Order by:
Sh.Amrinder Singh Sidhu, President
1. The complainant has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now under section 35 of the Consumer Protection Act, 2019) on the allegations that Raj Karni wife of the complainant had purchased a policy bearing No.474052936 from Opposite Party No.2-LIC vide which she was insured upto the extent of Rs.2 lakhs and she used to pay the installments of the said policy regularly. Further alleges that said Raj Karni remained admitted in Amrit Hospital on 20.09.2016 where she suddenly expired on 17.11.2016 due to heart attack and the complainant is the husband of said Raj Karni and being nominee, he has filed the present complaint. After the death of Life assured, the complainant approached the Opposite Parties to pay the sum assured of Rs.2 lakhs, but they refused and repudiated the claim of the complainant vide letter dated 21.08.2019 on the false ground of concealment of facts. It is pertinent to mention that said Raj Karni was thoroughly examined by the qualified doctor of the Opposite Parties and no disease was ever detected, so now the Opposite Parties are estopped by its own act and conduct in denying the claim of the complainant. The complainant made requests to the Opposite Parties to pay the insurance claim on the death of Raj Karni insured, but the Opposite Parties did not pay any heed to the request of the complainant and hence, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.
a) The Opposite Parties may be directed to pay the sum of Rs.2 lakhs in respect of the policy in question alongwith interest @ 12% per annum till its realization and also to pay Rs.2 lakhs on account of compensation for causing him mental tension and harassment or any other relief to which this District Consumer Commission may deem fit be also granted.
Hence, the Complainant has filed the present complaint for the redressal of her grievances.
2. Opposite Parties appeared through their counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the present complaint is not maintainable and is liable to be dismissed as there is no deficiency in service on the part of the Opposite Parties. In fact, Smt.Raj Karni took a life insurance policy on her own life bearing no.474052936 for a sum assured of Rs.2 lakhs under table term 814-15 from Branch Office, Zira, District Ferozepur with the date of commencement of risk as 15.09.2016. The life assured reportedly died on 17.11.2016. On lodging the claim, it was investigated being as early claim as the policy has run only for two months and two days. In the investigation, it was found that deceased life assured Raj Karni was suffering from advance stage of cancel of Gall Bladder with treatment history of three moths which goes back prior to the date of commencement of risk. As per the treatment record, the deceased life assured Raj Karni was admitted in Amrit Hospital, Moga on 20.09.2016 and was operated for removal of her Gall Bladder and discharged on 23.09.2016. Again on 16.11.2016 she was admitted in the hospital for cardiac arrest, respiratory distress and sudden loss of consciousness, where she died on 17.11.2016. At the time of taking the policy, the deceased life assured Raj Karni concealed her ailments and did not disclose her true state of health. In the proposal cum declaration form, she gave all the answers to question No.11 as negative which were false as can be seen from the treatment record of the hospital. The Opposite Parties obtained the opinion of medical referee who also opined that the claim is not payable. The suppression of material facts about the state of health of life assured has material bearing upon the judgement of Opposite Parties in accepting the risk, which has vitiated the contract of insurance. As the contract of life insurance is based upon the principles of ‘Uberrima fides’, the competent authority has decided to repudiate the claim on the basis of cogent and convincing evidence and after due application of mind on the recommendation of Divisional Office Disputes Redressal Commission and as per the terms and condition of the policy and has also recommended stern action against the agent. As such, the claim of the complainant was repudiated vide letter dated 21.08.2019. On merits, the Opposite Parties took up almost the same and similar pleas as taken by them in the preliminary objections and it was prayed that the complaint may be dismissed with costs.
3. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1/A alongwith copies of documents Ex.C1, Ex.C1/B and Ex.C2 to Ex.C4 and closed the evidence on behalf of the complainant.
4. On the other hand, the Opposite Parties also tendered into evidence the affidavit of Sh.Ramesh Kumar, Manager Legal Ex.OP1 & 2/A, copy of proposal form Ex.OP1 & 2/B, copy of policy bond alongwith terms and conditions Ex.OP1 & 2/C, form No. 3816 Ex.OP1 & 2/D, copy of opinion Divisional Medical referee Edx.OP1 & 2/E and closed the evidence on behalf of the Opposite Parties.
5. We have heard the ld.counsel for the parties and also gone through the documents placed on record.
6. Ld.counsel for the Complainant has mainly reiterated the facts as narrated in the complaint and contended that Raj Karni wife of the complainant had purchased a policy bearing No.474052936 from Opposite Party No.2-LIC vide which she was insured upto the extent of Rs.2 lakhs and she used to pay the installments of the said policy regularly. Further contended that said said Raj Karni remained admitted in Amrit Hospital on 20.09.2016 where she suddenly expired on 17.11.2016 due to heart attack and the complainant is the husband of said Raj Karni and being nominee, he has filed the present complaint. After the death of Life assured, the complainant approached the Opposite Parties to pay the sum assured of Rs.2 lakhs, but they refused and repudiated the claim of the complainant vide letter dated 21.08.2019 on the false ground of concealment of facts. The complainant made requests to the Opposite Parties to pay the insurance claim on the death of Raj Karni insured, but the Opposite Parties did not pay any heed to the request of the complainant and hence, there is deficiency in service on the part of the Opposite Parties.
7. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant and contended that Smt.Raj Karni took a life insurance policy on her own life bearing no.474052936 for a sum assured of Rs.2 lakhs under table term 814-15 from Branch Office, Zira, District Ferozepur with the date of commencement of risk as 15.09.2016. The life assured reportedly died on 17.11.2016. On lodging the claim, it was investigated being as early claim as the policy has run only for two months and two days. In the investigation, it was found that deceased life assured Raj Karni was suffering from advance stage of cancel of Gall Bladder with treatment history of three moths which goes back prior to the date of commencement of risk. As per the treatment record, the deceased life assured Raj Karni was admitted in Amrit Hospital, Moga on 20.09.2016 and was operated for removal of her Gall Bladder and discharged on 23.09.2016. Again on 16.11.2016 she was admitted in the hospital for cardiac arrest, respiratory distress and sudden loss of consciousness, where she died on 17.11.2016. At the time of taking the policy, the deceased life assured Raj Karni concealed her ailments and did not disclose her true state of health. In the proposal cum declaration form, she gave all the answers to question No.11 as negative which were false as can be seen from the treatment record of the hospital. The Opposite Parties obtained the opinion of medical referee who also opined that the claim is not payable. The suppression of material facts about the state of health of life assured has material bearing upon the judgement of Opposite Parties in accepting the risk, which has vitiated the contract of insurance. As the contract of life insurance is based upon the principles of ‘Uberrima fides’, the competent authority has decided to repudiate the claim on the basis of cogent and convincing evidence and after due application of mind on the recommendation of Divisional Office Disputes Redressal Commission and as per the terms and condition of the policy and has also recommended stern action against the agent. As such, the claim of the complainant was repudiated vide letter dated 21.08.2019.
8. We have gone through the rival contentions of both the parties. It is not denied that Raj Karni wife of the complainant had purchased a policy bearing No.474052936 from Opposite Party No.2-LIC vide which she was insured upto the extent of Rs.2 lakhs. It is also not denied that said Raj Karni remained admitted in Amrit Hospital on 20.09.2016 where she suddenly expired on 17.11.2016. The complainant lodged the claim for the insurance amount with the Opposite Parties. The main plea of the Opposite Parties is that at the time of purchasing the policy in question, the deceased life assured Raj Karni has suppressed the material facts about his pre existing decease of cancer. Perusal of the column No. 11 of Proposal for Insurance on own life Ex.OP1 & 2/B shows that against each question regarding her health status, the deceased life assured Raj Karni has answered as “No”. On the basis of said proposal form, the Opposite Parties have issued her policy in good faith. In this regard, Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No. 434 of 2017 titled as Shriram Life Insruance Company Limnited Vs. K.Viraja decided on 15th January, 2020 has held that the Insurance contracts are governed by the Principle of ‘UBERRIMA FIDE” and the proposer applying for insurance is expected to correctly furnish all the material information regarding his health, family history, personal medical history, income etc. Policyholder failed to disclose his pre-proposal health ailment of hypertension. According, the State Commission Order was set aside and the complaint dismissed. Furthermore, Hon’ble Supreme Court of India in Civil Appeal No.8701 of 1997 decided on 02.11.1999 titled as Ravneet Singh Bagga Vs. M/s.KLM Royal Dutch Airlines has held that a Bonafide decision in good faith and a bona fide dispute is not covered within the term of ‘deficiency in service and only inefficiency, lack of due c are, absence of bona fide, rashness, haste or omission like acts on the part of the agency rendering services under a contract may be held guilty of deficiency in rendering service.
9. Keeping in view the aforesaid facts and circumstances and replying upon the judgements of Hon’ble Supreme Court of India as well as Hon’ble National Commission, New Delhi (supra), we are of the view that the complainant has failed to prove any deficiency in service on the part of the Opposite Parties.
10. In view of the above discussions, there is no merit in the complaint and the same stands dismissed. Keeping in view the aforesaid facts and circumstances, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
11. Reason for delay in deciding the complaint.
This complaint could not be decided within the prescribed period because the State Government has not appointed any of the Whole Time Members in this Commission for about 3 years i.e. w.e.f. 15.09.2018 till 27.08.2021 as well as due to pandemic of COVID-19.
Announced in Open Commission.
Dated:28.03.2022.
