Haryana

Karnal

CC/794/2019

Subehari Devi - Complainant(s)

Versus

ICICI Prudential Life Insurance Company Limited - Opp.Party(s)

Sohan Sharma

08 Jun 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                         Complaint No.794 of 2019

                                                          Date of instt.29.11.2019

                                                          Date of Decision 08.06.2023

 

Subehari Devi, aged 35 years, wife of late Shri Raj Kumar son of Shri Panna Ram, resident of ward no.1, village Dabri, Tehsil Bhadra, District Hanumangarh (Rajasthan). Aadhar card no.4259 4314 5395.

 

                                                 …….Complainant.

 

                                              Versus

 

1.     ICICI Prudential life Insurance Co. Ltd. 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025, through its Managing Director/Authorized person.

 

2.     Muthoot Insurance Brokers Karnal, SCO-99-100, Sector-7, Main Market, near Easy Day Store, Karnal-132001, through its Manager/authorized person.

 

                                                                      …..Opposite Parties.

 

Complaint under Section 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary…..Member

 

 Argued by: Shri Sohan Sharma, counsel for complainant.

                    Shri Sandeep Rana, counsel for OP no.1.

                    Shri Raj Kumar Kamra, counsel for the OP no.2.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that on the allure of the agent of the OP no.1, the husband of complainant had purchased an insurance policy namely ICICI Pru iProject Smart bearing application no.OS08466762 dated 01.02.2018 for sum assured of Rs.25,00,000/- and paid the premium of Rs.7715/-. Subsequently, the husband of complainant had received papers of policy bearing no.21895750 for a sum assured of Rs.10,00,000/- having the premium amount of Rs.6153/- In the policy, complainant was the nominee of her husband. The policy in question was continuing at the time of death of husband of complainant. Unfortunately, the husband of complainant expired on 27.02.2018 due to natural death and prior to his death he was quite hale and hearty. The death intimation was given to the OPs. Complainant lodged the death claim of her husband with the OPs and completed all the formalities. Thereafter, complainant requested the OPs so many to settle the claim but OPs did not pay any heed to the request of complainant and lingered the mater on one pretext or the other and lastly repudiated the claim of complainant, vide repudiation letter dated 30.06.2019 on the ground that multiple policies were applied/taken on the life of the life assured. Then complainant sent a legal notice dated 15.10.2019 to the OPs but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that the contract of insurance based on “uberrimaefide” i.e. utmost good faith. The person seeking insurance knows all the facts, which materially affect the risk on his or her life. Under the provision of Section 45 of the Insurance Act, 1938, a life insurance policy can be called in question on the ground of fraud within three years of commencement of the policy. The DLA had obtained two insurance policies on 13.02.2018 and 15.02.2018 for a sum assured of Rs.10,55,123/- and Rs.3,30,508/- respectively from Max Life Insurance and one from OP for a sum assured of Rs.25 lakhs but since the profile of the husband of complainant is 10^th pass and agriculturist by profession, insurance cover is restricted to Rs.10 lakh. Prior to undertaking the risk, this information could potentially allow the insurer to question as to why the insured had in just 3 days obtained three different life insurance policies. Such a fact is sufficient to suspect the insurer to put the insurer to enquiry. Complainant’s husband had tried to obtain insurance cover of Rs.25lakhs from the company but because of his profile, insurance cover was restricted to Rs.10 lakhs and the complainant’s husband had never objected for the revised sum assured of Rs.10 lakhs. All the policies were purchased by the husband of complainant within a span of 4 days. The husband of complainant died within a period of 11 days which shows that this is a very well planned fraud against the insurance industry in order to grab huge unlawful and illegal money from the insurance companies. It is further pleaded that the age of the life assured was 32 years at the time of death and his cause of death is natural as mentioned in the claim form shows that he may have died under suspicious circumstances or may be murdered by someone in order to grab sum assured amount from the insurance companies. During the investigations, it is found that:

a)     In Aganwadi register of 2017-2018 in the serial no.16. It is mentioned that Raj Kumar son of Panna Ram died on 27.02.2018 and cause of death is heart attack and after that, in serial no.17,  date of death of Hawa Singh son of Mani Ram is mentioned which is 04.02.2018, which is prior to the date of death of life assured which shows that the said register is tampered. Also, date of death is not series wise.

b)     IN ANM register also, same fabricated date of death is mentioned as mentioned in the Aganwadi register. Entry is not reflecting datewise.

c)     In voter’s list of 2018, life assured’s  name is mentioned in the deletion list which was prepared as on January 01, 2018. Further, life assured’s father name, Panna Ram & age is also mentioned in the said voter’s list of 2018 which also matched with the details filled by him in the proposal form.

d)     Further, nominee Subehari Devi has also filed Ombudsman case against Max life Insurance which shows that her husband had taken policy form Max Life Insurance also.

