Haryana

Karnal

CC/758/2019

Shatrughan - Complainant(s)

Versus

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

Virender Pal Singh

20 Apr 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 758 of 2019

                                                        Date of instt.13.11.2019

                                                        Date of Decision:20.04.2022

 

Shatrughan aged about 37 years son of Shri Sompat, resident of House no.327, Gali no.4, Durga Colony, Karnal.

 

                                               …….Complainant.

                                              Versus

 

Life Insurance Corporation of India, Divisional Office, Jeevan Parkash Building, Model Town, Karnal, through its Divisional Manager.

 

                                                                      …..Opposite Party.

 

Complaint under Section 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member.

      Dr. Rekha Chaudhary…..Member

           

 Argued by: Shri Virender Pal, counsel for complainant.

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

 

                     (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that late Smt. Raj Kumari was the mother of the complainant and she got two LIC policies from the OPs i.e. policy no.178180697 dated 11.05.2018 for a sum assured of Rs.1,00,000/- with insurance premium of Rs.2975/-, valid from 11.05.2018 to 11.05.2033 and policy no.178180698 dated 11.05.2018 for a sum assured of Rs.1,00,000/- with insurance premium of Rs.2770/-, valid from 11.05.2018 to 11.05.2034.  The complainant is the nominee in the abovesaid polices. It is averred that before the issuance of the said policies, the mother of complainant was medically examined by the authorized/empanelled doctors of the OP and she was found quite healthy.  After four months of the purchase of the said policies, mother of complainant started suffering from fever and was admitted in Cygnus Hospital, Karnal, but her illness could not be cured and unfortunately she died on 11.09.2018. After death of his mother, complainant lodged the death claim with the OP and got completed all the formalities and OP assured the complainant that all the insurance benefit will be given to the complainant, but to the utter surprise of the complainant, OP sent a letter dated 27.03.2019, vide which the claim of the complainant has been repudiated, on the ground that deceased life assured was a K C/O HTN c past H/O surgery for Nephrolithiasis before taking insurance. She did not disclose these facts in the proposal form. In this regard, it is submitted that in the clause no.(a) it is mentioned that during the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week and same was alleged replied No. In this regard it is submitted that the mother of the complainant was having a stone problem and she got admitted only for one day in Miglani Hospital i.e.27.10.2013 and discharged on 28.10.2013 and question is regarding whether said treatment is requiring treatment for more than one week. Said treatment cannot be based of repudiation of the claim of the complainant. The repudiation of the claim of the complainant on the basis of said ground is null and void and not binding on the rights of the complainant. 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 and concealment of true and material facts. On merits, it is pleaded that Smt. Raj Kumari wife of Shri Sompat had taken two policies i.e. Ist policy no.178180697 dated 11.05.2018 for a sum assured of Rs.1,00,000/- with the half yearly insurance premium of Rs.2975/-, valid from 11.05.2018 to 11.05.2033 and second policy no.178180698 dated 11.05.2018 for a sum assured of Rs.1,00,000/- with half yearly insurance premium of Rs.2770/-, valid from 11.05.2018 to 11.05.2034.  The complainant is the nominee in the said policies. The life assured died on 11.09.2018, just after four months from the date of taking the said policies. Being early claim investigation was conducted under section 45 of the Insurance Act, 1938 and during investigation it was revealed that she was not having good health before taking policies as she was a known case of Hypertension c past history of surgery for Nephrolithiasis for which she had taken treatment in hospital. As per information provided by Sanjiv Bansal Cygnus Hospital, Karnal in form no.3816 under column 4(a) “Nature of complaint” shock c breathlessness, Anuria, Anuria in medical term is described as passage of less than 100ml. of urine in a day and it may occur because of some severe obstruction like kidney stones or tumors. Further, in column no.6 “what was diagnosis arrived at the hospital”-Acute viral syndrome c shock c hepathorenal failure. Hepatorenal failure is a type of progressive kidney failure. Hence Anuria and Hepatorenal failure conditions at the time of death of the life assured are directly related to the kidney stone diseases for which she got treatment from Miglani Nursing Home, Karnal by percutaneous nephrolithotomy in December, 2013. But in the proposal form dated 11.05.2018 she had answered the following question as under:-

11(a) during the last five years did not consult a Medical  

Practitioner for any ailment requiring treatment for more than a week? No

2.     Hypertension, Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, any disease of the Heart of arteries. No

4.     Any disease of Kidney/prostate or urinary system No

14.   Any operation, accident or injury/any bodily defect or Deformity No

11(g)What has been your usual state of health  Good.

 

Thereafter, life assured gave declaration in the proposal form in this regard. The suppression of material facts done with fraudulent intention which has had a bearing on the granting of risk, hence the claim has been repudiated on account of suppression of true and correct information regarding her health at the time of obtaining the polices in question. 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.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of repudiation letter dated 27.03.2019  Ex.C1, copy of application by complainant to OP Ex.C2, copy of Aadhar card of complainant Ex.C3, copies of receipts dated 11.05.2018 Ex.C4 and Ex.C5, copy of aadhar card of Raj Kumari deceased life assured Ex.C6, copy of death certificate of Raj Kumari Ex.C7 and closed the evidence on 08.03.2021.

5.             In additional evidence learned counsel for complainant has tendered into evidence death certificate of Raj Kumari Ex.C8                copy of death summary of Raj Kumar dated 11.09.2018 Ex.C9, copy of  ECG report of Raj Kumari Ex.C10 and Ex.C11, copy of medical report dated 11.09.2018 Ex.C12 and Ex.C13, copy of medical report dated 11.09.2018 Ex.C14, copy of medical record dated 10.09.2018 Ex.C15 to Ex.C25 and closed the additional evidence  on behalf of complainant on 25.02.2022 by suffering separate statement.

