Complainant Kawaljit Kaur has filed the present complaint against the opposite party U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite party to pay insured amount regarding the death claim of her husband alongwith interest @ 18% P.A. from the date of submitting the claim form and other documents and to get the same deposited with the opposite party no.1 as against the loan so availed by her husband and after adjusting the entire loan amount, the amount of installments so deposited by her after the death of her husband and the extra amount, if any be refunded to her and she may kindly be granted damages to the tune of Rs.2,00,000/- as against the opposite parties for unfair trade practice, physical harassment and mental agony etc.
2. The case of the complainant in brief is that she is widow of late Prabhjot Singh. Her husband had availed a Housing Loan of Rs.9.00 Lacs from the opposite party no.1 on 24.12.2009 vide loan account no.12580600011968 and he executed certain loan documents as required by the official of the bank/OP No.1. Her signature was also obtained by the officials of the opposite party no.1 on certain loan documents alongwith her husband by saying that it is just formality and the main borrower is Prabhjot Singh. The opposite party no.1 has tie up with the opposite party no.2 and 3 and the Branch Manager of the opposite party no.1 suggested her husband to take insurance policy under Master Policy of Group Credit life plan by depositing an amount of Rs.19,000/- as premium of the said policy, under single premium paying terms and it was told to her and her husband that in case of the death of her husband, the remaining balance amount of the loan shall be waived off. Her husband had paid the abovesaid amount against the said policy and the same has been debited from his account and credited in the account of the opposite party no.2 and 3. After availing the said loan, her husband repaid the monthly installments of the said loan but unfortunately her husband died on 7.2.2013. She has next pleaded that after the death of her husband, she moved an application to the opposite party no.1 on 28.9.2013 for making the death claim of the said policy vide death claim no.00002820, master policy no.G0000013/Life Insurance Name Prabhjot Singh Member No.07932 and submitted all the documents with the opposite party no.1 and the same were acknowledged by the opposite party no.1 vide letter dated 3.9.2013 and an intimation was also received from the opposite party no.2, on 24.4.2013 regarding the acknowledgement of the death claim. She supplied all the documents to the opposite parties as demanded vide application dated 24.4.2013. The opposite party no.2 and 3 repudiated the claim vide its letter dated 15.5.2013 on the ground that her husband was suffering from liver disease and diabetes but her husband was all right. After 15.5.2013, she approached the opposite party no.1 so many times through application dated 8.7.2013, 28.9.2013, 4.11.2013 for the settlement of the death claim of her husband and against the said applications the opposite party no.1 acknowledge the claim vide letter dated 3.9.2013 and intimated her that the abovesaid death claim was forwarded by the opposite party no.1 to the opposite party no.3 vide letter dated 3.10.2013 but nothing was done by the opposite party no.3. Vide letter dated 6.11.2013 the opposite party no.1 requested the opposite party no.3 for settlement of the claim and an intimation was also sent to her. She has further pleaded that under the compelling circumstances, she is paying the installment of the loan amounting to Rs.8703/- approximately since the date of disbursement till date, when the same should have been waived off as per the terms and conditions of the policy, but the opposite party no.1 with malafide intention and with the connivance of opposite party no.2 and 3 are getting the amount of loan alongwith interest after her husband’s death. She has paid Rs.4,98,455/- till today against the same, though she was legally not liable to pay the same. The demand being raised by the opposite party is illegal, unjust, improper and against the principles of natural justice. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.
