DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.287/2012
1. Smt. Somwati
W/o Late Sh. Ratan Lal
2. Sh. Hanuman Prasad
B/o Late Sh. Ratan Lal
S/o Late Sh. Ram Sahay
Both R/o
A-308, Dakshin Puri,
New Delhi-110062 ….Complainants
Versus
Future Generali India
Through its Branch Manager
Life Insurance Company Limited
M-10, South Extn., Part-II,
New Delhi-110049 ……Opposite Party
Date of Institution : 05.06.12 Date of Order : 10.03.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
The case of the Complainants is that the Complainant No.1 is the wife and the Complainant No.2 is the brother and nominee of the insured person Mr. Ratan Lal (now deceased) who was covered under insurance policy No.00008063. The deceased was a Mason/Contractor and an illiterate person. On 30.06.08, an agent of OP approached the insured and offered insurance plan namely, “Future Assured Plan” Product Code No. 133N001V01 which was accepted by the insurer (deceased). The OP prior to issue the policy had got conducted medical checkup by their own doctors at their expenses in accordance with the norms of the OP and after duly satisfied with the reports of the doctors, the OP issued the policy. All the documents were filled in by the agent and the OP issued a policy for Rs.1 lakh with term plan of 16 years with the premium opted quarterly @ Rs.1837/-. The deceased paid the six premiums till 15.1.10. He died on 16.01.2010 due to heart failure. The Complainant No. 2 informed the OP at the Delhi Branch on 13.03.10 regarding death of the insured. The OP’s Surveyor Ms. Loveena Rastogi prepared details of claim of the death benefit and filled the same on 15.03.10 and the complainants were advised to submit the claim form and documents as per instructions of OP. The OP vide letter No. 10037438/DT09100427/00008063 dated 30.04.10 informed the Complainants that on the basis of the investigation carried out by the OP, their claim had been repudiated. Complainants further pursued the matter with the Claim Review Committee of OP which also repudiated the claim vide letter dated 28.9.10. Complainants sent a legal notice on 03.06.10 to the OP. The action of the OP is arbitrary, illegal, unlawful and unwarranted. As there was deficiency in service on the part of OP, the complaint has been filed for the following reliefs:-
- Direct the OP to pass the sum assured amount of the Life Insurance for Rs.1 lac alongwith interest @ 18% per annum w.e.f. March, 2010 till its realization.
- Direct the OP to pay a sum of Rs.50,000/- as compensation for harassment and mental agony undergone by the Complainants.
OP in the written statement has stated that the contract of the insurance in this matter was void ab initio as the deceased policyholder had suppressed the material facts regarding his health condition at the time of availing the said policy. The deceased policyholder was diagnosed and under treatment for Coronary Artery Disease, Double Valve Disorder, Left Ventricular Dysfunction and Acute Oedema and was admitted in various hospitals between 2006-2008 ( i.e. months before proposing for the said policy). Further the deceased was also an alcoholic and an avid smoker but the said fact was not disclosed by the deceased policyholder at the time of filing of the proposal form and on this ground the OP are entitled to rescind the contract as per section 45 of the Insurance Act, 1938; that one of the most important and basic principle of the insurance is ubbermae fides i.e. “utmost good faith” but in this case the deceased policyholder had suppressed material facts about his health condition and hence the OP had rightly repudiated the claim of the Complainants on the ground of non disclosure of the material facts as per section 45 of the Insurance Act, 1938. The OP has further stated that after a detailed investigation, the OP had rightly repudiated the claim as the deceased policyholder had suppressed /non disclosed material fact about his health condition and the policyholder died within 561 days wherein as per the policy he should have completed two years. As such OP had rightly repudiated the claim as per section 45 of the Insurance Act. Matter was also referred to the Claim Review Committee which also repudiated the claim as per above mentioned reason and the same was communicated to the Complainants vide letter dated 28.09.2010. OP has prayed for dismissal of the complaint.
Complainants have filed rejoinder to the written statement of OP and stated that they have not suppressed any material fact regarding his health condition. The OP performed the medical checkup of the deceased insured/policyholder from their own doctors on panel before issuing the policy.
Complainant No.1 has filed her affidavit in evidence.
OP has been proceeded exparte vide order dated 15.07.13 passed by our predecessors.
Written arguments have been filed on behalf of the Complainants. We have heard the Complainant and have also gone through the file.
The OP has filed copies of certain medical papers marked as Annexure-1 containing the details of the insured person admitted in the hospitals in the year 2006 to 2008. These medical papers clearly demonstrate that the deceased insured/Policyholder was a known old case of heart disease and he had already got various treatments for the ailment.
