BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.252 of 2018
Date of Inst. 12.06.2018
Date of Decision: 10.12.2019
Rupinder Singh S/o Rattan Singh R/o Village Surakhpur, District Kapurthala.
..........Complainant
Versus
1. HDFC Standard Life Insurance Co. Ltd. through its Branch Manager, 1st & 2nd Flr, Gupta Chambers, Civil Lines, Jalandhar, Punjab 144001.
2. HDFC Standard Life Insurance Co. Ltd., through its Managing Director, 11th Floor, Lodha Excelus, Apollo Mills Compound, N. M. Joshi Road, Mahalaxmi, Maharashtra, Mumbai-400011.
3. HDFC Bank Ltd., Near Narinder Cinema, G. T. Road, Jalandhar through its Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. A. K. Arora, Adv. Counsel for the Complainant.
Sh. Vinay Kant, Adv. Counsel for the OPs No.1 & 2.
Sh. V. K. Gupta, Adv. Counsel for the OP No.3.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that he is the son of deceased policy holder Rattan Singh. The OP No.1 the branch office of OP No.2, who had issued insurance policy in favour of deceased father of the complainant Rattan Singh. The OP No.3 had financed the vehicle make Tata Prima 4023 for a sum of Rs.10,20,217/-, against which the life insurance policy was issued by OP No.1. The said vehicle was purchased by the deceased father of the complainant from Tata Motors Jalandhar. The complainant is also nominee of the said policy, therefore is a consumer within the ambit of the Consumer Protection Act. The insurance policy in question is under scheme of membership insurance and having policy No.CP000046 and Scheme Member Code 82487889 for assured amount of Rs.10,00,000/-, commencing from 06.03.2017 to 05.03.2019 stands in the name of the father of the complainant deceased Rattan Singh and wherein the complainant Rupinder Singh is a nominee.
2. That only the Policy Schedule was provided to the complainant at the time of issuance of policy of insurance and no terms and conditions of the policy of insurance including any hidden exclusion clauses were not provided to the complainant and as such, any hidden exclusion clause in the policy of insurance is not binding upon the complainant.
3. That the father of the complainant, insured Rattan Singh was gone to Dubai for his personal work and fell ill over there and was admitted on 19.07.2017 till 01.08.2017 in the Thumbay Hospital, Ajman UAE, as his condition was then diagnosed stable and normal and then he was discharged and was advised medical treatment at home. Thereafter, the insured came back to India and took treatment at Premier Gastroenterology Institute at Jalandhar from 01.08.2017 to 06.08.2017, where he was advised to consult the higher centre for his treatment. Thereafter, he took treatment at Mannat Super Specialty Hospital and was discharged on 11.08.2017 and his condition was termed as ‘Hemodynamically Stable’. The discharge summary was issued by the said hospital. The father of the complainant was not satisfied with the treatment at Jalandhar and therefore, he got himself admitted at PGIMER, Chandigarh on 12.08.2017 and was diagnosed with condition ‘Abdominal Distension and Jaundice’. He was given treatment and was discharged on 25.08.2017 and his condition was stated as ‘Hemodynamically Stable’. Thereafter, the father of the complainant came back home at Kapurthala in a healthy state and was under medication as advised by the doctors at PGIMER, Chandigarh. The father of the complainant enjoyed good health from 25.08.2017 to 03.09.2017. However, father of the complainant complained of high fever on 04.09.2017 and on the same day, he was taken to PGIMER, Chandigarh for his treatment. The father of the complainant continued his treatment at PGIMER, Chandigarh from 04.09.2017. He was shifted to ICU and while undergoing treatment in ICU, he took his last breath on 21.09.2017. The Liver Clinic File issued by PGIMER, Chandigarh on 04.09.2017 and Death Certificate of Rattan Singh was also placed on the file.
4. That the complainant being nominee of the Life Insured Rattan Singh, had lodged death claim of his father with OP No.1. To the utmost shock of the complainant, the said claim was rejected by the OPs No.1 & 2, vide letter dated 24.03.2018 after lapse of five months on the ground as stated therein as under:-
“Life insured was suffering from Diabetes for 6 years and Chronic Lever Disease prior to issuance of policy and the said information was not provided to the OPs No.1 and 2 by the father of the complainant at the time of taking of policy.”
