Punjab

StateCommission

A/284/2018

PNB MetLife India Insurance Company Ltd. - Complainant(s)

Versus

parveen kumar puri - Opp.Party(s)

mohanlal singhi

04 Apr 2019

ORDER

                                                     FIRST ADDITIONAL BENCH

 

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,     PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH

 

                   First Appeal No.284 of 2018

 

                                                          Date of Institution    :  15.05.2018       

                                                          Order Reserved on  : 29.03.2019

                                                          Date of Decision      : 04.04.2019

 

PNB Metlife India Insurance Co. Ltd., Claim Department, Branch Eminent  Mall, Mall Road, Amritsar through its Branch  Manager /Principal/ Principal Manager.

 

                                                                      ..Appellant/Opposite party          

                             Versus

 

Parveen Kumari Puri wife of Late Sh. Sunil Kumar Puri, r/o 5 F 7/392, Lane No.1, Kashmir Avenue, Amritsar, 9803671112

 

                                                                …..Respondent/Complainant

 

First Appeal against order dated 19.02.2018 passed by the District Consumer Disputes Redressal Forum,  Amritsar.

Quorum:-

          Shri J. S. Klar, Presiding Judicial Member

             Sh.Rajinder Goyal, Member.

Present:-

          For the appellant         :  Sh.Nitesh Singhi, Advocate

          For the respondent      :  Sh.Sukhandeep Singh, Advocate.

         

          . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

      Challenge in this appeal by appellant is to order dated 19.02.2018 of District Consumer Disputes Redressal Forum Amritsar, directing the appellant of this appeal to pay Rs.12 lac to respondent of this appeal, being nominee of the deceased Sunil Kumar Puri with interest @ 9% on the above said amount from date of filing the complaint till its payment, besides Rs.2,000/- as litigation expenses. The appellant of this appeal is opposite party in the complaint before District Forum below and respondent of this appeal is complainant therein and they be referred as such hereinafter for the sake of convenience.

2.                The complainant Parveen Kumari being nominee of life assured has filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against OPs on the averments  that her husband  procured the policy bearing no.21520378 on 14.03.2015 from OP. The policy holder/husband of complainant suddenly fell ill and was got admitted in Medicaid Hospital Amritsar on 16.01.2017 and died on 18.01.2017 due to cardiac arrest. After the death of her husband, she lodged insurance claim with submission of all requisite documents to OPs. OP repudiated her claim, vide letter dated 28.02.2017 on the ground of “non-disclosure of material facts” by insured, by suppressing the fact that life assured was suffering from left ventricular ejection fraction, left ventricular dysfunction, diabetes mellitus Type 2. She approached OP and requested to release the claim,  but to no effect.  She alleged deficiency in service and unfair trade practice on the part of OP, therefore, she filed the complaint  and prayed that OP be directed to pay the insured  claim amount of Rs.12 lac along with interest @ 12% per annum, besides Rs.1 lac as compensation and cost of litigation.

3.                Upon notice, OP appeared and filed written reply and contested the complaint of the complainant by raising preliminary objections that  she  does not fall under the definition of the consumer,  as per Section 2(i)(d) of Consumer Protection Act 1986. The complainant has not come to the Forum with clean hands. The complicated questions of facts and law are involved in the present complaint, which cannot be adjudicated in summary trial before Consumer Forum. The OP has discharged its contractual obligations and hence there is no deficiency in service on its part. On merits, it was averred that policy holder/husband of the complainant himself purchased insurance plans from OP with his own sweet Will. After death of life assured, complainant lodged claim  and enquiry was conducted by OP about the same, wherein, it was found that life assured was suffering from ‘left ventricular ejection fraction, left ventricular dysfunction, diabetes mellitus Type 2,  but same was not disclosed  in the proposal from at the time of inception of the policy. The entire story spun by complainant is afterthought and same is cooked up just to take advantage by way of filing this complaint by her.  As per terms and conditions of the policy,  the terms and conditions thereof are of paramount significance and neither party can go beyond the terms and conditions of the policy contract. The claim of the complainant was repudiated,  as per terms and conditions of the policy contract upon the basis of the non-disclosure of material facts by insured. The insurance contract is a special contract, which has to be governed by certain terms and conditions, upon which both parties had agreed upon  before the inception of the policy. Rest of the averments of the complainant were denied by OP and it prayed for dismissal of the complaint.

