BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

1. Pupinder Kaur, aged about 27 years, wife of late Sh. Pardeep Singh, R/o. Khanpura, Ambala, Haryana, pin-133205.
2. Manjit Kaur, aged about 44 years, w/o. Baljinder Singh, R/o. Khanpura-. Ambala, Haryana, pin-133205.
3. Ravneet Singh, aged about 7 years, S/o. late Pardeep Singh and Pupinder Kaur W/o late Sh. Pardeep Singh R/o. Khanpura, Ambala, Haryana, pin-133205. (through his mother i.e. complainant no.1)

          ……. Complainants

                                                Versus

1. Bajaj Allianz Life Insurance Company Ltd., Branch Office at, Parry Hotel, Opposite, GPO, Staff Road, Ambala Cantt, Haryana, pin-133001.
2. Bajaj Allianz Life Insurance Company Ltd., Registered office at Bajaj Allianz House, Airport Road, Yerawada, Pune, Maharashtra, pin-411006.
3. Yes Bank Ltd., Branch office at Ground Floor, 4307, Shanti Complex, Jagadhri Road, Ambala Cantt, Haryana, pin-133001.
4. Yes Bank Ltd. Branch Office at Ground Floor, village Ladwa, District Kurukshetra, Haryana, pin-136131.

                                                                                   ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                      Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

Present:       Shri Ashish Sharma, Advocate, counsel for the complainants.

                       Shri Puneet Sirpaul, Advocate, counsel for the OPs No.1 & 2.

                       Shri Bharat Bhushan Chawala, Advocate, counsel for OPs No.3 & 4.

Order:        Smt. Neena Sandhu, President.

1.                Complainants have filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay the death claim of Rs.3,50,000/-  to the complainants, along with up to date interest.
2. To pay Rs.1,00,000/-,as compensation and damages to the complainants, for the mental agony and physical and mental harassment caused to the complainants.,
3. To pay Rs.50,000/- as litigation expenses.
4. To pay the aforesaid amounts, jointly and severally.
382.  

Grant any other relief which this Hon’ble Commission may deems fit.

