Haryana

Ambala

CC/RST/52/09/11

BALAK SINGH - Complainant(s)

Versus

BAJAJ ALLIANZ INSS. - Opp.Party(s)

SUSHIL KUMAR

15 Feb 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

Complaint Case No.    : 52 of 2009/2011

Date of Institution       : 02.11.2011

Date of Decision         : 15.02.2017

 

Balak Singh son of Shri Sawan Singh R/o village Uplana P.O. Thakurpura, Tehsil Barara, District Ambala.                                                                                              

……Complainant. 

Versus 

1.         Bajaj Allianz Life Insurance Company Limited, GE Plaza, Airport Road, Yerawara,Pune 411006 through its Managing Director. 

2.         Bajaj Allianz Life Insurance Company Limited Opposite the Office of G.P.O., Ambala Cantt through its authorized Signatory. 

                                                                                                ……Opposite Parties. 

Complaint Under Section 12 of the Consumer Protection Act 

BEFORE:       SH. D.N. ARORA,  PRESIDENT.

                        SH. PUSHPENDER KUMAR, MEMBER.                       

Present:          Sh. Sushil Kumar, Adv. for complainant.

                        Sh. Ashutosh Aggarwal, Adv. for Ops. 

ORDER. 

                        In nutshell, brief facts of the complaint are that  wife of complainant Smt. Mahinder Kaur got insured herself from the OP vide policy no.0069573478 commencing from 08.10.2007 for a sum of Rs.2.50 lacs and installment of premium was to be paid @ Rs.25000/- per annum.  It has been submitted that one installment of Rs.25,000/- was paid to the Ops by  the life assured. It has been submitted that  at the time of taking the policy, life assured was hale and healthy, however, unfortunately the life assured died on 22.04.2008 due to brain hemorrhage. So, the complainant  who is legally entitled to the sum assured applied for the benefit under the policy, but the Ops wrongly and illegally declined the claim of complainant vide letter dated 10.09.2008.  So, complainant got issued a legal notice dated 14.12.2008 upon the Ops to do the needful but the OP has not responded positively. As such, the complainant has prayed that the Ops are deficient in providing proper service to the complainant. Hence, the present complaint seeking relief as per prayer clause.

2.                     Upon notice, Ops appeared through counsel and raised preliminary objections qua concealing of true facts by complainant as the life assured  was a diagnosed case of Concentric Left Ventricular Hypetrophy and Grade-1 Diastolic Lv Dysfunction as confirmed by the Echocardiography Report dated 08.08.2007 of Prime Diagnostic & Heart Institute, Chandigarh and had been consulting and taking treatment for the said disease from Dr.S.K.Gupta of S.K.Gupta Hospital, Naraingarh but she did not intimate about her illness to the OP prior to the date of acceptance of risk on 08.10.2007.  Moreover, the complainant himself has admitted in his written declaration given to the Op that the deceased life assured was suffering from High Blood Pressure since April 2007 and was taking treatment from Dr.S.K.Gupta.  It has been urged that if the deceased life assured had disclosed her true state of health at the time of proposal for issuance of insurance or before the acceptance of risk under the policy in question. On merits, it has been submitted that life assured expired within 6 months of the acceptance of risk under the policy and being a very early death claim, the investigation of the claim was conducted to ascertain the bonafide of the claim and the 3-D Investigation Agency, found that the deceased life assured was a diagnosed case of abovesaid ‘Concentric Left Ventricular………...’ but she knowingly and fraudulently did not intimate the insurance company about her ailments. As such, the OP insurance company has  acted  strictly as per the provisions of Section 45  of Insurance Act, 1938 and repudiated the  claim vide letter dated 10.09.2008. However, the Claim Review Committee on the representation of the complainant reconsidered the claim but the repudiation was upheld vide letter dated 13.07.2009.  As such, the OP has prayed that the complaint may kindly be dismissed with costs.

3.                     To prove her version, counsel for complainant tendered affidavits as Annexures CX & CY alongwith documents as Annexures C1 to C-5 and closed the evidence on 19.03.2013 whereas on the other hand, Ops failed to tender any evidence, as such, their evidence was closed by court vide order dated 29.01.2014.

