The facts of the dispute prompting the present complaint that somewhat in brief, are that “The late Sh. Dharminder Singh DLI (Deceased Life Insured) during his lifetime had applied for purchase (on 22.12.2016) of the life insurance policy # 18866280 (issued on 15.02.2017) with a Sum Assured of Rs 50 Lac with some of its salient features as: Sum Insured (S.I.): Rs 50 Lac payable at the death of the Life Insured (policy holder); Nominee: Smt. Jaswinder Kaur, the Nominee Widow and also the present Complainant; The then applicant (Dharminder Singh) was medically examined for clinical and other tests/ by medical team/ hospital of the Insurer’s choice and finding the same in order, the Policy was finally accepted on 17.02.2017 by the OP insurers. The issuance of Policy in question was preceded by successful conduct of the medical examination of the insured by the insurer’s designated Medical Practitioners/ Hospital and finding the applicant fit and fine, the policy was finally accepted; Somehow, Sh. Dharminder Singh insured expired suddenly on 28.12.2018 and the related insurance death-claim was filed by the nominee complainant; The OP insurers got conducted an investigation in order to settle the death-claim; The OP conducted investigation revealed that there existed pre-existing diseases and hence the OP repudiated the claim vide letter dated 14.03.2019; Hence prompted the present complaint, seeking the Sum Assured of Rs 50 Lac with interest @ 9% PA besides Rs 1.0 Lac as compensation and Rs 50,000/- as cost of litigation.
2. The complainant Smt. Jaswinder Kaur has filed the following evidentiary documents to prove her version of the complaint: Ex.Cw1/A Self Declaration deposing the contents of the complaint; Ex.C1 Policy Schedule (No. 18866280) Risk Commencement w e f 15.02.2017; Ex.C2 Insurance Death Claim dated 14.03.2019; Ex.C3 Copy of the OP’s mail (23.12.2016) directing the Applicant to undergo the prescribed clinical (and other) tests at their designated hospital; Ex.C4 Copy of the OP’s mail (24.12.2016) intimating the visit of the OP’s Rep. with details of the appointment for medical requirements; Ex.C5 Copy of the OP’s mail (17.02.2017) intimating acceptance of the application for purchase of the policy; Ex.C6 (plus Ex.C7 & Ex.C8) Legal Notice dated 16.03.2020 plus postal receipts; Written Arguments (12.05.2022) by the learned counsel for the complainant. Senior Court’s Judgments in support of the complainant’s version: 2017 (2) PLR 726; P & H High Court; CWP 15447 of 2014; 2011 (3) CLT 549; PSCDRC, CHD; FA 537 of 2008; 2018 (3) CPJ 172; PSCDRC, CHD; CC 100 of 2017;
3. The learned counsel of the complainant has pleaded and argued that the OP insurers have sanctioned the policy after getting complete medical check-up of the applicant/ life-assured and having found him eligible/ entitled to insurance. As the OPs have alleged pre-existing ailments on date of application (22.12.2016) so the Onus Of Proof lay heavily upon them (the OPs);The terms of the applicable policy were neither supplied to the insured nor have been produced during the course of present proceedings; 2017 (2) PLR 726; P & H High Court; CWP 15447/2014; The OIC Ltd. vs. Vishal Pal anr.“In the absence of any cogent evidence brought on record, the observation of the Hospital in which it is only mentioned that it is a known case of HTN & Diabetes, no benefit can be given to the petitioner as it goes to the patient”.
- CPJ 172; PSCDRC, CHD; CC 100 of 2017; Rajesh Singla vs. Max Bupa Ins.Co.“Moreover HTN is not a disease, which is required to be referred in the proposal form – OPs have failed to collect any that before taking policy the insured was ……”. The complainant closed the evidence and prayed for the relief as duly pleaded, above, in his complaint.
4. The titled opposite parties, in response to the commission’s summons appeared through their counsel and filed their written reply stating therein preliminary objections as: No cause of action in favor of the complainant; Complaint bad for non-joinder of necessary parties; Insurance is a contract between the two parties and binds both vide its terms and conditions; It is the complainant’s duty to disclose all the material facts at the time of purchase of the policy; No deficiency in service on the OP’s part as the policy was issued on the basis of information provided in the proposal form that turned up to be untrue as the Life Insured suffered from pre-existing ailments; Further, on merits, the OP’s in its written statement have either denied or shrugged the contents of the complaint addressing these as matters of records etc.; Finally, the OPs have sought dismissal of the complaint with costs being bereft of any merit.
