PER:

Nidhi Verma, Member

1        The complainant has filed the present complaint under Section 12 and 13 of the Consumer Protection Act (herein after called   as 'the Act') against the opposite parties by alleging that the complainant is widow of Sarwan Singh son of Mohinder Singh resident of village Hansawala Tehsil Khadoor Sahib District Tarn Taran who was insured with Life Insurance Policy by the opposite parties vide two insurance policies bearing No. 102394443 and No. 102394444 and the deceased Sarwan Singh made the complainant as nominee of this insurance policies while availing this policy by  paying for a sum of Rs. 6,142/- each as regular premium with tax on 21.9.2017.  The insurance premium was paid by the deceased to the opposite party No.1 in cash and as per the terms and condition of the policies, the opposite parties was given an insurance cover of Rs. 1 Lacs of each policy in case of the death of the insured to his nominee. The deceased Sarwan Singh unfortunately expired on 6.8.2018 due to natural causes and after his death the complainant lodged the Life Insurance claim of the deceased with the opposite parties and the opposite parties through their representatives demanded requisite documents which were supplied to them by the complainant and the opposite parties assured the complainant that the insurance claim will be released to them in a month times so the complainant awaited for the same for a long period but no claim was released to him in-spite of numerous reminders to them.  Later on the opposite parties vide their letter dated 01.10.2019 repudiated the claim of the complainant of the above said insurance policies of the deceased Sarwan Singh by saying that complainant is not entitled for the claim amount as the deceased was suffering from pre-existing disease which was not disclosed by him while getting insured with the opposite parties. The complainant was embarrassed by the act of the opposite parties and as such again approached the opposite party No.2 at its office to get the insurance claim as the reason given by the opposite parties for denying the claim to the complainant was vague one as the opposite parties had already medically examined the deceased Sarwan Singh and also had conducted medical tests of the deceased before insuring him with their policy but all in vain.  The complainant has prayed that the opposite parties may kindly be directed to release the insurance claim of Rs. 2,00,000/- to the complainant i.e. the claim amount of both policies of Life Insurance Policy of deceased Sarwan Singh and also prayed Rs. 25,000/- as compensation and Rs. 25,000/- as litigation expenses. Alongwith the complaint, the complainant has placed on record his affidavit Ex. C-1, self attested copy of proposal form of Life Insurance Policy Ex. C-2, Self attested copy of proposal form of Life Insurance Policy Ex. C-3, Self attested copy of Death certificate Ex. C-4, Self attested copy of Adhar Card of complainant Ex. C-5, Self attested copy of letter dated 1.10.2019 Ex. C-6.

2        Notice of this complaint was issued to the opposite parties and opposite parties appeared through counsel and filed written version by interalia pleadings that the present complaint is not maintainable. The complainant has not come to this Commission with clean hands, as such she is not entitled to the relief claimed in the present complaint. The claim of the complainant with respect to policies bearing Nos. 102394443 and 102394444 of the deceased Sarwan Singh was repudiated by the opposite parties on the basis of medical records of the hospitals where the said Sarwan Singh got remained hospitalized. While taking the policies in question, he had not disclosed past history of CAD (Coronary Artery Disease) and PTCA (Percutaneous Transluminal Coronary Angioplasty) which was done on 23.3.2017 in the Mahajan Hospital, Amritsar i.e. before taking the said policies. These facts were not disclosed by the deceased Sarwan Singh with the sole intention of defrauding the corporation i.e. opposite parties as the information regarding his critical illness was in his exclusive knowledge which he concealed intentionally at the time of proposal. The complainant has no cause of action. Both the policies bearing Nos. 102394443 and 102394444 were issued under Non-Medical scheme and were repudiated on the basis of medical records of the hospitals. The real facts are that the deceased Sarwan Singh took policies on 21.9.2017 and as per the treatment record of Mahajan Hospital, Khazana Gate, Amritsar where he was admitted on 21.3.2017 i.e. before taking policies, for severe pain in chest associated with 3-4 episodes of vomiting for last 3 to 4 days with indigestion. He was further diagnosed as a known case of alcoholic for 10 years and was consuming 1/4 bottle per day. He was also diagnosed as a case of CAD (Coronary Artery Disease) with diabetes and taking medicine on regular basis. He was also operated for PTCA (Percutaneous Transluminal Coronary Angioplasty) on 23.3.2017 in the said Mahajan Hospital and remained admitted in the hospital for 6 days and was discharged from the hospital on 26.3.2017 as per hospital record. These extremely material facts regarding his personal health were not disclosed by the deceased Sarwan Singh at the time of proposal. The proposal form dated 21.9.2017 relating to the above said policy Nos. 102394443 and 102394444 in which the said Sarwan Singh life assured has answered the following questions as noted herein below:-

