Delhi

North East

CC/1/2016

Sh. Jitender Kumar - Complainant(s)

Versus

M/s Exide Life Insurance company Ltd. - Opp.Party(s)

12 Jul 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 01/16

 

In the matter of:

	Sh. Jitender Kumar S/o Late Sh. Jai Dayal R/o H. No. 113, Gali No. 1 Village Chauhanpur, Badar Pur Khadar, North East Delhi-110094	Complainant
	Versus
1         2	M/s Exide Life Insurance Company Ltd. 4th Floor, Kanchanchanga Building Bara Khama Road, Cannaught Place New Delhi-110001   M/s Exide Life Insurance Co. Ltd First Floor, Gold Heel Spare No. 690 Hosur Road, Begur Hubli, Bangalore-560068   Also at:- M/s Exide Life Insurance Co. Ltd 3rd Floor, JP Techno Park, No. 3/1 Millers Road, Bengalure-560001	Opposite Parties

 

DATE OF INSTITUTION:     JUDGMENT RESERVED ON:               DATE OF DECISION      :

04.01.2016 12.07.2019 12.07.2019

 

N.K. Sharma, President

Ms. Sonica Mehrotra, Member

Order passed by Ms. Sonica Mehrotra, Member

 

ORDER

1. Concise factual matrix of the present complaint is that the deceased father of the complainant Late Jai Dayal had taken three Life Insurance Policies from the OP namely Secured Income Insurance Plan, New Fulfilling Life and Assured Gain Plus bearing numbers 02961222, 02967872 and 02976788 dated 08.08.2014, 25.08.2014 and 10.09.2014 respectively for Sum Insured Rs. 2,00,000/-, Rs. 1,50,000/- and Rs. 3,00,000/- against the respective policies cumulatively assured therefore for Rs. 6,50,000/- (hereinafter referred to as the policies). The complainant’s father had paid a premium of Rs. 14,125/-,  Rs. 16,180/- and Rs. 36,150/- to OP for the said policies through in cash. The complainant was appointed as the nominee in all the three policies. The father of complainant died on 21.12.2014 and OP released the claim amount of Rs. 33,046/- vide cheque no. 457176 dated 23.04.2015 in favour of complainant’s mother Mrs. Phoolwati (deceased’s wife) vide letter dated 30.04.2015 with respect to an earlier policy  bearing number 02136181 commenced in March 2011 which was duly credited in complainant’s account on 30.05.2015. However, when the complainant deposited the claim form against the aforementioned policies with OP on submission of all necessary documents viz verification / identification, medical documents / certificate / discharge summary / treatment record of his deceased father for release of the Life Insurance assured claim amount, the OP did not release the said amount despite the several follow ups. The complainant issued a legal notice dated 12.10.2015 to OP demanding released of the sum assured against the policies but to no avail in reply to which, OP vide repudiation letter dated 01.12.2015 rejected the claim of the complainant on ground that the said policies were taken by the deceased father of the complainant on concealment of his pre existing disease of tuberculosis which the OP had investigated on the death of the deceased an being early claim from the hospital records (Medical Attendant Certificate issued by Dr. Manoj Sahani) and since the said disease was prior to the submission of proposal with OP which the disease fully of aware of yet did not disclose, the same amounted to non disclosure of material fact covered u/s 45 of Insurance Act and therefore claim not payable and distinguished the payment of earlier policy on ground of the same being honored as fact of diagnosis of TB was not prior to the said policy and as such the same did not amount to non disclosure of material fact and therefore paid. Therefore feeling aggrieved at non release of the Insurance claim amount by the OP, the complainant was constrained to file the present complaint praying for issuance of direction for release of the sum assured i.e. Rs. 6,50,000/- alongwith interest @ 18 % p.a. thereon.
2. Complainant has attached copies of the cover notes of the Three Insurance Policies bearing numbers 02961222, 02967872 & 02976788 dated 08.08.2014, 25.08.2014 & 10.09.2014 under the seal of OP, copy of letter dated 30.04.2015 from OP to Mrs. Phoolwati, mother of complainant for payment of claim amount of Rs. 33,046/- against Exide Life Policy no. 02136181 with copy of cheque enclosed alongwith passbook entry of credit of the said amount on 30.05.2015 in the savings bank account of Phoolwati held with PNB, Karawal Nagar Branch, copy of death certificate of Jai Dayal, father of complainant issued by EDMC, GNCTD, copy of treatment records, lab investigation reports and discharge summary of Jai Dayal issued by Sudarshan Multi-Speciality Hospital, Ghaziabad for the period 13.12.2014 to 20.12.2014 filed by the complainant alongwith claim form with OP duly received by OP on 09.03.2015, copy of letters dated 13.05.2015 and 10.06.2015 by complainant to OP apprising of no previous ailment or hospitalization of Jai Dayal prior to hospitalization at Sudarshan Multi-Speciality Hospital on 12.12.2015, copy of legal notice dated 12.10.2015 by counsel for complainant to OP with postal receipt demanding release of insurance claim amount and copy of reply by OP dated 01.12.2015 to the legal notice in the nature of rejection of release of sum assured in favour of complainant as nominee in the policies in question on grounds of concealment of pre existing disease tuberculosis by the deceased father of complainant.