3. Upon notice, opposite party no.1 appeared through its counsel and filed its written reply taking preliminary objections that the complaint is not maintainable against the opposite party no.1 i.e. Bank of Baroda. On merits, it was submitted that the husband of the complainant Prabhjot Singh and the complainant had signed the loan documents as both are the borrower of the bank and the bank account is joint of both borrowers. It was correct that the husband of the complainant took the insurance policy under master policy of the group credit life plan by depositing the insurance premium. The insurance premium of the policy was debited from the account of the husband of the complainant and credited in the account of the opposite party no.2 and 3. The complainant had moved an application to the opposite party for lodging the death claim with the opposite party no.2 and 3. It was also submitted that as soon as the opposite party received the application from the complainant, the same was referred to the opposite party no.2 for lodging the death claim under policy. The claim of the complainant was referred to the opposite party no.2 and 3 and all the letters of the complainant regarding the settlement of the said claim received by the replying opposite party were also referred to the opposite party no.2 and 3. It was correct that complainant is paying the installments of loan amount to the opposite party. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Upon notice, opposite party no.2 and 3 appeared through their counsel and filed their joint written reply taking certain preliminary objections. On merits, it was submitted that after understanding all the terms and conditions of the Policy, Mr.Prabhjot Singh submitted the duly signed Declaration good health Form dated 23.3.2012 under Master Policy No.G0000013 Loan account no.12580600011968 giving all relevant details and information in the prescribed form for a sum assured of Rs.9,80,000/-. Thereafter based on the information provided and declaration made in the declaration of good health and on receipt of the premium, membership no.07932 under Master Policy no.G0000013 was issued to the DLA having the date of risk commencement as 23.3.2012. It was further submitted that claim filed by complainant, being an early claim and after perusal of the documents submitted by the complainant, the opposite party got an investigation done through Transparent World and independent Investigation agency. After the perusal of the documents provided by the complainant and procured during the investigation the opposite party came to know medical treatment record of DLA issued by Medanta, The medicity Hospital at Gurgaon DLA was having a premedical history of ethanal (Alcohol) related liver disease since last 10 years. He was diagnosed with Jaundice in October 2011 and Liver Cirrhosis in Jan 2012. He was admitted and was on treatment for the same and undergone Banding ligation procedure for esophageal varices on 27th Sept. 2012. As per the medical record DLA had undergone medical investigation on 23rd Oct 2011 and 27th Sept 2012 which confirms the diagnosis of Liver Cirrhosis with Esophageal varices and pulmonary Hypertension. Further opposite party no.2 and 3 came to know that he was also known case of diabetes since last three years. DLA did not disclose about his pre-medical history in the column of Declaration of Good Health. Hence it is crystal clear that DLA was taking treatment of above mentioned disease prior to signing of the declaration of good health form and these facts malafidely concealed by DLA at the time of issuance of the said policy. Thus, it clearly reveals that the deceased Life Assured had not disclosed about his past medical history, which was material for opposite party, therefore opposite party repudiated the claim of complainant under Section 45 of the Insurance Act and same was also intimated to the complainant vide repudiation letter dated 15.05.2013. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
5. Complainant tendered into evidence her own affidavit Ex.CW1/A, alongwith other documents Ex.C2 to Ex.C17 and closed the evidence.
6. Counsel for the opposite party no.1 tendered into evidence affidavit of Sh.Ashok Kumar Ranwat, Ex.OP-1/1 and closed the evidence.
7. Counsel for the opposite party no.2 and 3 tendered into evidence affidavit of K.R.Viswanarayan working as Head Governance and Company Secretary of India Ex.OP-2,3/1, alongwith other documents Ex.OP-2,3/2 to Ex.OP-2,3/9 and closed the evidence.
8. We judicially observe with the analytic but judicious precision and find that the OP insurers vide its letter (Ex.C8/Ex.OP2,3/9 dated 15.05.2013) have arbitrarily repudiated the complainant’s insurance death-claim (Ex.OP2,3/5 of 16.04.2013) on account of alleged non-disclosure and instead giving of false and misleading information by the DLA (Deceased Life Assured) in reply to the health queries as raised out in the proposal form/ declaration of good health (Ex.OP2,3/2) as put forth in precedent to the issuance of the applicable insurance life policy, and that in turn, has prompted the resultant repudiation.
9. The complainant through her learned counsel has vehemently refuted the alleged violation of policy terms by way of material non-disclosure/ suppression of any pre-existing ailment/health condition etc as the DLA has always been open to subjection to Medical Examination by OP1 Bank/ OP insurers’ designated doctor who could have conducted the complainant’s check-up to recommend him or not for the instant life insurance policy. The OP1 Bank and the OP2,3 insurers have knowingly let forego/waive such requisites, in their hurry, to successfully foreclose the sale of the related policy in one single day i.e., on 23.03.2013, itself; for undisclosed reasons best known to them, alone. The debiting of the DLA’s Savings Bank A/c with insurance premium of Rs.19,000/- (Ex.C3), filling up of proposal/health declaration form (Ex.OP2,3/2) and issuance of Certificate of Insurance (Ex.OP2,3/3) i.e., completion of all on the same single day (on 23.03.2013) proves the point besides the un-signed/un-acknowledged Ts & Cs of Master Policy (Ex.OP2,3/4).
