Punjab

StateCommission

FA/211/2014

ICICI Prudential Life Insurance Company Limited - Complainant(s)

Versus

Balwinder Kaur - Opp.Party(s)

K.S. Cheema, Chetan Gupta & P.S. Bhangu

10 Feb 2015

ORDER

 

 

 

2^nd  ADDITIONAL BENCH

 

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH

                                                                    

First Appeal No. 211 of 2014

 

Date of institution: 04.03.2014

Date of Decision:  10 .02.2015

 

1. ICICI Prudential Life Insurance Company Ltd., Vinod Silk Mills Compound, Chakarwarti Ashok Nagar, Ashok Road, Kandivali (E) Mumbai 400 101 through its Managing Director/Grievance Redressal Committee.
2. ICICI Prudential Life Insurance Company Ltd. Branch Office, Gaushala Road, Sangrur through its Branch Manager.

         …..Appellants/Opposite Parties

 

Versus

 

Balwinder Kaur wife of Late Gurmail Singh, Resident of Gali No. 8, Guru Teg Bahadur Colony, Kakarwal Road, Near 501 Godown, Dhuri, Distt. Sangrur.

                             ....Respondent/Complainant

        

First Appeal against the order dated 16.12.2013 passed by the District Consumer Disputes Redressal Forum, Sangrur.

 

Before:-

 

Sh. Gurcharan Singh Saran, Presiding Judicial Member

Sh. Jasbir Singh Gill, Member

Sh. Harcharan Singh Guram, Member

 

Present:-

 

For the appellant                   : Sh. K.S. Cheema,  Advocate

For the respondent                : Sh. Sanjeev Goyal,  Advocate

 

Sh. Harcharan Singh Guram, Member

 

                                                          ORDER

 

                  This appeal has been preferred by appellant/Opposite Parties under section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as the “Act”) against the order dated 16.12.2013 in C.C. No. 76 of 13.02.2012 passed by the learned District Consumer Disputes Redressal Forum, Sangrur (in short the ‘District Forum’) vide which the complaint filed by the complainant under section 12 was accepted with a direction to the Ops to pay to the complainant an amount of Rs. 2,40,000/- along with interest @ 9% from 13.02.2012 till its payment and also to pay an amount of Rs. 5000/- as litigation cost.

2.                The complaint was filed by the complainant on the allegation that deceased Gurmail Singh was her husband who expired on 21.09.2010. She submitted that her husband purchased Insurance policy No. 13192668 on 06.01.2010 from the Ops.  She submitted her claim under the said policy for payment of death claim of her husband and the said claim was received by Ops on 16.10.2010 It was repudiated by the Ops vide their letter dated 31.03.2011, on the ground that the policy was issued on 06.01.2010 and the Life Assured expired within nine months of the policy and he was suffering from Chronic Liver Disease and hypertension for the last 8 years and diabetes Mellitus for the last 6 years and he was Chronic Alcoholic for the last 8 years. On receipt of the repudiation letter, she served a legal notice on the Ops dated 06.01.2012 and requested the Ops to make the payment of Insurance claim. Even the service of the legal notice did not yield any result. The Act of the Opposite Party in not settling her claim amounts to deficiency in service. Therefore, she filed the complaint for the issuance of the directions to the Ops to pay the claim.

3.                The complaint was contested by the Ops by filing written reply before the District Forum, while denying the allegations made in the complaint. It was pleaded that the complainant had concealed the facts from the District Forum and did not come to the District Forum with clean hands and as such the complaint deserved to be dismissed. This complaint was filed by the complainant merely to harass and gain undue advantage and unjustified claim from them. The contract of Insurance was based on the Principle of good faith. The Life Assured concealed the facts that he was suffering from Chronic Liver Disease and hypertension for the last 8 years and Diabetes Mellitus for the last 6 years prior to filling up the proposal for Insurance policy. The Ops after exhaustive investigation of the claim and after collecting all the documents procured at the time of investigation had come to the findings that the said policy was taken after concealment of all the aforesaid material facts therefore, the claim of the complainant was rightly repudiated by them. It was further stated that the District Forum was having no jurisdiction to entertain the present complaint. It was stated that they had received death claim intimation on 16.10.2010, wherein it was stated that the Life Assured died on 21.09.2010 and the cause of death was mentioned as natural. But as per “Lama certificate issued by Daya Nand Medical College and Hospital, in which it was written that patient deceased Gurmail Singh was suffering from hypertension for 8 years on irregular medication and diabetes mellitus for 6 years. Treating doctors treatment certificates by Daya Nand Medical College and Hospital shows Chronic Liver Disease for 8 years, hypertension 8 years, diabetes 6 years and suffering from Chronic Alcohol Respiratory disease with PD with PL. Treating Doctors certificates issued by Shri. Rajeev Sharma MD, Physician of Rishi Hospital, Dhuri described the patient suffering from T2 and diabetes mellitus, Septicemia (post operative) primary cause death Cardiac Respiratory. Secondary cause of death Septicemia. Since the deceased had provided wrong information at the time of issuance of the policy the claim under the said policy was repudiated due to non-disclosure and suppression of material information and the same was communicated to the complainant vide their letter dated 31.03.2011 and Ops prayed for dismissal of the complainant.

