BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.              

                                                          Consumer Complaint no. 250 of 2018                                                              

                                                        Date of Institution :    11.10.2018

                                                          Date of Decision   :    05.08.2022.

Smt. Gomati Devi widow of Rameshwar Suthar, VPO Risaliakhera, District Sirsa.

                      ……Complainant.

                             Versus.
PNB Metlife India Insurance Company Ltd., Office of the Insurance Ombudsman SCO No.101, 102 & 103, 2^nd Floor, Batra Building, Sector-17D, Chandigarh- 160017.

…….Opposite Party

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

Before:       SH. PADAM SINGH THAKUR……. PRESIDENT

                   MRS.SUKHDEEP KAUR……………MEMBER.

                   SH. SUNIL MOHAN TRIKHA……… MEMBER             

Present:       Sh. S.L. Sidhu,  Advocate for the complainant.

                   Sh. Amit Goyal, Advocate for opposite party.

ORDER

                   In brief, the case of the complainant is that complainant is widow of Rameshwar Suthar son of Sh. Dungar Ram. The husband of complainant namely Sh. Rameshwar Suthar had purchased a policy bearing no. 21534540 from op for which premium amount of Rs.30,000/- per annum was to be paid for five years and after its maturity, an amount of Rs.3,00,000/- was to be paid by the op to the husband of complainant. That husband of complainant had paid three installments of Rs.30,000/- each on 23.3.2015, 29.4.2016 and 9.5.2017 from his account bearing No. 7317000100012709 maintained with Punjab National Bank, branch Risaliakhera, District Sirsa. It is further averred that Sh. Rameshwar husband of complainant expired on 25.6.2017 due to severe heart attack in the hospital at Bathinda. The complainant being nominee of his deceased husband is entitled for the above said amount of her husband. The complainant approached the op and requested to release the insured policy amount to her and also submitted all the required documents as demanded from complainant but thereafter op started to put off the matter on one pretext or the other and now op has flatly refused to pay the insured amount of policy to the complainant. In this way, the op is unnecessary harassing the complainant. It is further averred that complainant served a registered legal notice upon op on 18.08.2018 but the op intentionally did not receive the same and same was returned back to the complainant and has caused deficiency in service towards the complainant. Hence, this complaint.

2.       On notice, opposite party appeared and filed written statement taking preliminary objections that contract of insurance is a contract based on uberrimaefidei i.e. utmost good faith. The person seeking insurance is expected to maintain a higher and rigorous standard of good faith and he is having full knowledge, therefore, he is under an obligation to make a full and honest disclosure of the facts and materials to the insurer at the time of proposal as sought in the proposal form, that in the present case late Mr. Rameshwar Dass (hereinafter referred to as deceased life assured) suppressed material fact that he was suffering from diabetes mellitus Type II and was under treatment for the same since prior to insurance of subject policy. That even after being aware of his ailment he suppressed the same which amounts to material suppression of fact. During investigation, authorized investigator met complainant who provided her written statement wherein she categorically stated that DLA was suffering from diabetes mellitus type 2 since last three four years. Further Sarpanch has also given his statement stating the same pertaining to DLA. That through investigation, medical record in the name of DLA were also procured proving beyond any doubt that DLA had taken treatment from different hospital/s clinics and underwent various tests. Therefore, DLA was completely aware of his ailments, however deliberately suppressed the same in order to mislead insurance company. It is further submitted that even after receiving of repudiation letter, which is put on record by complainant alongwith complaint, complainant has not denied throughout her complaint about fact of pre-existing illness and therefore, same is admitted on the part of complainant, hence present complaint is liable to be dismissed in view of suppression of material acts by DLA at the time of issuance of subject policy; that it is well settled principle of law that a nominee of insurance policy is not the beneficiary under a life insurance policy and since complainant is not beneficiary of those services, complaint is liable to be dismissed.

