Haryana

Yamunanagar

CC/488/2012

Kusum Lata W/o Narender Singh - Complainant(s)

Versus

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

Vijay Deep

31 May 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR AT JAGADHRI.

 

                                                                                     Complaint No.488 of 2012.

                                                                                     Date of institution:18.5.2012.

                                                                                     Date of decision: 31.5.2017.

 

Kusum Lata widow of Late Narendera @ Narender Singh aged about 48 years, resident of village Dharamkot, Tehsil Bilaspur, Distt. Yamuna Nagar

                                                                                                            …Complainant.

                                    Versus

1.  Bajaj Allianz Life Insurance Co. Ltd. branch office opp. Madhu Petrol Pump, Jagadhri road, Yamuna Nagar, through its branch Manager.

                                                                                                             … Respondent.

 

BEFORE:      SH.ASHOK KUMAR GARG, PRESIDENT.

          SH.S.C.SHARMA, MEMBER.  

                       SMT. VEENA RANI SHEOKAND, MEMBER.

 

Present: Sh. Vijaydeep Singh, Advocate, counsel for complainant.   

              Sh. Rajiv Gupta, Advocate, counsel for Ops.

 

ORDER 

1.                     Complainant Kusum Lata widow of late Sh.Narender Singh has filed the present complaint Under Section 12 of the Consumer Protection Act 1986 against the respondent (hereinafter referred as OP).

2.                     Brief facts of present complaint are that Shri Narender Singh (Now deceased) had been obtained two Life Insurance Policies bearing No. 33914101 commencing from 26.12.2006 for Rs.100000/- and another policy bearing No. 100966483 commencing from 13.06.2008 for Rs.200000/-  making the complainant Smt. Kusum Lata as nominee and paid premium regularly to the OP Insurance Co.  unfortunately Narender Singh died on 3.3.2010 at Fortis Hospital, Mohali during his treatment where he was admitted on 3.3.2010 after complaining some pain and uneasiness.  The complainant approached the OP for death claim in respect of death of her husband but they did not release the death claim.  The complainant received the rejection letter on dated 7.2.2011.  Repudiation of claim by the OP was wrong and illegal, hence, this complaint.  Lastly the complainant prayed for making the payment of death claim against both the Insurance Policies and to pay compensation as well as litigation expenses. Hence, this complaint.   

3.                     Upon notice, OP appeared and filed written statement besides preliminary objections, it has been mentioned on merit, that it is not denied that the complainant had obtained two insurance policies bearing No. 33914101 and 100966483  Unit Linked Regular Premium Bajaj Allianz “Capital Unit Gain” and “Unit Gain Plus Gold” policies for risk cover of Rs. 1,00,000/- and Rs. 2,00,000/- on dated 26.12.2006 and 13.06.2008 respectively subject to terms and conditions of the policy in question. It has been submitted that as per various investigations and medical treatment record of Fortis Hospital, Mohali clearly revealed that the deceased life assured was a known case of Bicuspid Aortic Valve disease and had underwent Aortic valve replacement in (2002).  Had he disclosed the disease to which he was suffering even prior to signing the proposals, the risk on his life would not have been accepted by the OP Insurance Company. The deceased, as such, concealed the material facts regarding his health just to induce the OP Insurance Company to accept risk on his life. The   life assured knowing well that he was not keeping good health prior to the proposal form for insurance, intentionally concealed the material facts regarding his health. The life assured deliberately and fraudulently gave wrong and false answer to the questions of the proposal forms and subsequently expired on dated 3.3.2010 at Fortis Hospital, Mohali due to pre-existing disease.  Hence, the claim of the complainant has rightly been repudiated under the terms and conditions of the policy due to non-closure of material facts.  Rest contents of the complaint have been denied being incorrect, wrong and matter of record.

4.                     In support of his case, counsel for the complainant tendered into evidence affidavit of complainant as Annexure CW/A, and documents such as photocopy of Repudiation/ Rejection letter dated 7.2.2011 as annexure C.1, photocopy of death certificate as annexure C.2, photocopy of refund letter of paid up value dated 07.12.2013 as annexures C.3, C-4 and C-5 and closed the evidence on behalf of complainant.   

