Punjab

StateCommission

A/345/2018

KOTAK MAHINDRA LIFE INSURANCE CO. LTD. - Complainant(s)

Versus

GOPAL KRISHAN - Opp.Party(s)

P.S.Bhangu

20 Dec 2018

ORDER

                                                               FIRST ADDITIONAL BENCH

 

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,    PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH

 

                   First Appeal No.345 of 2018

 

 

                                                          Date of Institution   : 07.06.2018       

                                                          Order Reserved on : 18.12.2018

                                                          Date of Decision     : 20.12.2018

 

Kotak Mahindra Life Insurance Company Ltd., Registered Officer, 2^nd Floor, Plot No.C-12, G-Block, BKC Bandra (East),Mumbai 400 051

 

                                                                     ..Appellant/Opposite party         

                   Versus

 

Gopal Krishan, aged 56 years son of Sohan Lal, resident of Street No.1, Boys School, Talwandi Bhai, District Ferozepur- Punjab.

 

 

                                                      … Respondent/Complainant

 

First Appeal against order dated 09.03.2018 passed by the District Consumer Disputes Redressal Forum,  Ferpzepur.

 

Quorum:-

 

          Shri J. S. Klar, Presiding Judicial Member

            Smt. Kiran Sibal, Member

Present:-

 

          For the appellant         :  Sh.K.S Cheema, Advocate

          For the respondent      :  Sh.Parvez Chugh, Advocate

         

. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

                    Challenge in this appeal by appellant is to order dated 09.03.2018 of District Consumer Disputes Redressal Forum Ferozepur, accepting the complaint of the respondent of this appeal by directing appellant to pay the amount of Rs.1,90,000/- as medi claim with interest @ 8% per annum from 22.09.2016 till repudiation of claim, besides compensation of Rs.5000/- . The appellant of this appeal is opposite party in the complaint and respondent of this appeal is complainant in the complaint and they be referred as such hereinafter for the sake of convenience.

2.                The complainant has filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against OP on the averments that  he purchased Life Insurance Kotak Eternal Life Class Shield (UIN-107NO40VO1) bearing no. 02254605 for insured amount of Rs.4,50,000/- against premium of Rs.28,186/- . It was a whole life plan (Level Premium Plan) and he has been paying premium annually. The premium for the year 2016 became a bit late and it was deposited on 06.04.2016 by him. He suffered from cardiac problem and underwent angiography  from Global Heart and Superspeciality Hospital by paying Rs.9500/- as charges and thereafter he underwent  coronary bypass surgery   and was admitted in Tagore Hospital and Heart Care Centre Jalandhar  and incurred expenses of Rs.1,90,000/- on his treatment thereat. He lodged insurance claim with OP,  but OP repudiated his claim, vide letter dated 22.09.2016 on account of suppression of material information by him.   OP repudiated the claim of the complainant on the ground that he was diagnosed of coronary artery disease  prior to application of major revival thereof. The complainant has prayed that OP be directed to pay expenses incurred by him on his above treatment to the tune of Rs.1,95,500/-  with interest on the amount from the date of actual cause of action, besides Rs.1 lac as compensation for mental harassment and Rs.25,000/- as litigation expenses.

3.                Upon notice, OP appeared and filed written reply and contested the complaint of the complainant by raising preliminary objections that complaint is barred by limitation. The complainant has not come to this Forum with clean hands and suppressed the material facts with regard to his medical condition. It was admitted by OP that complainant purchased policy bearing no. 02254605, wherein premium was payable annually @ Rs.28,186/- with sum assured of Rs.4,50,000/- and critical illness benefit rider of Rs.2,00,000/-. It was denied by OP that complainant was paying the premium annually. It was also denied that payment for the year 2016 became a bit late, rather the policy was purchased by submitting proposal form at Ludhiana. The premium on due date on 21.03.2015 was not paid, whereby the policy stood lapsed for non-payment of premium and policy was revived after submission of request of revival of policy from complainant. The complainant was fully aware of the fact that he was already diagnosed with coronary artery disease, but the same was not disclosed but was rather concealed in the request for revival of the policy dated 18.03.2016 with an intention to get the payment of expenditure of medical treatment thereof by complainant. OP got the matter investigated thoroughly which revealed that complainant had made material concealment regarding condition of his health at the time of major revival of the policy, therefore, his claim was rightly repudiated, vide letter dated 22.09.2016. Rest of the averments of the complainant were denied by OP and it prayed for dismissal of the complaint.

4.                The complainant tendered in evidence his affidavit  Ex.C-1 along with copies of documents Ex.C-2 to Ex.C-8 and closed the evidence. As against it; OP tendered in evidence affidavit of Nirmal Gulhane Chief Manager Legal Kotak Mahindra Old Mutual Life Insurance Limited as Ex.OP-12 along with copies of documents Ex.OP-1 to Ex.OP-11 and Ex.OP-13 to Ex.OP-30 and closed the evidence. On conclusion of evidence and arguments, the District Consumer Forum Ferozepur accepted the complaint of the  complainant by virtue of order dated 09.03.2018. Aggrieved by above order of the District Forum Ferozepur, opposite party now appellant, has carried this appeal against the same.

