanding the terms and conditions of the policy in vernacular language. The opposite parties further pleaded that complainant sent a Claim Statement to the opposite party intimating that the Life Assured, Mr. Mahinder Singh died 05.11.2014 and requested the company to process the claim under the policy. The opposite party examined the matter in detail and possessed indisputable evidences which established that Mr. Mahinder Singh made mis-representation of income and also not disclosed the pre-existing diseases such as Diabetes Mellitus Type II, Hepatitis C prior to filing the proposal form. He disclosed wrong facts and the same has been lodged in order to deceive the opposite party through wrong declaration and by a well planned criminal conspiracy involving various individuals including the present complainant. The complainant has tried to challenge the veracity of the decision of the opposite party to repudiate the claim. The opposite party has repudiated the claim under the said policy by a speaking order and by no stretch of imagination the said decision can be brought under the umbrella of "Deficiency in Services". Further preliminary objections are that this Commission has no jurisdiction to entertain the present complaint. That the matter in question involves complicated questions of facts and law as well as voluminous evidence, which can only be dealt with by a civil court. That the complaint is devoid of any material particulars, and has been filed merely to harass and gain undue advantage and unjustified monies from the opposite party. It has been pleaded that opposite party has strictly acted as per the terms and conditions of the policy contract and terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitution. That this Commission cannot pass any order in contravention to the terms and conditions of the policy contract. That the complainant has not acted in good faith with respect to subject of this complant and has approached this Commission with unclean hands, whereas it is a settled legal preposition that "One who seeks equity must come with clean hands". The complainant is merely the nominee under the subject policy, and not the actual beneficiary of the policy proceeds. That as per the investigation, it was planned work executed by the complainant, Advisor and other individuals. Other documents have also been found manipulated and modified. That Life Assured has concealed material facts which were necessary to be disclosed at the time of taking insurance, thereby rendering the contract of insurance void-ab-initio and inoperative, which is the reason for the claim being repudiated. That Life Assured had not disclosed his correct Income and also concealed his health condition of his prior diseases. It is the duty of the Proposer/Life Assured, at the time of availing the policy, to disclose the material information, which is essential for the purpose of underwriting, during issuance of an insurance policy. It has been pleaded that the claim made by the complainant was repudiated by the opposite party on the ground of suppression of material facts and mis-representation by the Life Assured in the proposal form. On merits, the opposite parties have pleaded that the complainant sent a Claim Statement to the opposite party intimating that the Life Assured, Mr. Mahinder Singh died 05.11.2014 and requested the opposite party to process the claim under the policy. The opposite party examined the matter in detail and possessed indisputable evidences which established that Mr. Mahinder Singh was neither having the income as shown by him in the proposal form at the time of purchasing the policy and also made false declaration with regard to his health and these facts establisheded from investigation conducted by the opposite party and at the time of purchasing such policy the deceased life assured mis-stated his income and health in order to deceive the opposite party through false declartions. In further reply, the opposite parties reiterated their stand as taken in preliminary objections, detailed above. After controverting all other averments, the opposite parties prayed for dismissal of complaint. In support of her complaint, the complainant has tendered into evidence her affidavit dated 5-12-2017 (Ex. C-1), photocopy of Adhar Card of Mohinder Singh (Ex. C-2), photocopy of schedule of policy (Ex. C-3), photocopy of terms of policy (Ex. C-4) and photocopy of death certificate of Sh. Mohinder Singh (Ex. C-5). In order to rebut the evidence of complainant, the opposite parties have tendered into evidence photocopy of claim file – 68 pages (Ex. OP-1/1) and affidavit of Ratnesh Keshri, authorised signatory of Aviva Life Insurance (Ex. O-1/2). The learned counsel for the parties reiterated their stand as taken in their respective pleadings. We have heard learned counsel for the parties and gone through the record. There is no dispute between the parties that Mahinder Singh, husband of the complainant purchased Insurance Policy (Ex. C-3) Aviva Dhan Samrudhi bearing No. 10172791 effective from 27-10-2014 and date of maturity is 27-10-2034. The sum assured is Rs. 8,30,000/-. The nominee in the said policy is Shavinder Kaur, wife of life assured. Mr. Mahinder Singh died on 5-11-2014. The complainant, being nominee of life assured, filed claim but the opposite parties repudiated the claim on the ground that Mr. Mahinder Singh made misrepresentation of income and not disclosed the pre-existing diseases such as Diabetes Mellitus Type II, Hepatitis C prior to filing the proposal form. Ex. OP-1/1 (Page 68) is the repudiation letter dated 3-2-2015 which shows that opposite parties repudiated the claim of the complainant on the ground that : “As per our records, the deceased Mr. Mahinder Singh, was hospitalized and diagnosed of chronic liver disease, Diabetes mellitus, type II and Hepatitis C in August, 2014 prior to filing the proposal form on 09 Oct, 2014. This pre-existing ailment was not disclosed as he answered 'No' to the relevant question in the proposal form.” Hon'ble National Commission in the case titled New India Assurance Co. Ltd., Vs. Suresh Garg 2015(3) 799 has held : “Repudiation of medi-claim on ground of suppression of pre-existing ailment and wrong information at the time of obtaining policy/cover – Accepting premium and then issuing policy without medical examination as required in proposal form, completely nails case set out by appellant – Since medical examination of respondent was not conducted by the petitioner company, which was the most important part while giving an insurance policy on medical terms, therefore, there is a fault on the part of the petitioner company – Respondent has been made to suffer by non-settlement of his claim...” The deceased Mahinder Singh obtained the policy in question at the age of about 48 years. There is no evidence on file that opposite parties at the time of effecting insurance got conducted medical examination of life assured. The opposite parties are bound to get the medical conducted of the person to be insured before effecting insurance. The practice of rejecting claims by Insurance Companies by taking lame excuses at the time of payment of claim amounts to major lapse on their part. Moreover, in the case in hand, opposite parties have not examined the doctor who allegedly treated the complainant. As per own record produced on file by the opposite parties, the life assured Mahinder Singh died a natural death. The opposite parties could not bring on file any evidence that there is any nexus of alleged diseases with death of assured. It is pleaded case of the complainant that place of residence of deceased/insured is Village Bare ke, District Ferozepur and place of execution of proposal form (Ex. OP-1/1 – page 11-24) is Amritsar which itself proves that the Insurance Companies can do anything to increase number of policies and to get premium amount but when their turn comes to pay claim amount, then they concoct any story to repudiate claims. Hon'ble National Commission in Revision Petition No. 2939 of 2011 decided on 15-11-2017 case titled Vipin Grover & anothers Vs. New India Assurance Co. observed :- “If Insurance companies co-relate each and every disease with pre-existing condition, under such circumstances, insured i.e. helpless consumers will never succeed to get his genuine claim from Insurance Company.” Affidavit of complainant is also part of document Ex. OP-1/1 (page 5), which contains the fact that her husband (insured in this case) died in their home and he was not admitted in any hospital and he died of natural death. Thus, in the case in hand, the opposite parties failed to prove any nexus between the death of life assured Mahinder Singh, and alleged diseases. Hence, the opposite parties cannot consider every disease as pre-existing disease. Therefore, denial of claim by the opposite parties amounts to deficiency in service on their part. Ex. C-4/OP-1/1 (page 8) is the Most Important Terms about Aviva Dhan Samruddhi Policy of life assured Mahinder Singh. This document, under the heading What is the Benefits of this policy – finds mentioned that nominee Mr. Shavinder Kaur will get an assured payout of Rs. 8,30,000/- plus accumulated guaranteed additions, in case of death of life insured. The policy will terminate after the payout. Therefore, complainant is entitled to Rs. 8,30,000/- plus accumulated guaranteed additions, if any. In view of what has been discussed above, this complaint is partly allowed with Rs.10,000/- as cost and compensation. The opposite parties are directed to pay to complainant, being nominee of life assured Mahinder Singh, an amount of Rs. 8,30,000/- (sum insured) plus accumulated guaranteed additions, if any, with interest @9% p.a. w.e.f. 3-2-2015 (date of repudiation) till payment. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 09-2-2022 (Kanwar Sandeep Singh) President (Shivdev Singh) Member (Paramjeet Kaur) Member
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