Delhi

East Delhi

CC/180/2016

LAXMI NARAIN - Complainant(s)

Versus

INDIA FIRST LIFE INS - Opp.Party(s)

01 Feb 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

 

C.C. NO 180/16

 

Laxmi Narain Tomar                        

R/o House No. J 38-39, Gali No. 9

Pandav Nagar Delhi- 110 092

…Complainant

Vs.

 

 

India First Life Insurance Co. Ltd.

At Shop/ Plot No. 1, Pandav Nagar

Opposite Mother Dairy Patpar Ganj

Delhi- 110 092

…Opponent

 

 

Date of Institution: 13.04.2016

Judgement Reserved on: 01.02.2019

Judgement Pronouced on: 07.02.2019

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Harpreet Kaur Charya (Member)

 

Judgement

The present complaint pertains to the non-payment of claim pertaining to the policy issued by, India First Life Insurance Company Ltd., OP to the nominee of Deceased Life Assured (DLA), i.e. Shri Laxmi Narain Tomar. Briefly stated the facts of the complaint are that a policy was purchased in the name of Smt. Suman Tomar vide Policy bearing No. 70220484 from OP on 12.03.2015 for a term of 10 years with Rs. 99,900/- as premium. The mode of payment of premium was annually. It has been stated that at the time of purchasing the policy the DLA was having good health and the said policy was issued after medical examination conducted by the panel doctors of OP. On 14.10.2015, the DLA had some problem for which she was immediately hospitalized and expired on 24.10.2015. Death claim vide No. 00014817 alongwith documents was registered with OP through e-mail and the complainant also visited the office of OP on 16.11.2015. It has been further stated that after a period of 4 months OP transferred Rs. 87,392/- through NEFT in the account of the complainant without his consent and a letter of date 16.02.2016 mentioning the detail of death claim was sent to the complainant. The claim of the complainant had been repudiated on the ground that the ensured had provided false information regarding her health. The complainant has alleged that OP has repudiated the genuine and legal claim of the complainant and has failed to settle the same despite several visits to OP’s office. Hence, the present complaint alleging unfair trade practice and deficiency in service on part of OP. The complainant has prayed for directions to OP to pay sum assured i.e. Rs. 7,00,000/- alongwith interest @18% per annum from 24.10.2015 till realization, Rs. 2,00,000/- on account of compensation for harassment and mental agony and Rs. 25,000/- cost of litigation.

The complainant has annexed the copy of the policy alongwith terms and conditions, death summery of DLA, information report to OP through e-mail, repudiation letter dated 16.02.2016, NEFT details, death certificate of DLA, with the complaint.

2.         OP was served with the notice of the present complaint thereafter the reply was filed wherein they have taken several pleas in their defence such as the DLA had concealed material facts at the time of making declaration in the proposal form as she was suffering from Diabetes Mellitus- Grade-II and chronic kidney disease prior to the filling and signing of the proposal form; the contract of insurance is a contract of Uberrima Fides, thus, the DLA was bound to disclose the material facts pertaining to her health; it was further submitted that as the DLA had passed away within a short span of inception of policy itself raises a reasonable doubt that the DLA had made misrepresentation and concealed material facts in the proposal form. It was further submitted that the DLA had answered in negative to the questions asked in the proposal form

21 Are you currently taking medication or drugs, other than for minor conditions, (eg. cold and flu), either prescribed or not prescribed by a doctor, or have you suffered from any illness, disorder, disability or injury during the past five years which has required any form of medical or specialized examination (including chest X-rays, gynecological investigations, pap smear, or blood test), consultation hospitalization or surgery?.....NO

23 Do you suffer from or ever had any medical ailments such as diabetes, high blood pressure, cancer, respiratory disease (including asthma), kidney or liver disease, stroke, any blood disorder, heart problems?.....NO

28 In the last three years, have you ever been treated, are currently undergoing or have been advised for treatment from a doctor or specialist or undergone any cardiological, radiology or pathological tests (excluding routine checkups)?.....NO

The OP have also stated that as the DLA had signed the declaration and was also, thereby, aware that in case her statement was found to be untrue the contract of insurance shall be null and void. It was submitted that as the DLA was working as Assistant Manager with BSES and on the request of investigator, BSES provided the dispensary book of DLA as per which the DLA was taking regular treatment for diabetes from 09.07.2012 to 12.02.2015 which was much prior to singing of the proposal form. Rest of the content of the complaint have been denied.

