This is a case U/S-12 of the Consumer Protection Act, 1986 filed by the complainant against the O.Ps named above.
The fact of the case of the complainant, in a nutshell, is that the husband of the complainant during his lifetime insured his life under policy named “HDFC SL Pro-Growth Super II Insurance Policy” under the O.Ps for improvise benefit on 15/05/2015 vide Application No. 1100000070794, vide policy no. 17630031. The deceased husband of the complainant prayed for issuance of policy in the prescribed form with supporting documents and fees and the O.Ps after observing all formalities issued a valid policy showing therein the sum assured amounting to Rs. 3,50,000/- only.
The further case of the complainant is that at the time of issuing the said policy the O.Ps received the premium with an assurance that they will provide proper services to the deceased husband of the complainant and the O.Ps received money from the deceased husband of the complainant. Thereafter, due to high fever the husband of the complainant shifted to Apollo Hospital in Chennai where he died on 07/08/2016 and being the nominee the complainant is entitled to get the death benefit. Complainant informed the said death information to the O.Ps and submitted claim before the O.P No. 3 - the Branch Manager, HDFC Standered Life Insurance Co. Ltd., Cooch Behar Branch, Kotwali, Cooch Behar, Pin – 736101. The O.Ps issued compensation amounting to Rs. 1, 03,841.73/- only instead of Rs. 3, 50,000/- along with the forwarding letter dated 04/10/2016. On several occasions the complainant visited to the office of the O.Ps but the O.Ps did not pay the entire claim amount.
Hence, this case has been filed by the complainant against the O.Ps with prayers that the O.Ps be directed to pay Rs. 2, 46,158.27 with interest @ 18% Per annum and the O.Ps also be directed to pay Rs. 40,000/- as mental agony and sufferings and the O.Ps also be directed to pay 10,000/- as costs of the litigation, inter alia.
Appearance made on behalf of the O.Ps and written version has been submitted admitting the insurance policy on their behalf wherein categorical denials are made against the complaint and the O.P side took pleas that the insured person (husband of the complainant) concealed his pre-existing diseases by way of suppressing the real facts mentioning negations in
Contd.
Columns Nos. 23 & 32 i.e. “Personal Details of Life to be Assured” in the application form. As such being the nominee of the deceased insured person (Saiful Haque) the complainant is not entitled to sum assured amounting to Rs. 3,50,000/-. It is specific case of the O.Ps that the value of Rs. 1, 00,000/- has been returned to the complainant with interest amounting to Rs. 3,841.73/-. The O.Ps have denied the other allegations as leveled by the complainant against them and thus the O.Ps have prayed for dismissal of the case with exemplary costs in favour of the O.Ps.
Both the parties have also filed evidence-on-affidavits and written argument in support of their respective pleas.
We have heard arguments of both sides and also perused the materials on record very carefully.
Considering the above pleadings the following issues are necessarily come out for consideration to reach just decision of the case. Complainant has also filed some original documents with firisty. O.P side also filed documents as per their firisty.
POINTS FOR CONSIDERATION
- Is the complainant a consumer u/s.2 (1)(d)(ii) of Consumer Protection Act, 1986 ?
- Has this Forum jurisdiction to entertain the instant case?
- Have the O.Ps any deficiency in service as alleged by the complainant?
- Is the complainant entitled to get any relief/reliefs as she prayed for?
DECISION WITH REASONS
As all the points are interlinked to each other as such all the points are taken up together for consideration for the sake of brevity and convenience.
It is evident on record that during his life time the deceased husband of the complainant has insured his life under policy named “HDFC SL Pro-Growth Super II Insurance Policy” under the O.Ps for improvise benefit on 15/05/2015 vide Application No. 1100000070794, vide policy no. 17630031. It is also evident that O.P No. 4 is an employee cum Agent of O.P Nos. 1, 2 & 3.