2.             Brief facts of the case are that complainant no.1 is the widow of Mr. Pardeep Singh [deceased person/insured] and the complainant no. 2 is mother of Mr. Pardeep Singh [deceased person/insured] and the complainant no. 3 is minor child of late Mr. Pardeep Singh [deceased person/insured] and the complainant no. 3 has filed this complaint through his mother i.e. complainant no.1. Late Mr. Pardeep Singh [deceased person/insured) had bought a life insurance cover/policy at Ambala Cantt. from OP No.1 having its registered office at Pune, OP No.2, which is advanced through their selling agent i.e. OP No. 3, having its selling office at Kurukshetra, OP No. 4. Late Mr. Pardeep Singh [deceased person/insured] was enrolled as a member under the group insurance scheme namely group credit protection plus administered by Yes Bank Limited, under group credit protection plus [UIN: 116NO94V04] issued by Bajaj Allianz Life Insurance Company Limited to Yes Bank Ltd. bearing Master policy No. 0346254123. Late Mr. Pardeep Singh (deceased insured) was enrolled under the Insurance Policy/cover vide membership no. 0367766470 with date of commencement of risk dated 24.07.2019. The sum assured under the insurance cover/policy is Rs.3,50,000/- and a single premium paid by the deceased insured to the tune of Rs. 1936.38. The insurance policy cover, also included additional benefit of APTD SA (RS) 3,50,000/- cover also. The term period of policy is three years and the nominee to the policy/cover is complainant no.1, for the said life insurance cover of the deceased person, for the management and disbursement, in case of the claim under the unfortunate circumstances. The deceased person when he was alive was hale and healthy and was not suffering from any disease and was 28 years old young gentleman. He was not suffering from any physical and mental disease/disturbance of any kind and he was working as full time agriculturist farmer in his own fields and he was good build in his physical and mental traits. The deceased person was living a happy married life with his wife and his son and was working hard to manage his family affairs. On one unfortunate day, late Mr. Pardeep Singh, deceased person/insured felt some discomfort in relation to his health and therefore, he preferred to do rest for a day, but unfortunately he got desiccated and complained of vomiting and discomfort, therefore, his family members took him to nearby hospital, i.e primary health center, Ugala, of Tehsil Barara, District Ambala, where on the inception of the entry itself, he was declared as brought dead. The aggrieved family of the deceased insured informed this fact of death of the deceased person to OP No. 1 to 4 at their respective branches/offices and requested them for payment of claim amount, as he was duly insured under the said policy.   However, OP No.1 and 2 repudiated/denied the genuine death claim of the deceased person without any sufficient cause and reason. OP No.1 and 2 vide their letter dated 08.05.2021 repudiated/denied the death claim/insurance claim of the complainants by citing the reason as, "as per the various investigations done and as per medical records, life assured was suffering with depression and was taking treatment since September 2018, which was pre-proposal. This fact was deliberately and fraudulently suppressed in the proposal from dated 17-07-2019, with an intention to deceive insurer and to induce the insurer to issue the policy resulting into fraud [active concealment of fact by the insured having knowledge or belief of the fact]. OPs No.1 to 4 have wrongly, illegally and mischievously denied/repudiated the genuine/legal/claim of the complainants. Hence, the present complaint.
3.           Upon notice, OPs No.1 and 2, appeared and filed written version wherein they raised preliminary objections to the effect that this complaint is not maintainable; the complainants have attempted to misguide and mislead this Commission; the complaint is not maintainable and is liable to dismissed as no cause of action ever arose in favour of the complainants;  the complainants does not qualify the ingredients of a valid complaint as envisaged in Consumer Protection Act; the complainants while filing a joint complaint have not filed any application U/s 35(1)(c) of the Consumer Protection Act, 1986 for seeking permission to file a joint complaint;  because the basic transaction between the DLA and YES Bank Ltd. relates to a commercial transaction and just to secure the said loan taken for commercial purpose he got his life insured from the OP's, therefore, this Commission has no jurisdiction to try and decide the present complaint etc. On merits, it has been stated that the husband of the complainant no.1 i.e. Sh.Pardeep Singh (hereinafter referred to as DLA) took a loan from OPs No.3 and 4. In order to secure the loan he approached the OPs No.1 & 2 and submitted an enrollment form dated 17.07.2019 for the purchase of "Bajaj Allianz group Credit Protection Plus". The enrollment form accepted on the standard rates based on the information provided by the DLA and consequently the policy in question was issued in favour of the insured; Before acceptance of the enrollment form by OPs No.1 and 2, the contents of the enrollment form, terms and conditions of the policy and exclusions attached to the terms and conditions were read and explained to the DLA in the language best known to him by the concerned financial consultant. On the basis of the information furnished in the enrollment form, the same was processed by OPs No.1 & 2 and thereafter the said certificate of insurance alongwith the terms and conditions were issued to the complainant. It was only after being completely aware as regards to the features of the Plan and terms of the Plan including the premium amount to be paid annually towards the said Plan and after having understood and agreed to the terms and conditions attached therewith that, the DLA applied on his free will and consent. It has been alleged by the complainants that the DLA felt some discomfort and complained of vomiting, therefore, the family members took him to nearby hospital whereby on the inception of the entry itself, the DLA was declared as brought dead. The complainants intimated the death of DLA to the OPs and submitted the claim form. As it was an early death claim therefore OPs No.1 and 2 hired an investigation agency to know the history of the DLA. The investigation agency procured medical documents of the DLA and it came to the knowledge of OPs No.1 and 2  that the DLA was suffering from depression and since September 2018 was taking treatment from Miri Piri Institute of Medical Sciences & Research, Shahbad, District Kurukshetra, prior to the issuance of the policy. So accordingly the claim was rejected under non-disclosure of material information. The DLA made a false statement in the enrollment form, whereby he did not disclose the past history with regard to depression, from which he was suffering since 2018 i.e. prior to the inception of the policy. The psychiatric disease mentioned above can be adduced from the discharge card of Miri Piri Institute of Medical Sciences & Research, Shahbad, District Kurukshetra bearing CR No.201809041024. The said information was concealed by the DLA when specifically asked from him while filling the enrollment form. It is established that there has been breach of one of the basic principles of the life insurance which is of "Utmost good faith".  Since the facts about the health condition of the DLA were incorrectly disclosed in the enrollment form and the condition was material to the OPs No.1 and 2, from underwriting perspective. In view of the above facts the OPs No.1 and 2, vide letter dated 31.08.2020 denied the claim of the complainants after taking into consideration the provisions of Section 45 of the Insurance Act, 1938. OPs No.1 and 2 adhered with the provisions of Section 6(2) of the Insurance Regulatory and Development Authority (Protection of Policy Holder's Interest) Regulation, 2002, that every policy document sent by the Insurance Company is accompanied by forwarding a letter. It has been clearly mentioned in the said letter that in case if the Policyholder/Policy Proposer is not satisfied with the features/the terms & conditions of the policy then Policyholder/Proposer can withdraw/return the policy within 15 days of the receipt of the Policy Document i.e. under "Freelook Period" provision. However, in the present case the DLA had admittedly not approached the OPs No.1 and 2, within the Free look Period as mentioned in the terms and conditions of the Policy. The Hon'ble Supreme Court of India in several judgments has clearly laid down that the relationship between the insured and the insurer is of utmost good faith and is based on the Latin Maxim "Uberrima Fides" and it is the duty of the insured to show all Uberrima Fides. The complainants have not provided any document which could show that the DLA died due to Heart Attack.  Had the DLA disclosed about his mental problem in the enrollment form, the OPs No.1 and 2 would not have issued the certificate of insurance or the OPs No.1 and 2 would have charged high premium considering the mental state of the DLA. Rest of the averments of the complainant were denied by the OPs No.1 and 2 and prayed for dismissal of the present complaint with heavy costs.
4.           Upon notice, OPs No.3 and 4, appeared and filed written version wherein they raised preliminary objections to the effect the complaint of the complainants is not legally maintainable in the present form; the complainants have filed the present complaint by concealing the true and material facts from this Commission; the present complaint is not maintainable because OPs No.3 and 4 are only Corporate agent of  OPs No.1 and 2 and OPs No.1 and 2 is an insurance company who deals in insurance sector and the complainant purchase the insurance from OPs No.1 and 2 after considering all the norms and the conditions of the insurance. There is no deficiency in service on the part of OPs No.3 and 4 as they neither deal with the complaint in insurance nor issued the insurance policy. On merits, it is stated that OPs No.3 and 4 never received a single premium of the policy in question. OPs No.1 and 2 rightly discarded the claim of the complainants after conducted the investigation. Rest of the averments of the complainants were denied by the OPs No.3 and 4 and prayed for dismissal of the present complaint with heavy costs.
5.           Learned counsel for the complainants tendered affidavit of complainant No.1 as Annexure CW1/A alongwith documents as Annexure C-1 to C-6 and closed the evidence on behalf of complainants. On the other hand, learned counsel for the OPs No.1 and 2 tendered affidavit of Ms.Swati Seth, Zonal Legal Head-North-1 of OPs No.1 and 2, Legal & Compliance, Bajaj Allianz Life Insurance Co. Ltd. as Annexure OP-W1/A alongwith documents Annexure OP-1/1 to OP-1/7 and closed the evidence on behalf of OPs No.1 and 2. Learned counsel for the OPs No.3 and 4 tendered affidavit of Rashi Rana, Branch Manager of OPs No.3 and 4-Yes Bank Limited, Ladwa Branch, District Kurukshetra as Annexure OP-3/A and closed the evidence on behalf of OPs No.3 and 4.
6.           We have heard the learned counsel for the complainants and learned counsel for the OPs No.1 to 4 and have carefully gone through the case file and also gone through the written arguments filed by the learned counsel for the complainants.                                                                                                                                                                         
7.           Learned counsel for the complainants submitted that neither any wrong information was provided by the insured with regard to his health at the time of filling up of the proposal form nor he was suffering from any pre-existing disease of depression, yet, after his death, the genuine claim filed by the complainants being legal heirs of the insured has been repudiated by the OPs, which act amounts to deficiency in providing service.  In support of his contention, the learned counsel for the complainants, placed reliance upon the judgment dated 08.05.2018 passed by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi, in the case of Life Insurance Corporation of India Vs. Jyotsana Rawal, Revision Petition No.864 of 2018 and the judgment dated 12.03.1998, passed by the Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh in the case of Life Insurance Corporation of India Vs. Malkiat Kaur & Others.
8.           On the contrary, the learned counsel for the OPs No.1 and 2 submitted that since there has been concealment of material facts with regard to the disease i.e. depression, suffered by the insured, at the time of obtaining the insurance policy in question, as such, the claim of the complainants was rightly rejected by the OPs No.1 and 2, strictly as per terms and conditions of the insurance policy.
9.           Learned counsel for OPs No.3 and 4 submitted that the insurance policy was issued by the OPs No.1 & 2 and the claim was also rejected by them, as such, OPs No.3 and 4 being Bank, have no role to play. Thus, the present complaint filed against OPs No.3 and 4, deserves dismissal with costs.   
10.           It is clearly coming out from the repudiation letter dated 31.08.2020, Annexure OP1/6, claim of the complainants stood repudiated by the OPs No.1 and 2  on the ground that insured had concealed the fact that he was suffering from depression and on treatment since September 2018, which was pre-proposal, to corroborate this fact, the Ops No.1 and 2 have placed on record Discharge Card, Annexure OP1/7, issued by Miri Piri Institute of Medical Sciences and Research, Kurukshetra, Haryana, from the perusal of same, it is evident that the insured was admitted in the said hospital for taking treatment of depression for the period from 07.09.2018 to 11.09.2018.  It may be stated here that it is the definite case of the complainants that the insured died because of heart attack and not of depression, which the OPs have failed to disprove by placing on record any contrary evidence to the same.  Under these circumstances, the moot question now which falls for consideration is, as to whether, OPs No.1 and 2 have been able to prove their case that the treatment taken by the complainant qua depression for the period for the period from 07.09.2018 to 11.09.2018 in (Miri Piri Institute of Medical Sciences and Research, Kurukshetra, Haryana) had any direct nexus with the death of the insured i.e. with heart attack on account of which he died.  Not even a single document has been placed on record by OPs No.1 and 2 to prove that there was any nexus of depression with heart attack suffered by the insured. It is significant to mention here that a similar question whether depression has any direct nexus with heart attack and that whether the insurance company can repudiate claim on this ground fell before the Hon’ble National Commission in LIFE INSURANCE CORPORATION OF INDIA Versus DR. NILAM HETALKUMAR PATEL & 4 ORS., REVISION PETITION NO. 1096 OF 2019 decided on 20 September 2023 which was answered in favour of the insured by holding as under:-  

