Punjab

Ludhiana

CC/21/56

Ritu - Complainant(s)

Versus

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

Randeep

09 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:56 dated 04.02.2021.                                                 Date of decision: 09.06.2023.

1. Ritu aged 48 years wife of deceased Gulshan Kumar, R/o. H. No.103, Punjabi Bagh Colony, Salem Tabri, Ludhiana.
2. Mudit Arora aged 24 years son of ate Gulshan Kumar, R/o. H. No.103, Punjabi Bagh Colony, Salem Tabri, Ludhiana.                                                                                                                           .…Complainant

                                                Versus

1. PNB Metlife India Insurance Company Limited, Registered Office, Unit No.701, 702, 703, 7^th Floor, West Wing, Raheja Towers, 26/27, M.G. Road, Bangaore-560001 through its Authorized Officer.
2. The Director, Operations & Services, PNB Metlife India Insurance Company Limited, Ludhiana.

....Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Narinder Singh, Advocate.

For OPs                          :         Sh. Sudhir Gakhar, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, the facts of the complaint are that Gulshan Kumar, deceased husband of complainant No.1 took Life Insurance Policy Plan i.e. “PNB Metlife Jeevan Suraksha Plan” on 01.11.2018 from the opposite parties for a sum of Rs.30,00,000/- vide policy No.22683312 from Sourcing Branch, Ludhiana-II by paying premium of Rs.19,647/- for the premium term of 18 years. According to the complainants, deceased Gulshan Singh completed all the formalities prior to taking the policy and supplied all the documents to the opposite parties. His medical check-up was done by Dr. Pawan Katyal and Dr. Gulati who are empanelled doctors of the insurance company and after getting fitness certificate from the doctors, insurance policy was issued to late Sh. Gulshan Kumar. Then the first installment regarding the premium of Rs.22,656/- including service tax/GST was deposited by Sh. Gulshan Kumar. The complainants stated that due to some urine output, abdominal distension problem, Sh. Gulshan Kumar was admitted in Bassi Hospital on 13.11.2018 where he was referred to Neuro City on 14.11.2018 and then doctors of Neuro City referred him to SPS Hospital where he was admitted on 02.12.2018 and expired on 05.12.2018. Death summary certificate was issued by Dr. Gurpreet Singh, Senior Consultant and Joint Coordinator. The complainants further stated that as per the policy, the four options regarding the benefits were given and one of the option No.3-fixed income which is reproduced as under:-

                   "OPTION 3 FIXED INCOME

On the first occurrence of death or diagnosis of terminal illness, sum assured on death shall be payable. Sum assured on death shall be equal to lump sum amount payable immediately plus fixed monthly income payable over 120 Months in installments, where the first installment of monthly income will be payable one from the date of death of the life assured. Lump sum payable is equal to 100 times of monthly income chosen at the time of inception".

The complainants further stated that prior to taking the policy the deceased Sh. Gulshan Kumar was not patient of Chronic disease and the opposite parties already get all the fitness requisite Health Certificate from their panel doctors and the deceased Sh.Gulshan Kumar has not concealed any disease prior to taking the policy. Moreover, as per the Death Summary Report, nothing has been mentioned regarding the chronic disease. After the death of Sh.Gulshan Kumar, the claim statement for the death claim was submitted by complainant No.1 being the wife of the deceased Late Sh.Gulshan Kumar along with all relevant documents required to get the claim but the same has been illegally rejected only on the ground that as per the medical records, Late Mr.Gulshan Kumar was suffering from Morbid obesity, Peripheral Artery Disease, Acute Limb Ischemia, left Foot Drop, Thrombosis Left Femoral Artery, Post Left Femoral Artery embolectomy and fasiotomy with post left leg Debridement prior to policy insurance. According to the complainants, the concerned question in the Application Form dated 28.09.2018 the seeking insurance cover under this policy was answered as "No".  Prior to taking the policy, Late Sh.Gulshan Kumar was medically examined i.e. TMT at the Clinic of Dr. Pawan Katyal, Cardiologist and thereafter, PNB Metlife Insurance was issued to

 