4.                     We have heard learned counsel for the parties and gone through the record very carefully.  It has been admitted by the Ops that deceased life assured Smt. Mahinder Kaur was insured by them on 08.10.2007 for a sum of Rs.2,50,000/- vide Annexure C-2. Copy of Death Certificate (Annexure C-6) reveals that Smt. Mohinder Kaur died on 22.04.2008.  Counsel for OP has argued that deceased life assured was having pre-existing Heart disease and this fact was suppressed by her at the time of taking the policy.  On the other hand, counsel for complainant has argued that life assured died due to brain hemorrhage as per treatment record (Annexure C-9) which was a sudden attack to the life assured as such she had not suppressed any material facts from the OP insurance company and thus she rightly answered the questions mentioned in column no.14 (a) to (m) of the proposal form. Perusal of repudiation letter Annexure C-4 reveals that the claim of complainant had been repudiated on the ground that “The company had covered the risk for the abovesaid policy on the basis of the facts mentioned in the proposal form. However, on receiving the death claim intimation for the abovesaid policy, the various investigation done, the various medical records received confirm that late Mrs. Mahinder Kaur was diagnosed of concentric left ventricular hypertrophy and grade-1 diastolic LV dysfunction on August 2007. These facts known to late Mrs. Mahinder Kaur were not disclosed before issue of first premium receipt on 08.10.2007.” To rebut the contention of Ops, counsel for complainant has placed reliance on case law rendered by Hon’ble National Consumer Disputes Redressal Commission in Revision Petition No.2370 of 2012 titled as Abdul Lateef & others Vs. The Life Insurance Corporation of India & others decided on 04.07.2014 reported in 2014(3) CLT Page 386 wherein it is held that “Insurance claim- Material facts-Fraudulently suppression-Death of insured due to Cancer-Repudiation of Claim on the ground that  insured suppressed the previous illness i.e. bipolar mood disorder-Held- There is no nexus at all between the illness suppressed  and cause of death i.e. Cancer-insured did not suppress any material fact with any fraudulent intention-Revision Petition allowed. The counsel for the complainant also placed reliance on another  case law reported in 2012 (1) CLT Pg. 185 titled as Life Insurance Corporation of India & Another Vs. Ashok Manocha decided by Hon’ble National Commission, New Delhi in Revision Petition No.10 & 11 of 2007.  Counsel for complainant further placed reliance on another case law rendered by Hon’ble Andhra Pradesh State Commission reported in 2014(4) CLT Pg. 115 wherein General Observations have been rendered by the Hon’ble Bench that “we have been observing that in a number of cases, the insurance companies are issuing policies basing on the statements made by the proposer in utmost good faith but when it comes to settlement of claims, they start examining the matter under the microscope.  In a majority of policies issued by the insurance companies they were routed through their agents. The agents in their anxiety to get their commission and the insurance company in order to do more and more business see that  the policies are  issued the moment they received the premium amount. Even the insurance companies are not aware as to who is the proposer, what is his /her status or health condition etc.. Here, the intention is very clear that first they induce the people to purchase the policies and later they start litigation.  Even in the instant case also, the proposal was made through agent.  On Ex.B1 we find the rubber stamps of the agent and specified person code and license Nos. on the first and last pages of the proposal.  A  close scrutiny of the proposal form would reveal  even the columns were filled up by the agent and simply obtained the signatures of proposer on ‘x’marks. It is manifest that the proposal was routed through the agent of the LIC.  If we may say so, the agents are playing fraud on LIC as well as gullible consumers with false assurances.  When the policy was issued by the insurance company with utmost good faith, the same yardstick has to be applied while settling  the claims also.  The LIC ought to have made thorough enquiry, investigation or necessary medical health check—ups before issuance of policy irrespective of the amount involved.  Without doing so, when they have issued the policy, now they cannot turn round and contend that they need not pay any amount as there was suppression of material information with regard to his health”. 

