Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 77/03.04.2019
Master Depanshu Mehta (through its natural guardians)
Smt. Suman Mehta, w/o Lt. Sh. Ajay Kumar Mehta,
R/o 325-B/324-A, DDA Flats,
Ghazipur Dairy Farm, Delhi-110096 …Complainant
Versus
P.N.B. Metlife India Insurance Co. Ltd., (through its Chairman)
Having its Registered Office at:-
Third Floor, 10201-10202, Padam Singh Road,
Karol Bagh, (above SBI Bank) Delhi-110005 ...Opposite Party
Date of filing 03.04.2019
Date of Order: 04.08.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
ORDER
Inder Jeet Singh , President
1.1. (Introduction to dispute ) – This complaint is filed by Master Depanshu Mehta (minor, through his mother/natural guardian Smt. Suman Mehta) alleging deficiency of services since his father Sh. Ajay Kumar Mehta/Insured obtained PNB Metlife Endowment Saving Plan Plus/Policy, in which he was appointed nominee, however, his father expired and OP declined the valid claim. That is why the complaint seeking sum insured of Rs. 10,00,000/- being death benefit and compensation of Rs. 1,00,000/- apart from cost of Rs. 25,000/- and other appropriate relief.
1.2. The OP denied the allegations of deficiency of services that repudiation of the claim was within the parameter of policy as well as the insured concealed material fact of his ailment at the time of furnishing the proposal form, which was basis of the contract and policy was obtained fraudulently. The complaint deserves dismissal.
2. (Case of complainant) – Complainant’s father Sh. Ajay Kumar took PNB Metlife Endowment Savings Plan Plus-117N099V01, having Policy No. 22261335 (briefly saving plan or policy) on 07.07.2017 from OP against deposit of Rs. 1,04,500/- against receipt being first installment. The complainant was 17 years of age.
However, complainant’s father Sh. Ajay Kumar Mehta was hospitalized at Metro Hospital and Heart Institute, where he had died on 14.09.2017, which was informed to OP and claim was lodged, which was rejected on 15.03.2018 by the OP. The acts of OP are of cheating, fraud and deficiency in services, which was not accepted. The trust and faith of complainant has been breached by the OP. Complainant suffered great mental pain, harassment, etc. The opposite party is liable to reimburse the sum insured as well as to pay compensation of Rs. 1,00,000/- apart from cost etc. The complainant has no source of income. The complainant is having no alternate except to file the complaint. The complaint is accompanied with copy of policy and claim rejection letter.
3.1 (Case of OP)- The OP opposed the complaint by filing a lengthy written statement on long paper (size-legal) that too on small font size, by mentioning preliminary submission, preliminary objections, facts of the case, definitions, re-production of terminology but very briefly paragraph-wise reply, as per its own convenience but contrary to rule of pleadings. Moreover, the detailed written statement is also composite of case law and argumentative, which are not generally done in the written statement as the requirement of law of pleading is to narrate material and relevant facts. The written statement also mentions general plea like there is a complicated question of fact and law to be determined by civil court, without elaborating and so on. However, the relevant facts, features, date, etc will be mentioned.
3.2. The complaint is not maintainable, since contract of insurance is based on utmost good faith but the insured suppressed material information and knowledge about his ailment which was in existence prior to furnishing the proposal form. On scrutiny of medical papers filed with the claim form revealed that insured was suffering from various severe ailments, as he was diagnosed with coronary artery triple vessel disease, severe liver dysfunction, angina with liver function, rupture appendix, liver abscess, sepsis, encephalopathy for which he had also underwent medical treatment, however, failed to disclose the same at the time of proposal for subject policy. That information of his ailment was in the personal knowledge of insured, had it been disclosed in the proposal form being substantial in nature the insurer/OP had to consider it, while underwriting the risk. Therefore, the proposal form filled in with the wrong information that insured was not suffering from any disease is breach of utmost good faith in a insurance policy contract.
3.3. The death of life assured occurred within two months from the date of issue of policy, therefore, section 45 of the Insurance Act, 1938 applies with regard to incorrect declaration in the proposal form. As such, the OP issued the insurance policy in conformity with the proposal form declared by insured and policy was issued but complainant is not entitled for any relief because of concealment of material ailment.
3.4. The complainant has locus-standi to file the complaint, since complainant is a nominee and it is settled law that a nominee is not beneficiary under life insurance policy vis-à-vis complainant is not a consumer.
The complainant has approached the Commission with un-cleaned hands and one who seeks equity must come with clean hands and there is no reason for the complainant to allege deficiency in services. The discharge summary clearly demonstrates that insured was very well aware about his ailment, as the discharge summary mentioned the history as “Patient with K/C/O Ruptured Appendix, Liver Abscess, Pleural Effusion, Sepsis, MODS Encephalopathy with CAD P/PTCA and DM type 2.” but he failed to disclose them in the proposal form or otherwise. The written statement reproduces various medical terms apart from the proposal form and proposal form defined in IRDA (Protection of Policyholders’ Interest) Regulation 2017. Thus, had the OP knowing about such ailments of insured, which were concealed from the proposal form, the OP would not have issued the subject policy. The complaint is liable to be dismissed.
3.5. The reply is accompanied with copy of policy along with proposal form, death certificate of insured, copy of investigation report by the investigator appointed, discharge summary on request issued by hospital, death summary, repudiation letter dated 15.03.2018
4. (Replication of complainant) - The complainant filed rejoinder to the reply of OP, the complainant denies all the allegation of written statement by reaffirming the complaint as correct. Further, the policy was obtained by the insured without any fraud or concealment of any fact, as a matter of fact the insured was examined medically before issuing the policy and the doctor had visited at the residence of insured. The proposal form was signed blank by the insured and the contents of proposal form were filled in by the agent of OP. The provisions of section 45 of Insurance Act, 1938 does not apply in respect of declaration of insured. There is deficiency of services on the part of OP and complainant is entitled for relief claimed.