10. Lastly, we find that the OP insurers have failed to prove its allegations of non-disclosure/suppression of pre-existing diseases/ailments through some cogent evidence and in its absence the lone ‘depositions’ amount to ‘bald’ statements, only. And, instead the OP insurers have attempted to justify the impugned repudiation by placing reliance upon investigation, treatment, discharge summaries & others alike (Ex.OP2,3/6) by the Hospital giving current treatment who have simply made a passing reference to the pre-existed but allegedly non-disclosed past ailments and that too at the information orally provided by the patient’s attendants at the time of admission with no subsequent evidence of past medical treatment/history and/or other etc and not supported by any deposition etc. Further, the OP insurers have placed forth its repudiation reliance upon the investigation report Ex.OP2,3/7 & investigator’s deposition (amounting to hear-say statement, only) Ex.OP2,3/8 and lastly upon the patient’s hear-say health history sans any evidence of past hospitalization/medical treatment etc except the one for knee-fracture. None of the referred exhibits has been accompanied by the requisite first–hand deposition/affidavit(s) to support its contents. The investigation report confirms having made no subsequent investigations into the past medical treatment of the allegedly suppressed ailments and has simply recommended ‘claim repudiation’ in a stereotyped pre-determined manner and thus deserves an outright rejection. The complainant’s deposition statement has been honest and stands opposed to the claim repudiation. Again, the treating Hospital’s History sheet simply reproduces the oral information (in writing) on the complainant’s past health as provided by him and the accompanying attendants at the time of admission in the heat of the moment sans any authoritative evidence etc. Thus, we find that the OP insurers have totally failed to prove the legal validity of its arbitrary repudiation of complainant’s death-claim and that lines them up to an adverse statutory award under the applicable Act.
11. Thus, the alleged misrepresentation/concealment/non-disclosure of material facts etc do not stand proved. In such like repudiations the onus of proof always lay heavily upon the insurers but here they have miserably failed to legally discharge the same successfully. We are strengthened in our above proposition by virtue of the valuable comments as made out by the honorable Punjab State Commission in the FA # 537 of 2008 titled: LIC of India vs. Priya Sharma & ors., as: “…. in this case, there is no evidence on record to prove that the deceased life assured was suffering from any pre-existing disease at the time of purchasing the policy. …. There is no evidence to prove that the deceased was ever admitted or took any treatment from any hospital or the doctor regarding the alleged pre-existing disease. …”. The honorable National Consumer Commission has further elaborated the legal proposition in RP # 218 of 2008 titled United India Insurance Co. Ltd., vs. Anumolu Rama Krishan as: “7… Even if Respondent was suffering from these diseases which admittedly do not occur overnight, it is both possible and plausible that he was unaware of it since these can be ‘silent diseases’ and a person suffering from them may not even be aware until the condition aggravates and overt symptoms appear….”. We also find that the instant claims as put forth by the complainant has been kept illogically deferred awaiting ‘settlement’ for collateral but arbitrary reasons. Even, the expert professional opinion pertaining to pre-existing disease cannot be taken as an evidence of its ‘non-disclosure/suppression’ by the insured since he may not be ‘himself’ aware of the disease present in its latent hibernating state.
12. We also find that the Master Policy, in the event of insured’s demise, provides for payment of full insurance-claim (equivalent to the sum insured) available for liquidation of balance outstanding in the loan A/c with the remnant claim balance payable to the DLA’s policy nominee. The OP1 Bank has also bruised the complainant’s legal right by charging interest in the DLA’s Loan A/c after the date of death and thus the OP1 Bank are directed to refund her back the interest in full along with other charges etc, if any, charged after the death of life insured besides refunding her the balance of insurance claim after appropriation of outstanding loan amount (as on date of death) upon receipt from the OP insurers.
13. In the light of the all above, we are of the considered opinion that the OP insurers have blatantly bruised the consumer rights of the present complainant by employing ‘unfair trade practice’ amounting to ‘deficiency in service’ (on their part) and that lines them up for an adverse statutory award under the applicable Consumer Protection Act’ 1986.
14. We, therefore, partly allow the present complaint and thus ORDER the OP insurers to settle and pay the present ‘insurance claim’ as per the governing ‘terms’ of the applicable Insurance Policy (to its full benefits) but strictly in accordance with the IRDA guidelines on ‘settlement of claims’ to the OP1 Bank for appropriation as directed hereinabove besides to pay to the complainant Rs.10,000/- as cost and compensation within 30 days of receipt of the copy of the present orders otherwise the aggregate award amount shall attract interest @ 9% PA from the date of the orders till actual payment.
15. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President
ANNOUNCED: (Jagdeep Kaur)
November, 24 2016. Member
*MK*
