Before the District Consumer Disputes Redressal Commission, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No   :         72 of  2019

Date of Institution                      :        03.09.2019

Date of Decision               :        24.01.2023

Harpreet Kaur w/o Late S. Pardeep Singh R/o village Dibbi Pura, Tehsil Patti, District Tarn Taran.

                                                                             …..Complainant

Versus

1. HDFC Life Insurance Company Ltd. having its registered office at 13^th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai-400 011 through its authorized  signatory/ incharge
2. HDFC Life Insurance Company Ltd. having its branch Office at 1/197, Canara Bank Building, 1^st Floor, Near Maata Ganga Girls College Jandiala Road, Tarn Taran 143401 through its Branch Manager/ Authorized Signatory

                                                                             …Opposite Parties

Complaint Under Section  11, 12and 13 of the Consumer Protection Act

Quorum:               Sh. Charanjit Singh, President

Ms. Nidhi Verma Member

Sh. Varinder Pal Singh Saini, Member

For Complainant                     Sh. Amit Monga Advocate

For Opposite Parties               Sh. Mohan Arora Advocate

ORDERS:

Charanjit Singh, President

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11, 12 and 13 against the opposite parties on the allegations that as the company officials and agents approached the complainant and her husband and gave lucrative offers for having a life insurance policy and they were attracted to the offers made by the opposite parties agents. The husband of the complainant had obtained a life insurance policy from opposite parties vide policy No. 18769505. The said Policy was under the Plan Name of HDFC SL PRO GROWTH SUPER II. The Life Insurance Policy commenced w.e.f. 6.8.2016 and the sum assured was Rs. 2,50,000/- and yearly premium to be paid fixed for Rs. 25,000/-. The complainant was nominee in the said insurance policy which was taken by her husband Pardeep Singh son of Dhanna Singh. Unfortunately, on 17.4.2019 the husband of the complainant expired at village Dibbi Pura tehsil Patti, District Tarn Taran. After the death of  husband of complainant on 12.6.2019 submitted his death claim alongwith all the requisite original documents with the opposite party. The claim was lodged at the branch office of the insurance company at Tarn Taran. Now vide impugned communication dated 21.6.2019, the death claim for the policy purchased by the husband of the complainant was rejected by the opposite party by holding that the LA(life assured) was suffering from Diabetes and Hypertension with Diabetic Maculopathy prior to policy issuance which was not disclosed in the application dated 6.8.2016. Shockingly the opposite parties have rejected the claim of the complainant by holding that the LA not disclosed the Diabetic and Hypertension with Diabetic Maculophathy. The husband of the complainant was neither suffering from diabetic and hypertension with diabetic as alleged in the rejection letter nor any false information (personal detail) was furnished at the time of applying the said policy. The opposite parties have not given / attached any proof of any alleged ailment of LA with the rejection letter. After submitting the claim of her husband, the complainant made numerous requests to the opposite parties orally as well as telephonically but all the ended in smoke and opposite parties made an amount of Rs. 76,223.30 as part payment in bank account of complainant. The complainant has prayed the following reliefs:-

1.  Opposite parties No. 1 and 2 be directed to settle the claim and to pay remaining amount of Rs. 1,73,777/- to the complainant being the sum assured as per the insurance policy alongwith interest @ 18% per annum
2. Compensation of Rs. 1,00,000/- on account of mental pain, agony, inconvenience and harassment suffered by the complainant may be awarded to him against the opposite parties.
3. Costs of proceedings alongwith sum of Rs. 11,000/- as advocate fees
4. Interest @ 18% be awarded on the amount above mentioned.

Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, self attested copy of Adhar Card Ex. C-2, self attested copy of Adhar Card Ex. C-3, self attested copy of document / death claim Ex. C-4, self attested copy of death certificate Ex. C-5.

