BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BHIWANI.
Complaint No.: 131 of 2016.
Date of Institution: 04.07.2016.
Date of Decision: 08.05.2019.
Ratipal Singh Tanwar son of Shri Kanwar Singh, resident of village & post office Palwas, Tehsil & District Bhiwani.
….Complainant.
Versus
1. Life Insurance Corporation of India, Divisional office, SCO 3-4-5, Sector-1, Rohtak through its Senior Divisional Manager.
2. Life Insurance Corporation of India, having its Branch office at Jeevan Jyoti, B-1/B-2, HUDA City Centre, near Mini Secretariat, Bhiwani-127021 through its Manager.
…...Opposite Parties.
COMPLAINT UNDER SECTIONS 12 AND 13 OF
THE CONSUMER PROTECTION ACT, 1986.
Before: - Hon’ble Mr. Manjit Singh Naryal, President.
Hon’ble Mr. Parmod Kumar, Member.
Hon’ble Mrs. Saroj Bala Bohra, Member.
Present: Shri Amarjit Beniwal, Advocate for the complainant.
Shri Pankaj Chhikara, Advocate for the OPs.
ORDER:-
PER MANJIT SINGH NARYAL, PRESIDENT
Brief facts of the case are that the complainant’s wife Smt. Suman Tanwar has taken insurance policy No.179885678 from the OPs by paying premium for sum assured Rs.5,00,000/- under term table T-T 815-16 commencing from 14.3.2015 and the same was to be matured on 14.3.2031. It is further alleged that the premium was Rs.39,601/- per year with date of last premium 14.3.2030. It is alleged that on 15.5.2015 the life assured suffered suddenly fever/stomach pain and prior to reach the doctor, she expired away in the house. It is further alleged that the intimation of the death of the deceased was immediately given to OPs explaining the cause of death. It is further alleged that the complainant being the nominee lodged the claim after completing all the formalities with the OPs. It is further alleged that vide letter dated 11.12.2015, OP No. 1 direct the complainant to submit the form No.3784 and 3816, because during investigation it was found that the deceased life assured Suman Tanwar was suffering from chronic kidney disease, as per outdoor patient register, DMR opinion and F. No.3816 record dated 8.1.2015 of Patanjali Hispital, Haridwar. It is further alleged that the complainant sent the reply through registered post on 22.12.2015 that his wife had never suffered any disease prior to 15.5.2015 and she was never got admitted in any hospital. It is further alleged that the OPs vide registered letter dated 1.3.2016 repudiated the claim of the complainant on the ground that the deceased has withheld correct information regarding her health at the time of affecting the policy. It is further alleged that at the time of submitting the proposal form dated 14.3.2015 thorough medical examination of the deceased life assured was got done and she was found hale & healthy. It is further alleged that the deceased life assured never suffered from chronic kidney disease and nor got any treatment from Pantanjali Hospital, Haridwar. Hence, it amounts to deficiency in service on the part of OPs and hence, this complaint.
2. On appearance, the OPs filed written statement denying all the allegations of the complainant. It is alleged that the Suman Tanwar has not expired due to stomach pain and she was suffering from chronic kidney disease and she remained under treatment for this disease with Pantanjali Hospital, Haridwar as outdoor patient as per record dated 8.1.2015 and form No.3816 and DMR opinion. It is further alleged that the life assured has not mentioned material facts regarding his health in proposal form. It is further alleged that in terms of the policy contract and the declaration contained in form of proposal for assurance, the OPs repudiated the claim and conveyed the same to the complainant vide letter dated 1.3.2016. Hence, there is no deficiency in service on the part of OPs and complaint of the complainant is liable to be dismissed with costs.
3. Ld. counsel for the complainant has placed on record duly sworn affidavit as Annexure C1/A, documents Annexure-C1 to Annexure-C18 in support of his case and closed the evidence.
4. On the other hand, the OPs has placed on record documents Annexure R1 to R7 in support of their case and closed the evidence.
5. We have heard ld. counsel for both the parties at length.
6. Ld. Counsel for the complainant reiterated the contents of the complaint. Ld. Counsel for the complainant has contended that OPs have wrongly & illegally repudiated the claim and no cogent & convincing evidence has been produced on record by OPs to prove that Suman Tanwar, wife of the complainant was suffering from the chronic kidney disease, prior to the commencement of insurance policy. Therefore, repudiation of claim of the complainant vide letter dated 1.3.2016 is illegal and liable to be set aside and the complaint is liable to be accepted with costs. Ld. Counsel for the complainant has placed his reliance upon National Insurance Company Limited Vs Ravidutt Sharma and another PLR (2011-4), 154 and RP No. 2049 of 2000 Smt. Santosh Kanwar Vs LIC of India, decided vide order dated 9.9.2008 by the Hon’ble National Commission, New Delhi.
