Haryana

Karnal

CC/114/2022

Parvesh Rani - Complainant(s)

Versus

SBI Life Insurance Company Limited - Opp.Party(s)

Samay Singh

20 Mar 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 114 of 2022

                                                        Date of instt.07.03.2022

                                                        Date of Decision:20.03.2023

 

Parvesh Rani widow of Shri Bir Singh son of Shri Devi Chand, resident of village Biana, Tehsil Indri, District Karnal.

 

                                               …….Complainant.

                                              Versus

 

SBI Life Insurance Company Ltd. SCO 144, 2^nd floor, near OPs Vidhya Mandir School, Urban Estate, Karnal through its Branch Manager.

 

                                                                      …..Opposite Party.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri Ram Lal Bilan, counsel for the complainant.

                    Shri N.K. Zak, counsel for the OP.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP) on the averments that complainant’s husband namely Bir Singh (since deceased) had purchased a insurance policy i.e. SBI Life-Smart Elite Plan God Option bearing no.53554447606 on 30.08.2019, which was valid upto 30.08.2029 for a sum of Rs.15,00,000/- and in the said policy, complainant was a nominee. The husband of complainant has paid a sum  of Rs.3,75,000/- to the OP by way of five installments. In the month of December, 2021, the husband of complainant developed severe chest pain and he was taken to Dua Multispecialty Hospital, Randhir Lane, near Dayal Singh College, Karnal where he remained admitted from 10.12.2021 to 13.12.2021 and ultimately, he died on 13.12.2021 in the said hospital. After the death of her husband, complainant lodged her claim with the OP seeking claim amount of Rs.15,00,000/-. However, the OP refunded the amount of Rs.3,75,000/- to the complainant, but OP repudiated the claim of the complainant for the rest amount, vide letter dated 07.02.2022, on the ground that late Bir Singh was suffering from Heart disease and was taking treatment for the same prior to date of commencement of policy i.e. 30.08.2019. However, these material facts were not disclosed in the proposal form. The repudiation of the claim of the complainant is totally illegal and unlawful as the at the time of proposal, all the facts related to the health of husband of complainant were told to the OP and nothing was concealed. However, OP intentionally and deliberately, in order to avoid the payment of abovesaid claim, repudiated the claim on the false and frivolous ground. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that SBI Life offers an individual insurance scheme, wherein each individual to be insured furnishes full information about his personal and family history, his health and habits, his income, his date of birth, and details of existing insurance cover with all insurance companies. Relying on the information so furnished, the company grants insurance over on the principle of Utmost Good Faith. Any suppression of material facts in the proposal form will render the insurance cover invalid in respect of that individual insured member. In the present case, the insurer late Mr. Bir Singh committed a breach of the principle of Utmost Good faith by suppressing the material facts that he was suffering from heart disease and was taking treatment for the same prior to the date of applying for insurance policy. If the DLA had disclosed the existence of Heart Disease at the time of taking the policy, the insurance cover would not have been granted to DLA by the OP. There is no negligence, carelessness or deficiency in service on the part of the OP as laid down under the Act, as the DLA himself is guilty of suppressing and concealing the material and true facts regarding his pre-existing illness at the time of taking the policy. It is further pleaded that Bir Singh is reported to have died on 13.12.2021. The OP received the death claim intimation on 12.01.2022. As stated in the claim intimation, the DLA died at Dua Multispecialty Hospital, Karnal due to sudden heart attack on 13.12.2021. As per records of Dua Multispecialty Hospital, Karnal, the DLA was a “K/C/O (known case) of CKD (chronic kidney disease), CAD (coronary artery disease), CABG (coronary artery bypass graft) done in 2018, on dialysis since January, 2021, ganggerus RT food leg, DM”. It is proved from the said document that the DLA was suffering from Heart Disease, undergone Coronary Artery Bypass Graft in 2018 and thus was under treatment for the same prior to the date of signing of the proposal form dated 20.08.2019, but the DLA did not disclose the material facts regarding his pre-existing illness in the proposal from. There is deliberate suppression material fact with a fraudulent intention to obtain insurance. Hence, the claim of the complainant was rightly repudiated as per the terms and conditions of the insurance policy. On repudiation, OP paid Rs.3,75,000/- vide direct credit to bank account no.82700100037461 held in Punjab National Bank, on 04.02.2022, towards refund of premiums as per amended insurance law. The same was communicated to the complainant, vide claim repudiation letter dated 07.02.2022. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence her affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy of Indoor Final Bill Ex.C2, copy of death certificate of Bir Singh Ex.C3, copy of repudiation letter dated 07.02.2022 Ex.C4, copy of Aadhar card of complainant Ex.C5, copy of Aadhar card of Bir Singh Ex.C6 and closed the evidence on 26.08.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Neelam Singh Ex.OP1/A, copy of proposal form Ex.OP1, copy of insurance policy Ex.OP2, copy of claimant statement Ex.OP3, copy of treatment record Ex.OP4, copy of repudiation letter dated 07.02.2022 Ex.OP5 and closed the evidence on 14.12.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that Bir Singh (since deceased) during his life time had purchased a life insurance policy for the sum assured of Rs.15,00,000/- and paid a sum of Rs.3,75,000/- to the OP for five installments. The husband of complainant had expired on 13.12.2021 due to heart attack. The complainant being nominee, lodged the claim under the abovesaid Policy, but OP repudiated the claim of the complainant, vide letter dated 07.02.2022, on the ground that late Bir Singh was suffering from Heart disease and was taking treatment for the same prior to date of commencement of policy. He further argued that DLA was not suffering from any disease at the time of obtaining the insurance policy as alleged by the OP. He further argued that OP has only refunded the amount of Rs.3,75,000/- to the complainant and remaining amount has not been refunded by the OP without any cogent reason and lastly prayed for allowing the complaint. Learned counsel for complainant relied upon the judgment of Hon’ble Supreme Court of India in case titled as Sulbha Prakash Motegaoneka Versus Life Insurance Corporation of India, in civil appeal no.8245 of 2015, decided on 05.10.2015; Chanda Devi Vs. LIC in complaint no.551/2016, decided on 23.11.2021 of Hon’ble Delhi State Commission; Religare Health Insurance Company Versus Harwant Singh, decided on 08.02.2021 of Hon’ble State Commission, Chandigarh; Satish Chander Madan Vs.Bajaj Allianz General Insurance Company Ltd. (2016) CPJ 613 (NC) and Aditya Birla Health Insurance Co. Ltd. & anr. Versus Deepinder Singh & anr. I 2021 CPJ 156 (Punjab.