5.                     On the other hand, the counsel for Ops has argued that at the time of filling of proposal form, deceased Mahinder Kaur (life assured) did not disclose true facts about his pre-existing disease intentionally and made a false answer to the questions mentioned in the proposal form.  Had he disclosed the said disease in the proposal form, the OP insurance company would not have issued the policy in question to the life assured. As such, he has played fraud upon the answering OP.  Thus under the terms and conditions of the OP-company, if any information given by the assured person in the proposal form is found false or incorrect, in that event, the contract  become void ab-initio and nothing is payable to the insured person and the amount deposited by him/her shall be forfeited.  Hence, OP have rightly repudiated the claim of the complainant. The counsel for the Ops has placed reliance on case law rendered by Hon’ble Supreme Court of India in Civil Appeal No.2776 of 2002 titled as Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. decided on 10.07.2009 reported in 2009(4) RCR (Civil) Page 692  wherein it has been held that “Insurance Act, 1938, Section 45-Consumer Protection Act, 1986 Sections 2(1)(o)(g) and (c)(xiii)-Insurance Regulating and Development Authority (Protection of Policy holders interests) Regulations, 2002 Regulation 2(1(d)-Repudiations of medical insurance claim-Material Fact-Suppression of -“Material fact” means  any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether to accept the risk or not-If the proposer has knowledge of such fact, he is obliged to disclose the same-Failure to do so entitled the insurer to repudiate his  liability under the policy”. The counsel for the Ops also placed reliance on another case law rendered by Hon’ble National Consumer Disputes Redressal Commission, Circuit Bench, Hyderabad in First Appeal No.401/2003 titled as Goparatnam and others Vs. LIC of India & others decided on 27.01.2005 and reported in 2005(2) CLT Page 174 wherein it has been held that “Insurance contract-Held that contract of life insurance is a contract of good faith-Violation of it by any of the party ousts its claim against the other-Appellant having suppressed the information of his past ailment both at the time of revival of the two policies not entitled to any relief”.  

 6.                    Perusal of the proposal form which was placed on record by complainant at the time of arguments reveals that it has been filled up by Ranjeet Singh-may be a Agent of OP insurance company and he simply obtained the signatures of life assured Mahinder Kaur on the proposal form meaning thereby that the proposal was routed through the agent of OP Insurance company. The main objection of the OP insurance company is that the life assured was suffering from the abovesaid pre-existing disease before issuing of the policy to her but the OP has failed to adduce any evidence despite availing sufficient opportunities  and their evidence was closed by court vide order dated 29.01.2014.  Further, the citations referred above submitted by the counsel for complainant are conforming to the facts and circumstances of the present case whereas the citations submitted by counsel for the Ops are not applicable to the facts and circumstances of the present case and thus are not helpful in deciding the case in hand.

7.                     So, from the facts narrated above, we are of the confirmed view that OP-Life insurance company has failed to establish that the cause of death of life assured was due to ailment alleged by them nor could prove any nexus between the alleged ailment & cause of death and thus the OP insurance company has wrongly repudiated the claim of  the complainant for which he was legally entitled.  Now next  question arises for consideration before the Forum is that after the death of Mahinder Kaur, whether complainant  alone is entitled to succeed the claim amount from OP Insurance Company. From the perusal of proposal form,  it is established that complainant Balak Singh has been specifically mentioned as nominee of the Life Assured.  So, the complainant  alone is entitled  to succeed the benefits of policy being nominee.  Accordingly, the complaint is allowed and the Ops are directed to comply with the following directions within thirty days from the communication of this order:-

(i)        To pay a sum of Rs.2,50,000/- (sum assured as mentioned in Annexure C-2) to the complainant alongwith simple interest @ 9% per annum from the date of filing of complaint to till its actual realization.

 

                        Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room after due compliance. 

ANNOUNCED ON:  15.02.2017                                                    Sd/-               

                                                                                            (D.N. ARORA)

                                 PRESIDENT                

 

                                                                                                       Sd/-

(PUSHPENDER KUMAR)

                                                                                                            MEMBER