Haryana

Karnal

CC/586/2021

Damini Saini - Complainant(s)

Versus

Life Insurance Corporation Of India - Opp.Party(s)

Vishal Kundi

08 Apr 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 586 of 2021

                                                        Date of instt.19.10.2021

                                                        Date of Decision:08.04.2022

 

Damini Saini wife of late Shri Hitesh Saini, resident of 346/2, behind UBI Building, Model Town, Karnal-132001.

 

                                               …….Complainant.

                                              Versus

 

Life Insurance Corporation of India Divisional office, P.O. box no.106, Jeevan Prakash Building, 489, Model Town, Karnal-132001.

 

                                                                        …..Opposite Party.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary….Member

 

 Argued by: Shri Vishal Kundi, counsel for complainant.

                    Shri C.J. Wadhwa, counsel for opposite party.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that husband of complainant (since deceased) during his life time had purchased a life insurance policy bearing no.479408000 on 12.10.2017 from the OP, for the consideration of Rs.1,77,826/-. The complainant is the nominee in the said policy. It is further averred that due to unavoidable circumstances, the husband of complainant could not pay the installments due in year 2019 and 2020. However, the policy was duly revived in February, 2021 and late husband of complainant paid all the due premium alongwith late fee for a total revival amount of Rs.3,94,458/-. It is further averred that at the time of revival of the insurance policy, the husband of complainant was medically examined by the penal doctors of the OP. All his medical reports were normal. This fact was duly corroborated by lab tests; ECG etc. The husband of complainant had expired on 22.05.2021 due to heart attack. The complainant being nominee lodged the death claim of her husband with the OP and requested for settlement of the claim but OP always postponed the matter on one pretext or the other and lastly repudiated the claim of the complainant, vide letter dated 12.08.2021, on the ground that since the policy has not completed three years from the date of revival, the settlement of claim is considered under the provisions of section 45 of the Insurance Act. The life assured has not suffered any disease, injury, and treatment etc. prior to taking the policy and he was in good health. It is alleged in the letter that the life assured was having history of cirrhosis of liver/portal hypertension before the date of revival.  The repudiation of the claim of complainant is completely wrong, unjustified, illegal and without any application of mind. The OP has failed to take note of the fact that the concerned doctor who conducted the medical examination of the complainant has also certified through letter dated 01.02.2021 that the complainant had not previous history of such disease. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence, complainant filed the present complaint seeking direction to the OP to pay the claim amount of Rs.25,00,000/- alongwith interest @ 18% per annum and also to pay a sum of Rs.1,00,000/- as compensation for mental agony and litigation costs.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the policy no.479408000 was taken by Shri Hitesh Saini son of Shri Ashok Saini for sum assured of Rs.25,00,000/- from Branch Office Karnal-1 under Plan and Term 833-18 (15) (LIC’s Jeeven Lakshya Plan) with the commencement of policy as 12.10.2017 and date of commencement of risk 31.10.2017. The yearly premium under the policy was Rs.1,77,826/- and he paid first premium on 31.10.2017 and second installment of premium due on 10/2018 was paid on 15.10.2018. After the policy became lapse due to non-payment of premium due on 10/2019 and 10/2020 and policy was revived on 02.03.2021 by paying two installments of premium on the basis of “Personal statement of health” dated 01.02.2021. After that life assured expired on 22.05.2021, so the duration of policy was only 2 months 20 days from the date of revival and the claim was examined Under Section 45 of Insurance Act, 1938 and during investigation it was revealed that the life assured remained admitted in Amritdhara Hospital, Karnal from 20.04.2020 to 22.04.2020. He was admitted in hospital with complaint of UGI Bleed and 10 to 12 episode of Hemtemsis melena and he was diagnosed suffering from Alcoholic Liver Disease, cirrhosis of liver, portal hypertension, hepatitis C positive, post EVL, post operated spine, post operated Hip. He was again admitted in same hospital from 11.05.2020 to 14.05.2020 with complaint of Alcohol Intake Yesterday, Nausea, Abdominal Discomfort, weakness and was diagnosed HSV positive, Alcoholic Liver disease, Chronic Liver disease, UGI Bleed, Gastric Ulcer, Anemia. But this material information which was in the knowledge of life assured, was not disclosed by him in the “Personal statement of health” dated 01.02.2021 and false answers were given at the time of revival of the policy in question. It is further pleaded that the policy was revived on the basis of false information and declaration with the intent to defraud the Corporation. The competent authority after examining the whole record has repudiated the claim with forfeiture of all money received under the policy and decision has been conveyed to claimant (complainant), vide detailed letter dated 12.08.2021. In the said letter the claimant was informed the address of appellant authority and she preferred appeal before the Zonal Manager and the ZOCDRC (Zonal Office Claim Disputes Redressal Committee) has reviewed the claim of claimant. This committee also consists of one external member form judiciary and the committee after examining the whole record upheld the decision of repudiation  and the decision was duly conveyed to claimant vide letter dated 01.11.2021. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of policy revival quotation Ex.C1, copy of medical examination report of life assured Ex.C2, copy of electro cardiogram report Ex.C3, photograph of life assured Ex.C4, copy of aadhar card of life assured Ex.C5, copy of repudiation letter dated 12.08.2021 Ex.C6 and closed the evidence on behalf of complainant on 18.01.2022 by suffering separate statement.