5.1. (Evidence)- Complainant’s mother Smt. Suman Mehta led evidence for complainant in detail having support of documents filed with the complaint apart from filing with affidavit identity proof of complainant and of deponent.
5.2. On the other side, OP led evidence by filing affidavit of Sh. Rajiv Sharma, Senior Manager (Legal) and it is detailed affidavit being replica of reply (except case law), it is also supported with the documents filed with the reply.
6.1 (Final hearing)- The complainant filed his written arguments followed by oral submissions by Ms. Riya Goyal, Advocate for complainant.
6.2. The OP also filed its written arguments followed by oral submissions by Ms. Lubhanshi Tanwar, Advocate for OP.
6.3. The rival contentions of the party are not repeated here, as the case of parties have already been detailed.
7.1 (Findings)- The contentions of both the sides are considered keeping in view the material on record. The issues raised will be determined one by one.
7.2. The OP has raised issue of locus-standi of present complainant to file the complaint as a nominee has no beneficiary right under the law to file the claim, while referring case of Smt. Sarbati Devi & Another vs. Smt. Usha Devi (1984) 1 SCC 424. On the other side, the complainant has reservations that he has been nominated in the policy and it makes him entitled to file the complaint.
On perusal of the record, there is point no. 24 in the terms & conditions of the policy and it mentions that nominee is entitled to receive admissible benefit in the event of death of life assured in terms of section 39 of Insurance Act, 1938. To say, nominated person has right to make claim or to file the complaint, whereas the plea by way case law being rendered on behalf of OP is that a nominee is not a beneficiary. It depends on the facts and features of the each case, whether or not a nominee is a beneficiary in that particular situation. So far filing of the present complaint by present complainant is concerned, he is nominated by the insured and once nomination is accepted by the OP, then OP cannot deny the status of nominee in subject policy, since OP had not put any condition that only beneficiary is to be nominated as nominee. Therefore, it is held that complainant has locus-standi to file the present complaint. The complaint is competent.
7.3. So far other issues of ailments, its disclosures, waiting period, death benefits, exclusions, etc are concerned, the facts and feature of the case are inter-mingled with each other, therefore, all of them are being taken together. The following conclusions are drawn:-
(i) The insured took the savings plan/policy having commencement from 11.07.2017 but he died on 14.09.2017. He died within 71 days of obtaining the policy. As per terms & conditions no. 45 (waiting period) there will be waiting period of 90 from the policy inception. However, the insured died within waiting period of 90 days.
(ii) The OP has proved proposal form dated 10.07.2017 and in the appropriate column of medical detail, the insured had denied all ailment from row -1 to row 16, which also includes for which he had undertaken treatment from Metro Hospital.
(iii) The OP has proved surveyor’s report dated 11.03.2018, thereby discharge summary of insured for his treatment from 24.11.2016 to 30.11.2016 was taken from Metro Hospital and insured was got his discharge on 30.11.2016 on request.
The other discharge summary has also been proved by OP that insured was treated as indoor patient from 04.06.2017 to 20.06.2017 at Metro Hospital. Further, the OP has also proved death summary in respect of insured Ajay Mehta, who was indoor patient from 24.08.2017 to 14.09.2017 at Metro Hospital, where he had died on 14.09.2017.
The proposal form is of 10.07.2017 and the insured had already taken treatment from 24.11.2016 to 30.11.2016 in Metro Hospital then again treatment was taken as indoor patient from 04.06.2017 to 20.06.2017 at Metro Hospital but these facts were not disclosed in the proposal form, which are material in nature insured that he was suffering from various ailments. The insured has withheld and suppressed material information which he was supposed to declare in the proposal form.
(iv) There is a clause no. 6.9 in the policy which mandates that any disease occurring within 90 days of start of coverage would be excluded, the complainant is taken the plea that the ailment develop after taking the policy i.e after 7.7.2017, however, even from that point of view (just for the sake of arguments) clause 6.9 does not entitle the complainant for any relief. In fact, the documents of discharge summary proved clearly spells out that the insured was suffering from ailment from the year 2016 much prior to date of proposal form dated 10.07.2017.
(v) The complainant maintains that proposal form was filled in by an agent of OP or it was signed blank by the insured but on the other wise OP claims that as per law when proposal form is filled in, the agent acts as an agent of proposer and not an agent of insurance company. However, this plea of complainant would not give any benefit, since the insured was suffering from ailments and proposal was required to mention such ailment in the proposal form; the signing the blank proposal form, if so, would not exonerate the insured from such obligation to disclose the material information, so far the feature of this case are concerned.
The aforementioned conclusion drawn are demonstrating and establishing that the insured failed to mention and declare material information in the proposal form despite he was suffering from serious ailments prior to filling in proposal form. But the insurance policy was issued by acting upon such declaration, however, it does not absolve the proposer/insured from the obligations posed by law. The complainant is not entitled for any relief either as reimbursement of sum insured amount or of compensation. The complaint fails. The complaint is dismissed. No order as to cost.
8: Announced on this 4th August, 2023 [श्र!वण 13, साका 1945].
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances.
[Vyas Muni Rai] [Shahina] [Inder Jeet Singh]
Member Member (Female) President
