BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.606 of 2019
Date of Instt. 24.12.2019
Date of Decision: 19.05.2023
1. Mrs. Dipty Jain aged 32 years wife of Late Deepak Jain resident of NL-83, Mohalla Mohindru, Near Shiv Mandir, Jalandhar City.
2. Rishita Jain aged 8 years daughter of Late Deepak Jain resident of NL-83, Mohalla Mohindru, Near Shiv Mandir, Jalandhar City through her natural guardian mother Dipty Jain.
3. Rishabh Jain aged 10 years son of Late Deepak Jain resident of NL-83, Mohalla Mohindru, Near Shiv Mandir, Jalandhar City through her natural guardian mother Dipty Jain.
..........Complainants
Versus
1. Life Insurance Corporation of India, Zonal Office, Central Office, CRM Department, 5th Floor, Yogakshema building, Jeevan Bima Marg, Mumbai-400021 through it's Zonal Manager/Authorized Representative.
2. Life Insurance Corporation of India, Divisional Office, Model Town Road, Jalandhar, through its Senior Divisional Manager.
3. Life Insurance Corporation of India, Branch Office SO CLIA, Life Insurance Corporation of India, Roop Complex, Kapurthala Road, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Y. V. Rishi, Adv. Counsel for the Complainants.
Sh. S. C. Sood, Adv. Counsel for OPs No.1 to 3.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainants, wherein it is alleged that complainant is a law abiding citizen of India. Shri Deepak Jain husband of the complainant no.1 and father of complainant no.2 and 3 was an insurance minded and conscious to the need for risk coverage provided by insurance and had taken policies from National Insurance Co. Ltd. and had been regularly paying insurance premium of said policies. Deepak Jain (since deceased) whilst alive got his life insured vide policy bearing No.134190584 for Sum Assured Rs.10,00,000/- through Branch Office SO CLIA, Life Insurance Corporation of India, Roop Complex, Kapurthala Road, Jalandhar through its Branch Manager/authorized Officer under the administrative and supervisory control of the Opposite Party. The policy was under plan Jeevan Lakshya (with profits) and With Accident Death and Disability Benefit Rider UIN 512B209V01 for term 18 years. The date of proposal was 11.02.2017 under Medical Scheme. The risk of the policy commenced from 11.02.2017. The signature of the life assured on prescribed printed Proposal Form No.300 dated 05.02.2017 were taken in routine and mechanically on dotted lines on the blank proposal form filled in English by securing agent of Opposite Parties. That life assured underwent complete comprehensive and careful medical checkup by panel doctor (Medical Examiner) Dr. Rohit Gambhir of choice of OPs at the time of submission of proposal form for life insurance. The panel doctor examined thoroughly and did not find any malady or adverse symptom or sign related to health profile of life assured. The OPs accepted Medical Examiner's Confidential Report dated 05-02-2017 which was given more than eleven months before death. The life assured unfortunately died on 12.01.2018 due to heart attack. The policy was alive on the date of death of the life assured. The life assured has good and perfect health, insurability as standard life with no trace of any physical infirmity and disease/illness after clinical and physical check up was duly certified by the panel doctor in prescribed medical examination report in Form No.LIC 03-001HP in answer to specific query/question. The Panel Medical Examiner further certified that panel doctor did not notice any adverse feature of past history disease/illness and habit or existence of any other health complaint/complication and that panel doctor had examined the life assured in private and recorded true findings in his own hand on the eve of proposing for life insurance. The OPs obtained reports on the requisite forms from Securing Agent, Development Officer and Moral Hazard Report etc. on the eve of proposing for insurance and carefully and thoroughly scrutinized and verified before acceptance of proposal. All of them in their respective reports recommended for the insurance of Life Assured as would be clear from their reports with OPs pertaining of policy subject matter of complaint. That this policy was taken from Branch Office SO CLIA, Life Insurance Corporation of India, Roop Complex, Kapurthala Road, Jalandhar, under the supervision and administrative control of OPs. Sh. Deepak Jain, life assured, lived without any trace of any ailment or sickness. He was hale