“…9.      The main reason for repudiation of claim is that deceased has suppressed the material facts of his ailment that was depression. The Complainants have contended  before the State Commission that medical certificate regarding ailment of depression cannot be looked into as evidence as it was  not supported by the affidavit of the doctor who issued the certificate.  However, the State Commission, relying on the judgment of Hon’ble Supreme Court in Satwant Kaur Sandhu Vs. The New India Assurance Co. Ltd. (2009) 8 SCC 316 and keeping in view the authorisation of deceased in the proposal form to LIC to get information from any hospital regarding health,  have observed that no affidavit of the doctor is required in support of the certificate.  Hence, admitting the certificate of the doctor for  the ailment of depression, the State Commission held that there was suppression about the ailment  of the deceased when policies were taken.  However, the State Commission was of the view that main question is whether  there is any nexus between ailment and cause of death.  State Commission further observed that from the medical literatures for depressive disorder produced by LIC, one cannot conclude that this is a serious ailment.  Further,  the State Commission observed that there is nothing on record which may show that ailment of depression may lead to heart failure.  There is no nexus between the ailment and the cause of death i.e. heart failure.  State Commission relied upon judgment of Abdul Latif and Others Vs. LIC of India III ( 2014) CPJ  357( NC) and Sulbha Prakash Motogaonkar and Others Vs. Life Insurance Corporation of India and Others 2021 13 SCC 561 decided on 05.10.2015 in this regard.  Hon’ble Supreme Court has observed in this case

