Punjab

Sangrur

CC/560/2014

Bachni - Complainant(s)

Versus

DHFL Pramerica - Opp.Party(s)

Shri Sanjeev Goyal

20 Mar 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

 

                                                Complaint No.    560

                                                Instituted on:      23.09.2014

                                                Decided on:       20.03.2015

 

 

Bachni wife of Mukhtiar, resident of H.No.353, Street No.4, Ward No.9, Dashmesh Nagar, Patiala Road, Sangrur through its special power of attorney Salma daughter of Bikram, resident of H.No.353, Street No.4, Ward No.9, Dashmesh Nagar, Patiala Road, Sangrur.

                                                        ..Complainant

                                        Versus

 

1.             The Branch Manager, DHFL Pramerica Life Insurance Company Limited, 1^st Floor, Dr. Mittal Building, Sunami Gate, Sangrur through its Branch Manager.

2.             DHFL Pramerica Life Insurance Company Limited, 4^th Floor, Building No.9B, Cyber City, DLF City, Phase-III, Gurgaon-122 002 through its Managing Director.

                                                        ..Opposite parties

 

 

For the complainant    :       Shri Sanjeev Goyal, Adv.

For OPs                    :       Shri G.P.Sharma, Adv.

 

 

 

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Smt. Bachni wife of Mukhtiar,  complainant (referred to as complainant in short) has preferred the present complaint through Smt. Salma daughter of Bikram, who is special power of attorney of the complainant Bachni Devi, against the opposite parties (referred to as OPs in short) on the ground that in the month of September 2011, the agent of the OPs allured the daughter of the complainant Smt. Krishna Devi  and her family to make investment in their company with high returns and huge sum assured in case of unfortunate death of the insured. As such, the daughter of the complainant namely, Smt. Krishna availed the services of the OPs by getting herself insured under the policy number 000173585 for an amount of Rs.5,00,000/- for the period from 29.9.2012 to 28.09.2027 by paying annual premium of Rs.50,000/-.  It is further averred that the complainant was the nominee under the policy. It is further averred that the OPs issued the policy after conducting medical test/check up of Krishna Devi.

 

2.             Further case of the complainant is that unfortunately Smt. Krishna Devi ( referred to as DLA in short) died on 24.10.2013 at Sibia Hospital, Sangrur due to heart attack.  Thereafter, the complainant being the nominee under the policy lodged the claim with the Ops and submitted all the relevant documents, but the Ops after lapse of eight months repudiated the claim of the complainant vide letter dated 25.6.2014 on false and vague grounds that the DLA was suffering from bronchial asthma and refunded the fund value of the policy through NEFT in the bank account of the complainant. The complainant has alleged that the Ops have wrongly and illegally repudiated the rightful claim of the complainant.  Thereafter the complainant got served a legal notice dated 11.7.2014, but nothing happened despite doing so. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.5,00,000/- along with all other benefits and interest @ 18% per annum from the date of death till realisation and further claimed compensation and litigation expenses.

 

3.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complaint is false, malicious, incorrect one, that the complaint is not maintainable and that the contract of insurance including the contract of life assurance are contracts uberrima fides and declaration was also made by the DLA stating that no material facts have been suppressed by her and in case, if any material non disclosure is discovered, the insurer shall have the right to repudiate the claim under the policy.  However, it is admitted that on receipt of the premium, policy bearing number 000173585 with benefit commencement date 29.9.2012 was issued in favour of the DLA and under the policy in question premium was Rs.50,000/- was to be paid annually for the period of 5 years and the policy term was 15 years. It is further averred that on 2.12.2013, the death claim intimation form was received by the OPs that the DLA expired on 24.10.2013 due to acute respiratory failure.  Thereafter, the OPs got the claim investigated from ‘Sakshi Investigation & Detective Agency’ to process the claim of the complainant as per the terms and conditions.  After receiving the investigation report, the same was perused and it was found that the DLA was suffering from Bronchial Asthma and had undergone treatment prior to the date of the application and this information was not disclosed. It is further averred that the DLA was suffering from Acute Severe Asthma and Bronchial Asthma for 6 years which goes prior to prior issuance.  It is submitted that the DLA was admitted in Sibia Healthcare, Heart & Multi Speciality Centre in May, 2012 for five days.  It has been stated that further the prescriptions of 2010 and 2011 of Sibia Healthcare Centre revealed that the DLA was taking treatment for the said disease prior to policy issuance. The DLA was also a patient of hyper tension and asthma, which fact was also concealed. Hence, it is stated that the DLA was under treatment prior to signing the proposal form and the said facts malafide concealed by the DLA at the time of issuance of the said policy.  It is stated that the DLA  gave wrong answers to the questions.  It is stated that had the DLA gave right answers to the questions, as such, the OPs would not have issued the policy in question.  It is stated that the contract of insurance is on the basis of utmost good faith.  As such, it is stated that the claim has rightly been repudiated. Lastly, the OPs have prayed for dismissal of the claim with special costs.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-2 affidavits, Ex.C-3 copy of policy, Ex.C-4 copy of legal notice, Ex.C-5 to Ex.C-6 receipts, Ex.C-7 reply of legal notice, Ex.C-8 copy of death certificate and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OP-1 copy of proposal form, Ex.OP-2 copy of policy schedule, Ex.OP-3 copy of death claim intimation, Ex.OP-4 affidavit along with investigation report, Ex.OP-5 copies of treatment records, Ex.OP-6 copy of checklist for DHLF Pramerica, Ex.OP-7 copy of repudiation letter, Ex.OP-8 affidavit and closed evidence.