and healthy and kept good health with temperate and sober habits at the time of taking insurance on his life. The life assured had healthy existence and normal physical conditions during his life span and was not harboring and laboring under any disease or sickness when he sought insurance on his life under the policy subject matter of the complaint. The OPs accepted Medical Examiner's Confidential Report dated 05-02-2017 more than 11 months before death, The life assured unfortunately died on 12-01-2018 due to heart attack. The policy was alive on the date of death of the life assured. Subsequent to death of life assured, the complainants as a nominee appointed under Section 39 of the Insurance Act lodged claim by death with OPs through its policy servicing Branch Office for payment of full Sum Assured with accrued Bonus and other benefits flowing from the policy subject matter of complaint. The complainants completed and complied with all requirements and submitted requisite claim forms whichever was obliged to complete for quick settlement. The death of the life assured was due to heart attack and had taken place earlier than the date of maturity of the policy. That claim by death so made covered by the Complainants has been repudiated vide letter Ref: Claims/Repudiation/36 dated 09.04.2018 by registered Post by Opposite Parties on a flimsy ground that the insured had withheld correct information regarding his ill health and habits at the time of effecting assurance with the OPs. The information in respect of questions which are alleged to have been withheld is in no manner caused the death of life assured. Besides, the life assured had only signed the blank proposal form and was never asked about the said queries by the Agent/representative of the opposite parties before filing up said blanks. There is no malafide intentions of the life assured to conceal any such information from the opposite parties. Besides the death of life assured in no manner was due to the reasons alleged and misinterpreted by the OPs. The reason of death of the life assured was heart attack and the life assured was never under observation, treatment or operated or got checked up at any time for heart problem. In order repudiate the claim under the impugned Insurance Policy, the opposite parties are with a malafide intentions misused the questionnaire in the proposal form filled up by their own representative without consulting the life assured. The life assured maintained good state of health at the time of taking insurance policy and this fact has been duly certified by the empaneled qualified doctor of the choice of opposite parties. The repudiation of claim of the complainant that life assured has ill health since the replies to the questionnaire in para no.11 of the proposal is not correct is absolutely without any substance, especially keeping in view of the fact that at the time of taking the said policy the life assured was medically checked by the qualified empanelled Doctor of the choice of OP who has after thorough medical checkup of the life assured declared him by his medical certificate that the life assured is keeping good health. Further, as per claims enquiry report of the OPs the Investigation Officer appointed by opposite parties in reply to question no.15 has stated that DLA was enjoying good health and at the time of death suddenly on 12.1.2018 he had suffered heart attack and he was taken to Sikka Hospital, Jalandhar, but Doctors on duty declared him dead. The OPs has failed to appreciate that none of the answers to the questionnaire in para 11 of the Proposal form was relevant to the immediate cause of death of the life assured by heart attack. The OPs have wrongly and without any proper reason with a malafide intentions has repudiated the claim of the complainant who had just signed the proposal form while it was blank. The refusal of OPs to pay just, rightful and genuine claim is wrongful, arbitrary, mala fide, capricious and palpable and untenable and unsustainable allegations, based on spurious reasons and invalid justification, whatsoever. The repudiation of claim was totally wrong, perverse, arbitrary, mala fide and wholly unwarranted made on misapplication of independent mind, on conjectures and surmises in routine and mechanical manner when OPs was under obligation to pay the claim by death for full sum assured covered by the policy. The life assured had not made any deliberate and incorrect