          On the basis of hospital record, it is very well proved that all the above answers given by proposer in the proposal form were false. The deceased Sarwan Singh was again admitted in Ohri Hospital, Putligarh, Amritsar on 9.4.2018 on complaint of chest pain and breathlessness for two days. As per hospital record he was further diagnosed as a case of CAD (Coronary Artery Disease) 35% EF [ejection fraction] which means pumping ability of the heart reduced to 35% with CHF/Septic Congestive Heart Failure. In the treatment record of Ohri Hospital, it is clearly mentioned that deceased Sarwan Singh had a past surgical history of PTCA (Percutaneous Transluminal Coronary Angioplasty) which was done in the year 2017 i.e. before proposing for the two insurance policies. This suppression of material facts, which had a bearing on the acceptance of risk, was clearly done by the said Sarwan Singh with sole intent to defraud the opposite parties i.e. Corporation, as the information regarding his critical illness/ill-health was in his exclusive knowledge which he concealed intentionally at the time of proposal. Hence the above said claim was repudiated by the opposite parties on the basis of material records of hospitals.  The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit of Jaswinder Singh Manager Ex. OP1 & 2/1,  Self attested photocopy of Proposal form dated 21.9.2017 Ex. OP1 & 2/2, Self attested copy of Addendum to proposal for multiple proposals on the basis of single proposal Ex. OP1 & 2/3, Self attested photocopy of proposal Review Slips regarding policy No. 102394443 Ex. OP1 & 2/4, Self attested photocopy of Proposal Review Slip regarding Policy No. 102394444 Ex. OP1 & 2/5, Self attested photocopy of policy bond bearing Policy No. 102394443 Ex. OP1 & 2/6, Self attested photocopy of Policy bond bearing Policy No. 102394444 Ex. OP1 & 2/7, self attested photocopies of treatment record of deceased Sarwan Singh at Mahajan Hospital Khaana Gate, Amritsar (total 14 Pages) Ex. OP1 & 2/8, Self attested photocopies of treatment record of deceased Sarwan Singh at Ohri Hospital, Putlighar, Amritsar (total 12 pagees) Ex. OP1 & 2/9, self attested photocopy of Form No. 3816 certificate of Hospital Treatment Ex. OP1 & 2/10, Self attested photocopy of repudiation letter dated 1.10.2019 Ex. OP1 & 2/10

3        We have heard the Ld. counsel for complainant, opposite parties and have also carefully gone through the evidence and documents on the file.

4        In the present complaint, the complainant is a widow of Sarwan Singh, who was insured with life insurance policy by the O.Ps vide two insurance policies bearing No. 102394443 and 102394444 by paying for a sum of Rs. 6142/- each as regular premium with tax on 21.09.2017. The deceased Sarwan Singh unfortunately expired on 6.8.2018 due to natural causes and after his death the complainant lodged the life insurance claim of the deceased with the O.Ps . Later on the O.Ps vide their letter dated 01.10.2019 repudiated the claim of the complainant by saying that complainant is not entitled for the claim amount as the deceased was suffering from pre existing disease which was not disclosed by him while getting insured with the O.Ps.

5        O.Ps stated in their written version that while taking the policies in question he had not disclosed past history of CAD (coronary artery disease) and PTCA (percutaneous transluminal coronary angioplasty) which was done on 23/03/2017 in the Mahajan Hospital, Amritsar i.e. before taking said policies. Both the policies were issued under Non- Medical scheme and were repudiated on the basis of medical records of the hospitals. The proposal form dated 21/09/2017 relating to the above said policies in which the said Sarwan Singh life assured has answered the following questions as noted herein below:-

6        On the basis of hospital record (Ex.OP 1&2/8), it is very well proved that all the above answers given by proposer in the proposal form were false. It is further mentioned here that the deceased Sarwan Singh was again admitted in Ohri Hospital, Amritsar on 09/04/2018 on complaint of chest pain and breathlessness for 2 days (Ex.OP 1&2/9) . As the information regarding his critical illness/ ill health was in his exclusive knowledge, which he concealed intentionally at the time of proposal. Hence, the above said claim was repudiated by the O.Ps on the basis of medical records of hospitals.

