Haryana

Karnal

CC/269/2015

Sunita W/o Late Shri Suresh Kumar - Complainant(s)

Versus

Bajaj Allianz Life Insurance Company Limited - Opp.Party(s)

Parveen Kumar

19 Mar 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.269 of 2015

                                                         Date of instt. 04.11.2015

                                                         Date of decision:19.03.2018

 

Sunita wife of late Shri Suresh Kumar son of Shri Ballu Ram resident of House no.79, ward no.6, Shiv Colony, Assandh, District Karnal age 40 mobile no.9354942800.

                                                                                                                                                                        …….Complainant.

                                        Versus

 

1. Bajaj Allianz Life Insurance Company Limited, Branch office, SCO 226, Sector 12, Urban Estate Karnal.

2. Sombir Dahiya son of Shri Ran Singh agent of Bajaj Allianz Life Insurance Company Limited, resident of village Adiyana, Tehsil and District Panipat.

 

                                                                     …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.    

 

Before   Shri Jagmal Singh……President.

              Ms Veena Rani…..Member

              Shri Anil Sharma……Member

 

Present  Shri Parveen Kundu Advocate for complainant.

               Shri N.K.Zak Advocate for OP no.1

               OP no.2 exparte.

 

ORDER:                    

 

                         This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that wife of late Shri Suresh Kumar (policy holder and now deceased and hereinafter referred as policy holder) and nominee as per the policy documents. The policy holder was insured with a life insurance plan vide policy bearing no.0315957231 and same was commenced from 11^th of June, 2014 for the term of 20 years and maturity date is 10^th of June, 2034 and as per the policy the sum assured is Rs.5,00,000/-on maturity and sum assured Rs.10,00,000/- in case of death. Unfortunately, the policy holder was expired due to electrocution on 21.7.2014. Complainant being nominee lodged the claim with the OPs and submitted all the documents demanded by the OPs, but OPs did not pay any claim to the complainant. Then complainant served a legal notice dated 18.8.2015 in that regard but to no effect. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs. OP no.1 appeared and filed written statement raising preliminary objections with regard to maintainability; locus standi and cause of action; mis-joinder and non-joinder of necessary parties; complainant is estopped by her own act and conduct; jurisdiction and concealments of true and material facts. The true facts are that the policy bearing no.0315957231 was obtained by deceased Suresh Kumar and the sum assured was Rs.10,00,000/- for a term of 20 years and the date of commencement was 11.06.2014 and Sunita Devi, as his nominee. The policy in question run only about 2½ months from its commencement. In fact the life assured while submitted the proposal form concealed the material information regarding the status of his previous policies and further to avoid the adverse medical reports, the life assured intentionally and malafidely has not disclosed the sum assured of the earlier policies obtained by him and also the fact that one insurance company had infact declined his proposal to accept and issue policy in view of the adverse findings received by it in the ECG report under the generic medical test concluded against the said application. All these facts were observed during the investigation done on receipt of the claim which had arisen within less than 3 months from the issuance of the policy. Had the life assured answered the questionnaire of the proposal form correctly and truthfully, the OP no.1 would not have covered the risk of life assured. The contract of insurance is based on the principle of oberimafide i.e. utmost good faith and the proposer is legally and morally bound to disclose all the facts and circumstances regarding his state of health, paying capacity, earlier policies, truthfully and correctly and in case the proposer failed to do so, the insurance company has got every right to call the policy in question. The death claim under the policy in question was repudiated vide letter dated 29.05.2015 by the competent authority after considering all the facts, circumstances and material by a detailed and speaking order. Hence there was no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.2 did not appear and proceeded against exparte by the order of this Forum dated 29.12.2015.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C12 and closed the evidence on 2.1.2017.

5.             On the other hand, OP no.1 tendered into evidence affidavit of Tarun Gupta Ex.OP1/A and documents Ex.O1 and Ex.O2 and closed the evidence on 23.10.2017.

6.             We have heard the learned counsel for both the parties and have gone through the record available on the file carefully.

7.             From the pleadings of the parties, it is clear that the husband of the complainant namely late Shri Suresh Kumar obtained Life Insurance Plan vide policy no.0315957231 from OP no.1 through OP no.2 commencing from 11.06.2014 for 20 years term and the maturity date was 10.06.2034 for sum assured of Rs.five lakhs on maturity and sum assured Rs.10 lakhs in case of death. The policy holder Shri Suresh Kumar died on 21.07.2014. The complainant being nominee of her husband made claim with the OPs.

8.             The OP no.1 repudiated the claim of the complainant vide letter dated 29.05.2015 Ex.C10 which runs as under:-

        “We would like to inform you 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 investigations done, the various medical records received reveal certain facts, which were known to the deceased life assured and were not disclosed to us. Hence the death claim under above mentioned policy has been declined for the following reasons.:

        Active concealment of disproportionate insurance (Prior Insurance Policies were not disclosed) and also declination of risk cover by one of the insurance companies due to adverse ECG findings was also no disclosed with an fraudulent intent.

        Had these facts been disclosed the company would not have covered the risk for the abovesaid policy under the same term and conditions.

        Hence, the claim has been repudiated due to misrepresentation of material facts.”