7. On the other hand, ld. counsel for OPs reiterated the contents of the written statement. Ld. Counsel for the OPs has contended that the life assured was not honest in making the disclosure about his state of health when the proposal form was filled up by her. He further contended that in view of these circumstances the claim of the complainant was rightly repudiated vide letter dated 1.3.2016. Hence, there is no deficiency in service on the part of OPs and the complaint of the complainant is liable to be dismissed. He placed his reliance upon ICICI Prudential Life Insurance Vs Lalita Jain, FA No. 246 of 2010, decided on 10.2015 by Hon’ble National Commission, New Delhi and Sunanda Dhananjay Lahoti Vs Met Life India Insurance Co. Ltd. & Anr., RA No.455 & 456 of 2014, decided on 25.1.2017 by the Hon’ble National Commission, New Delhi, Charanjit Singh Vs LIC of India & Anr., RP No. 1610 of 2017, decided on 19.1.2018 by the Hon’ble National Commission, New Delhi & Murti Devi Vs Birla Sun Life Insurance Company Limited, FA No. 652 of 2017, decided on 2.11.2017 by the Hon’ble State Commission, Haryana, Panchkula. But these judgments are not applicable to the facts of present case due to peculiar facts.
8. Now question of law arises as to whether the insurance company was justified in repudiating the claim of the complainant. The sought answer is “No”. The claim of the complainant was repudiated on the allegations that the insured had made false statement in the proposal form knowingly as she was suffering from the chronic kidney disease prior to issuing of insurance policy, because she had taken treatment from Pantanjali Hospital, Haridwar as outdoor patient and in support of their plea placed on record Form No. 3816, DMR opinion and record dated 8.1.2015 as Annexure R3 to R6. This plea of the OPs cannot be taken into count, because from these documents it is not proved on record that the disease was chronic one, as no history of the dialysis treatment of the life assured has been placed on record by the OPs to show that she was suffering from the chronic kidney disease. The dialysis treatment is very much necessary for the patient of chronic kidney disease, but to the OPs have failed to produce on record copy of dialysis treatment in support of plea taken by them. Moreover, the OPs have also failed to place on record some documentary evidence to prove on record that the cause of death of the life assured was chronic kidney disease. It was bounden duty of the company to get the person medically examined before insuring her/him. If the interpretation of insurance company is accepted, in that eventuality insurance company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer, because the insurance company relies on their Clause that the deceased life assured had concealed the true facts as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him/her, which he/she is genuinely unaware of the same. Hindsight everyone realize much later that he or she should have known from some symptom. If this is so, every person should do medical studies and further not to take any insurance policy. Even on the facts of record there is no material to show that the deceased life assured had any disease at the time of proposal form. Since there were no symptoms, the question of linking up the symptoms with a disease does not arise in any case. The OPs alleged that the life assured was suffering from chronic kidney disease and placed on record Annexure R3 to R6. From the perusal of above documents, it is not proved on record that the life assured died due to chronic kidney disease. So, it is clearly proved on record that the life assured was fit and hale at the time of issuance of insurance policy in question and it cannot be said that she had concealed anything regarding her health at the time of submitting proposal form and taking insurance policy. Moreover, it was the duty of the OPs to produce treatment record i.e. dialysis record of kidney taken by the life assured to prove that she was suffering from the any serious kidney disease prior to taking the insurance policy, but they have failed to do so. So, the concealment of disease, if any, was not of such an important significance, because nothing prevented the OPs from getting the medical examination of the assured for prescribing certain tests. It appears that they did not do so either because of the overzealousness to assure the people by supplementing their income through premiums or due to their cavalier and careless approach in insuring a person on the basis of self declaration. So, whenever a person is assured for policy minimum precaution, the insurance company is expected to take it to get the medical examination as well as other examinations which are required for the insurance policy. It is pertinent to mention here that there is no doubt medical examination might have been got done, as without getting medical examination, no insurance policy can be issued. It is also cannot be disputed that medical board/MO certainly had declared the life assured fit and only then the insurance policy were issued in favour of life assured. So, it is clear that at the time of issuance of insurance policy the life assured now deceased was not suffering from any disease.
