Chandigarh

DF-I

CC/396/2021

Sunny Bhatia - Complainant(s)

Versus

Bajaj Allianz life Insurance Co. Ltd. - Opp.Party(s)

Narinder Singh

14 Feb 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/396/2021
Date of Institution	:	17/6/2021
Date of Decision	:	14/2/2024

 

 

Sunny Bhatia aged 34 years S/o Sh. Satish Bhatia and Late Smt. Neelam Bhatia R/o H. No. 3186, Sector 28-A, Chandigarh.

complainant

 

Versus

 

1. Bajaj Allianz life insurance company Ltd. Regd. Office: Allianz House, Airport Road, Yerwada, Pune 411006. Through its director/board of directors/Managing Director/Authorised Signatory.

 

2. Bajaj Allianz life insurance company Ltd. The Branch Manager Bajaj Allianz life insurance company Ltd. Sco-215-216-217 4Th Floor, Sector 34/A Chandigarh, through its director/board of directors/Managing Director/Branch Manager/Authorised Signatory.

 

3. Bajaj Finserv Limited, through its director/board of directors/Managing Director/Authorised Signatory, Regd. Office, Akurdi, Pune 411035.

 

4. CPP group India A-370, II Floor, Kalkaji, New Delhi, India 110019. Through its director/board of directors/Managing Director/Authorised Signatory.

 

2nd Address:-

 

Primary business address: Ground Floor, Wing-A GolfView Corp, Tower-A GolfCourse Road, DLF-V Sector 42. Gurgaon 122002 Haryana India

 

3rd Address:-

 

CPP group, 6 East Parade Leeds LSI 2AD United Kingdom

 

Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                       

ARGUED BY	:	Sh. Narinder Singh, Advocate for complainant.
	:	Ms. Monika Thatai alongwith Shruti Sharma, Advocate for OPs No.1&2.
	:	Sh. Anirudh Gupta, Advocate for OP No.3
	:	None for OP No.4.

Per surjeet kaur, Member

     Briefly stated the complainant’s mother while availing loan from OP No.3 took Term Life Insurance Cover from OP No.4 with critical illness rider including “Death Claim” having coverage of Rs.3,50,000/- by paying premium amount of Rs.4699/- which was valid w.e.f.17.2.2020 to 16.2.2021. At the time of taking the policy the mother of the complainant was hale and hearty.  However on 28.12.2020  the complainant’s mother Smt. Neelam Bhatia (now deceased ) was  admitted in city hospital Madhya Marg  Chandigarh with septic shock type 2 respiratory failure, and metabolic acidosis and during treatment she was expired due to sepsis with septic shock as per  reasons assigned by the treating hospital.  The complainant lodged a claim with OP No.1 but to the utter surprise of the complainant same was repudiated by the OPs vide Annexure C-7 on the ground of non disclosure of material fact. It is stated that the mother of the complainant was healthy and treatment from the shivalik Hospital was in the knowledge of the OPs and was disclosed to the OP No.3.  Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed.

