Punjab

StateCommission

FA/494/2014

Aviva Life Insurance Company Limited - Complainant(s)

Versus

Sawinder Singh - Opp.Party(s)

Sanjeev Goyal

01 Mar 2016

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,   PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

                                     

                   First Appeal No.494 of 2014

 

                                                Date of Institution: 28.04.2014

                                                Date of Decision:  01.03.2016

 

Aviva Life Insurance Company India Limited, Branch Office, SCO 32, Pal Plaza, 3rd Floor, District Shopping Complex, B-Block, Ranjit Avenue, Amritsar through their Duly Constituted Attorney Vivek Yadav available at Aviva Tower, Sector Road, Opposite DLF Golf Club, Sector 43, Gurgaon 122003.

 

                                                                   Appellant/Opposite party

                             Versus

 

Sawinder Singh S/o Sh. Jaswant Singh, resident of House No.126, Paris Avenue, Wadali Road, Chheharta, Amritsar

 

 

                                                                  Respondent/Complainant

         

First Appeal against order dated 18.02.2014 passed by the District Consumer Disputes Redressal Forum,  Amritsar.

Quorum:-

          Shri J. S. Klar, Presiding Judicial Member.

            Shri.H.S.Guram, Member

Present:-

          For the appellant              : Sh.Sanjeev Goyal, Advocate 

          For the respondent          : Sh.Munish Goyal, Advocate

          . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

         J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

          Aggrieved by order dated 18.02.2014 of District Consumer Disputes Redressal Forum Amritsar (in short, the District Forum), the appellant of this appeal (the opposite party in the complaint) has directed this appeal against the respondent of this appeal (the complainant in the complaint). The District Forum, Amritsar accepted the complaint of the complainant by directing the OP to pay the insured amount of DLA Paramjit Kaur to complainant to the tune of Rs.12 lacs within one month from the copy of receipt of this order, failing which complainant shall be entitled to interest @ 9% p.a from the date of filing the complaint till payment, besides Rs.2,000/- as costs of litigation. The instant appeal has been preferred against the same by the opposite party now appellant in this appeal.

2.      The complainant Sawinder Singh has filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OP on the averments that the representative of the OP prevailed upon mother of the complainant to purchase the policies. The mother of the complainant obtained three policies, vide proposal form bearing no.000925 for Rs.5 lac against annual premium of Rs.25258/-, proposal form bearing no.012700 for Rs.4 lac against annual premium of Rs.20206/- and proposal form bearing no.008445 for Rs.3 lacs against annual premium of Rs.15232 covering total risk of Rs.12 lac. The mother of complainant appointed complainant, as her beneficiary under the above policies. She was medically checked up by empanelled doctors of OP and was found all right. Unfortunately, she felt ill and was admitted in the hospital on 26.12.2011 for treatment, where she had died on 09.01.2012. The complainant being legal heir of her mother lodged the insurance claim with OP for disbursement of the insured amount of Rs.12 lac. The complainant received three letters i.e. Claim Decline Letters dated 27.03.2012 in respect of policy for Rs.5 lacs and two letters dated 24.09.2012 in respect of policies of Rs.4 lac and Rs.3 lacs respectively from OP, vide which OP  unlawfully rejected the genuine insurance claim for compensation. The claim was repudiated by OP on the ground that mother of the complainant was suffering from Diabetes Millitus for 6 years , hypertension for 6 years and cholecystostomy for 2 years. The repudiation of insurance claim of the complainant was termed as illegal, arbitrary and unjust on flimsy grounds. The complainant has, thus, prayed that OP be directed to pay the insurance claim amount of Rs.12 lac along with interest @ 18% per annum, besides Rs.2,00,000/- as compensation and Rs.50,000/- as costs of litigation.

3.      Upon notice, OP appeared and filed written reply and contested the complaint of the complainant vehemently. It was averred in preliminary objections that Paramjit Kaur assured fraudulently concealed the material facts regarding her health at the time of purchase of insurance policy. She gave wrong answers to questions in the proposal form. She stated that she was in good health but she died on 26.12.2011 within a few days from the date of purchase of the policy. From the medical documents provided by the complainant and on investigating the claim of the complainant, it was revealed to the OP that life assured was not keeping good health prior to purchase of insurance policy. She was suffering from Diabetes Mellitus for 6 years, hypertension for 6 years and Cholecystectomy for 2 years. She suppressed the above-referred pre-existing disease fraudulently from OP and thereby obtained the insurance policies. The Contract of Insurance is based on "Utmost Good Faith" and she betrayed good faith and is not entitled to any insurance claim. The Contract of Insurance is vitiated by fraud and misrepresentation in this case. The life assured gave the declaration in the proposal form giving negative answer to questionnaire regarding her health. It was further averred that policy-bearing no.ASSIII3087 was issued to life assured with effective date of coverage as 10.03.2011, policy-bearing no.ASS1119691 with effective date of coverage as 05.05.2011 and policy bearing no.ASS1270205 with effective date of coverage as 12.12.2011. OP received death claim intimation of insured on 14.02.2012, stating that deceased life assured passed away on 09.01.2012 due to cardiac arrest. The OP appointed an investigator agency "hawk vision" to investigate the claim. The medical documents provided by the complainant and investigator revealed that she was suffering from diabetes mellitus for 6 years, hypertension for 6 years and cholecystectomy for 2 years. She intentionally suppressed these material facts at the time of taking the insurance policies. Death certificate issued by Fortis Escorts on 09.01.2012 has clearly explained that  the antecedent cause i.e. Morbid conditions, if any giving rise to the above cause, stating the underlying conditions of death of "MRD (Medical Renal Disease), HTN (Hypertension), DM (Diabetes Mellitus) and it is signed by Dr. H.P Singh (Cardiology). The complainant had also attached the said death summary report of deceased life assured in its complaint itself. The triage history and physical sheet dated 09.11.2011 having IPID No.58532 procured by the investigator also revealed that history of present illness as DM for 6 years, HTN for 6 years and H/C/O MRD. It was admitted that Paramjit Kaur obtained insurance policies, but she is alleged to have obtained them by suppressing the material facts regarding her above-referred pre-existing ailments. OP prayed for dismissal of the complaint.

