View 480 Cases Against Pnb Metlife India Insurance
PNB METLIFE INDIA INSURANCE CO. filed a consumer case on 23 Feb 2024 against MANDEEP DEVI in the StateCommission Consumer Court. The case no is A/913/2018 and the judgment uploaded on 11 Mar 2024.
STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA
Date of Institution: 23.07.2018
Date of final hearing: 16.01.2024
Date of pronouncement: 23.02.2024
First Appeal No.913 of 2018
1. PNB Metlife India Insurance Company Ltd., (Formally known as Metlife) Branch Office at: SCO No. 223, 2nd Floor, Sector-12, Karnal.
2. PNB Metlife India Insurance Company Ltd., (Formally known as Metlife) Registered Office at: Unit No. 701, 702 & 703, 7th Floor, West Wing, Raheja Towers, 26/27, M G Road, Bangalore-560001. Appellants
Mandeep Devi aged about 25 years d/o Late Shri Rameshwar R/o Village Balbehra, Tehsil Guhla, District Kaithal, Now R/o Village and Post Office: Diwan, Tehsil Pehowa, District Kurukshetra.
CORAM: Sh. Naresh Katyal, Judicial Member
Argued by:- Sh. Rohit Goswami, proxy counsel for Sh. Vaibhav Jain, counsel for appellants.
Sh. Sansar Kundu, counsel for respondent.
ORDER
NARESH KATYAL, JUDICIAL MEMBER:-
Delay of 23 days in filing of this appeal stand condoned for the reasons stated in the application.
2. Challenge in this Appeal No.913 of 2018 of appellants/OPshave been invited to the legality of order dated 14.05.2018 passed by District Consumer Disputes Redressal Forum, Karnal, (In short “District Consumer Commission”) in complaint case No.77 of 2017, vide which complainant’s complaint has been allowed.
3. Factual matrix:Complainant’s father Rameshwar purchased life insurance policy No. 21888607 on 27.04.2016 for Rs. 14,20,000/- from OPs and paid annual premium of Rs. 8,212/- to OP No. 1/appellant at Karnal. Complainant is nominee in said policy. It is pleaded that: at the time of issuance of policy; complainant’s father was hale and hearty. Unfortunately, on 27.05.2016 he died due to sudden heart-attack. Complainant, being nominee of her father, submitted death claim with OPs after completing formalities. Vide letter dated 31.12.2016, OPs repudiated death claim of complainant on ground that: her father was suffering from cancer, prior to issuance of policy and was having other insurance policy. It is pleaded that it is a matter of common knowledge that at the time of insurance; insured is examined by empanelled doctor; insurance policy is issued when there is no adverse report from doctor with regard to insured. Hence, question of her father suffering from alleged disease (Cancer) does not arise. There is deficiency in service of OPs which caused illegal harassment to complainant. Repudiation of lawful claim of complainant by OPs is illegal, arbitrary, null and void. Complaint has been filed for issuing directions to OPs to pay Rs. 14,20,000/- with interest @ 18 % P.A. from date of death of insured, till final payment and to pay Rs. 50,000/- on account of mental pain, agony and physical harassment caused to her.
4. Upon notice, OPs resisted the claim. In defence, OPs have denied allegations of complaint and asserted that complaint is malicious, incorrect and filed with mala fide intention. It is an abuse of process of law. There is no deficiency in service of OPs. Deceased life assured (Late Rameshwar) after completely understanding the terms and conditions of ‘Met Family Income protect Plus’submitted duly signed proposal form on 26.04.2016 and offered to pay Rs. 9403/- annually, towards initial premium, against sum assured of Rs. 14,20,000/-. In proposal form, he had given declaration that, he has furnished information after fully understanding terms and conditions of plan and has made true and correct disclosure of all facts, and has not withheld any information. In proposal form, there was a column wherein deceased life assured (DLA) was required to provide answer with respect to his medical history and he replied that: he was not suffering from any disease, neither he was taking any medical treatment. On receipt of duly filled proposal form, and believing the information provided by DLA to be true and correct alongwith initial premium; OPs evaluated and processed the proposal form and issued policy bearing No. 21888607, with risk commencement date 27.04.2016. it is admitted that complainant was made nominee in the policy. As per plea; DLA fully understood terms and conditions of policy and agreed under agreement that: if any untrue statement be contained in application/proposal form; policy contract shall be null and void and money which have been paid by DLA shall stand forfeited to OPs.
5. Death claim intimation was received on 03.09.2016. Intimating that insured person died on 27.05.2016 due to chest pain. OPs, as per procedure, carried out investigation to settle claim of complainant. During investigation and assessment of claim, it was revealed to OPs that: DLA did not provide true and correct information while filing of proposal form with respect to his medical history. It was revealed that DLA was suffering from cancer, prior to issuance of policy. OPs have rightly repudiated complainant’s claim vide letter dated 31.12.2016 on grounds of false information as to material facts with respect to his medical history, at the time of filing proposal form.
6. Parties led their respective evidence, oral as well as documentary. Learned District Consumer Commission, after imparting subjective analysis is to evidence, has allowed the complaint vide order dated 14.05.2018. Directions has been issued to OPs to pay Rs.14,20,000/- sum insured to complainant and to pay Rs.5500/- on account of mental agony and harassment suffered by him and for litigation expenses.
7. Feeling aggrieved; OPs have filed this appeal.
8. I have heard learned counsel for parties at length and with their able assistance; record has been perused.
9. Learned counsel for the appellants has urged that there was active concealment of material facts by deceased-life assured Rameshwar with regard to his previous medical history of being suffering from cancer, prior to issuance of policy in question. It is urged that claim of complainant, who was nominee of deceased under policy has been rightly repudiated. Learned District Consumer Commission has not appreciated this fact in right perspective and hence impugned order dated 14.05.2018 does not carry any credence. It is urged that learned District Consumer Commission has illegally ignored the investigator report dated 14.10.2016-Ex.R-7.
