| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No.214 of 22.09.2020 Decided on : 05-06-2024 Ashok Kumar aged about 48 years S/o Tarsem Chand R/o Ward No.15 Near M.S.D. School, Maur Mandi, District Bathinda ........Complainant Versus ICICI Prudential Life Insurance Company Limited, Registered Office ICICI Prulife Towers, 1089, Appasahib Marathe Marg, Prabha Devi MD/Chairman/Director. ICICI Prudential Life Insurance Company Limited, Bibiwala Road Near DAV College, Mumbai, Bathinda, through its Regional/Branch Manager.
.......Opposite parties Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Smt. Priti Malhotra, President Smt. Sharda Attri, Member Present : For the complainant : Sh.Vikas Gupta, Advocate. For opposite parties : Sh.Sanjay Goyal, Advocate. ORDER Priti Malhotra, President The complainant Ashok Kumar (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against ICICI Prudential Life Insurance Company Limited and other (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he purchased mediclaim insurance policy bearing No.21495953 for the period of 10 years with commencement date 23.10.2017 from opposite parteis by paying premium of Rs.12,642/- annually and he was insured for Rs.10,00,000/- and critical illness benefits for Rs.5,00,000/-. Opposite parties assured that the insurance policy covers all type of medical expenses on the treatment in case of any disease or accident. The officials of opposite parties took the signatures of the complainant on proposal form and never disclosed any terms and conditions of the policy, rather only policy number was supplied/intimated. It is alleged that at the time of purchase of the policy, opposite parties got the complainant medically examined, but he was not suffering from any critical disease at that time. During the policy period, he suddenly suffered from some disease. He consulted Dr.Sumit Gupta and Dr.Gurpreet Singh of Daya Nand Medical College & Hospital, Ludhiana on 20.8.2019 and 24.9.2019. After medically examine and conduct various tests of the complainant, doctors declared that the complainant is suffering from cancer. As such, he was advised for admission. He got admitted himself in Rajiv Gandhi Cancer Institute and Research Centre, New Delhi on 29.9.2019 for treatment and he discharged on 1.10.2019. He was again admitted in this hospital on 30.10.2019 and discharged on 31.10.2019 and similarly, he again got admitted in this hospital on 6.11.2019 for treatment and he was again discharged from hospital on 7.11.2019. He remained under treatment with this hospital till date he had spent about Rs.10,00,000/- on his treatment. It is further alleged that the complainant lodged the claim for Rs.5,00,000/- with opposite parties on 13.12.2019, but they illegally, wrongly and arbitrarily rejected his genuine claim vide letter dated 23.1.2020 on the ground that he was suffering from the abovesaid disease prior to the inception of the policy and wrongly and illegally refunded the premium. The repudiation letter dated 23.1.2020 is totally illegal, null and void and having no binding effect on and the the rights of the complainant as he is entitled for claim for his sufferings from opposite parties as he is covered under the policy for all types of diseases. It is also alleged that due to non-payment of claim of Rs.5,00,000/- against the mediclaim policy to the complainant by opposite parties, he has suffered from mental, agony, pains and sufferings. On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay a sum of Rs.5 lakhs on account of mediclaim as per claim lodged with them alongwith interest @ 18% p.a. and to pay Rs.50,000/- as compensation and Rs.11,000/- as litigation expenses. Upon notice, opposite parties appeared through counsel and contested the complaint by filing written version and raising preliminary objections that the contract of insurance is a contract based on 'uberrime fides' i.e. utmost good faith. The person seeking insurance knows all the facts that materially affect the risk. The insurer company cannot have any information or knowledge. The person seeking insurance is the only person having full knowledge and he is under an obligation to make a full and honest disclosure of the facts and materials to the insurer at the time of proposal. The person seeking insurance is expected to maintain a higher and rigorous standard of good faith. The claim in dispute was submitted by the complainant on 13.12.2019 for treatment of Cancer that was done on 23.09.2019 i.e. 23 months (within 2 years approximately) from the date of issuance of subject policy that was on 23.10.2017. As such, the disputed claim was squarely covered under the definition of an early claim as per Section 45 of the Insurance Act, 1938. Opposite parties called the policy into question in accordance to Section 45 of the Insurance Act, 1938 that allows an insurer to call a policy into question within 3 years of issuance and thus, vide letter dated 26.12.2019, opposite parties requested the complainant to provide the first consultation reports, current and previous medical records. Accordingly, he submitted the same on 28.12.2019 and through examination of these documents, it was clearly revealed that the subject policy was obtained through fraud by active concealment of material facts by the complainant pertaining to his prior medical history. It was revealed that life assured had provided incorrect information and suppressed material fact that he was diagnosed with Carcinoma Right Buccal Mucosa involving Gingivobuccal Cancer Stage IV (unresectable) on 20.7.2017 i.e. just 3 months prior to the issuance of subject policy and he was undergoing treatment for the same since then. Despite being aware of his diagnosis and treatment, the same was suppressed at the time of filling and submitting proposal form for insurance. It amounts to clear suppression of material fact, thus breaching the golden principle of uberrima fides. Further preliminary objections are that the Out-Paitent Card of Dayanand Medical College & Hospital Ludhiana dated 20.7.2017 clearly shows that the complainant was diagnosed with "CA RT BUCCAL MUCOSA + CA GB SULCUS" i.e. Carcinoma Right Buccal Mucosa involving Carcinoma Gingivobuccal Sulcus on 20.7.2017. As such, the complainant cannot dispute this fact that the Cancer had originated post to issuance of the policy and he was already taking treatment for the cancer before availing this policy from opposite parties. As such, the treatment mentioned on the same is an admitted fact on the part of the complainant that was suppressed by him at the time of proposal. The