Sh.Gulshan Kumar and one installment was deposited by Sh.Gulshan Kumar which shows that Sh.Gulshan Kumar fulfilled all the terms and conditions regarding the policy and the same was issued after medical checkup and verified all the requisite documents regarding the policy. When the claim statement was submitted by the complainants, immediately the opposite parties refunded one installment already deposited by the Sh.Gulshan Kumar prior to his death which shows the malafide intention of the opposite parties and same is against the terms and conditions of the policy and the complainants are entitled to the claim of Rs. 30,00,000/- due after the death of Late Sh.Gulshan Kumar. Late Sh.Gulshan Kumar had not concealed any facts regarding the medical problem and other formalities were completed by the opposite parties and thereafter, insurance policy was issued. The opposite parties have adopted unfair trade practices and are guilty of deficiency in services. In the end, the complainants prayed for directing the opposite parties to pay Rs.30,00,000./- as insured amount due against death of Sh. Gulshan Kumar and also to pay compensation and litigation expenses.

2.                Upon notice, opposite parties filed joint written statement by taking preliminary objections that the complaint is not maintainable; the complainant has suppressed the material facts; lack of cause of action etc.  The opposite parties stated that the policy under question “PNB Metlife Mera Jeevan Suraksha Plan” bearing No.22683312 was issued by them on the basis of information provided by late Mr. Gulshan Kumar Life Assured (DA) in the proposal form dated 28.09.2018. According to the opposite parties, the claim was investigated under Section 45 of the Insurance Act, 1956 to verify the veracity of the claim.

"Section 45 In accordance to the Section 45 of the Insurance Act, 1938 no policy of life insurance shall after the expiry of three years from the date on which it was effected, be called in question by an insurer of the Policy, was inaccurate of false, unless the insurer shows that statement was on material to disclose and that it was fraudulently made by the Policy holder and that the policy holder knew at the time of making it that the statement was false or that it was material to disclose."

During the investigation & claim evaluation process it was found that the DLA at the time of filling up the proposal form, did not disclose the correct information about his health. The DLA remained admitted in DMC Ludhiana vide CR No. 204577 (Admission No.88831) from 04.02.2015 to 11.03.2015 and again admitted vide admission No.89991 from 18.03.2015 and discharged on 01.04.2015. From the discharge summary dated 01.04.2015 of DMC Ludhiana, procured during investigation it was found that DLA was suffering from the following diseases.

a.	Type 2 Diabetes
b.	Morbid Obesity
c.	Peripheral Artery Disease
d.	Acute Limb Ischemia
e.	Left Foot Drop
f.	Thrombosis Left femoral Artery (DVT-Deep vein thrombosis)
g.	post left femoral artery Embolectomy
h.	Fasiotomy with Post Left leg Debridement

 

The DLA was getting regular treatment from DMC, Ludhiana which was prior to the issuance of policy. However, the relevant question in the application form dated 28.09.2018 seeking insurance cover under this policy was answered as "NO" by DLA. The said medical record was prior to the proposing the Insurance policy and the same was not disclosed to the Company with malafide intention. The opposite parties further stated that it is evident that the DLA had given wrong information and suppressed material facts in order to wrongfully obtain the subject policy from the Company. The policy in question was issued on 31.10.2018 and the DLA allegedly died on 05.12.2018 within 35 days from the date of issuance of policies. The alleged early death of the life assured and taking of high sum assured policy, clearly proves that the policy in question has been taken by the DLA only to play fraud with the opposite parties. The opposite parties further alleged that recently the Haryana Police Special Task Force (STF) unearthed a syndicated Insurance fraud in which the insurance policies were taken in the name of cancer/critical illness patient and thereafter their death was shown as accident in connivance with the Doctors and Police Officials and in this regard the STF has registered an FIR at Sonipat Police Station. The said gang was operating in Karnal, Sonipat, Rohtak, Jhajjar & Hissar Districts. The leading newspaper of Hindustan Times in its 15.05.2019 edition also highlighted the said scam in its full two pages article, which is reproduced as under:-           

“4. Haryana based Gang allegedly identified terminal cancer patients from rural, low income backgrounds, got them to insured themselves with multiple insurance companies by hiding their condition, waited for them to die and put their dead bodies through accidents. The gang kept a part of the insured sum, between Rs 8 and Rs 20 Lacs in each case and distributed the rest among its partners in crime i.e. family members, police officers, record keepers, Doctors, Insurance agents & public prosecutors. At least 100 people have been accused of being complicit in the scam that allegedly carried on for two years executed nearly a 100 cases and cheated more than 25 insurance companies of over 100 Crore according to STF.”