8.             From the above repudiation letter, it is clear that the OP no.1 has received the various investigations done and various medical record. It is pertinent to mention here that Suresh Kumar had obtained two insurance policies from the OPs and regarding both the policies two cases are pending before this Forum. The OP no.1 has produced the investigation report Ex.O-1 conducted in two policies obtained by the insured deceased Suresh Kumar.

9.             The most relevant part of the investigation report are mentioned as under:-

Part-A (General Investigation)

3) Mention any deformity, peculiarities etc. in the physique, health and habits of the deceased discovered during the enquiry (as per the knowledge of neighbors, friends & local people, etc.)

Answer: In this investigation found that insured was suffering from cancer on Penis problems by last 1-2 years. Neighbors ignoring to give any written statement about illness without presence of LA’s family.

11) Summary of the last illness/accident with specific reference to the event/cause of death. (In case of unnatural or mysterious death like accident, suicide, murder etc. give summary mentioning details of death with reference to police FIR/PN/Inquest). Also mention source of information.

Answer: Information collated by beneficiary, relatives and neighbor.

                In this case investigator found LA suffering from cancer on Penis problems prior to death but authentic document not found.

14) Has a Vicinity check with hospitals, pharmacies, chemists & local doctors revealed any information of relevance? Provide the names and contact numbers of persons and establishments interviewed in this regard.

Answer: No record found with vicinity survey.

             In actual LA was suffering from cancer on Penis problems wherein LA’s treatment conducted by mentioned hospital but due to lacking of authentic information no authentic details found by this investigation.

Part-B (Medical Investigation)

3) For his/her last illness (mention the period of hospitalization, name(s) of the doctors attended an d IP/OP no.)

Answer: Actual details not found.

7) Duration of last illness

Answer: Insured family saying that last illness duration was just 2-3 days. In local enquiry neighbor saying that LA suffering from last 1-2 years by cancer on Penis problems but authentic documents not available.

10.           From the above, it is clear that the report of the investigation has not been supported by any cogent evidence on the basis of which the finding can be proved. The investigator has clearly stated in the report that nobody gave in writing that the insured was suffering from Cancer on penis for the last 1-2 years nor any authentic documents was found nor medical record was found. It is also mentioned that due to lacking of authentic information no authentic details found by the investigator. The OP no.1 has not produced any such statements or documents vide which the findings of the investigation can be said to have been proved. It is pertinent to mention here that according to complainant, the insured died due to electrocution i.e. electric shock and the investigator stated that insured died due to cancer on penis but the investigator as well as OP no1 has failed to prove their stand by producing cogent evidence in this regard. The investigator and the OP no.1 has also failed to produce any medical record to support their version. So, we have no hesitation in holding that the investigation report is not based on any cogent evidence. Therefore, the OP no.1 has wrongly repudiated the claim of the complainant on the ground that various investigations done and various medical records received revealed certain facts, which were known to the DLA and were not disclosed.

11.           Now coming to the contention of the OP no.1 that the prior insurance policies were not disclosed by the Deceased Life Assured (DLA). In this regard we can rely upon the decisions passed by the Hon’ble Punjab and Haryana High Court in CWP no.24862 of 2017 decided on 2.11.2017 in case Bajaj Allianz Life Insurance Company Ltd. Versus Santosh and another and  CWP no.24733 of 2017 decided on 1.11.2017 in case Aviva Life Insurance Company Ltd. Versus Permanent Lok Adalat (PUS), Bhiwani and another. In both these authorities the claim was repudiated on the ground that the insured did not disclose in the proposal form that he had other insurance policies as well. The Hon’ble High Court dismissed both the CWP filed by the insurance companies, upholding the order of the Permanent Lok Adalat on the ground that non-disclosure of the policies obtained by the insured from other insurance companies is not suppression of material facts because there is no bar in obtaining/pertaining various insurance policies. These authorities are fully applicable to the fact of the present case.

12.           Moreover, it is also mentioned here that the DLA has died due to electric shock while putting water in the cooler at his house and this fact is proved from the document Ex.C-5 the bed head ticket of the DLA issued by the Government Hospital Assandh wherein in the column of diagnosis mentioned electric shock. No doubt the OPs have denied the manner of death of the DLA but the OPs have failed to prove the same. On the other hand, Ex.C5 is the record of a Government Hospital which cannot be ignored. So, we are of view that the DLA had died due to electric shock. Therefore, if it is presumed to be true that the DLA has not disclosed the prior policies even then there was no nexus between the cause of death and the suppression of facts. In the above facts and circumstances of the case, we are of the considered view that the OP no.1 has committed a mistake in repudiating the claim of the complainant. Hence the OP no.1 is deficient in service.

13.           As a sequel to the foregoing discussion, we accept the present complaint and direct the OPs to pay Rs.10,00,000/- the insured amount (being the death of insured) to the complainant. We further direct the OPs to pay Rs.5500/- on account of mental pain, agony, harassment and for litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order failing which the complainant shall be entitled interest @ 8% per annum from the date of order till its realization.  The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 19.03.2018

                                                               

                                                                 President,

                                                        District Consumer Disputes

                                                        Redressal Forum, Karnal.

 

 

                        (Veena Rani)                     (Anil Sharma)

                          Member                              Member