They have annexed copy of proposal form as Annexure OP-1, copy of policy document as Annexure OP-2, copy of death certificate as Annexure OP-3, copy of death summery, pathological and other test reports of DLA issued by Metro Hospital and Cancer Institute, Delhi as Annexure OP-4 (Colly.), copy of response and dispensary book of DLA received from BSES and copy of investigation report and affidavit of investigator as Annexure OP-5 (Colly.) and Annexure OP-6 (Colly.) respectively, Repudiation Letter dated 16.02.2016 has been annexed as Annexure OP-7.

Rejoinder to the written statement was filed by the complainant where they have denied that the wife of the complainant was suffering from diabetes, it was stated that the DLA had been medically examined by the panel doctors of OP and it was only after that the policy was issued. The complainant has stated that as per Clause 3.1 Death Claim; the company was liable to pay the sum assured to the nominee/ legal heir of the insured. Rest of the contents of the written statement have been denied and those of the complaint have been reaffirmed.

Evidence by way of affidavit was filed by the complainant where he has got himself examined and has reaffirmed the averments made by him in the complaint and has got exhibited his Aadhar Card and that of the DLA as Ex-CW1/1 and CW1/2, copy of the policy as Ex-CW1/3 (Colly.), Death Certificate of DLA and Death Summery as            Ex-CW1/4 and Ex-CW1/5 respectively.

OP have got examined Sh. K.R. Viswanarayan, Head Governance and Company Secretary of OP, who has deposed on oath the contents of their written statement on oath and has got exhibited; copy of proposal form as Exhibit-OP-1, copy of policy document as Exhibit-OP-2, copy of Death Certificate as Exhibit-OP-3, copy of death summery, pathological and other test reports of DLA issued by Metro Hospital and Cancer Institute, Delhi as Exhibit-OP-4 (Colly.), copy of response and dispensary book of DLA received from BSES as Exhibit-OP-5 (Colly.), copy of investigation report and affidavit of investigator as Exhibit-OP-6 and copy of Repudiation Letter dated 16.02.2016 as Exhibit-OP-7.

We have heard the arguments on behalf of the Ld. Counsel for the complainant and Ld. Counsel for OP. The claim of the complainant has been rejected on the ground that the life insured had given false and misleading information to OP at the time of filing the proposal form. If we look at Exhibit OP1 which is the proposal form where the DLA has answered all the questions in negative under the head “life style questions and personal medical history of the Life to be Assured”, categorically to the question reproduced here under:-

Do you suffer from or ever had any medical ailments such as diabetes, high blood pressure, cancer, respiratory disease (including asthma), kidney or liver disease, stroke, any blood disorder, heart problems?

No

 

Further, OP has also placed on record the photocopy of the medical book of Shri Laxmi Narain, E No. 40131597 as the complainant was employee of BSES Yamuna Power Limited, which is Ex-OP5 wherein it is observed that the DLA had been taking medication for blood sugar since 10.05.2013. Even in the Death Summary dated 24.10.2015, which is Ex.-OP4, it has been written that the DLA was a known case of DM-II and was on regular treatment.  

It is settled principle of law that the contract of insurance is based on the Uberrima Fides i.e. of utmost good faith and the person entering into contract is under a solemn obligation to make disclosure of material facts which may be relevant for the insurer to taken into account while deciding whether the proposal should be accepted or not, but in the instant case the Life Assured has concealed the fact that she was suffering from DM-II and was under medication of the same. Since, the contract of insurance was entered by concealing the material facts from OP and the OP has discharged their onus by placing on record documents showing that the assured was suffering from DM-II prior to the filing and signing of the proposal form. Thus, they have rightly repudiated the claim and no deficiency in service and unfair trade practice can be attributed on their part. Hence, the present complaint is dismissed being devoid of merits, without order to cost.  

Copy of the order be supplied to the parties as per rules.

            File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                    (HARPREET KAUR CHARYA)     Member                                                           Member

 

 

(SUKHDEV SINGH)

          President