Haryana

Karnal

CC/45/2017

Kuldeep - Complainant(s)

Versus

PNB Met Life Insurance Company Ltd - Opp.Party(s)

Ravinder Kumar

14 May 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL. 

                                                     Complaint No. 45 of 2017

                                                    Date of instt. 03.02.2017

                                                     Date of decision 14.05.2018

 

Kuldeep aged about 22 years son of late Shri Gajiya Singh @ Gaje Singh r/o village Kalwan Tehsil Narwana District Jind.

                                                                                 ……..Complainant.

                                        Versus

1. PNB Metlife India Insurance Company Ltd. SCO no.223, 2^nd floor. Sector-12 Karnal through its Branch Manager.

2. PNB Metlife India Insurance Company Ltd. Registered office unit no.701, 702 & 703 7^th floor. West Wing, Raheja Towers, 26/27 M.G. Road, Bangalore-560001 through its Managing Director/Chairman.

 

     ..…Opposite Parties.

 Complaint u/s 12  of the Consumer Protection Act 1986.

 

Before     Sh. Jagmal Singh……….President.

                Sh.Anil Sharma…….Member.

 

Present: Shri Ravinder Kumar Advocate for complainant.

               Shri Narinder Sukhan Advocate for OPs.

          

ORDER:

 

                (JAGMAL SINGH, PRESIDENT)

 

                This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986, on the averments that the father of complainant namely Gajiya purchased a life insurance policy no.218889697 on 29.04.2016 for a sum of Rs.14,20,000/-from OPs and paid its annual premium of Rs.10339/- to OP no.1 at Karnal Branch. The complainant was nominee in the said policy. At the time of issuance of the insurance policy her father was hale and hearty. Unfortunately, on 19.05.2016 the father of complainant naturally died due to sudden heart attack. After death of his father, complainant being nominee submitted death claim with OPs after completing all necessary formalities. It is matter of great surprise that instead of making payment of death claim of above insurance policy to complainant, vide letter dated 23.12.2016 the OPs have repudiated the death claim of complainant on the ground that father of the complainant was suffering from Throat Cancer prior to policy issuance. It is alleged that at the time of insurance, the insured is examined by the empanelled Doctors and only then the insurance policy is issued when there is no adverse report from the concerned Doctor with regard to the insured. So the repudiation of the claim is illegal, arbitrary, null and void and is liable to be set aside as the father of the complainant was not suffering from the alleged disease. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written statement raising preliminary objections with regard to cause of action; complaint is false and frivolous and concealment of true and material facts. On merits, it is submitted that Late Gajiya Singh (hereinafter referred as Deceased Life Assured/DLA”) after completely understanding the terms and condition of our product “Met Family Income Protect Plus” had submitted the duly signed Proposal Form on 28.04.2016 and offered to pay Rs.11,838/- annually towards the initially premium against the Sum Assured of Rs.14,20,000/-. It is submitted that the contents of the Proposal Form were explained to the DLA and he had given a Declaration stating that he has furnished the information after fully understanding the contents thereof and also after understanding the terms and conditions of the plan he had applied for and has made true and accurate disclosure of all the fact and has not withheld any information. In the proposal form, there was a column wherein the DLA was required to provide answers with respect to his Medical History and the DLA replied that he was not suffering from any disease neither he was taking any medical treatment. It is further submitted that upon receipt of the duly filled up Proposal Form and believing the information provided by the DLA to be true and correct, alongwith the initial Premium, the OP evaluated and processed the Proposal Form on the basis of the information furnished by DLA and issued the policy bearing no.21889697 with Risk Commencement date 29.04.2016. Complainant was made the nominee in the said policy. Thereafter, the Policy Documents alongwith the Schedule and the standard terms and conditions thereto and a Welcome Letter were dispatched at the address of DLA which were duly delivered. Thus, the DLA in case had fully understood the terms and conditions of the Policy and further agreed under the Agreement therein that if any untrue statement be contained in the application/Proposal Form, the policy contract shall be null and void and the money which have been paid by DLA shall stands forfeited to PNB MetLife. It is further submitted that the OP received the Death Claim Intimation from the complainant on 15.07.2016 thereby intimating them that the person insured died on 19.05.2016, which was duly acknowledged by OPs vide letter dated 16.07.2016. The claim being an early claim, as the person insured died within a short span of only 20 days, the OPs as per the procedure, carried out an investigation to settle the claim of the complainant. During the course of investigation and assessment of the claim, it was revealed to the OPs that DLA did not provide true and correct information while filling up the proposal form with respect to his medical history. It revealed that the DLA was suffering from Throat Cancer prior to the issuance of the policy. Thus, the OPS have rightly repudiated the claim of the complainant vide its letter dated 23.12.2016 on the ground that false information as to material facts with respect to his medical history, at the time of filling up of a Proposal Form, based on which the said Policy was issued by the OPs to him. Hence there was no deficiency in service on the part of the OPs. Hence prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C9 and closed the evidence on 18.12.2017.

