Punjab

Sangrur

CC/1406/2021

Rekeena - Complainant(s)

Versus

Future Generali India Insurance Company Limited - Opp.Party(s)

Sh. Amrik Singh Dullat

30 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                        Complaint No. 1406

 Instituted on:   18.11.2021

                                                                         Decided on:     30.09.2024

 

Rakeena @ Sukhpreet Kaur Daughter of Mohd. Sarajdin, resident of Village Gujran, Distt. Sangrur now wife of Rupinder Singh, now residing at Near Bus Stand, Village Lohara, Tehsil and Distt. Moga.

                                                         …. Complainant.     

                                                 Versus

1.             Future Generali India Total Insurance Company Limited, Corporate and Registered office: 6^th Floor, Tower-3, Indian Bulls Finance Centre, Senapati Bupat Marg, Elphinstone Road, Mumbai 40013 through its MD/Chairman.

2.             Manager, Future Generali India Total Insurance Company Ltd. Sandhu Tower, 2^nd Floor, Ferozepur Road, Ludhiana, Punjab.

                                                        ..Opposite parties.

 

For the complainant    :       Shri A.S.Dullat, Adv.

For Opposite parties   :       Shri Sushil Kumar, Adv.

 

 

Quorum                                           

Jot Naranjan Singh Gill                             : President

Sarita Garg                                               : Member

Kanwaljeet Singh                                        : Member

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that mother of complainant, Najira purchased a policy number 1574492 dated 7.12.2019 under money back policy with profits and ACC benefit of Rs.4,00,000/- and the complainant is the nominee under the policy in question.  Unfortunately, on 19.02.2020 the mother of the complainant died and the complainant lodged her claim with the OPs for getting the policy amount and submitted all the relevant documents to the OPs, but the OPs repudiated the claim of the complainant vide letter dated 31.08.2020 on flimsy grounds. After receipt of the above said letter, the complainant again approached the OPs and requested them to release the claim amount, but the OPs refused to accede the request of the complainant. It is further mentioned in the complaint that at the time of obtaining the above said insurance policy, the doctor of the OPs checked the mother of the complainant medically and submitted his report to the OPs before issuance of the insurance policy.  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 the claim amount of Rs.4,00,000/- alongwith with interest and further claimed compensation and litigation expenses.

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the allegations levelled in the complaint which are contrary to or inconsistent with what is averred herein are denied, the complaint is not maintainable in the present form, that the complainant did not approach during the free look period of 15 days and the insurance contract are contracts based   on utmost good faith. The person seeking insurance knows all the facts, which materially affect the risk on his or her life. After receipt of claim form on 07.08.2020 an investigation was conducted and it came to the knowledge of the OPs that the DLA had provided incorrect information about her health in the proposal form for insurance. The life assured died on 19.02.2020 within two months of the policy issuance as she was a known case of Seizure Disorder and was taking treatment for the same from PGI, Chandigarh, but the same was not revealed at the time of taking the insurance policy, which information was withheld by the life assured and it further shows that the life assured had an intention to defraud the company, as such, the repudiation of the claim is said to be justified. Further the OPs in the reply have stated that the OP company had received a duly filled proposal form and accordingly the policy number 01574492 was issued to Nazira and the sum insured was Rs.1,32,000/-. Further it is averred in the reply that the OP company received the claim intimation form dated 07.08.2020 from the complainant, which shows that the life assured died on 19.2.2020 i.e. within two months of the policy issuance and after that the OP company got conducted a statutory investigation in order to verify the authenticity of the said claim and during investigation it came to the knowledge of the OPs that the DLA had provided incorrect information about her health in the proposal form for insurance as the DLA was a known case of Seizure Disorder and was taking treatment for the same from PGI Chandigarh but the same was not disclosed at the time of taking the insurance policy. Therefore, life assured intentionally withheld the material information despite there were specific questions being asked in the proposal form. This shows that the life assured had an intention to defraud the company. During the investigation following facts and documents were discovered:

a)     Life Insured was taking treatment from PGI Chandigarh, November, 2011 when on 14/11/2019 MRI was conducted.

b)     OPD Notes of PGI clearly state that the LA was a Known case of Seizure Disorder since 2015.

c)     Lama Summary also clearly states that the LA was a known case of Seizure Disorder since 2015.