5.                We have heard learned counsel for the parties and have also examined the record of the case.

6.                The forceful submission raised by counsel for the appellant before us is that Gopal Krishan /complainant  being respondent in this appeal has not disclosed the ailment of coronary artery disease before taking the policy ,  as the previous policy stood lapsed on account of non-payment of premium even within grace period of 30 days. It was contended by counsel for appellant that the policy in had is the new policy and it is under the new contract between the parties and it cannot be read in continuation with the previous policies. On the other hand, counsel for respondent of this appeal being complainant submitted that he has been taking the policies since 2011 from OP by paying the premium. He was bit late in making the premium in the case in hand and thereafter he paid premium to insurance company, which was duly accepted by it and policy in hand came into existence thereby by reviving it.

7.                The forceful submission of counsel for appellant is that since complainant has not paid premium even within the grace period of 30 days and as such, the previous policy have come to an end and it is new contract between the parties after lapsation of the policy. The evidence on the record has been carefully perused by us. There is no dispute of this fact that complainant has obtained the policy from OPs since 2011 by paying premium therefor. The complainant was late and paid premium to OP for this policy on 06.04.2016, whereas previous policy came to an end even earlier. The reliance of counsel for appellant is that even premium was not paid by the complainant within 30 days grace period and hence  this is a new contract between the parties after lapsation of the policy. The matter in hand can be settled on the basis of terms and conditions of the policy only. Clause 4 of terms and conditions of the policy is relevant provision of law which is reproduced as under :-

 

4. Revival of Lapsed Policy:

“In case the premiums for the first three policy years are not paid within the grace period as mentioned in Clause 2,  the policy together with the rider benefits, shall lapse from the due date of the first unpaid premium.

However, the policyholder can revive the lapsed policy with or without rider benefits added to the policy, by making an application within a period of two years from the due date of the first unpaid premium and before the date of maturity of the policy.

Within six months from the due date of first unpaid premium.	Without evidence of health	On payment of a) Premiums in arrears, and b) Interest at such rates as may be prescribed by the company from time to time on premiums in arrears.
After six months but within two years from the due date of the first unpaid premium and before the date of maturity of the policy.	On production of evidence of good health and good habits to the satisfaction of the Company and also the evidence of there being no adverse change in the personal or family history or occupation	At such premium rate and from such date as may be fixed by the Company. In addition to payment of premiums an interest change would have to be paid at such rates as may be prescribed by the Company from time to time.

 

The company may, accept or decline the request for revival (made by the policyholder in writing) of a lapsed policy, or accept the request for revival on such terms and conditions at it deems fit. The revival of the policy will be effective after the Company’s approval is communicated in writing to the policyholder.

In case the policy is not revived within the above mentioned period, the same shall stand terminated.

It is, thus, evident from perusal of this Clause 4 of the policy dealing with revival of lapsed policy that in case the premiums for the first three policy years are not paid within the grace period of 30 days, policy together with the rider benefits shall lapse from the due date of the first unpaid premium. However, policyholder can revive the lapsed policy with or without rider benefits added to the policy by making an application within a period of two years from the due date of the first unpaid premium and before the date of maturity of the policy.  Policy may be revived within six months from the due date of the first unpaid premium without evidence of health by the policy holder on payment of premiums in arrears and interest if any.

Herein, the complainant revived the policy within six months period without any evidence of health and OP duly accepted it. As per clause 4 of the terms and conditions of the policy, revival was done by OP in favour of complainant within six months period from the date of end of previous policy without evidence of health and insurance company accepted it and as such, it cannot be said that policy stood lapsed as per revival within above stipulated period by complainant under the terms and conditions of the policy. There is no evidence on the record that complainant had suffered from problem of angiography since 2011, when he started taking the policies from OP. Consequently, complainant cannot be said to have suppressed the material information from OP with regard to his above ailment and with regard to treatment received by him from Tagore Hospital & Health Care Centre, Jalandhar,  since policies stood revived and is in continuation of the previous policies and as such  it cannot be said that this is a new contract entered upon between the parties in this case.  

8.                No other point was urged by counsel for appellant during the arguments in this appeal. As such, the order passed by District Forum Ferozepur under challenge in this case is found suffering  from no illegality or material infirmity and same is affirmed in this appeal and appeal of the appellant is hereby dismissed.

9.                The appellant had deposited an amount of Rs.25,000/- in this Commission at the time of filing the appeal and further deposited Rs.1,00,000/- as per compliance of the order of this Commission. Both these amounts with interest, if any, accrued thereon, be remitted by the registry to the respondent/complainant of this appeal by way of crossed cheque/demand draft within 45 days. Remaining amount,  if any, due shall also be paid to complainant by the appellant within 45 days from receipt of the copy of this order.

10.              Arguments in this appeal were heard on 18.12.2018 and the order was reserved. Certified copies of the order be communicated to the parties as per rules.

11.              The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                       (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

 

                                                                      (KIRAN SIBAL)

                                                                             MEMBER             

                                                         

December  20, 2018                                                           

(ravi)