BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BHIWANI.
Complaint No.: 178 of 2015.
Date of Institution: 18.06.2015.
Date of Decision: 08.04.2019.
Saroj Devi widow of Shri Mahender Singh, resident of in front of New Bus Stand, Bank Colony, Bhiwani, Tehsil & District Bhiwani.
….Complainant.
Versus
1. Manager, Life Insurance Company Limited, Bhiwani.
2. Senior Division Manager, Manager, Life Insurance Company Nigam Limited, Divisional Officer, Rohtak.
…...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 Sanjay Dadma, Advocate for the complainant.
Shri N. S. Vijayrania, Advocate for the OPs.
ORDER:-
PER MANJIT SINGH NARYAL, PRESIDENT
This complaint has been dismissed for non-appearance by the ld. Predecessor of this Forum vide order dated 4.7.2017, but the complainant has challenged the said order before the Hon’ble State Commission and the Hon’ble State Commission vide its order dated 12.3.2018 has remanded back this complaint with the direction for adjudication on merits.
2. Brief facts of the case are that the complainant’s husband Shri Mahender Singh has taken two insurance policies bearing No.179757904 and 179757905 on 26.6.2014 from the OPs by paying Rs.9291/- and Rs.8067/- as premium vide receipts No.3045526 and 3045527. It is alleged that the husband of the complainant at the time of issuance of insurance police was of good health and was not suffered from any disease. It is further alleged that the OPs have got medico legally examined the husband of complainant before insurance and no disease was found. It is further alleged that in the month of August, 2014 suddenly the husband of the complainant fallen ill due to liver infection and died on 2.11.2014. It is further alleged that the complainant has lodged the insurance claim with OP No.1 for both polices i.e. Rs.3,00,000/- and Rs.2,00,000/-, but the OP No. 2 has repudiated the claim of the complainant on the ground that the husband of the complainant was suffering from liver infection disease before the issuance of insurance and he has given wrong answers of the questions asked in the proposal form, whereas the husband of the complainant was not suffering from any disease before issuing of insurance policies. Hence, it amounts to deficiency in service on the part of OPs and hence, this complaint.
3. On appearance, the OP filed written statement alleging therein that on having intimation of death of the life assured Mahender Singh holder of insurance policy Nos. 179757904 & 179757905 date of commencement 26.6.2014, plan & term 815-20 & 220-20, mode half yearly installments of Rs. 9013/- & Rs.7825/- and sum assured Rs.3 Lacs and Rs. 2 Lacs respectively, showing the date of death as 2.11.2014 issued by the branch office, Bhiwani all claims papers were called for consideration of the claim. It is further alleged that the above said policy had run 4 months 6 days from the date of first premium receipt. It is further alleged that as per early claim, the matter was investigated and during investigation, it was revealed that while getting the insurance policies, the life assured provided wrong information and he suppressed the material facts relating to the state of his health and he gave false answers to the questions in the proposal forms thereby inducing the insured to accept the risk. It is further alleged that claim enquiry report reveals that the deceased life assured was suffering from liver disease and lungs got damaged because he was habitual of taking alcohol and consuming excessive liquor. It is further alleged that in terms of the policies contract and declaration contained in the forms of proposal for assurance, the OPs have repudiated the claim being not liable for any payment under the policies and all moneys that have been paid in consequences thereof belong to the OPs, which was duly intimated vide registered letter Claims/Rep/2014-15 dated 21.4.2015. Hence, there is no deficiency in service on the part of OPs and complaint of the complainant is liable to be dismissed with costs.
4. Ld. counsel for the complainant has placed on record duly sworn affidavit of the complainant as Ex. CW1/A and documents Annexure-C1 to Annexure C4 and closed the evidence.
5. On the other hand, the OP has placed on record documents Annexure R1 to R9 in support of its case and closed the evidence.
6. We have heard ld. counsel for both the parties at length.
7. Ld. Counsel for the complainant reiterated the contents of the complaint. Ld. Counsel for the complainant has further contended that OPs have wrongly & illegally repudiated the claim of the complainant because no cogent and convincing evidence has been produced to prove that Mahender Singh, husband of complainant was suffering from liver disease & lungs, prior to the commencement of insurance policy, because he was habitual of taking alcohol and consuming excessive liquor. Therefore, repudiation of claim of the complainant vide letter dated 21.4.2015 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.