4.             On the other hand, OPs tendered into evidence affidavit of Rajeev Sharma Ex.RW1/A and documents Ex.R1 to Ex.R15 and closed the evidence on 12.04.2018.

5.             We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             It is not disputed that complainant is the son of the late Gajiya Singh @ Gaje Singh and said Gajiya Singh purchased a life insurance policy no.21889697 on 29.04.2016 for a sum of Rs.14,20,000/- from the OPs. The complainant is the nominee of her father in the said policy. Said Rameshwar was died on 19.05.2016. The complainant filed the claim with the OPs and the same has been repudiated by the OPs.

7.             From the pleadings, evidence and submissions of the parties, it is clear that the claim of the complainant has been repudiated by the OPs, vide letter dated 23.12.2016 Ex.R15 which runs as under:-

Subject: Claim under policy no.21888507 on the life of late Mr. Rameshwar

 

        “This is with reference to the claim made under the above mentioned policy on the life of Late Mr. Gajiya Singh.

        We have reviewed and evaluated the claim and wish to bring to your attention, that during the course of reviewing the claim, we have received medical records which indicate that Late Mr. Gajiya Singh was suffering from Throat Cancer prior to policy issuance and also found that prior to solicitation of the impugned insurance policy, late Mr. Gajiya Singh was already insured with other life insurance companies as follows. However, the concerned question in the application form dated 28.04.2016, seeking insurance cover under this policy was answered as “NO” by Late Mr. Gajiya Singh.

Name of Ins. Co.      Policy no./Application no.     proposal date       Sum Assured

Bharti Axa Life             501-4101702                           25.02.2016       361115

Ins.Co.Ltd.

 

        We wish to state that the above mentioned fact was a material fact for the purposes of underwriting of the risk and that if this material fact was disclosed to us in the application form, we would not have issued the policy at all. As you may be aware, Insurance contracts are based on the principle of “utmost good faith” and the policies are issued based on the representations made in the application form and any non-disclosure or misrepresentation in the application form, which are material for the purposes of underwriting the risk, renders the contract voidable at the option of the insurer.

        Therefore, through this letter, we regret to inform you that we are unable to admit liability for the above claim due to non-disclosure of material facts, as highlighted herein above, as per the terms and conditions of the insurance policy.”

8.             From the repudiation letter it is clear that the repudiation has been made on the ground of non-disclosure of material facts regarding pre-existing disease of Throat Cancer as well as the insurance policies already taken by the DLA. As the OPs repudiated the claim, therefore, the onus to prove the grounds of repudiation was upon the OPs. The OPs have stated that the investigation in the matter has been got conducted by Investigation Agency Third Eye Investigation Pvt. Ltd. and other investigation agency Prefecture and referred the investigation report Ex.R13 in this regard. 

9.             The head investigative findings and conclusion of the investigation report of Prefecture Agency runs as under:-

. During the course of investigation the only feedback we have received that LA was suffering from Throat Cancer from the last 8-10 months prior to his death.

. But nobody was able to elaborate the exact details pertaining to LA’s ailment details.

.  Name of the hospital highlighted was PGI Rohtak.

.  However, due to lack of exact details of treatment and strict norms at the mentioned hospital we are unable to get any detail concerning LA taking a treatment.

.  Nominee remained on his stand of LA’s death was sudden and not suffering from any major ailment.

        During the investigation we have been able to check all possible/highlighted medical centers. However, any substantial evidence confirming LA’s any other critical ailment prior the issuance of this could not established due to non-cooperation from the highlighted hospitals.