5.                     On the other hand, counsel for OP tendered into evidence affidavit of Shri Shiv P. Singh, Branch Manager as annexure RA and documents such as photocopy of proposal form No. 0082604425 as annexure R.1, photocopy of proposal form No.0045055736 as annexure R.2, photocopy of letter dated 26.12.2016 as annexure R.3, photocopy of letter dated 30.12.2016 as annexure R.4, photocopy of summary of patient Mr. Narender Singh as annexure R.5, photocopy of rejection letter dated 7.2.2011 as annexure R.6 and closed the evidence on behalf of OP.

6.                     We have heard the learned counsel for the parties and have gone through the pleadings as well as documents placed on the file very minutely and carefully.

7.                     There is no dispute that the complainant’s husband obtained two insurance policies one bearing No. 0100966483 for a sum insured of Rs. 2,00,000/- and second policy bearing No. 0033914101 for a sum insured of Rs. 1,00,000/- from the OP Insurance Company which is duly evident from the copy of insurance policies Annexure R-3 and R-4 and paying the premium regularly and the policies were not in lapse mode at the time of death of life assured Sh. Narender Singh. It is also not disputed that the complainant Smt. Kusum Lata is the nominee in both the policies which is duly evident from the copy of proposal forms Annexure R-1 and R-2. It is also not disputed that the life assured Sh. Narender Singh expired on 03.03.2010 due to heart attack which is also duly evident from the death summary Annexure R-5.

8.                     The only plea of the OP Insurance Company in repudiating the claim of the complainant is that life assured Sh. Narender Singh was a known case of Bicuspid Aortic Valve disease post Aortic Valve replacement (2002). Learned counsel for the OP draw our attention towards death summary of the patient issued by Fortis Hospital at the time of death on dated 03.03.2010 (Annexure R-5) and argued that as per history mentioned in this letter Annexure R-5, it is duly evident that the deceased life assured was having pre-existing disease since 2002 but he suppressed these material facts from the OP Insurance Company at the time of filling proposal form on 26.12.2006 for the first policy for Rs. 1,00,000/- and on 30.06.2008 for second policy for a sum insured of Rs. 2,00,000/-. Further, learned counsel for the OP argued that the OP Insurance Company had already paid the fund value amounting to Rs. 48,579/- against the policy bearing No. 100966483 on 22.11.2013 and Rs. 41,317/- against the policy bearing No. 33914101 on 22.11.2013 and draw our attention towards the photo copy of cheque and forwarding letter Annexure C-4 and C-6 and now nothing is payable against these policies to the complainant.  Lastly, learned counsel for the OP referred the case law titled as Life Insurance Corporation of India Versus Smt. G.M. Channabascmma, AIR 1991 Supreme Court page 392 wherein it has been held “that Assured is under solemn obligation to make full disclosure of material facts- Allegation of insured being guilty of making false representations and suppressing material facts- Burden of proof- It is on Corporation”. And further referred the case law titled as Sr. Divisional Manager, LIC of India Versus Smt. Gangama and another, III(2002) CPC page 56 (NC) wherein it has been held “that repudiation of claim- Suppression of material fact- Deceased had malignancy, obtained treatment, proved by documents on record- Suppression proved- Order of State Commission allowing claim set aside.” Lastly, prayed for dismissal of complaint as claim of the complainant has been rightly repudiated by the OPs Insurance Company vide its repudiation letter dated 07.02.2011 Annexure R-6.

9.                     On the other hand, learned counsel for the complainant argued at length that genuine claim of the complainant has been wrongly and illegally repudiated by the OPs Insurance Company on the flimsy ground whereas the OPs Insurance Company has totally failed to prove that the deceased Narender Singh was suffering from any pre-existing disease. Learned counsel for the complainant argued that no affidavit of any doctor has been placed on file in support of facts mentioned in the death summary dated 03.03.2010 issued by the Fortis Hospital (Annexure R-5). Learned counsel for the complainant further argued that except this letter (death summary) Annexure R-5, no other treatment record of any hospital has been placed on file by the OP Insurance Company to prove that the deceased Narender Singh was having any pre-existing disease. Learned counsel for the complainant further argued that even for the sake of argument it be presumed that some treatment was taken by the deceased in the year 2002 even then the OP Insurance Company cannot repudiate the claim of the complainant after a lapse of considerable time i.e. near about 8 years on account of mis-representation of suppression of the material facts regarding the state of health. Learned counsel for the complainant draw our attention towards section 45 of the Insurance Act 1938 wherein it has been so recorded that “ No policy of life insurance effected after coming into the force of this act shall, after the expiry of 2 years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured or in any other document leading to the issue of policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder.”  Learned counsel for the complainant further draw our attention towards the latest amendment under section 45 (1) of the Insurance Law Act 2015 wherein also it has been mentioned “ that no policy of the life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy i.e. from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later”. Lastly, argued that in the present case first insurance policy was obtained by the husband of the complainant on 26.12.2006 i.e. prior to 3 ¼ years from the date of death of the life assured and in continuity the life assured obtained the second insurance policy on 13.06.2008 i.e. 1 year and 9 months prior to his death i.e. on 03.03.2010, so as per section 45 of the Insurance Act, OP Insurance Company has wrongly and illegally repudiated the claim of the complainant. Lastly, prayed for acceptance of complaint.

