DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR
BEFORE TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law) .…. PRESIDENT
THIRU. J.JAYASHANKAR, B.A, B.L. ..… MEMBER-I
THIRU.P.MURUGAN, M.COM., ICWA(Inter),B.L., ......MEMBER-II
CC. No.108/2022
THIS TUESDAY, THE 27th DAY OF SEPTEMBER 2022
Mr.M.Gajaendran (Ex-Army),
S/o.Late V.C. Murugesan,
36/1, Sri Ganesh Apartment’A‘ Block,
Ground Floor, 3rd Street, Sabinagar,
Muthapudupet, IAF Avadi, Chennai -600 055. ……Complainant.
//Vs//
1.The Branch Manager,
ICICI Lombard General Insurance,
Nungampakkam High Road,
Chhotabhai Centre, 140 Second & Third Floor,
Chennai -600 034, Tamil Nadu.
2.The Manager,
ICICI Lombard General Insurance,
Banjara Hills, D.N.6-3-352/1,
Osman Plaza Road No.1, Banjara Hills,
Panjagutta, Hyderabad – 500 034, Telengana. …..opposite parties.
Counsel for the complainant : Party in person
Counsel for the opposite parties : Mr.D.Kamal Kumar, Advocate.
This complaint is coming before us on various dates and finally on 13.09.2022 in the presence of the complainant who appeared party in person and upon perusing the documents and evidences of both parties this Commission delivered the following:
ORDER
PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI, PRESIDENT.
This complaint has been filed by the complainant u/s 12 of the Consumer
Protection Act, 1986 alleging deficiency in service against the opposite parties in repudiation of the insurance claim along with a prayer to pay a sum of Rs.5,00,000/- towards the insurance claim with bank interest and to pay a sum of Rs.50,000/- towards compensation for the mental agony caused to the complainant and to pay a sum of Rs.10,000/- towards cost of the proceedings to the complainant.
Summary of facts culminating into complaint:-
The case of the complainant was that he approached PNB Housing Finance Limited at Royapettah Branch during March 2014 for home loan but as the coordinator compelled him to take insurance policy one Mr.Vinoth from ICICI Lombard General Insurance Company was referred who took the signature of the complainant in the proposal form. He did not enquired about any diseases nor any medical examination was suggested by him. The complainant received the policy document No.4080/PNB-GSM/88351596/00/000 dated 13.03.2014. On 21.03.2017 the complainant suffered chest pain and got admitted in Frontier Life Line Hospital, Mugappair, Chennai and underwent CABG X 3 grafts on 22.03.2017. When the complainant forwarded the claim to the insurance company on 20.04.2017 along with supporting medical documents the same was rejected for the reason that he did not disclose pre-existing diseases of Diabetic and Hypertension. When the complainant approached the Insurance Ombudsman, the Ombudsman rejected the claim of the complainant. Thus contending that the policy was taken at the compulsion of the opposite party and it was only the responsibility of the insurance company to ask and check the existing diseases of the customers and when the policy was taken in 2014 and the Bypass heart surgery was done during 2017, contending that there is no nexus between both, the present complaint was filed aggrieved by the rejection of the claim by the complainant.
Defence of the opposite parties:-
Both the opposite parties jointly filed written version disputing the complaint allegations contending inter alia that the complaint was based totally on presumptions and conjectures and not based on any cogent and valid documents or opinion, that the issuance of insurance policy for a period of five years vide No.4080/PNS-GSM/88351596/00000 was admitted but the same was subject to the terms, conditions, exceptions, exclusions and limitations governing the policy. It was submitted that the policy was based on the prominent principles of “UBERRIMAE FIDEI” i.e. utmost good faith and if one has misrepresented information regarding subject matter or one’s own personal medical history, then the insurance company’s liability becomes void. The complainant had covered himself under Group Secure Mind Policy issued to the home loan customers of PNB Housing Finance Limited and the insurance cover was for a period of five years subject to terms and conditions. The complainant was admitted in the Frontier Life Line Hospital, Chennai on 12.03.2017 and undergone CABG X 3 grafts for treatment of coronary artery diseases. The claim for insurance was repudiated as per section 2.1.4 of the policy which reads as follows;
“The company shall not be liable to make any payment or indirectly arising out of the following events: (a) Any Pre-Existing Disease – Any Insured Event arising on account of or in connection with any Pre-Existing Disease”
As the complainant was a known case of diabetes (DM) and hypertension (HT) in 2011 itself as per consultation paper of ECHS Hospital, Chennai and DM &HT are co-morbid factors for CAD, the claim of the complainant was repudiated. The claim was also repudiated as per Incontestability and Duty of Disclosure clause (Condition No.1 of the Standard Terms and Conditions) of the policy. The lame excuse of the complainant that he was not well versed in English language resulting in blindly signing the proposal form was not accepted as the complainant was an ex-army serviceman and by virtue of his employment he would come across various verifications. Thus he contending that he had insufficient English knowledge and blindly signed the proposal form could not be accepted. Further the policy document was sent to the complainant along with the terms and conditions. It was further submitted that any admission or dismissal of any diseases covering under a policy was subject to the terms and conditions governing such policy. Thus the claim of the complainant had been repudiated for the reason of “NON-DISCLOSURE OF PRE-EXISISING DISEASE” at the time of submission of the proposal for the policy. It was submitted that the insurance Ombudsman after consideration of the documents placed by the complainant had upheld the repudiation of the claim and had dismissed the claim of the complainant. If the existence of diabetes and hypertension were made available in the proposal form, the opposite party would have had the chance to examine the proposal after examination. Thus contending that there is no deficiency in service on their part sought for the dismissal of the complaint.
