Haryana

Karnal

CC/65/2022

Vinod Kumar - Complainant(s)

Versus

HDFC Life Insurance Company Limited - Opp.Party(s)

S.S. Moonak

17 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.65 of 2022

                                                        Date of instt.04.02.2022

                                                        Date of Decision: 17.09.2024

 

Vinod Kumar, aged 40 years, son of Shri Pala Sham, resident of village Pabana Hassanpur, Bloc no.1, Tehsil and District Karnal. Aadhar no.9592 3060 7192.

                                                                        …….Complainant.

                                              Versus

 

HDFC Life Insurance Company Limited, through its authorized person, above HDFC Bank, Kunjpura Road Karnal.

 

                                                                …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri S.S. Moonak, counsel for the complainant.

                    Shri Vikas Bakshi, counsel for the OP.

       

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that father of complainant namely Pala Sham obtained the insurance policy (HDFC Life Sanchay Par Advantage) from the OP, vide policy no.22619183. The policy was issued on 26.05.2020. The installments of the policy was Rs.99,000/- per annum. The maturity amount of the said policy was Rs.12,00,000/-. The complainant is the nominee in the said policy. The father of complainant had paid two installments. Prior to issuing of the said policy, Pala Ram was medically examined. He was hale and hearty and was not suffering from ailment of illness at the time of issuing the policy. Unfortunately, Pala Sham died on 12.09.2021 due to heart attack. After his death, complainant being nominee, approached the OP and submitted the claim and other relevant documents alongwith original policy with the OP to settle the claim. But despite waiting for sufficient time, no amount was paid to the complainant and ultimately, declined the claim of the complainant by the OP, vide letter dated 17.11.2021 on the false and frivolous ground. It is further averred that OP, at its own has refunded an amount of Rs.1,98,000/- to the complainant in his bank account, without his consent and knowledge. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence complainant filed the present complaint seeking direction to the OP to pay Rs.12,00,000/- as insured amount alongwith bonus and other benefits and interest @ 24% per annum from the date of death of Pala Ram and to pay Rs.1,00,000/- as damages on account of mental pain, agony and harassment and any other relief which this Commission deems fit.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the in the present case, deceased life assured (father of complainant) at the time of making the proposal had misrepresented about his health i.e. he was suffering from “Carcinoma of Tongue” prior to issuance of policy and DLA has suppressed this material fact. This fact is very much evident from the medical records obtained by the OP in which DLA was shown to be suffering from chronic disease of “Carcinoma of Tongue” prior to issuance of the policy. Thus, the death claim filed by the complainant has rightly been repudiated by the OP, vide letter dated 17.11.2021. A sum of Rs.1,98,000/- refund of the premium amount was credit in the saving account of the complainant. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of repudiation letter dated 17.11.2021 ExC1, copy of premium receipt Ex.C2, copy of bank copy Ex.C3, copy of death certificate Ex.C4, copy of insurance policy Ex.C5 and closed the evidence on 22.09.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Gurpreet Singh, Deputy Manager Ex.OPW1/A, authority letter Ex.OP1, copy of proposal form Ex.OP2, copy of customer consent document Ex.OP3, copy of medical record Ex.OP4 to Ex.OP13, copy of repudiation letter Ex.OP14 and closed the evidence on 10.04.2024 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainants, while reiterating the contents of the complaint, has vehemently argued that Pala Ram (since deceased) purchased insurance policy from the OP. Complainant is the nominee in the said policy. On 12.09.2021, Pala Ram died due to heart attack. Complainant lodged the claim with the OP and submitted all the required documents to settle the claim but OP did not settle the claim and repudiated the claim on the false and frivolous ground. Thus, there is deficiency in service and unfair trade practice on the part of the OP and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the policy in question was obtained by deceased life assured by way of fraud and misrepresentation. At the time of purchase of the policy, the insured was not having a good health and was suffering from “Carcinoma of Tongue and insured did not disclose the said illness at the time of purchasing of the policy. Thus, the claim of complainant has rightly been repudiated by the OP and premium received has already been refunded to the complainant and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, Pala Ram (since deceased) purchased an insurance policy from the OP and complainant is the nominee in the said policy. It is also admitted that the sum assured in the said policy (Ex.C5) is Rs.11,88,000/-. It is also admitted that OP has refunded the premium amount of Rs.1,98,000/- to the complainant.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C1/Ex.OP14 dated 17.11.2021 on the ground that the deceased life assured has past medical history of “Carcioma of Tongue” and hypertension’ prior to taking policy and said facts had not disclosed by the life assured at the time of purchasing the policy.

