Haryana

Karnal

CC/230/2022

Gagandeep Singh - Complainant(s)

Versus

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

Sahib Singh Bajwa

04 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 230 of 2022

                                                        Date of instt.19.04.2022

                                                        Date of Decision:04.07.2024

 

1. Gagandeep Singh son of late Shri Resham Singh.
2. Jitender Kaur wife of late Shri Resham Singh.

Both residents of village Bdhanpur Viran, P.O. Balu, District Karnal.

 

                                               …….Complainants.

                                              Versus

 

Life Insurance Corporation of India, Branch Sector-12, Karnal through its Branch Manager.

…..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri S.S.Bajwa, counsel for the complainants.

                    Shri Anuj Gupta, counsel for the OP.

 

                     (Dr. Suman Singh, Member)

ORDER:   

                

                The complainants have filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that the father of the complainant no.1 and husband of complainant no.2 namely Resham Singh (since deceased) had purchased an insurance policy bearing no.144925903, valid from 28.10.2019 to 28.10.2034 for a sum of Rs.3,00,000/- and in the said policy, the complainant no.1 was nominee. Shri Resham Singh paid a sum of Rs.9157/- at the time of purchasing the said policy to the OP. Thereafter, he also paid a sum of Rs.9779/- on 21.01.2020, Rs.9627/- on 23.06.2020 and Rs.9419/- on 20.11.2020 and Rs.9419/- on 17.05.2021. On 02.07.2021, Shri Resham Singh started suffering from abdomen pain and pain in his anus area. He was admitted in Gandhi hospital, Karnal and was discharged on 08.07.2021 with stable condition and lateron, he expired on 11.08.2021. Thereafter, complainants lodged claim with the OP for the release of the insured amount under the said policy but OP vide letter dated 05.01.2022 repudiated the claim of the complainants on the ground that the deceased was k/c/o Aden Carcinoma rectum/DM-2/CLD/ALD & PHTM/Umbilical Hernia prior to taking insurance. The claim of the complainants was repudiated by the OP on the false and frivolous ground as Shri Resham Singh was not suffering from the abovesaid disease. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the policy no.144925903 was issued in the name of Shri Resham Singh son of Shri Updesh Singh on the date of first premium receipt dated 21.01.2020 for a sum assured of Rs.3,00,000/- under plan/term/premium paying term-843/15/15 for a premium of Rs.9212/- by Branch Officer Karnal-2 and the first unpaid premium under the policy was 10/2021. The life assured died on 11.08.2021. The aforesaid policy has not completed three years from the date of commencement of risk i.e. 21.01.2020 which is early to date of death of life assured. As such the competent authority has examined the claim in view of provisions of section 45 of the Insurance Act, 1938 and repudiated the claim with refund of premiums received as the deceased/life assured was k/c/o Aden Carcinoma rectum/DM-2/CLD/ALD C PHTN/Umbilical Hernia prior to taking policy but he did not disclose these facts in the proposal form dated 21.01.2020. Hence, the claim of the complainants has rightly been repudiated  by the OP, vide letter dated 05.01.2022 and premium received have been refunded to nominee on 21.02.2022 and claims under policy nos.178126661, 178126662, 178126663, 178126664 were non-early, therefore, liabilities have been discharge thereunder.  The policy in question was maliciously obtained by way of fraud and misrepresentation. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.  

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainants has tendered into evidence affidavit of Gagandeep Singh Ex.CW1/A, copy of insurance policy Ex.C1, copies of premium receipts Ex.C2 to Ex.C5, copies of insurance policies Ex.C6 to Ex.C9, copy of transferred certificate Ex.C10, copy of claim form Ex.C11, copy of repudiation letter dated 05.01.2022 Ex.C12, letter of OP Ex.C13 regarding why insurance claim, copy of death certificate Ex.C14 and closed the evidence on 22.09.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Anju Arora, Manager Ex.OPW1/A, copy of proposal form Ex.OP1, copy of status report Ex.OP2, copy of death certificate Ex.OP3, copy of repudiation letter dated 05.01.2022 Ex.OP4, copy of admission file Ex.OP5, copy of discharge summary Ex.OP6 and closed the evidence on 08.01.2024 by suffering separate statement.

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

7.             Learned counsel for complainants, while reiterating the contents of the complaint, has vehemently argued that Resham Singh (since deceased) had purchased an insurance policy from the OP. Complainant no.1 is a nominee in the said policy. On 02.07.2021, Resham Singh started suffering from abdomen pain and pain in his anus area. He was admitted in Gandhi hospital, Karnal and was discharged on 08.07.2021 with stable condition and lateron, he expired on 11.08.2021. Complainants lodged the claim with the OP and submitted all the required documents for settlement of the claim but OP did not settle the claim and repudiated the claim of the complainants on the false and frivolous ground and thus there is deficiency in service and unfair trade practice on the part of the OP and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the policy in question was obtained by deceased life assured by way of fraud and misrepresentation. The policy in question was issued in the name of Resham Singh (since deceased), for a sum assured of Rs.3,00,000/-. The life assured died on 11.08.2021. The said policy has not completed three years from the date of commencement of risk i.e. 21.01.2020, which is early to date of death of life assured. Thus, the claim of complainants was rightly repudiated by the OP and premium received have been refunded to nominee on 21.02.2022 and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, Resham Singh (since deceased) purchased a Life Insurance policy from the OP and complainant no.1 is the nominee in the said policy. It is also admitted that the sum assured in the said policy is Rs.3,00,000/-.

11.           The claim of the complainants has been repudiated by the OP, vide repudiation letter Ex.C12/Ex.OP4 dated 05.01.2022 on the ground that the deceased/life assured was k/c/o Aden Carcinoma rectum/DM-2/CLD/ALD C PHTN/Umbilical Hernia prior to taking policy but the said facts did not disclose by the life assured in the proposal form dated 21.01.2020, which is an early claim.