9. The further arguments of the learned counsel for the OPs is that the claim of the complainant is not tenable because the said policy had run about 02 months from the date of first premium. This plea of the OPs is not tenable at all because neither any instruction has been produced by the OPs nor it has been brought into the notice of the complainant. It is also not disputed that the wife of the complainant had obtained the insurance policy bearing No. 179885678 for a sum of Rs.5,00,000/-. Meaning thereby the policy was issued after conducting medical examination. From this fact it is clear that as soon as the cover note was issued, life assured becomes entitled to get the insurance amount. It is worthwhile to mention here that as soon as insurance policy commenced then the contract becomes complete on that date. Hence, argument of early claim cannot be accepted. From perusal of record, it is clear that no such instruction has been brought on record by the OPs. So, instructions if any it cannot be disentitled the complainant from getting his genuine claim. In Annexure R3, prescription slip, the doctor has nowhere mentioned that the disease of the life insured cannot be cured. From the perusal of the Annexure R4, it is not clear on record that by whom proposal form was filled. The onus to prove on record the facts mentioned in proposal form beyond doubt is upon the OPs by placing on record some cogent and convincing evidence, but they failed to do so. Moreover, OPs have accepted the proposal form at the time of issuing the policy. It is the duty of OPs to complete all formalities with open eyes before issuing the insurance policy to avoid unnecessary harassment to the life assured. The Insurance Companies adopt very unethical and wrong procedure just grab the money from the poor peoples and harass them and their legal heirs when they are in need of the money. It is also moral & social duty of the insurance companies to conduct proper medical checkup of the buyers of the insurance policies before they accept the hard earned money on account of premium from policy buyers, as lateron they are on giving hand and they cannot escape from their liability and also cannot harass the poor people on unnecessary excuses especially at the time of giving the claim to the insured or his legal heirs. Generally it is routine practice that as and when a common person searches on internet about insurance/mediclaim policies, then he receives many unwanted telephone calls from the different insurance companies and these companies try to induce the poor people through their agents without disclosing the entire terms & conditions and at that time the only purpose of their agents is to extort money from public and to get the commission on that amount and they complete all the formalities by themselves including filling of proposal form and they also obtained the signature of assured on some blank forms and for this they always adopt the unethical, unsocial and un-genuine procedure to issue the insurance policy. As and when the assured need for the claim and apply for the same, then agents of the insurance companies some-times unethically bargains for settling the claim. So after considering all above mentioned important issues, we come to the conclusion that the insurance companies should have held liable for their errors & negligence committed on their part and to protect the interest of genuine buyers of the insurance policies. The Insurance Companies and their agents are also duty bound to disclose all hidden terms & conditions of the insurance policy to protect the interest of the consumers and these companies are also duty bound to get investigate the assured with their entire satisfaction before issuing the insurance/mediclaim policies. In our view, generally only 2-3 persons approached the insurance company for claiming the insurance claim, out of every 10 persons, but the insurance companies use to raise baseless objections to harass them for getting their insurance claims. It cannot be said that insured has suppressed material facts regarding his health, because everything was within the approachable hand of the OPs and they must investigate all the facts pertaining to the insured before repudiation of the claim to provide proper justice to the needy claimants. Thus, there is clear cut deficiency in service and unfair trade practice on the part of the OPs. Hon’ble Punjab & Haryana High Court, Chandigarh titled as National Insurance Company Limited Versus Ravidutt Sharma and another PLR (2011-4) 154 held as under:-
The insurance companies, in my view, are not acting fairly in all such matters after charging huge premium intention is always to repudiate the claim on one ground or the other. The conditions of the insurance agreements are so minutely printed that per-son gets hardly any time to go through such conditions to make it legally binding in any appropriate manner.
10. Moreover, the Insurance Companies deliberately with malafide intention does not settle the claim of its consumers in time and harassed them without any reason. So in our view the complainant is also entitled for compensation on account of mental and physical harassment & punitive damages for deficiency in service & mal trade practice on the part of the Insurance Company. Therefore, in view of the facts and circumstances mentioned above, complaint of the complainant is allowed and the OPs are directed:-
i) To pay the insured amount of policy i.e. Rs5,00,000/- (Five lacs only) along with interest @ 9% p.a. from the date of filing of the complaint till its realization.
ii) To pay Rs.50,000/- (Fifty thousand only) as compensation on account of mental agony, physical harassment & hardship, due to deficiency in service & mal trade practice on the part of OPs and punitive damages.
iii) To pay Rs.7000/- (Seven thousand only) as counsel fee as well as the litigation charges.
The compliance of the order shall be made within 30 days from the date of the order. Certified copies of the order be sent to parties free of costs. File be consigned to the record room, after due compliance.
Announced in open Forum.
Dated: - 08.05.2019.
(Saroj Bala Bohra) (Parmod Kumar) (Manjit Singh Naryal)
Member. Member. President,
District Consumer Disputes
Redressal Forum, Bhiwani.