4.                The complainant tendered in evidence her affidavit Ex.CW-1/A along with copies of documents Ex.C-2 to Ex.C-6 and closed the evidence.  As against it; OP tendered in evidence affidavit of Sh. Ankur Sanan Branch Service Manager as Ex.OP-1/A along with copies of documents Ex.OP-1 to Ex.OP-10 and closed the evidence.   On conclusion of evidence and arguments, the District Forum Amritsar accepted the complaint of the complainant by virtue of order dated 19.02.2018. Dissatisfied with the order of the District Forum Amritsar dated 19.02.2018, opposite party now appellant, carried this appeal against the same.

5.                We have heard learned counsel for the parties and have also examined the record of the case.

6.                The OP now appellant has placed on record the medical record of Sunil Kumar Puri insured  issued by Fortis Escorts Hospital Amritsar  Ex.R-11 by way of additional evidence, which was allowed to insurer in the appeal. Pleadings and evidence on the record has been scrutinized by us in this case. The complainant swore her affidavit Ex.CW1/A on the record stating that her husband Sunil Kumar Puri since deceased took the insurance policy no. 21520378 on 14.03.2015 from OP and declared her to be his nominee. The policy was for the term of 15 years for sum assured of Rs.12 lac. The policyholder Sunil Kumar Puri was admitted in Medicad Hospital on 16.01.2017 at Amritsar and died on 18.01.2017 due to cardiac arrest. The insurance claim was lodged by the complainant as his nominee, but it was repudiated by OP, vide letter dated 28.02.2017 on the ground that insured suffered from Left Ventricular Ejection Fraction, Left Ventricular Dysfunction , Diabetes Mellitus Type 2 before taking the policy.  She has challenged repudiation letter dated 28.02.2017,  as illegal on the record issued by OP. Ex.C-1 is document proving that the total premium was of Rs.36,925/- and assured amount of Rs.12 lac and policy term was 15 years. Ex.C-2 and Ex.C-3 are the premium paid certificates. Photocopy of certificate  issued by Medicad Hospital Amritsar  is Ex.C-4 to the effect that late Sunil Kumar Puri  son of Brij Lal Puri aged 53 years was admitted in the hospital on 16.01.2017 with  complaint of abdomen pain and nausea and general body weakness and he died due to cardiac arrest on 18.01.2017. The death certificate of Sunil Kumar Puri is Ex.C-5, proving his date of death as 18.01.2017 at Medicad Hospital Amritsar. OP repudiated the claim on account of non-disclosure of material facts by the insured with regard to his pre- existing cardiac ailments, vide repudiation letter Ex.C-5. The complainant assailed the repudiation of the insurance claim by OP on wrongful assumptions.