statement nor withheld correct, information regarding his health at the time of effecting and revival of life insurance policy as imputed in repudiation letter. He had not concealed any discloseable material information in his proposal form and DGH got filed up at the time of revival of policy. There was no miss-declaration or suppression of material information by the life assured. The assertions so made in letter of repudiation against the life assured are totally erroneous and perverse and are vehemently and specifically denied. The repudiation of liability of death claim was not made on germane facts rather on conjectures OPs failed to adopt fairness and transparency, human approach and liberal attitude to advance avowed purpose of taking life insurance and also failed in performance of statutory duty and obligation enjoyed upon OPs under the contract of insurance in dealing with the claim of the claimant which caused harassment, hardship, mental tension and agony suffered by and subjected to the Complainants by OPs and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay sum assured of Rs.10,00,000/- along with Bonus accrued and covered under LIC Jeevan Lakshya (with profits) Policy No.134190584 with interest @ 12% per annum from the date of death of the life assured up to date of actual payment to the Complainants which is just and reasonable. Further, OPs be directed to pay a compensation of Rs.50,000/- for causing mental tension and harassment to the complainant and Rs.10,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, who filed joint written reply and contested the complaint by taking preliminary objections that at the time of taking the policy the life assured concealed the material facts of his ailments and did not disclose his ill health and have not given correct answers in the proposal form, as such the contract is null and void. The life assured obtained the policy by mis-representation, as such the complaint is to be dismissed. It is further averred that the complainants are estopped by their own act, conduct and acquiescence to file the present complaint. The life assured despite having full knowledge of his ill-health obtained the policy without disclosing his illness in the proposal form with fraudulent intention. In terms of policy contract and declaration contained in the form of proposal for insurance and on the basis of personal statement the case was rightly repudiated. On merits, it is admitted that Deepak Jain took the policy bearing No.134190584 for sum assured Rs.10 Lacs and it is also admitted that the policy was taken by life assured, Deepak Jain under Medical Scheme. It is also admitted that the date of proposal was 11.02.2017. The facts regarding repudiation of the claim is also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the OPs very minutely.
6. It is admitted and proved fact that the deceased Deepak Jain took the policy bearing No.134190584 for sum assured of Rs.10,00,000/- under medical scheme on 11.02.2017 Ex.C-1. The complainant has proved on record that at the time of taking the policy the deceased Deepak Jain was medically checked-up by the medical team of the LIC i.e. OPs and the report of the team has been proved by the complainant as Ex.C-7. It is also proved that after 11 months of the inception of the policy, the life assured died due to heart attack. The death certificate has been proved by the complainant as Ex.C-2. The complainant has alleged that the claim of the complainant has been repudiated wrongly and illegally on the ground that he has concealed the material facts from the OPs. He has proved on record the repudiation letter Ex.C-12, which includes the order passed in the appeal, vide which the order of the OP was upheld.
7. The contention of the OP is that as per the provisions and terms and conditions of the LIC, the complainant is not entitled to any claim as he has concealed the material facts about his pre-existing disease. The OP has proved on record the discharge summary Ex.O-5 of the deceased Deepak Jain dated 02.04.2014. It has been alleged by the OP that the life assured i.e. Deepak Jain had undergone Mini Gastric Bypass Surgery on 31.03.2014. As per discharge summary, the weight of the deceased Deepak Jain at that time was 174 KG and this was a material fact which was not disclosed by the deceased at the time of taking the policy, therefore the claim of the complainant was rightly repudiated and appeal was also rejected.
