District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.303/2021.
Date of Institution: 01.07.2021.
Date of Order: 07.11.2022.
1. Sarida aged about 35 years W/o late Rafeeq Aadhaar No. 748396112571.
2. Tamjum aged about 15 years D/o latae Rafeeq.
3. Simra aged about 13 years S/o late Rafeeq.
4. Mohd. Shameem aged about 10 years S/o late Rafeeq.
5. Rabiya aged about 6 years D/o late Rafeeq
Minors through their mother and natural guardian and next friend Sarida W/o late Rafeeq.
All R/o village Khori Jamalpur, Tehsil and District Faridabad.
…….Complainants……..
Versus
1. M/s. Universal Sompo General Insurance Company Ltd., SCO-9, First floor, Above Central Bank of India, Sector-10, Panchkula – 134109 Haryana through its Divisional Manager/Principal Officer.
2. M/s. ICICI Prudential Life Insurance co. Ltd., Unit No. 1A & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad (East),Mumbai – 400 097 through its MD/Principal Officer.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. A.K.Sharma, counsel for the complainant.
Sh. Nitish Kumar, counsel for opposite party No.1.
Sh. Vijay Singh, counsel for opposite party No.2.
ORDER:
The facts in brief of the complaint are that the husband of the complainant No.1 and father of complainants No.2 to 5 namely Mr. Rafeeq S/o Zahuruddin was registered owner of vehicle (Maruti Ertiga VDI car) bearing registration No. HR-51-BY-4096, which was duly insured with opposite party No.1 vide insurance policy NO. 23836033658196000 valid form 25.11.2019 to 24.11.2022. The owner-driver of the said vehicle was also insured with said policy as the opposite party had received further premium for owner-driver (personal Accident covers) as Rs.632/- and as per clause “limit of liability” P.A. cover under section 111 for owner-driver (CSI) for Rs.15,00,000/-. Opposite party No.2 also insured the husband of complainant No.1 vide policy No. 48539163 dated 30.09.2019. The husband of the complainant was suffering from cancer disease, the husband of complainant came to know when he was examined and test report of Pulmonogy in QRG Central Hospital and Research Centre, Sector-20A, Ajronda Faridabad and he was getting treatment from Acharya Tulsi Regional cancer Treatment and Research centre, Bikaner (Rajasthan) and due to this he was expired on 17.03.2020. The complainant No.1 duly intimated the opposite parties and submitted the requisite documents as demanded by the opposite party and got the claim lodged with the opposite party being legal heir of the insured- Rafeeq. After submission of said documents, the officials of the opposite parties assured the complainants that after some quarries, the claimed amount should be disbursed in favour of the complainants shortly. The complainant NO.1 contacted the concerned officers/officials of the office of the opposite parties and requested several times telephonically, as well as personnel visits, but there was no satisfactory response from the opposite parties as the concerned official avoided to accede to the legitimate request of the complainant NO.1 on one pretext or the other and lastly opposite party No.2 sent a impugned letter dated 3.3.2021 and declined the death claim of the complainant. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) disburse the claimed amount of Rs.15,00,000/- alongwith interest @ 18% p.a. from the date of accident till its actual realization.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 21,000 /-as litigation expenses.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant No.1’s husband did not have any policy in his name from answering opposite party company. It was further submitted that the complainant No.1’s husband did not had any policy in his name from answering opposite party company. Opposite party No. 1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that on 30.12.2019 the opposite No.2 received a duly filled Member Consent Form/Proposal bearing No. PG0465C18000115 from Mr. Rafik, for an ICICI Group Loan Secure Policy for a single premium of Rs.6654/- plus tax, Based the information provided in the form, the opposite party No.2 issued the policy baring No. 48539163 on 30.,09.2019 to the Life assured. It was to be noted that at the time of issuance of the subject policy, the complainant did not disclose about his pre-existing illness in the proposal form under the relevant questions. It can be seen that the complainant had replied that the question raised by the company as regards the health status of the LA was “Not Applicable” to him and he had also answered in negative to the question if answer to any of the questions regarding health, diseases and treatments taken by him were negative. The company had also asked specific question as to tuberculosis and other respiratory diseases, In accordance to clauses 8 (1) & (6) of IRDA Regulations 2017, the opposite party company had sent the policy documents including the proposal/member consent form to his registered address on 05.10.2019 vide speed post. The complainant had not disputed the receipt of the same, hence it was assumed that the policy documents were duly received by the life assured.