 

5.             We have very carefully perused the pleadings of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             In the present case, it is admitted fact that Smt. Krishna Devi  was insured with the Ops under policy in question for the period from 29.9.2012 to 28.9.2027 by paying the requisite premium of Rs.50,000/- on annual basis and was insured for Rs.5,00,000/- as is evident from the copy of the insurance policy Ex.C-3.  It is also an admitted fact that the DLA died on 24.10.2013 at Sibia Hospital, Sangrur, the intimation of which was given to the OPs and the Ops after receiving the intimation got investigated the claim from Sakshi Investigation & Detective Agency and the investigator found that the DLA was suffering from Bronchial Asthma prior to the issuance of the insurance policy and had undergone treatment prior to getting the policy, as such, the claim was repudiated by the OPs.

 

7.             Further in the present case, the DLA had obtained the policy in question from the OPs by paying a sum of Rs.50,000/- being the amount of the premium and the Ops had issued the policy for the period from 29.9.2012 to 28.9.2027.  The complainant being the nominee in the present case is a consumer of the Ops, as the policy holder expired on 24.10.2013 as per the copy of death certificate, which is on record as Ex.C-8.  On the death of the DLA due to heart attack in the Sibia Hospital, Sangrur, the complainant had submitted the claim papers with regard to the policy to the OPs, but the OPs have not paid the claim and repudiated the same vide letter dated 25.6.2014 on the ground that the deceased/assured was suffering from bronchial Asthma for the last six years and the same was conveyed vide letter dated 28.7.2014 to the advocate of the complainant in response to his legal notice vide document Ex.C-7 on record.

 

8.             After hearing the arguments of the learned counsel for the parties and on perusal of the documents placed on record, we find that in order to settle the claim, the Ops had got the claim investigated from Sakshi Investigation & Detective Agency.  We have also gone through the report of the investigator, in which it has been mentioned that on 24.10.2013 at around 09.30 p.m., the LA’s health started to fall down. She was getting breathless and restless. So, her daughter, Salma, took her to Sibia Healthcare. The LA was admitted there at 11:15 p.m. with complaints of breathlessness and anxiety. She was given medical treatment. She was under observation of Dr. Prabjot Singh Sibia. But the LA died in the hospital at 11:30 p.m. As per the treatment papers the LA had a history of Hypertension and Asthma. But the time period of these diseases was not mentioned in the papers and even not told by the doctor when asked.

 

9.             As per this report, the period of disease has not been mentioned in the document procured from Sibia Hospital, Sangrur and even the concerned doctor has not disclosed anything with regard to the period of the disease of the DLA.  So, when there is no documentary evidence with regard to the prior illness of the DLA, the repudiation of the claim by the Ops is not justified.  Moreover, the report submitted by the investigator has not been supported by the affidavit of the investigator and in the absence of an affidavit of the investigator, we are unable to rely upon the contents of the investigation report.

 

10.            Moreover, in the investigation report, the documents which have been procured from Sibia Health Care Pvt. Ltd, are also subject to suspicion as the Ops have not led any evidence as to how the investigator had procured the same from the hospital. At some place of the papers of the hospital, which the investigator had attached with his report, the signatures of the patient, date and time have also not been mentioned. The document Ex.OP-4 also does not bear the signatures of the concerned doctor and at some place the rubber stamp placed on the papers is not at the proper place as the same has been affixed much below the document.  In the complaint, the complainant has himself mentioned that the deceased/insured was admitted at Sibia Hospital, Sangrur where she died on 24.10.2013 due to heart attack. So, there is no denial to the effect that the DLA was not admitted in the Sibia Hospital, Sangrur, but all the documents procured by the investigator cannot be considered as the same were without the signatures of the concerned doctor.

