The complainant has filed the instant complaint under section 12 of the Consumer Protection Act, 1986, wherein alleged that the wife of the complainant namely Sarabjeet took the life Insurance Policy bearing No.474012601 of Rs.1,00,000/- on 28.01.2016 from opposite party. The commencement of risk started from 24.02.2016 and installment of basic premium was fixed as Rs.3,439/-. The daughter of complainant was appointed as Nominee whereas, the complainant is appointee of the policy being husband of Sarabjeet. Sarabjeet was medically examined in presence of officials of opposite party and after that, the policy was issued. The Sarabjeet paid the first premium Installment on 24.02.2016 and due receipt was issued for it. Thereafter, on l4.03.2016 Sarabjeet suffered sudden cough problem and she was taken to Civil Hospital, Gurdaspur. But lateron, referred her to Guru Nanak Dev Hospital, Amritsar on 17.03.2016, where she remained admitted. But, on 31.03.2016 during her treatment, Sarabjeet got died. The complainant, immediately informed the office of opposite party about sudden death of his wife and requested to release the policy amount. But the opposite party instead of releasing the Insurance Policy, firstly did not take any action on the letter/request of the complainant for many months. At last, on 22.12.2016 the opposite party issued false letter vide which they repudiated the claim of the complainant having suppressed that the deceased was suffering from Hypertension and breathlessness problem. Infact, Hypertension is not such disease, which requires any regular treatment or medicine. Whereas, breathlessness is very common thing in daily life and cannot be treated as disease in the eyes of medical line. Even same can be caused due to overdoing of household work and which will be relieved just by taking rest within few minutes. Then how the claim of the complainant be repudiated on these grounds. Moreover, she was medically examined before the issuance of Policy in question and there was no complaint of any such disease in their own medical examination of the deceased. Above all, it was alleged that she was patient of Hypertension from last 5 years. But there is no such record or evidence collected by the officials of opposite party. There is nothing to reject or repudiate the genuine claim of the complainant. As such, the deceased was faithful Policy Holder of opposite party and after her death, her husband and family is fully entitled for Policy claim. But the opposite party refused to admit their claim, hence this complaint filed by the husband of the policy holder with the prayer that the policy amount alongwith Rs.40,000/- towards mental agony as well as physical harassment to the complainant besides Rs.20,000/- as litigation expenses.
2. Notice of the complaint was given to the opposite party, accordingly opposite party appeared through his counsel and contested the case by filing written reply by taking preliminary objections that the complainant has not come to the court with clean hands and has concealed the true facts from this Forum; the present complaint is not maintainable in the present form; the complainant has no cause of action to file the present complaint. On merits, it is admitted that the wife of the complainant obtained policy and also was died during her treatment. It is further averred that the repudiation of the claim of the complainant was not on the false ground. In fact, according to the record of the Civil Hospital, Gurdaspur i.e General Case Sheet Sarbjeet was suffering from chronic hypertension for the last 5 years, but this fact was concealed by the Sarbjeet at the time of taking policy and thus, concealed material facts from the opposite party, therefore, claim of the complainant has been repudiated on this sole ground. Rest of the allegations as made in the complaint were categorically denied and prayed for the dismissal of the complaint.
3. Ld.counsel for the complainant tendered in evidence affidavit of the complainant Ex.C1 and documents Ex.C2 to Ex.C12 and closed the evidence on behalf of complainant. Whereas, Ld.counsel for the opposite party tendered in evidence affidavit Ex.OP1/A, copy of General case sheet Ex.OP1 and closed the evidence on behalf of the opposite party.
4. We have gone through the written arguments submitted by the ld.counsel for the opposite party, also heard the ld.counsel for the parties and gone through the case file very minutely.
5. Ld.counsel for the complainant contended that the wife of the complainant was insured on 28.01.2016 with opposite party vide Insurance policy No.474012601 for a sum of Rs.1,00,000/-. It is further argued that only after getting medical check-up the alleged insurance policy was issued to the wife of the complainant. Unfortunately, complainant suffered sudden cough problem and was admitted to hospital, but on 31.03.2016 died during her treatment. The opposite party was timely intimated about the death of his wife and submitted the claimed documents, but opposite party repudiated the genuine insurance claim on the ground of concealment of material facts. Thus, there is deficiency in service on the part of the opposite party.
6. On the other hand, Ld. Counsel for the opposite party took plea that complainant is himself guilty of concealing of material facts and the claim was denied on the ground of non-disclosure of material facts. As per available documents, patient is a known case of chronic hypertension since five years which is prior to the policy inception and it is a Non-medical case, as such, medical of deceased was not conducted. Hence, the claim has been repudiated. Opposite party denied all other allegations and prayed for dismissal of complaint.
7. Now the main question to be decided is whether the opposite party has rightly repudiated the claim of complainant or not? The main plea of opposite party about rejection of claim is that the complainant did not disclose about the disease of hypertension.
8. From the appreciation of the facts and circumstances of the case, it emerges that the policy in question was in operation on 24.02.2016 and the fact of death of Sarabjeet has not been denied in their written version by the opposite party. The complainant further placed on record death certificate of Sarabjeet Ex.C6, and also perused claim file documents placed on the file. Furthermore, Ld.counsel for the opposite party in their written arguments submitted that this is a Non-Medical Case and Medical of the deceased Sarabjeet was not conducted by any doctor and she had concealed the material facts from the opposite party. Ld.counsel for the Opposite party has not revealed as to why the deceased Sarabjeet was a case of Non-Medical case and as to what were the consequences which led opposite party not to get conducted her medical tests. Moreover, neither the complainant nor the opposite party has placed on the file the insurance policy documents. Thus, non production of documents shows the malafide intention of the opposite party. However, it is clear cut onus of the opposite party to produce the documents to controvert the allegations of the complainant and also to get the medical fitness of the insured before issuing the insurance policy. But at this stage, if the opposite party feels that plea or by any means they can escape from the liability of releasing the insured amount to the complainant, then they are in the illusion state of mind and opposite party has to come out of it. The only ground on which the claim of the complainant has been repudiated, is that the complainant was suffering from Hypertension i.e. 5 years prior to the issuance of the insurance policy. Qua this factum, there are numerous case law on the point. Hypertension is not a disease. In such a situation, it is preposterous to presume that said disease was pre-existing or that non-disclosure thereof at the time of obtaining the insurance policy amounts to concealment. Even otherwise, hypertension is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“ So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension, diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
9. We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
10. In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
11. From the aforesaid discussion, it transpires that opposite party has wrongly repudiated the claim of the complainant. As such, opposite party is directed to make the death claim of Sarabjeet to the tune of Rs.1,00,000/- to the nominee of the insured and the complainant. Complainant is also entitled to Rs.10,000/- as compensation on account of harassment and mental agony and Rs 5,000/- as litigation expenses from the opposite party. Opposite Party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.
12. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. The complaint could not be decided within prescribed time due to rush of work.
ANNOUNCED: (Shri Raj Singh) (Rajita Sareen)
December 02, 2019. Member Presiding Member
MK