5. It is further submitted that the questionnaire was filled by the agents of OPs No.1 and 2 on their own without inquiring the same from the deceased. As such, the rights of the legal heirs of the deceased cannot be waived off on the basis of this wrongly filled questionnaire. However, the father of the complainant was not suffering from any Chronic Lever Disease with Portal Hypertension, Diabetes Mellitus at the time of taking of insurance policy from the OPs. The OPs No.1 and 2 has rejected the claim of the complainant on false and flimsy grounds in order to avoid their liability. The said life insurance was done at the instance of OP No.3, who assured the father of the complainant that in case of any mis-happening, the amount of the loan shall be adjusted from the insurance money received from OPs No.1 and 2. The family of the deceased father of the complainant was immensely dependent on the earnings of the deceased and after his death is unable to maintain themselves and also not in a financial position to repay the loan. Taking benefit of the said fact, the OP No.3 is threatening the family of the deceased Rattan Singh to repay the outstanding loan amount or they will take the possession of the vehicle forcibly. The act and conduct of the OPs is tantamount to deficiency in service, which caused mental tension and agony to the complainant and accordingly, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs No.1 and 2 be directed to make the payment of Rs.10,00,000/- to the complainant being the amount of insurance policy and further, OP No.3 may kindly be restrained from taking possession of the loaned vehicle till the time the present dispute is decided by the Forum and further, OPs No.1 and 2 be directed to pay interest @ 18% per annum upon the awarded amount and further, OPs No.1 and 2 be directed to pay litigation expenses of Rs.20,000/-.
6. Notice of the complaint was given to the OPs and accordingly, OPs No.1 and 2 appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that at the very outset the answering OPs No.1 and 2 deny all the allegations, facts and averments stated in the complaint filed by the complainant except to the extent they are expressly admitted therein and further averred that the complaint under reply is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead the Forum and as such, the complaint is liable to be dismissed on this ground. It is further alleged that no cause of action has ever accrued in favour of the complainant to file the present complaint and thus, the same is liable to be dismissed and further submitted that the complainant has concealed the material facts. It is further averred that the deceased life insured i.e. Rattan Singh had submitted to the OP No.3 a proposal/application for the purchase of Group Insurance Policy bearing No.CP000046 i.e. “HDFC Life Group Credit Protect Insurance Plan” and deceased insured was accepted and policy was issued on 06.03.2017 by issuing a Member No.82487889. It is further alleged that the deceased Rattan Singh insured at the time of making the said proposal had misrepresented about his health i.e. the deceased was suffering from Diabetes Mellitus for the last six years & Chronic Liver disease with Portal Hypertension prior to issuance of the policy and 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 facts. This very fact is very much evident from the medical records obtained by the OPs No.1 and 2 in which the deceased life insured was diagnosed with aforesaid disease. So, it is established that the deceased life assured has suppressed and concealed the very material facts of the suffering from chronic pre-existing disease at the time of issuance of the policy. Thus, the complaint is liable to be dismissed and as such, the claim of the complainant has been rightly repudiated, vide letter dated 24.03.2018 on the ground of suppression of material facts by the insured at the time of filling up the proposal form. On merits, it is admitted that the policy in question was obtained by the father of the complainant and who took a treatment and died in the hospital, thereafter insurance claim was filed by the complainant, the same was repudiated rightly. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
7. Replication to the written reply of the OPs No.1 and 2 filed, whereby reasserted the entire facts as detailed in the complaint and denied those of the written statement.
8. OP No.3 filed its separate reply and contested the complainant by taking preliminary objections that the instant complaint is not maintainable against the answering OP No.3 and is liable to be dismissed with heavy cost. The OP No.3 is unnecessarily dragged in the instant complaint because there is an inter-se dispute between the complainant and the OPs No.1 and 2 and as such, the instant complaint qua OP No.3 is liable to be dismissed. It is further averred that there is no deficiency in service or negligence alleged on the part of the answering OP and further submitted that the father of the complainant Sh. Rattan Singh availed credit/loan facility from the OP No.3 for the purchase of the commercial vehicle under the loan account No.82487889. However, the said loan account presently running highly irregular. It is submitted that the complainant himself stood as guarantor for the repayment of the above said dues, but he and other LRs are of late Sh. Rattan Singh are not making the payment of the same and further submitted that the bank has first charge over the amount any received from the insurance company. On merits, the factum as narrated in the complaint are controverted and lastly submitted that the complaint of the complainant qua answering OP is without merits, the same may be dismissed.
