Punjab

Ludhiana

CC/23/505

Geeta - Complainant(s)

Versus

PNB Metlife India Ins.Co.Ltd. - Opp.Party(s)

27 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 505 dated 02.11.2023.                                                        Date of decision: 27.03.2024.

 

Geeta Wd/o. Om Parkash, R/o. H. No.763, O/S. Makhu Gate, Gali Sethi Model School, Ferozepur.

                                                                                      ..…Complainant

                                                Versus

1. PNB Met Life India Insurance Company Ltd., 4^th Floor, Kunal Towers No.88, The Mall Road, Ludhiana through its Branch Manager.
2. Managing Director of PNB Metlife India Insurance Company Limited, No.25, Ist Floor, Thunga Complex, 32^nd A Cross Road, Jayanagar 7^th Block, Opp. Bangalore International Academy, Beside City College, Bengaluru, Karnataka-560082.                                                                                                                                               …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Kartikeya Swaroop Mehta, Advocate.

For OPs                          :         Sh. Anmol Jindal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

 

1.                Briefly stated, the facts of the complaint are that in 2014, agent of the OPs approached and allured husband of the complainant to purchase insurance policy, upon which Om Parkash, husband of the complainant purchased Life Insurance Policy No.21450508 from the OPs for sum assured of Rs.8,95,116/- by paying requisite premium. The complainant was nominee in the said insurance policy. The complainant stated that her husband died of natural death on 05.03.2015 and intimation of death was given to the OPs. The complainant being nominee of her husband, lodged claim of Rs.8,95,116/- by submitting all the original documents with the OPs who assured to settle the claim at the earliest. The representative of the OPs visited house of the complainant and took all the original documents from the complainant with assurance of early settlement of the claim. According to the complainant she requested the officials of the OPs to settle her claim but no response was given. After waiting for few months, the complainant again requested the OPs but again no response was received. The complainant further stated that she is not in possession of original documents as she has already handed over the same to the representative of the OPs. The OPs have wrongly withheld and delayed the claim of the complainant to deprive her from her lawful claim, which amounts to deficiency in service and unfair trade practice on the part of the OPs. In the end, the complainant has prayed for issuing directions to the OPs to produce all the documents pertaining to insurance policy of deceased Om Parkash; to settle the claim of the insurance policy and to pay the insured amount of  Rs.8,95,116/- w.r.t of death of Om Parkash along with benefits and interest; to pay compensation of Rs.1,00,000/- for mental torture and agony and to pay litigation expenses of Rs.25,000/-.

2.                The OPs appeared and filed joint written statement and assailed the complaint by taking preliminary submissions as well as preliminary objections on the ground of maintainability of the complaint; the complaint being abuse of process of law; concealment and suppression of material facts; the complaint is time barred; the complaint being barred under Section 26 of the Consumer Protection Act etc. The OPs averred that the life assured died on 05.03.2015 after issuance of policy No.21450508. The claim was filed on 03.10.2015, which was investigated and repudiated vide letter dated 29.12.2015 and same was intimated to the complainant. However, the complainant preferred the complaint in 2018 i.e. after delay of more than 3 months regarding which no application for condonation of delay has been filed by the complainant. The Ops further stated that the contract of insurance is a contract based on “uberrrimaefidei” i.e. utmost good faith but the DLA has suppressed the material fact that he was suffering from Tuberculosis since 17.09.2012 which is prior to issuance of the insurance policy and was taking treatment for the same. The OPs further stated that the complaint can only be adjudicated in civil court by holding a proper trial and substantive evidence. The OPs denied any deficiency in service on their part.

