Complaint No: 232 of 2022.
Date of Institution:15.11.2022.
Date of order:24.08.2023.
Amarjit Masih son of Lakha Masih Resident of Village Johal Nangal, Tehsil and District Gurdaspur.
.....Complainant.
VERSUS
- Life Insurance Corporation, Branch Jalandhar Road Batala, District Gurdaspur through its Branch Manager.143505.
- Life Insurance Corporation, Divisional Office, 4-5 District Shopping Complex, Ranjit Avenue, Amritsar through its Divisional Manager. 143001.
.....Opposite parties.
Complaint U/S 12 of the Consumer Protection Act.
Present: For the Complainant: Sh.Uttam Raj Sharma, Advocate.
For the Opposite Parties: Sh.A.K.Joshi, Advocate.
Quorum: Sh.Lalit Mohan Dogra President, Sh.Bhagwan Singh
Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Amarjit Masih, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act, (here-in-after referred to as 'Act') against the L.I.C (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that mother of him namely Gurmit Kaur obtained insurance policy from OP.No.1 bearing Policy No. 146796831 on 27.11.2020and maturity amount of the policy was Rs.1,50,000/- and he was nominated as nominee by the mother of him. The mother of him was depositing the installments of the policy regularly without any default. That, on 29.12.2021, the mother of him died and information regarding the death of mother of complainant was given to the OP’s. It is alleged that the OP.No.1to prepare the death claim case of the mother of complainant and he completed all the required formalities of the OP’s and handed over the original policy, death certificate of Gurmit Kaur and other relevant documents to the OP’s. It is further alleged that the OP.No.1 asked to complainant that death claim case of mother of complainant has been sent to OP.No.2 and whenever the OP.No.2 disbursed the death claim of Gurmit Kaur and information regarding the same will be given to him and the insured amount will be disbursed to him. It is further alleged that thereafter he many times approached to the OP.No.1 and asked to him about the death claim of his mother, but the OP.No.1 put the matter with one pretext or the other and has not disbursed the amount of death claim of his mother so far. It is further alleged that the OP’s issued a letter Bearing No.Claims/Repd.No.2210/1081 dated 21.10.2022 in which the OP’s alleged that he is not entitled for the death claim of deceased Gurmit Kaur as mother of complainant was diagnosed as suffering from Hypertension and Diabetes Mellitus on 18.08.2020 i.e. prior to date of commencement of risk on 27.11.2020. This fact is totally wrong as the mother of complainant was not suffering from Hypertension and Diabetes Mellitus as alleged by the OP’s. The mother of complainant was keeping good health at the time of obtaining insurance policy. It is further alleged that the act of the OP’s in which the OP’s have repudiated the death claim of the mother of complainant, is illegal, null and void, against the law. Due to this illegal act and conduct of the opposite parties he has suffered great loss and also suffered mental harassment and inconvenience. So, there is a clear cut deficiency on the part of the opposite parties.
On this backdrop of facts, he has alleged deficiency in service and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to pay the death claim of the mother of complainant along with interest @ 18% per annum from the date of due till its realization. The 
opposite parties may further be directed to pay the cost of litigation and compensation amount of Rs.50,000/- on the account of in the interest of justice.
3. Upon notice, opposite parties appeared through counsel and filed their written reply, stating therein that the deceased life assured Ms. Gurmit Kaur wife of Lakha Masih, took a Life Insurance Policy bearing no. 146796831 for a Sum Assured of Rs.1,50,000/- under plan 944-18, with Date of Commencement is 27.11.2020 from L1C Branch Office Batala- 2 with mode of payment half yearly in the policy with the premium of Rs.3,747/-. As per the policy records, nominee under the policy is Sh. Amarjit Singh, son of deceased life assured. The death claim was filed with the opposite party Corporation by the complainant Sh. Amarjit Masih being the nominee of the deceased life assured. It is pleaded that the date of death of deceased, as per death certificate is 29.12.2021. As on the date of death, the policy has run for a period of one year, one month and two days from the date of risk, leading to Early Claim under the policy. It is further pleaded that As per Discharge Summary of Satsar Hospital, Batala, which is prior to the purchase of the policy, the deceased life assured was suffering from Hypertension and Diabetes Mellitus prior to taking the policy. As per the medical treatment record of the deceased life assured, she remained admitted in Satsar Hospital, Batala from 18.08.2020 to 23.08.2020 vide IPD No. 7676 and Registration no. 545461 and was suffering from Hypertension and Diabetes. It is further pleaded that the above said facts were in exclusive knowledge of the deceased life assured, which she willfully did not disclose at the time of effecting insurance with the Corporation and hence, suppressed the material information about her ill health, which was very much necessary and indispensable for the L.1.C of India to know while underwriting the proposal. It is further pleaded that she willfully deceived the Corporation by not providing the correct information about her previous ill-health and due to this reason, risk run was entirely different from the risk understood. By concealing the material information in the Proposal Form, which was in her exclusive knowledge, the deceased life assured had violated the principle of Utmost Good Faith, which is a pre requisite and the basis for any insurance contract. It is further pleaded that as per the terms of the policy contract, death benefit liability under the policy was repudiated and it was decided to refund the premiums received, towards full and final settlement of the Claim .The premium amount of Rs.11,271/-received under the policy was refunded on 3.11.2022 to the nominee through NEFT. It is further pleaded that the complainant approached this Hon’ble Court without exhausting the other remedies available under the law for redressal of his complaint and the complainant should have approached the office of "Insurance Ombudsman", Chandigarh for redressal of his grievance, if any. It is further pleaded that the claim has been repudiated as per the conditions and privileges of the policy contract printed on the back of the policy bond, under the heading 'FORFEITURE REGULATIONS' (Clause 2 of the Part D) which reads as under
(ii) FORFEITURE IN CERTAIN OTHER EVENTS In case any condition herein contained or endorsed hereon be contravened or in case it is found that any untrue or incorrect statement is contained in the proposal, personal statement, declaration and connected documents or any material information is withheld, then and in every such case, this policy shall be void and all the claims to any benefit by virtue hereof shall be subject to the provisions of Section 45 of the Insurance Act, 1938, as amended from time to time.