According to the opposite parties the facts of the present case are similar to the modus operandi used by the said syndicate fraud which has been unearthed by the Haryana STF as in the present case also the DLA died within short span. Prior to this, the deceased was having no policy. The complainant & DLA might have proposed multiple policies from other insurance companies. Taking of high sum assured policy corroborated the policy in question was taken only to play fraud and is a part of similar racket which was operating in the State of Haryana.

                   The opposite parties further stated that the insurance contracts are contracts based on “Utmost Good Faith” and the life assured/proper is bound to disclose all the material facts known to him at the time of proposal. Moreover, the contract of the insurance is based on the doctrine of “Uberrimae Fidei”. The insured is under obligation to give full and correct information. The complainant had concealed and suppressed material facts from this Commission. The life assured at the time of submitting the proposal form gave the answer of following questions in negative.

“Medical detail

Have you ever had symptoms of, been treated for, been advised to receive treatment or have undergone any investigations for any of the following. (The below conditions are provided as examples only and would request you to disclose all disorders, disease or other health conditions, which are, or might be relevant. If answer for any of the questions in this section is "Yes" please provide all medical reports, if available.)
1	High Blood Pressure, Chest Pain, Angina, Heart Attack or any other ailment pertaining to the Heart or Circulatory System?	N
2	Seizures, Stroke, Paralysis, Epilepsy, Parkinson's, Multiple Sclerosis or any other Disorder of the Brain or Nervous System?	N
3	Tuberculosis, Asthma, Bronchitis, Avian Flu, Shortness of Breath or any other Respiratory Disorder?	N
4	Cancer, Tumour, Cyst, Leukemia, Growth, Lump or other Malignancy?	N
5	Any Kidney, Liver, Bladder Disorder or Prostate Disease, Blood/Protein in Urine?	N
6	Ulcers or any Stomach or Intestinal Disorder?	N
7	Diabetes, Thyroid or any other Gland Related Disorders?	N
8	Any Disorder related to Ear, Nose and Throat?	N
9	Any Back, Arthritic, Joint or Bone Disorders or Skin Lesion?	N
10	Do you have Anaemia, Leukaemia or any other blood related disorders?	N
11	Depression, Stress, Anxiety, Attempt to Suicide or any other Psychological or Emotional Disorder or Nervous Breakdown or Mental Illness or symptoms of the same?	N
12	Have you or your spouse ever been tested of or received any medical advice, counseling or treatment in connection with HIV/AIDS or Hepatitis B/C orany Sexually Transmitted Diseases?	N
13	During the past five years,	N
(a)	Have you Consulted any doctor or health practitioner for illness lasting for more than 4 days except for fever, common cold or cough?	-
(b)	Have you Undergone ECG, x-rays, blood test or other tests?	-
(c)	Have been admitted/advised to be admitted to any hospital or any other medical facility?	-
14.	Do you have any Physical Deformity/Defect?	N
15	Has there been drastic weight loss or weight gain (>=5 Kgs) in the past year?	N
16	Have you undergone or been advised to undergo surgery of any kind or any major organ transplant?	N

 

The life assured also given the following declaration in the proposal form.

DECLARATION:

1/We have read this application or got read/ explained the Application, and furnished the information, after fully understanding the contents thereof. I/we have made complete, true and accurate disclosure of all facts to the best of my/our knowledge and belief and that I/we have not withheld any information. I/We hereby declare, on my/our behalf and on behalf of the person proposed to be insured, that the above statements, answers and/or particulars given by me/us are true and complete. In all respects to the best of my/our knowledge and that I/we am/are authorized to propose on their behalf. I/We understand that the information provided by me/us form the basis of the insurance policy and that the policy is subject to the Board approved underwriting policy of PNB Metlife India Insurance Company Limited (PNB Metlife) and that the cover will come into force and effect only after full receipt of the premium chargeable and upon issuance of the policy.