9. Replication to the written reply of the OP No.3 not filed.
10. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB alongwith some documents Ex.C-1 to Ex.C-12 and closed the evidence.
11. Similarly, counsel for the OPs No.1 and 2 tendered into evidence affidavit Ex.OPA alongwith some documents Ex.OP-1 to Ex.OP-6 and closed the evidence and then counsel for the OP No.3 tendered into evidence affidavit Ex.R3/A alongwith some documents Ex.R-1 and Ex.R-2 and closed the evidence
12. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
13. From the pleadings of the parties, one thing is admitted to the extent that the father of the complainant insured Rattan Singh got Group Insurance Policy from OPs No.1 and 2 and also got financed for purchase of the vehicles as a Life Group Credit Protect Insurance Plan. It is necessary to make it clear that the father of the complainant insured got four Group Insurance Policies and accordingly, purchased four vehicles and the same were got insured under the Group Protect Insurance Plan and all the four cases are pending today simultaneously. In all the four cases, the policy number is same i.e. CP000046, but the Scheme Member Code are different in all the four cases which are, in the case of hand 82487889 and in other cases 82487903, 82487894, 82469808 and amount of insured is Rs.10,00,000/- in three cases and Rs.12,00,000/- in fourth case and date of commencement and validity upto are also same i.e. 06.03.2017 and 05.03.2019 and in all the cases, complainant Rupinder Singh is admittedly nominee, this fact is not denied by the OPs No.1 and 2. It is also admitted that the father of the complainant insured Rattan Singh was remained admitted firstly in Thumbay Hospital, Ajman UAE, then Premier Gastroentology Institute at Jalandhar, then in Mannat Super Specialty Hospital, Jalandhar and thereafter, PGIMER, Chandigarh and where he admittedly died on 21.09.2017 and after the death, the son of the complaint filed insurance death claim of his father in all the four cases and the same were repudiated by the OPs, vide separate letter dated 24.03.2018 and there-upon necessity arose to the complainant to challenge the said repudiation letters through separate complainants.
14. We do not find any need to repeat the facts of the complaint or reply of the OPs and further like to discuss that the complainant has not claimed anything from OP No.3 rather the OP No.3 is only impleaded in this case as party, being reason the complainant alleged that a loan was obtained for purchase of the vehicle from OP No.3 and asked the relief only qua OP No.3 to restrain the OP No.3 from recovering the vehicle in question till the disposal of this complaint. Now, case is going to dispose and thus, we find that no claim is remained qua OP No.3, but OP No.3 alleged that if the complainant succeed to get award from insurance company, then the financial institution OP No.3 has a first right to recover the remaining loan stand in the name of deceased insured Rattan Singh. We admitted that the financial institution has a first right to recover the loan amount from the awarded amount from insurance company, during the course of argument, the counsel for the complainant submitted that the LR of the deceased insured Rattan Singh has already paid the entire due loan amount in all cases, if so, then we find there is nothing remained due to be recovered by OP No.3 from the complainant. If in case anything remained due towards the said loan amount of the OP No.3, then OP No.3 is at liberty to recover the said remaining amount from LRs of the loanee as per law.
15. Coming to the controversy between the complainant and OPs No.1 and 2. Admittedly, the insurance claim of the complainant has been repudiated by the OPs No.1 and 2, vide repudiation letter Ex.C-12 dated 24.03.2018 on the ground that a short medical questionnaire in the member enrollment form was put to each assured and the answer given by deceased Rattan Singh is incorporated as under:-
“Have you ever suffered or are currently suffering from: (a) Chest pain or heart attack or any other heart disease (b) Cancer, tumor growth or cyst of any kind (c) Stroke, paralysis, Epilepsy any psychiatric/mental disorder, disorder of brain/nervous system or any kind of physical disabilities (d) Asthma Tuberculosis or lung disorder (e) Disease or disorder of muscles, bones or joint, arthritis or blood disorder (anaemia) or any endocrine disorder (f) Disease of the kidney, digestive system (stomach, pancreas, gall bladder, intestine) liver, hepatitis B or C or HIV/AIDS infection (g) Diabetes, high blood pressure, answer is ‘No’.