“6.……. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with his lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified”.

10.    State Commission also relied upon judgment in P.Venkat Naidu Vs. Life Insurance Corporation of India IV ( 2011) CPJ 6 ( SC), which was upheld by the Supreme Court.  Other case law relied upon by the State Commission was case of LIC Vs. Jyotsna Rawal, RP No. 864 of 2008 decided by the National Commission, relying on the judgment of Hon’ble Supreme Court in  Sulbha   Prakash  Matogaonkar  and  Ors. (supra) and case of Neelam Chopra Vs. LIC and Ors in RP No. 4461 of 2012.   After taking note of various judgments of this Commission and Hon’ble Supreme Court, the State Commission concluded that “ …….It is very clear that the husband of original complainant no.1 was suffering from major depression and he died due to heart attack.  Thus, it cannot be said that there is any nexus between the ailment and the cause of death.  Hence, the repudiation of the claim made by the LIC on the ground of non disclosure of material facts is not justified.”  State Commission also duly considered various case laws cited by LIC in support of their contention that there was non-disclosure of material facts and even if there is no nexus with the disease and the cause of death of deceased, then also the LIC was entitled to repudiate the claim of the Complainant and observed as follows:

“All the above cited cases are decided by the Hon’ble National Commission in the year 2014-2015 in which it was held that if there is non disclosure of material facts then nexus between the disease and the cause of death is not material.  This pronouncement is now no longer a good law as the contrary view has been taken by the Honourable Supreme Court of India  in the case of Sulbha Prakash case ( supra ), which was followed by the Honourable National Commission  in the latest judgment which was delivered in December 2018 in the case of Reliance Nippon Life Insurance Co. Ltd. Vs. Yellapu Venkata.”

