BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 15 of 2011
Date of Institution : 19.01.2011
Date of Decision : 19.9.2016.
Sunita Devi widow of late Shri Surinder Kumar son of Shri Jagdish Parshad, resident of Opp. Main Bazar, Gandhi Chowk, Ellenabad, Tehsil Ellenabad District Sirsa.
….Complainant.
Versus
- Birla Sun Life Insurance Company Limited, Vaman Centre, 4th Floor, Makhwana Road, Marol Naka, Off Andheri-Kurla Road, Andheri (East), Mumbai- 400 059, through its authorized signatory.
- The Branch Manager, Birla Sun Life Insurance Company Limited, Parmeshwar Service Station, adjoining BPCL Petrol Pump, Dabwali Road, Sirsa, District Sirsa.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI S.B.LOHIA. ……………………..PRESIDENT.
SHRI RANBIR SIGH PANGHAL……..MEMBER.
Present: Sh. Ravinder Goyal, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for the opposite parties.
ORDER
In brief, the complainant’s case is that her husband Surinder Kumar purchased a life insurance policy bearing No.002597070 from the opposite parties on 4.3.2009 with maturity date as 4.3.2034 and paid the insurance premium of Rs.9,988.32ps. to the ops at Sirsa. The policy was issued for basic sum assured of Rs.97,109.50ps, guaranteed maturity benefit of Rs.1,79,500/- and enhanced sum insured of Rs.9,20,000/-. The complainant was made nominee in the said policy by her husband. At the time of purchase of above said policy, husband of the complainant was got medically checked up by the ops and they after fully satisfying themselves with the health etc. of Surinder Kumar had issued the policy to him. Moreover, at that time, Surinder Kumar was not suffering from any disease and he gave correct answers to the queries of the ops about his health. However, Surinder Kumar husband of complainant fell ill on 30.10.2009 and he was taken to the hospital of Dr. Arun Kalra, M.D. cardio-respiratory physician at Sri Ganga Nagar. He was referred to Dr. L.D. Bhardwaj in Jindal Hospital and after that he was admitted in Tantia Hospital on 6.11.2009 and was discharged on 12.11.2009. Thereafter, he was further referred to PGI Chandigarh where he was admitted on 13.11.2009 and was diagnosed as severe bronchitis asthma and he remained admitted there up to 28.11.2009. Then he was further admitted in Fortis Hospital, Mumbai on 28.11.2009 till 9.12.2009 and after that he was admitted in Tantia General Hospital till his death i.e. 11.12.2009. The cause of death of Surinder Kumar as opined by the doctors was “Immediate respiratory arrest”. However, before 30th October, 2009 he had no health problem at all regarding bronchial asthma or respiratory arrest. The complainant spent a huge amount upon the treatment of her husband in various hospitals. After the death of her husband, the complainant being his nominee and widow lodged her claim with the opposite parties at Sirsa for payment of sum assured and other benefits as per policy and provided all the necessary documents. However, the ops vide letter dated 30.1.2014 have repudiated the claim of the complainant and decided to refund the surrender value of Rs.885.69/- to the complainant with the observation that the life assured was suffering from diabetes, mellitus, hypertension and asthma and was undergoing treatment for the same much prior to the insurance and gave wrong replies to the questions No. IX, D1, 2(a), 3(a) (b) and (c). The said observation of the ops is wrong and incorrect. After repudiation of the claim, she also moved an application on 29.9.2010 for reconsideration of their decision, but the same was also rejected by the ops on 9.10.2010. Hence, the present complaint.
2. Upon notice, opposite parties appeared and contested the complaint by filing joint reply asserting therein that life assured at the time of filing the application mis-stated the material facts pertaining to his medical and health information which were well within his knowledge and were liable to be disclosed to the ops and as such the ops have a right to dislodge the claim of the complainant under Section 45 of the Insurance Act, 1938. As per the underwriting norms, the DLA was required to undergo medical examination from an empanelled doctor of the ops and submit the Medical Examiner’s Report (MER) alongwith routine urine test being part of the said MER. The said MER is physical examination of the life assured and noting of replies given by the life assured with respect to the questions relating to his medical conditions before the empanelled doctor of the ops. The life assured had signed a declaration in the said MER and the same is reproduced as under:-
“ I, Surinder K, declare that I have made no statement to the medical examiner, agent or any person connected with the Company which in any way qualifies or modifies the above answers which I have read and certify to be full and true to the best of my knowledge and belief.
It is further asserted that life assured was issued the policy on 4.3.2009 on the basis of information provided by him in the said application and MER and believing the same to be true and correct. The ops received claimants statement dated 13.1.2009 from the complainant intimating the sad demise of her husband on 11.12.2009 due to respiratory arrest. The claimant statement also contained other questions relating to the past medical history of the life assured, which were not replied in detail by the complainant. The complainant had submitted medical attendant’s certificate dated 14.1.2010 issued by Dr. Seema Maheshwari of Tantia General Hospital, Sr. Ganganagar which stated that the immediate cause of death of the DLA was respiratory arrest while the primary cause being DM (Diabetes Millitus) with HTN (Hypertension), Br. Asthma with lung cavity with septicemia with ARF. The DLA expired within 9 months from the date of issuance of the policy. It is further asserted that as a normal practice and company procedure, the ops carried out the investigation with respect to the death claim of the life assured. The medical records procured during investigation clearly stated that the life assured was a known case of Diabetes, Mellitus, Hypertension, Bronchial asthma, lung cavity and septicemia prior to the applying for the said policy. So, the claim has been rightly repudiated by the ops.