The opposite parties further asserted that they sought answers to specific health related question from the DLA during the proposal stage but the DLA deliberately and fraudulently concealed his prior medical ailments and replied all answers in negative for questions relating to heart ailments and past medical history and as such, the claim was validly repudiated.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties submitted that they received proposal/application form bearing No.678534598 signed by the DA for issuing insurance on his life under “PNB Metlife Mera Jeevan Suraksha Plan” on the basis of which the company issued the policy having following details:-

Policy No.	22683312
Policy plan	Metlife Mera Jeevan Suraksha Plan
Name of the Life Assured	Mr. Gulshan Kumar
Name of the Policy Holder	Mr. Gulshan Kumar
Premium amount	Rs.19,647/-
Premium Mode	Annual
Total Sum Assured	Rs.30,00,000/-
Date of issue	31.10.2018

The complainant was the nominee under the policy. The opposite parties further submitted that the policy in question was proposed by Mr. Gulshan Kumar in a preplanned manner in order to play fraud with the company. Routine medical tests i.e. Human Immuno Deficiency Virus-EI, Fasting Blood Sugar Test, Urine Routine Analysis, Serum Creatinine, Hepatitis-B Surface Anti were conducted and at the time of his medical examination, the DLA concealed the material fact about taking treatment by him at DMC, Ludhiana. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                The complainant filed replication to the written statement of opposite party No.1 and 2 reiterating the facts mentioned in the complaint and controverting those made in the written statement.

4.                In support of their claim, the complainants tendered their joint affidavit Ex. CA in which they reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents i.e. Ex. C1 is the copy of welcome letter and policy documents, Ex. C2 is the copy of proposal form, Ex. C3 is the copy of claim decision letter dated 16.05.2019, Ex. C4 is the copy of first premium receipt dated 02.11.2018, Ex. C5 is the copy of death summary of SPS Hospital, Ex. C6 is the copy of death certificate of Gulshan Kumar, Ex. C7 is the copy of Claimant Statement of Death Claim-Form A, Ex. C8 is the copy of PAN card of complainant No.1  Ritu, Ex. C9 is the copy of Aadhar card of complainant No.1 Ritu, Ex. C10 is the copy of Aadhar card of complainant No.2 Mudit Arora and closed the evidence. 

5.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Manoj Thakur, authorized signatory of the opposite parties along with documents Ex. OP1 is the copy of proposal form, Ex. OP2 is the copy of welcome letter and policy documents, Ex. OP3 is the copy of Claimant Statement for Death Claim-Form A, Ex. OP4 is the copy of investigation report of Sai Associate and Innogative Pvt. Ltd. Ex. OP5 is the copy of treatment record, Ex. OP6 is the copy of discharge summary of Hero DMC Heart Institute, Ludhiana, Ex. OP7 is the copy of claim decision letter dated 16.05.2019 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, replication, affidavit and annexed documents and written replies along with affidavit and documents produced on record by both the parties.

7.                On 28.09.2018, a proposal for obtaining the policy of insurance was submitted by Gulshan Kumar deceased. The proposal form Ex. C2 = Ex. OP1 contained “Medical Details”  respondend by deceased to the 16 queries as to whether the deceased had ever symptoms of, been treated for, been advised to receive treatment or have undergone any investigations with regard to the specific diseases therein. The deceased answered all the queries in ‘Negative’ and also submitted a categoric declaration to this regard. Relying upon the disclosures and declaration of the deceased, the opposite parties issued an insurance policy “PNB Metlife Jeevan Suraksha Plan” Ex. C1 = Ex. OP2 along with policy documents on 01.11.2018. The policy was valid for 18 years for a sum assured of Rs.30,00,000/-. On 13.11.2018, Gulshan Kumar was hospitalized at Bassi Hospital from where he was referred to Neuro City where he remained hospital from 13.11.2018 to 02.12.2018. Finally he was shifted to SPS Hospital on 02.12.2018 where he expired on 05.12.2018. Death summary is Ex. C5.

8.                Complainant No.2 being wife and nominee and complainant being son, preferred a claim dated 16.04.2019 Ex. C7 = Ex. OP3 which was investigated and processed by the opposite parties. M/s. Sai Associate & Innogative Pvt. Ltd. were appointed as investigator who submitted his final report Ex. OP4, operative part of which is reproduced as under:-

“The name of life assured was Mr. Gulshan Kumar, his date of birth was 27/06/1970 & he was 48 yrs. Old. By profession he was an accountant & his annual income was Rs.5,00,000 approx. He was died on dated 05/12/2018 in the SPS Hospital.