                As such after carefully consideration of the documents and information received, the claim of the complainant was repudiated due to non-disclosure and suppression of material information vide letter dated 31.08.2020. Lastly, OPs have prayed that the complaint be dismissed.  

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-6 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 to Ex.OPs/6 copies of documents and affidavit and closed evidence.

4.             We have gone through the pleadings put in by the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that life assured Najira was insured with the OPs under the policy in question. The contention of the complainant is that during the subsistence of the insurance policy on 19.02.2020 the insured Nazira died and the complainant intimated the OPs about her death and requested for payment of the claim amount.  The OPs appointed investigator to get investigated the claim and the investigator intimated the Ops that the life assured was a known case of Seizure Disorder, but the same was not revealed at the time of taking the policy by the life assured. It is further not in dispute that the life assured died within three months of taking the insurance policy in question.  It is also an admitted fact that the OPs repudiated the claim of the complainant vide letter dated 31.08.2020, Ex.C-1 as the investigations revealed that insured was suffering from Seizure Disorder even prior to the date on which the application was signed and the complainant has not disclosed these facts in the application/proposal form. The OPs have also produced on record the copy of customer declaration form Ex.Ops/1 dated 7.12.2019 which is duly signed by Najira and complainant and in the form Life Insurance Application at page number 2 of 4,  various questions such as at point No.m Nervous, psychiatric or mental disorder/depression/ stress related problems at point no.o stroke, multiple sclerosis, tremors, numbness, paralysis/epilepsy/brain disorder and at point number r  In last five years, any ailment/injury requiring treatment or undergone/currently undergoing/advised to undergo any form of medical treatment, investigation or test were asked to the life assured, which were replied by the life assured in (No), meaning thereby the life assured replied all the questions in negative. A bare perusal of the document i.e. out patient record of Post Graduate Institute of Medical Education and Research (Nehru Hospital), Chandigarh Ex.OPs/4, clearly shows in the column of history and physical examination : k/c/o/ (Known case of) Seizure Disorder since 2015 and on 14.11.19 MRI was done and even findings of the MRI was mentioned. Further at page number 2 LAMA (Leave Against Medical Advice) summary this document shows that Najira was admitted in the hospital on 8.12.2019 and date of LAMA (Leave Against Medical Advice) is 09.12.2019, whereas the policy was taken on 7.12.2019. Further it is worth mentioning here that in the document Ex.OPs/4 at the bottom of page number 2 in the consent column, the complainant Rakeena signed on 9.12.2019 and consented that she have been clearly explained in her understandable language about the condition of her patient, need for continuous in hospital care and possible outcome. Still, she wanted to leave the hospital with her patient against medical advice. She shall be responsible for any adverse outcome including death of her patient. It clearly shows that the life assured taken the policy on 7.12.2019 and visited/admitted in the Post Graduate Institute of Medical Education and Research (Nehru Hospital), Chandigarh for treatment of Seizure Disorder. It is worth mentioning here that this problem cannot arise within one day, moreover when it is established on the record that the life assured was suffering from the above said problem since the year 2015 as it is clearly mentioned in the document Ex.Ops/4. Further submissions of the reply of the OPs is duly supported by the affidavit of Reena Kamath, Deputy Manager Legal of the OPs.   It is further worth mentioning here that the complainant has not denied this fact that the life assured was not suffering from the problem of Seizure Disorder since the year 2015. In Smt. Shalini Srivastava versus Aviva Life Insurance Co. Ltd., First Appeal No.1295 of 2014, decided on 23.04.2024, the Hon’ble National Commission observed that the DLA was under obligation to disclose all material facts known to him at the time of availing the policy. It is not material whether the cause of death was related to or not related to the facts not disclosed. The investigations of the respondent have revealed facts which were admittedly not disclosed at the time of the DLA’s proposal for the policy. These have not been controverted by the appellant. Hence, respondent cannot be faulted for repudiating the claim on the basis of non-disclosure of material facts, the appeal of the complainant was, therefore, dismissed.   In the circumstances of the case, we find that it is a case of pre-existing disease as proved by the OPs on record and accordingly, we find no case made out of any deficiency in service on the part of the OPs.

6.             In view of our above discussion, we dismiss the complaint of the complainant being without merits. However, the parties are left to bear their own costs.

7.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

8.             Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                        Pronounced.

 

                September 30, 2024.

 

 

           (Kanwaljeet Singh)  (Sarita Garg) (Jot Naranjan Singh Gill)

                  Member               Member                   President