Haryana

Karnal

CC/310/2019

Mrs. Sushma Gupta - Complainant(s)

Versus

Bharti AXA Life Insurance Company Limited - Opp.Party(s)

Ashok Kapoor

14 Sep 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                          Complaint No. 310 of 2019

                                                          Date of instt.29.05.2019

                                                          Date of Decision 14.09.2021

 

Mrs. Sushma Gupta w/o Lt. Vinod Kumar Gupta, resident of House No.202 behind Mata Mandir Ramnagar, Karnal.

 

                                                 …….Complainant.

                                              Versus

 

1.     Bharti AXA Life Insurance Company Ltd. Spectrum tower 3^rd floor,  Malad Link Road Malad, (west) Mumbai, 400064 Maharashtra.

 

2.     Bharti AXA Life Insurance Co. Ltd. SCO no.101,102 and 103, 2^nd floor Batra Building, Sector 17-D Chandigarh-160017.

 

3.     Bharti Axa Life Insurance Co. Ltd. SCO no.82,83, 1^st floor and 2^nd floor, Mughal Canal, Karnal, 132001.

 

                                                                     …..Opposite Parties.

 

Complaint Under section 12 of the Consumer Protection Act, 1986 as amended Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

 

 Argued by: Shri Ashok Kapoor, counsel for complainant.

                    Shri Vikas Chauhan, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:   

                

                        The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that the husband of complainant namely Mr. Vinod Kumar Gupta, obtained a life insurance policy bearing no.5018018670 dated 03.10.2018. At the time of purchasing of policy, husband of complainant paid Rs.38,002/- as premium and the insured amount was of Rs.5,00,000/-. On 09.02.2019, the husband of complainant died. Thereafter, complainant being nominee visited the office of OPs for releasing the insurance claim under the abovesaid policy but OPs refused to pay the claim and repudiated the same, vide repudiation letter dated 31.03.2019, on the ground, that the late Mr. Vinod Kumar Gupta had undergone the kidney treatment since 2016. It is pertinent to mention here that there was no kidney problem or medical history regarding such disease. So, the said repudiation letter is illegal, null and void and not binding upon the rights of the complainant. In this way, there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             On notice, OPs appeared and filed written version, raising preliminary objections with regard to maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that the policy in question was issued on 03.10.2018 and the life assured died on 09.02.2019 within four months of insurance policy, thus the claim falls in the category of early claim. During the claim investigation, it was found that the life assured was a known case of kidney problem and was under treatment for the same. This medical history was prior to the life insured filling the proposal form for the policy and the answers furnished by him were false and he had given false and misleading information to the OPs. It is further pleaded that if the life insured replied correctly and truthfully, while signing the proposal form and had informed the OPs of his health status/hospitalization and report, OPs under no circumstances would have enrolled him under the subject policy. The OPs were thus misled into issuing the policy by non-disclosure/suppression of material facts. The case was investigated by Probe India Investigation Agency and it was found that the Life Assured was taking treatment for Kidneys from Moolchand Kidney Hospital and Urological Institute, Karnal, and other hospitals in Delhi. The said diagnose and treatment was not intimated to the company though it was prior to issuance of the policy and was required to be informed in terms of the proposal form and policy. It is further pleaded that the OP had accordingly, repudiated the claim lodged by the complainants for non-disclosure/suppression of material information by way of repudiation letter dated 31.03.2019. In the said repudiation letter, it was specifically stated that in case the complainants were not satisfied with the same they could approach the Grievance Redressal Mechanism, however, rather, than doing so, the complainants have presented this complaint. There is no deficiency in service on the part of OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             The parties then led their respective evidence.

4.             Complainant tendered into evidence her affidavit Ex.CW1/A, copy of legal notice dated 20.04.2019 Ex.C1, copy of repudiation letter dated 31.03.2019 Ex.C2 and closed the evidence on 14.01.2020 by suffering separate statement.

5.             On the other hand, OPs tendered into evidence affidavit of Snehal Sawant Associate Manager of OPs Ex.OPW1/A, resolution dated 24.01.2019 Ex.OP1, customer declaration form Ex.OP2, proposal form Ex.OP3, application Form Ex.OP4, claimant statement form Ex.OP5, investigation report Ex.OP6, claim repudiation letter Ex.OP7 and closed the evidence on 17.02.2021 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties

7.             Learned counsel of complainant while reiterating the contents of the complaint, has vehemently argued that husband of complainant namely Mr. Vinod Kumar Gupta (since deceased) had obtained a life insurance policy dated 03.10.2018 and the insured amount was of Rs.5,00,000/-. On 09.02.2019 the husband of complainant had died. Thereafter, complainant being nominee, applied for the insurance claim under the abovesaid policy with the OPs, but OPs refused to pay the same, vide repudiation letter dated 31.03.2019, on the ground that the late Mr. Vinod Kumar Gupta had undergone the kidney treatment since 2016. He further argued that deceased life assured was not having any kidney problem or medical history and prayed for allowing the complaint.