The complainant had ample opportunity to go through and understand the terms and conditions of the policy. Further the policy documents were duly annexed by the complainant alongwith claimant statement form. The complainant did not approach the opposite parties with any discrepancies regarding the benefits payable or any of the terms and conditions of the subject policy, neither did he approach the company for cancellation of the policy during the Free Look Period thereby implying that he had agreed to all the terms and conditions of the policy. Hence, the subject policy continued. The LA disnot make any efforts to approach the company so as to revise the misleading answers given to the company as regards his health condition. If the same was disclosed to the company atleast during the Freelook period, the company would have cancelled the policy then the there itself. The policy T &C had clearly included the terms regarding the right of the company to void the policy incase of non-disclosure/misrepresentation/fraud and had also reproduced S.45 of the Insurance Act, 1938 vebatim. On 23.01.2021 the opposite party received a claimant statement form (death claims) from the complainant stating that her husband had passed away on 17.03.2020 i.e. within just 6 months from the date of issuance of the subject policy. Upon examination into the genuineness of the documents submitted by the complainant alongwith the claim statement and sent to the company thereafter. It was found that the life assured had been under treatment for pulmonary tuberculosis with pleural effusion. Infact the medical document submitted by the complainant herself had clearly revealed that the DLA had history of ATT treatment and plural effusion since 10.05.2019. The diagnosis papers of 10.05.2019 and CT Scan reports of the same date revealed that the DLA was suffering from major lung problems. The USG Scan done on 28.05.2019 and consultation papers dated 24.07.2019 also revealed the same alongwith confirming that the DLA was a severe case of tuberculosis. Upon the basis of the material non-disclosure of the pre-existing illness, the opposite parties repudiated the death claim submitted by the complainant and the same was communicated to the complainant vide letter dated 24.03.2021. In accordance to Section 45 of the Insurance Act, 1938, Rs.7841/- which was received towards the premium under the subject policy was also duly refunded to the Magma FinCorp Limited. The opposite party company was deceived into providing life cover, to the Life Assured and was denied a fair chance to assess the risk on life of the life assured, as material information regarding the health and medical history of the Life Assured was not disclosed to the opposite party company by the life assured at the time of issuance of the subject policy. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties–Universal Sompo General Insurance Company with the prayer to: a) disburse the claimed amount of Rs.15,00,000/- alongwith interest @ 18% p.a. from the date of accident till its actual realization. b)pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 21,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Sarida, Ex.C-1 - RC,, Ex,C-2 – Certificate cum policy schedule, Ex.C-3 – Diagnostic Medical Thoracoscopy, Ex.C-4 – Death certificate, Ex.C5 – letter dated March 03,2021.
On the other hand counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party No.1, Ex.RW1/A- affidavit of Shri Prashant V Shukla.
As per the evidence of opposite party No.2 Ex.RW2/A – affidavit of Swathy Nair, Manager – Legal and Authorized representative of ICICI Prudential Life Insurance company ltd., Mumbai, Ex.R.-1 – Member Consent/Declaration Form, Ex.R-2 – ICICI Pru Group Loan Secure, Ex.R-3 – Claim Statement Form – Lender Borrower Group, Ex.R-4 - Discharge summary, Ex.R-5 – letter dated March 24, 2021.
7. In this case that Universal Sompo General Insurance Company i.e opposite party No.1 is a General Insurance Company and the same has nothing to do with ICICI Prudential Life Insurance company. The claim with respect to the
opposite party No.1 is for policy No. 2383033658196000 and the complainant has alleged in the complaint that they are entitled to receive Rs.15,00,000/- for the General Insurance Policy only. Since the complainant herself admits in the complaint that the LA died due to cancer and not in any accidents, the question with respect to the general insurance personal accident claim is purely if the said event of death falls within personal accident and the question with respect to the Life Insurance Policy is, if there are material information with held at the time of proposal. Both disputes involves different questions to be answered and cannot be merged together for the sake of saving court fee and litigation charges.
On 30.09.2019 the opposite party No.2 received a duly filled Member Consent Form/Proposal bearing NO. PG0465C18000115 from Mr. Rafik, for an ICICI Group Loan Secure Policy for a single premium of Rs.6654/- plus tax. Based on the information provided in the form, the opposite party No.2 issued the policy bearing No.48539163 on 30.09.2019 to the Life Assured covering the risk from 25.09.2019. On 23.1.2021 the opposite party received a claimant statement form (death claims) from the complainant stating that her husband had passed away on 17.03.2020 i.e within just 6 month from the date of issuance of the subject policy. Upon examination into the genuineness of the document submitted by the complainant alongwith the claim statement and the documents of previous treatment sent to the company official by the complainant, it was found that the Life Assured had been under treatment for Pulmonary Tuberculosis with Plerual Effusion. Infact the medical document submitted by the complainant herself has clearly revealed that the DLA had history of ATT and plural effusion since 10.05.2019. The diagnosis paper of 10.05.2019 and CT Scan reports of the same date revealed that the DLA was suffering from major lung problems. The USG Scan done on 28.05.2019 and consultation papers dated 24.07.2019 also revealed
the same alongwith confirming that the DLA was severe case of tuberculosis. Medical document regarding cancer dated 18.10.2019 i.e. post issuance of the policy also corroborate the history of tuberculosis (pulmonary Koch) and plural effusion and also that the LA was on ATT CATR-1 since 10.05.2019. The policy was issued on 30.09.2019 and the same was not disclosed at the time of issuance of the subject policy.
The policy was obtained by the Life assured in breach of basic doctrine of utmost good faith by willfully and intentionally understating his health issues. The present claim in dispute being an early claim with 3 years from the issuance of the policy, the company is under the right to call the bonafides of the policy and the accuracy of the details disclosed into question anytime within 3 years of issuance as per S.45 of the Insurance Act 1938. Hence, the disputed claim was repudiated in due compliance of provision of section 45 of insurance Act, 1938.
8. In this complaint, the complaint was filed for personal accident. The policy was issued earlier from M/s. Universal Sompo General Insurance Company for 3 years i.e. 25.09.2019 to 24.09.2022 and the extra premium was paid by the complainant to the opposite party. But the claim was rejected on behalf of non disclosure of the pre existing disease of the deceased husband of the complainant. After going through the evidence as per Ex.R4, no doubt deceased was having the treatment of the cancer since May 2019. As per Ex.R4 and after going through the proposal form there is no disclosure about the disease. It is settled law by the Ld. Supreme Court of India when the Consumer has knowledge of his disease but it was not disclosed in the proposal form by the complainant or the deceased
(RAFIK). Issues goes in favour of the opposite parties. To prove his case, opposite party No.2 has placed on record Ex. R-1 to R-5.
9. After going through the evidence led by both the parties, the Commission is of the opinion that no deficiency in service on the part of the opposite parties have proved. Hence, the complaint is dismissed. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 07.11.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