8.             Per contra, learned counsel for OP, while reiterating the averments made in the written version, has vehemently argued that DLA was suffering from Heart Disease, undergone Coronary Artery Bypass Graft in 2018 and thus was under treatment for the same prior to the date of signing of the proposal form dated 20.08.2019, but the DLA did not disclose the material facts regarding his pre-existing illness in the proposal from. There is deliberate suppression material fact with a fraudulent intention to obtain insurance. Hence, the claim of the complainant was rightly repudiated as per the terms and conditions of the insurance policy. On repudiation the OP paid Rs.3,75,000/- vide direct credit to bank account no.82700100037461 held in Punjab National Bank, on 04.02.2022, towards refund of premiums as per amended insurance law. The same was communicated to the complainant, vide claim repudiation letter dated 07.02.2022 and prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, the husband of complainant had purchased an insurance policy i.e. SBI Life-Smart Elite Plan God Option on 30.08.2019, which valid upto 30.08.2029, for the sum insured of Rs.15,00,000/-. It is also admitted that in the said policy, complainant was a nominee. It is also admitted that on 13.12.2021 insured had expired due to heart attack. It is also admitted that insured had paid a sum of Rs.3,75,000/- to the OP. It is also admitted that after the death of insured, OP has refunded the said amount to the complainant.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.OP5 dated 07.02.2022 on the ground that prior to purchase the policy in question, the life assured was suffering from Heart Disease and was taking treatment for the same.