5. The OPs in support of their version and pleadings in defense have produced the following evidentiary documents: Ex.OP1,2/1 Self declaration by the Legal Manager Sh. Gurpreet Singh deposing the contents of the written reply as well as the sanctity of the evidence; Ex.OP1,2/1Investigation Report by Sh. Abhishek Kr Jha Investigator of Eagle Eye Consultant Pvt. Ltd., sans the necessary affidavit mandatory to be filed with surveyor/ consultant/ investigator report in terms of NCDRC Judgment (2012) (I) CPR 386 (NC); Ex.OP1,2/2 Daily Doctor’s Progress Notes (9 pages) of Fortis Hospital, Amritsar Unattested pages (most of these are unnamed and undated) and not accompanied by the Hospital’s Certificate; Ex.OP1.2/3 Application dated 22.12.2016 for purchase of the policy, Ex.OP1,2/4 Repudiation Letter (of Death Claim) dated 14.03.2019; Ex.OP1,2/5 Unattested copy of Cardiac History & Physical History Sheet dated 16.08.2107 at Fortis Hospital, Amritsar; As desired, the OPs have somehow, not filed their written arguments;
6. The learned counsel for the OP insurers has pleaded and argued that the policy was issued on the basis of self declaration by the applicant/ life assured that was later found to be false and thus the death claim was repudiated. There’s no deficiency in service on the part of the OP insurers. The Investigator’s report provides ample proofs for causing repudiation of the claim.
7. We have examined the available documents/ evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen on account of the impugned ‘repudiation’ of the insurance death-claim pertaining to the Policy in question, by the opposite party insurers, as filed by the present complainant pertaining to the ‘death-claim’ of her late (demised) husband Dharminder Singh, the DLA (deceased life assured). The complainant has been the legal heir of DLA besides being the registered nominee.
8. We observe that the one and the only prime eventful aspersion founding/supporting the repudiation of the impugned 'death claim' in question has been the non-disclosure/ concealment (by the DLA) of his pre-existing ailments at the time of purchase of the policy, in question. Somehow, we do not concur with the logic of the repudiation and are inclined to examine the validity & legality of the impugned repudiation (of the related insurance death-claim) in the back-drop of the preceding and also the succeeding acts & events in the light of the facts on records and current law on insurance vis-à-vis consumer proposition’s subject matter, in issue. We find that the related insurance policy was admittedly issued on the strength of the DLA undergoing an exhaustive medical examination at the hands of medical staff of the OP’s nomination and thus his health status (including pre-existing diseases, if any) were fully known to the OPs and its representatives and presently the OPs are estopped from repudiating the death-claim on the strength of Investigator’s report based on the randomly procured documents from the Fortis Hospital at Amritsar. Moreover, section 45(3) of the Insurance Act, 1938 (as amended up to date) bars repudiation of Policy on account of mis-statement(s) and/or suppression of fact(s) that are within the knowledge of the insurers or its representatives. And, to top it up all the OPs have ignored to produce the DLA’s Medical Examination Reports and also the governing Terms & Conditions of the applicable policy.
- Thus, the OP have failed to produce some cogent evidence, to support its prime allegation of intentional non-disclosure/ suppression of pre-existing ailments. We find that the OP insurers here have arbitrarily repudiated the present claim merely on the ‘presumption’ that the DLA had knowledge of his pre-existing ailments. To remove all ambiguity, it may be clarified here that an ‘insurance claim’ and for that matter any ‘issue’ can be neither legally ‘favored’ nor legally ‘ousted’ on mere ‘presumption’ how strong it might appear to be.
- We further find that the present policy in question was purchased through the services of insurers representative(s)/ agent(s) carrying their name(s)/ nos/ signature(s) on the policy and the proposal/ report(s) etc; hence it is understood that all the DLA’s information in totality was fully available in the hands of the OP insurers’ Representative(s)/ Agent(s) and thus the OP are estopped from taking the plea of non-disclosure etc. We further find that the insurance company is relying upon a document of Fortis Hospital, but the same pertains to the August 2017, and the policy was issued in the year 2016, as such the said documents are not relevant as it pertains to the period after issuance of the policy. The opposite party has relied upon the notes in which only in the column history the facts regarding the alleged diabetes and hypertension is mentioned but have failed to produce any such cogent evidence and as such said observation carries no value without any cogent and convincing evidence. There is no evidence from OP side that before taking policy the insured was suffering from any such alleged disease. The OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial review and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law.
- Finally, in the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s impugned repudiation of the death-claim being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’. Thus, we ORDER the OP insurers to pay the impugned ‘insurance claim’ to the full Sum Insured (S.I.) of Rs 50 Lac pertaining to the related Policy, in question, with full accrued benefits, if any, along with Rs. 50,000/- as compensation for the undue harassment inflicted upon the widow complainant besides Rs.10,000/- as cost of litigation; within 45 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.
- The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
- Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (R.S.Sukhija)
MAY 12, 2022. Member.
YP.