7        We have gone through the rival contention of the parties. It is observed that on perusal of photocopy of insurance policy under the heading general Terms and Conditions we find that if any untrue or incorrect statements are made or there has been a misrepresentation, mis- description or non- disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policy holders or insured person or any one acting on his/her behalf, the company shall have no liability to make payment of any claim and the premium shall be forfeited to the company. We have also perused photocopy of proposal form annexed with the written version (Ex. OP 1 & 2/2) and find that the complainant given answer to the following questions:-

The medical records of Mahajan Hospital Amritsar ( Ex.OP1&2/8) clearly shows the deceased life assured was suffering from pre existing diseases which was not disclosed by him in the proposal form, while getting insured with the O.Ps . The real facts are that the deceased Sarwan Singh took policies on 21/09/2017 and as per the treatment record of Mahajan Hospital Amritsar he was admitted on 21/03/2017 i.e. before taking policies. For severe pain in chest associated with 3-4 episodes of vomiting for last 3 to 4 days with indigestion.  He was also diagnosed as a case of CAD( Coronary Artery  Disease) with diabetes and taking medicine on regular basis. He was also operated for PTCA (Percutaneous Transluminal coronary angioplasty)  on 23^rd March 2017 in the said Mahajan Hospital and remained admitted in the hospital for 6 days and was discharged from the hospital on 26^th March 2017 as per hospital record .These extremely material facts regarding his personal health were not disclosed by the deceased Sarwan Singh at the time of Proposal. Further, He was again admitted in Ohri Hospital Amritsar on 9^th April 2018 ( Ex.Op 1&2/9) on complaint of chest pain and breathlessness for 2 days.  He was further diagnosed as a case of CAD 35% EF( ejection fraction)  which means pumping ability of the heart reduced to 35% with CHF/ septic congestive heart failure .In the treatment record of Ohri Hospital it is clearly mentioned that deceased Sarwan Singh had a past surgical history of PTCA which was done in the year 2017, that is before purposing for the two insurance policies. This suppression of material facts which had a bearing on the acceptance of risk, was clearly done by the deceased Sarwan Singh with sole intent to defraud the opposite parties. As the information regarding his critical illness / ill-health was in his exclusive knowledge which he concealed intentionally at the time of proposal. To prove all the above said Medical history of the deceased Sarwan Singh, O.Ps placed on record the medical records of both the hospitals i.e. Mahajan Hospital and Ohri Hospital. Further, O.Ps placed on the record the photocopy of the proposal form where deceased clearly hide the material facts of his pre-existing disease. On other hand the complainant failed to provide any cogent evidence on record which shows that the deceased was died due to natural death . The core question for consideration is that at the time of taking policies, the policy holder was suffering from CAD and PTCA is a material facts and therefore on account of non disclosure of these facts in the proposal form, the OP.s are justified in law in repudiating the claim of the complainant.

8        Contract of insurance is based upon the principle of good faith it is the obligation of complainant/ insured to disclose each and every fact to insurer at the time of taking the policy . The decision of the insurer is totally dependent upon this fact, whether to underwrite the risk involved in the policy or not and in case there is suppression of material facts by the insured deliberately and consent of the insurer has been obtained by not disclosing the correct particulars then the contract of insurance can be avoided on account of exercise on misrepresentation by insured .The insurer might not have issued the policy to Insured after knowing his pre existing disease .It is not the case of the complainant/ insured that the contents of the proposal form was not disclosed to him when he filed in the  proposal form and he is not aware of the same. Complainant/ insured being an advocate signed the declaration being part of the proposal form. Wherein he made the statement disclosing true facts of the purpose form. The Hon’ble Supreme court in the case of “Satwant Kaur Sandhu vs New India Assurance Company Ltd. Reported in IV(2009) CPJ 8 (S.C.) observed as follows :- if the proposer has knowledge of any fact, he is obliged to disclose it particularly while answering questions in the proposal form .Needless to Emphasize that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract on insurance”.

9        Moreover, the complainant is bound by the terms and conditions of the Insurance policy in dispute and the terms and conditions of the Insurance policy cannot be interpreted in the manner either to subtract or add anything therefrom . Reliance in this connection can be had in M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd-Appellant Vs. United India Insurance Co.Ltd. & another –Respondents  2010(4) RCR (Civil), wherein it has been laid down that in a contract of insurance , rights and obligations are strictly governed by the terms of the policy and no exception of relaxation can be given on the ground of equity. It has further been held in this judgment that  in construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the court to add, delete or substitute any words. In this judgment it has been further held by the Hon’ble Supreme Court that where there is  breach of conditions of the insurance contract by the insured, the insurance company is not liable to pay compensation in case of loss. This position of law has been further fortified in the latest judgment of Hon’ble National  Commission titled as M/s. V.K. Karyana Store Vs. Oriental Insurance Co. Ltd. 2014(3) CLT page 47 wherein it has been held that it is well settled principle of law that parties are bound by terms and conditions of the insurance policy and none of the parties can seek any  relief beyond those terms and conditions.

10      In the light of the above observation, we hold that there is no case of deficiency in service has been established and O.Ps has rightly repudiated the claim of the complainant on the ground of suppression of material facts. Thus, consumer complaint is not maintainable in its present form and in law. Therefore the complainant is not entitled to get any relief as prayed for. The parties are left to bear their own costs.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission

14.06.2023