Haryana

Fatehabad

CC/142/2020

Kanta - Complainant(s)

Versus

Life Insurance Corporation - Opp.Party(s)

Mangat Ram Saini

15 Nov 2023

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHABAD.

                                      Sh.Rajbir Singh, President.                                               Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

 

                                                Complaint Case No.: 142 of 2020.

                                             Date of Institution:    28.08.2020

                                                        Date of order:            15.11.2023.      

 

Smt.Kanta wife of late Shri Rajesh Kumar son of Sh.Mangat Ram, resident of Saini Chowk, Thakar Basti, Fatehabad Tehsil & District Fatehabad.

 

                                                                          ….. Complainant.

                                          Versus     

 

1.Life Insurance Corporation of India,Divisional Office, 3 HUDA, Fatehabad Tehsil & District Fatehabad through its Branch Manager.

2.Life Insurance Corporation of India, Divisional Office SCO 3,4 & 5, Sector I HUDA, Rohtak District Rohtak through its Senior Divisional Manager.

 

….Opposite parties.

 

Complaint U/s 35 of the Consumer Protection Act

                                                                                

Present:          Shri Mangat Ram Saini, Advocate for the complainant.

                  Shri Naresh Sachdeva, Advocate for the opposite parties.

 

 

ORDER

SH.RAJBIR SINGH, PRESIDENT

                   Brief facts of the present complaint are that husband of the complainant namely Sh.Rajesh Kumar (herein after to be referred as Life Assured) took an insurance policy No.119020306 dated 28.09.2018 for sum assured of Rs.4 lacs from the Ops; that the complainant was nominee under the said policy;  that the life assured died on 22.12.2019 and the complainant lodged the claim with the OPs besides submitting all the requisite documents  to release the claim; that the Ops wrongly, illegally and on flimsy grounds  have repudiated the claim of the complainant vide letter No.Claims/Rep/2019-2020/17D  dated 11.03.2020 despite the fact  that the life assured was thoroughly medically examined and on being hale and hearty, the insurance policy in question was issued to life assured;  that the complainant requested the Ops number of times to release the claim of the policy in question but to no avail; that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice. Hence, this complaint. 

2.                Averments of the complaint have been strongly opposed in the joint written statement filed on behalf of Ops wherein several preliminary objections such as maintainability, concealment of material facts, locus standi and estoppal etc. have been taken. It has been further submitted that being an   early death claim, the matter was examined in view of Section 45 of Insurance Act; that the aforesaid policy had not completed three years from the date of  FPR i.e. 09.10.2018;  that in the proposal form dated 09.10.2018,  the life assured had answered the following questions:-

During the last five years, did you consult a medical practitioner for any ailment requiring treatment for more than a week?	No
Have you ever been admitted to any Hospital or nursing home for general check-up, treatment or operation?	No
Have you remained absent  from place of work on grounds of health  during last five years	No
Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, high blood pressure, low blood pressure, cancer, epilepsy, Hernia, Leprosy, or any other disease?	No
Are you suffering from or have you ever suffered from ailment pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or nervous system?	No
What has been your usual state of health:	good

 

It has been further submitted that the life assured had taken treatment from Jindal Hospital, Hisar on 15.12.2018 with C/o Jaundice, Altered behavior, loss of consciousness, pain in abdomen of 2 days duration and diagnosed as cirrhosis of liver, HEG III, CVA (Cerebro Vascular Accident) and he was discharged on 19.12.2018 against medical advice; that the life assured has violated the terms and conditions of the policy in question, therefore, the ops have rightly repudiated the claim of the complainant as the policy in question was purchased with malafide intention. Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint.

3.                In evidence, the complainant has tendered his affidavit as Annexure CW1 and documents Annexure C1 to Annexure C3. On the other hand, no evidence has been led on behalf of Ops despite having ample opportunities, therefore, the evidence of the Ops was closed on 13.03.2023 by the order of the Commission.

4.                We have heard learned counsel for the parties and with their kind assistance, the material available on the case file, have been perused and examined.

6.                Learned counsel for the complainant argued that claim of the complainant regarding death of her husband, who was insured with OPs has been wrongly & illegally rejected by the OPs on the ground that the deceased (life assured) had made incorrect statement and withheld correct information regarding his health at the time of effecting insurance. He has further contended that life assured was not suffering from disease before he proposed for the policy. It has been further argued that before issuance of the policy to the deceased, he was thoroughly examined by the empanelled doctors of the Ops and after declaring him hale and healthy, the Ops had issued the policy in question to the deceased (life assured).    Lastly, he prayed for acceptance of the complaint.

7.                On the other hand, learned counsel for Ops has argued that at the time of filling of proposal form the life assured did not disclose true facts about his pre-existing disease intentionally and made false answers to the questions mentioned in the proposal form regarding his health. It has been further argued that had the life assured disclosed the true status qua his health in the proposal form, the OPs would not have issued the policy in question to the life assured. Since, the life assured had violated the terms and conditions of the policy, therefore, the claim was rightly repudiated vide letter dated 11.03.2020. Lastly, prayer for dismissal of the complaint has been made.

8.                          In the insurance policy (Annexure C1), the date of commencement is mentioned as 28.09.2018 and the date of maturity has been shown as 28.09.2034.  Perusal of  this document also reveals that the premium amounting to Rs.8760/- was received by the Ops for the policy commencing in question with sum assured of Rs.4 lacs. The Ops have come with the plea that the policy in question was purchased by the life assured by concealing the material facts of his health from the Ops but perusal of the case file reveals that there is nothing on the case file to support the contentions put-forth by the Ops in their joint reply that the life assured had ever taken treatment from Jindal Hospital, Hisar. In the present case, it appears that the Ops are only interested in earning the premiums and find ways and means to decline the claim in question without leading concrete and authentic evidence because  the burden of proof was upon the OPs to prove that the life insured was suffering from pre-existing diseases prior to taking the policy, but they have miserably failed to discharge this onus, by not leading any cogent and convincing evidence to prove this fact. On this point, reliance can be taken from the case law titled as Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC),  wherein it was held by the Hon'ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus, the repudiation of the claim on the ground of pre-existing disease was held to be invalid. After considering all the facts and going through the material available on the case file, we have no hitch to reach at a conclusion that the Ops are only trying to back out from the contract and it is a general observation that in a number of cases, the insurance companies are issuing policies basing on the statements made by the proposer in utmost good faith but when it comes to settlement of claims, they start examining the matter under the microscope. 

9.                          Thus, as a sequel to our above discussion, we accept the present complaint and direct the Ops to pay the amount of Rs.4 lac (sum assured) to the complainant alongwith interest @ 6% per annum from the date of filing of present complaint till actual realization. We also direct the Ops to further pay a sum of Rs.11,000/- for mental agony and harassment including litigation expenses to the complainant.  The order be complied within a period of 45 days from today failing which the awarded amount would carry interest @ 9 % per annum from the date of filing of the compliant till its realization.

10.                        In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                            Dated: 15.11.2023

 

                                                                                                        

          (K.S.Nirania)                       (Harisha Mehta)                (Rajbir Singh)                              Member                               Member                                           President