Chandigarh

DF-I

CC/213/2018

Atul Narang - Complainant(s)

Versus

ICICI Prudential Life Insurance Co. Ltd. - Opp.Party(s)

Yoginder Nagpal

25 Mar 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                               

Consumer Complaint No.	:	CC/213/2018
Date of Institution	:	09/05/2018
Date of Decision	:	25/03/2019

 

Atul Narang s/o Sh. Avinash Narang r/o H.No.2403, Sector 22-C, Chandigarh 160022.

… Complainant

V E R S U S

1.     ICICI Prudential Life Insurance Company Limited, Grievance Redressal Committee, Claims Cell, Ground Floor, Unit No.I-A & 2-A, Raheja Tipco Plaza, Rani Sati Marg, Malad (East), Mumbai-400097 through its Authorised Signatory.

2.     ICICI PruLife Towers, Regd. Office at 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025 through its Authorised signatory.

3.     ICICI Prudential Life Insurance Company Limited, SCO 134-135-136, Madhya Marg, Sector 8, Pin 160017 Chandigarh through its Authorised Representative.

… Opposite Parties

 

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                    

ARGUED BY	:	Sh. Yoginder Nagpal, Counsel for complainant
	:	Sh. Gaurav Bhardwaj, Counsel for OPs.

Per Rattan Singh Thakur, President

1.         Averments are, complainant on 9.5.2016 had purchased a life and health policy from OPs which was valid till 9.5.2046, having policy term of 30 years, mode of payment was yearly, and the premium amount was Rs.12,531/-.  The sum assured was Rs.4.00 lakhs.  Complainant’s case is, at the time of filling up the proposal form, he had told the OPs of him being a casual drinker though they had jotted down his reply in the negative with regard to consumption of tobacco, alcohol and narcotics. 

                On 11.9.2017, complainant had suffered a brain stroke and encountered same brain stroke again in January 2018 and was hospitalized.  The various clinical tests and investigations revealed that he had a hole in his heart. Resultantly, surgical procedure was performed and total amount spent by him was Rs.3,88,384/-.  His case is, on claim being submitted, it was repudiated by the OPs on the ground that he had concealed earlier transient ischemic attack 10 years back as well as of him being in the habit of smoking and consumption of liquor for the last 13 years.  Hence, pleaded that the claim was wrongly repudiated and prayer is made for refund of Rs.3,88,384/-, Rs.90,000/-as compensation for mental harassment, Rs.21,000/- as cost of litigation and any other relief as deemed fit by this Forum.

2.         OPs contested the consumer complaint, filed their joint reply and the admitted the purchase of the policy, its validity and receipt of premiums.  The repudiation of the claim was justified on the ground of concealment of material facts that complainant had suffered Transient Ischemic Attack 10 years back when he was hardly 25 years old.  The complainant had also denied of taking liquor and smoking. On these lines, the cause is sought to be defended.
3.         Parties led evidence by way of affidavits and documents.
4.         We have heard the learned counsel for the parties and gone through the record of the case. After scanning of record, our findings are as under:-
5.         Broadly speaking the admitted facts are complainant had paid two premiums of till date he had suffered stroke.  These facts are not in dispute.  His case is, he was occasional drinker but in the proposal form, OPs had jotted down his answers of pertaining to consumption of tobacco, alcohol and narcotics in the negative.  These were the blanket replies.       No material was brought on record to show occasional consumption of tobacco, alcohol or narcotics led to brain stroke as well as Transient Ischemic Attack 10 years back.  The medical record produced does not show that the said stroke was caused due to consumption of alcohol.
6.         There is only a passing reference in the record of complainant’s medical history as habitual smoker and drinker for the past 13 years.  These were only aggravating factors and not the original causes of the disease.  Though it definitely puts a person in high risk zone if he continues cigarette smoking and heavy drinking.
7.         There were terms and conditions which were referred in the reply but the fact remains that two premiums were charged and the OPs are making use of only those passing references of which history was narrated at the time of admission in the PGI.  Who had given such history to the attending doctor has not been explained?  What was the quantum of drinks taken daily or the quantity of cigarette smoking per day, so as to term the complainant as alcoholic or a chain smoker?  These facts have not been specified at all.  For example, if the complainant had given the reply that he once or twice had smoked a cigarette in his life till 35 years age or say had taken occasional drinks on special occasions that would not have formed the genesis to say that he has suffered the given diseases.  It is also not the case had such answers been given of occasionally taking drinks or smoking then the policy was not to be issued by the OPs.  In such like situation the counsel for the complainant relied on case titled as PNB Metlife India Insurance Co. Ltd. Vs. Sunita Goyal, 2016 (3) CPR 672 (NC).  The crux of relevant paragraphs No.8 to 10 is reproduced below:-

“8.    A perusal of the proposal shows that the deceased had disclosed in the aforesaid document that he was an alcoholic and was consuming wine. There is no evidence of the deceased consuming an alcoholic drink other than wine. Therefore, there was no misrepresentation by the deceased as regards his being an alcoholic. However, in the proposal form the deceased gave a false answer as regards his habit of smoking. He replied in negative as to consumption of tobacco and smoking and therefore, to this extent a misrepresentation was made by him to the proposal form.

9.     The next question which arises for consideration is as to whether a false statement as regards his smoking habit amounts to misrepresentation on a material fact or not. If the policy of the insurer is to deny insurance to a person who has been smoking or a person who has been smoking for a long period, the concealment of the smoking habit particularly when a person has been smoking for such a long duration would amount to concealment of a material fact since in the event of the aforesaid habit being disclosed, the insurance would be denied to him. If, however, the policy of the insurer is not to deny the insurance even to a person who has been smoking for a long duration, it would be difficult to say that such a misrepresentation was on a material fact.

10.    When this petition came up before this Commission on 4.7.2016, the petitioner was directed to file an affidavit stating therein as to whether the policy would have been granted to the deceased or not had he disclosed that he had been smoking for more than 5 years before submitting the proposal.  The petitioner company, in compliance of the aforesaid direction, has filed an affidavit of Motty John who has stated that had the policyholder disclosed the fact that he had been smoking for more than 5 years before submitting the proposal, the policy would have been issued but the  premium would have been on higher side. Thus the policy of the insurer was not to deny insurance to a smoker though it would have charged a higher premium while insuring the life of such a person. The affidavit filed by the petitioner company does not indicate the extent to which the premium would have increased in the case of a smoker. Considering all the facts and circumstances of the case, I am of the considered view that the insurer should pay 75% of the insured amount to the complainants, without any interest on that amount, provided payment is made in a time-bound manner. Such an order, in my view, would meet the ends of justice since there will be some penalty for not disclosing the habit of smoking to the insurer and at the same time it will not fully deny the benefit of the insurance policy to the legal heirs of a person who did not pay the full premium applicable in his case.”

In such like situation, 75% of the insured amount was given to the complainant of that case without interest and costs.  We do rely on this precedent.

8.         In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. 

Relief

9.         OPs are directed to make payment of 75% of the claim amount of Rs.3,88,384/- to the complainant which comes out to Rs.2,91,288/-. However, the prayer of the complainant for grant of compensation for mental harassment/stress and litigation expenses is declined.
10.         This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amount mentioned above, with interest @ 9% per annum from the date of this order, till realization.
11.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
25/03/2019	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President