5.             On the other hand, learned counsel for OP has tendered into evidence affidavit of Puneet Kumar, Manager as Ex.OP1/A, copy of proposal form Ex.OP1, copy of insurance policy Ex.OP2, proposal form for revival of insurance policy dated 01.02.2021 Ex.OP3, copy of repudiation letter dated 12.08.2021 Ex.OP4, repudiation letter dated 18.10.2021 Ex.OP5, opinion of Dr. Sandeep Chaudhary dated 03.08.2021 Ex.OP6, copy of treatment dated 11.05.2020 to 14.05.2020 Ex.OP7,  dated 20.04.2020 to 22.04.2020 Ex.OP8, copy of status report Ex.OP9, copy of death certificate of life assured Ex.OP10 and closed the evidence on behalf of complainant by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that husband of complainant namely Hitesh Saini (since deceased) during his life time had purchased a life insurance policy for the sum assured of Rs.25,00,000/-. He further argued that due to unavoidable circumstances, the husband of complainant could not pay the installments due in year 2019 and 2020. However, the policy was duly revived in February, 2021 and late husband of complainant paid all the due premium alongwith late fee for a total revival amount of Rs.3,94,458/-. At the time of revival of the insurance policy, the husband of complainant was medically examined by the penal doctors of the OP. All his medical reports were normal. The husband of complainant had expired on 22.05.2021 due to heart attack. The complainant being nominee lodged the claim under the abovesaid Policy. All the relevant documents were also submitted with the claim form in the office of OP, but OP repudiated the claim of the complainant, vide letter dated 12.08.2021, on the false and frivolous ground. Hence, prayed for allowing the complaint. Learned counsel for complainant relied upon the judgment of Hon’ble Supreme Court of India in case titled as Sulbha Prakash Motegaoneka Versus Life Insurance Corporation of India, in civil appeal no.8245 of 2015, decided on 05.10.2015; Chanda Devi Vs. LIC in complaint no.551/2016, decided on 23.11.2021 of Hon’ble Delhi State Commission; Religare Health Insurance Company Versus Harwant Singh, decided on 08.02.2021 of Hon’ble State Commission, Chandigarh; Satish Chander Madan Vs.Bajaj Allianz General Insurance Company Ltd. (2016) CPJ 613 (NC) and Aditya Birla Health Insurance Co. Ltd. & anr. Versus Deepinder Singh & anr. I 2021 CPJ 156 (Punjab.

8.             Per contra, learned counsel for OP, while reiterating the averments made in the written version, has vehemently argued that the policy became lapse due to non-payment of premium due on 10/2019 and 10/2020 and policy was revived on 02.03.2021 by paying two installments of premium on the basis of “Personal statement of health” dated 01.02.2021. Life assured expired on 22.05.2021, so the duration of policy was only two months twenty days from the date of revival and the claim was examined and during investigation, it was revealed that the life assured remained admitted in Amritdhara Hospital, Karnal from 20.04.2020 to 22.04.2020 and was diagnosed from Alcoholic Liver Disease, cirrhosis of liver, portal hypertension, hepatitis C positive, post EVL, post operated spine, post operated Hip. He was again admitted in same hospital from 11.05.2020 to 14.05.2020, with complaint of Alcohol Intake, and was diagnosed Alcoholic Liver disease. But this material information which was in the knowledge of life assured, was not disclosed by him in the “Personal statement of health” dated 01.02.2021 and false answers were given at the time of revival of the policy in question. The competent authority after examining the whole record has repudiated the claim of the complainant, vide detailed letter dated 12.08.2021. Hence, prayed for dismissal of the complaint. Learned counsel for the OP relied upon the judgment of Hon’ble National Commission in case titled as Usha Dinkar Saindane Vs. LIC of India Legal Digest, in revision petition no.1004 of 2010, April/July 2015 and Padaman Ram Paswan Versus Life Insurance Corporation of India in Writ Petition © no.48 of 2003 of Hon’ble High Court of Jharkhand at Ranchi.  

9.             We have duly considered the rival contentions of the parties.

10.           The OP has admitted the fact that husband of complainant namely Hitesh Saini had purchased a life insurance policy for the sum assured of Rs.25,00,000/-. It is also admitted fact that the policy in question had lapsed for non-payment of premium for the period from October, 2019 and October, 2020 and same was revived on 02.03.2021, by paying two installments of premium alongwith late fee for a total revival amount of Rs.3,94,458/-. It is also admitted fact that complainant is the nominee in the policy in question.  It is also admitted fact that the husband of complainant expired on 22.05.2021, during the subsistence of the policy in question.

11.           The claim of the complainant has been repudiated by the OP only on the grounds of concealment of material facts with regard to pre-existing disease at the time of revival of the policy in question and claim of the complainant was an early claim.

12.           The husband of the complainant have purchased the policy in question in the year 2017 and had paid two yearly premiums on 31.10.2017 and 15.10.2018. After that policy was became lapse due to non-payment of premium amount due on 10/2019 and 10/2020 and the policy was revived on 02.03.2021 by paying two installments of premium. The life assured expired on 22.05.2021.

