BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.844 of 2013

Date of Institution: 20.12.2013

Date of Decision: 09.11.2015 

Mrs.Sunita Rani widow of Shri Bhushan Kumar, resident of village: Khalra, Tehsil: Patti, District Tarn Taran.

Complainant

Versus

PNB Metlife India Insurance Company Limited, having its Branch Office at Pal Building, District Shopping Complex, Ranjit Avenue, Amritsar, through its Branch Manager/ Principal Officer.   

Opposite Party

Complaint under section 11/ 12 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh. Vikram Puri, Advocate.

              For the Opposite Party: Sh. Sanjay Kapoor, Advocate.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Mrs.Sunita Rani under the provisions of the Consumer Protection Act alleging therein that Bhushan Kumar husband of the complainant had obtained insurance policy bearing No. 20664379 for a period of 15 years commencing from 21.10.2011 having annual premium of Rs.1 lac and on completion of 15 years duration, the insured was to get maturity amount of Rs.13 lacs and in the event of death of policy holder during the continuation of the policy, the nominee appointed by him was to get the entire maturity amount of Rs.13 lacs. The complainant being wife, was the nominee of policy holder Bhushan Kumar under the aforesaid policy. Bhushan Kumar policy holder paid two annual premiums of Rs.1 lac each during the year 2011 and 2012. Complainant alleges that unfortunately Bhushan Kumar policy holder expired on 8.4.2013 and on his death, the complainant became entitled to get the entire maturity amount of Rs.13 lacs against the aforesaid policy. After the death of policy holder Bhushuan Kumar, the complainant being nominee lodged the claim with the Opposite Party for disbursement of the sum assured of Rs.13 lacs and also submitted all the relevant documents with the Opposite Party including original insurance policy as well as original first premium receipt and the Opposite Party assured the complainant that her claim would be settled within a very short period, but the Opposite Party vide letter dated 13.6.2013 has wrongly and illegally rejected the genuine and legitimate claim of the complainant on the ground that the policy holder was suffering from Hypertension since 3 years, Diabetes Mellitus since 10 to 12 years and this fact was not disclosed by the policy holder to the Opposite Party at the time of obtaining the insurance policy. The fact remains that Deceased Life Assured (here in after called as ‘DLA’) Bhushan Kumar was not suffering from any such alleged disease and the Opposite Party has taken false plea only to reject the genuine claim on flimsy ground. DLA Bhushan Kumar was medically checked up by the empanelled doctors of the Opposite Party before affecting the insurance policy and during such medical check up, the DLA Bhushan Kumar was found all right and not suffering from any sort of disease. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay the claim amount of Rs. 13 lacs alongwith interest @ 18% per annum from the date of lodging of the claim till payment. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party appeared and filed written version in which it was submitted that the DLA Bhushan Kumar after complete understanding the terms and conditions of the product, had submitted the duly signed proposal form on 21.10.2011 and offered to pay Rs.99,006/- yearly for 15 years. The proposal form of the DLA Bhushan Kumar was processed on the basis of the information furnished by DLA Bhushan Kumar and thereafter, the Opposite Party issued the policy in question with commencement dated 21.10.2011 at a yearly premium of Rs.99,006/- to be paid for a period of 15 years against the face amount of Rs.13,04,000/-. It is submitted that the Opposite Party received the death claim intimation alongwith other documents intimating that the person insured died on 8.4.2013 due to sudden cardiac attack, which was duly acknowledged by the Opposite Party by their Condolence Letter dated 16.5.2013. Thereafter, the claim of the complainant was investigated and assessed by the Opposite Party through an investigation agency named as Eagle Eye consultant Private Limited. During the course of investigation and assessment of the claim, it was revealed to the Opposite Party that DLA Bhushan Kumar was suffering from Hypertension (HTN) from 3 years, Diabetes Mellitus (DM-II) for last 10 to 12 years and was on Insulin prior to applying for the said policy and he had taken treatment for the same from Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar. This implies that DLA Bhushan Kumar was well aware about his health condition before filling up  the proposal form, still he did not reveal this information in the proposal form. Thus, even after being aware of the fact that he was suffering from such dreadful disease he applied for the policy to get the undue advantage out of the same and suppressed the said fact of treatment and also the disease he was suffering from,  from the Opposite Party and thereby made the misrepresentation before the Opposite Party by suppressing the material medical facts and thus played a fraud with the Opposite Party. The Opposite Party does not incur any liability on the complainant for any sort of compensation as there is no deficiency or unfair trade practice adopted by the Opposite Party.  While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence her affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C7 and closed the evidence on behalf of the complainant.