3. Notice was issued to the OPs on 27.01.2016 which was received back unserved vide postal remark ‘Refused’ which is deemed service u/s 28 A (3) of CPA.  Accordingly, OPs were proceeded against ex-parte vide order dated 05.04.2015. Ex-parte evidence by way of affidavit was filed by the complainant exhibiting documents (in original) relied upon / filed alongwith complaint as Ex CW 1/1 A to CW 1/M.
4. Written arguments were filed by the complainant in reassertion of his grievance against the OP for non release of the sum assured in his favour in the policies taken by his deceased father in which he was appointed as the nominee.
5. We have heard the arguments advanced by the counsel for complainant and thoroughly perused the documents placed on record and have given our thoughtful consideration to both aspects. It is clear that the complainant’s deceased father had taken three Life Insurance Policies in question between August 2014 to September 2014 for a total sum assured of Rs. 6,50,000/- and had duly appointed the complainant, his son as nominee therein. The OP had honored an earlier policy of 2011 post his death and released the claim amount in favour of his wife in 2015 but rejected the claim of the complainant on grounds of concealment of pre existing disease TB as can be seen from its letter dated 01.12.2015 on the pretext that the diagnosis of TB was prior to the policies in question which was concealed by the DLA despite being fully aware of his diagnosis at the time of submitting proposal form for the policies. The defence taken by OP in the said letter in our view is vague and unsubstantiated in as much as OP failed to appear before this Forum and filed it rebuttal / defence to the complaint by placing any conclusive evidence to support its contention of pre existing TB of the DLA as ground for rejection for release of sum assured. It is apparent that OP was prone to pocket the hefty premiums and did not take precaution to ensure whether the DLA / father of the complainant was fit to take the policy by getting a medical examination and necessary test done before extending life coverage to him. It is strange that OP has taken a dual stand by alleging that DLA has suppressed pre existing disease TB for releasing one insurance claim amount and declining to release other three claim amounts in a mechanical way by imputing knowledge of the said disease to the deceases without coming forth before this Forum to establish the same to justify its stand. When the claim was preferred by the complainant, the OP cannot now retract its steps in the absence of any conclusive evidence. The Hon'ble National Commission  in Birla Sun Life Insurance Co. Ltd. and Anr Vs. Arvind Kaur I (2018) CPJ 301 (NC) and in National Insurance Co. Ltd Vs Shyam Babu and Ors I (2018) CPJ 198 (NC) held that it was obligatory for insurer to either produced the treating Doctor or to file its affidavit to establish pre existing disease as mere production of unattested, unverified and unauthenticated photo copies cannot be basis for repudiation of claim on ground of suppression of pre existing disease. Further the Hon'ble National Commission in NIC Vs Shyam Babu (supra ) had upheld the judgment and observations of District Forum Delhi and Hon'ble SCDRC Delhi in favour of complainant against the Insurance Company for wrongful repudiation of claim on ground of pre existing disease.
6. After appreciating the facts of the case, we are of the considered view that the repudiation by OP to release the sum assured was unlawful, arbitrary, erroneous, vague and unsubstantiated by any documentary evidence. Moreover, its failure to appear before this Forum resulting in the allegations leveled by the complainant in complaint gone unrebutted has not supported the case of OP any further. We hold the OP guilty of deficiency for service and unfair trade practice for having failed to release the sum assured against the policy.
7. We therefore direct the OP to refund i.e. Rs. 6,50,000/- alongwith interest @ 9% thereon to the complainant from the date of filing of the complaint till realization.
8.  Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
9.  File be consigned to record room.
10.  Announced on 12.07.2019.

 

(N.K. Sharma)      President

(Sonica Mehrotra)  Member