DEBASIS BHATTACHARYA:- PRESIDING MEMBER
The instant case filed under section 35 of the Consumer Protection Act 2019 arises out of the grievances of the complainant, being the sole nominee, in the matter of repudiation of a claim against two Insurance policies of Reliance Nippon Life Insurance Company Limited i.e. OP 1 and OP 2 in general, purchased by one Sri Nikhil Mazumdar, since deceased. The Complainant as it is mentioned earlier is the nominee of the deceased insured in the instant case.
The brief facts of the case is that one Sri Nikhil Mazumder, since deceased, purchased two insurance policies from the OP Insurance Company one on 19.12.2019 and the other on 08.12.2020. Sri Mazumder is claimed to have paid due premiums in respect of the said policy. Reportedly Sri Mazumder had to undergo certain medical tests at the pathological laboratory nominated by the OP Insurance Company prior topurchase of the said policies. Thus the proposal of Sri Mazumder was accepted by the OP Insurance Company on being satisfied about the state of health of Sri Mazumder.
Here, at this point, it is claimed by the Complainant that Sri Mazumder at the time of
inception of the policy, was ‘made to put his signature’ in the proposal form and trusting the concerned agent i.e. OP 3 in the instant case, Sri Mazumder put his signature. It is further claimed that that the rest of the form was filled up by the agent or on her direction by some other person but not by the insured person i.e. Sri Nikhil Mazumder. Reportedly at that point of time, Sri Mazumder had good health and that was certified and verified by the concerned agent.
However on 03.08.2021 Sri Nikhil Mazumder expired due to massive cerebral attack and that was certified by one Dr. Partha Pratim Dutta, a homeopath.
Subsequent to that, intimation of death was conveyed to the OP Insurance Company on 28.08.2021 and the relevant claims against the policies were lodged with the said Insurance Company.
On 03.09.2021 OP Insurance Company by a letter asked the Complainant to submit certain documents pertaining to the deceased Sri Nikhil Mazumder.
On 25.12.2021 the OP Insurance Company sought for certain other documents viz. family physician’s certificate stating the health condition of the insured person, bank statement for last two years and duration of diabetes mellitus and hypertension of the insured person.
The Complainant claims to have submitted all the required papers including the medical certificate issued by one Dr. Uttam Kumar Mondal, stating the status of health of Sri Mazumder who was his patient since 2019.
Finally, by a communication dated 29.03.2022, the OP Insurance Company repudiated the claim stating that there was active concealment/non-disclosure of material information and also false and inaccurate answers and thus the claim was repudiated in terms of Section 45 of the Insurance Act 1935.
On 26.05.2022, the Complainant requested the OP Insurance Company to pass necessary order and settle the dispute.
On 15.06.2022 the OP Insurance Company through an e-mail refused to entertain the claim/request.
Thereafter the issue was referred to the Insurance Ombudsman on 11.07.2022 but after hearing, the claim was rejected by that forum by an order dtd. 14.09.2022.
Now the Complainant claims that the insured Sri Nikhil Mazumder during his lifetime was a reputable person and there is no question of any suppression and non-disclosure of material facts. The Complainant further submits that as thorough check-up and verification of medical reports by the OP Insurance Company preceded the opening of the policies, the repudiation was thoroughly unjustified. This repudiation of claims allegedly on false and frivolous grounds, causing mental agony and financial loss, compelled the Complainant to approach to this Commission with a prayer to impose direction upon the OP not only to liquidate the claim amount but to pay compensation to the extent of Rs.8,00,000/- , litigation cost of Rs.50,000/-, cost of the suit and any other relief/reliefs as is found fit and proper.
In spite of proper service of notices none of the opposite parties appeared before this Commission at any stage of the proceedings of the case. Thus, the case ran ex parte against all the opposite parties.
The petitioner to substantiate his complaint has annexed copies of documents like 1) Policy documents, 2) Medical Reports of the concerned pathological laboratory, nominated by the OP Insurance Company 3) SMS received from the OP Insurance Company, 4) Initial premium and renewal premium deposit receipt, 5) Post expiry report issued by the concerned physician 6) Medical prescription of another physician dtd.26.12.2021, 7) The repudiation letter dtd.29.03.2022, 8) Communication dtd.26.05.2022 made by the Complainant to the OP Insurance Company, 9) E-mail dtd.15.06.2022 received from the OP Insurance Company, 10) Insurance Ombudsman’s observation dtd.14.09.22 and 11) Order of the NCDRC in the case of LIC of India vs. Mamata Sipani dt.02.03.2022
Evidence on affidavit and brief notes of argument filed by the complainant are almost a replica of the complainant petition.