10.                   After hearing both the parties, we are of the considered view that there is a deficiency in service and unfair trade practice on the part of the OP Insurance Company as the OP Insurance Company has totally failed to place on file any treatment record of any hospital or any doctor vide which the deceased Narender Singh obtained his treatment. The OP Insurance Company only wants to get the benefit form the death summary (Annexure R-5) issued by the Fortis Hospital but this document has not been duly proved by the OP Insurance Company as no affidavit in support of the facts mentioned in this letter has been placed on file nor any record from the hospital has been summoned to prove the same. Moreover, as per this letter, the deceased Narender Singh was treated whatsoever in the year 2002 whereas he died in the year 2010 i.e. after a period of near about 8 years so it cannot be presumed that deceased Narender Singh died due to pre-existing disease. No medical record for taking the treatment since 2002 to 03.03.2010 i.e. the date of death has been placed on file to prove that the complainant was suffering from any disease and was on any medicine. So, in the absence of any cogent evidence that the deceased Narender Singh was suffering from any pre-existing disease i.e. hypertension etc., we are of the considered opinion that the Op Insurance Company has wrongly repudiated the claim of the complainant. Moreover, as per section 45 of the Insurance Act and further as per amendment in section 45(1) of the Insurance laws Act reproduced above, repudiation done by the OP Insurance Company is also illegal as the complainant had obtained the first insurance policy more than three (3) years prior to the date of his death and in its continuity he obtained the second insurance policy one year 9 months prior from the date of his death. The OP Insurance Company has totally failed to prove that there was any malafide intention on the part of the deceased due to which he obtained the insurance policy from the OP Insurance Company. This fact cannot be ignored that the deceased Narender Singh had invested his money by taking the insurance policies namely Unit Linked Regular Premium Bajaj Allianz “Capital Unit Gain” and “Unit Gain Plus Gold” not the medical policy. So, it cannot be said that the complainant obtained the insurance policies in question just to extract the illegal money from the OP Insurance Company.

11.                   Even on the other angle also, there is a deficiency in service and unfair trade practice on the part of the OP Insurance Company as the OP Insurance Company firstly rejected the claim of the complainant under both the policies vide letter dated 07.02.2011 Annexure C-1 but after filing the present complaint i.e. on 18.05.2012 the OP Insurance Company paid only the paid up value amounting to Rs. 41,317.42 and 48548/- on dated 22.11.2012 vide cheque No. 063635 and 063748 dated 22.11.2013.   

12.                   In the circumstances noted above, we are of the considered view that the OP Insurance Company has wrongly and illegally repudiated the claim of the complainant vide letter dated 07.02.2011 and after filing the present complaint made the payment of paid up value which constitute the deficiency in service and unfair trade practice on the part of OP Insurance Company. Hence, the complainant is entitled for relief.

13.                   Resultantly, we partly allow the complaint of the complainant by directing the OPs-Insurance Company to pay Rs. 58,683/- i.e. (Rs. 1,00,000/- sum insured minus Rs. 41317/- already paid ) against policy bearing No. 0033914101 dated 26.12.2006 and also to pay Rs. 1,51,421/- i.e. (Rs. 2,00,000/- sum insured minus Rs. 48,579/- already paid) against policy bearing No. 100966483 dated 13.06.2008. Meaning thereby that the OPs are directed to pay total amount of Rs. 2,10,104/-   to the complainant alongwith interest at the rate of 6% per annum from the date of filing of complaint till its realization and also to pay Rs. 2200/- as litigation expenses.  Copies of this order be sent to the parties concerned as per rules.  File be consigned to the record-room after due compliance.

Announced in open court.31.05.2017.           

 

                                                                                         (ASHOK KUMAR GARG)

                                                                                           PRESIDENT.

 

 

         (VEENA RANI SHEOKAND)                 (S.C.SHARMA)

                        MEMBER                                                MEMBER.