16. The above questionnaire elaborated in the said repudiation letter by the OP that from the investigation, it is established that the life assured was suffering from Diabetes Mellitus for the last six years and Chronic Liver disease with Portal Hypertension prior to issuance of the policy and by invoking the above alleged concealment, the claim of the complainant has been repudiated by the OPs. Admittedly, the OPs No.1 and 2 also brought on the file Inquiry Report conducted by Zenith Groups Investigation, the same is available on the file Ex.OP-4. In the said investigation report in first page, it is categorically mentioned that the deceased insured was 56 years old at the time of death i.e. 21.09.2017, if the deceased insured was 56 years old on 21.09.2017, then why the medical examination of the insured Rattan Singh was not got conducted by the OP from any Doctor. It is mandatory duty of the OP to medically examined every insured prior to inception of the insurance policy, but the OP, for the best known reason itself not got medical examined the insured Rattan Singh at the time of issuing the policy, if medical conducted, then why the same is not brought on the file. So, this factor goes against the OPs No.1 and 2 for not conducting medical examination of the insured Rattan Singh.
17. The next point which required deep consideration is that the plea of the OPs No.1 and 2 that the deceased insured Rattan Singh concealed the material facts in regard to pre-existing disease that he was suffering from Diabetes Mellitus for the last six years and Chronic Liver disease with Portal Hypertension prior to issuance of the policy and in support of this, the investigator took the documents from all medical hospitals i.e. from UAE, Jalandhar as well as Chandigarh and in the Discharge Summary Ex.C-8, issued by PGIMER, Chandigarh wherein under the heading ‘Past History’, H/O DM type 2 for 6 years is categorically mentioned and this wording of the Discharge Summary has been taken into consideration by the Investigator and accordingly by relying upon the report of the investigator, the OPs No.1 and 2 make a mind that the insured deceased Rattan Singh was having pre-existing disease and accordingly, repudiated the claim, but we find that simply giving a writing by treating doctor in patient’s history that he is having Diabetes Mellitus for the last six years & Chronic Liver disease is not acceptable because the OP has not brought on the file any other solid and documentary medical proof to establish that the deceased insured ever took any medicine for the said disease or underwent any test or any other investigation, but there is no evidence on the file that father of the complainant ever took any medicine or test from any hospital prior to taking of the insurance policy i.e. 06.03.2017, if so, then we find that the opinion made by the OPs No.1 and 2 that deceased insured Rattan Singh was having pre-existing disease, is not established or acceptable and in support of this observation, we like to refer a pronouncement of our Hon’ble State Commission, cited in 2007(1) C. P. J. 260, titled as “Oriental Insurance Company Limited Vs. Chain Singh and anr.”, wherein his Lordship held as under:-
“Insurance- Mediclaim policy-Policy valid from 02.10.2003 to 01.10.2004- In November 2003, complainant hospitalized in Heart Institute- Underwent CABG operation – Claim repudiated on ground that complainant was known case of coronary artery disease for last 5-6 years- complaint allowed by District Forum – Appeal against – Nothing on record that complainant ever took any medicine for said disease or underwent any test or any other investigation – As per opinion of doctor, disease not pre-existing at time when initial policy taken i.e., 01.08.1998- Order of District Forum affirmed.”