4. Opposite Party tendered into evidence affidavit of Sh.Udhey Kumar Jain Ex.OP1 alongwith documents Ex.OP2 to Ex.OP27 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that Bhushan Kumar husband of the complainant obtained insurance policy bearing No. 20664379 with date of commencement 21.10.2011. The policy term was 15 years and premium payment term was also 15 years. Annual premium was  Rs.1 lac and the sum assured was Rs.13 lacs. Insured Bhushan Kumar appointed the complainant being his wife as nominee under the policy in question.  Bhushan Kumar policy holder paid two annual premiums of Rs.1 lac each during the year 2011 and 2012. Unfortunately Bhushan Kumar policy holder expired on 8.4.2013. The complainant being widow and nominee of DLA Bhushan Kumar, lodged the claim with the Opposite Party for the disbursement of the sum assured. However, the Opposite Party illegally repudiated the claim of the complainant vide letter dated 13.6.2013 Ex.C3 on the ground that DLA Bhushan Kumar was suffering from Hypertension and Diabetes Mellitus-II and this fact was not disclosed by DLA Bhushan Kumar at the time of obtaining the insurance policy. Complainant submitted that husband of the complainant namely Bhushan Kumar was not suffering from any such alleged disease. Opposite Party has taken this plea only to reject the genuine claim under the aforesaid policy. Complainant further alleged that DLA Bhushan Kumar was medically checked up by the empanelled doctors of the Opposite Party before affecting the insurance policy and at that time, no such disease was detected. Complainant approached the Opposite Party to accept the genuine claim of the complainant regarding the death of DLA Bhushan Kumar under the policy, but the Opposite Party did not pay any heed to the request of the complainant      Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party qua the complainant.
7. Whereas the case of the Opposite Party is that DLA Bhushan Kumar in order to obtain the policy filled in and signed the proposal form Ex.OP2 in which he did not disclose the real status of his health and he did not disclose the true facts, but the DLA Bhushan Kumar was suffering from Hypertension for the last 3 years and Diabetes Mellitus-II for the last 10 to 12 years and was on insulin as per the history of the DLA Bhushan Kumar recorded by Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar when he was admitted in Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 2.3.2013 and was discharged on 13.3.2013 as per discharge summary of the patient Ex.OP26 and he was again admitted in Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 6.4.2013 as per Patient’s Admission Request Ex.OP27. DLA Bhushan Kumar was obliged to give full and correct information on all matters which would influence the judgement of a prudent insurer in determining whether he will accept the risk, and if he would, at what rate of premium and subject to what conditions. Ld.counsel for the Opposite Party submitted that Opposite Party was justified in repudiating the claim of the complainant vide letter dated 13.6.2013 Ex.C3. The grievance of the complainant regarding the death of DLA Bhushan Kumar was considered and was dismissed by the Claim Review Committee of the Opposite Party vide letter dated 2.8.2013 Ex.C4. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.
8. From the entire above discussion, we have come to the conclusion that Bhushan Kumar husband of the complainant  obtained insurance policy bearing No. 20664379 Ex.OP5 with date of commencement 21.10.2011. The policy term was 15 years and premium payment term was also 15 years. The amount of premium was Rs.1 lac per annum and the sum assured was Rs.13,04,000/- as per schedule of the policy Ex.OP5. Said Bhushan Kumar paid 2 annual premiums for the year 2011 and 2012. However, he fell down and suffered injury on left leg due to slip. He was admitted in Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 2.3.2013 and was discharged on 13.3.2013 as per discharge summary Ex.OP6. He was again admitted in the same hospital i.e. Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 6.4.2013 and ultimately, Bhushan Kumar insured died in that hospital on 8.4.2013. The complainant being  widow of DLA Bhushan Kumar and nominee under the aforesaid policy,lodged claim regarding the death of DLA Bhushan Kumar  with the Opposite Party for the disbursement  of the assured amount. But the Opposite Party repudiated the claim of the complainant vide letter dated 13.6.2013 Ex.C3 on the ground that DLA Bhushan Kumar  was suffering from Hypertension and Diabetes Mellitus-II at the time, when he obtained the policy, but he did not disclose these facts to the Opposite Party whereby he obtained the policy in question from the Opposite Party by misrepresentation of the facts, when he filled in and signed the proposal form Ex.OP2 to obtain the policy in question from the Opposite Party. In this regard, Opposite Party  produced the Patient Discharge Summary Ex.OP26 in which the past history of DLA Bhushan Kumar was written, as that DLA Bhushan Kumar  was suffering from Hypertension for 3 years and Diabetes Mellitus-II for the last 10 to 12 years and was on insulin. DLA Bhushan Kumar  was well aware about his health condition. Opposite Party also produced on record Patient’s Admission card Ex.OP27 about the fact that the patient was again admitted in Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 6.4.2013 and he ultimately expired in that hospital on 8.4.2013. Opposite Party no doubt examined