12.           The onus to prove its version was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of OP is based upon the treatment record of Bir Singh Ex.OP4 dated 10.12.2021 issued by Dua Multispecialty Hospital, Karnal. In the said treatment record, issuing doctor has mentioned that dialysis was done in 2018. But OP failed to obtain the treatment record, from where DLA had taken a treatment for dialysis in the year 2018 as alleged by the OP. OP neither examined the doctor of Dua Multispecialty Hospital, Karnal  nor tendered his affidavit in evidence to prove its version. Furthermore, the said treatment record is a photocopy and is also not properly readable. Thus, the same has no weightage in the eyes of law. It was the duty of the OP, to collect the record from the hospital from where the DLA has taken a treatment as alleged by the OP in its pleading.  The OP had taken a plea that the DLA was suffering from heart disease and in this regard OP has relied upon the treatment Ex.OP4, wherein treated doctor has only mentioned that the DLA had taken a dialysis in the year 2018. If the contention of the OP is to be considered as a true then there is no nexus between the cause of death and prior disease as alleged in the treatment record Ex.OP4. When there is no nexus between the cause of death and disease mentioned in Ex.OP4, then the claim of the complainant cannot be repudiated. In this regard, we relied upon in Sulbha Prakash’s case (supra) wherein Hon’ble Supreme Court held that the suppression of information regarding any pre-existing disease, if it has not resulted in death or has no connection to cause of death it would not disentitle the claimant for the claim. Further, in Chanda Devi’s case (supra) wherein Hon’ble State Commission, Delhi held that if the reason of the death is not in nexus with pre-existing disease and there is no evidence placed on record by the OP to show that the death was on account of pre-existing disease of the life assured, then the contention of the OP in the repudiation letter has no merit. Further, in Harwant Singh’s case (supra) wherein Hon’ble State commission, Panchkula held that hypertension is a common ailment and it can be controlled by the medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack or other ailment. Similar view was taken by the Hon’ble National Commission in case titled Satish Chander’s case (supra). In Deepinder Singh’s case (supra) wherein Hon’ble Punjab State Commission held that “Consumer Protection Act, 1986- Sections 2(1)(g), 14(1)(d), 15- Insurance Regulatory and Development Authority (Protection of Policy holders’s interest) Regulations, 2017- Regulation 10- Insurance (Mediclaim)- Surgery of shoulder- Alleged non-disclosure of pre-existing disease- Repudiation of claim- Deficiency in service- District Forum allowed complaint- Hence appeal- Respondent/ complainant was admitted to hospital on 10.10.2018 with problem of right shoulder pain and after surgery was discharged on 21.10.2018 in satisfactory condition- Expenditure of Rs.81,595/- was incurred on said treatment- Complainant lodged reimbursement claim for Rs.82,981/- and same was repudiated- Except medical record of ailment, OPs have not placed on record any independent evidence that insured had knowledge or that he had been taking treatment of disease, before purchasing this policy- In absence of any specific evidence on record how disease, if any, to which insured does not have knowledge can be termed as pre-existing disease- Repudiation not justified- Complaint was rightly allowed.

13.  

“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”.

 14.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

15.           As per insurance policy Ex.C1/Ex.OP2, the sum assured is Rs.15,00,000/-. OP has already transferred Rs.3,75,000/- in the account of complainant. Hence, the complainant is entitled for the said amount of Rs.11,25,000/- (Rs.1500000-3,75,000=11,25,000) alongwith interest, compensation for mental harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.11,25,000/- (Rs. eleven lakhs twenty five thousand only)  to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:20.03.2023

                                                                       

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

       

                (Vineet Kaushik)        (Dr. Rekha Chaudhary)      

                      Member                        Member