O R D E R
The present complaint case has been filed by complainant Shivani Jayswal, being the wife of the deceased life assured Suman Jayswal r/o village- Hansdiha, P.S+ P.O.- Hansdiha, District-Dumka for self and on behalf of her two minor children against the opposite parties i.e.(i) Manager,Bajaj Allianz Life Insurance Company Ltd Dumka branch,(ii) Manager,Bajaj Allianz Life Insurance Company Ltd.Kolkata(West Bangal),(iii) Manager claims Review Committee,Bajaj Allianz Life Insurance Company Ltd. Pune and (iv)Manoj Kumar Yadav ,Bajaj Allianz Life Insurance Company Ltd ,Dumka u/s-12 of the Consumer Protection Act,1986 for illegally and arbitrarily repudiating death claim of life assured Suman Jayswal, who was insured by O.P’s Bajaj Allianz Life Insurance Company Ltd ,Dumka branch vide Policy no.0291948297 on 24.01.2013 for a sum assured of Rs.4,75,000/-(Four lac seventy five thousand )in which the complainant being the wife was cited as nominee and thereby committed negligency and deficiency in service. .The complainant has prayed to direct the O.P’s to pay a sum of Rs. 4,75,000/- (Four lac seventy five thousand)towards claim amount, further to pay compensation of Rs.10,000/-(Ten thousand) for mental agony etc. and Rs.5000/-(Five thousand) towards cost of litigation and in total claimed Rs.4,90,000/-(Four lac ninety thousand) . The complainants has also prayed to direct O.P’s to pay interest @9%.p.a. on the sum assured amount since the date of institution of this case till its payment.
2. The brief facts of the case as revealed from the complaint petition and the documents annexed there in are as follows:-
That the husband of the complainant Suman Jayswal s/o Arjun Jayswal resident of village and P.S.- Hansdiha and district- Dumka, was insured with Bajaj Allianz Life Insurance Company Ltd,Dumka branch on 24.01.2013 for sum assured of Rs.4,75,000/-(Four lac seventy five thousand)vide policy no.0291948297 in which the complainant no(1)(a) was cited as nominee .
The complainant’s further case is that the life assured the Suman Jayswal died on 26.02.2013 at his resident due to C.R. arrest and thereafter the complainant informed the death of the deceased life assured to the local office of the O.P’s company at dumka branch who issued a claim form with a direction to submit the same after duly filling up along with required documents, Accordingly, the complainant submitted the duly filled up claim form along with original policy bond, voter I.D. card of DLA, voter I.D. card of the nominee, death certificate of DLA issued by Dr.Om Prakash ,P.M.C.H. Saraiyahat , Dumka dated 26.02.2013 and death certificate of deceased issued by registrar birth and death, Block- Saraiyahat ,P.S-Hansdiha, Dumka .The complainant after submission of the death claim continuously visited the local office of the O.P’s where she was solaced that her claim will be paid shortly but all went in vain as the O.P’s Insurance Company sent a repudiation letter dated 03.09.2014 on the basis of concocted story of suppression of disease prior to the policy and on forged documents.
The complainant has claimed that the deceased life assured was neither suffering from any disease and no any investigation was ever carried out nor the DLA was treated by any doctor. It is also claimed that if the O.P’s are carrying any documents regarding treatments or investigation of DLA then such documents are forged as they do not contain signature of the nominee .It is alleged that the O.P’s Insurance Company is trying to escape from its liability and to seek excuse, so, that they may not have to pay insured amount, which is nothing but deficiency in service, deceptive trade practice and negligent attitude towards the nominee. The complainant/nominee lastly having no option filed this case on 24.10.2014 for redressal of her grievance before this forum.
3. Having recieved the Complaint petition filed by the complainant, it was admitted on 24.10.2014 and notices were directed to be issued upon O.P’s. O.P’s no i to iii appeared on 03.08.2015 and filed written statement, whereas opposite no-iv Manoj Kumar Yadav appeared on 18.01.2016 and filed written statement.
