Chandigarh

DF-I

CC/530/2017

Janinder Singh - Complainant(s)

Versus

Max Life Insurance Co. Ltd. - Opp.Party(s)

Munish Kumar

25 Jun 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/530/2017
Date of Institution	:	20/07/2017
Date of Decision	:	25/06/2019

 

 

Janinder Singh son of Sh. Ranbir Singh r/o H.No.2928, Sector 37-C, Chandigarh.

… Complainant

V E R S U S

Max Life Insurance Co. Ltd.  (Now known as Max New York Life Insurance Co. Ltd.), Madhya Marg, Chandigarh through its Branch Manager. 

… Opposite Party

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                    

ARGUED BY	:	Sh. Munish Kumar, Counsel for complainant
	:	Sh. Vishal Gupta, Vice Counsel for Sh. Nitesh Singhi, Counsel for OP

 

Per Rattan Singh Thakur, President

1.         Allegations are, deceased Ms. Satbir Kaur happened to be the real sister of the complainant. She, being a spinster, was living with the complainant and happened to be the member of the family of the complainant. She had purchased life insurance policy called Max Life Fast Track Super Regular Pay floated by the OP having annual premium of Rs.25,000/- and the sum assured was Rs.2,50,000/-.  The first premium was paid on 20.7.2016 and the second premium was paid for the year 2016-17 and she was all well till December 2016.   She was a govt. employee and served in Railway Claims Tribunal, Chandigarh as Superintendent. Maintained, in the last week of December 2016, during the validity of the policy in question, she complained of pain in her heart and was rushed to the Fortis Hospital, but, could not be saved and had expired on 31.12.2016.  In the policy, the deceased had nominated complainant as her nominee. The claim was submitted but it was repudiated on 31.1.2017 on the grounds that she had concealed the pre-existing disease.  However, the OP had transferred an amount of Rs.50,000/- i.e. the originally deposited amount of two installments of Rs.25,000/- each in the account of the complainant.  The repudiation grounds were invalid, therefore, there has been deficiency in service and indulgence in unfair trade practice on the part of the OP. Hence, the present consumer complaint praying for release of remaining sum assured of Rs.2,00,000/- alongwith interest, compensation and litigation expenses etc.
2.         OP contested the consumer complaint and filed reply.  Its claim is, material facts were concealed as on the date of issuance of the policy, complainant had pre-existing disease i.e. kyphoscoliosis, congenital restrictive lung disease, Type 1 respiratory failure and on Bilevel Positive Airway since 10 years i.e. prior to the signing of the proposal form.  Hence, as per terms and conditions, the claim was repudiated which is justifiable in facts and law. On these lines, the cause is sought to be defended.
3.         Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.         Parties led evidence by way of affidavits and documents.
5.         We have heard the learned counsel for the parties and gone through the record of the case. After appraisal of record, our findings are as under:-
6.          Per pleadings of the parties, admittedly, the policy was got renewed on payment of second premium of the amount of Rs.25,000/-.  It is the case of the complainant of deceased being fit and fine till December 2016. Under paragraph No.13 of the consumer complaint, the complainant had allegated that original deposit of Rs.50,000/- of two installments of Rs.25,000/- each was transferred in the account of the complainant being her nominee.  The said facts were not specifically denied as per reply furnished to the allegations made under paragraph No.13 of the consumer complaint.  The case of the complainant is, the said amount was accepted under protest.  Disbursement of Rs.50,000/- in the account of the nominee i.e. the complainant itself shows the stand of the OP being dwindling one and tacitly they had admitted of deceased being alright on point of her health issue on the date of issuance of the policy in the year 2015. Being so, where was the situation to withhold the remaining sum assured of Rs.2,00,000/- by the OP of her nominee i.e. the complainant.
7.         The defence of the OP is based on some passing reference made by Fortis Hospital in the death certificate (Annexure R-3) of Ms. Satbir Kaur which shows final diagnosis as complaint of kyphoscoliosis with pulmonary hypertension with restrictive lung disease. The cause of death was opined as sudden cardiac arrest and the immediate cause as Type II respiratory failure.  However, who has given this history in the death summary to the hospital has not been disclosed.  The observations made by Dr. A.K. Mandal, HoD Pulmonology is that the patient was brought to the emergency in unresponsive state allegedly for 20 minutes, breathlessness for last 5 days and the pulse was unrecordable and it was known case of kyphoscoliosis, congenital restrictive lung disease, Type 1 respiratory failure and on Bipap for last 10 years. 
8.         Per record deceased as per observations was unresponsive, therefore, who had given such history has not been disclosed.  Not only this, so much so, the person who has given such history to the doctor not been examined and even the affidavits of Dr. A.K. Mandal, HoD Pulmonology and Dr. Karnail, Resident emergency not produced that she had such confirmed history for the last 10 years.  It was simply a complaint made and no authentic record of such treatment has been produced by the OP to say she had concealed the said disease at the time of issuance of the policy by the OP.
9.         The cause of death was allegated to be cardiac arrest which is as per Webster’s new world Medical dictionary is a heart attack in which the heart suddenly stops pumping sufficient blood and it was a myocardial infarction acute which has been defined as heart muscle (myocardium) experiences sudden deprivation of circulating blood, which results in death (necrosis) of myocardial tissue and other changes.  The interruption of blood is usually caused by arteriosclerosis with narrowing of the coronary arteries, the culminating event being a thrombosis (clot). 
10.         Now there is no authentic evidence on record that cardiac arrest or say myocardial infarction acute had a nexus with the alleged disease of kyphoscoliosis with pulmonary hypertension with restrictive lung disease.  In the absence of the link of cardiac arrest with the said disease, it cannot be said that the alleged disease led to cardiac arrest.
11.         The learned counsel for the complainant has relied on case titled as LIC of India & Anr. Vs. Smt. Jaimanti Sharma & Anr. decided on 11.12.2009 by the Hon’ble HP State Commission and the relevant paragraph No.15 thereof reads as under :-