According to our report, LA was died due to Septic Shock, Multi Organ Failure in the SPS Hospital on dated 05/12/2018 as per the claimant and neighbours. Claimant also explained us that LA was suffering from urological problem and he had hospitalized on 13^th of November, 2018 in Bassi Hospital, Ludhiana. In 2015, he had some problem in the left leg and found that some blood clots and he had operated in Hero Heart DMC Hospital and after that operation; he was give up to 3 years. But, neighbours told us that before his death, he was suffered from hypertension and diabetes 2 and he was treated his disease from DMC Hospital, yet not sure about the date or year of his treatment. Dr. Gurpreet Singh declared LA was died on dated 05/12/2018 due to Septic Shock, Multi Organ Failure. When we checked in the DMC Hospital, then found that LA was a known case of Type 2 Diabetes Mellitus, Morbid obesity, Peripheral Artery Disease, Acute Limb Ischemia, Left Foot Drop, Thrombosis Left Femoral Artery, Post Left Femoral Artery Embolectomy, + Fasiotomy, Post Left leg Debridement.

LA was admitted in this hospital on dated 18.03.2015 and he was discharged on dated 01.04.2015 where his admission no. was 89991 as well as C.R. No. was 204577. The details are prior to proposal.

Before his death, LA was under treatment in Bassi Hospital for his disease. After two days of treatment, they referred him to Neurocity Hospital. Late on he was shifted him in the same day on 15^th of November, 2018. In the Neurocity Hospital, no recovery found in his health again on 02/12/2018 he was referred him to SPS Hospital but he could not survived and expired after three days of treatment on 05/12/2018 at 03:45 am. His cremation was done at local cremation ground in presence of all relatives and neighbours.”

9.                On the basis of the investigation report, whereby concealment of previous hospitalization from 04.02.2015 to 11.03.2015 and from 18.03.2015 to 01.04.2015 at DMC Hospital, Ludhiana was detected and on the basis of the investigation report, claim of the complainants was repudiated vide repudiation letter Ex. C3 = Ex. OP3. The operative part of the repudiation letter reads as under:-

“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. Gulshan Kumar was suffering from Morbid obesity, Peripheral Artery Disease, Acute Limb Ischemia, Left Foot Drop, Thrombosis Left Femoral Artery, Post Left Femoral Artery Embolectomy and Fasiotomy with Post Left leg Debridement prior to policy issuance. However, the concerned question in the application form dated 28/09/2018 seeking insurance cover under this policy was answered as “NO” by Late Mr. Gulshan Kumar.

We wish to state that the above mention 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 on existing terms/we would not have issued the policy at all. As you may be aware, Insurance contracts are based on the principles of “utmost food faith” and the policies are issued base 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.”

10.              The Insurance Regulatory and Development Authority of India (IRDAI) in its notification dated 16.10.2002 issued the Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations 2002 whereby the “Proposal Form” is defined in Regulation 2(d) as under:-

“2(d) “Proposal form” means a form to be filed in by a proposer for insurance, for furnishing all material information required by the insurer in respect of a risk, in order to enable the insurer to decide whether to accept or decline, to undertake the s\risk and in the event of acceptance of the risk, to determine the rates, terms and conditions of a cover to be granted.

Further Regulation 4, deals with proposals for insurance as under:-

1. Except in cases of a marine insurance cover, where current market practices do not insist on a written proposal form, in all cases, a proposal for grant of a cover, either for life business or for general business, must be evidenced by a written document. It is the duty of an insurer to furnish to the insured free of charge, within 30 days of the acceptance of a proposal, a copy of the proposal form.
2. Forms and documents used in the grant of cover may, depending upon the circumstances of each case, be made available in languages recognized under the Constitution of India.
3. In filling the form of proposal, the prospect is to be guided by the provisions of Section 45 of the Act. Any proposal form seeking information for grant of life cover may prominently state therein the requirements of Section 45 of the Act.
4. Where a proposal form is not used, the insurer shall record the information obtained orally or in writing, and confirm it within a period of 15 days thereof with the proposer and incorporate the information in its cover note or policy. The onus of proof shall rest with the insurer in respect of any information not so recorded, where the insurer claims that the proposer suppressed any material information or provided misleading or false information on any matter material to the grant of a cover.”

11.              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 held as under:-

(i) There is a duty or obligation of disclosure by the insured regarding any material fact at the time of making the proposal. What constitutes a material fact would depend upon the nature of the insurance policy to be taken, the risk to be covered, as well as the queries that are raised in the proposal form.