3. By way of evidence, the parties have placed on file affidavits and documents. The complainant has tendered in evidence her affidavit Ex.C1, copy of repudiation letter dated 30.1.2010 Ex.C2, copy of application for reconsideration of claim Ex.C3, copy of letter dated 8.10.2010 Ex.C4, copy of receipt of Rs.9988/- Ex.C5, first premium receipt Ex.C6, copy of claim form Ex.C7, copy of medical attendant’s certificate Ex.C8, copies of treatment record Ex.C9 to C17, copy of death certificate of Surender Kumar Ex.C18, copy of voter card of Surender Kumar Ex.C19. Whereas, the opposite parties have tendered in evidence affidavit Ex.R1 and documents Ex.R2 to R41
4. We have heard learned counsel for the parties and have gone through the case file carefully.
5. There is no dispute that Surinder Kumar husband of the complainant had taken a policy from the opposite parties on 4.3.2009 with maturity date as 4.3.2034 and paid the insurance premium of Rs.9988.32/- to the opposite parties. The basic sum assured in the policy was Rs.97,109.50/-, guaranteed maturity benefit was Rs.1,79,500/- with enhanced sum assured of Rs.9,20,000/- as is evident from the documents placed on file i.e. first premium receipt Ex.C6, policy information and policy Ex.R2. The complainant claims that her husband fell ill only on 30.10.2009 i.e. after taking the policy and prior to that he had no health problem and after the death of her husband on 11.12.2009, her claim has been wrongly repudiated by the opposite parties on the ground that life assured had concealed the material information regarding his illness at the time of taking the policy in question. The complainant submitted her claim form Ex.C7 to the opposite parties alongwith medical attendant certificate Ex.C8 which goes to show that Surinder Kumar husband of the complainant was admitted in Tantia Hospital, Sri Ganga Nagar (Rajasthan) on 6.11.2009 with the complaint of respiratory distress and duration of ailment has been mentioned as 3-4 days and he was discharged on 12.11.2009. Prior to that complainant was admitted in Nehru Hospital, Chandigarh on 13.9.2009 for fever and cough problem as evident from the treatment record placed on file by the complainant. Then from prescription slip Ex.C11 placed on file by the complainant, it is evident that Surinder Kumar was treated by Dr. Arun Kalra on 30.10.2009 and subsequently for asthma, hypertension and diabetes problem. Thereafter, he was admitted in PGI Chandigarh on 13.11.2009 and was diagnosed as severe bronchial asthma and remained admitted there up to 28.11.2009 as is evident from Ex.C11. All the above said medical records produced by the complainant go to show that husband of the complainant became ill on 30.10.2009 i.e. after more than seven months of taking the insurance policy.
6. The opposite parties have also placed on file the above said treatment record as produced by the complainant as Ex.R6 to Ex.R38. Learned counsel for the opposite parties has contended that life assured was already suffering from disease of asthma and diabetes and has placed reliance in this regard on the prescription slip of Dr. Arun Kalra dated 30.10.2009 wherein it is mentioned that patient is asthmatic since 2-3 years and diabetic since February. But in fact there is no document from the said hospital stating that at the time of treatment the life assured had stated that he was suffering from asthma since 2-3 years and diabetes since February. The opposite parties were required to produce evidence either from that hospital or from the doctor who treated the life assured to prove that the life assured at the time of admission in the hospital had himself stated that he was suffering from above said disease since 2-3 years. There is also possibility that a person is suffering from such disease like diabetes and hypertension but he is not actually aware of the same. There is no other medical record produced on behalf of the opposite parties to prove that life assured was actually treated for the above said diseases prior to the taking of the policy in question. It is not in dispute that before issuance of the policy in question by the opposite parties the life assured was got medically checked-up from penal of doctors and if the life assured was suffering from such disease like asthma, it would have come in the knowledge of the doctors at that time because in an asthmatic patient, there is problem of taking breath and breath comes hardly and the doctor can catch the said disease at the time of examination. Moreover, the Hon’ble National Commission in case titled as United India Insurance Co. Ltd. & Anr. Versus S.K. Gandhi 2015 (2) CLT 71 has held that “The petitioner- company has not placed on record either the discharge summary of the complainant or any medical document signed by the doctors who treated him in Kailash Hospital, to show that the complainant, when he was admitted to the said hospital had himself stated that he was suffering from hypertension from last 8-9 years. In fact there is no document from Kailash Hospital, Noida stating therein that at the time of admission the complainant had stated that he was suffering from hypertension from the last 8-9 years. It is quite possible that the complainant, despite suffering from hypertension was not actually aware of the same. In that case, he cannot be accused of misstatement or concealment. The onus was upon the Insurance Company to prove that he had made a misrepresentation while obtaining the insurance policy. In order to succeed the insurance company was required to produce evidence either from Kailash Hospital or from the doctor who treated the complainant to prove that the complainant at the time of admission in this hospital had himself stated that he was suffering from high blood pressure from last 8-9 years.” Reliance in this regard can also be placed on the observations of the Hon’ble Uttrakhand State Commission, Dehradun in case titled as New India Assurance Company Ltd. Vs. Shashi Rani & ors. I (2014) CPJ 75.
7. Thus, as a sequel to our above discussion and in view of the above said law, we are of the considered view that opposite parties have wrongly repudiated the claim of the complainant. Hence, we allow the present complaint and direct the opposite parties to pay the death claim/ sum assured, maturity benefit and enhanced sum assured as per policy to the complainant within a period of 45 days from today, failing which the complainant will be entitled to the interest @9% per annum from the date of filing of present complaint i.e. 19.1.2011 till actual payment. We also direct the opposite parties to pay a sum of Rs.20,000/- to the complainant as compensation for harassment and Rs.5000/- as litigation expenses. A copy of this order be given to the parties as per rules. File be consigned to record room after due compliance.
Announced in open Forum. President,
Dated: 19.9.2016. Member. District Consumer Disputes
Redressal Forum, Sirsa.