11.    Accordingly, State Commission held that “……… if there is no nexus between the disease and the cause of death then the repudiation of the claim has been made by the Insurance company is not legal and valid.  In the instant case, the deceased insured before taking the policies was suffering from major depression but he died due to cardiovascular arrest and therefore, the repudiation of the claim made by the LIC was not legal and valid” and upheld the order of the District Forum and dismissed seven appeals and also allowed the two Consumer Complaints.

12.    We have carefully gone through the facts and circumstances of the case, orders of the State Commission, other relevant records, case laws relied upon by the parties / State Commission and rival contentions of the parties and are of the view that State Commission has correctly placed reliance on the judgment of Hon’ble Supreme Court in Sulbha Prakash Motogaonkar (supra) that as there is no nexus between the disease, information about which was not disclosed and the cause of death, hence the repudiation of the claim by OP Insurance Company is not correct. 

13.    In view of the foregoing, we find no illegality or material irregularity or jurisdictional error in the orders(s) of the State Commission, hence the same is upheld.  Accordingly, Revision Petitions No. 1096 to 1102 of 2019 and First Appeals No. 921 and 922 of 2019 are dismissed…...”

11.            In the case of Life Insurance Corporation of  India Vs. Jyotsana Rawal, (Supra), the Hon’ble National Commission  held as under :

8.      In this context, I would like to rely upon the decision of Hon'ble Supreme Court in Civil Appeal No.8254 of 2015 in the case of Sulbha Prakash Motegaonkar & Ors. Vs. Life Insurance Corporation of India, decided on 05-10-2015. This was the case where the deceased died due to Ischemic Heart disease and myocardial infarction. There was a concealment of lumbar spondylitis with PID with sciatica and, therefore, the insurance company repudiated the claim. Hon'ble Supreme Court held that it was not the case of insurance company that the deceased was suffering from life threatening disease which could or did cause death of the insured. The Court observed as below:

"We are of the opinion that the National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischemic heart disease and myocardial infarction had nothing to do with his lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.

12.           In Pratibha Bevinal Vs. Metlife India Insurance Co. Ltd., Consumer Complaint No. 88 of 2011 decided on 07.10.2022 the Hon’ble National Commission  held as under :

7………This Commission in Revision Petitions (supra) has also been guided by this judgement of the Hon'ble Supreme Court and these orders have attained finality. In the instant case, the opposite party's ground for repudiation of the policy is the concealment of a heart condition and diabetes mellitus. However, the cause of death of the DLA is a road accident due to rash and negligent driving by a motor cyclist. I am, therefore, of the view that the matter is squarely covered by Sulbha Prakash Motegaonkar (supra) and therefore the complaint is liable to succeed.

13.           Considering that there was no nexus between the material fact /information relating to depression alleged to have been suppressed and the cause of death of the insured, Keeping in view the decision of Hon’ble Supreme Court in Sulbha Prakash Matogaonkar (supra) and other judgments of the Hon’ble National Commission  cited above,  we are of the view that repudiation of the claim by OPs No.1 and 2 is not correct and the complainants are thus held entitled to the assured amount, as the insured died during the subsistence of the policy in question. In the copy of certificate of insurance, Annexure C-2 and OP1/3, the sum assured amount of Rs.3,50,000/-, has been found mentioned. Hence, the insurance company i.e OPs No.1 and 2 are liable to pay the sum assured amount of Rs.3,50,000/-, to the complainants, alongwith interest. They are also liable to pay the compensation for the mental agony and physical harassment caused to the complainants alongwith litigation expenses.
14.           Complaint against OPs No.3 and 4 is liable to be dismissed as no deficiency in service has been proved on their part.
15.           In view of the aforesaid discussion, we hereby dismiss the present complaint against OPs No.3 and 4 and allow the same against OPs No.1 & 2 and direct them, in the following manner:-
    1. To pay the sum assured amount of Rs.3,50,000/-, to the complainants alongwith interest @6% p.a. w.e.f 31.08.2020, i.e the date of repudiation of the claim, onwards. 
    2. To pay Rs.5,000/-, as compensation for the mental agony and physical harassment suffered by the complainants.
    3. To pay Rs.3,000/- as litigation expenses.

               The OPs No.1 and 2 are further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs No.1 and 2 shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 19.01.2024.