(ii) What may be a material fact in a case would also depend upon the health and medical condition of the proposer.

(iii) If specific queries are made in a proposal form then it is expected that specific answers are given by the insured who is bound by the duty to disclose all material facts.

(iv) If any query or column in a proposal form is left blank then the insurance company must ask the insured to fill it up. If in spite of any column being left blank, the insurance company accepts the premium and issues a policy, it cannot at a later stage, when a claim is made under the policy, say that there was a suppression or non­disclosure of a material fact, and seek to repudiate the claim.

(v) The insurance company has the right to seek details regarding medical condition, if any, of the proposer by getting the proposer examined by one of its empanelled doctors. If, on the consideration of the medical report, the insurance company is satisfied about the medical condition of the proposer and that there is no risk of pre­existing illness, and on such satisfaction it has issued the policy, it cannot thereafter, contend that there was a possible pre­existing illness or sickness which has led to the claim being made by the insured and for that reason repudiate the claim.

(vi) The insurer must be able to assess the likely risks that may arise from the status of health and existing disease, if any, disclosed by the insured in the proposal form before issuing the insurance policy. Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured.

(vii) In other words, a prudent insurer has to gauge the possible risk that the policy would have to cover and accordingly decide to either accept the proposal form and issue a policy or decline to do so. Such an exercise is dependant on the queries made in the proposal form and the answer to the said queries given by the proposer.               

In the present case, the opposite parties have sought the information with regard to pre-existing disease by making a specific 16 queries as detailed in para No.2 hereinbefore. It was the duty of the deceased to make full disclosure and no information, substance or interest was required to be concealed or omitted. It may be noticed that the deceased was admitted in Bassi Hospital within 12 days from the inception of the policy and practically, he remained as indoor patient till he breathed lastly on 05.12.2018. So he died within 35 days from the issuance of the policy.

12.              Section 45 of the Insurance Act provides that no policy of life insurance shall after the expiry of three years from the date on which it was effected, be called in question by an insurer of the Policy, was inaccurate of false, unless the insurer shows that statement was on material to disclose and that it was fraudulently made by the Policy holder and that the policy holder knew at the time of making it that the statement was false or that it was material to disclose. The previous admission/hospitalization of the deceased from DMC Hospital, Ludhiana was a relevant and material fact which was required to be disclosed at the time of obtaining the policy in question by the insured/deceased. So there is a concealment and suppression of material facts which could have affected the decision of the opposite parties with regard to the terms and conditions of the policy. So the opposite parties have rightly revoked Section 45 of the Insurance Act.

                   Reference can be made to Branch Manager, Bajaj Allianz Life Insurance Company Ltd. and others Vs Dalbir Kaur in 2021 (217) AIC 50 whereby the Hon’ble Supreme Court of India has held that the contract of insurance is one of the utmost good faith and proposer who seeks to obtain policy of life insurance is duty bound to disclose all material facts bearing upon issue as to whether insurer would consider it appropriate to assume risk which is proposed. The Hon’ble Supreme Court has further held that the proposer failed to disclose vomiting of blood which had taken place barely month prior to issuance of policy of insurance and of hospitalization which had been occasioned as consequences. The assured was suffering from pre-existing ailment and judgment of NCDRC directing payment of sum insured was set aside.  

                   Further reference can be made to Reliance life Insurance Co. Ltd. and others Vs Rekhaben Nareshbhai Rathod in 2019 (2) R.C.R. (Civil) 909 whereby the Hon’ble Supreme Court of India has held that two months prior to policy obtained from appellant insured obtained policy from another company and this fact was not disclosed by the insured. Repudiation was made within two years period from commencement of insurance cover. The proposer was aware of contents of form that he was required to fill and disclosure of material for assessment of risk which was being taken by insurer which entitled the insurer to repudiate the claim. In the light of above said facts and circumstances, the opposite parties were justified in repudiating the claim of the complainant and as such, there is no deficiency in service on the part of the opposite parties.

13.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

14.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:09.06.2023.

Gobind Ram.

 

 

Ritu Vs PNB Metlife                                                      CC/21/56

Present:       Sh. Narinder Singh, Advocate for complainant.

                   Sh. Sudhir Gakhar, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:09.06.2023.

Gobind Ram.