Being a nominee of the insured person under the O.Ps the complainant became a consumer u/s – 2(1)(d)(ii) of the Consumer Protection Act, 1986 and she is entitled to have
Contd.
legitimate services from the O.Ps (i.e. for receiving the assured amount from the policy). The complainant has been residing in Vill. & P.O.- Madhya Rangali Bajna, P.S. –Madarihat, Dist. – Alipurduar. On the other hand O.P No. 4 has been residing at Alipurduar, P.S. & Dist.- Alipurduar, Pin – 736122. The claim amount of the complainant does not exceed the pecuniary jurisdiction of this Forum. As such this Forum has both territorial as well as pecuniary jurisdictions to try this case.
In the hearing of argument Ld. Agents / Advocates appearing on behalf of the O.P side submitted that there are sufficient discrepancies / evidence lying to disprove the plaint case such as the deceased Saiful Haque deliberately suppressed the material informations regarding his health while submitting the proposal for obtaining the policy. O.P side drew our attention to the screenshot of a prescription issued by Appollo Hospital. They also drew our attention on Column Nos. 23 & 32 in part – II of the application form for obtaining policy wherein negations are made by the insured person Saiful Haque by putting “NO” against the Column No. 23 “Have you ever suffered from diabetes / high blood sugar / sugar in urine, high blood pressure / hypertension, heart disease, stroke” and in Column No. 32 “During last 5 years have you undergone or been recommended to undergo hospitalization” despite his pre-existing diseases like hypertension, heart disease, diabetes, blood sugar etc. In support of their contentions Ld. Agents for the O.Ps cited following references ;-
- (2018) CPJ 29 (Har). Hariyana State Consumer Disputes Redressal Commission, Panchkula; decided on 02/11/2017 vide First Appeal No. 652 of 217 in Murti Devi (Appellant) Vs Birla Sun Life Insurance Company Ltd. & Another (Respendents).
- (2018) CPJ 204 (NC), National Consumer Disputes Redressal Commission, New Delhi, Charanjit Singh (Petitioner) Vs The Insurance Corporation of India and Another (Respondents); decided on 19/01/2018.
- Chhattisgarh State Consumer Disputes Redressal Commission, Pandri Raipur (C.G.) Muhammad Faruk Javed (Appellant) Vs The Zonal Manager and Others (Respondents); decided on 03/08/2016,
and walked through the legal corridors of some provisions related to Insurance Policy. They have opined that the instant case shall fail to achieve it’s success basing on the spirit of law as they pointed out above.
To establish the plaint case Ld. Agent appearing on behalf of the complainant submitted that the insured person Saiful Haque died on 07/08/2016 while he was 56 years aged. The date of execution of the Insurance Policy is on 15/05/2015. Therefore, almost one year back the execution of the Insurance Policy was done between the parties. He argued further that as per Insurance Policy Rules medical tests are required if the policy holder is above 40 or 45 years of age so that the insurer is aware of the policy holder’s current medical fitness and if there are any pre-existing medical conditions. Therefore, Ld. Agent for the complainant opined that responsibility shifted upon the shoulders of the insurance company and after execution and making payment of premium towards policy there is no scope to escape such responsibility on part of the Insurance Policy side basing on which they can took defence that the beneficiary /
Contd.
nominee of the insured person is debarred to have the insured benefit on the ground of premature policy. In support of his contention he cited …..
- Oriental Insurance Company Ltd. Vs G. Irusappa Pillai, 2003(2) CPR 313 (TN) S.C.D.R.C. …… 2003 (2) CPJ 299. (158) Life Insurance Policy - Repudiation on suppression of fact,
- P. Sharda (Smt.) Vs LIC of India Ltd., 2003(3) CPR 537 (Chhattisgarh) S.C.D.R.C. (135) - Repudiation of claim deficiency in service when,
- Life Insurance Corporation of India Vs Dholi Devi @ Dholi Bai, 2003(3) CPR 411 (Raj) S.C.D.R.C., 2003 (3) CPJ 348. (129) Life Insurance Policy – No evidence that deceased was suffering from diabetes – claim allowed,
- Life Insurance Corporation of India Vs (Smt.) Meera Deval 2003(3) CPR 453, (Uttaranchal) S.C.D.R.C. : 2003(3) CPJ 525. (130) Truck carrying 7 passengers fell in Khad – compensation granted.