10. Refuting these contentions learned counsel for the complainant/respondent has supported impugned order dated 14.05.2018 passed by learned District Consumer Commission by urging that it is outcome of proper appreciation of facts and evidence by it and same does not warrant any interference.
11. Admittedly, Rameshwar was deceased-life assured who had obtained policy No. 21888607 from OPs with risk commencement date from 27.04.2016. Admittedly, complainant-daughter of deceased/life assured was his nominee under policy. As per plea of complainant; deceased life assured had suffered natural death on 27.05.2016 due to sudden heart attack and complainant, in her capacity of nominee, submitted death claim under policy to OPs. Sole ground to justify repudiation of death claim by OPs is that: deceased life assured had past medical history of being suffering from cancer, prior to issuance of policy in question, in his name. In proposal form, he had not indicated anything with regard to his past medical history.
12. Law on exclusion of insurer from policy is no more res integra. It is, by now well settled legal proposition that if insurer invokes exclusion from policy; then it (insurer) alone has to lead specific positive evidence in order to establish its exclusion. Reliance, in this regard can be placed upon ratio of law laid down by Hon’ble Apex Court in case of National Insurance Company Limited Vs. Vedic Resorts and Hotels Pvt. Ltd. in Civil Appeal No.4979 of 2019 decided on 17.05.2023; wherein it has been held that “It is trite to say that wherever such an exclusionary clause is contained in a policy, it would be for the insurer to show that the case falls within the purview of such clause.”
13. Too much of emphasis in present appeal, has been laid by insurer/appellants on investigator report dated 14.12.2016-Ex.R-7. Even, this report will not sub-serve any majestic cause of insurer/appellants to sail them out from consequences flowing from policy issued by it in favor of Rameshwar (deceased-life assured). Material aspect of this report reads as under:-
“Vicinity Survey:We did strong vicinity survey and met several persons without asking their name and contact number for want of vital clue. They all stated that LA died due to throat cancer. All knows him very well.
PGI, Rohtak- We visited hospital and met MRD in-charge and asked him to trace record whether there is entry in the name of LA. We visited hospital and met MRD in-charge and asked to trace record whether there is entry in the name of LA but without IPD number he showed us inability tracing record of any patient.
Doctors of village
Dr. Rajesh- 9050234681- Balbehra
Dr. Jeela- 09813063305- Balbehra
We met above mentioned doctors and asked about LA whether they treated LA before in any manner. They stated that they do not know LA and never treated him before in any manner”.
14. Investigator’s report-Ex. R-7 also reflects that: interviews were taken from neighbours/friends/workmates and their statements were recorded. In this process, as per this report Ex.R-7 deceased suffered from throat cancer and took treatment from PGI-Chandigarh. He suffered operation of throat in 2014. However, as it is clear from glancing at this report Ex.R-7 that: neither any record from PGI-Rohtak concerning treatment of deceased life assured could be secured, nor any record from PGI-Chandigarh regarding throat cancer treatment of deceased life assured could be secured. Had the investigator been apprised by neighbourers/friends and workmates that deceased obtained treatment of throat cancer from PGI-Chandigarh and had operation of throat in year 2014, then at least, it was expected from investigator to make an effort to lay his hand on above quality medical record from PGI-Chandigarh concerning life assured, but he failed in that arena. Much less than that two doctors of village of deceased life assured had revealed to investigator that they never treated deceased life assured in any manner and there is no specific reference of person(s), by his/their name, address etc. who revealed to investigator that life assured died due to throat cancer. Collectively, Investigator report Ex.R-7 is unambiguous and uncertain with regard alleged past history of deceased life assured being a cancer patient, prior to obtaining policy from OPs/appellants. This being so, it is established and proved that insurer/appellants had not led any cogent and convincing evidence in order to prove its pleaded case that deceased life assured has past medical history of being a patient of cancer. Hon’ble Apex Court in case titled as P. Vankat Naidu Vs. Branch Manager, LIC, Kurnool and another in Civil Appeal No. 7437 of 2011 decided on 26.08.2011 has held:-
“since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. However, as found by the District Forum and the State Commission, the respondents did not produce any tangible evidence to prove that the deceased had withheld information about his hospitalization and treatment. Therefore, the National Commission was not justified in interfering with the concurrent finding recorded by the District Forum and the State Commission by asking a wild guesswork that the deceased had suppressed the facts relating to his illness. In the result, the appeal is allowed.”
15. In opinion of this Commission, above cited judgments squarely cover this case and on applying the ratio laid down to this case, the only inescapable conclusion is that appellants/insurer have failed to prove its case with regard to its exclusions from policy. It is established that appellants cannot avoid their liability to pay the insured amount of Rs.14,20,000/- to complainant (nominee of deceased-life assured) under policy. Direction to pay amount of Rs.5500/- to complainant also does not warrant any interference. Learned District Consumer Commission has meticulously analyzed all relevant facets of controversy and has rightly non-suited insurer/appellants through order dated 14.05.2018. There is no fallacy in the approach of learned District Consumer Commission. Impugned order dated 14.05.2018 is upheld, maintained and affirmed. Present appeal being devoid of merits is hereby dismissed.
18. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
19. File be consigned to record room.
Date of pronouncement: 23rdFebruary, 2024.
Naresh Katyal Judicial Member
Addl. Bench-III
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