4.      The complainant tendered in evidence, his affidavit Ex.C-1 along with copies of documents Ex.C-2 to Ex.C-12. As against it; OP tendered in evidence copies of documents Ex.OP-1 to Ex.OP-23. On conclusion of evidence and arguments, the District Forum Amritsar, accepted the complaint of the complainant by virtue of order dated 18.02.2014. Dissatisfied with the order of the District Forum Amritsar dated 18.02.2014, the OP the present appellant, carried this appeal against the same.

5.      We have heard learned counsel for the parties and have also examined the evidence on the record in this case. The only point falling for adjudication in this appeal is whether life assured Paramjit Kaur concealed the material facts of her pre-existing disease to the effect that she was suffering from diabetes mellitus for 6 years, hypertension for 6 years and cholecystectomy for 2 years and thereby the Contract of Insurance stood vitiated. The version of the OP now appellant is that life assured Paramjit Kaur gave the answers in negative to the declaration made by her in the proposal form, while taking the policies and she intentionally suppressed the fact of her pre existing disease. The relevant evidence on the record has been examined by us in this regard. The affidavit of complainant is Ex.C-1 on the record and he denied this fact that Paramjit Kaur life assured suffered from pre-existing diseases i.e. diabetes mellitus for 6 years, hypertension for 6 years and cholecystectomy for 2 years. Ex.C-2 is statement of account. Ex.C-3 is voter card of Sawinder Singh. Ex.C-4 is proposal form no.000925, Ex.C-5 is proposal form no.012700 and Ex.C-6 is proposal form no.008445. Ex.C-7 to Ex.C-9 are claims decline letters sent by OP to complainant. Ex.C-10 is copy of death certificate of the mother of the complainant. Ex.C-11 is copy of ration card. Ex.C-12 is death summary prepared by Dr.H.P Singh (Cardiology) of Fortis Escorts. He recorded that on 09.01.2012 at 3.45 am the patient Paramjit Kaur suddenly suffered cardiac arrest and immediately CPR to start and continue. Her blood pressure and pulse became unrecordable with high doses inotropic support. But she has not responded to any treatment and was declared dead on 09.01.2012 at 4.15 am. The OP relied upon the certificate of Dr. Anurag Gupta Deputy Medical Superintendent of Fortis Escorts Hospital dated 31.01.2012 with regard to date of birth of patient, as 02.08.1953. It is recorded in Triage History and Physical Sheet Ex.OP-22 that Paramjit Kuar was suffering from diabetes mellitus for 6 years, hypertension for 6 years and cholecystectomy for 2 years. The reliance of the OP is on copy of Triage History and Physical Sheet Ex.OP-22 on the record.

6.      The District Forum observed in the order under challenge that life assured was examined by the empanelled doctors of OP, but no such disease was detected in her, when she took the insurance policy at the time of her medical examination. The District Forum relied upon judgment of National Commission in Life Insurance Corporation of India and others versus Kunari Devi IV (2008) CPJ 89 (NC) that no document has been produced in support of allegations 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. We further find that it is only concealment of fact within the knowledge of life assured, which is material to render the Contract of Insurance, as void. The OP has not led any cogent evidence on the record that complainant was in the knowledge of suffering from above-referred diseases and she intentionally gave wrong answer thereto. Many persons are suffering from hypertension and diabetes without even being aware of this fact that they were suffering from them. The OP, thus, could not establish it on the record that complainant knew this fact that she was suffering from above-referred diseases and she intentionally concealed them from OP. The very fact that she was medically examined by the empanelled doctors of the OP at the time of taking policy, but nothing was detected therein goes against the case of the complainant. There is no evidence of any hospital, where life assured Paramjit Kaur was admitted for the above-referred treatment prior to her admission in the Fortis Escort Hospital in this case on 26.12.2011. Consequently, we do not find any illegality or material infirmity in the order of the District Forum calling for any interference therein.

7.      As a result of our above discussion, we affirm the order of the District Forum Amrtisar dated 18.02.2014, under challenge in this appeal and resultantly the appeal filed by the appellant/opposite parties is ordered to be dismissed.

8.      The appellant had deposited an amount of Rs.25,000/- with this Commission at the time of filing the appeal and further deposited Rs.3,75,000/- in compliance of order dated 06.05.2014. Both these amounts with interest, if any, accrued thereon, be refunded by the registry to the complainant by way of crossed cheque/demand draft after the expiry of 45 days. Remaining amount shall also be paid to complainant by the appellant as per order of the District Forum within 45 days from receipt of the copy of this order. 

9.      Arguments in this appeal were heard on 23.02.2016 and the order was reserved. Copies of the order be communicated to the parties as per rules.

10.    The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                          (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

                       

                                                         

                                                                           (H.S GURAM)

                                                                              MEMBER

 

March 1,   2016                                                          

(ravi)