3.       On merits, the pleas taken in the preliminary objections are reiterated. It is submitted that insurance company was in receipt of duly filled and signed proposal form from DLA for issuance of insurance policy on his life as per details filled in the proposal form. That DLA had responded in negative as to all questions seeking medical history of DLA thereby keeping op under the impression that DLA was a hale and healthy person and was not suffering from any health issues. It is further submitted that specifically question no.7 under Medical Details has been reproduced herein for perusal:

                   Further, one Pawan Kumar had signed declaration in the proposal form declaring that he had truthfully recorded the replies in the proposal form as given by the life assured/ proposer after fully explaining the contents of the form and life assured/ proposer has fully understood the contents of the same. Further DLA also put thumb impression under the declaration stating that the contents of the proposal form have been fully explained to him and on understanding the substance he had provided his response. Hence, op relied upon the contents of the proposal form since DLA was the appropriate individual knowing all facts about himself. It is further submitted that had op been aware about said true facts at the time of assessment of risk, op would not have certainly issued subject policy at all. That on the basis of these conclusion during the claim assessment of the deceased, the death claim was repudiated on the ground of non disclosure of prior medical conditions in the proposal form and same was conveyed to complainant vide letter dated 17.2.2018. Further as a gesture of good will, op duly refunded the premium paid under subject policy amounting to Rs.91,239.35 which was paid to complainant through online bank transfer to bank account of complainant. It is further submitted that claim under subject policy is not payable as per the terms and conditions of the subject policy. As per terms and conditions of the policy, in case of suppression of material facts, op is well within its right to reject the claim. Remaining contents of complaint are also denied and prayer for dismissal of complaint made.

4.       The complainant has tendered her affidavit Ex.CW1/A, repudiation letter dated 7.9.2018, copy of letter dated 17.2.2018 Ex.C2, copy of legal notice Ex.C3, certificate of doctor regarding death of Rameshwar Dass Ex.C4, copy of pass book Ex.C5 and copy of adhar card of complainant Ex.C6.

5.       On the other hand, op has tendered affidavit of Sh. Arijit Basu, National Nodal Officer & Senior Manager Legal Ex.R1, copy of policy features, benefits and premium payment conditions Ex.R2 with copy of proposal form, copy of death/ disability/ critical illness claim intimation Ex. R3, copy of investigation report Ex.R4, copy of statement of Sarpanch of Gram Panchayat Risaliakhera Ex.R5, copy of statement of complainant Ex.R6 and copies of treatment record of Rameshwar Ex.R7 (pages 1 to 29) and letter dated 17.2.2018 Ex.R8.   

6.We have heard learned counsel for the parties and perused the case file carefully.

7.Admittedly, the husband of complainant namely Rameshwar obtained policy from op and he was to pay premium amount of Rs.30,000/- per annum for five years and sum insured in the policy was Rs.3,00,000/-. It is also undisputed fact between the parties that husband of complainant paid three installments of Rs.30,000/- each on 23.3.2015, 29.4.2016 and on 9.5.2017 and said fact is also proved from copy of pass book placed on file by complainant as Ex.C5. The complainant is nominee of Rameshwar life assured in the said policy. On 24.6.2017, the husband of complainant Rameshwar was taken to Delhi Heart Institute & Multispecialty Hospital, Bathinda as he suffered heart attack and he died on 25.6.2017 due to heart attack and in this regard doctor of said hospital has given certificate Ex.C4 that his death was due to heart attack. After death of life assured, complainant approached to op for release of claim amount i.e. insured amount in the policy and submitted claim form and also submitted all the relevant documents to the op as is evident from claim form Ex.R3 but however, the claim of the complainant was repudiated vide letter dated 17.2.2018 on the ground of non disclosure of prior medical conditions in the proposal form. The op has averred that deceased life assured Rameshwar was suffering from Diabetes Mellitus Type II disease prior to the inception of the policy in question and was under treatment from various hospitals for the same since last 3-4 years from the date of issuance of the policy in question but in the proposal form he had suppressed about the said disease and as such op has rightly rejected the claim of the complainant on the ground of concealment of material fact regarding health of life assured at the time of taking the policy in question. The op has also refunded the premium amount of Rs.91,239.35 to the complainant while rejecting the claim of the complainant.