8. On the other hand, ld. counsel for OPs reiterated the contents of the written statement. Ld. Counsel for the OPs has further 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 him. He further contended that in view of these circumstances the claim of the complainant was rightly repudiated vide letter dated 21.4.2015. 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 Mithoo Lal Vs LIC, CA No.224 of 1959, decided on 15.1.1962 by the Hon’ble Supreme Court of India, P. C. Chacko and Anr. Vs LIC, CA No.5322 of 2007, decided on 20.11.2007 by the Hon’ble Supreme Court of India, Ritesh Chopra & Anr. Vs TATA AIA Life Insurance, RP No.1052 of 2015, decided on 19.1.2016 by the Hon’ble National Commission, Lata Vs LIC, RP No.1598 of 2015, decided on 3.6.2016 by the Hon’ble National Commission, Dilraj Singh Vs LIC, RP No.1863 of 2014, decided on 17.9.2015 by the Hon’ble National Commission and LIC of India Vs Jyothi Sudhir, RP No.1134 of 2016, decided on 20.10.2015 by the Hon’ble National Commission. But these judgments are not applicable to the facts of the present case due to peculiar facts & circumstances.
9. 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 complainant had made false statement in the proposal form knowingly as he was suffering from liver and lungs disease prior to issuing of insurance policy, because he was habitual of taking alcohol and consuming excessive liquor. This plea of the OPs cannot be taken into count, because no party can be allowed to take an undue advantage of its own acts and conduct and omissions. It was bounden duty of the company to get the person medically examined before insuring 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 relies 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 liver & lungs disease, because he was habitual of taking alcohol and consuming excessive liquor, but they failed to produce any medical history or prescription slip to prove that the life assured was suffering from liver & lungs disease prior to taking the insurance policy and had taken treatment for the above diseases. So, it cannot be said that he had concealed anything regarding his health at the time of submitting proposal form and taking insurance policy. Moreover, it was the duty of the OPs to produce treatment record of the life assured to prove that he was suffering from the any serious disease prior to taking the insurance policy, but they have failed to do so. So, 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 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 the medical examination no insurance policy can be issued. It is also cannot be disputed that the 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 policies the life assured now deceased was not suffering from any disease.
10. The further arguments of the learned counsel for the OPs is that claim of the complainant is not tenable because the said policy had run 04 months 6 days 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 husband of the complainant had obtained the insurance policy bearing No. 179757904 & 179757905 for a sum of Rs. 3,00,000/- and Rs. 2,00,000/-. Meaning thereby the policies were issued after conducting medical examination. From this fact it is clear that as soon as the cover notes were issued, life assured becomes entitled to get the insurance amount. It is worthwhile to mention here that as soon as insurance policies commenced then the contract becomes complete on that date. Hence, plea of early claim cannot be accepted. From the perusal of record no instruction has been brought on record. So, instructions if any it cannot be disentitled the claim of the complainant. Annexure R4, statement of one Shri Parvinder son of Shri Om Parkash, in which he stated that insured use to take drinks occasionally. He has not mentioned any particular date of treatment of the life insured for the first time. Annexure R6, the Certificate of Hospital Treatment from 1.11.2014 to 2.11.2014, in clause No. 4 of the same, duration of complaint as reported by him is mentioned last two days. Annexure R7, Certificate issued by Medical Officer/doctor, in which the treating doctor has not given his complete opinion/answer on the points of clause No. 4 of the same. The doctor has mentioned that the life insured was suffering from chronic liver disease, but he has no where mentioned that how much old the chronic liver disease was from which life assured was suffering. He has not mentioned the particular period of the chronic disease. Moreover, Annexure R1, proposal form, in which doctor of the OPs after examining the life insured, accepted the proposal form. From the perusal of the proposal form, it is not clear on record that by whom proposal form was filled. It is also highly questionable thing that the insured had given the consent yes or no in the proposal form. 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 the OPs to complete all formalities with open eyes before issuing the insurance policy to avoid unnecessary harassment of 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 were 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 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.
11. 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 partly allowed and the OPs are directed:-
i) To pay the insured amount of two policies i.e. Rs.3,00,000/- (Three lacs only) + Rs.2,00,000/- (Two lacs only) along with interest @ 9% p.a. from the date of filing of the complaint till its realization.
ii) To pay Rs.5000/- 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.5000/- (Five 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: - 08.04.2019.
(Saroj Bala Bohra) (Parmod Kumar) (Manjit Singh Naryal)
Member. Member. President,
District Consumer Disputes
Redressal Forum, Bhiwani.
