BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KAITHAL.
Complaint no.111/15.
Date of instt.: 05.06.2015.
Date of Decision:18.8.2016.
Shakuntla , wife of Shri Sheru, resident of House No.61/3, Village Polade Siwan, Tehsil and Distt. Kaithal (Haryana).
……….Complainant.
Versus
- Birla Sun Life Insurance Company Ltd. through its Branch Manager, Kaithal.
- Branch Manager, Birla Sun Life Insurance Company Ltd., 314, Wadhwa Complex, near Metro Station, Vikas Marg, Laxmi Nagar, Delhi-110093.
- Managing Director/Asstt. Manager (Claims) Birla Sun Life Insurance Company Ltd., 1, India Bulls Centre, Tower-I, 16th Floor, Jupitor Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400013.
..……..Opposite Parties.
COMPLAINT UNDER SEC. 12 OF CONSUMER PROTECTION ACT, 1986.
Before: Sh. Jagmal Singh, President.
Sh. Rajbir Singh, Member.
Smt. Harisha Mehta, Member.
Present : Sh. Dinesh Pathak, Advocate for complainant.
Sh. Vikram Tiwari, Advocate for the opposite parties.
ORDER
(JAGMAL SINGH, PRESIDENT).
The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that the husband of complainant namely Sheru got insured himself with the Ops vide policy “BSLI Vision Life Secure” No.006287211 dt. 29.10.2013 for the sum of Rs.8,00,000/-. It is alleged that the husband of complainant expired on 24.11.2013 and complainant being nominee lodged the claim with the Op and submitted all the necessary documents but the Op did not settle the claim of complainant. This way, the Ops are deficient in service. Hence, this complaint is filed.
2. Upon notice, the opposite parties appeared before this forum and filed written statement raising preliminary objections with regard to maintainability; cause of action; locus-standi; that the complainant has concealed the true and material facts from this Forum. The true facts are that the deceased was suffering from serious stomach ailment called “Acute Pancreatitis” for 5 to 6 months prior to the issuance of the said policy i.e. on 29.10.2013 and more so, the life assured died exactly after one month i.e. 24.11.2013 and the fact that the life assured was taking treatment for the said stomach ailment from Dev Nursing Home, Kaithal and the said prescription dt. 23.10.2013 also referred him to GMC, Sector-32, Chandigarh and suppression of this material fact at the time of filing and signing the proposal form based on which the said policy was issued amounts to suppression of true and material facts. There is no deficiency in service on the part of answering Ops. On merits, the contents of complaint are denied and so, prayed for dismissal of complaint.
3. In support of his case, the complainant tendered in evidence affidavits Ex.CW1/A, Ex.CW2/A, Ex.CW3/A and documents Ex.C1 and Mark C2 to Mark C10 and closed evidence on 25.04.2016. On the other hand, the Ops tendered in evidence affidavit Ex.Op1/A and documents Op1 to Ex.Op8 and closed evidence on 10.06.2016.
4. We have heard ld. counsel for both the parties and perused the case file carefully and minutely and have also gone through the evidence led by the parties.
5. Learned counsel for the complainant reiterated all the facts mentioned in the complaint. He argued that the husband of complainant namely Sh.Sheru since deceased had got himself insured with OP No.2 vide policy No.006287211 dated 29.10.2013 under the BSLI Vision Life Secure for a sum of Rs.8,00,000/- on depositing the premium worth Rs.17,414.80 paisa plus Rs.522.44 paise and education cess Rs.15.67 paise. He further argued that the husband of the complainant expired on 24.11.2013 and information regarding the death of Sheru was given to the Ops. He further argued that the complainant has fulfilled all the requirements of the Ops. He further argued that OPs have failed to make the payment of the sum insured as well as the other benefit of the said policy. He further argued that the deceased Sheru was whole and hearty and was not suffering from any disease. He further argued that Ops have wrongly repudiated the claim of the complainant. Ld. Counsel for the complainant placed reliance upon the authorities titled as Life Insurance Corporation of India vs. District Permanent Lok Adalat & Anr., 2005(1) Civil Court Cases, page 128 (Rajasthan High Court); Oriental Insurance Co. Limited versus Baby Simran Kaur, 2014(2) CLT, page No.361/362 (NC); Nirmala Devi versus Birla Sunlife Insurance Co.ltd., 2014(3) CLT, page No.207, Rajasthan State Commission,; AIR, 1971, Andhra Pardesh, page No.41 titled as LIC Vs. B.Chandravathamma. On the other hand learned counsel for the Ops argued that the deceased had misrepresented about his health at the time of filling the proposal form because the deceased was suffering with serious stomach ailment called ”acute Pancreatitis” for 5 to 6 months prior to the issuance of the policy i.e.29.10.2013. He further argued that the life assured was taking treatment for the said stomach ailment from Dev Nursing Home, Kaithal and in this regard, he referred Ex.OP/5 the prescription slip dated 23.10.2013 issued by Dev Nursing Home, Kaithal vide which he was referred to GMCH, Sector-32, Chandigarh. He further argued that the life assured has concealed these material facts at the time of filling and signing proposal form. He further argued that life assured got the policy by suppressing of true and material facts. He further argued that life assured was suffering from chronic pre-existing decease at the time of issuance of the policy in question. He further argued that life assured has submitted a fake driving licence as age proof, which on investigation by the Ops was found to be fake. He further argued that the Ops have rightly repudiated the claim of the complainant vide its letter dated 30.6.2014 Ex.OP-7. Ld. Counsel for the OPs placed reliance upon the authorities titled as Satwant Kaur Sandhu versus New India Assurance Company Limited, 2009(8), SCC, page No.316(SC); Smt. Vidya Devi etc. versus Life Insurance Corporation of India, 2003(II) CPJ, Page 106 (NC).