8.No doubt, in the proposal form against the question No.7 allegedly put to the life assured that whether he is suffering from Diabetes, Thyroid or any other gland related disorders, answer has been tick-marked as ‘NO’. Similarly beside question no.7 regarding suffering of above said diseases, the proposal form also contain total 18 questions regarding ever suffering of any of chronic diseases and answers of these questions have also been tick marked as NO. Though, op has pleaded that one Pawan Kumar had signed declaration in the proposal form declaring that he had truthfully recorded the replies in the proposal form as given by the life assured after fully understanding the contents of the form, but however, said plea of op is not proved through any cogent and convincing evidence. The op has not furnished affidavit of said Pawan Kumar that he actually put above said questions regarding health to life assured Rameshwar and he replied the above said answer to the questions in negative i.e. he was not suffering from any diseases as mentioned in questions No.1 to 18. Rather it appears from the proposal form itself that the person who filled the proposal form himself tick marked the answers as NO in the proposal form. It is also a general practice that at the time of selling of insurance policies to the customers, the agent of the insurance company himself fills proposal form and at that time no care is taken that person to whom they are selling insurance policies is suffering from any disease or not and insurance is done without knowing actual disease of the insured. So, in this case it cannot be said at all that deceased life assured voluntarily and intentionally concealed the factum of his pre-existing disease from the op at the time of issuance of the policy in question. Moreover,Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.”

9.The above said authority is also fully applicable to the facts and circumstances of the present case. The contention of op that they have rightly repudiated the claim of complainant as deceased life assured suppressed his disease of diabetes mellitus at the time of taking policy in question has no substance because op has failed to prove on record that deceased life assured himself denied that he was not suffering from said disease and therefore, suppression of pre-existing disease is not proved at all. Though, op has relied upon medical record of treatment of diabetes of life assured and also statements of complainant and Sarpanch but the said evidence is immaterial in this case because the op should have proved through cogent and convincing evidence that is by examining the person who filled proposal form to prove the fact that deceased himself denied about having any pre-existing disease. Moreover, insurance company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing policy whether a person is fit to be insured or not. It appears that insurance companies do not discharge this obligation as half of the population is suffering from such disease and they would be left with no or very little business. Further more, if such a disease that can be easily detected by subjecting the insured to basic tests like blood test etc., the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person. In the present case, it has not come on record that life assured was subjected to medical examination before issuing of the policy in question and therefore, now the op insurance company is estopped from taking such plea of suppression of pre-existing disease by the life assured. Reliance in this regard can be placed on the observations of the Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Oriental Insurance Company Ltd. vs. Sunil Dutt Singla & Ors. FA No.40 of 2019 decided on 10.11.2020.  Moreover, the deceased life assured suffered sudden attack of cardiac arrest and died due to heart attack and there is no nexus between cause of death and disease of diabetes from which he was suffering. In these circumstances, the op insurance company has wrongly, illegally and arbitrarily repudiated the genuine claim of the complainant and thus repudiation of the claim of complainant is set aside. The complainant being nominee is entitled to insured amount of Rs.3,00,000/- from the op insurance company. Since, the op insurance company has already made payment of 91,239.35 being premium amount of three installments, therefore, op is liable to pay remaining amount of insured amount after deducting the above said amount of Rs.91,239.35 to the complainant.

10.     Keeping in view of our above discussion, we allow the present complaint and direct the opposite party to make payment of Rs.2,08,760.65 to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to interest on the above said amount at the rate of @6% per annum from the date of this order till actual payment. We also direct the op to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant. The op is liable to comply with this order within above said stipulated period of 45 days from the date of receipt of copy of this order, failing which complainant will be at liberty to initiate proceedings under Section 71/72 of the Act against the op. A copy of this order be supplied to the parties as per rules. File be consigned to the record room after due compliance.                                       

Announced.                    Member     Member                          President,

Dated: 05.08.2022.                                                        District Consumer Disputes

                                                                             Redressal Commission, Sirsa.

JK