Madhya Pradesh

StateCommission

CC/17/123

SMT.INDIRA BAI - Complainant(s)

Versus

HDFC STANDARD LIC - Opp.Party(s)

SH.SANDEEP GURU

03 May 2023

ORDER

M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BHOPAL

PLOT NO.76, ARERA HILLS, BHOPAL

 

                                                   CONSUMER COMPLAINT NO.123 OF 2017

                                                                                                                           FILED ON 09.10.2017

                                                                                                 DECIDED ON 03.05.2023

 

 

SMT. INDIRA BAI MALVIYA,

W/O LATE SHRI KARAN SINGH,

R/O VILLAGE-BAGER, TEHSIL-ASHTA,

DISTRICT-SEHORE (M.P.)                                                                        …          COMPLAINANT.

 

Versus

                 

1. MANAGING DIRECTOR.

    HDFC STANDARD LIFE INSURANCE CO.LTD.

    REGISTERED OFFICE- 11^TH FLOOR, LODHA EXCELUS

    APOLLO MILLS COMPOUND, N.M.JOSHI ROAD,

    MAHALAXMI, MUMBAI-400 011 MAHARASHTRA  

 

2. BRANCH MANAGER,

    HDFC STANDARD LIFE INSURANCE CO.LTD.

    SECOND FLOOR, BANSI TRADE CENTRE,

    PALASIA, INDORE – 452 001                                                                  …         OPPOSITE PARTIES

 

 

BEFORE :

            HON’BLE SHRI JUSTICE SHANTANU S. KEMKAR   :  PRESIDENT

            HON’BLE DR. SRIKANT PANDEY                               :  MEMBER

            HON’BLE DR. (MRS) MONIKA MALIK                         :  MEMBER

 

                     

COUNSEL FOR PARTIES :

                Shri Sandeep Guru, learned counsel for the complainant.

           Shri Vivek Anand Nema appears for Shri Sunil Nema, learned counsel for the opposite parties.

          

                                                   

                                                            O R D E R

                             (Passed On 03.05.2023)

                   The following order of the Commission was delivered by Dr. Monika Malik, Member:

 

                   This complaint under Section 17 (1) (a) of the Consumer Protection Act, 1986 (for short ‘Act’) is filed by the complainant alleging

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deficiency in service on part of the opposite parties for not giving the insurance claim of her deceased husband.

2.                Briefly put, facts of the case are that the complainant’s husband, Late Shri Karan Singh (hereinafter referred to as ‘deceased-insured’) during his life time had obtained ‘HDFC Life Click 2 Protect Policy’ on 30.03.2013 from the opposite parties after paying requisite premium. It is submitted that the duration of the policy was 20 years i.e. the policy was w.e.f. 02.02.2013 to 02.02.2032 for sum assured of Rs.25,00,000/- and the complainant was nominee under the said policy. First instalment of Rs.12,501/- was paid to the opposite parties.  The deceased-insured died on 07.03.2013 regarding which the opposite parties were informed.  It is stated that the claim form, with requisite formalities was submitted with the opposite parties but the opposite parties did not decide the death claim of her husband.  The complainant also alleged that the opposite parties-insurance company obtained signatures from deceased on various documents before providing the policy cover and various medical tests were carried out and other formalities were fulfilled by them. It is alleged that despite the aforesaid, the opposite parties did not pay the insurance claim of the deceased-insured and therefore alleging deficiency in service on part of the opposite parties, the complainant approached this Commission, seeking relief.

 

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3.                The complainant in her complaint sought relief of sum assured i.e. Rs.25,00,000/-, towards death benefits,  from the opposite parties with interest @ 24% p.a. from the date of filing of claim with the opposite parties till payment along with compensation as this Commission deems fit.

4.                The complainant has filed her affidavit, along with set of documents in support of complaint filed by her. 

5.                The opposite parties-insurance company in their written statement made a submission that the proposal form dated 18.02.2013 was filled by the deceased-insured online, after accepting/agreeing to the given terms and conditions, in order to obtain the subject insurance policy.  Thereafter, policy no.15717482 was issued in the name of the deceased-insured on 31.03.2013.  The deceased-insured died on 07.03.2013. On claim being filed, it was observed that the deceased-insured had given wrong information regarding his health condition in the proposal form filled by him.  As there was misrepresentation and concealment of material information on part of the deceased-insured, the claim was not payable and the same was denied by the opposite parties-insurance company.  It is further submitted that after denial of the claim by the insurance company, the complainant approached this Commission after a long period of 4 years.  It is therefore submitted that the complaint filed by the complainant is barred by limitation and deserves to be dismissed.

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6.                The opposite parties-insurance company has filed affidavit of Shri Kunal Kumar S/O Shri Shyam Vishwakarma, Deputy Manager, HDFC Standard Life Insurance Co. Ltd. M. P. Nagar Branch, First Floor, State Planet Building, Plot No.9, Zone-II, M. P. Nagar, Bhopal along with set of documents, in support of reply filed by the opposite parties.