4.                Both the parties produced their evidence in support of their averments.

5.                The Learned Counsel for the complainant produced Ex-C/1 and Ex-C/2 affidavits of the complainant, Ex-C/3 policy, Ex-C/4 death claim intimation, Ex-C/5 lama summary, Ex-C/6 to Ex-C/8 copy of treating doctor certificate, Ex-C/9 and Ex-C/10 copy of legal notice, Ex-C/11 postal receipts, Ex-C/12 receipts, Ex-C/13 copy of letter, Ex-C/14 policy certificate, Ex-C/15 copy of death certificate in her evidence. On the other hand, the learned Counsel for the Ops number 1 and 2 have tendered Ex-R/1 proposal form, Ex-R/2 copy of policy document, Ex-R/3 death claim intimation, Ex-R/4 lama summary, Ex-R/5 and Ex-R/6 treating doctor certificate, Ex-R/7 copy of letter dated 31.03.2011, Ex-R/8 reply of notice and Ex-R/9 affidavit of the Ops and closed their evidence.

6.                District Forum after going through the same and after hearing Learned Counsels on their behalf allowed the complaint, vide aforesaid order.

7.                Aggrieved with order of the District Forum the OPs have filed the present appeal and have taken the plea that the “Insurance is contract of utmost good faith requiring of the proposer and the Life assured to disclose all material facts and not to suppress any material facts in response to the questions in the proposal form. Further the Life Assured gave an undertaking to the company that in case of any mis-statement or suppression of material information given to the company at the time of taking of the Insurance Policy, the company on coming to know that the information given by the assured had given mis-statement or suppressed material information, then under such circumstances company has right to repudiate the claim under the policy. It was submitted that the death claim intimation was received at their end on 16.10.2010 where in it was stated that the life assured died on 21.09.2010 and the cause of death of the life assured was mentioned as natural death. The Ops had to go for certain process of documentation and verification for settlement of early claim i.e. within 2 years of issuance of the policies. Since the Life assured expired within 9 months from the date of insurance policy, hence, the said claim falls in early claim category and in order to verify the authenticity of the proposed claim an investigation was ordered to be carried out. As per lama notes given by the Daya Nand Medical Hospital on 20.09.2010 the Life Assured was suffering from various chronic disease which was mentioned in the discharge summary given by the DMC Hospital Ludhiana. Even as per certificate given by the Dr. Rajeev Sharma of Rishi Hospital, Dhuri, the cause of death though it was Cardiac Respiratory failure but initial diagnosis was diabetes mellitus as mentioned in the said certificates. Thus the claim was rightly repudiated by them.

8.                On the other hand Counsel for the respondent stated that the order of the District Forum is well reasoned and detailed order and needs to be upheld.

9.                During the course of arguments specific query was raised to the Learned Counsel for the OPs that besides lama summary obtained from Daya Nand Medical Hospital by the complainant herself, any other medical record consisting of these ailments were ever procured by them. But the Learned Counsel continued to agitate the matter that the mis-statement given by the Life Assured at the time of taking policy had been duly explained in the lama notes.

