BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 2 of 2017
Date of Institution: 02.01.2017
Date of Decision: 05.12.2017
Smt.Reena Nanda wife of late Sh.Susheel Nanda, resident of H.No.43, Kamla Devi Avenue, Nangli Abadi, Fatehgarh Churian Road, Amritsar.
Complainant
Versus
Life Insurance Corporation of India, Jiwan Parkash Building, Division Office, Ranjit Avenue, Amritsar, through its Senior Divisional Manager.
Opposite Party
Complaint under section 11 & 12 of the Consumer Protection Act.
Present: For the Complainant: Sh.Rajinder Joshi, Advocate.
For the Opposite Party:Sh.Subodh Salwan, Advocate.
Coram
Sh.Anoop Sharma, Presiding Member
Ms.Rachna Arora, Member.
Order dictated by:
Sh.Anoop Sharma, Presiding Member
1. The complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that Susheel Nanda son of Prem Nath Nanda was husband of the complainant who has expired on 9.8.2015 leaving behind the complainant as his legal heir being his widow and after his death, she is entitled to inherent the estate of the deceased Susheel Nanda, hence the present complaint is filed by the complainant being widow/ nominee of the deceased Susheel Nanda and is beneficiary of the claimed amount under the policy in dispute and as such, she is a consumer as defined in the Act, as amended upto date. Late Susheel Nanda during his life time obtained a life insurance policy bearing No.473547502 for Rs.4 lacs with the date of commence as 28.3.2013 and duly appointed the complainant as his nominee and deceased Susheel Nanda also obtained policy No.472970773 for Rs.1 lac only, and policy No.470741896 for Rs.1 lac and policy No.471637483 for Rs.2 lacs only from the Opposite Party. It is pertinent to mention over here that deceased Susheel Nanda was in sound and good health at the time of obtaining the aforesaid policies and before effecting the aforesaid policies on the name of Susheel Nanda by Opposite Party, the deceased was medically examined by the qualified doctors of the Opposite Party and he was found perfectly fit and not suffering from any type of the disease and it was after due satisfaction regarding the health of Susheel Nanda, the life assured, the policies in question were released by the Opposite Party in the name of Susheel Nanda, husband of the complainant. Life assured Susheel Nanda due to some minor weakness and resiperately distress was admitted to Smt.Parvati Devi Hospital Amritsar on 2.8.2014 and it was diagnosed by the doctors of the hospital to be a case of diabetes and hypertension and the deceased was discharged on 11.9.2014 in symptomatically better condition. At the time of discharge on 11.9.2014 and thereafter for follow up purposes remained admitted in the same hospital three to four occasions for short period of 1-2 days and lastly admitted in the same hospital on 7.8.2015 and unfortunately died on 9.8.2015 due to respiratory distress/ cardiac arrest. The deceased was not suffering from any type of the disease when he proposed for insurance. The deceased was medically examined by the qualified doctors of the Opposite Party and after full satisfaction regarding the health of life assured, the policy in dispute was issued in the name of husband of the complainant. Nor the life assure ever admitted in any hospital for any disease nor consulted any doctor and was in sound and perfect health at that time. After the death of Susheel Nanda, the complainant being his widow, under the death claim of all the above said polices with the Opposite Party with the request to release the insured amount to her as per the terms and conditions of the policies and supplied all the documents to the Opposite Party as required by them and the Opposite Party paid the insured amount of policy No. 472970773, policy No.470741896 and policy No.471637483, but to the utter surprise of the complainant, the Opposite Party vide letter dated 12.3.2016 repudiated the genuine claim of the complainant with respect to policy No.473547502 on flimsy ground alleging that the deceased life assured was not having good health prior to the date of proposal and was suffering from DM-2 for 19 years, but these allegations are totally wrong and incorrect. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Party be directed to pay the insured amount of Rs.4 lacs alongwith accrued bonus with respect to policy No.473547502 alongwith interest from the date of submission of claim till realization.
b) Opposite Party be directed to pay the compensation of Rs.50,000/- to the complainant.
c) Opposite Party be directed to pay the adequate cost of the litigation.
d) Any other consequential relief to which the complainant is entitled to under the law, equity, justice and fairplay be also awarded.
Hence, this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the complainant has filed a baseless, frivolous and an imaginary claim with an ulterior motive and the same is bad in law and can not be entertained. The complainant has not come to this Forum with clean hands and has suppressed the material facts from this Forum. On merits, it is averred that except the insurance policy bearing No.473547502 for an amount of Rs.4 lacs, the payment of other policies have already been released to the complainant, keeping in view the terms and conditions of the policies applicable to the aforesaid policies. While filling the proposal form dated 30.3.2013 the deceased policy holder withheld the correct information with respect to his ill health and consequent treatment taken by him prior to date of proposal. As per the proposal form, the life assured had concealed the fact with regard to his ailment from DM-2 (diabetes at advance stage) for the last nineteen years. As such, the policy holder deliberately suppressed the material facts of his ill health and therefore, the claim of the complainant with regard to policy in question is rightly repudiated vide repudiation letter dated 12.3.2016. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. In her bid to prove the case, complainant tendered into evidence affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C10 and closed her evidence.