8.             Per contra, learned counsel of OP while reiterating the contents of written version, has vehemently argued that the policy in question was issued on 03.10.2018 and the life assured died on 09.02.2019 within four months of insurance policy. The claim falls in the category of early claim. During the claim investigation, it was found that the life assured was a known case of kidney problem and was under treatment for the same. This fact was not disclosed by the deceased life assured at the time of issuing of the policy. Thus, the claim of the complainant has been rightly repudiated by the OPs on the ground, of suppression of material facts regarding his health and prayed for dismissal of the complaint.

9.             Admittedly, the deceased life assured was insured with the OPs for the sum assured of Rs.5,00,000/- and the policy in question was issued on 03.10.2018. It is also admitted that the husband of complainant expired during the subsistence of the insurance policy i.e. on 09.02.2019. It is also admitted that complainant is the nominee of the deceased life assured. The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C2/Ex.OP7 on the following grounds:-

“As per investigation procured at claims stage, it has been observed that the Life Insured was known case of kidney problem and was under treatment for the same. This history is prior proposal for insurance and the aforesaid replies were false.

In view of the above, it is clear that the life insured has given false and misleading information to the company and had the life insured replied to the aforesaid questions truthfully and correctly in the proposal form, the company would not have issued the above mentioned policy at all. It is evident that the company has been led to issue the policy by suppressing material facts regarding past medical history.

In the said circumstances, the company is therefore repudiating the claim for non-disclosure of medical history at the time of proposal for insurance.”

 

10.           The claim of the complainant has been repudiated by the OPs only on the ground of providing false and misleading information to the OPs at the time of purchasing of insurance policy.  The onus to prove that DLA was having kidney disease prior to taking the policy was upon the OPs but OPs have totally failed to prove its version by leading any cogent and convincing evidence. The OPs have relied upon the investigating report Ex.OP6 whereby, investigator of OPs come to the conclusion that LA was suffering from kidney disease since 2016 and for the same he had taken treatment from PGI Chandigarh. On visiting the said hospital to procure the medical records of LA, the authority verbally confirmed that LA had taken OPD treatment from their hospital in 2016 for kidney disease but the OPs did not place on record any medical history/medical record of DLA of the concerned hospital to prove its version. Moreover, the report of the Investigator of the OPs is based upon the verbal averments which is not admissible in the eyes of law. Hence, the plea taken by the OPs have no force at all.

11.           It is pertinent to mention here that in para No.12 of preliminary submissions of written version filed by the OPs, it has specifically mentioned that the LA was taking treatment for kidneys from Moolchand Kidney Hospital and Urological Institute, Karnal and other hospitals in Delhi but as per the alleged investigation report Ex.OP6, the LA was taking treatment from PGI Chandigarh. Meaning thereby, that the OPs are not standing on their own legs and are taking two contradictory pleas just to deprive the complainant from her genuine claim and are harassing her mentally and physically. Now a days, it has become trend on the part of the insurance company to repudiate the claim of the insurer on the false and flimsy grounds which is otherwise proved genuine one. Thus, the plea taken by the OPs is having no force.

12.           The insurance policy was purchased by the LA on 03.10.2018 and he expired on 09.02.2019 i.e. after four months of purchasing the insurance policy. Admittedly, as per death certificate issued on 07.03.2019, the age of deceased was 53 years. Hence, it is evident that the age of DLA was more than 45 years at the time of purchasing of insurance policy. Thus, the OPs were duty bound to get the medical examination of the LA conducted as per the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI). In this regard, we place reliance upon case titled as  National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016, wherein Hon’ble State Commission U.T. Chandigarh has held that if the complainant and his wife both are older than 45 years of age but there is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDAI) is must in such like cases. Similarly, view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  and held that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained. Hence, plea taken by the OPs is having no force.

13.           Keeping in view the ratio of the judgments, facts and circumstances of the case, the act of the OPs amounts to deficiency in service and unfair trade practice while repudiating the claim of complainant, which is otherwise proved genuine one.

14.           Admittedly, the sum assured of the insurance policy is to the tune of Rs.5,00,000/-. Hence, complainant is entitled for Rs.5,00,000/- alongwith compensation and litigation expenses etc.

15.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.5,00,000/- (Rs. five lacs only) as insured amount to the complainant with interest @ 9% per annum from the date of repudiation of claim till its realization.  We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment suffered by her and Rs.11,000/- for litigation expenses. This order shall be complied with within 45 days from the receipt of copy of this order. However, the opposite parties are at liberty to recover the amount of Rs.11,000/- of litigation expenses from the Investigator who had submitted baseless and arbitrary investigation report Ex.OP6, which warranted both the parties to an unwanted litigation. The parties concerned be communicated the order accordingly, and the file be consigned to the record room, after due compliance.

 

Announced

Dated: 14.09.2021    

                                                               

                                                              President,

                                                 District Consumer Disputes

                                                 Redressal Commission, Karnal.

 

                 (Vineet Kaushik)              

                      Member