On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A6. In spite of sufficient opportunities the opposite parties did not turn up before this commission to file written argument and also did not appear for presenting oral arguments.
Points for consideration:-
1) Whether the act of opposite parties in repudiating the insurance claim made by the complainant is not proper and amounts to deficiency in service?
2) If so to what relief the complainant is entitled?
Point:1
The following documents were filed on the side of complainant in support of his contentions;
Policy Proposal Form was marked as Ex.A1;
Policy document No.4080/PNB-GSM/8835596/00/000 dated 12.03.2014 was marked as Ex.A2;
Claim Form for secure mind policy was marked as Ex.A3;
Complaint rejection letter dated 19.06.2017 was marked as Ex.A4;
Petition filed by the complainant insurance Ombudsman dated 05.07.2017 was marked as Ex.A5;
Judgement of Insurance Ombudsman dated 13.07.2018 was marked as Ex.A6;
We perused the pleadings and documents submitted by both the parties. As the complainant is a Party in Person this commission does not insist him for filing written arguments. Further in spite of sufficient opportunities the opposite parties did not turn up before this commission to file written arguments and also did not appear for presenting oral arguments.
The crux of the oral arguments advanced by the complainant/Party in Person is that he had signed the proposal form blindly and he was not enquired about any pre-existing diseases of diabetic and Hypertension at the time filling the form. Thus he submitted that as a layman he could not be find fault for non disclosure of pre-existing diseases and he sought for the complaint to be allowed.
On the side of opposite parties no documents was filed and also no written argument was filed on their side. However, they have filed detailed written version wherein it has been clearly stated that the complainant was a known case of diabetes (DM) and Hypertension (HT) in 2011 itself as per the case papers of ECHS Hospital, Chennai and as DM and HT are co-morbid factors for CAD, the claim of the complainant was repudiated. Further they referred the terms of the policy “The company shall not be liable to make any payment or indirectly arising out of the following events: (a) Any Pre-Existing Disease – Any Insured Event arising on account of or in connection with any Pre-Existing Disease”.
This commission was well aware of the procedure that it is only the insured who makes proposal to the insurance company and on verifying the proposal the insurer/insurance company shall decide as to whether accept the proposal or to reject it. When it has been specifically asked about any Pre-Existing Disease in the proposal form it is the duty of the complainant to disclose the same while filling the form. However, it is the case of the complainant that as he was a layman and as he was not enquired by the employee of the insurance company about the Pre-Existing Disease he did not disclose the same. The said contention could not be accepted for the reason that as rightly pointed by the opposite parties the complainant being an ex-army serviceman and had worked under various auxiliary services. The life assured or proposer is under solemn obligation to make full, complete, true and correct disclosure of the material facts which may be relevant for the insurer to take into account while deciding whether the proposal should be accepted. If the life assured or proposer failed to disclose the true and correct material facts to the insurer, then the policy obtained by the life assured or proposer stands vitiated and the life assured or any person claiming under the policy is not entitled for any benefits under the said policy as per Section 45 of the Insurance Act, 1938. The Supreme Court in United India Insurance Company Limited Vs Harchand Rai Chandan Lal reported in (2004) 8 SCC 644 and in Vikram Greentech (I) Ltd. & Anr. Vs New India Assurance Co. Ltd reported in (2009) 5 SCC 599, has held that an insurance policy is to be construed strictly as per the terms and conditions of the policy document which is a binding contract between the parties and nothing can be added or subtracted by giving a different meaning to the words mentioned therein. Therefore, violation of any terms and conditions mentioned in the policy document by the insured such as suppression of material facts or intentional non-disclosure by the insured lead to discharge of the insurer from his liability to approve the claim.
Therefore when there is specific terms in the policy that the policy becomes null and void in the event of incorrect statements, misrepresentation, non- disclosure in any material particular in the proposal form, personal statement and declaration, this commission is of the view that the repudiation of the claim by the opposite party could not be termed as deficiency in service when it is also a known admitted fact that diabetes (DM) and hypertension (HT) could cause coronary Artery Disease. Apart from that whether DM and HT could lead to artery disease was not the contention of the opposite party when the non-disclosure of Pre-Existing Disease itself makes the policy void. In such circumstances we hold that the repudiation of the insurance claim based on the violation of terms and conditions of the policy could not be termed as deficiency in service. Thus the point is answered accordingly in favour of the opposite parties and as against the complainant.
Point No.2:
As we have held above that the opposite parties have not committed any deficiency in service in repudiation of the insurance claim the complainant is not entitled any reliefs as claimed in the complaint. Thus we answer the point accordingly.
In the result, the complaint is dismissed. No order as to cost.
Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 29th day of September2022.
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MEMBER-II MEMBER I PRESIDENT
List of document filed by the complainant:-
Ex.A1 10.03.2014 Policy Proposal Form. Xerox
Ex.A2 13.03.2014 Policy Document No.4080/PNB-GSM/88351596/00/000. Xerox
Ex.A3 20.04.2017 Claim Form. Xerox
Ex.A4 19.06.2017 Claim rejection letter. Xerox
Ex.A5 15.07.2017 Petition filed Insurance Ombudsman. Xerox
Ex.A6 13.07.2018 Judgement of Insurance Ombudsman. Xerox
List of documents filed by the opposite parties;
Nil
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MEMBER-II MEMBER I PRESIDENT