insurance company most rightly rejected the claim of complainant and also refunded the premium paid i.e. Rs. 44,754/-as per Section 45 of the Insurance Act. The complainant is not entitled to the Critical Illness Benefit Rider (CIBR) of Rs.5 lakhs under this policy. Opposite parties were deceived into undertaking risk on life of the complainant. The questions pertaining to existing prior medical condition specifically asked in the proposal form and status therof are material for underwriting the risk on the life of life assured. The underwriting is a vital step while issuing any insurance policy. The underwriting insurance company calculates the risk to be covered under any insurance policy keeping in view various factors. The insurance company does not have any personal knowledge about life assured so responses provided in proposal form play a substantial role while underwriting the risk. When an information on a specific aspect is asked for in the proposal form by the insurer, the proposer is under a solemn obligation to make a true and full disclosure of the information on the subject that is within his/her knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. It is further pleaded that the complainant had concealed and suppressed the material and relevant facts that the deceased life assured was suffering from Cancer i.e. pre-dated the issuance of the subject policy. Taking into consideration the replies given to the questions regarding health and lifestyle and depending on the age, proposed sum assured and premium amount payable, no medical examination were triggered by the company. Even if, medical examinations are conducted on a proposed life assured by the company, it is only to have additional comfort and it does not absolve the proposer/life assured from making the required disclosures. The complaint being frivolous and vexatious is liable to be dismissed U/s 26 of 'Act' as the complainant has failed to make out a case of 'Deficiency of Service' as alleged or otherwise, within the meaning of 'Act', as such, the complaint is not maintainable. There is no deficiency of service or unfair trade practice on the part of opposite parties. The consumer complaint does not disclose any cause-of-action against opposite parties with regard to any deficiency in the services provided by them. To support their version, opposite parties have referred some cases law. It is further pleaded that on 16.10.2017, opposite parties received a duly filled online proposal form bearing No.OS11094051 alongwith a duly filled and signed customer declaration form (CDF) by the complainant for an ICICI Pru iProtect Smart (T47) for an annual premium of Rs.12,642/-. At the time of proposal, the complainant responded in negative to all the questions with respect to his medical history thereby keeping insurance company under impression that he was hale and healthy with no medical history. Based on the information provided in the application form, opposite parties issued a policy bearing No.21495953 on 23.10.2017 to the life assured. Opposite parties had sent the policy documents to the communication address mentioned in the proposal forms that contains policy terms and conditions and free look provision alongwith a copy of proposal form. The policy documents were dispatched on 26.10.2017 that was duly delivered on 2.11.2017. On merits, opposite parties have reiterated their version as taken in the preliminary objections as detailed above and controverted all other averments of the complainant and prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 18.9.2020 (Ex. C20) and the documents, (Ex.C1 to Ex. C19). In order to rebut the evidence of complainant, opposite parties have tendered into evidence affidavit of Pardeep Sawant dated 21.12.2020,(Ex. OP1/1) and documents, (Ex.OP1/2 to Ex.OP1/8). We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stand as taken in their respective pleadings as detailed above. We have given careful consideration to these submissions. Admitted facts are that the complainant purchased mediclaim insurance policy bearing No.21495953 for the period of 10 years with commencement date 23.10.2017 from opposite parties and he was insured for critical illness benefits for Rs.5,00,000/- under this policy. It is proved on record that the complainant had suffered from Cancer disease. He got treatment for Cancer from Rajiv Gandhi Cancer Institute and Research Centre, New Delhi and spent amount on his treatment. Bills, (Ex.C10 to Ex.C18) prove this fact. He lodged the claim with opposite parties on 13.12.2019, but they rejected his claim vide letter dated 23.1.2020, (Ex.C9) on the ground that the complainant was suffering from Carcinoma Right Buccal Mucosa involving Gingivobuccal Cancer disease prior to the inception of the policy and refunded him the premium amount of Rs.44,754/-. The complainant himself has produced on record Out Patient Card dated 20.7.2017 of Dayanand Medical College & Hospital, (Ex.C2). It is clearly mentioned in this card “Diagnosis:- IHD-Old ASMI/LV dysfunction. CA RT Buccal Mucosa + CA GB SULCUS Stage IV (unrespectable)”. The complainant was sufferings from Cancer on 20.7.2017 prior to commencement of the policy i.e. 13.12.2019. It proves that he has concealed the fact regarding his disease of Cancer from opposite parties before commencement of policy as he has nowhere mentioned in the proposal form regarding his Cancer disease. The support can be sought by the following cases law:- (i) 2009 (4) CPJ 8 case titled Satwant Kaur Sandhu Vs. New India Assurance Company Ltd.; (ii) 2008 (3) CLT 380 titled P.C. Chacko and another Vs. Chairman, Life Insurance Corporation of India and others; (iii) 2010 (3) CPC 222 case titled M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd., Vs. United India Insurance Co. Ltd.,. and another; (iv) 2009 (2) CPC 593 case titled Vikram Greentech (I) Ltd., and Anr., Vs. New India Assurance Co. Ltd.; (v) Decision of Hon'ble Apex Court rendered in Civil Appeal No.3944 of 2019, Decided on 15.4.2019 in case Life Insurance Corporation of India Vs. Manish Gupta. In view of the cases law cited above and what has been discussed above, we are of the considered opinion that the complainant has concealed the facts of his Cancer disease from opposite parties. As such, opposite parties have rightly rejected the claim of the complainant. Hence, the present complaint is hereby dismissed without any order as to cost. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 05-06-2024 - (Priti Malhotra)
President (Sharda Attri) Member
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