BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 27 of 2017
Date of Institution : 8.2.2017
Date of Decision : 30.10.2017.
Naseera widow of Parbhat Hussain, resident of village Chaharwala, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Exide Life Insurance, SCO-145, First Floor, Red Square Market, Delhi Road, Opposite ICICI Bank, Hotel Miava, Hisar District Hisar through its Manager/ Authorized Signatory.
2. Exide Life Insurance, Regd. Office 3rd Floor, JP Techno Park No.3/1, Millers Road, Bangalore- 560 001, through its Director/ Manager.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SMT. RAJNI GOYAT ………………… MEMBER
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. Suraj Kiran, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for opposite parties.
ORDER
The case of the complainant in brief is that husband of complainant namely Parbhat Hussain son of Nababdin during his life time had obtained an insurance policy from the opposite parties vide policy no.03114363 dated 25.5.2015 for a sum assured of Rs.4,91,862/-. Prior to the issuance of insurance policy, the medical checkup of husband of complainant was conducted and on receiving medical checkup report, the insurance policy was issued by the ops. That the complainant was the nominee of the deceased Parbhat @ Parbhat Hussain @ Hussain being his wife. He was making the payment of the installments regularly. It is further averred that unfortunately the husband of complainant suddenly died on 14.8.2015 and prior to it, he was not suffering from any disease. After the death of her husband, the complainant also intimated to the ops regarding the death of her husband and submitted all the documents as per the instruction of ops for settlement of the claim and it was assured to the complainant that the claim of death of husband of complainant will be settled soon. The complainant visited the office of the ops time and again but no satisfactory reply was given to the complainant and now it has been told to her that her claim has been repudiated whereas in this regard no letter or intimation has been given to the complainant. That the complainant also served a legal notice dated 3.9.2016 upon the ops but to no effect. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement and submitted that life assured Sri. Parbhat @ Prabhat with surname Husen alias Hussain submitted duly filled proposal form dated 25.5.2015 to the op insurance company proposing for exide life guaranteed income insurance plan a life insurance product offered by op, which is approved by the Insurance Regulatory Development Authority of India (in short IRDAI) a statutory body created by an Act of the Parliament. The premiums opted was Rs.24,250/- Semi- Annually with premium paying term of 15 years and sum assured under policy was Rs.4,91,862/- for policy tenure of 30 years. It is further submitted that life assured after due understanding of the product features gave declaration to the extent that he understood the policy and signed the same. Based on the proposal form submitted by the LA, the ops had issued the insurance policy bearing No.03114363 and sent the same to the LA alongwith a covering letter dated 25.5.2015. It is further submitted that as per Regular 6(2) of Regulation 2002 issued by the IRDAI, the policy holder/ proposer is at liberty to review the terms and conditions of the policy and has the option to cancel the policy by stating the reason for his/her objection within 15 days of receipt of policy bond. In such a case, the company shall refund the premium received for this policy after deducting the proportionate risk premium for the period of risk cover and expenses incurred by the company on account of medical examination and on stamp duty charges. The said facts were clearly intimated in the welcome letter which was issued to the LA alongwith the policy schedule and terms and conditions. However, LA had never approached the ops within free look period. Hence it is presumed that LA is duly satisfied with the policy terms and conditions. It is further submitted that in the proposal form (Section VII- Health Details of the LA) submitted by the life assured, he had answered the following questions as under:-
RELEVANT QUESTIONNAIRE UNDER DECLARATION OF HEALTH FORM | ANSWERS GIVEN BY LIFE ASSURED |
70. Are you currently taking any medication or drugs either prescribed or not prescribed by a Doctor? | NO |
72. Have you suffered from any illness, disorder, disability or injury during past 5 years which has required any form of medical or specialized examination (including Chest X-ray, ECG, Stress Test, Angiography, MRI/ CT Scan or blood, urine tests, pap smear test, mammography etc.) or consultation or hospitalization or Surgery? | NO |
75. Have you ever been diagnosed or have suffered from any of the diseases | NO |
76. Have you ever had or are you currently suffering from any illness, disease, disorder, impairment, deformity, disability not yet mentioned above? | NO |
It is further submitted that thus based on the information and declarations provided by the life assured in the proposal form as above to be true and sincere, op company issued the insurance policy. The ops received death intimation cum claim form dated 30.10.2015 from Smt. Naseera W/o LA and the complainant herein, informing that the life assured has died on 14.8.2015. As death of LA has taken place within a period of three months from the date of commencement of the policy, an internal investigation was conducted as per the routine business practice of the ops. During the investigation, the company has collected crucial medical records and information which confirmed that the life assured had pre-existing critical illness of cancer prior to the submission of the proposal form and was taking treatment at Jindal Hospital, Hisar. Further, medical record of operation from MAX Care Hospital Cancer Care Centre dated 02/03.3.30215 of Sri Ganganagar reveals that the LA had undergone operation for cancer at rectum on 3.3.2015 and was in the hospital till 8.3.2015. It is further submitted that from the above facts and material documents, it is clear that the life assured had pre-existence of life threatening critical health problems related to cancer and consequently also undergone operation. Though, the LA had undergone operation on 3.3.2015, same was withheld/ suppressed intentionally by the LA in the proposal form dated 25.5.2015. It is evident that LA has concealed the prior existence of illness in the proposal form from the Op company by providing wrong declarations. Had the LA revealed the critical material information of his past health history, ops would not have accepted the proposal and would not have issued the insurance policy. With these averments, dismissal of complaint has been prayed for.
