Haryana

Karnal

CC/46/2017

Ravinder - 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. 46 of 2017

                                                    Date of instt. 03.02.2017

                                                     Date of decision 14.05.2018

 

Ravinder aged about 22 years son of late Sh. Parmanand r/o House no.79/37/14 Om Nagar, near Sunrise School, Amarheri Road, Jind The. & 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 Sudhir Chauhan 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 Parmanand purchased a life insurance policy no.21889689 on 29.04.2016 for a sum of Rs.14,20,000/-from OPs and paid its annual premium of Rs.11972/- to OP no.1 at Karnal Branch. The complainant was nominee in the said policy. At the time of issuance of the insurance policy his father was hale and hearty. Unfortunately, on 09.06.2016 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 30.12.2016 the OPs have repudiated the death claim of complainant on the ground that son 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 son 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 Parmanand (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.13,708/- 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.21889689 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 in the moneys which have paid in respect of shall stands forfeited to PNB MetLife. It is further submitted that the OPs received the Death Claim Intimation from the complainant on 19.07.2016 thereby intimating them that the person insured died on 09.06.2016 due to Chest Pain, which was duly acknowledged vide condolence letter dated 20.07.2016. The claim being an early claim, as the person insured died within a short span of only 85 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 Diabetes prior to the issuance of the policy. Thus, the OPS have rightly repudiated the claim of the complainant vide its letter dated 30.12.2016 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 15.09.2017.

4.             On the other hand, OPs tendered into evidence affidavit of Rajeev Sharma Ex.RW1/A and documents Ex.R1 to Ex.R12 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 Parmanand and said Parmanand purchased a life insurance policy no.21889689 on 29.04.2016 for a sum of Rs.14,20,000/- from the OPs. The complainant is the nominee of his father in the said policy. Said Parmanand was died on 09.06.2016. 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 30.12.2016 Ex.R12 which runs as under:-

Subject: Claim under policy no.21889689 on the life of Late Mr. Parmanand.

 

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

        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. Parmanand was suffering from Throat Cancer prior to policy issuance. 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. Parmanand.

        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 as the OPs alleged that the DLA was suffering from Throat Cancer prior to the issuance of the policy, therefore, the onus to prove the same was upon the OPs. The OPs have stated that the investigation in the matter has been got conducted by Investigation Agency PREFECTURE, New Delhi and referred the investigation report Ex.R11 in this regard. 

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

. During the course of investigation the only feedback we have received that LA was suffering from Throat Cancer from last 1 year 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 & Jindal Hospital, Hissar.

.  However, due to lack of exact details of treatment and strict norms at the mentioned hospitals we are unable to get any details confirming LA taking treatment.

.  We visited all the possible recognized hospitals in order to check LA’s treatment record of ailment.

. However, no exact proof pertaining to any treatment details could be procured during the course of investigation due to non-cooperation from the highlighted hospital & lack of information.

.  Hence due to lack of substantial information & non-compliance from the highlighted hospital we are unable to establish LA’s pre-existing medical ailment prior to policy commencement.

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

During 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 the policy could not established due to non-cooperation from the highlighted hospitals.”

 

10.            So, from the above facts, it is clear that the investigator could not collect any record/medical record on the basis of which it can be said that the DLA was suffering from Throat Cancer. Rather from the  conclusion of the investigator it is very much clear that the investigator was unable to establish that LA was having a pre-existing medical ailment prior to the issuance of the policy. The OPs have not produced any other evidence vide which it can be said that the complainant was having ailment of Throat Cancer prior to issuance of the policy in question.

11.            The complainant has produced the two 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. Both these authorities are fully applicable to the facts of the present case. So, in view of the aforesaid authorities as well as the facts and circumstances of the case, we are of the considered view that the OPs have failed to prove by cogent evidence that the complainant was suffering from Throat Cancer prior to issuance of the policy, therefore, the OPs have committed a mistake in repudiating the claim of the complainant. Hence, the OPs are deficient in providing services to the complainant.

12.            Thus, as a sequel to above discussions, we allow the present complaint and direct the OPs to pay Rs.14,20,000/- the sum insured to the complainant. We further direct the OPs to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order. The 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