It is further pleaded that the complaint of the complainant is bad for mis-joinder or non-joinder for all the necessary parties. All the Class-I legal heirs of the decreased are the necessary parties.
On merits, the opposite parties have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Learned counsel for the complainant has tendered into evidence affidavit of Amarjit Masih Complainant as Ex.CW-1/A alongwith other document as Ex.C-1.
5. Learned counsel for the opposite parties has tendered into evidence affidavit of Sudeep Kumar Sharma, Manager (Legal), L.I.C, Divisional Office, Amritsar as Ex.OP-1,2/A alongwith other documents as Ex.OP-1 to Ex.OP-10.
6. Rejoinder filed by the complainant.
7. Written arguments not filed by both the parties.
8. Counsel for the complainant has argued that mother of the complainant had purchased a policy of insurance from opposite parties on 27.11.2020 and maturity amount of the policy was 1,50,000/-. It is further argued that on 29.12.2021 during the continuation of the policy of insurance mother of the complainant died and complainant being nominee had lodged claim with the opposite parties but the same was repudiated by the opposite parties with excuse that mother of the complainant was already suffering from hypertension and diabetes mellitus and concealment of said diseases amounts to breach of terms and conditions of the policy of insurance. However, mother of the complainant has not concealed anything from the opposite parties. Moreover, the agents of opposite parties obtained signatures on dotted lines without explaining anything to the insured. As such repudiation of claim amounts to deficiency in service.
9. On the other hand counsel for the opposite parties has argued that Ms.Gurmit Kaur took a life insurance policy Ex.OP-1 for sum assured of Rs.1,50,000/- and as per death certificate she died on 29.12.2021 as on the date of death policy has run for a period of one year, one month and two days from the date risk, leading to Early Claim under the policy. As per discharge summary from Satsar Hospital, Batala life assured was suffering from hypertension and diabetes mellitus prior to purchase of the policy. As such violated the terms and conditions of the policy and accordingly, the total premium of Rs.11,271/- was refunded to the nominee of the life assured and as such there is no deficiency in service on the parties.
10. We have heard the Ld. counsels for the parties and gone through the record. It is admitted fact that Ms.Gurmit Kaur had purchased a policy of insurance on 27.11.2020 with sum assured of Rs.1,50,000/-. It is further admitted fact that Gurmit Kaur life assured died on 29.12.2021. It is further admitted fact that opposite parties repudiated the claim lodged by the complainant vide letter dated 21.10.2022 Ex.C-1 and the amount of premium i.e. Rs.11,271/- has been refunded to the complainant being nominee. The only question before this Commission is whether the repudiation of the claim by the opposite parties on the ground of pre-existing diseases i.e. hypertension and diabetes mellitus amounts to deficiency in service on the part of the opposite parties. Perusal of policy document Ex.OP-1 shows that it is having of 20 pages and it has not been pleaded or proved by the opposite parties that all the terms and conditions mentioned in Ex.OP-1 were ever read over and explained to the life assured. As such the opposite parties cannot claim that in the proposal form dated 27.11.2020 the life insured gave wrong answers to the questions. Moreover, if the opposite parties were so much concerned about pre-existing disease in that case the opposite parties should had insisted the life assured to get herself medically examined before obtaining her signatures on the proposal form instead of getting proposal form signed with stereo type answers as 'NO'. The opposite parties have not proved this fact that who was the official of the opposite parties who filled the proposal form and on what basis he recorded answers to all the questions as 'NO'. Meaning thereby it shows that the signatures of the life assured were obtained on blank forms and proposal form and thereby filled in routine manner.
11. As far as the pre-existing diseases as mentioned by the opposite parties i.e. hypertension and diabetes mellitus is concerned the opposite parties have failed to establish and prove this fact that the life assured was suffering from any such disease as mentioned above. Moreover, the opposite parties have not proved the existing of such pre-existing diseases through any doctor from whom the life assured took treatment. Moreover, it has been held in number of judgments by the Hon'ble Supreme Court of India and Hon'ble National Commission, New Delhi that hypertension and diabetes mellitus are life style diseases and every third person has one time or other time suffered from such like diseases and got cured from such diseases.