 

By not disclosing the material facts to the OP in the proposal form clearly proves the fraudulent and malafide intention of deceased life assured behind taking the captioned policy, hence, the claim of complainant was rightly declined and policy was rightly declared null and void, vide letter dated 30.06.2019 on the ground of non-disclosure of other insurance policies and also refunded he premium amount of Rs.7261/- on 03.07.2019 through NEFT in the complainant’s account. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.2 filed its separate written version raising preliminary objections with regard to maintainability; jurisdiction and concealment of true and material facts. On merits, it is pleaded that OP no.1 insurance company, which is totally a separate legal entity and the OP is only the facilitators to the policy purchased by the complainant from OP no.1. The complainant is entitled to the insured amount by the OP no.1 subject to fulfillment of terms and conditions of the policy terms and OP no.1 can repudiate the claim on reasonable and justified grounds.  The answering OP has no liability or responsibility as far as the insurance or the approval/repudiation of claim is concerned. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of complaint dated 26.07.2019 before Insurance Ombudsman, Rajasthan Ex.C2, copy of repudiation letter dated 30.06.2019 Ex.C3, copy of legal notice Ex.C4, postal receipt Ex.C5, copy of form J dated 25.01.2018 Ex.C6, copy of form J dated 24.01.2018 Ex.C7 and closed the evidence on 01.06.2022 by suffering separate statement.

6.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Amit Aggarwal Senior Manager Ex.OP/1, copy of declaration from Ex.R1, copy of proposer/life assured basic details Ex.R2, copy of insurance policy alongwith terms and conditions Ex.R3, copy of letter dated 20.02.2018 Ex.R4, copy of email dated 02.04.2019 Ex.R5, copy of claim investigation report Ex.R6, copy of repudiation letter dated 30.06.2019 Ex.R7, copy of email dated 07.10.2019 Ex.R8, copy of email dated 09.10.2019 Ex.R9,  copy of letter dated 31.10.2019 Ex.R10, copy of award dated 16.07.2019 Ex.R11 and closed the evidence on 09.01.2023 by suffering separate statement.

7.             Learned counsel for the OP no.2 has tendered into evidence affidavit of Satinder Gakhar Ex.OP/2 and closed the evidence on 09.01.2023 by suffering separate statement.

8.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

9.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the Raj Kumar(since deceased), got insured his life with the OP no.1 for a sum assured of Rs.10,00,000/-. Complainant is the nominee of the said policy.  The life assured died on 27.02.2018 due to natural death. After the death of life assured, complainant being nominee has submitted the death claim with the OP no.1 but the claim of the complainant was repudiated by the OP no.1, vide letter dated 30.06.2019 on the ground that complainant had suppressed the material facts with regard to multiple policies were taken on the life of the life assured. The allegations levelled by the OPs are false and frivolous and lastly prayed for allowing the complaint.

10.           Per contra, learned counsel for OP no.1, while reiterating the contents of written version, has vehemently argued that the husband   of complainant during his life time had purchased the policy in question for the sum assured of Rs. ten lakhs. The life assured died on 27.02.2018 and after his death, complainant lodged the claim with the OP.  The claim being early claim was investigated and during investigation, it was found that the life assured had also purchased two other life insurance policies from Max Life Insurance  on dated 13.02.2018 and 16.02.2018.  All the policies were purchased by life assured within a span of 4 days. The husband of complainant died within a period of 11 days from obtaining the insurance policies. A sum of Rs.7261/- on 03.07.2019 through NEFT as premium installment amount has been refunded to the complainant and prayed for dismissal of the complaint.

11.           Learned counsel for the OP no.2, while reiterating the contents of written version, has vehemently argued that OP is only the facilitators to the policy purchased by the complainant from OP no.1 and the OP has no liability or responsibility for the approval/repudiation of claim and prayed for dismissal of the complain qua OP no.2.

12.           We have duly considered the rival contentions of the parties.

13.           Admittedly, deceased life assured had purchased the policy in question for the sum assured of Rs.10,00,000/- and deceased life assured had paid premium of Rs.6153/-. It is also admitted that complainant is the nominee in the said policy. It is also admitted that on 03.07.2019 the premium amount of Rs.7261/- has been refunded by the OP no.1.