6.             On the other hand, learned counsel for OP has tendered into evidence affidavit of Puneet Kumar, Manager Ex.OPW1/A, copy of insurance policies Ex.C1 an Ex.C2, copy of proposal form dated 11.05.2018 Ex.C3, copy of repudiation letter dated 27.03.2019 Ex.OP4, copy of OPD slip of Raj Kumari dated 28.12.2013 Ex.OP5, copy of enquiry report Ex.OP6, copy of claim form Ex.OP7, copy of test report dated 10.09.2018 Ex.OP8 and Ex.OP9, copy of death certificate of Raj Kumar  Ex.OP10, death summary of Raj Kumari Ex.OP11, copy of medical certificate Ex.OP12 and closed the evidence on behalf of OP on 04.01.2022 by suffering separate statement.

7.             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.

8.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that mother of complainant has obtained two life Insurance polices. Before issuance of the policies in question the mother of complainant was medically examined by the authorized/empanelled doctors of the OP and she was found quite healthy. After four months of the purchase of the said policies, mother of complainant started suffering from fever and was admitted in Cygnus Hospital, Karnal but her illness could not be cured and unfortunately she died on 11.09.2018. After death of his mother complainant lodged the death claim with the OP but OP did not pay the claim and lingered the matter on one pretext or the other and lastly repudiated the claim of complainant on the false and frivolous ground. Hence prayed for allowing the complaint.

9.             Per contra, learned counsel for OP, while reiterating the contents of the written version, has vehemently argued that deceased life assured has concealed the true and material facts regarding her health at the time of obtaining the policies in question. The contract of insurance is based on the principal of ‘Uberrima fide” i.e. utmost good faiths, where a legal obligation cast upon the party seeking insurance to disclose all the facts and material information truly to the OPs. Hence, prayed for dismissal of the complaint.

10.           We have duly considered the rival contention of the parties.

11.           Admittedly, Smt. Raj Kumari mother of the complainant (since deceased) had taken two LIC policies on 11.05.2018 for the sum assured of Rs.1,00,000/- each.  It is also admitted that the complainant is nominee in the said polices. It is also admitted that lie assured (Raj Kumari) expired on 11.09.2018.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C1/Ex.OP4 Dated 27.03.2019 on the ground that life assured was a known case of Hypertension c past history of surgery for Nephrolithiasis before taking insurance policies. She did not disclose these facts in the proposal form.

12.           The mother of complainant had obtained the policies in question on 11.05.2018 and she expired on 11.09.2018, just after four months from the date of said policies. Being early claim investigation was conducted by the OP and during the investigation it was found that she was not having good health before taking policies as she was a known case of Hypertension c past history of surgery for Nephrolithiasis for which she had taken treatment in hospital. As per information provided by Sanjiv Bansal Cygnus Hospital, Karnal in form no.3816 under column 4(a) “Nature of complaint” shock c breathlessness, Anuria, Anuria in medical term is described as passage of less than 100ml. of urine in a day and it may occur because of some severe obstruction like kidney stones or tumors. Further, in column no.6 “what was diagnosis arrived at the hospital”-Acute viral syndrome c shock c hepathorenal failure. Hepatorenal failure is a type of progressive kidney failure. Hence Anuria and Hepatorenal failure conditions at the time of death of the life assured are directly related to the kidney stone diseases for which she got treatment from Miglani Nursing Home, Karnal by percutaneous nephrolithotomy in December, 2013. This fact has not been disclosed by the life assured at the time of taking the policy and concealed the said facts.

13.           Admittedly, life assured has deposited only one half yearly premium for the policies in question for an amount of Rs.2975/- and Rs.2770/- respectively and she expired just after four months of obtaining the policies. The facts regarding taking the treatment from Miglani Hospital, Karnal, in December, 2013, not denied.  As per the medical report Ex.C8 to Ex.C25 of Sanjiv Bansal Cygnus hospital Karnal, it has been proved that life assured was having Acute viral syndrome c shock c hepathorenal failure. Hepatorenal failure is a type of progressive kidney failure. Such type of disease could not be developed immediately and same has taken time for developing. There is direct nexus between the treatment taken by the life assured from Miglani Hospital in year, 2013 and the present disease i.e.11.09.2018. Hence, it has been proved on record that at the time of taking the policy life assured has concealed the true and material facts with regard to her health. Taking the policies in the same day also creates the doubt in our mind that the life assured was having any disease at that time as the reason for obtaining two policies on the same day was known to the policyholder.

14.           It is settled principle of insurance law that contract of insurance is a contract uberrima fides and utmost faith must be observed by the contracting parties. Every material fact must be disclosed, otherwise there is good ground for rescission of contract. If, there are misstatements or suppression of material facts, the policy can be called into question. In this regard reference may be made to the judgment of the Hon’ble Supreme Court in case titled Satwant Kaur Sandhu Versus New India Assurance Co. IV( 2009) CPJ 8 (SC) and judgment of Hon’ble National Commission in case Life Insurance Corporation of India and another Versus Bimla Devi Revision Petition no.3806 of 2009 decided on 12.8.2015.

15.           Thus, as a sequel to abovesaid discussion and in view of law cited above, we do not find any merits in the complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:20.04.2022

 

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                    Member                         Member