4. The case of the opposite parties no (I to iii) as emerged from their written statement and short notes of argument in which they besides being taking preliminary objection such as non maintainability and lack of cause of action for the complaint, has admitted that the deceased life assured namely Suman Jayswal got his life insured with this O.P. Bajaj Allianz Life Insurance Company Ltd , Dumka branch on 24.01.2013 for a sum assured of Rs.4,75,000/-(Four lac seventy five thousand) in which the complainant being the wife was cited as nominee. The life assured died on 26.02.2013 due to cardio respiratory arrest and accordingly, the complainant requested O.P’s. company for payment of the sum assured under the said policy but the company vide its letter dated -03.09.2014 repudiated the claim on the ground of suppression of disease.
The further case of the answering O.P’s is that the life assured purposely suppressed the pre-proposal diagnosis and treatment of hypertension, Diabetes Mellitus , Coronary artery disease, CSAII, SVD, PCI, LAD, Post PTCA single stent and on the basis of non-disclosure of the material facts the claim was rejected by the answering company.
The further case of the answering O.P’s is that the life assured in order to get his life assured with this answering company made a proposal to Dumka branch and filled up proposal from on 15.01.2013 mentioning all his related facts and the company under bonafide belief and in good faith accepted the proposal and accordingly issued policy no.291948297. It is further averred that in the said proposal form life assured submitted declaration of good health and specifically replied to all the quarries in negative and on the basis of said declaration of good health made to the company it was decided to issue policy. It is further stated that in the said proposal the life assured did not disclose about cardiac treatment at P G I Chandigarh and in case this facts had been disclosed, the company would not have issued the policy.
The further case of the answering O.P’s is that the policy in question commenced on 24.01.2013 but only after 32 days the life assured died on 26.02.2013 and on receiving the death claim intimation ,the company appointed the investigator Saystruth ,B-63/B,FF Panchsheel Vihar,New Delhi. who conducted investigations and received medical records of DLA Suman Jayswal which confirmed that Suman Jayswal was a chronic patient and suffering kidney failure prior to the policy and he took regular treatment from various Doctors including P G I Chandigarh .It is alleged that life assured Suman Jayswal was treated at cardiology department of PGI Chandigarh where stent was implanted in the year2011 and again life assured was treated at the department of Renal Clinic and Nephrology of PGI Chandigarh. It is alleged that life assured although well know of the said facts but intentionally and deliberately, did not disclose the same in the proposal from and thereby obtained the policy fraudulently. It is asserted that the claim of the complainant has rightly been repudiated and there was neither any deficiency in services on the part of the O.P’s company nor there was any negligency on the part of the employee of the company . The complainant has not suffered any injury or harassment and not submitted any evidence rather all are cook and bull story. Therefore, prayed to dismiss this case with cost.
5. The case of the opposite party no-IV is that he is an agent of Bajaj Allianz Life Insurance Company Ltd vide code no 1000991249.He went to the resident of the life assured and explained about the policy to him ,who agreed and took the policy after putting signature on the proposal form and this opposite party duly filled the form before the life assured Suman Jayswal. At the time of the filling of proposal form life assured was healthy and he was neither under treatment of any doctor nor suffering from any disease. .It is further stated that on the same day company’s Dr. B.S. Podwal examined the life assured and being satisfied signed on the proposal form. Thereupon premium amount Rs.8,709.04 was accepted and policy was issued on 24.01.2013 for a term of 25 years. This opposite party has admitted the assertion made from Para 1 to 12 of the complain petition and prayed to accept this written statement and pass necessary order.
6. The respective parties in support of their claims have adduced oral as well as documentary evidence.
The complainant in support of her claim has examined as many as two witness, out of them C.W.-1 Shivani Jayswal is the complainant herself and C.W.-2 Subodh Jayswal is the relative of the complainant. Bersides oral evidence she has adduced the following documentary evidence:-
Ext-1. Photocopy of policy bond of DLA Suman Jayswal;
Ext-2. Photocopy of death dead carrying certificate issued by Dr.Om
Prakash, PHC, Sariyahat, Dumka;
Ext-3.Photocopy of Votor ID card of Suman Jayswal ;
Ext-4. Photocopy of Votor ID,card of Shivani Jayswal ;
Ext-5. Photocopy of Pass-book of saving Bank account of
S.B.I.Hansdiha in the name of Shivani Jayswal;
Ext-6. Photocopy of death certificate of Suman Jayswal issued by
Government of Jharkhand;
Ext-7. Photocopy of repudiation letter dated 03.09.2014 by the Bajaj
Allianz Life Insurance Company Ltd.