14.           The claim of the complainant has been repudiated by the OP no.1, vide repudiation letter Ex.C3/OP7 dated 30.06.2019 on the grounds, which is reproduced as under:-

“We have examined the claim on the basis of the documents leading to issuance of the abovementioned policy, the documents submitted by you at the claim stage and the documents obtained by us during the course of the investigation carried out by us at the claim stage. After a detailed examination of the facts, circumstances of the case and on the basis of the aforesaid documents we have decided to decline the claim. In this connection, we state that following points, which are without prejudice to one another;

In this connection, we wish to state that the company had received the proposal for insurance on February 01, 2018 alongwith a duly signed Customer Declaration Form (CDF) confirming the truthfulness and correctness f the details provided in the online proposal form and that any mis statement or suppression or non-disclosure of material information will lead to rejection of the claim. Relying on the replies/declaration provided in the proposal for insurance, the proposal was accepted and policy bearing no.21895750 was issued on February 16, 2018. We have enclosed the copy of the proposal form for your immediate reference.

Please note that the insurance business operates on the principle of utmost good faith and the company relies on the details provided by the life assured to evaluate the risk.

The company received the claim intimation on April 16, 2019 informing of the alleged death of your husband Mr. Raj Kumar on 27 February 2018 i.e. Within twelve days of policy issuance.

Amongst other details of life insurance policies held is also key factor considered at the time of risk assessment of the insurance proposal. Our investigation has established that multiple policies were applied/taken on the life of the life assured to the tune of Rs.23.8 lakhs (including the aforesaid policy), out of which Rs.13.8 lacs was prior to issuance of the aforesaid policy.

In view of the above mentioned facts, the company concludes that it has sufficient reasons to believe that the information furnished in the proposal for insurance was incorrect and misleading and was furnished purely with an intent to induce the company to issue a life insurance policy.

In the light of the above facts, we are constrained to decline your claim for the aforesaid policy. However, we are processing payment of premiums paid amounting to Rs.7261/- under the policy towards full and final settlement. The said amount has been credited in the account of complainant”.

 

15.           The claim of the complainant has been repudiated by the OP no.1 on the ground of the multiple policies in the short span. Life assured had filled up the proposal from on 01.02.2018, Risk Commencement date was 16.02.2018 and policy in question was issued on 16.02.2018. Life assured had expired on 27.02.2018 i.e. within eleven days after purchasing of the policy. Deceased Life Assured had also purchased two other policies on 13.02.2018 and 15.02.2018 from Max Life Insurance.  This fact has not been denied by the complainant. All the policies were purchased by the deceased life assured within one month i.e. February, 2018. As per complainant, life assured had expired due to natural death but as per the OP, the  life assured expired due to heart attack. In the present case the cause of death is not proved. It appears that that deceased life assured was suffering from heart disease prior to purchasing of the policy in question and all the policies were purchased by the life assured only to grab the money. In this regard, we are fortified with the observations of Hon’ble Supreme Court in case titled as Branch Manager, Bajaj Allianz Life Insurance Company Ltd. and others Vs. Dalbir Kaur in civil appeal no.3397 of 2020 decided on 09.10.2020 wherein Hon’ble Supreme Court held that a policy of insurance is governed by the principles of utmost good faith. The suppression of material facts by the insured/policyholder entitles the OP to repudiate the policy under section 45 of the Insurance Act. The said authority is fully applicable to the facts of the present case.

16.           It is settled principle of insurance law that contract of insurance is a contract uberrima fides and utmost faith must be observed by the contracting parties. Every material fact must be disclosed, otherwise there is good ground for rescission of contract. If, there are misstatements or suppression of material facts, the policy can be called into question. In this regard reference may be made to the judgment of the Hon’ble Supreme Court in case titled Satwant Kaur Sandhu Versus New India Assurance Co. IV      ( 2009) CPJ 8 (SC) and judgment of Hon’ble National Commission in case Life Insurance Corporation of India and another Versus Bimla Devi Revision Petition no.3806 of 2009 decided on 12.8.2015 and Sunita Rani Versus PNB Metlife India Insurance Company Limited in appeal no.1252/2015 decided on 21.04.2017.

17.           Thus, in view of the above, the present complaint is devoid of any merits and deserves to be dismissed and same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 08.06.2023                                                                    

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

       

(Vineet Kaushik)                (Dr. Rekha Chaudhary)         

        Member                             Member