                    Under the column Facts of the case, the OPs stated that after receipt of duly filled and signed proposal form, they issued insurance policy to DLA Mr. Om Parkash, the details of which is reproduced as under:-          

Policy Number	21450508
Policy Plan	Met Endowment Saving Plan
Policy Status	Repudiated
Life Assured	Mr. Om Parkash
Nominee	Mr. M. Sivakumar Reddy
Sum Assured	Rs.8,95,116.00
Proposal Date	11.12.2014
Risk Commencement Date	15.12.2014
Policy Issue Date	19.12.2014
Premium	Rs.29100.00
Total Premium Paid	1
Policy Term	15 years
Premium Paying Term	15 Years
Premium Frequency	Semi-Annual

 

The policy documents were duly sent, which were received by the DLA. The DLA never raised any grievance in proposal form during Free Look Period. The OPs stated that they received death claim intimation under the policy on 03.12.2015 regarding death of Life Assured on 05.03.2015 due to ‘Heart Attack’. The DLA died within 4 months from date of issuance of policy on 19.12.2014 and as such, the claim being Early Claim was covered under Section 45 of the Insurance Act. As such, investigation was conducted  and after careful evaluation of the records during the claim processing, it was revealed that the Life Assured had provided incorrect information and suppressed material fact that he was suffering from Tuberculosis since 17.09.2012 which is prior to issuance of subject policy and was under treatment for same which amounts to material suppression of act. Even the investigator during the investigations met the neighbours of the DLA who informed that DLA was suffering from Tuberculosis. The investigator also met Sister Saveriya of Mother Teresa NGO, Ferozepur who informed that LA had undergone treatment in their hospital from 17.08.2012 to 13.02.2013 but she refused to provide any medical record. The investigator also visited Mr. Kamal of T.B. Office, Ferozepur who confirmed that name of the DLA was mentioned in their record for 2012-2015. The investigator further visited Mr. Gulshan of T.B. Officer, Faridkot who provided medical records of DLA in TB register where name of DLA was registered vide TB card No.974 dated 17.09.2012. Even the DLA had taken the entire six month course treatment for said ailment.

                   The OPs further stated that the DLA has given false answer to the question No.3(3) of the proposal form, which is reproduced as under:-

Ques. No.	Question	Answer
3(3)	Tuberculosis, asthma, bronchitis, Avian Flu, Shortness of breath or any other respiratory disorder?	No

 

The DLA has suppressed the material facts and information while submitting the proposal form and as such, the death claim of DLA was repudiated on the ground of non-disclosure of prior medical conditions and same was conveyed to the complainant vide letter dated 29.12.2015.

                   Under the column Parawise Reply, the OPs reiterated the crux of averments made in the preliminary objections. The OPs have denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of her claim, the complainant tendered her affidavit Ex. CW in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of legal notice dated 11.02.2017, Ex. C2 is the copy of postal receipt, Ex. C3 is the copy of death certificate of Om Parkash, Ex. C4 is the copy of welcome letter dated 20.12.2014 along with policy documents and closed the evidence.

4.                The OPs did not tender any formal evidence. However, the OPs submitted certain documents at the time of filing written statement.

5.                The consumer complaint No.RBT/CC/208 of 2018, filed by the complainant was dismissed by the Camp Court at Ludhiana vide its decision dated 12.09.2022. The complainant preferred First appeal No.1039 of 2022 before the Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh which was allowed vide order dated 08.09.2023 vide which the order dated 12.09.2022  passed by the District Consumer Disputes Redressal Commission Ropar, Camp Court at Ludhiana was set aside. The respondents/OPs were burdened with costs of Rs.10,000/- for relying upon the documents, which do not relate to the DLA Om Parkash. The Hon’ble State Commission remanded the case to this Commission with direction to this Commission to decide the same afresh on merits by taking into consideration the contents of the complaint, written reply filed by the OPs and after verifying the documents/evidence as available on record after affording adequate opportunity of hearing to both the parties. The parties are at liberty to produce any additional evidence before the District commission, if any. The District Commission shall decide the complaint within a period of 6 months from the date of receipt of certified copy of the order. The parties were directed to appear before this Commission on 09.10.2023.

                   Accordingly, on 09.10.2023, Sh. Anmol Jindal, Advocate appeared on behalf of the OPs and presented cheque of Rs.10,000/- in the name of the complainant, notice of which was issued to the complainant for 02.11.2023. However, Sh. Kartikeya Swaroop Mehta, Advocate appeared and field memo of appearance on behalf of the complainant on 21.11.2023. The case was adjourned to 18.12.2023 for collecting the cheque by the complainant and for producing additional evidence by the parties. Sh. Kartikeya Swaroop Mehta, Advocate requested to receive the cheque on behalf of the complainant, which was allowed and cheque of Rs.10,000/- dated 06.10.2023 No.652454 was handed over to him by recording his statement and case was adjourned to 05.01.2024 for additional evidence of the parties.

