BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 26 of 2017
Date of Institution : 8.2.2016
Date of Decision : 28.9.2017.
Ranjit son of Purkha Ram, resident of village & post office Banmandori, Tehsil and District Fatehabad.
……Complainant.
Versus.
1. Kotak Mahindra Old Mutual Life Insurance Limited, Registered Office : 2nd Floor, Plot No.C-12, G-Block, BKC, Bandra (E), Mumbai-400051 through its Chairman-cum- Managing Director.
2. Branch Manager, Kotak Mahindra Old Mutual Life Insurance Company Limited, Ramnagria Ground Floor, Plot No.13, opposite Tara Baba Kutia, Near Grover Atta Chakki, Rania Road, village Ram Nagaria, Sirsa- 125055 (Haryana)- India.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SMT. RAJNI GOYAT ………………… MEMBER
SH. MOHINDER PAUL RATHEE …… MEMBER.
Present: Sh. Sukhbir Dhaka, Advocate for the complainant.
Sh. Sandeep Kamboj, Advocate for opposite parties.
ORDER
The case of the complainant in brief is that son of the complainant namely Lilu Ram had got himself insured with the opposite parties vide insurance policy No.CC000014 dated 30.10.2015 for sum assured of Rs.5,00,000/- and he made the payment of insurance premium to the ops. The complainant is nominee in respect of the said insurance policy. That Lilu Ram son of complainant died on 18.11.2015 and after his death, complainant submitted the claim form with the ops for settlement of claim and the ops assured the complainant to settle the claim of the complainant very soon but the ops instead of settling the claim of complainant and releasing the payment benefits of sum assured have wrongly and illegally repudiated the claim of the complainant vide letter dated 22.11.2016 on false and flimsy grounds of not furnishing the correct information whereas all the correct information was furnished the ops. The ops after satisfying themselves in all respects had insured the son of the complainant and the issuance of the repudiation letter is with a view to escape the legal liability of the ops in indemnifying the complainant as per the terms and conditions of the policy of insurance. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections regarding maintainability; non joinder of necessary parties as complainant has failed to implead Kotak Mahindra Bank who is the policy holder under the said cover and also the loan was granted by the Bank. It is submitted that ops had entered into a contract of insurance under the group policy i.e. Kotak Complete Cover Group Plan with Kotak Mahindra Bank- Agri Business division. In group insurance policies, as per the said policy contract, a group of members as specified by the policy holder ( in the member data submitted by the policy holder) availing any loan from the policy holder for specific purposes as specified in the schedule of the policy contract may be covered by the ops under the group insurance policy for the period and amount as specified in the certificate of insurance issued to every such specified member subject to the terms and conditions of the policy. The ops shall receive a premium amount from the policy holder on behalf of the members seeking subscription to the said cover for the specified period for the specific no. of members. It is further submitted that member has to provide a duly signed declaration of good health thereby assuring the insurer that the member is medically fit for availing the said insurance cover. That in accordance to policy terms and to join the pool of members, the deceased Mr. Leelu Ram provided a declaration of good health dated 30.10.2015 which is pre requisite for availing a group insurance cover thereby assuring the ops that he was medically fit to avail the said policy and was not suffering from any ailments/ diseases. The contents of the DOGH were explained to the deceased member by Mr. Sanjeev who acted as scribe to the said DOGH. Further no medicals were conducted by the ops on the basis of said DOGH. That thereafter the ops received a death claim intimation dated 20.9.2016 alongwith death certificate and other requisite documents from the policy holder stating that the member had expired on 18.11.2015 i.e. within 17 days from the date of issuance of insurance cover. On receipt of death claim intimation, the ops immediately initiated the process of investigation in order to verify the authenticity of the claim. The Investigator appointed in the said case was Probe India and the investigator was Mr. Mahesh Singh. Further, M/s Probe India’s authorized signatory i.e. Mr. Piyush Pandey has provided his affidavit that during the process of claim investigation it was revealed that the member was suffering from metastatic carcinoma of base of tongue and was under treatment for the same prior to signing the DOGH dated 30.10.2015. The patient summary dated 16.2.23015 and follow up details from 16.2.2015 till 8.9.2015 issued by Acharya Tulsi Regional Cancer Treatment & Research Centre, Bikaner clearly indicates that the LI was well aware that he was suffering from Metastatic Carcinoma and was also regularly taking up treatments for the same. Thus, the patient summary clearly shows that he was suffering from cancer. So, the opposite parties vide letter dated 22.11.2016 have repudiated the claim of the complainant by explaining the reason behind the same.