2. The Opposite Parties NO.1&2 in their reply while admitting the factual matrix of the case stated that the answering OP acted as per terms and conditions of the insurance policy. After the death of DLA, her son, the complainant filed for the death claim of the policy. As it was an early death claim, therefore the answering opposite parties decided to investigate the matter. It is pertinent to mention here that on investigation it was discovered that the DLA was suffering from Hypertension, Diabetes, thyroid, sepsis with septic shock and type 2 respiratory failure.  Medical records from various hospitals and clinics including "Shivalik Hospital & Trauma Centre and IVY Hospital" clearly show that the DLA was not only diagnosed with these medical issues but was also undergoing treatment since 2014, which fact was never disclosed by the complainant while availing the loan and before issuance of policy. Thus the claim of the complainant was rightly denied. All other allegations made in the complaint has been  denied being wrong.
3.  OP No.3 in its reply stated that the answering OP  has no role in approval or rejection of the insurance claim as the OP is a mere financer and is not in the business of the insurance and the answering OP cannot be held liable for any claim made by the Complainant and the complainant has no cause of action against the answering OP. As the complainant has not approached before the Hon'ble Commission with clean hands and has suppressed the true and material facts hence the complaint is liable to be dismissed with costs. Denying any deficiency on its part a prayer for dismissal of the complaint has been made.
4. OP No.4 in its reply stated that the answering Opposite Party is not an insurance company. In fact, Term Life Insurance of the Complainant was insured by Opposite Party Nos. 1 & 2. The role of answering Opposite Party is of 'Master Policyholder' and is limited to that of a mere 'facilitator'. The answering Opposite Party qua 'facilitator' got the Complainant insured by Opposite Party Nos. 1 & 2. As such, claims if any, were to be processed and settled by Opposite Party Nos. 1 & 2 and not by the answering Opposite Party. Denying deficiency on its part a prayer for dismissal of the complaint has been made.
5. No rejoinder filed.
6. Contesting parties led evidence by way of affidavits and documents.
7. We have heard the learned counsel for the contesting parties and gone through the record of the case.
8. It  is an admitted case of OPs No.1&2 that on the basis of telephonic call and answers given by the complainant, the mother of the complainant (now deceased) was insured for a sum of Rs.3,50,000/-  through Group Insurance  Policy “Bajaj Alliance Group Term Life”  and consequently the certificate of insurance  was issued.
9. As per allegations of the OP insurance company the complainant’s mother, the insured  was having pre-existing disease as she was suffering from hyper tension, diabetes, thyroid  sepsis  etc.  As the insured did not disclose the past history of ailment and treatment taken by her the OP insurance company rightly repudiated the claim holding that the insured was responsible for suppressing material fact from the OP insurance company.  
10. Perusal of terms and conditions at page 21 of the complaint reveals that there is rider benefit which is reproduced as under:-

“Rider Benefit

On first diagnosis of any of the 11 Critical Illnesses (as defined below) on the life of the Member or joint member incase of joint life coverage is opted during the term of the Policy provided the Rider is not terminated (as per condition/s given) then, the Company, subject to Non-forfeiture Revival/ Exclusions, shall pay the Rider Sum Assured to the Member. The diagnosis of the Critical Illness needs to be confirmed by a registered Medical Practitioner appointed by the Company and has to be supported by acceptable cinical radiological, histological and laboratory evidence. The Company should be informed of the Critical Illness within 30 days of diagnosis of the Critical Illness.”

11. Perusal of the aforesaid contents clearly indicates that before issuance of the policy it was the duty of the OP insurance company to get the diagnosis of the critical illness of the insured confirmed by registered medical practitioner appointed by the insurance company but in the present  case admittedly no such formality or procedure was conducted.  As per written statement of OPs the policy was issued on the basis of call and answer given by the complainant and not by his mother, the insured.  The cause of death is clearly mentioned as spesis with septic shock. Moreover, the OPs insurance company have placed on record copy of conversation Annexure OP-3/A  which reveals that the insurance was paperless. Thus,  in our opinion it was the responsibility of the OP insurance company to get the medical examination of the insured done before issuing the policy in question and receiving premium from the complainant. Thus there is deficiency on the part of the Ops No.1&2.
12. Even otherwise also, it has been held by the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) that common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies. The relevant portion of the order is reproduced as under:-

 “Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

1. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“14. Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

2. Further, the Hon’ble National Commission in the case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) while dealing with the question of suppression/ non-disclosure of material facts has held as under :-

   12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

    “We have heard learned Counsel for the parties.

         It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

         We are of the opinion that 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 ischaemic heart disease and myocardial infarction had nothing to do with this 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.”

3. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the Ops No.1&2 have not been able to connect the previous diseases/ailments with the diseases/ailments owing to which the insured died.  Thus, the complainant has proved his case and the complaint is liable to be allowed.    

13. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs No.1&2 are directed as under:-

1. to pay Rs.3,50,000/- with interest @9% P.A. from the date of filing the instant complaint till onwards.
2. to pay Rs.10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

14.      This order be complied with by the OPs No.1&2 within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
15. Complaint qua rest of the Ops stands dismissed.
16. Pending miscellaneous application(s), if any, also stands disposed off.
17.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member   Sd/-
14/2/2024			[Suresh Kumar Sardana]
mp			Member