6.                On 05.01.2024, the complainant filed rejoinder to the written reply of the OPs by reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement.

                   The counsel for the complainant also closed additional evidence by suffering separate statement.

                   Further the case was adjourned to 31.01.2024 for additional evidence of the OPs subject to costs of Rs.200/-. On 31.01.2024, the OPs deposited the costs of Rs.200/- and closed additional evidence after tendering affidavit Ex. OP1-2/A of Sh. Sanchit Gupta, Manager – Legal, authorized representative of PNB Met Life India Insurance Co. Ltd. along with documents i.e. Ex. OP1-2/B is the copy of proposal form, Ex. OP1-2/C is the cop of policy No.21450508, Ex. OP1-2/D is the copy of death claim form, Ex. OP1-2/E is the copy of investigator report, Ex. OP1-2/F is the copy of details of Revised National Tuberculosis Control  Program – TB Register, Ex. OP1-2/G is the copy of claim decision letter dated 29.12.2015 and closed the additional evidence.

7.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and affidavit produced on record by both the parties. We have also gone through written arguments submitted by the complainant.

8.                It is an admitted case of the complainant, that her husband Sh. Om  Parkash obtained a Met Endowment Saving Plan Ex. C4 = Ex. OP1-2/C for sum assured of Rs.8,95,116/- effective from 15.12.2014. The complainant Smt. Geeta has been shown as nominee. Unfortunately, the insured Sh. Om Parkash died on 05.03.2015 due to heart attack. The complainant preferred death claim with the OPs vide Claim Form dated 03.10.2015 Ex. OP1-2/D. The OPs appointed Prefecture investigating agency to investigate into the matter who vide its report dated 15.12.2015 Ex. OP1-2/E in which the Investigator Mr. Ashish made the following findings and conclusion:-

                   “Investigative Findings & Conclusion

                   Conclusion:

• During the course of investigation the only feedback we have received that LA was suffering from Tuberculosis from past two & half year prior to his death.
• Moreover, we were highlighted that LA had undergone treatment from Mother Teresa NGO, Ferozepur & was verbally confirmed that LA had undergone treatment in the said hospital from 17/08/2012 which is prior to the commencement of policy.
• Moreover, the basis the TB card of Faridkot procured confirming LA had taken the entire six month medicines from the said medical centre (Civil Hospital, Faridkot) confirming LA’s ailment prior to the commencement of policy.
• On the basis of our investigations and medical documents (first hand evidence) procured, we conclude that LA was TB Patient and had started his treatment from 17/08/2012  14/09/2014 which is apparently prior to the policy.
• The said case is deliberate act of concealment of facts of LA’s pre ailment at the time of application of the policy.
• Hence basis the above mentioned substantial medical evidence we have been able to establish LA’s pre-existing medical ailment prior to the commencement of the policy.

                   Hence, said case is deliberate act of concealment of facts of LA’s pre ailment at the time application of the said policy.”

On the basis of said investigation report, the OPs repudiated the claim vide letter dated 29.12.2015 Ex. OP1-2/G, the operative part of same reads as under:-

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

We regret to bring to your kind attention that during the course of assessing the claim, we have received medical evidence which shows that Late Mr. Om Parkash was suffering from TB prior to policy issuance. The concerned question in the application form dated 15.12.2014, seeking insurance cover under this policy was answered as “NO” by Late Mr. Om Parkash and thus denied us the opportunity to assess the risk properly.

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 renders the contract voidable at the option of the insurer.

We therefore regret to inform you that we are unable to admit liability for the above claim due to non disclosure of material facts and have treated the said policy as void ab-initio.”

