Delhi

East Delhi

CC/384/2017

ANJU - Complainant(s)

Versus

LIC - Opp.Party(s)

17 May 2019

ORDER

          DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.        384/2017

                                                                                                   Date of Institution                26/09/2017

                                                                                                   Order reserved on               17/05/2019        

                                                                                                   Date of Order                       20/05/2019                                                                                  

In matter of

Mrs. Anju w/o Late Sh Anil Yadav    

R/o  HN 19/65 Block No. 19,

West Moti Bagh, Sarai Rohilla, Delhi 110035…........…………….Complainant                             

                                      Vs

1 The Branch Manager

Life Insurance Corporation of India,   

District Branch Office - C 12K

F 149 Laxmi Nagar District Centre, Delhi 110092

 

2 The General Manager

Life Insurance Corporation of India,   

Registered Office - 12^th Floor Jeevan Bharti Building

124 Connaught Circus New Delhi 110001………….…….…………..Respondents

 

Complainant  Advocate……………………Mr Arun Yadav   

Opponent Advocate………………………..Mr Ajay Kumar    

 

Quorum          Sh Sukhdev  Singh       President

                         Dr P N Tiwari                Member

                         Mrs Harpreet Kaur      Member                                                                                              

 

Order by Dr P N Tiwari  Member  

Brief -This complainant has been filed u/s 12 of the Consumer Protection Act, 1986 against OP for alleged deficiency in their services for refusing death claim.  

 

Facts of the case                                                                                                

Complainant  purchased LIC New Endowment Plan with profits policy from OP/LIC vide policy no. 127765866 on 28/05/2015 after filling policy proposal form (Ex CW1/1) and got payment receipt (Ex CW1/1A)  with policy schedule. Complainant opted half yearly premium payment mode as May and November every year so paid two half yearly premium of Rs 12,444/. It was stated by the complainant that her husband got sever pain in stomach and was admitted in Ram Manohar Lohia Hospital, New Delhi on 22/03/2016 and during treatment he expired on 23/03/2016 (Discharge summary as Ex CW1/2) Complainant filed death claim with OP and claimed sum assured Rs 5Lacs. Even visiting repeatedly to OP office, claim was not entertained. She gave a written note also on 19/12/2016 to OP1 office. Her claim was later repudiated on 3/02/2017. Thereafter, complainant gave legal notice for reconsideration of her claim on 25/05/2017, but did not get any reply, so filed this complaint before New Delhi Forum for deficiency in services of OP1 and 2 for repudiating death claim without considering policy terms and conditions. As New Delhi Forum did not have territorial jurisdiction to entertain complaint so complainant withdrew and filed before this Forum. Complainant claimed entire death benefits with sum insured Rs 5 Lacs and compensation of Rs one Lacs for mental harassment and agony.

After receiving notice, OP submitted written statement denying all the facts and allegations of deficiency in services and justified their repudiation of death claim. It was admitted that complainant had purchased LIC’s New Endowment Plan (with profits) policy no. 127765866 (table 814 20 20) had tenure from 28/05/2015 to 28/05/2035 with all terms and conditions (Ex OPW1/1&2) on half yearly mode of payment of premium Rs 12444/-(Ex OPW1/3). After accepting all terms and conditions and declaring in detail about his health conditions as ‘GOOD’ in all required questioner table of policy proposal form (Ex OPW1/4), policy was issued.

The death claim was repudiated on the finding of ailments written in discharge summary of hospital which stated that DLA was chronic Alcoholic and had CLD, PHTN, De-compensated Ascitis & Hepato-Encephalopathy and was even advised for Liver Transplantation as his liver had developed Liver Cirrhosis. After proper investigation, it was seen that DLA was suffering from liver Cirrhosis with its complications which were clearly evident from OPD card vide no. 20150653672 dated 24/08/2015 of Dr Ram Manohar Lohiya Hospital (Ex OPW1/5&5A) and also took indoor treatment. So all ailments were present much before taking LIC policy by DLA on 28/08/2015, clearly proved intentional hiding all ailments as material facts before OP which were sufficient to deny policy, but based on good faith and declaration in policy proposal form, policy was issued. As DLA had only paid two half yearly premium and expired during treatment just after one day clearly establishes non disclosure of all material facts (various diseases) which were essential to OP and as age was 35 years so no specific medical tests were required and policy was issued.  It was admitted that repudiation was justified based on opinion of Zonal Office Claims Dispute Redressal Committee at LIC Delhi II as claim was early death claim and repudiation was immediately intimated to DLA’s wife/complainant on 03/02/2017 and again on 21/03/2017 (Ex OPW1/3). Hence there was no deficiency in service of OP and this case be dismissed.