8. It is admitted and proved that at the time of inception of the policy, the deceased was checked-up by the medical team of the OP. Perusal of Ex.C-5 is the confidential report of the agent and as per this confidential report, the general state of health of the proposal was good at the time when he was checked up and this relates to 5th February, 2017. This clearly shows that at the time of policy, the state of health of the deceased was good and as per the defence of the OPs, the complainant took the policy in the year 2017. This shows that for the continuous three years, the premium was paid by the deceased and this policy was extended on the yearly basis by the OPs. During this period of three years, the OPs could not verify and see as to whether the deceased had any problem or had he not concealed anything. The contention of the OPs is that this report was given on the basis of the answers given by the complainant. This contention is not tenable as it is the duty of the OPs to provide the services and provide the insurance policies to proposers after getting themselves satisfied about their state of health. Ex.C-10 is the claim inquiry report. This document clearly shows that the cause of death of Deepak Jain is heart attack and under the question No.15, it was mentioned that the DLA was enjoying good health at the time of proposal. Suddenly on 12.01.2018, he had a serious heart attack and he was taken to Sikka Hospital, Jalandhar, but doctors on duty declared him dead. No urgent aid could be provided to him. During inquiry, it was found that he had undergone Obesity Surgery on 31.03.2014 in Jammu Hospital, Kapurthala. Perusal of Ex.O-5 shows that he was admitted on 30.03.2014 and was discharged on 02.04.2014. He was diagnosed with complaints of morbid obesity with snoring, dysponea and the surgery was done on 31.03.2014. When the complainant was operated, he was not having any heart problem nor he died due to the consequences of the operation for obesity. There is no connection of the surgery with the heart attack. It has been held by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi, in a case titled as ‘PNB Metlife India Insurance Company Ltd. Vs. Godavariben Kalubhai Vaghela’ that ‘Insured had suffered a heart attack and he died - Complainant being nominee, claimed amount under the policy, which was denied by the petitioner on ground that insured had concealed material fact at the time of buying policy- Insured was not suffering from any heart ailment when he filled up proposal form- only defence taken is that insured had underwent treatment for T. B. and this fact was concealed – insured had died after about six months of buying the policy – Concealment of fact regarding treatment of T. B., if any, cannot be termed as concealment of material fact – There is no nexus between concealment of alleged fact and cause of death.’ It has been held by the Hon’ble Delhi State Commission Disputes Redressal Commission, New Delhi, in a case titled as ‘Gurpreet Kaur Vs. Bajaj Allianz Life Insurance Co. Ltd. & Ors., that ‘Death of life assured occurred due to heart attach/cardiac arrest, which is not connected with pre-existing disease and nor there is any evidence to show that death was on account of pre-existing disease of life insured- Repudiation of claim is not justified.’ It has been held by the Union Territory Consumer Disputes Redressal Commission, Chandigarh, in a case titled as ‘Life Insurance Corporation of India & Ors. Vs. Shiv Singh’ that ‘insured got examined from insurance doctor, found healthy – Deceased allegedly suffered from chronic obstructive pulmonary disease and chronic asthma – No nexus between cause of death and alleged ailment of deceased – Fraudulent suppression of material facts not proved- insurer liable.’
The law referred by the Ld. Counsel for the OPs, titled as ‘PNB Metlife India Insurance Company Ltd. Vs. Godavariben Kalubhai Vaghela’ is not applicable to the facts of the present case as in the present case the complainant was not having any heart problem. He took the policy in the year 2017, which was extended upto 2019. So, he did not die within few months of the insurance policy, therefore it cannot be said that there was any mis-statement and the same was intentional to seek the claim.
9. The law referred by the Ld. Counsel for the OP titled as ‘Gurpreet Kaur Vs. Bajaj Allianz Life Insurance Co. Ltd. & Ors.’ is also not applicable to the facts of the present case as in the present case, there are no such allegations that the deceased was to give some loan or he was having prior apprehension that he would die of heart attack. Also the law referred by the Ld. Counsel for the OP ‘Life Insurance Corporation of India & Ors. Vs. Shiv Singh’ is also not applicable to the facts of the present case as the complainant was not having any problem which was having direct nexus between the surgery conducted upon the complainant in the year 2014 and the cause of death i.e. of heart attack in the year 2018.
10. In view of the above detailed discussion, the case of the complainant is fully proved and the complaint of the complainant is partly allowed and OPs are directed to pay Rs.10,00,000/- i.e. sum assured with all the benefits i.e. Bonus etc. with interest @ 6% per annum from the date of death of the life assured till its realization and further OPs are directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Dr. Harveen Bhardwaj
19.05.2023 Member President
