Haryana

Ambala

CC/322/2019

Govind Singh - Complainant(s)

Versus

Kotak Mahindra Life Insurance Co Ltd. - Opp.Party(s)

Anil Shanker

07 Dec 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	322 of 2019
Date of Institution	:	04.10.2019
Date of decision	:	07.12.2022

Sh. Govind Singh age about 70 years son of Late Sh. Banta Singh, Resident of House no.1692 B-12, Geeta Nagri Ambala City.

…..Complainant

Versus

 

1. Kotak Mahindra Life Insurance Company Limited through its General Manager, II floor Plot # C-12, G Block, BKC Bandra East Mumbai- 400051.
2. Kotak Mahindra Life Insurance Company Limited through its Branch Manager, 16- C, IInd floor, Sangeeta Complex, Prem Nagar, Ambala City.

 

….…. Opposite Parties

Before:        Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member.    

       

 

Present:       Shri Anil Shankar, Advocate, counsel for the complainant.         

                Shri Rohit Bector, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

1.                 Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

a) To pay claim amount of Rs.4.30 lacs along with interest @ 18%, till realization.

b) To pay Rs.25,000/- towards damages and compensation on account  of mental agony/torture and physical harassment caused to the complainant.

c) To pay Rs.21,000/- towards counsel fee.

d) To pay Rs.10,000/- towards litigation expenses.

e) Grant any other relief which this Hon’ble Commission deems fit in facts and circumstances of the present complaint.

2.             Brief facts of this case are that the complainant is the father of Navdeep Singh, who unfortunately expired on 18 February 2018. The son of the complainant had purchased life insurance policy no. CR0000020 (Loan A/C No. 4898175) on 29th July 2017 from the OPs. He appointed Complainant as nominee in the said policy. The son of the complainant had paid the premium to the OPs and while issuing the said policy, the OPs had assured that the policy covers reimbursement of all kinds. The son of complainant died during the subsistence of the above said policy therefore the complainant submitted claim with the OPs. The complainant is an old man and is in the last leg of his life but despite his pitiable condition he had to run pillar to the post to the office of the OPs for settlement of the claim filed by him, but the same was repudiated vide letter dated 04-09-2018, Annexure C-3. Under those circumstances, he served legal notice dated 22-04-2019, Annexure C-4 upon the OPs but to no avail.  Hence this complaint.
3.           Upon notice, the OPs No.1 and 2 appeared and filed written version and raised preliminary objections with regard to maintainability, cause of action, not come with clean hands and suppressed the material facts etc.  On merits, it has been stated that claim of the complainant has been repudiated on the ground that the deceased life assured/son of the complainant had not disclosed correct information and suppressed material facts in the proposal form with regard to his pre-existing illness. The OPs received death claim intimation dated 1.08.2018 alongwith the death certificate and other requisite documents from the policyholder, informing that the insured expired on 18.02.2018 i.e. within 7 months from the date of issuance of the insurance cover. Upon receipt of the said intimation, the OPs with a bonafide intention conducted a statutory investigation under clause 14(2) of the Insurance Regulatory and Development Authority (Protection of Policyholder's interest) Regulations, 2017 in order to verify the authenticity of the said claim. During the process of the claim investigation, it revealed that the insured was suffering from ALD (Alcoholic Liver disease)/Liver Fibrosis since 2015; he was taking treatment for the same from Fortis Hospital, Mohali since 24/10/2015 and the said fact was suppressed by him in the declaration of good health submitted at the cover issuance stage which was in the year 2017. In view of the foregoing facts and based on the ground of intentional non-disclosure of pre-existing disease, untrue statement contained in the declaration of good health, the OPs repudiated the claim and the same was communicated to the complainant and the policyholder vide letters dated 4.09.2018. Annexure R-7 (colly). Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with exemplary costs
4.           Learned counsel for complainant tendered affidavit of the complainant as Annexure CW1/A alongwith documents as Annexure C-1 to C-4 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for the OPs tendered affidavit of the Charu Gandhi, Chief Manager-Legal, working at Kotak Mahindra Life Insurance Company Ltd. as Annexure OP/A alongwith documents as Annexure OP-1 to OP-8 and closed the evidence on behalf of the OPs.
5.           We have heard the learned counsel for the parties and carefully gone through the case file.
6.           Learned counsel for the complainant submitted that by repudiating the genuine claim filed by the complainant in respect of his deceased son, who was insured under the policy in question, the OPs were deficient in providing service and  also indulged into unfair trade practice.
7.           On the other hand, learned counsel for the OPs submitted that since the insured had concealed material facts with regard to his pre-existing disease and also the treatment taken by him before obtaining the policy in question, as such, his claim was rightly repudiated by the OPs.   
8.            Since, the facts with regard to obtaining the policy in question by the son of the complainant from the OPs; death of the son of the complainant on 18.02.2018; and repudiation of his claim vide letter dated 04.09.2018, Annexure C-3 by the OPs are not in dispute, as such, the only question that falls for consideration in the present case is, as to whether, the OPs were right in repudiating the claim of the complainant or not. Before proceeding on merits, it is significant to mention here that in Satwant Kaur Sandhu v New India Assurance Co. Ltd, (2009) 8 SCC 316 the Hon’ble Supreme Court held that under a contract of insurance, the insured is under a “solemn obligation” to make a true and full disclosure of information asked for in the proposal form. Relevant part of the said order is reproduced hereunder:- 