Further, in the same line of action, we referred a pronouncement of Hon’ble State Commission, Haryana, cited in 2019 (1) C.P.J. 172, titled as “United India Insurance Co. Ltd. Vs. Bimla Saini & Ors.”, wherein his Lordship held as under:-
“Consumer Protection Act, 1986-Sections 2(1)(g), 14(1)(d), 15- Insurance (Mediclaim)- Jaundice- Chronic alcoholic abuse- Alleged suppression of material fact- Claim repudiated – Deficiency in service –District Forum allowed complaint – Hence appeal- Opposite No.1 could not adduce any document or any other convincing evidence to establish that insured ever got treatment regarding liver functions abnormalities or any disease relating to jaundice prior to date of providing insurance policy- Merely, because treating doctor in patient history mentioned that it is a case of chronic alcoholic abuse, findings cannot be given that insured was habitual or addicted to drinking and used to consume alcohol every day- It is not always necessary that cause of ailment of jaundice and liver functions abnormality is always consumption of alcohol- Persons who never consume alcohol also can face problems with liver- Doctor concerned has not given any sound reasons regarding his opinion that it is a case of chronic alcoholic disease – Treating doctor has not made it clear as to whether deceased himself had told him regarding his drinking habits or he got information in this regard from any other source-Repudiation not justified.”
Apart from above, we further have gone through the documents and find that the deceased insured Rattan Singh obtained the insurance policy on 06.03.2017 and thereafter, first time he got himself admitted Thumbay Hospital, Ajman UAE on 19.07.2017 and remained there admitted till 01.08.2017. During the period from date of issuing of the insurance policy i.e. 06.03.2017 to the date of admission first time in hospital Ajman, UAE i.e. 19.07.2017, there is no medical evidence, treatment obtained by the father of the complainant from any hospital, means the insured deceased Rattan Singh was himself not aware regarding his disease, if he was not aware, then how he can disclose the said disease to the insurance company. So, it means the version of the complainant that his father was not having any pre-existing disease, prior to obtaining the insurance policy and this fact has been very much pleaded by the complainant in para No.9 in the last 3-4 lines. So, if the father of the complainant was not aware regarding any disease, which was find out by the hospital in Dubai first time, then we can say that there is no concealment/suppression of material facts on the part of the insured Rattan Singh and thus, we conclude that the insurance claim of the complainant has been wrongly and illegally repudiated by the OPs and in support of this observations, we like to refer a pronouncement of Hon’ble National Commission, cited in 2010(1) C.P.R. 263, titled as “National Insurance Co. Ltd. Vs. P. Govindarajulu and Reddy and another”, wherein his Lordship held as under:-
“Consumer Protection Act, 1986 Sections 12 and 17 Repudiation of Medi-claim on ground of suppression of earlier disease- Insured fell down, developed severe pain in both knees and was operated by surgery incurring total expenditure of Rs.3,47,274/- -Complaint allowed by District Forum- Revision petition against – Question arises to whether there was in fact any concealment of pre-existing disease by complainant-Discharge-summary though mentioned “pain swelling stiffness both knees joints since one year, but no mention that patient was suffering from Rheumatoid Arthritis before commencement of policy- Medical opinion of orthopaedic surgeon produced by appellant got no support by affidavit and nor that surgeon had ever examined the complainant- Failure on part of OP produce any evidence regarding any treatment for that disease prior to taking policy- Surveyor appointed by appellant was bachelor in Technology and not an orthopaedic surgeon- No interference warranted”
On the same point, we further like to refer an other pronouncement of Hon’ble Delhi State Commission, cited in 2004(1) C.P.J. 388, titled as “New India Assurance Co. Ltd. Vs. Pushpa Verma”, wherein his Lordship held as under:-
“Consumer Protection Act, 1986 Section 15 Insurance- Medi-claim policy- Repudiation of claim on ground of pre-existing disease – No reliable evidence adduced in support – Repudiation arbitrary- Deficiency in service proved- Damages and cost reduced in appeal”
If we see the case of the complainant in the light of above detailed discussion, then we find that the insurance claim of the complainant has been wrongly repudiated by the OPs No.1 and 2 for which the complainant being the nominee as well as LR of deceased insured Rattan Singh, is entitled alongwith litigation expenses as well as interest.
18. As an upshot of our above detailed discussion, the complaint of the complainant is partly accepted and OPs No.1 and 2 are directed to pay death insurance claim of insured Rattan Singh of Rs.10,00,000/- to the complainant alongwith interest @ 12% per annum from the date of repudiation i.e. 24.03.2018, till realization and further, OPs No.1 and 2 are directed to pay litigation expenses of Rs.15,000/- to the complainant, no compensation has been claimed by the complainant. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
19. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
10.12.2019 Member President