12.           The claim of the complainants has been repudiated by the OP on the abovementioned ground. The OP has mentioned in his affidavit Ex.OPW1/A that life assured suffered from cancer since November, 2018 i.e. prior to taking the policy. The treatment record of Gandhi Hospital, Karnal shows that the deceased life assured was admitted in hospital from 02.07.2021 to 08.07.2021 with compliant of abdominal pain/heaviness/incomplete digestion and he had history of k/c/o Adeno Carcinoma rectum/DM-2/CLD/ALD C PHTN/Umbilical Hernia and prior to this he had taken Chemo and Radiotherapy from PGI Chandigarh. The onus to prove its case was relied upon the OP, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon treatment record (admission file) Ex.OP5 dated 02.07.2021 and discharge summary Ex.OP6. The OP has not placed on record treatment record with regard to Cancer since 2018 as alleged by OP. Moreover, neither doctor of Gandhi Hospital, Karnal, who has issued the said treatment record was examined nor his affidavit was tendered into evidence by the OP to prove its version. Moreover, said treatment records are only photocopies and same are not admissible in the eyes of law. It was the duty of the OP, to verify the record from the hospital from where the life assured has taken treatment as alleged by the OP in its affidavit Ex.OPW/A.  Furthermore, OP did not disclose the fact that the  life assured was suffering from Cancer since 2018 in its written version. Thus, it has not been proved on the record that deceased life assured was having any pre-existing disease and has concealed the true facts at the time of purchasing the policy. In this regard, we relied upon case titled as Sucha Singh Vs. Head Brach Office, HDFC Life and Another 2022 CJ 901 (NC) wherein Hon’ble National Commission held that death due to heart attack-claim repudiated on ground of pre-existing ailment-complaint dismissed by State Commission-Insurance Company cannot travel beyond grounds mentioned in repudiation letter-When policy has been revived, it revives from date when it was originally issued-Insurance Company had failed to prove that insured had concealed his medical conditions on the date when he took policy-There is nothing on record to show that deceased was suffering from chronic alcoholic condition and was suffering with chronic liver disease and that he submitted fake documents at the time of obtaining original policy-State Commission had adopted wrong approach while rejecting complaint-Respondent shall pay to complainant assured amount alongwith 9% interest. Further in case titled as Bajaj Allianze Life Insurance Co. Ltd. and others Vs. Vinod Kumar Kaushik (since deceased) 2021 CJ 956 (NC), Hon’ble National Commission has held that Mediclaim-Family Care First Plan (Medical Policy)- Surgery for total hip replacement- Non-settlement of claim by Insurance Company on ground of pre-existing condition-Complaint allowed by Fora below-Averments made by OP were not supported by documentary evidence-OP relied on treatment record relating to past history of insured, which were neither verified not supported by proper evidence-In absence of any evidence, it cannot be said that insured was having any past history-Petitioners have failed to point any illegality or irregularity in order passed by State Commission, warranting interference in exercise of Revision-Revision Petition dismissed. Further in case titled as SBI Life Insurance Co. Ltd. Vs. Lakshiben Naginbhai Chauhan and others 2020 CJ 110 (NC) and Authorised Signatory, Hon’ble National Commission has held that Insurance-SBI Home Loan Master Policy-Repudiation of death claim on ground of concealment of pre-existing disease-Complaint allowed by fora below-Both District Forum and State Commission had reached to conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision petition dismissed. Further in case titled as Bajaj Allianz Life Insurance Co. Ltd. and 2 others Versus Kanduru Gangadhara Rao in Revision Petition no.1054 of 2020, decided on 07.10.2021 Hon’ble National Commission held that Insurance Law-concealment of disease-Death claim repudiated by insurer on ground that life assured suppressed her health condition of her taking treatment for  placed reliance on the treatment record, ‘Chronic non-specific cervicitis’ prior to obtaining the policy-Hence this complaint-Held, insurance company placed reliance on treatment record, which was a mere photocopy and not certified. The Doctor who treated the Life Assured was also not examined nor was his affidavit filed by the insurance company. Also, insurance company failed to satisfy this Commission that there was any co-relation between death of the Life Assured and the suppression of ailment "Chronic non-specific cervicitis". Complaint allowed. Thus, keeping in view the ratio of law laid down in the aforesaid judgments, the repudiation of the claim is based only on the basis of presumption and assumption, which is not admissible in the eyes of law.

13.           As per insurance policy Ex.C1, the date of birth of deceased life assured is 20.05.1964 and policy in question purchased on 21.01.2020. Thus, at that time the age of complainant was more than 65 years. It was the duty of the OP to get the medical examination of the deceased life assured as per the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI). In this regard, we place reliance upon case titled as  National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016, wherein Hon’ble State Commission U.T. Chandigarh has held that if the complainant and his wife both are older than 45 years of age but there is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDAI) is must in such like cases. Similarly, view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  and held that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

 14.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“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.”

 

 15.          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 complainants amounts to deficiency in service and unfair trade practice, which is otherwise proved genuine one. 

16.           As per insurance policy Ex.C1, the sum assured is Rs.3,00,000/-( Rs.three lakhs only). Hence, the complainants are entitled for the all the benefits under the policy in question alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.3,00,000/- (Rs.three lakhs only) i.e. sum assured  to the complainants alongwith interest @ 9% per annum from the date of repudiation of the claim  i.e. 05.01.2022 till its realization. We further direct the OP to pay Rs.25,000/- to the complainants on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. However, OP is at liberty to deduct the premium refunded from the awarded amount.  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: 04.07.2024   

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                 Member                            Member