Haryana

Fatehabad

CC/156/2020

Parmod Kumar - Complainant(s)

Versus

LIC - Opp.Party(s)

Sukhbir Dhaka

07 Apr 2023

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                      Sh.Rajbir Singh, President.                                                         Sh.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                Complaint Case No.: 156 of 2020.

                                             Date of Institution:    10.08.2020

                                                        Date of order:            07.04.2023.      

 

Parmod Kumar son of Brij Lal resident of village Nuiyanwali Tehsil & District Sirsa

                                                                          ….. Complainant.

                                          Versus     

 

1.Life Insurance Corporation of India,Divisional Office, 3,4,5 SCO Sector 1, Rohtak through its Divisional Manager.

2.Branch Manager, Life Insurance Corporation of India, Sector-3 HUDA, Fatehabad.

….Opposite parties.

 

Complaint U/s 35 of the Consumer Protection Act

                                                                                

 

Present:         Shri Sukhbir Dhaka, Advocate for the complainant.

                  Shri Naresh Sachdeva, Advocate for the opposite parties.

 

 

ORDER

SH.RAJBIR SINGH, PRESIDENT

                   Brief facts of the present complaint are that brother of the complainant namely Sh.Raj Pal (herein after to be referred as Life Assured) took an insurance policy No.504822168, by making insurance premium of Rs.5151/-,  for sum assured of Rs.15 lacs (proposal dated 25.10.2017) from the OPs, valid from 28.10.2017 to 28.10.2031; that the complainant was nominee under the said policy;  that the life assured died on 04.02.2019 and the complainant lodged the claim with the OPs besides submitting all the requisite documents  to release the claim; that the Ops wrongly, illegally and on flimsy grounds  have repudiated the claim of the complainant vide letter dated 19.03.2020 despite the fact  that the life assured was thoroughly medically examined and on being hale and hearty, the insurance policy in question was issued to life assured;  that the complainant requested the Ops number of times to release the claim of the policy in question but to no avail; that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice. In the end, the complainant has sought directions to the OPs to release the sum assured of Rs.15 lac along with interest @ 12 % per annum besides compensation of Rs.50,000/- for mental agony, physical harassment as well as litigation expenses. Any other relief at the discretion of this Commission has also been sought. 

2.                Averments of the complaint have been strongly opposed in the joint written statement filed on behalf of Ops wherein several preliminary objections such as maintainability, concealment of material facts, locus standi and estoppal etc. have been taken. It has been further submitted that being an   early death claim, the matter was examined in view of Section 45 of Insurance Act; that the aforesaid policy had not completed three years from the date of FPR i.e. 11.11.2017; that the life assured had concealed the health status at the time of obtaining the policy in question because as per bed head ticket issued by Civil Hospital, Sirsa, he was admitted there on 02.11.2017 and remained admitted upto 05.11.2017 with case of vomiting; that he was not able to drink water being alcoholic for the last for than 10 years; that as per medical record he was diagnosed as Grade-I fatty liver with gall bladder sludge;  that in the proposal form dated 08.11.2017,  the life assured had answered the following questions:-

During the last five years, did you consult a medical practitioner for any ailment requiring treatment for more than a week?	No
Have you ever been admitted to any Hospital or nursing home for general check-up, treatment or operation?	No
Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, high blood pressure, low blood pressure, cancer, epilepsy, Hernia, Leprosy, or any other disease?	No
Are you suffering from or have you ever suffered from ailment pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or nervous system?	No
What has been your usual state of health:	Yes

 

 

It has been further submitted that the life assured has violated the terms and conditions of the policy in question, therefore, the ops have rightly repudiated the claim of the complainant as the policy in question was purchased with malafide intention. Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint.

4.                The parties then led their respective evidence by way of affidavits and documents. The complainant has tendered in evidence his affidavit as Annexure CW1/A and documents Annexure C1 to Annexure C4. On the other hand, the Ops have tendered into evidence affidavit of Sh.D.K.Jain, Manager (Legal) as Annexure RW1/A, and documents Annexure R1 to Annexure R17.

5.                We have heard learned counsel for the parties and with their kind assistance, the material available on the case file, have been perused and examined.