On the other hand the contesting opposite parties (no i to iii) have adduced an oral evidence as O.P.W.No.1 S.K. Sharma, Besides oral evidence answering O.P’s have adduced following documentary evidence :-
Ext.A. Proposal form of life assured Suman Jayswal;
Ext-B. Investigation report of Saystruth company;
Ext-C. In-patient record of Suman Jayswal dated-23.08.2011 by the Cardiology Department of P.G.I. Chandigarh;
Ext-D. Point wise reply of medical record department and report of renal clinic and Nephrology department of P.G.I Chandigarhin respect of DLA Suman Jayswal dated 15.12.2012;
Ext-E. Re-under writing opinion dated 01.09.2014 of the opposite parties company in respect of the policy of Suman Jayswal;
Ext-F. Medical Prescription dated-24.02.2012 to 05.04.2012 of Dr.Chitranjan Sharma of Gaya,(Bihar) in respect to Suman Jayswal;
Extr-G. Medical Prescription dated 10.08.2012 to 05.10.2012 of Dr. N.L. Choudhary, Rajgir , Nalanda in respect of Suman Jayswal.
7. We have examined the entire material on record and given a thoughtful consideration to the arguments advanced before us.
8. There are two major points for consideration before this forum:-
(i) Whether the complainant has come before this forum with clean hand or the deceased life assured has deliberately suppressed the material information from the Insurance Company at the time of filing the proposal form?
(ii) Whether the complainant is entitled to the reliefs claimed?
F I N D I N G S
9. Point no-1:- First point for discussion is whether complainant has come up with clean hand or life assured has suppressed /the material information at the time of filing proposal form?
The admitted position of this case is that the life assured Suman Jayswal got his life assured with Bajaj Allianz Life Insurance Company Ltd. Dumka branch on 24.01.2013 for a sum assured of Rs.4,75,000/-(Four lac seventy five thousand ) vide policy no.0291948297 in which the complainant being the wife stood as nominee. The said life assured died on 26.02.2013 i.e. only after 32 days of the commencement of the policy due to cardio - respiratory arrest. The complainant being nominee after the death of DLA requested the opposite parties for payment of the sum assured under the said policy but the company vide its letter dated 03.09.2014 repudiated the claim on the ground of suppression of disease prior of the policy
The complainant has asserted that the DLA was neither treated by any doctor nor he was suffering from any disease as alleged by the O.P’s(no.i to iii).She has further asserted that O.P. no.IV, the agent of O.P’s Insurance Company had filled up proposal form in the house of DLA on 15.01.2013 who noticed him in hale and hearty condition and this fact has been supported by O.P.no.IV in his written statement. The complainant has also asserted that the O.P.no.i to iii in their written statement have mentioned that life assured was suffering from Kidney failure prior to the policy but it is not mentioned in the repudiation letter dated 03.09.2014 and thus without any proof the O.P’s no(i) to (iii) have repudiated the claim. It is further claimed by the complainant that reports submitted by P.G.I. Chandigarh dated 11.08.2017 are forged and fabricated besides the prescription of the doctor’s i.e. Dr. Chittaranjan Sharma and Dr, N.L. Chaudhary have contradictions and the same are not reliable.
10. The contesting opposite party (i toiii) on page 3 of the written statement have stated that life assured in the proposal form dated 15.01.2013 has made declaration of his good health by replying all the quarries in negative made in column no.22 of the proposal form. Against the quarry under column no.22 (g) of the proposal form with the question “Have you ever been treated or currently under treatment for any diseases for any diseases and disorders of the metabolic and endocrine system such as but not limited to diabetes, hypothyroidism, hyperthyroidism, goiter or other endocrine diseases he replied as “No”. Further the quarry under colume no.22 (f) of the proposal form with the question “Have you ever been treated or currently under treatment for any diseases and disorders of the Genitourinary system such as but not limited to blood in urine, infected urinary bladder or tumor kidney disease, he again replied as “No”. It is further asserted that on the basis of disclosure of good health made by the life assured of the company, the company decided to issue policy and in case the life assured would have disclosed that he was suffering from kidney failure disease and implanting stent in his body at P.G.I. Chandigarh, the company would not have decided to issue policy.