In view of the discussion made hereinabove and on examination of available records, it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(7)(ii) of the Consumer Protection Act 2019 are concerned.
One of the opposite parties, at the time of institution of the complaint had a branch office within the district of Hooghly. The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/- Thus this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
Now the issues, whether there was any deficiency on the part of the Opposite parties and whether the Complainant is entitled to get any relief, are taken together for the sake of convenience as the issues are mutually interrelated.
Decision with reasons:-
Materials on records are perused.
So far as the terms and conditions related to the policies, incorporated in the key feature documents and customer Information Sheet are concerned, pre-existing disease means any condition, ailment, injury or disease;
- That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or
- For which medical advice or treatment was recommended by, or received from a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.
Now in the instant case, the first policy was incepted on 19.12.2019 and the second on 08.12.2020. On 28.08.2021 the intimation of death was passed on to the OP Insurance Company and the claim against the policies was also lodged on the same day. Thus within 48 months from the date of inception of the first policy the claim was lodged.
While repudiating the claim the OP Insurance Company mentioned in their letter that during processing of the claim it was found that there was an active concealment and non-disclosure of a material fact that the Life Assured Mr. Nikhil Mazumder was suffering from diabetes and mild left ventricular systolic dysfunction in June 2019. Reportedly it was also found that Sri Mazumder had history of Coronary Artery Angiography two years back and diabetes type 2 since 8-9 years which is prior to the inception of the policies and same were left undisclosed in the proposal form dtd.10.12.2019.
Here it will not be irrelevant to refer to the observation made by the Insurance Ombudsman.
It transpires from The Insurance Ombudsman’s observation which is filed by none other than the Complainant himself, that since this was an early claim and as per regulation 16(2), The OP Insurance Company initiated investigation through one ‘Maddox Investigation Services Pvt. Ltd.’, wherein investigation revealed that Sri Mazumder was suffering from Hypertension, Type 2 Diabetes Mellitus and Hyperlipidaemia and also underwent Coronary Artery Angiography.
However while answering to the SMQ (Short Medical Questionnaire) incorporated in the proposal form, the deceased life assured (hereinafter referred to as DLA) did not disclose the material facts.
It further appears from the observation of the Insurance Ombudsman that the DLA prior to his expiry was admitted into a hospital in one occasion and the OP Insurance Company produced papers before the Insurance Ombudsman, of Emergency Department of that hospital dtd.28.05.2021. From the discharge summary of that hospital dtd.28.05.2021 it was revealed that the DLA had undergone Coronary Angiography two years back i.e. in 2019. The Insurance Ombudsman points out that the discharge summary also mentioned the diagnosis as ischemic heart disease, minor coronary artery disease, systemic hypertension, Type-2 Diabetes Mellitus.
Even without being influenced by the observation of another statutory authority it can be said that the Complainant has not submitted any sort of rebuttal so far as the revelations as highlighted by the Insurance Ombudsman are concerned.
For a fitting rebuttal to the observation made by the Insurance Ombudsman the Complainant should have produced exhaustive medical documents related to the treatment and hospitalization of the DLA which is reported to have been happened at a particular point of time between inception of the policies and the expiry of the DLA.
The policies in the name of the DLA were incepted when he was 53/54 years old. The claim arose within 20(twenty) months of the inception of the policies. Naturally the claim was an early one.
The Complainant in his petition took recourse to the plea that the DLA during the time of purchase of the policies was made to put his signature in the proposal form and ‘on the basis of trust on the agent’ put his signature. Allegedly the rest of the form was filled up by the agent or on her direction by any other person but not by the insured person. Obviously, these are all allegations and apparently baseless allegations. The Commission cannot be inclined to take these allegations into consideration.
The Commission is compelled to observe that the plea taken by the Complainant is too hollow to be appreciated.
Now considering the facts and circumstances of the case the Commission is of the opinion that the possibility of non-disclosure/suppression of medical history of the DLA to a considerable extent at the time of submission of the proposal forms cannot be ruled out.
Thus, so far as the terms and conditions of the said insurance policies are concerned, the OP Insurance Company was not in a position to entertain the claims. Considering the facts and circumstances of the case this District Commission draws the inference that any sort of mala fide intention of the OP insurance Company cannot be substantiated.
Hence, it is
ORDERED
that the Complaint case no.238/2022 be and the same stands dismissed ex parte with no order as to costs.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgements/sent by ordinary post for information and necessary action.