7.                Heard.

8.                Learned counsel for the complainant argued that the deceased-insured, being an uneducated person could not read the terms and conditions given in the proposal form. He signed the declaration towards the end of the proposal form as the same was specified in ‘Hindi’.  As regards misrepresentation on part of the deceased-insured while filling the proposal form, learned counsel argued that the opposite parties had carried out medical tests of the deceased-insured and thus they have no right to question the alleged concealment of material facts which  they have failed to prove also. Learned counsel further submitted that the opposite parties kept the claim of the deceased-insured pending for very long period and did not even reply to the legal notice given by the complainant. He therefore argued that the opposite parties have been deficient in service and prayed that the complainant be given sum assured along with compensation, as has been sought by her, in the relief clause of the complaint.

 

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9.                Learned counsel for the opposite parties primarily raised the objection regarding limitation in filing the complaint.  He argued that the opposite parties had rejected the claim of the deceased-insured on 06.11.2013 regarding which the e-mail to the complainant was also sent on 14.11.2013.  Therefore, when the claim was rejected in the year 2013 and the same was communicated to the complainant then the complaint filed by the complainant in the year 2017, is barred by limitation.

10.              Learned counsel further argued that the deceased had expired before commencement of the policy cover, which is another reason that the claim is not payable.  He also referred to an investigation report which is available in the record and submitted that the deceased was suffering from cancer and died due to same on 07.03.2013 but he had concealed the aforesaid information while filling up the proposal form in order to obtain the subject insurance policy. He argued that the complaint deserves to be dismissed.

11.               Points for determination, which arise in the case, are as under:-

                   1) Whether in this case, the complainant is a ‘consumer’ as defined under Section 2(1) (d) of the Consumer Protection Act, 1986?

                   2)  Whether the complaint filed by the complainant is barred by limitation?

 

 

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3) Whether the opposite parties-insurance company have committed deficiency in service/unfair trade practice by not giving insurance claim of the complainant’s deceased husband?

                   4)  Whether the complainant deserves any relief?

12.              Since the subject insurance policy was issued by the opposite parties-insurance company in the name of the deceased-insured and the complainant is nominee under the said policy, the complainant is a ‘consumer’ as defined under Section 2(1) (d) of the ‘Act’.

13.              The insurance company has stated to have repudiated the complainant’s claim on 06.11.2013 and had also communicated via e-mail to the complainant on 14.11.2013. Exhibit C-5, filed by the complainant is e-mail dated 04.11.2013 whereby the insurance company has communicated with the complainant stating that:

 “Claim repudiated for non-disclosure of moderately differentiated squamous cell carcinoma of right RMT, chemotherapy and radiotherapy done prior to the proposal date.”

 

                   This document is proof in itself that the complainant had knowledge of repudiation of the claim by the insurance company. Therefore the complaint filed on 09.10.2017, which was filed after nearly four years from the date of repudiation of claim, is clearly barred by limitation.

14.              Also on merits, we observe that the Histopathology report of Biopsy RMT dated 03.10.2011 of Jawaharlal Nehru Cancer Hospital & Research Centre, Bhopal (JNCHRC) gives impression that:

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                      ‘Moderately Differentiated Squamous Cell Carcinoma’.

                This report further suggests that it is likely a recurrent disease.            

                    CT Scan Face & Neck dated 08.05.2012 of JNCHRC shows that deceased-insured is a:

                     ‘Case of Ca right RMT-post RT/CT (Radiotherapy & Chemotherapy).’ 

                      The CT Scan Face & Neck report dated 17.11.2012 also suggests that the deceased-insured is a:

‘Case of right RMT-post RT/CT/OP (right commando procedure-right hemimandibulectomy with right upper alveolectomy with MND and PMMC flap)’ and it is likely a recurrent disease.

 

                     The aforesaid documents are available in record and there is no specific rebuttal from the complainant’s end.

15.              That apart, the deceased-insured while filling up the proposal form on 18.02.2013 had replied in negative to the relevant queries raised regarding his health.  The proposal form was filled and signed by him.  The insurance company repudiated the claim on the ground that the deceased-insured had given wrong information regarding his health condition in column no.32, 34, 37 and 39 of the proposal form.

16.              On the basis of evidence available before us, we deduce that the deceased-insured was suffering from ‘Squamous Cell Carcinoma’ and was operated for the same and had undergone Chemotherapy and

 

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Radiotherapy in aforesaid regard as well but he had concealed this information while filling up the proposal form in order to obtain the subject insurance policy.  Since there has been suppression of material facts on part of the deceased-insured we find that there has been no deficiency in service on part of the insurance company in denying the complainant’s claim.

17.              To conclude, we find that the complaint is barred by limitation as also on merits, the complaint deserves to be dismissed. With this, we decide all the points for determination framed in the matter.

18.              As a result, the complaint is dismissed with no order as to costs.

19.              Let the record be deposited in the record room after noting down the order.

 

  (Justice Shantanu S. Kemkar) (Dr. Srikant Pandey) (Dr. Monika Malik)           

                 President                          Member                    Member