4. On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.Rajinder Kumar, Manager Legal Ex.OP1/A alongwith copies of documents Ex. OP1 to Ex.OP9 and closed the evidence on behalf of the Opposite Party.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. The complainant has submitted his affidavit Ex.C1 in which he has reiterated the facts as detailed in the complaint and contended that Susheel Nanda son of Prem Nath Nanda was husband of the complainant who has expired on 9.8.2015 leaving behind the complainant as his legal heir being his widow and after his death, she is entitled to inherent the estate of the deceased Susheel Nanda, hence the present complaint is filed by the complainant being widow/ nominee of the deceased Susheel Nanda and is beneficiary of the claimed amount under the policy in dispute and as such, she is a consumer as defined in the Act, as amended upto date. Late Susheel Nanda during his life time obtained a life insurance policy bearing No.473547502 for Rs.4 lacs with the date of commence as 28.3.2013 and duly appointed the complainant as his nominee and deceased Susheel Nanda also obtained policy No.472970773 for Rs.1 lac only, and policy No.470741896 for Rs.1 lac and policy No.471637483 for Rs.2 lacs only from the Opposite Party. It is pertinent to mention over here that deceased Susheel Nanda was in sound and good health at the time of obtaining the aforesaid policies and before effecting the aforesaid policies on the name of Susheel Nanda by Opposite Party, the deceased was medically examined by the qualified doctors of the Opposite Party and he was found perfectly fit and not suffering from any type of the disease and it was after due satisfaction regarding the health of Susheel Nanda, the life assured, the policies in question were released by the Opposite Party in the name of Susheel Nanda, husband of the complainant. Life assured Susheel Nanda due to some minor weakness and resiperately distress was admitted to Smt.Parvati Devi Hospital Amritsar on 2.8.2014 and it was diagnosed by the doctors of the hospital to be a case of diabetes and hypertension and the deceased was discharged on 11.9.2014 in symptomatically better condition. At the time of discharge on 11.9.2014 and thereafter for follow up purposes remained admitted in the same hospital three to four occasions for short period of 1-2 days and lastly admitted in the same hospital on 7.8.2015 and unfortunately died on 9.8.2015 due to respiratory distress/ cardiac arrest. The deceased was not suffering from any type of the disease when he proposed for insurance. The deceased was medically examined by the qualified doctors of the Opposite Party and after full satisfaction regarding the health of life assured, the policy in dispute was issued in the name of husband of the complainant. Nor the life assure ever admitted in any hospital for any disease nor consulted any doctor and was in sound and perfect health at that time. After the death of Susheel Nanda, the complainant being his widow, under the death claim of all the above said polices with the Opposite Party with the request to release the insured amount to her as per the terms and conditions of the policies and supplied all the documents to the Opposite Party as required by them and the Opposite Party paid the insured amount of policy No. 472970773, policy No.470741896 and policy No.471637483, but to the utter surprise of the complainant, the Opposite Party vide letter dated 12.3.2016 repudiated the genuine claim of the complainant with respect to policy No.473547502 on flimsy ground alleging that the deceased life assured was not having good health prior to the date of proposal and was suffering from DM-2 for 19 years, but these allegations are totally wrong and incorrect.
7. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that except the insurance policy bearing No.473547502 for an amount of Rs.4 lacs, the payment of other policies have already been released to the complainant, keeping in view the terms and conditions of the policies applicable to the aforesaid policies. While filling the proposal form dated 30.3.2013 the deceased policy holder withheld the correct information with respect to his ill health and consequent treatment taken by him prior to date of proposal. As per the proposal form, the life assured had concealed the fact with regard to his ailment from DM-2 (diabetes at advance stage) for the last nineteen years. As such, the policy holder deliberately suppressed the material facts of his ill health and therefore, the claim of the complainant with regard to policy in question is rightly repudiated vide repudiation letter dated 12.3.2016.
8. The only ground for the repudiation of the claim of the complainant is that the life assured had concealed the fact with regard to his ailment from DM-2 (diabetes at advance stage) for the last nineteen years and as such, the policy holder deliberately suppressed the material facts of his ill health, copy of the repudiation letter dated 12.3.2016 accounts for Ex.OP5. But diabetes 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 and diabetes 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.”.
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.
9. Not only this, the Opposite Party could not examine any medical practitioner/ doctor who has treated the life assured for diabetes nor the Opposite Party has filed any affidavit of any doctor who has medically treated the life assure for the disease prior to taking of the policy. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies upon the insurer- If assured was suffering from pre-existing disease why insurer had not checked it at the time when proposal form was accepted by its staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled to claim alongwith interest @ 9%. In the present case, the Opposite Party has simply relied upon the history of the life assured recorded at the time of his admission in the hospital.
- 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 pesters 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 seams 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.
- From the aforesaid discussion, it transpires that Opposite Party has wrongly repudiated the genuine claim of the complainant. Hence the Opposite Party is directed to pay the insured amount of Rs.4 lacs alongwith accrued bonus with respect to policy No.473547502. Opposite Party is also directed to pay the amount of Rs.5,000/- to the complainant on account of compensation for causing her mental tension and harassment. The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 6% per annum from the date of order until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated:05.12.2017. (Rachna Arora) (Anoop Sharma) Member Presiding Member