2        Notice of this complaint was sent to the opposite parties and opposite parties appeared through counsel and filed written version inter-alia pleadings that the complainant has not approached this commission with clean hands. The present complaint should be dismissed forthwith on the grounds of being malafide, baseless and lacking of bonafide cause of action. The opposite parties at the very beginning states that there has been no negligence or deficiency in services whatsoever, on part of the opposite parties in dealing with the concerned policy, thus, the present complaint is liable to be dismissed by this commission. The instant complaint lacks cause of action and the complaint is based on mere surmises and conjectures. It is an established principle of law that the machinery of law cannot be invoked on the basis of mere conjectures. Therefore, this complaint is liable to be dismissed on want of cause of action. The complainant is trying to deceive and mislead the commission by stating wrong facts and statements based on his whims and fancies which in reality does not hold true. In the present case, the deceased Pardeep Singh LA at the time of making the said proposal had misrepresented about his health .i.e. the deceased was suffering from decease of "Diabetes and hypertension with Diabetic Maculopathy" prior to issuance of the policy & the suppression of this material facts at the time of filling and signing the proposal form based on which the said policy was issued amounts to suppression of true & material facts. This very fact is very much evident from the medical records obtained by the opposite parties in which the deceased LA was diagnosed with chronic decease of "Diabetes and hypertension with Diabetic Maculopathy". This very fact clearly established that the deceased life assured has suppressed & concealed the very factum of the suffering from chronic pre-existing decease at the time of issuance of the policy i.e. disease of "Diabetes and hypertension with Diabetic Maculopathy". That the death claim filed by the complainant has been rightly repudiated vide letter dt 21.06.2019. Thus, the present complaint is liable to be dismissed by this Commission on this ground alone being devoid of any merits. Non-disclosure of the material facts by the deceased LA is a sufficient ground for the dismissal of the said complaint. It is submitted that deceased life insured while applying for the policy gave wrong information pertaining to his health. After investigation, it was found by the opposite parties that the deceased life insured was suffering from the pre-existing disease of "Diabetes and hypertension with Diabetic Maculopathy" which the deceased LA had not disclosed & had with-held material information that at the time of filing of the proposal form. As per the proposal form the life insured deceased vide column’s No. 13, 18, 21 and 23 of the Personal Details of life to assured which is reproduced as under whereby the deceased life insured Pardeep Singh Life Assured had declared that he was not suffering from any disease whatsoever and all the questions were answered in negative. The relevant columns are reproduced as under:-

 In the said proposal form which was duly filled up at the instructions of the deceased life insured and proposal form clearly states that if it is found that the statement, answers or particulars stated in the proposal form and it’s questionnaire are incorrect or untrue in any respect; the insurance company shall incur no liability under the insurance. The deceased life insured in this case had fully understood the terms and conditions of the policy and further agreed under the agreement therein that if any untrue statement be contained in the application, the policy contract shall be null and void and the money which have paid in respect thereof shall stands forfeited. The opposite parties does not hold any liability under the said policy as the life insurance contracts are contracts ‘uberrimae fides’ where observance of utmost good faith is enjoined on the parties to the contract i.e.  they must disclose all material facts in respect of the risk to be covered by the insurance. The insured is obliged to give full and correct information on all matters which would influence the Judgment of the prudent insurer in determining whether he will accept the risk, and if he would, at what rate of premium and subject to what condition. It is admitted that the deceased life insured had purchased a life insurance policy having policy No., 18769505 i.e. HDFC SL PRO GROWTH SUPPER II having risk commencement date as 6.8.2016 and having a sum assured Rs. 2,50,000/- and the complainant was the nominee in the said insurance policy.  The death claim submitted by the complainant has been repudiated vide letter dated 21.6.2019 by the opposite parties detailing the reason thereof i.e. the deceased insured was as patient and suffering from Diabetes and hypertension with Diabetic Maculopathy prior to the issuance of the policy and was taking regular treatment from the Punjab Health Systems Cor. Civil Hospital Patti (Tarn Taran) and vision Plus Eye Hospital, Amritsar  and further it is worthwhile to mention here that a sum of Rs. 76,223.33 was credited in the account of the complainant vide account No. xxxxxx5851 mentioned with HDFC Bank towards the fund value payable under the above said policy.  The present complaint has been repudiated on the grounds of non discousure of the material information at the time of taking/ purchasing the insurance policy and not on the flimsy grounds.  The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. alongwith the written version, the opposite parties have placed on record affidavit of Arpit Higgins Manager Manger Legal Ex. OP1, authority letter Ex. OP2, Proposal form alongwith addendum Ex. OP3, Payment letter Ex. OP4, Repudiation letter Ex. OP5, investigation report Ex. OP6, medical record of vision Plus Eye Hospital Amritsar Ex. OP7, Medical record of Punjab Health Systems Corp. Civil Hospital Patti, Tarn Taran Ex. OP8.