10.            Similarly, the Third Eye Investigation Private Limited could not collect any evidence vide which it can be said that the DLA was suffering from Throat Cancer prior to the issuance of the policy.

11.            So, from the above facts, it is clear that the investigators could not collect any record/medical record on the basis of which it can be said that the DLA was having Throat Cancer prior to issuance of the policy. The OPs have not produced any other evidence vide which it can be said that the complainant was having Throat Cancer prior to issuance of the policy in question.

12.            The OPs have also repudiated the claim of the complainant on the ground that the DLA has failed to disclose information about earlier policy.  In this regard the OPs have specifically mentioned in the repudiation letter the name of the insurance company, the policy number, date of proposal and sum assured. The policy in question was issued on 29.4.2016 whereas the previous policy was issued on 25.02.2016. Therefore, the DLA should have disclosed the information about this earlier policy but the DLA has not do so. The complainant has not explained about the same in his complaint.

13.            The complainant has produced the authorities (i) the copy of the decision dated 26.08.2011 of the Hon’ble Supreme Court of India in Civil appeal no.7437 of 2011 (Arising out of Special Leave Petition (c) no.35382 of 2010 titled as P.Vankat Naidu Versus Branch Manager, Life Insurance Corporation of India, Kurnool and Another wherein it has been held that since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. However, as found by the District Forum and the State Commission, the respondents did not produce any tangible evidence to prove that the deceased had withheld information about his hospitalization and treatment. Therefore, the National Commission was not justified in interfering with the concurrent finding recorded by the District Forum and the State Commission by asking a wild guesswork that the deceased had suppressed the facts relating to his illness. In the result, the appeal is allowed.

                The other authority is the copy of order dated 17.08.2016 passed by Hon’ble State Commission Haryana in first appeal no.528 of 2016 titled as Life Insurance Corporation of India Versus Sarojini and another which is also on the same footing.

                The complainant produced a copy of order dated 2.11.2017 passed by the Hon’ble Punjab and Haryana High Court in CWP no.24862 of 2017 titled as Bajaj Allianz Life Insurance Company Versus Santosh Another wherein it is held that non-disclosure of policy obtained by the insured from other insurance company is not suppression of material facts.

14.            On the other hand, the OPs produced an authority cited in 2018(1) CPR 34 (NC) titled as Sanjay Atmaram Patel Versus Divisional Manager, LIC of India and others, the head note (A) of the same is as: “Insurance-Mediclaim Policy-Jeevan Shree Without Profit (Without Accident Benefit) Policy-Claim preferred by Petitioner repudiated by Insurance Company on ground that complainant/Insured had failed to disclose information about an early policy that insured did have to previous insurance policy but failed to disclose this fact at the time of obtaining policy in question-Non-disclosure of earlier policy amounted to suppression of a material fact, particularly in Mediclaim policy and Insurance Mediclaim Policy and Insurance Company was justified in repudiating the claim-Revision Petition dismissed.”

15.             In the above facts and circumstances of the case, we are of the considered view that the OPs have failed to prove that the DLA was suffering from Throat Cancer prior to the issuance of the policy in question but the OPs have proved on the file that the DLA has not disclosed the information about an earlier policy obtained by him. On the point of disclosure about the earlier policy, both the parties have produced the authorities mentioned above. The complainant has produced the authority of the Hon’ble Punjab and Haryana High Court whereas the OPs have produced the authority of the Hon’ble National Commission New Delhi. Moreover, the authority of the Hon’ble National Commission is later in time than the authority of the Hon’ble Punjab and Haryana High Court. The Hon’ble National Commission has held that non-disclosure of earlier policy amounted to suppression of material fact and the revision of the complainant was dismissed. This authority of the Hon’ble National Commission is fully applicable to the facts of the present case. So, keeping in view this authority of the Hon’ble National Commission as well as the facts and circumstances of the case, we are of the considered view that the insurance company was justified in repudiating the claim. Hence we found no deficiency on the part of the OPs.

16.            Thus, as a sequel to above discussion, we do not find any merits in the complaint and the same is hereby dismissed. No order as to costs. Parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:14.05.2018

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

                     (Anil Sharma)

                          Member