8.                Now the question arise whether the rejection of claim on the ground mentioned therein is valid or not? The rejection of the claim of the complainant was effected by the OPs by invoking the reason that the DLA had not disclosed about the pre-existing disease of Tuberculosis prior to obtaining the insurance policy. In the proposal form Ex. OP1-2/B under the column of medical details, the DLA the answered all the questions in negative. The claim of the complainant is sought to be rejected on the ground that the DA was a patient of Tuberculosis prior to issuance of the insurance policy and had undergone treatment from Mother Teresa NGO, Ferozepur from 17.08.2012 and had started his treatment from 17.08.2012 to 13.02.2013. This fact has been also mentioned in their written statement by the OPs. It is a matter of common knowledge that as a normal practice the form is filled by the insurance agent. In addition to this, despite being of age of about 46 years at the time of issuance of the policy, the DLA Om Parkash was not got medically examined and moreover, the insurance company may have additional questions for the insured or may ask him to undergo medical tests to complete full medical assessment. No evidence has been lead by the opposite parties as to whether any additional questions were put to the complainant or not nor any evidence has been adduced that the complainant was subjected to some medical tests at the time of issuance of the policy on 15.12.2014. Even no medical opinion of any medical expert has been produced on record by the OPs.

9.                The OPs have mainly based the grounds of repudiation of the claim of the complainant on the ground of report of investigator Ex. OP1-2/E. A close scrutiny of report of investigator reveals that although the investigator claims to have visited Mother Teresa NGO, Ferozepur (Sister Saveriya) but he failed to take any record from that hospital to establish that DLA had undergone some treatment from said hospital from 17.08.2012 to 13.02.2013. His visit to T.B. Office, Ferozepur also resulted unfruitful. Further the investigator visited T.B. Hospital, Faridkot and took some record but he was unable to conclude that the patient had actually cured or not. The entry as contained in Ex. OP1-2/F at the face of it connect the DLA that this entry due to lack of complete particulars. Further the entries of the register are unauthentic and the name of the institution, the person who maintained it, has not been mentioned. The investigation report does not mention the fact that the DLA was under treatment for Tuberculosis at the time of obtaining the policy. Even affidavit of the investigator was not brought on record to substantiate its findings. Moreover, Tuberculosis is a disease which can be preventable and curable with use of antibiotic medicines usually takes 6 to 9 months. Therefore, any treatment taken by the DLA prior to taking the policy about which no questions were asked in the proposal form, it cannot be said that the OPs are justified in rejecting the claim on the ground of suppressing his  having treatment of Tuberculosis in 2012. As per Claim form Ex. OP1-2/D the reason of death of DLA was mentioned as ‘Heart Attack’ on 05.03.2015 i.e. within the first policy period which commenced from 15.12.2014. The DLA died much after taking the treatment for Tuberculosis from 17.08.2012 to 13.02.2013. Therefore, the alleged pre-existing disease of Tuberculosis has no connection or nexus with Heart Attack. Therefore, the rejection of the claim on the ground that the treatment was in respect of a pre-existing disease cannot be sustained in the eyes of law. Reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified.

10.              Further in a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has observed as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”   

Therefore, in our considered view, the rejection of the claim on the basis of   non-disclosure of pre-existing diseases could not have  been made a ground to   reject the claim and this ground cannot be sustained  in the eyes of law.  The insurance companies are required to be more liberal in their approach without being too technical. In the given set of above said facts and circumstances, it would be just and appropriate if the opposite parties are directed to settle and reimburse the death claim submitted by the complainant regarding death of DLA Sh. Om Parkash within 30 days from the date of receipt of copy of order. The OPs are further burdened with composite costs of Rs.20,000/-.

11.              As a result of above discussion, the complaint is partly allowed with an order that the opposite parties are directed to settle and reimburse the death claim submitted by the complainant regarding death of DLA Sh. Om Parkash within 30 days from the date of receipt of copy of order. The OPs shall further pay a composite cost of Rs.20,000/- (Rupees Twenty Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.     

 

(Monika Bhagat)                                 (Sanjeev Batra)        

                    Member                                              President 

 

Announced in Open Commission.

Dated:27.03.2024.

Gobind Ram.