13.           As per discharge summary Ex.OP8, the life assured was admitted in Amritdhara Hospital, Karnal, on 20.04.2020 and discharged on 22.04.2020 and he was diagnosed  as under:-

Aid/cirrhosis of liver

Portal hypertension

Hepatitis C positive

Post EVL

Post operated spine #

Post operated hip #

Admitted with UGI bleed

 

 

And as per discharge summary Ex.OP7, the life assured was again admitted in the said hospital on 11.05.2020 and discharged on 14.05.2020 and he was diagnosed  as under:-

 

HCV+VE

Alcoholic Liver Disease

UGI Bleed

Gastric Ulcer

Anemia

 

14.           The claim of the complainant has been repudiated on the basis of abovesaid discharge summary as Ex.OP7 and Ex.OP8. The life assured was admitted the abovesaid hospital lastly on 11.05.2020 and expired on 22.05.2021. The duration between the last date of admission in the hospital and date of death is more than one year. After 11.05.2020 there is no record placed on the file by the OP that life assured had remained under the treatment mentioned in the discharge summary Ex.C7 and Ex.C8. Meaning, thereby, after that life assured was not having any disease.

15.           OP relied upon the opinion Ex.OP6 dated 03.08.2021 of Dr. Sandeep Chaudhary wherein said doctor has opined that life assured has suffering from cirrohosis of liver and hypertension (ceuse alcohol+HCV) which appears to have been concealed a pre-existing disease. Meaning, thereby, the said doctor was not sure of whether the life assured was actually having any pre-existing disease. Moreover, OP has failed to examine and place on file affidavit of the said doctor to prove its version.  Rather, it is evident from Ex.C4, that at the time of revival of the policy in question, the life assured was medically examined by the empanelled doctors of the OP and found medically fit. On the recommendation of the said empanelled doctors, the policy in question was revived by the OP. The onus to prove that the life assured was having pre existing disease, lies upon the OP, but OP miserably failed to prove its case by leading any cogent and convincing evidence.

16.           For the sake of arguments, if it is presumed that the life assured was having any pre existing disease at the time of revival of the policy in question, then the question arises whether there is nexus between the cause of death and the disease mentioned in the case summary Ex.OP7 and Ex.OP8.

17.           The complainant has specifically mentioned in para no.5 of the complaint as well as in her affidavit Ex.CW1/A that the cause of death was sudden massive heart attack. The cause of death has not been denied by the OP. Hence, it has been proved on record that the life assured died due to heart attack. When there is no nexus between the cause of death and disease mentioned in Ex.OP7 and Ex.OP8, then the claim of the complainant cannot be repudiated. In this regard, we relied upon in Sulbha Prakash’s case (supra) wherein Hon’ble Supreme Court held that the suppression of information regarding any pre-existing disease, if it has not resulted in death or has no connection to cause of death it would not disentitle the claimant for the claim. Further, in Chanda Devi’s case (supra) wherein Hon’ble State Commission, Delhi held that if the reason of the death is not in nexus with pre-existing disease and there is no evidence placed on record by the OP to show that the death was on account of pre-existing disease of the life assured, then the contention of the OP in the repudiation letter has no merit. Further, in Harwant Singh’s case (supra) wherein Hon’ble State commission, Panchkula held that hypertension is a common ailment and it can be controlled by the medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack or other ailment. Similar view was taken by the Hon’ble National Commission in case titled Satish Chander’s case (supra). In Deepinder Singh’s case (supra) wherein Hon’ble Punjab State Commission held that “Consumer Protection Act, 1986- Sections 2(1)(g), 14(1)(d), 15- Insurance Regulatory and Development Authority (Protection of Policy holders’s interest) Regulations, 2017- Regulation 10- Insurance (Mediclaim)- Surgery of shoulder- Alleged non-disclosure of pre-existing disease- Repudiation of claim- Deficiency in service- District Forum allowed complaint- Hence appeal- Respondent/ complainant was admitted to hospital on 10.10.2018 with problem of right shoulder pain and after surgery was discharged on 21.10.2018 in satisfactory condition- Expenditure of Rs.81,595/- was incurred on said treatment- Complainant lodged reimbursement claim for Rs.82,981/- and same was repudiated- Except medical record of ailment, OPs have not placed on record any independent evidence that insured had knowledge or that he had been taking treatment of disease, before purchasing this policy- In absence of any specific evidence on record how disease, if any, to which insured does not have knowledge can be termed as pre-existing disease- Repudiation not justified- Complaint was rightly allowed.

18.  

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

 19.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

20.           The authorities cited by the learned counsel for OP are not applicable to the facts of the present case.

21.           As per insurance policy Ex.OP2, the sum assured is Rs.25,00,000/-( twenty five lakh only). Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

22.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.25,00,000/- (Rs. twenty five lakhs only) i.e. sum assured  to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:08.04.2022.

                                                                       

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

       

                (Vineet Kaushik)        (Dr. Rekha Chaudhary)      

                      Member                        Member