“18…Nonetheless, it is a contract of insurance falling in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, the obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment…”
 

9.           However, when we go through the record of this case, it is found that though as per  proposal form dated 29.07.2017, Annexure OP-1, the insured-Navdeep Singh, son of the complainant, has given a declaration of good health as under:-

“……"I hereby declare that I am in sound health, and I do not have any physical defect, deformity or disability. I further declare that I perform all my routine activities independently, that I do not have any history of, have never suffered from, am not currently suffering from, nor have 1 received, nor do I expect to receive any treatment, nor been hospitalized, nor do I expect to be hospitalized for any of the following......

 

1 to 8………………….

9. Liver Disease including Hepatitis

10 to 14…………………

 

"I further declare that the above statements are true and complete in every respect related to my health and will form the basis of granting insurance cover to me, from Kotak Mahindra Old Mutual Life Insurance Ltd.(KLI). I further hereby agree and give my consent to the policy holder for use of the contents of this Declaration by KLI for examining and processing any claim arising, in respect of the insurance cover that may be provided to me under the referred group policy. I hereby confirm that my intent to participate in the above plan for the policyholders customers is purely on a voluntary basis, and have further understood the terms and conditions of the life insurance cover that may be extended to me. I confirm and agree that the insurance cover, if provided, will be governed by the provisions of the Insurance Act, 1938 and the policy Contract under the cover will be offered to me.........

 

....I understand and agree that if any untrue statement be contained herein, I, my heirs, executors, administrators or assignees shall not be entitled to receive any benefits which may be provided to me on the faith of this declaration, including, inter alia the aforesaid insurance cover.……”

 

10.           However, at the same time, when we go through the medical record i.e. LAMA summary bearing UHID no.574660 dated 26.10.2015, Annexure OP-4 it is evident that the insured was taking treatment for ALD from the hospital since 2015 i.e. prior to the issuance of the insurance cover. The said  summary also states that the insured was diagnosed with Chronic Opium/Alcohol Addiction since 7-8 years, Hiatal Hernia, Grade B Esophagitis, Short Segment Barrets Esophagus and Hypertension. However, from the medical treatment record of the insured, which was taken by him in the Fortis Hospital on 24.10.2015, Annexure OP-5 also revealed that the insured was diagnosed with AWS (Alcohol withdrawal Syndrome) and had a history of being Chronic Alcoholic and opium addiction for the past 6 years. Also, it states history of Epistasis. It is very significant to mention here that the UHID no. under LAMA summary, Annexure OP-4 and medical records, Annexure OP-5 is the same which is 574660 and has been issued by the same doctor Mr. M. Chabbra. Thus, from these documents, it can easily be culled out that the insured had concealed all these material facts of his treatment at the time of filling up the proposal form. Thus, in our considered opinion, the insurance policy, Annexure OP-2 was obtained by making untrue and incomplete disclosure of the information, which was within the knowledge of the insured and as such, the present case, attracts the principle of law laid down in  Satwant Kaur Sandhu v New India Assurance Co. Ltd. case supra.
11.           In this view of the matter, since it has been clearly agreed by the insured that in the declaration good health form Annexure OP-1 that if any untrue statement is contained therein, he, his heirs, executors, administrators or assignees shall not be entitled to receive any benefits which may be provided to him on the faith of this declaration, including, inter alia the aforesaid insurance cover, as such, the complainant is not entitled to get any relief. The OPs have thus not committed any deficiency in service by repudiating the claim of the complainant.  
12.           It is therefore held that since the complainant has failed to prove his case, as such, no relief can be granted to him in that regard. Resultantly, this complaint stands dismissed with no order as to cost.  Certified copies of the order be sent to the parties concerned as per rules. File be annexed and consigned to the record room.                             

Announced:- 07.12.2022.

 

	(Ruby Sharma)	(Neena Sandhu)
	Member	President