7.                The OP tendered in evidence affidavit of Ankur Sonon Branch Manager PNB Met Life as Ex.OP-1/A admitting the fact of taking insurance policy by DLA. The insured submitted proposal form after understanding the terms and conditions thereof. He further stated that insured was suffering from pre-existing ailments, which fact has been suppressed by him deliberately from  OP at the time of filling up the proposal form. Ex.OP-1 is questionnaire with the terms and conditions of the policy fielded to the prpopser. Ex.OP-2 is the premium details. Ex.OP-4 is terms and conditions of the policy. Ex.OP-6 is KYC verification form. Ex.OP-8 is policy on the record. OP’s version is that complainant suppressed the material fact of his ailment and obtained contract of insurance by keeping OP in dark about correct picture. OP brought on record the record of Fortis Escorts Hospital Amritsar Ex.R-11 in additional evidence in this appeal to the effect that Sunil Kumar Puri insured was admitted in Department of Cardiology in Fortis Hospital on 03.08.2013 and was discharged on 25.08.2013 therefrom. His diagnosis was severe LV Dysfunction Type II DM Acute LV Dysfunction. The past history is recorded as K/c/o Type II DM x 14 years. H/o Recently Diagnosed? DCM (Severe LVD, LVEF 25%). OP now appellant heavily relied upon this record of Fortis Hospital  to the effect that insured was admitted in the above hospital on 03.08.2013 and discharged on 25.08.2013 with the above referred ailment  before taking this policy. The Fortis Escort Hospital is also a known hospital and there is no question of falsely preparing this record by it. Even affidavit by Fortis Hospital is not required to substantiate this record,  because it is not prepared by some unsung doctor. This fact is established on record that DLA/Sunil Kumar Puri suffered from  severe LV Dysfunction Type II DM Acute LV Dysfunction on 03.08.2013,  even prior to taking this policy. The submission of counsel for complainant is that this record does not prove the identity of the complainant is without any force in our opinion. Even in the documents of insurance company of policy Ex.C-3 with regard to premium paid certificate, it also  recorded the address of the insured as Sunil Kumar Puri, H.No. 5, F7/392, Lane no.1, Kashmir Avenue, Amritsar, which is almost identical with his address, as recorded in the Fortis Hospital record Ex.R-11. The reliance of counsel for complainant now respondent in this appeal on law laid down by Apex Court in P. Vankat Naidu versus Life Insurance Corporation of India and another reported in 2011(4) CPJ 6, “National Insurance Company Ltd versus Sardar Kulbir Singh” reported in 2010(3) CPJ 276 by National Commission and “Life Insurance Corporation of India and another versus Murti Devi” reported in 2012(3) CPC 375 by our own Commission are not applicable to the factual matrix of the case. The ratio decidendi of the cited case operates as per the factual situation of the case on hand to be adjudicated. Herein Fortis Hospital record prepared by famous hospital Ex.R-11 has proved this fact that complainant suffered from severe LV Dysfunction Type II DM Acute LV Dysfunction in the year 2013 and he took the policy thereafter in the year 2015 only. The insured was under contractual obligation to disclose the correct facts to the insurance company in the proposal form for taking the policy. It is conduct of the parties at the time of entering into contract of insurance, which counts heavily. The repudiation of contract of insurance by OP is justified in this case on account of suppression of material fact of pre-existing heart ailment by insured knowingly from OP in obtaining this policy.   Even cause of death of insured is cardiac arrest and he was also admitted in Fortis Hospital for the same ailment coupled with diabetes Type II, wherewith he was afflicted for the last 14 years and his heart function was 25% only. Suppression of these material facts by DLA deliberately from OP justifies the repudiation of contract of insurance by OP on account of his conduct which lacks good faith on his part.

8.                As a result of our above discussion, order of the District Forum Amritsar dated 19.02.2018  is unsustainable in the eyes of law and is ordered to be set aside by accepting the appeal of the appellant,  resulting into dismissal of the complaint of the complainant.

9.                The appellant had deposited an amount of Rs.25,000/- with this Commission at the time of filing this appeal. This amount with interest, if any, accrued thereon, be refunded by the registry to the appellant of this appeal by way of crossed cheque/demand draft after the expiry of 45 days. The amount of Rs.10,000/- was deposited vide receipt dated 11.12.2018 in compliance of the order dated 12.11.2018, whereby the application filed by the appellant for summoning of record was allowed, subject to payment of cost of Rs.10,000/- payable to respondent/complainant. As such, this amount of Rs.10,000/- along with interest accrued thereon, if any be remitted to respondent /complainant of this appeal, if not already remitted as payment of cost.

10.              Arguments in this appeal were heard on 29.03.2019 and the order was reserved. Certified copies of the order be communicated to the parties as per rules.

11.              The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                       (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

 

                                                          (RAJINDER KUMAR GOYAL)

                                                                         MEMBER

                    

                                                                  

April  4 , 2019                                                             

(ravi)