He drew attention on the cause of death of the insured person Saiful Haque in his Embalming Certificate and on death certificate wherein it is mentioned that death was caused due to Neutropenic Sepsis with Multiorgan dysfunction Simprophoma. He submitted further that the defence as raised by the O.P side that the insured person has suppressed his pre-existing diseases is immaterial here whereas the insured person did not die due to his pre-existing diseases. Ld. Advocate Mr. Das opined that the defence side failed to disprove the plaint case and as such the complainant is entitled to relief as she prayed for.
Upon the hearing of argument of both sides as well as on perusal of the materials available on the case record it is appeared to us that the O.P side has based on their plea that the insured person has concealed the materials facts i.e. his pre-existing diseases and he has died before completion of the policy. The O.P side also inferred banking upon the death certificate of insured person Mr. Saiful Haque that prior to the execution of the Insurance Policy during last 5 years from that execution he has been undergone hospitalization and that has been concealed by him.
On perusal of the materials available in the case record we found nothing reliable evidence to substantiate such plea of the O.P side.
The Insurance Policy executed between the parties when the age of the insured person was above 45 years of age. As such our view is that the Insurance Company (O.Ps side) ought to cause pre-policy medical checkup / test of the insured person (Saiful Haque). In our view the cause of death as mentioned in the death certificate of Saiful Haque can not be the hindrance in sanctioning his insured (assured) amount.
Contd.
We have gone through the references as cited by both sides and that apart we have gone through the decisions referred in;-
- III(2014) CPJ 340 (NC), New India Assurance Company Ltd. Vs Rakesh Kumar,
- 2016(1) CPR 566 (NC), LIC of India & Another Vs Kolla Santhi & Another,
- 1(2016) CPJ 613 (NC), Satish Chander Madan Vs Bajaj Alliance General Insurance Company Ltd. –
and we also gone through the decision of the Hon’ble Supreme Court decided in “Biman Krishna Bose Vs United India Ins. Company”; Civil Appeal No. 3438 of 1995.
In consonance with the spirit of the decisions as we have gone through we put reliance on the references as cited by the Ld. Agent on behalf of the complainant. Considering the facts & circumstances of this case we deferred with the opinion of the O.P side and we do not accept the spirit of the references as cited by the O.P side.
Considering the facts & circumstances as discussed above there is no hesitation to hold that there is deficiency in service on part of the O.P side as they failed to serve their legal obligation for making payment of the assured amount to the nominee / complainant and in our view that it should be justified to award the assured amount of Rs. 3, 50,000/- minus refunded amount of Rs. 1, 00,000/- i.e. Rs. 2, 50,000/- in favour of the complainant.
In drawing such conclusion we have also followed the spirit of the decision referred in I(2019) CPJ 172 (Har), Haryana State Consumer Disputes Redressal Commission, Panchkula, United India Insurance Company Ltd. (Appellant) Vs Bimala Saini & Others (Respondents).
In view of the positive results of the foregoing discussed points Point No. 4 also bears positive result and that shall be reflected in the ordering portion.
Thus all the points are disposed of accordingly.
Fees paid are correct.
Hence, for ends of justice; it is;-
ORDERED
that the instant case be and the same is allowed on contest with costs.
Contd.
The complainant Baby Tajminara Begam do get a decree of assured sum amounting to Rs. 2,50,000/- as her legitimate claim and she do get a further decree of Rs. 40,000/- for her mental agony and sufferings + Rs. 10,000/- as litigation costs against the O.P Nos. 1 to 3. The O.Ps are hereby directed to pay the total decreetal amount of Rs. 3,00,000/- to the complainant within 30 days from this day failing which the complainant will be at liberty to put this decree into execution according to law.
Considering the status of O.P No. 4 (Agent –cum-employee of the O.P Nos. 1 to 3) we do not pass any order of payment against him.
In case of realization of the decreetal dues through execution the complainant be entitled to 8% interest per annum on the decreetal dues from the date of filing of this case from 21/11/2017 till liquidation of the entire decreetal dues and the O.P Nos. 1 to 3 shall have to pay Rs. 50/- as fine per-day to the Consumer Legal Aid Account of District Consumer Disputes Redressal Forum, Alipurduar.
Let a copy of this final order be sent to the concerned parties through registered post with A/D or hand over forthwith for information and necessary action.