10.              We have looked into Ex-R/4 and R/5 and R/6, R-4 pertains to lama summary.  It is clear from lama summary that this document does not bear the names of the doctors along with their designation and their signatures. Ex-R/5 is a document pertaining to ICICI Prudential treating doctor’s certificates. Wherein no date of issuance of said certificates was written. In the said certificate Chronic Liver disease is mentioned as 8 years, hypertension 8 years and diabetes 6 years. This certificate was counter signed by medical Superintendent DMC hospital Ludhiana, Associates Professors Dept of Surgery DMC hospital Ludhiana and resident surgeon DMC hospital Ludhiana, but no date is mentioned under their signatures. Ex-R/6 also does not bear date on the first page i.e. certificate issued by Doctor Rajeev Sharma, Rishi Hospital, Dhuri. In this certificate there is no mention regarding the diseases suffered by the Life Assured at the time of admission in that hospital.

11.              However in Ex-R/16 the cause of death was mentioned as cardiac respiratory and secondary cause of death was mentioned septicemia and this certificate was duly signed by Rajeev Sharma Rishi Hospital, Dhuri on 8^th Day of December 2010. These two documents i.e. Ex-R/5 & R/6 depict the history of the patient, which was given by the family members to two different doctors at the time of hospitalization in two different hospitals and reflects contradictory averments pertaining to the patient’s health.

12.              As per law laid down by Punjab State Consumer Disputes Commission, in citation CLT 1999 (1) Vol 13 Smt. Tripta Rani v/s LIC of India which states as under :

“Apart from the above history of the patient recorded in the hospital at the time of his death, the Corporation did not take into possession any evidence that the deceased had taken treatment earlier either at the same hospital or from any other doctor. Simple assertions made on the history of the patient recorded in the hospital records is not considered sufficient to hold that the patient had earlier taken treatment for such like diseases. Thus, it is held that the repudiation of the claim solely on the basis of the history recorded in the hospital record is arbitrary and illegal. Non settlement of the claim on that account amounts to deficiency in rendering service. Finding of the District Forum in this respect is affirmed and the complainant was held entitled to all the benefits under the policy”.

13.              Moreover, the Supreme Court in the judgment dated 10.10.1995 recorded in Biman Krishan Bose/United India Insurance Company Civil Appeal number 3438 of 1995 had stated: “that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the Insurance company. Moreover hypertension is not a material disease which is fatal in itself.

14.              So far as diabetes is concerned the same parameter will apply. Disease of diabetes is so common in our country-men at least in this part of the country, that almost every third person is suffering from it. If proper check is maintained on that disease it is not fatal and a person suffering from diabetes can live even for 20 to 30 years, if he is taking proper medicines. Therefore non disclosure of this disease by the assured does not entitle, the insurance companies to repudiate the Insurance claim”.

15.              Similarly the Hon’ble Delhi State Consumer Disputes Redressal Commission, in case of Life Insurance Corporation of India versus Sudha Jain” 2007 (2) CLT 423 as drawn the conclusions in para 9 and had stated as under.

        “Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.”

 

16.              Since the said certificates as Ex-R/5 & R/6 were procured by the “ICICI Prudential Insurance Company and these are not duly supported by the affidavits of doctors the same cannot be relied upon.

17.              From the above it is quite clear that the Ops as well as TPA has failed to prove that the deceased life assured was suffering from pre-existing disease at the time of taking the policy. As such the non -payment of the claim by the Insurance Company amounts to deficiency in service on their part.

18.              From our above discussion we conclude that the Opposite parties No. 1 & 2 were not justified in repudiating the claim of the complainant on the ground of pre-existing disease. Correct findings were recorded by the District Forum and we do not find any grounds for disagreeing with those findings. There is no merit in this appeal and the same is dismissed.

19.              The appellant/Ops have deposited a sum of Rs. 25,000/- at the time of filing the appeal and thereafter another sum of Rs. 2,00000/- was deposited as per the directions of this Commission, registry is here by directed to remit these amounts along within interest, if any, after 45 days from the date of this order to the respondent/complainant. The Ops are further directed to pay the remaining amount to the respondent as per the directions of the District Forum.

20.              The arguments in this case were heard on 4.02.2015 and the order was reserved. Now the order be communicated to the parties as per rules.

21.              This appeal could not be decided within the statutory period due to heavy pendency of court cases.

                                                (GURCHARAN SINGH SARAN)

                                                PRESIDING JUDICIAL MEMBER

 

           (JASBIR SINGH GILL)

            MEMBER

 

                                                                                                          (HARCHARAN SINGH GURAM)

February 10 , 2015                                                                                                                                                       MEMBER             

Surinder