Sh.Jatinder Kumar, Store Incharge/ Record Keeper of Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 29.7.2015, who brought the treatment file of patient Bhushan Kumar and deposed that as per the history of Bhushan Kumar at the time of his admission in hospital on 2.3.2013, it is written that the DLA is a  known case of cirrhosis of liver, he was suffering from Diabetes Mellitus-II, Hypertension and was diagnosed HCV+ve. He was discharged on 13.3.2013. Again he was admitted in Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 6.4.2013. History of the patient was got recorded by Manoj Kumar son of patient Bhushan Kumar. Patient expired on 8.4.2013. But this witness has stated that he has not brought the treatment record of the patient prior to 2.3.2013 due to shortage of time. So he was directed to produce the treatment record of the patient prior to 2.3.2013. This witness however,  appeared again on 7.9.2013, but stated that the record of the patient Bhushan Kuamr prior to 2.3.2013 is not traceable. He further deposed that the patient was treated by Dr. J.P.S.Chinna and Dr.J.S.Sidhu. They can disclose about the history of the patient recorded by them or about diagnose and treatment of the patient, but the Opposite Party neither examined Dr.J.P.S.Chinna, who treated and got recorded the history of  patient Bhushan Kumar  in the record of Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar Ex.OP26 nor the Opposite Party examined Dr.J.S.Sidhu who diagnosed and treated the patient as per his treatment record Ex.OP27. The patient was 60 years old when he was given insurance policy by the Opposite Party. He must have been medically examined by the empanelled doctors of the Opposite Party and this fact has been deposed by the complainant in her affidavit Ex.C1 that Bhushan Kumar insured was medically examined by the empanelled doctors of the opposite party. But this fact was not rebutted by the Opposite Party. So, the Opposite Party when issued the policy in question to DLA Bhushan Kumar  must have examined him medically and at that time, the patient was not suffering from any such disease i.e. Hypertension and Diabetes Mellitus-II . DLA Bhushan Kumar  was not having knowledge of these diseases, if any. Opposite Party could not produce any treatment record of DLA Bhushan Kumar  prior to inception of the policy dated 21.10.2011 nor the Opposite Party could examine any doctor or medical practitioner who treated the patient for the aforesaid diseases nor the Opposite Party filed any affidavit of any doctor who ever diagnosed or treated  DLA Bhushan Kumar  for the aforesaid diseases prior to the obtaining of the policy i.e. 21.10.2011.  Even the person examined by the Opposite Party namely Jatinder Kumar, Record Keeper of Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar has himself stated that he neither recorded the history of patient when the patient i.e. DLA Bhushan Kumar  was admitted in Smt.Parvati Devi Hospital,  Ranjit Avenue, Amritsar on 2.3.2013  nor he had any personal knowledge about the diseases of the patient and the treatment. The patient was diagnosed and treated by Dr.J.P.S.Chinna and Dr.J.S.Sidhu, but the Opposite Party did not examine Dr.J.P.S.China and Dr.J.S.Sidhu, to prove that on which basis they recorded the history of patient DLA Bhushan Kumar. Even this witness was directed to produce the treatment record of the patient DLA Bhushan Kumar  prior to 2.3.2013, but this witness has deposed that the treatment record  of DLA Bhushan Kumar  prior to 2.3.2013 is not traceable. So the Opposite Party could not produce any medical treatment record of DLA Bhushan Kumar  to prove that he was suffering from or he had knowledge that he was suffering from Hypertension and Diabetes Mellitus-II prior to inception of the policy on 21.10.2011. It has been held by the Hon'ble State Commission of Punjab in case  Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff. Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest @ 9%.
9. Ld.counsel for the Opposite Party further submitted that it is a case of early death i.e. immediately after taking the policy in question. This plea of the ld.counsel for the Opposite Party is not tenable, because DLA Bhushan Kumar  was insured with policy bearing  20664379 issued by the Opposite Party with date of commencement 21.10.2011. The insured paid 2 annual installments of Rs.1 lac each in 2011 and 2012 and he expired on 8.4.2013 i.e. after a lapse of  a period of about 1 ½ years from the date of commencement of the policy in question. As such, we hold that Opposite Party was not justified in repudiating the claim of the complainant on the ground that the DLA Bhushan Kumar  was suffering from Hypertension and Diabetes Mellitus-II at the time of taking the policy and he had not disclosed these facts to the Opposite Party, vide letter dated 13.6.2013 Ex.C3 and vide Review decision dated 2.8.2013 Ex.C4.
10. Consequently, we allow the complaint with costs and the Opposite Party is directed to pay the insured amount of Rs.13 lacs (Rupees Thirteen Lacs only) to the complainant within one month from the date of receipt of copy of this order failing which the complainant shall be entitled to interest @ 9% per annum on this amount from the date of filing of the complaint till the payment is made to the complainant. Opposite Party is also directed to pay litigation expenses to the complainant  to the tune of Rs. 2000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 09-11-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member