12. This Commission has placed reliance on judgment of Hon'ble Supreme Court of India 2023(2) Law Herald (SC) 1560 titled as Om Parkash Ahuja Vs. Reliance General Insurance Co. Ltd. Etc. wherein it was held by the Hon'ble Supreme Court of India as under
Consumer Insurance Health Insurance Non mentioning of disease from which the deceased suffered at the time of purchasing the policy was not material, as the death was caused from a different disease all together Both had no relation with each other Insurance Company directed to pay.
As per this judgment it was held by the Hon'ble Supreme Court of India that non mentioning of disease from which wife of the applicant was suffering at the time purchasing policy is not material and the death was caused from different disease all together.
13. Further, reliance is be placed on another judgment of Hon'ble Supreme Court of India reported in 2018(1) Law Herald (SC) 832 wherein it was held by Hon'ble Supreme Court of India as under:-
Insurance Life Insurance Premium accepted without conducting of medical examination Amounts to waiving off condition precedent in proposal form Insurer held liable to pay.
The ground for repudiation of the opposite parties regarding non settlement of the claim is previous history of hypertension but this Commission is of the view that hypertension is a common life style disease and it is not necessary that person suffering from hypertension would always suffer from some other disease and this Commission has placed reliance an order of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2017(3) CLT 140 wherein it was held as under
Hypertension is a common disease and it can be controlled by medication.
14. We are of the view that the opposite parties cannot refuse to settle the claim of the complainant by demanding record of previous ailments with which there is no nexus of cause of death. Moreover, the opposite parties have issued the policy of insurance after receiving premium. As such having issued the policy of insurance without having availed medical examination of the complainant prior to issuance of the policy amounts to waiver and as such opposite parties cannot refuse to settle the clam by referring to the documents regarding previous ailment which are proved on record by producing evidence.
15. We placed reliance upon judgment of Hon'ble Supreme Court of India reported in 2022 LiveLaw (SC) 506 wherein it was held by the Hon'ble Supreme Court of India as under:-
Insurance Insurance companies refusing claim on flimsy grounds and or technical grounds While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. (Para 4.1).
16. We also placed reliance upon judgment of Hon'ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No.3619 of 2013 in case title as Satish Chander Madan Versus M/s Bajaj Allianz General Insurance Co. Ltd. wherein it was held by the Hon'ble National Consumer Disputes Redressal Commission, New Delhi as under
Consumer Protection Act, 1986 Sections 2(1)(g) and 21(b) Insurance Policy Bypass surgery Claim for insurance Repudiation of claim Grounds of concealment of pre existing disease Alleged deficiency in service Complaint filed Allowed by District Forum State Commission allowed appeal Hence, revision petition before National Commission Fact that, petitioner prior to obtaining insurance policy was having history of hypertension Hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack - Treatment for heart problem cannot be termed as claim in respect of pre existing disease Claim was wrongly repudiated Finding of the State Commission regarding suppressing of material fact is based upon surmises and conjectures and it cannot be sustained Revision petition allowed. (Paras , 10 and 11).
17. As such we are of view that the opposite parties have not been able to prove that the life assured was suffering from hypertension and diabetes mellitus on the basis of which claim was repudiated by the opposite parties vide letter Ex.C-1. The next contention of counsel for the opposite parties is that claim was required to be lodged within 90 days from the date of death. However, in the present case claim has been lodged/intimated after five months, eight days from the date of death, as such claim has been rightly repudiated. However, we are of the view that the said delay of approximately two months has not caused any prejudice to the opposite parties and the delay has not in any way hampered the settlement of claim by the opposite parties. As such we do not agree with the contention of the counsel for the opposite parties. Ld. counsel for the opposite parties has further contented that complainant was required to approach Zonal Office, Claims Revenue Committee New Delhi and Insurance Ombudsman Chandigarh before filing the present complaint. However, we also do not agree with this contention of the counsel for the opposite parties as the remedy available under Consumer Protection Act is in addition to any to other remedy provided under the law.
18. From the above discussion and evidence on record and on the basis of case law cited above complainant has fully proved deficiency in service on the part of the opposite parties. Accordingly, the present complaint is partly allowed and opposite parties are directed to pay Rs.1,50,000/- i.e. sum assured to the complainant being nominee as per the policy alongwith interest @ 9% P.A. from the date of filing of the complaint till its realization after deducting the amount of Rs.11,271/- which was refunded to the complainant on 03.11.2022. Since the complainant has definitely suffered mental tension, harassment, agony and had to approach the Commission for redressal of his grievance, as such opposite parties are further directed to pay Rs.5,000/- as compensation which includes costs of litigation. Entire exercise will be completed within 30 days from the date of receipt of copy of this order.
19. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases.
20. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
Aug. 24, 2023 Member.
*YP*