3. The complainant produced her affidavit Ex.CW1/A, copies of policy documents Ex.C1 to Ex.C3, copy of legal notice Ex.C4, postal receipts Ex.C5, Ex.C6 and copy of death certificate Ex.C7. On the other hand, ops produced affidavit of Sh. Bharadwaj, Assistant Manager Legal Ex.R1, copy of proposal form Ex.R2, copy of welcome letter dated 29.5.2015 Ex.R3, copy of premium receipt Ex.R4, copy of terms and conditions Ex.R5, copy of death intimation cum claim form Ex.R6 and Ex.R7, copy of death/ rider claim investigation report Ex.R8, copy of death certificate Ex.R9, copies of voter identity card, aadhar card and ration card etc. Ex.R10 to Ex.R14, copy of middle examination certificate Ex.R15 and copy of treatment record of Maxcare Hospital Ex.R16, copy of repudiation letter dated 5.2.2016 Ex.R17 and copies of letters Ex.R18 and Ex.R19.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The record reveal that complainant has filed this complaint with the averments that husband of the complainant namely Parbhat Hussain had obtained an insurance policy from the opposite parties for a sum assured of Rs.4,91,862/- on 25.5.2015 and paid the requisite premium but unfortunately he died on 14.8.2015 and death claim was duly lodged by the complainant being his nominee with the ops but the ops have repudiated the claim of the complainant illegally and arbitrarily. In order to prove her case, she has furnished her affidavit Ex.CW1/A in which she has reiterated all the averments made in the complaint and also placed on record copies of policy documents Ex.C1 to Ex.C3, copy of legal notice Ex.C4, postal receipts Ex.C5, Ex.C6 and copy of death certificate Ex.C7.
6. On the other hand, there is a specific plea of the opposite parties that husband of the complainant has concealed the material and important facts from the ops. The life assured husband of the complainant had concealed the fact qua his suffering pre-existing critical illness of cancer prior to submission of the proposal form and while furnishing the declaration form in which he had denied illness of any kind despite knowing well that he was suffering from cancer and in March, 2015 he got operated from MAX Care Hospital at Sri Ganganagar (Rajasthan) and remained admitted from 2.3.2015 to 8.3.2015. In order to prove the defence plea, the ops furnished affidavit of Sh. Bhardawaj, Assistant Manager Legal as Ex.R1 in which he has reiterated all the averments made in the written statement. He has specifically deposed qua the LA suffering from cancer prior to the filling of the proposal form and the declaration. He has further deposed that this fact has been found during the course of investigation which was got conducted by the ops as the death of LA took place within three months of the issuance of the policy. The ops have also placed on record documents Ex.R2 to Ex.R19. The perusal of Ex.R16 i.e. treatment record file of Max Care Hospital, Sri Ganganagar reveal that the deceased LA Parbhat Hussain son of Sh. Navab, resident of village Chaharwala, Tehsil and District Sirsa remained admitted from 2.3.2015 to 8.3.2015 and got operated for cancer disease. The record further reveal that this plea was taken by the ops specifically in their written statement but perusal of the affidavit of complainant Smt. Naseera reveals that she has not uttered even a single word controverting the plea of ops that her husband deceased was suffering from cancer and he got operated prior to the inception of the policy on 25.5.2015. Nor she has deposed that the evidence produced by ops qua her husband suffering from cancer is a false and fabricated record.
7. During the course of arguments though the learned counsel for complainant has strongly contended that the death of LA took place due to heart attack but the evidence of the complainant reveal that complainant has not placed on record any document or copy of post mortem report or any medical evidence from which it could be presumed that death of LA took place due to heart attack. But it is a fully proved fact on record that the deceased LA had concealed the fact qua his suffering from cancer and got operated from Max Care Hospital, Sri Ganganagar during period from 2.3.2015 to 8.3.2015 while filing proposal form and furnishing the declaration qua his pre-existing disease, if any. As per the terms and conditions of the policy, the LA who concealed the fact qua his pre-existing disease makes the policy null and void.
8. In view of the above discussion, we are of the considered opinion that since life assured had concealed fact qua his pre-existing disease of cancer, as such the ops have rightly repudiated the claim of the complainant. Hence, the complaint of the complainant is hereby dismissed but with no order as to costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:30.10.2017. Member Member District Consumer Disputes
Redressal Forum, Sirsa.