Annexure-2 filed on behalf of the OP is the copy of proposal form. Columns therein have been filled in English language neatly and cleanly. Rattan Lal (deceased) was undisputably an illiterate man. Therefore, he could not have filled in the blank columns for providng details about the family background, state of health of the family members and also the state of health of himself.
We do not have any doubt in our minds that it was some employee of the OP or OP’s agent who had filled in the columns and ticked the information under Column 8.2, “HEALTH DETAILS OF LIFE TO BE ASSURED”. Therefore, we are not inclined to believe that it was Rattan Lal (deceased) who had intentionally provided false information regarding his own state of health on the date of signing the proposal form vide Annexure 3. It is quite interesting to note that after receiving the claim papers from the complainants, the OP got conducted a detailed inquiry and collected the copies of medical reports/records in respect to the treatment received by the deceased Rattan Lal during the period 2006 to 2008.
In the present case, the averments made by the complainants are that before issuing the policy in question, the deceased insured had undergone some medical tests conducted by OP’s doctors themselves. He had undergone medical checkup by the doctors of the OP itself and the said averment has not been denied in the written statement. It clearly proves that the OP has admitted that before issuing the policy in question the deceased Rattan Lal had undergone medical examinations by the doctors who were on the panel of the OP. It is the OP only who could be in possession of these medical reports but, however, the OP has not filed the medical reports in original or even the copies thereof on the record to show its bonafide. Had these reports in original or copies thereof been filed on the record, this Forum would have certainly got an opportunity to peruse the same and to see whether there was or was not any mention of the heart ailment of deceased Rattan Lal from which he was suffering at the time of issuance of the policy. It means that the OP has also suppressed the material facts from this Forum. At the most, it was a case of collusion between the deceased insured on the one hand and the employees and doctors of the OP on the other hand and, thus, the LRs of the deceased insured cannot be made to suffer for this reason. Therefore, in our considered opinion, the provisions of section 45 of the Insurance Act do not apply to the facts of the present case though the death of the insured Rattan Lal had taken place before expiry of two years period from the date of issuance of the policy in question to him.
Therefore, we come to the conclusion that the OP committed deficiency in service while repudiating the claim of the complainants.
The deceased insured has left behind him complainant-1 (his wife) and two children (as mentioned in the proposal form).
In view of the above discussion, we direct the OP to pay Rs. 1 lakh towards the insurance amount alongwith interest @ 6% per annum from the date of filing of the complaint, Rs. 15,000/- towards mental harassment etc. and litigation charges to the Complainant-1 within a period of 30 days from the date of receipt of copy of this order failing which the OP shall become liable to pay interest @ 9% p.a. on the amount of Rs. 1 Lakh from the date of filing of the complaint till realization. OP shall, however, not make the payment of Rs. 1 Lakh along with interest to the complainant-1 directly but a Pay order/Demand Draft in her name shall be deposited in this Forum. Thereafter this Forum shall get her Bank account opened in a nationalized bank in the name of complainant-1 and the complainant-1 shall be entitled to withdraw Rs. 7000/- each p.m. in order to maintain herself and her children in a smooth manner. We are putting these conditions in order to ensure that insurance amount may not be misused. The complainant-1 shall be entitled to the interest as per the banking rules on the said amount. However, the complainant-1 shall be entitled to move an application before this Forum if she find herself in urgent need of more money for any cogent and valid reason to the satisfaction of this forum.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 10.03.16.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Case No. 287/12
10.3.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. OP is directed to pay Rs. 1 lakh towards the insurance amount alongwith interest @ 6% per annum from the date of filing of the complaint, Rs. 15,000/- towards mental harassment etc. and litigation charges to the Complainant-1 within a period of 30 days from the date of receipt of copy of this order failing which the OP shall become liable to pay interest @ 9% p.a. on the amount of Rs. 1 Lakh from the date of filing of the complaint till realization. OP shall, however, not make the payment of Rs. 1 Lakh along with interest to the complainant-1 directly but a Pay order/Demand Draft shall be deposited in this Forum. Thereafter this Forum shall get her Bank account opened in a nationalized bank in the name of complainant-1 and the complainant-1 shall be entitled to withdraw Rs. 7000/- each p.m. in order to maintain herself and her children in a smooth manner. We are putting these conditions in order to ensure that insurance amount may not be misused. The complainant-1 shall be entitled to the interest as per the banking rules on the said amount. However, the complainant-1 shall be entitled to move an application before this Forum if she find herself in urgent need of more money or not for any cogent and valid reason to the satisfaction of this forum. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