 

11.            On going through the document Ex.OP-1, which is an application for the policy of the DLA, we find that the insured had signed the same  in Punjabi and the declaration number 47 in this document has not been explained to the insured as there are no signatures of the declarant and at serial number 49 and serial number 50, where the insured had been explained by Shri Kamal Kataria, but from the documents tendered by the OPs, we do not find any affidavit of Shri Kamal Kataria, in support of version of the OPs that he had read over and explained the contents of the document to the applicant.  In order to prove his version, the learned counsel for the complainant has cited the judgment of Hon’ble Punjab State Commission Chandigarh delivered in the first appeal number 1037 of 2007, decided on 16.8.2012 in case titled as Life Insurance Corporation of India versus Murti Devi, in which the Hon’ble State Commission has held “it was clear that insured had signed in Punjabi and whereas the proposal form was in English. Terms and Conditions were not duly explained to the insured.” In the present complaint also, Shri Kamal Kataria is  a Sales Employee and his affidavit was also necessary in the light of judgment of the Hon’ble National Commission titled as Life Insurance Corporation of India versus Ram Murti 2009(4) CPJ 24(NC). But, the Ops have not produced any sworn affidavit of Shri Kamal Kataria, to support their case.

 

12.            Further on the death of the DLA, the complainant had submitted the claim papers to the OPs, but the Ops have repudiated the claim as per the report of the investigator considering that the DLA was sick at the time of obtaining the insurance policy.  The Ops had also got the DLA examined from their own doctor at Patiala on 28.11.2012 i.e.  much after the date of issuing of the insurance policy as the policy was enforced from 29.09.2012 to 28.09.2027, but the doctor of the OPs found that the contents mentioned in the application form of the DLA are correct and after proper investigation, as per the document Ex.OP-6, the doctor had not found anything serious with regard to ailment, as alleged by the Ops to avoid settlement of the claim is not tenable.

 

 

13.            We have further examined the document Ex.OP-6, which is the report of doctor of OPs with regard to the medical examination of the DLA and he has got the DLA fully medically examined as is apparent from the lengthy medical tests conducted by the doctor, but inspite of all tests and medical examinations, the doctor of the Ops had found that the insured was fit to obtain the insurance policy and was not suffering from any disease.  In the present case, the onus to prove the suppression of disease was with the Ops as they have not been able to produce any reliable, cogent and trustworthy evidence with regard to the pre existing disease of the DLA.  So, the OPs are deficient in rendering service towards the complainant by not paying the genuine claim to the complainant. To support such a contention, reliance can also be placed on United India Insurance Co. Ltd. versus Krishna Prakash Dubey 2012(1) CLT 584 (NC), wherein the Hon’ble National Commission has clearly held that the burden to prove that the complainant had any prior knowledge about his medical problem was squarely on the insurance company and  the insurance company is bound to discharge the same satisfactorily.  But, in the present case, the OPs have miserably failed to do so.

 

14.            Further the insurance companies are in the habit of repudiating the claim of the complainants on one ground or the other and in the present complaint in order to avoid their liability, the OPs have offered to refund the fund value by way of NEFT in the bank account of their own without even considering that the policy is still in force and they were not even asked for to cancel the policy in question.  Further the learned counsel for the complainant has cited SBI Life Insurance Company Limited versus D. Leelavathi and another 2012(2) CPC 133 (NC), wherein the Hon’ble National Commission upheld the order of the State Commission allowing the insurance claim of death by heart attack, where the insurance company had repudiated the claim with the plea that he was suffering from various diseases prior to the policy.  From the evidence on record, the death was natural and no prior disease was proved from the record.  As such, compensation of Rs.20,000/- was also awarded. The same view has also been taken by the Hon’ble Supreme Court of India in P.Vankat Naid versus Life Insurance Corporation of India and another 2011(3) CPC 350 (Supreme Court).

 

15.            The learned counsel for the OPs has further contended that the income of the insured was less and the age of the insured was also not mentioned correctly, but then this was pre-requisite for the issuing of the policy and as the Ops have ignored this fact at the time of issuance of the policy, such flimsy grounds at the time of settling the claim at a very belated stage are not justified.  Had there been any irregularity of such nature, then the OPs should have not issued the policy to the DLA.

 

 

16.            In view of our above discussion and circumstances of the case, we allow the complaint and direct the Ops to pay to the complainant an amount of Rs.5,00,000/- (after deducting the amount paid to the complainant through NEFT, if any) along with interest @ 9% per annum from the date of filing of the complaint i.e. 23.09.2014 till realisation.  The Ops are further directed to pay to the complainant an amount of Rs.20,000/- on account of compensation for mental tension and harassment and Rs.10,000/- as litigation expenses.

 

 

17.            This order of ours be complied with within a period of thirty days of communication.  A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                March 20, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                                                (Sarita Garg)

                                                                   Member