6.                Learned counsel for the complainant argued that claim of the complainant regarding death of his brother, who was insured with OPs has been wrongly & illegally rejected by the OPs on the ground that the deceased (life assured) had made incorrect statement and withheld correct information regarding his health at the time of effecting insurance. He has further contended that life assured was not suffering from disease before he proposed for the policy. It has been further argued that before issuance of the policy to the deceased, he was thoroughly examined by the empanelled doctors of the Ops and after declaring him hale and healthy, the Ops had issued the policy in question to the deceased (life assured).    Lastly, he prayed for acceptance of the complaint. In support of his contentions he has relied upon the case law titled as LIC Versus Reena Nanda CLT 2019 (1) page 380.

7.                On the other hand, learned counsel for Ops has argued that at the time of filling of proposal form the life assured did not disclose true facts about his pre-existing disease intentionally and made false answers to the questions mentioned in the proposal form regarding his health. It has been further argued that had the life assured disclosed the true status qua his health in the proposal form, the OPs would not have issued the policy in question to the life assured. Since, the life assured had violated the terms and conditions of the policy, therefore, the claim was rightly repudiated vide letter dated 19.03.2020. Lastly, prayer for dismissal of the complaint has been made. In support of his contentions learned counsel for the Ops drew the attention of this Commission towards the medical record dated 02.11.2017 of deceased (Annexure R4).

8.                          In the insurance policy (Annexure R8), the date of commencement is mentioned as 28.10.2017 and the date of maturity has been shown as 28.10.2032.  Perusal of Annexure C2 reveals that the first premium amounting to Rs.5150.70/- was received by the Ops for the policy commencing from 28.10.2017 with sum assured of Rs.15 lacs.  In order to resolve the controversy between the parties one another document i.e. proposal form has also been placed on the case file as Annexure R2 and perusal of this documents reveals that the life assured was thoroughly medically examined by Dr.Sanjay Bansal, MBBS and he also affixed his signature on the bottom on the photograph of the life assured affixed on this very document. If we read all these three documents together one thing is very much clear that the contract between the insurance company and life assured (deceased) was completed and it can be easily concluded that the Ops had accepted the premium without any objection and further in due process issued the policy in question (Annexure R8).  Therefore, the Ops, at this stage, cannot dispute policy after completing the contract with the deceased (life assured).  Another strange factor, which this Commission has noticed that the premium amount is still retained by the insurance company.

9.                          Now, another point for consideration before this Commission is as to whether the deceased (life assured) had concealed his health status from the Ops before issuance of the said policy or not?

10.                        In order to prove the fact of concealment of pre-existing disease at the time of purchasing the policy in question by the deceased (life assured), learned counsel for the Ops has placed on record medical history of the deceased (life assured) as Annexure R4 but he has failed to prove on the case file that the disease (Grade-I fatty liver with gall bladder sludge, Vomiting) mentioned in medical record has any nexus with the death of deceased (life assured).  The burden of proof was upon the OPs to prove that the insured was suffering from pre-existing diseases prior to taking the policy, but they have miserably failed to discharge this onus, by not leading any cogent and convincing evidence to prove this fact. On this point, reliance can be taken from the case law titled as Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC),  wherein it was held by the Hon'ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus, the repudiation of the claim on the ground of pre-existing disease was held to be invalid. After considering all the facts and going through the material available on the case file, we have no hitch to reach at a conclusion that the Ops are only trying to back out from the contract and it is a general observation that in a number of cases, the insurance companies are issuing policies basing on the statements made by the proposer in utmost good faith but when it comes to settlement of claims, they start examining the matter under the microscope.  The present case is squarely covered by the case law relied upon by learned counsel for the complainant.

10.                        Thus, as a sequel to our above discussion, we accept the present complaint and direct the Ops to pay the amount of Rs.15 lac (sum assured) to the complainant alongwith interest @ 6% per annum from the date of filing of present complaint till actual realization. We also direct the Ops to further pay a sum of Rs.11,000/- for mental agony and harassment including litigation expenses to the complainant.  The order be complied within a period of 30 days from today.

11.                        In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                            Dated: 07.04.2023

 

                                                                                                        

          (K.S.Nirania)                       (Harisha Mehta)                (Rajbir Singh)                              Member                               Member                                           President