12.           The claim of the complainant has been repudiated by the OP on the abovementioned ground. OP has alleged that life assured was suffering from “Carcioma of Tongue” prior to purchase the insurance policy. The onus to prove its case was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon treatment record Ex.OP5 to Ex.OP13. All the above medical records are photocopies.  Moreover, OP neither examined the doctors who issued the said treatment record nor tendered their affidavits in evidence to prove its version. Thus, the said medical records have no weightage in the eyes of law. Life assured died due to heart attack and in the medical record he has taken treatment as alleged by the OP.  Hence, there is no nexus between the cause of death and prior disease as alleged by the OP. When there is no nexus between the cause of death and prior disease then the claim of the complainant cannot be repudiated. In this regard, we are fortified with the observation of Hon’ble Supreme Court in case law titled as Sulbha Prakash Motegaoneka Versus Life Insurance Corporation of India, in civil appeal no.8245 of 2015, decided on 05.10.2015; wherein Hon’ble Supreme Court held that the suppression of information regarding any pre-existing disease, if it has not resulted in death or has no connection to cause of death it would not disentitle the claimant for the claim. Further, in Chanda Devi Vs. LIC in complaint no.551/2016, decided on 23.11.2021 of Hon’ble Delhi State Commission wherein Hon’ble State Commission, Delhi held that if the reason of the death is not in nexus with pre-existing disease and there is no evidence placed on record by the OP to show that the death was on account of pre-existing disease of the life assured, then the contention of the OP in the repudiation letter has no merit. Further, in Religare Health Insurance Company Versus Harwant Singh, decided on 08.02.2021 of Hon’ble State Commission, Chandigarh wherein Hon’ble State commission, Panchkula held that hypertension is a common ailment and it can be controlled by the medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack or other ailment. Further, in case Sucha Singh Vs. Head Brach Office, HDFC Life and Another 2022 CJ 901 (NC) wherein Hon’ble National Commission held that death due to heart attack-claim repudiated on ground of pre-existing ailment-complaint dismissed by State Commission-Insurance Company cannot travel beyond grounds mentioned in repudiation letter-When policy has been revived, it revives from date when it was originally issued-Insurance Company had failed to prove that insured had concealed his medical conditions on the date when he took policy-There is nothing on record to show that deceased was suffering from chronic alcoholic condition and was suffering with chronic liver disease and that he submitted fake documents at the time of obtaining original policy-State Commission had adopted wrong approach while rejecting complaint-Respondent shall pay to complainant assured amount alongwith 9% interest. Further in case titled as Bajaj Allianze Life Insurance Co. Ltd. and others Vs. Vinod Kumar Kaushik (since deceased) 2021 CJ 956 (NC), Hon’ble National Commission has held that Mediclaim-Family Care First Plan (Medical Policy)- Surgery for total hip replacement- Non-settlement of claim by Insurance Company on ground of pre-existing condition-Complaint allowed by Fora below-Averments made by OP were not supported by documentary evidence-OP relied on treatment record relating to past history of insured, which were neither verified not supported by proper evidence-In absence of any evidence, it cannot be said that insured was having any past history-Petitioners have failed to point any illegality or irregularity in order passed by State Commission, warranting interference in exercise of Revision-Revision Petition dismissed. Further in case titled as SBI Life Insurance Co. Ltd. Vs. Lakshiben Naginbhai Chauhan and others 2020 CJ 110 (NC) and Authorized Signatory, Hon’ble National Commission has held that Insurance-SBI Home Loan Master Policy-Repudiation of death claim on ground of concealment of pre-existing disease-Complaint allowed by fora below-Both District Forum and State Commission had reached to conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision petition dismissed. Further in case titled as Bajaj Allianz Life Insurance Co. Ltd. and 2 others Versus Kanduru Gangadhara Rao in Revision Petition no.1054 of 2020, decided on 07.10.2021 Hon’ble National Commission held that Insurance Law-concealment of disease-Death claim repudiated by insurer on ground that life assured suppressed her health condition of her taking treatment for  placed reliance on the treatment record, ‘Chronic non-specific cervicitis’ prior to obtaining the policy-Hence this complaint-Held, insurance company placed reliance on treatment record, which was a mere photocopy and not certified. The Doctor who treated the Life Assured was also not examined nor was his affidavit filed by the insurance company. Also, insurance company failed to satisfy this Commission that there was any co-relation between death of the Life Assured and the suppression of ailment "Chronic non-specific cervicitis". Complaint allowed.

13.           Thus, keeping in view the ratio of law laid down in the aforesaid judgments, the repudiation of the claim is based only on the basis of presumption and assumption, which is not admissible in the eyes of law. Thus, it has not been proved on the record that deceased life assured was having any pre-existing disease and has concealed the true facts at the time of purchasing the policy.

14.           As per insurance policy Ex.C4, the date of birth of deceased life assured is 01.01.1961 and policy in question purchased on 26.05.2020. Thus, at that time the age of complainant was more than 59 years. Hence, it was the duty of the OP to get the medical examination of the deceased life assured as per the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI). In this regard, we place reliance upon case titled as  National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016, wherein Hon’ble State Commission U.T. Chandigarh has held that if the complainant and his wife both are older than 45 years of age but there is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDAI) is must in such like cases. Similarly, view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  and held that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

 15.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.”

 

 16.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP, while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice, which is otherwise proved genuine one. 

17.           As per insurance policy Ex.C5, the sum assured is Rs.11,88,000/-. The OP has already refunded the premium amount of Rs.1,98,000/- in the account of complainant. Thus, complainant is entitled for Rs.9,90,000/- (Rs.11,88,000-Rs.1,98000/-) alongwith interest, compensation for mental, pain agony and harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.9,90,000/- (Rs.nine lakhs ninety thousand only)  to the complainant alongwith interest @ 9% per annum from the date of filing the complaint i.e.04.02.2022 till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. However, OP is at liberty to deduct the premium refunded from the awarded amount.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced                                                  
Dated:17.09.2024

         President,

      District Consumer Disputes                           

      Redressal Commission, Karnal.

 

                   ( Neeru Agarwal)            (Sarvjeet Kaur)

                     Member                        Member