Delhi

New Delhi

CC/1060/2010

Harjinder Kaur - Complainant(s)

Versus

M/S. Aviva Life Insurance Company India Ltd. - Opp.Party(s)

03 Jun 2016

ORDER

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE, NEW DELHI-110001.

 

Case No.C.C./1060/2010                                                                                                        Dated:

In the matter of:

HARJINDER KAUR

W/o Late Sh. Inderjit Singh,

R/o 958, Arjun Nagar,

Opp. Defense Colony,

New Delhi-110003

 

        ……..COMPLAINANT

 

VERSUS

 

AVIVA LIFE INSURANCE COMPANY INDIA LTD.,

2^nd Floor, Prakashdeep Building,

7 Tolstoy Mar,

New Delhi-110001

 

 

               .... OPPOSITE PARTY

 

PRESIDENT: S.K. SARVARIA

ORDER

 

Repudiation of the insurance claim of the complainant by the OP insurance company has led the complainant file the present complaint under section 12 of The Consumer Protection Act, 1986. The case of the complaint, in brief is that her husband Sh. Inderjit Singh had taken the Safeguard Policy No. SVG1120984 with sum assured of Rs. 1,20,000/– commencing from 15/10/2004 for a period of 15 years from the OP insurance company. The husband of the complainant had been regularly paying the yearly instalments of premium in the sum of Rs.12,000/– to the OP insurance company till October 2010.  Hence, the complainant's husband had paid a total premium of Rs.72,000/– to the OP insurance company.

Unfortunately, the husband of the complainant, passed away on 29/9/2009 due to cardiac attack. The fact of the death of the husband of the complaint was timely informed to the OP, accordingly. The OP wrote a letter dated 24/11/2009 to the complainant, asking her to furnish the series of documents and complainant completed the same by depositing the required documents with the OP on 5/12/2009, along with a covering letter.

The OP, by letter dated 27/1/2010 rejected the claim of the complainant on the ground that the deceased was under treatment for systematic HT, Anterior Wall Mi and Post Mi Angina in the year 1993 and was under treatment of the same from various doctors and this fact was not disclosed in the proposal form dated 13/10/2004. According to the complainant. Even if there were some problem with the deceased in the year 1993 relating to heart the same was flawed. Simultaneously, and with effect from 1993 till the death, i.e., 29/9/2009, which is almost 16 years, deceased was completely fit and had good health condition. Therefore, the rejection of claim of the complainant by OP shows dishonest and mala fide intentions of not paying the claim/benefits as per the policy despite the letter dated 3/2/2010 written by complainant to the claims review committee of the OP and despite legal notice dated 19/2/2010 to the OP sent by registered post and UPC, through her counsel, the OP has not paid the compensation to the complainant, causing mental pain, agony and harassment and humiliation. The complainant has prayed for the following reliefs:

a)   Direct the OP to release all the benefits up-to-date of the said save guard policy No. SVG1120984 in favour of the complainant.

 

b)  Direct the OP to pay the sum of Rs. 4,00,000/- to the complainant on account of damages and compensation for causing mental pain, agony, harassment, humiliation and enormous inconvenience.

 

 

c)   Cost of the litigation is awarded in favour of the complainant and against the OP.

 

d)  Any other or further relief/s as this Hon’ble Forum deems fit and proper may be awarded in the interest of justice.

 

Notice of the complaint was given to the OP insurance company who contested the complainant and filed reply admitting that the husband of the complainant submitted proposal form dated 13/10/2004 for issuance of Save Guard Policy. The decision of the insurance company, whether to grant insurance cover to the applicant/proposal solely depends upon the various fact disclosures, information, statements and declarations made by the applicant/proposer in the Proposal Form. Further, various terms and insurance contract/cover, including the premium amount, maturity amount etc depends solely upon disclosure/information statements and declaration in the Proposal Form. In the Proposal Form, deceased husband of the complainant has stated that he has not had a heart condition, diabetes, stroke, cancer, HIV infection or AIDS, nor he was then in hospital and/or receiving medical treatment or advice for the above. Based on this declaration decision has been taken for an annual premium of Rs. 12,000/– payable under policy and the sum of Rs. 120,000/– was assured, subject to terms and conditions of the policy. In November 2009 OP received intimation of the death of the insured from the complainant by an email sent to the Customer Service Centre of the OP. OP sent a letter dated 24/11/2009 asking complainant to file some documents and the complainant filed death claim form which was received by OP on 30/12/2009, along with other documents.