C.W-1 Shivani Jayswal the complainant herself in her affidavited statement has supported her case in para-3 of the affidavit statement saying that her husband died due to heart failure and dehydration on 26.02.2013 and prior to that he was not undergoing treatment of any doctor. She has denied that her husband was undergoing treatment of P.G.I. Chandigarh since 2011.She has also denied O.P’s suggestion that as her husband was suffering from kidney disease hence he died during treatment but he concealed these facts at the time of taking policy.
C.W.-2 Subodh Jayswal in his affidavited statement has stated that he is the elder brother of Suman Jayswal .His brother Suman Jayswal was a healthy man having no any disease but died suddenly due to heart attack and dehydration. His brother was never treated anywhere.
Ext. A. is the proposal form of the life assured Suman Jayswal and from perusal of this documents it is clear that in Colum no-22(g) and Colum no 22(f) the life assured in reply to the quarries of agent of the company Categorically denied that he was suffering from any disease and disorders of the metabolic , endocrine and genitourinary system such as diabetes, hypothyroidism, goiter, blood in urine, infection in urinary bladder or tumor Kidney disease. The contesting O.P’s no.i to iii have filed investigation report of saystruth company about D.L.A. Suman Jayswal. On careful perusal of this investigation report it appears that the investor company conducted various investigation and received various medical records of Suman Jayswal which conform that he was a chronic patient and was suffering from kidney failure prior to the policy and also took regular treatment from various doctors including P.G.I. Chandigarh. Further from perusal of Ext-C it appears that life assured Suman Jayswal was treated in cardiology department of P.G.I. Chandigarh where stents was implanted in his body in the year2011.Further more from perusal Ext-D the point wise reply of P.G.I. Chandigarh it appears that life assured Suman Jayswal was treated at the department of Renal clinic and Nephrology department of P.G.I. Chandigarh from 17.08.2011 to 26.12.2012.Further also form perusal Ext-F and G it revealed that life assured Suman Jayswal was under regular treatment of Dr. Chitrenjan Sharma of Gaya( Bihar) and Dr. N.L. Choudhary of Rajgir, Nalanda (Bihar) and both the doctor found life assured suffering from chronic diabetes and the his entire body had swollen. These documents have been procured from the P.G.I. Chandigarh and investigater company Saystruth, so there is no any point of suspicion.
O.P.W-1 Sanjay Kumar Sharma has filed affidavited statement stating on oath that his agency was deputed by Bajaj Allianz Life Insurance Company Ltd to investigate policy no.291948297 issued to late Suman Jayswal . During investigation documents including medical papers and claim related documents were procured and from said documents it appeared that life assured took Renal failure treatment and heart treatment at P.G.I. Chandigarh in the year 2012 besides life assured also took treatment of Dr.Chitranjan Sharma on 24.02.2012for chronic diabetes and renal failure and also took treatment of Dr. N.L. Choudhary on 10.08.2012 and claimed that all these documents relates to treatment of life assured. Whereas the complainant had claimed that all the documents adduced on behalf of O.P’s no.(i) to (iii) are forged and fabricated as these documents do not bear the signature of the nominee,but this claim of the complainant is not at all acceptable as because all the documents related to treatment of life assured have been transmitted to this forum directly from the department of cardiology,renal clinic and nephrology and also from the medical record department of P.G.I. Chandigarh. These documents sent by the Senior Medical Record officer ,medical record department, Nehru hospital, P.G.I.M.E.R. Chandigarh to this forum vide letter no. P.G.I/MRD/217/3488 dated 31.10.2017hence,they are genuine and reliable documents. Ext.F and G are the photocopy prescriptions of Dr.Chitranjan Sharma of Gaya(Bihar) and Dr. N.L. Chaudhary, Rajgir,Nalanda (Bihar) respectively and both these document supports the case of the O.P’s company. The complainant failed to disprove these documents .Therefore, claim of the complainant that all the documents are forged and fabricated is completely absurd rather these documents clearly proof that life assured Suman Jayswal was undergoing treatment of Chronic diabetes, kidney problem and heart problem since 2011 and he deliberately suppressed the treatment from before issuance of policy and obtained the policy intentionally by misrepresenting the material facts. It also appeared that O.P.no-IV, the agent of the insurance company who has claimed that he is the local to the deceased life assured and he noticed him hale and hearty at the time of assurance of the policy shows that he has misguided the insurance company and as such he acted as conspirator with the deceased life assured. These facts clearly show that life assured did not disclose the material information faithfully about all the disease while filling the proposal form rather deliberately suppressed and all these facts must have been in the knowledge of the complainant/ nominee and hence we are of the view that she did not come to this forum with clean hand and the life assured had deliberately suppressed the material information in obtaining insurance from O.P’s company.