3        The complainant has filed rejoinder to the written version filed by the opposite parties and denied all the pleas taken in the written version and reiterated the stand as taken in the complaint.

4        We have heard the Ld. counsel for the parties and have carefully gone through the record placed on the file.

5        In the present case insurance is not disputed the opposite parties in para No. 3 of on merits have admitted that the deceased life insured had purchased a life insurance policy having No. 187695065 i.e. HDFC SL PRO GROWTH SUPPER II having risk commencement date as 6.8.2016 and having a sum assured of Rs. 2,50,000/- and the complainant was the nominee in the said insurance policy.  The present complaint has been repudiated the claim of the complainant vide Ex. OP5 and relevant portion reproduced as follows:-

………..However, from investigations it was established that the Life Assured was suffering from Diabetes and Hypertension with Diabetic Maculopathy prior to policy issuance which was not disclosed in the application dated August 06, 2016 had this information been provided to the company at the time of applying for the insurance policy, we would have declined the application.

Since  the vital information was not provided to us at the time of applying for the insurance policy, we regret our inability to accept your claim under the policy 18769505.

Also, we would be processing an amount of INR 76,223.33 to your account No. xxxxxx5851 maintained with HDFC Bank Furnished to us by our towards the fund value payalble under the above said policy……….”

The claim of the complainant has been repudiated only on the ground that the patient was suffering from Diabetes and Hypertension with Diabetic Maculopathy prior to policy insurance which was not disclosed. The hypertension and diabetes is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-

“So far as hypertension and diabetes is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer 14 from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.

We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.  Moreover, the opposti party has failed to establish the relation between fractured neck treatment and DM Type II and HTN. The complainant has not suffered and treated for DM Type and HTN.

6        Not only this, the Opposite Party could not examine any medical practitioner/ doctor who has treated the life assured for diabetes nor the Opposite Party has filed any affidavit of any doctor who has medically treated the life assure for the disease prior to taking of the policy. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies upon the insurer- If assured was suffering from pre-existing disease why insurer had not checked it at the time when proposal form was accepted by its staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled to claim alongwith interest @ 9%. In the present case, the Opposite Party has simply relied upon the history of the life assured recorded at the time of his admission in the hospital. Moreover, the opposite party has failed to prove that LA died due to hypertension and diabetes Miletus. There should be a cogent evidence on record to prove the reason of death due to above said disease.

7        In such a situation the repudiation made by the Opposite Parties regarding the genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon‟ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This „take it or leave it‟, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon‟ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

 “It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

8        As per admission of the opposite parties sum assured in the policy is Rs. 2,50,000/- out of which an amount of Rs. 76,223.33 has been credited in the account of complainant which is not disputed by the complainant and now the complainant is entitled to remaining amount of Rs. 1,73,776.67 Paise (2,50,000-76,223.33=1,73,776.67) from the opposite parties.

9        In view of above discussion, the present complaint is allowed and opposite party is directed to pay Rs. 1,73,776.67 Paise to the complainant.  The complainant has been harassed by the opposite party unnecessarily for a long time. The complainant is also entitled to 20,000/- as compensation on account of harassment and mental agony and Rs 11,000/- as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainants are entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission.

24.01.2023

 (Charanjit Singh)

       President

(Nidhi Verma)                        (V.P.S. Saini)        

                                        Member                                  Member