“15. At the risk of repetition, we may point out here again, that there is nothing on record even to remotely suggest that the deceased was aware on 30.3.1998 on his suffering from throat cancer, which plea is the sheet anchor of the appellants in this appeal. Once this conclusion is arrived at, we find no reason to interfere with the order passed by the District Forum below.”

12.         Further he banked upon case titled as Smt. Kalpana Rajendra Chavan Vs. Life Insurance Corporation of India decided on 11.12.2013 by the Hon’ble State Commission, Maharashtra in which under paragraph No.9 it was held as under :-

“9. Therefore, the non-disclosure of chronic Dyspepsia in the proposal form cannot be a ground for repudiation of the claim as rightly urged on behalf of the Complainant and ruling of the Hon’ble National Commission relied by the Complainant is applicable to the case on hand. In yet another order passed by the Himachal Pradesh State Consumer Disputes Redressal Commission, Simla in case of LIC of India & Anr. V/s. Jaimanti Sharma & Anr., reported in (2010) 4 CPR 126, it was held that, the life assured is supposed to give true and correct facts regarding state of health in the proposal form. However, it was held that it cannot be presumed that the deceased was well aware regarding his state of health (throat cancer) while filling the proposal form and the appeal of LIC was dismissed.”

 

This shows, as per precedents the life assured is supposed to give true and correct facts regarding state of health in the proposal form and not supposed to disclose the nature of disease which the life assured had suffered. 

13.         Further relied on case titled as Religare Health Insurance Company Ltd. Vs. Subhash Chander Aggarwal decided on 26.4.2017 by the Hon’ble Punjab State Commission and the relevant paragraph No.10 thereof reads as under :-

              “10. Whether Hypertension is a disease which is required to be referred in the proposal form. There is a judgment of Hon'ble National Commission reported as "Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd", I (2016) CPJ 613 (NC), in which it was observed by the Hon'ble National Commission that Hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified. Otherwise in the discharge summary of Smt. Paarvati Devi Hospital Ex. C-7 in which there is no reference of Hypertension. Discharge summary of Medanta Hospital Ex. C-14, in which there is a reference of Diabetes Mellitus but no reference of Hypertension. Then there is another referred document i.e. Ex. OP-21 dated 05.03.2015 i.e. after taking the policy in which the B.P. of the complainant is 140/180 which is quite normal at the age of complainant. Therefore, the ground that the complainant was suffering from hypertension is not corroborated on the basis of the evidence on the record.”

14.         In view of the above discussion and the precedents relied upon, repudiation of the claim was not justified particularly so when part of the amount i.e. Rs.50,000/- already stood disbursed to the nominee of the complainant i.e. the present complainant. Resultantly, the present consumer complaint succeeds and the same is accordingly partly allowed.  OP is directed as under :-

1. To pay the sum of Rs.2,00,000/- to the complainant alongwith interest @ 9% per annum w.e.f. 31.1.2017 i.e. the date of repudiation till realization.
2. To pay an amount of Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

15.         This order be complied with by the OP within thirty days from the date of receipt of its certified copy, failing which, it shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
16.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
25/06/2019	[Suresh Kumar Sardana]	[Rattan Singh Thakur]
hg	Member	President