3. The complainant produced his affidavit Ex.CW1/A, repudiation letter dated 22.11.2016 Ex.C1, certificate of insurance Ex.C2 and death certificate Ex.C3. On the other hand, ops produced affidavit Ex.RW1/A and documents Ex.R1 to Ex.R7.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. Learned counsel for complainant has contended that it is proved on record that son of the complainant namely Lilu Ram had got himself insured with the ops vide insurance policy No.CC000014 dated 30.10.2015 for sum assured of Rs.five lacs and further son of the complainant died on 18.11.2015. The complainant lodged claim with the ops being nominee of his son Lilu Ram but, however, ops repudiated the claim of the complainant vide letter dated 22.11.2016 on false and flimsy grounds of not furnishing the correct information whereas correct information was furnished to the ops and ops after satisfying themselves in all respects had insured the son of the complainant and the issuance of the repudiation letter is with a view to escape the legal liability. During the course of arguments, learned counsel for complainant has also relied upon judgments reported as III (2014) CPJ 184 (MP) titled as Kalyan Dutta vs. LIC, III (2014) CPJ 221 (NC) titled as Bajaj Allianz Life Insurance Co. ltd. & ors. Vs. Raj Kumar and I (2015) CPJ 7 (Chha.) titled as LIC vs. Kanchan Thawait.
6. On the other hand, learned counsel for the opposite parties has strongly contended that deceased insured had fully concealed facts qua his pre-existing disease that he was suffering from cancer since long and had been getting regular treatment from the hospital at Bikaner and he remained admitted from time to time for number of days. The son of the complainant namely Lilu Ram made his declaration of good health on 30.10.2015 and denied in the column that he is suffering from any disease though he was suffering from metastatic carcinoma of base of tongue and was under treatment for the same prior to signing of DOGH dated 30.10.2015. No doubt, the policy was issued on 2.11.2015 on the declaration made by son of the complainant but, however, he died on 18.11.2015 and the claim of the complainant has rightly been repudiated by the ops as the deceased insured had violated the terms and conditions of the policy and the policy was a nullity since the day of its inception and further more it has been contended that judgments relied upon by learned counsel for complainant are not help to the case of the complainant as the facts are quite different from the facts of the present case.
7. We have considered the rival contentions of both the parties. The perusal of complaint reveals that complainant in order to prove his case has furnished his affidavit Ex.CW1/A, repudiation letter dated 22.11.2016 Ex.C1, certificate of insurance Ex.C2 and death certificate Ex.C3. On the other hand, ops in order to prove their defence plea placed on record affidavit Ex.RW1/A and documents Ex.R1 to Ex.R7. The perusal of declaration form Ex.R1 which was allegedly signed by son of complainant reveals that son of complainant did not make any declaration about his pre-existing disease though as per evidence of the ops he was suffering from pre-existing disease of cancer. The ops have tendered in their evidence investigation report Ex.R4 by which it has been reported that LA was suffering from cancer due to which he was treated at PBM, Bikaner for the same and he expired on 18.11.2015 at his residence due to his ailment. They have also furnished the affidavit of Mr. Piyush Pandey Authorized signatory of the Probe India duly authorized by Kotak Mahindra Old Mutual Life Insurance Ltd. who has deposed during investigation they found that LA was a farmer from which he was earning Rs.2,00,000/-P.A. and they found that LA was suffering from cancer due to which he was treated at PBM, Bikaner for the same. He expired on 18.11.2015 at his residence due to his ailment. The ops have also placed on file the record of treatment Ex.R5 of Acharya Tulsi Regional Cancer Treatment & Research Centre, Bikaner (Rajasthan) dated 16.2.2015 which reflects the name of the patient as Leelu Ram son of Ranjit, resident of village Mandori, Bhattu, age 45 years and thereafter he was admitted in the hospital on 24.2.2015, 16.3.2015, 8.4.2015, 11.5.2015, 18.5.2015, 25.5.2015, 1.6.2015, 8.6.2015, 15.6.2015, 22.6.2015, 27.7.2015, 14.8.2015 and on 8.9.2015. So, it appears from this record that he was suffering from cancer and had been getting regular treatment from time to time from this hospital and remained admitted on different occasions for number of days but however, the perusal of the declaration reveals that he did not make any such declaration at the time of getting the policy from the ops and concealed all these facts. Since the insurance policy is a contract of good faith and deceased had concealed all these facts qua his pre-existing disease which is violation of the terms and conditions of the policy and makes the policy as nullity. So complainant does not appear to be entitled to get any claim being nominee of the deceased under the terms and conditions of the policy and the insurance company has rightly repudiated the claim of the complainant.
8. In view of our above discussion, we find no merit in the present complaint and same is hereby dismissed but with no order as to costs. However, opposite parties are at liberty to make refund of the premium amount which was deposited by the deceased insured with them to the nominee/ complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:28.09.2017. Member Member District Consumer Disputes
Redressal Forum, Sirsa.