On 5/1/2010 OP engaged Sharp Illegal Investigation firm to investigate/check/verify the cause of death, medical history of the deceased and other details. In response, Sharp Eagle vide it's letter dated 27/1/2010, submitted their Final Report along with certain documents procured by them during the course of investigation. The documents inclusive of original prescription of Dr A. K. Bajaj and the Clinical Card of National Heart Institute were procured by the investigation firm Sharp Eagle, during their investigation. It is specifically stated in said Original Prescription that the husband of the complainant was suffering from C/O of HTN and CAD since 1993 which is an ailment that was serious enough to have caused death. OP submitted that final the cause of death was Heart Attack, which is directly related to the medical history of the deceased Life Assured and had not been disclosed by him. This amounts to misrepresentation and nondisclosure of material information. OP has also alleged that husband of the complainant declared in the Proposal Form that answer given by him to the questions in the Proposal Form is an information given to Medical Examiner of the Company about Health and Habits of life, were correct. Therefore, the claim of the complainant was rightly repudiated by the OP insurance company. The OP has denied other facts stated in the complaint and has prayed for its dismissal with costs and legal expenses in favour of the OP.

In the rejoinder to the reply of the OP, the complainant has denied the averments made in it and has reaffirmed the facts stated in the complaint. In support of her case, the complaint has filed her affidavit in evidence. On behalf of the OP the affidavit in evidence of Mr Gaurav Malhotra, constituted attorney of the OP insurance company is filed. Both parties have filed written arguments. The arguments were heard in this case on 17/10/2013 and matter was reserved for final order. Later on, some learned Members of this District Forum changed, so, the outgoing learned President on 24/11/2015 again fixed the matter for re-arguments on 18/4/2016. The matter was adjourned on that day and arguments were heard from both sides on 31/5/2016.

We have heard the learned counsel for the parties and have gone through the written arguments of the parties, record of the case and relevant provisions of law.

The basic facts are not in dispute. Admittedly, the husband of the complainant submitted proposal form dated 13/10/2004 for issuance of Save Guard Policy. The husband Sh. Inderjit Singh had taken the Safeguard policy No. SVG 1120984 with sum assured of Rs. 120,000/- commencing from 15/10/2004 for a period of 15 years from the OP insurance company. The husband of the complainant had been regularly paying the yearly instalments of premium in the sum of Rs. 12,000/- to the OP insurance company till October 2010.Hence, the complainant's husband had paid a total premium of Rs. 72,000/- to the OP insurance company. Unfortunately, the husband of the complainant, passed away on 29/9/2009 due to cardiac attack. It is also not disputed that the complainant filed insurance claim with the OP after informing about death of the husband, and the claim was repudiated by OP insurance company by letter dated 27/1/2010 alleging that the husband of the complainant took treatment for the heart disease in 1993.

In the backdrop of the above admitted position, it is to be seen whether the repudiation of the insurance claim of the complainant against the insurance policy in question is justified or not? No doubt, the deceased husband of the complainant in the proposal form in question before obtaining insurance policy did not inform that in 1993 he was treated for any heart problem. But a lot of water has flown through Ganges after that. The insurance policy in question was obtained by husband of the complainant in 2004. There is no material on record to suggest that since 1993 after obtaining the treatment for heart problem, the husband of the complainant took treatment or was suffering from heart ailment during this long period of time up to 2004. Even the investigator appointed by OP insurance company has not stated that during this period of about a decade before obtaining insurance policy, the husband of the complaint was suffering from heart problem. Therefore, there does not seem to be anything wrong if the husband of the complainant considered himself to be free from heart ailment and has chosen not to disclose that in 1993 he took treatment for heart problem. Secondly, the OP insurance company was also supposed to get a proper medical checkup of the husband of the complainant to ascertain whether the husband of the complainant was suffering from any heart problem or not at the time of taking insurance policy. It looks unreasonable on the part of OP insurance company that it has obtained yearly premium of Rs. 12,000/– for six years, totaling Rs. 72,000/– from the husband of the complainant and did not verify during this period that husband of the complainant took treatment for heart problem in 1993. But when the occasion for meeting the liability under the insurance policy arose, instead of discharging the duty of making payment to the widow of deceased insured person OP insurance company came out with the investigation to repudiate on 27/1/2010 the genuine insurance claim of the complainant on the pretext of the medical treatment for heart problem taken by the deceased husband of the complainant about 17 years ago in 1993. We treat this repudiation of insurance claim of the complainant by OP insurance company as unjust and untenable, leading to the inference of the deficiency in service on the part of OP insurance company. Some judgments are quoted in the written arguments on behalf of OP insurance company, but these are not produced for the inspection of this District Forum to ascertain their applicability on the facts and circumstances of the present complaint case.

In the light of the above discussion, we allow the complaint and direct the OP insurance company to pay a sum of Rs. 120,000/– to the complainant along with simple interest at the rate of 10% per annum from the date of filing of the complaint till realisation of the said amount. In addition, we also direct the OP insurance company to make the payment in the sum of Rs. 30,000/– to the complainant on account of mental agony and harassment suffered by her and this amount is inclusive of litigation costs also. This order be sent to server (www.confonet.nic.in ). A copy of this order each be sent to both parties free of cost by post.

The file be consigned to the record room.

Announced in open Forum on 3/6/2016.

 

(S K SARVARIA)

PRESIDENT

 

(NIPUR CHANDNA)

MEMBER