Complainant filed her rejoinder and denied all the replies submitted by OP and stated that her husband/DLA was never had any ailments as stated by OP in their written statement. It was also denied for liver transplantation advice. All facts were submitted by OP were wrong and false. All the contents of her complaints were correct and true. She submitted evidences on her own affidavit and relied on all evidences as policy proposal form, premium receipts (two) paid on half yearly mode and legal notice sent to OP which were on record and so prayed for passing death claim with benefits as per policy terms and conditions.

OP also submitted their evidence on affidavit through Md. Deepa Sinha working as Manager (L&HPF) and reaffirmed on oath that all their evidences were on record and repudiation was based on the final opinion from Zonal Office Claims Dispute Redressal Committee at LIC Delhi II office and DLA was timely intimated about the final decision taken from Head Office. (ExOPW1/1,2&C). It was also stated that death claim was repudiated due to non disclosure of material facts which were procured during investigation which showed that DLA had clear knowledge about his health and various ailments whose medications were continued, but did not disclose in policy proposal form. So this was a clear case of non disclosure of material facts in policy proposal form at the time of taking policy. Hence there was neither deficiency in services nor any careless act was done. Their all services were as per IRDA guidelines, so this complaint may be dismissed, still OP intimated for refund of Rs 24,888/- if complainant wish to take refund.

Arguments were heard from both the party counsels and order was reserved.

Appreciating arguments of complainant’s counsel and OP counsel, complainant counsel stressed more on death claim benefits based on policy terms and conditions where DLA had no ailments or ever drunk Alcohol in his life time. While OP counsel submitted that whenever early death claim was reported with OP, proper investigation was done and in this case during investigation, OP procured treatment documents like OPD card prior to the date of inception of policy clearly show uncontrollable complications due to CLD in k/c/o Alcoholic habits. So this complaint be dismissed.  

After perusal of all evidences on record, it was seen that OP had properly investigated the case and pre inception policy evidence were available which clearly proves that DLA had intentionally hidden all material facts pertaining to his health at the time of taking policy from OP by stating all facts wrongly in policy proposal form. It is mandatory by OP to conduct proper investigation as onus is on OP and here it has been done before repudiating early death claim.

CLD is not an acute condition which could precipitate very shortly in days and DLA had clear knowledge about his health conditions. Thus, corroborating various medical diagnosis and their complications in CLD in k/c/o Alcoholic and scrutinizing all treatment documents showing line of treatment protocol in CLD with legal application and implications in reference to policy terms and conditions in policy proposal form, we come to the conclusion that complainant had proper knowledge of all benefits in Endowment Policy. Repudiation of early death claim by OP was justified after properly seeing medical factors first and then legal issues based on policy terms and conditions, there was no deficiency in services of OP in proceeding in death claim.

To consider the various laws laid down by Honble Supreme Court and NCDRC, we have referred certain judgments as-

1. Reliance Life insurance Co, Ltd &others vs Rekhaben Nareshbhai Rathod, II (2019)CPJ 53 SC, decide on 24/04/2019
2. Alka Shukla vs LIC of India, II(2019) CPJ 67 SC, decided on 24/04/2019
3. Darshan Singh vs HDFC Standard Life Insurance Co. Ltd & others, II(2019)CPJ243 NC, decided on 30/01/2019.

It has been laid down by Supreme Court and NCDRC that suppression of material facts about health in policy proposal form by complainant cannot claim if claim is repudiated. If death occurred within two years of commencement of life policy and violation of policy terms and condition were found, rejection was justified. Hence based on outcome of above judgments and medical facts, repudiation of death claim was justified, but as OP stated to refund the premium amount complainant may take within 30 days after receiving this order.

 

The copy of the order be sent to the parties under the Regulation 18 of the Consumer Protection Regulation 2005 (in short the CPR) and the file be consigned to Record Room under regulation20(1) of the CPR.

 

(Dr) P N Tiwari  Member                                                                       Mrs  Harpreet Kaur  Member                                                   

                                                  

                                                     Sukhdev Singh  President