6. From the pleadings, evidence and facts of the case it is not disputed that the husband of the complainant had purchased insurance policy No.006287211 dated 29.10.2013 under BSLI Vision Life Secure for a sum of Rs.8,00,000/- on depositing the premium amount. The Ops have only repudiated the claim of the complainant on the ground that the deceased assured was suffering from serious stomach ailment i.e. Acute Pancreatitis for 5 to 6 months prior to the issuance of the policy in question and suppressed and concealed this material fact while filling the proposal form. Now, the question arises whether the insurer deceased was suffering from acute Pancreatitis disease prior to the issuance of policy and he had suppressed the same while filling the proposal form or not. The onus to prove these facts was upon the Ops. The Ops in this regard has placed documents from Dev Nursing Home, Kaithal, Ex.OP-5. This document is with regard to patient namely Shemsher Son of Ishwar Singh. The name of the life assured in the policy in question is not Shemsher Singh, but Sheru as is clear from the proposal form and other documents issued by the Ops. The learned counsel for Ops referred the affidavit of the complainant, Ex.OP-6 and stated that according to this affidavit the husband name of the complainant was also Shemshar Singh. Even from this affidavit, it is not proved that the medical certificate Ex.OP-5 is related with the life assured namely Sheru. From the perusal of proposal form Ex.OP-8, it is clear that the father’s name of the life assured was Ishar Dass, whereas in the medical certificate Ex.OP-5, the father’s name of the Shemshar Singh is mentioned as Ishwar Singh. Further with regard to the report of investigators wherein it is mentioned that they spoke to one Dr.Birbal (local doctor) who told that the assured was suffering from stomach infection, but the investigator has not placed any document or statement signed by said doctor on the file which could prove that the Dr.Birbal has stated so. The investigator further stated in his report that they collected medical documents of life assured and found that life assured was taking treatment in Deep Shikha Nursing Home under Dr.Pardeep Singla, who referred him to Sanjivni Hospital, but the family member of the life assured rushed to Dev Nursing Home, where he was admitted on 24.11.2013 and was discharged on the same day around 9 p.m. The investigator has not placed any such document or statement from Deep Sikha Nursing Home on the file that the life assured was referred to Sanjivni Hospital. Only a certificate from Dev Nursing Home Ex.OP-5 has been placed on the file by the OPs. According to which the date of admission was 23.10.2013 and the date of discharge is also 23.10.2013. The investigator also alleged that they have got the information from few people. But no statement of any such person is placed on the file to prove that they have stated the facts as alleged by the investigator. Without the signed statement of such person, the fact raised by the investigator can not be believed to be true. The Ops have failed to prove that the document Ex.OP-5 relates to the life assured Sheru. The Ops have also failed to prove on the file that the life assured was suffering from acute Pancreatitis prior to the issuance of the policy in question. In the authority Nirmla Devi versus Birla Sunlife Insurance Co. ltd.(supra) produced by the complainant it is held that “ The burden heavily lies on the Insurance Company to prove the allegation of deliberate concealment and mis-representation-in the present case the respondent has failed to discharge the burden-An apparent look at the policy would show that the conditions are printed in such a small type that even a normal person can not read them-That apart it has not been proved that the agent had fully explained all the conditions before getting the proposal form signed, more so when the whole proposal form has been filled in by the agent-Mere presumption never make any proof.” In the present case also, the Ops have failed to prove that the agent has fully explained all the conditions before getting the proposal form signed. In case titled as Oriental Insurance Co.Ltd versus Baby Simran Kaur (supra), it is mentioned in the head-note that “Insurance claim (Medi-claim)-Suppression of material facts-Pre-existing disease-Prior knowledge of the disease before taking policy-The claim was repudiated on the ground that the claimant had a pre-existing congenital disease, which was not disclosed, while taking the policy-Held-That if a person is suffering from something like a defect in the heart-valve since birth, aberrant pancreas, ectopic pancreas or any other ailment in the internal organs of the body, it could be termed as an internal congenital disease-The exclusion clause in the insurance policy is not attracted-No suppression of material facts or misrepresentation of any kind on the part of the policy holder-Revision petition dismissed.” These two authorities produced by the complainant are fully applicable in the present case. The authorities produced by the Ops are not applicable to the facts of the present case. In view of above authorities and circumstances of the case, we are of the considered opinion that the Ops have failed to prove on the file that the life assured namely Sheru had any pre-existing disease before issuance of policy as alleged. Therefore, the Ops have wrongly repudiated the claim of the complainant, hence, they are deficient in providing service to the complainant.
7. Thus in view of above discussion, we allow the complaint and direct the Ops to pay Rs.8,00,000/- as insured value of the policy to the complainant and further to pay Rs.3,000/- as lump sum compensation on account of harassment, mental agony and costs of litigation charges. Let the order be complied with within 30 days, failing which, the complainant shall be entitled interest @ 8% p.a. from the date of commencement of order till its realization. A copy of this order be sent to both the parties free of costs. File be consigned to the record room after due compliance.
Announced.
Dt.18.08.2016.
(Jagmal Singh),
President.
(Harisha Mehta), (Rajbir Singh),
Member. Member.