11. Learned Counsel for the complainant in support of its case has relied upon following case laws:-
1-2012(1`) CPR-391(NC);
2-2012(4) CPR-231 (NC);
3-2009 (3) CPR-290 (NC);
4-2012 (3) CPR.-302(NC).
In all these case law’s the Hon’ble National Consumer Disputes Redresses Commission, New Delhi have categorically held that repudiation of death claim for suppression of pre-existing medical condition must be supported with cogent and acceptable medical evidence.
On the other hand Learned Counsel of the O.P’s No.(i) to(iii) have relied upon following case law’s:-
1. Mithoolal Nayak Vrs L I C of India reported in AIR1962 Supreme Court page-814;
2. United India Insurance Company Vrs M K J corporation, reported in AIR 1997Supreme Court page408;
3. Life Insurance Corporation of India &other Vrs Asha Goel & another, decided on 13.12.2000 by the Hon’ble Supreme Court;
4. The Senior Divisional Manager Vrs Raksha Goyal, decided on 03.10.2001 by the Hon’ble National Commissio,New Delhi;
5. L I C of India Vrs Smt. Kusum Patro, decided on 19.03.2012 by Hon’ble National Commission,New Delhi;
6. Sunita Goyal Vrs Bajaj Allianz Life Insurance Company Ltd,decided on 07.09.2017 by the Hon’ble National Commission New.Delhi.
The Learned Counsel for the opposite parties no. i to iii on the basis of above case law’s contended that the contract of life insurance is based on the principle of “Uberrima Fides” i.e. utmost-good faith hence each and every material facts must be disclosed and the concealment of any material information or providing any false or incorrect information in the policy is the violation of the insurance contract. In the present case it is proved that there was concealment of material facts on the part of the life assured Suman Jayswal therefore ,the insurance company has rightly repudiated repudiation the claim.
12.We have gone through above case law’s of both sides in which the Hon’ble courts in many cases have held that every material facts must be honestly disclosed by the life insured ,otherwise there is good ground for rescission. In the present case it is proved that the insured was suffering from diabetes, hypertension, kidney failure etc. and getting regular treatment from various doctors including P.G.I. Chandigarh and therefore he was duty bound to have disclosed these facts but he has deliberately concealed these material informations.
Thus, we find that the opposite parties no (i) to (III) have clearly proved that the life assured had actively concealed the material facts and obtained the policy by playing fraud and misrepresentation. Therefore, the O.P’s company has rightly repudiated the claim. Besides, O.P no (IV) has conspired with the life assured and concealed the material facts. Therefore, complainant not entitled to any relief.
13.Upon consideration of the above facts, evidence and case law’s we are of the consistent view that the life assured Suman Jayswal at the time of taking policy had suppressed the material facts about his pre-existing health condition for obtaining insurance policy and therefore the insurance company has rightly repudiated the nominee’s claim we are also of the view that the life insurance company (no. I to iii) should take appropriate action against O.P.no-IV for conspiring with the life assured by mentioning false statement in the proposal form about health condition of the insured. Besides O.P.no.IV vide para-4 of his written statement-cum-Short notes of argument dated 18.01.2016 has admitted his involvement in suppression of material facts of life assured in such fact the insurance company has rightly repudiated the complainants death claim and therefore there was neither any deficiency nor negligency in the service on the part of the O.P’s company.
In the result,
O R D E R E D
The case be and the same is dismissed without cost .The O.P’s insurance company (no. i to iii) is directed to take suitable action against O.P.no-IV i.e. agent Manoj Kumar Yadav code No.1000991249. The death claim of the life assured Suman Jayswal was rightly been rejected.
