Sh.Anoop Sharma, Presiding Member
1. The complainants have brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that Ashok Kumar purchased policy No.21557885 from the Opposite Parties and said Ashok Kumar father of complainant No.1 and 2 and husband of complainant No.3 died leaving behind above three legal heirs/ complainants. Unfortunately Ashok Kumar insured person died on 6.11.2015 for which the complainants lodged claim with the Opposite Parties and completed all the formalities. Thereafter, the complainants sent so many letters/ reminders for payment of insurance amount and the Opposite Parties vide letter dated 1.1.2016 informed the complainants that their claim has been approved for Rs.9,99,990/-, copy of letter is attached. Not only this, the original policy and other relevant documents submitted with claim application are lying with Opposite Parties. But all of the sudden in a arbitrary and illegal manner sent a letter dated 8.4.2016 to the complainants alleging that they had reviewed and evaluated the claim and during the course of reviewing the claim, they have received medical records which indicate that Ashok Kumar was suffering from Chronic Kidney Disease prior to the issuance of the policy. Further in this letter, the Opposite Parties alleged that they had transferred the fund value of Rs.75,670.44 paisa accrued in the account No.444OU16057451478 being full and final payment of the claim of the complainants as per the terms and conditions of the policy. This act of the Opposite Parties is totally unwarranted, illegal and unconstitutional, however, the complainants are entitled to the amount of sum insured. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Parties be directed to make the payment of claim amount alongwith interest @ 12% per annum for the delayed period and also pay compensation of Rs.1 lac for causing mental tension, harassment and agony to the complainants on account of unfair trade practice and deficiency in service plus litigation expenses against the Opposite Parties.
Hence, this complaint.
2. Upon notice, opposite parties appeared and contested the complaint by filing joint written statement taking preliminary objections therein inter alia that the instant complaint is false, malicious, incorrect and with malafide intent and is nothing, but an abuse of the process of law. It is submitted that late Ashok Kumar-DLI (deceased life insured) after completely understanding the terms and conditions of the product had submitted the duly signed proposal form dated 8.4.2015 and offered to pay Rs.99,999/- annually towards the initial premium against the sum assured of Rs.9,99,900/-. It is submitted that the contents of the proposal form were explained to the DLI 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 had applied for and has made true and accurate disclosure of all the facts and has not withheld by information. In the said proposal form, the DLI replied that he was not suffering from any disease neither he was taking any medical treatment and on the basis of information furnished by DLI the policy in question was issued with risk commencement dated 10.04.2015. It is submitted that the Opposite Party received the death claim intimation dated 17.12.2015 from the complainant thereby intimating that the person insured died on 6.11.2015 which was duly acknowledged by the Opposite Party vide letter dated 18.12.2015. During the course of investigation and assessment of the claim, it was revealed that the DLI was suffering from chronic kidney disease and was on dialysis for the last one year. The medical documents of Tagore Hospital and heart care centre, Jalandhar clearly establishes that the DLI was suffering from chronic kidney disease and was on Haemo-Dialysis for the past one year i.e. prior to the issuance of the policy. It is once again pertinent to mention that the DLI by concealing this material fact with respect to his medical history, played fraud upon the Opposite Party induced the Opposite Party to issue the policy in his favour. It is also to be noted that the DLI expired only within a short span of 7 months from the date of issuance of the policy. Even after being aware that he was suffering from such a deadly disease, he opted for the policy to get the undue advantage out of the same and provided false information in the proposal form. On merits, the Opposite Parties took same and similar pleas as taken up by them in the preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. In their bid to prove the case, complainant tendered into evidence affidavit Ex.CW1/A in support of the allegations made in the complaint and also produced copies of documents Ex.C1 to Ex.C3 and closed their evidence.
4. On the other hand, to rebut the evidence of the complainant, the Opposite Parties tendered into evidence the affidavit of Sh.Motty John, Legal General manager Ex.OP1,2/A alongwith copies of documents Ex. OP1,2/1 to Ex.OP1,2/4 and closed the evidence on behalf of the Opposite Parties.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. Ld.counsel for the complainants has reiterated the facts as narrated in the complaint and contended that Ashok Kumar purchased policy No.21557885 from the Opposite Parties and said Ashok Kumar father of complainant No.1 and 2 and husband of complainant No.3 died leaving behind above three legal heirs/ complainants. Unfortunately Ashok Kumar insured person died on 6.11.2015 for which the complainants lodged claim with the Opposite Parties and completed all the formalities. Thereafter, the complainants sent so many letters/ reminders for payment of insurance amount and the Opposite Parties vide letter dated 1.1.2016 informed the complainants that their claim has been approved for Rs.9,99,990/-, copy of letter is attached. Not only this, the original policy and other relevant documents submitted with claim application are lying with Opposite Parties. But all of the sudden in a arbitrary and illegal manner sent a letter dated 8.4.2016 to the complainants alleging that they had reviewed and evaluated the claim and during the course of reviewing the claim, they have received medical records which indicate that Ashok Kumar was suffering from Chronic Kidney Disease prior to the issuance of the policy. Further in this letter, the Opposite Parties alleged that they had transferred the fund value of Rs.75,670.44 paisa accrued in the account No.444OU16057451478 being full and final payment of the claim of the complainants as per the terms and conditions of the policy. This act of the Opposite Parties is totally unwarranted, illegal and unconstitutional, however, the complainants are entitled to the amount of sum insured.
7. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contentions of the ld.counsel for the complainant on the ground that late Ashok Kumar-DLI (deceased life insured) after completely understanding the terms and conditions of the product had submitted the duly signed proposal form dated 8.4.2015 and offered to pay Rs.99,999/- annually towards the initial premium against the sum assured of Rs.9,99,900/-. It is submitted that the contents of the proposal form were explained to the DLI 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 had applied for and has made true and accurate disclosure of all the facts and has not withheld by information. In the said proposal form, the DLI replied that he was not suffering from any disease neither he was taking any medical treatment and on the basis of information furnished by DLI the policy in question was issued with risk commencement dated 10.04.2015. It is submitted that the Opposite Party received the death claim intimation dated 17.12.2015 from the complainant thereby intimating that the person insured died on 6.11.2015 which was duly acknowledged by the Opposite Party vide letter dated 18.12.2015. During the course of investigation and assessment of the claim, it was revealed that the DLI was suffering from chronic kidney disease and was on dialysis for the last one year. The medical documents of Tagore Hospital and heart care centre, Jalandhar clearly establishes that the DLI was suffering from chronic kidney disease and was on Haemo-Dialysis for the past one year i.e. prior to the issuance of the policy. It is once again pertinent to mention that the DLI by concealing this material fact with respect to his medical history, played fraud upon the Opposite Party induced the Opposite Party to issue the policy in his favour. It is also to be noted that the DLI expired only within a short span of 7 months from the date of issuance of the policy. Even after being aware that he was suffering from such a deadly disease, he opted for the policy to get the undue advantage out of the same and provided false information in the proposal form.
8. It is not the denial of the case of the parties that Ashok Kumar purchased policy No.21557885 from the Opposite Parties and said Ashok Kumar father of complainant No.1 and 2 and husband of complainant No.3 died leaving behind above three legal heirs/ complainants. Unfortunately Ashok Kumar insured person died on 6.11.2015 for which the complainants lodged claim with the Opposite Parties. The case of the Opposite Parties is that late Ashok Kumar-DLI (deceased life insured) after completely understanding the terms and conditions of the product had submitted the duly signed proposal form dated 8.4.2015 and offered to pay Rs.99,999/- annually towards the initial premium against the sum assured of Rs.9,99,900/-. It is submitted that the contents of the proposal form were explained to the DLI 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 had applied for and has made true and accurate disclosure of all the facts and has not withheld by information. In the said proposal form, the DLI replied that he was not suffering from any disease neither he was taking any medical treatment and on the basis of information furnished by DLI the policy in question was issued with risk commencement dated 10.04.2015. It is submitted that the Opposite Party received the death claim intimation dated 17.12.2015 from the complainant thereby intimating that the person insured died on 6.11.2015 which was duly acknowledged by the Opposite Party vide letter dated 18.12.2015. During the course of investigation and assessment of the claim, it was revealed that the DLI was suffering from chronic kidney disease and was on dialysis for the last one year. The medical documents of Tagore Hospital and heart care centre, Jalandhar clearly establishes that the DLI was suffering from chronic kidney disease and was on Haemo-Dialysis for the past one year i.e. prior to the issuance of the policy. But the Opposite Party could not produce any treatment record of DLA Ashok Kumar prior to inception of the policy nor the Opposite Party could examine any doctor or medical practitioner who treated the patient for the aforesaid diseases nor the Opposite Party filed any affidavit of any doctor who ever diagnosed or treated DLA for the aforesaid diseases prior to the obtaining of the policy. So the Opposite Party could not produce any medical treatment record of DLA Ashok Kumar to prove that he was suffering from or he had knowledge that he was suffering from any such disease prior to inception of the policy. It has been held by the Hon'ble State Commission of Punjab in case Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease which was not disclosed- apparently, burden to prove lies upon the insurer- If assured was suffering from pre-existing disease why insurer had not checked it at the time when proposal form was accepted by its staff. Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled to claim alongwith interest @ 9%.
- Ld.counsel for the Opposite Party further submitted that it is a case of early death i.e. immediately after taking the policy in question. This plea of the ld.counsel for the Opposite Party is not tenable, because DLA Asho Kumar was insured with policy in question issued by the Opposite Party with date of commencement 10.04.2015. As such, we hold that Opposite Party was not justified in repudiating the claim of the complainant on the ground that the DLA Ashok Kumar was suffering from any such disease at the time of taking the policy and he had not disclosed these facts to the Opposite Party.
- Consequently, we allow the complaint with costs and the Opposite Parties are directed to pay the insured amount to the complainants after deducting the payment, if any, already made to the complainants, within one month from the date of receipt of copy of this order failing which the complainants shall be entitled to interest @ 6% per annum on this amount from the date of filing of the complaint till the payment is made to the complainant. Opposite Parties are also directed to pay litigation expenses to the complainants to the tune of Rs. 2000/-. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
