Haryana

Karnal

CC/198/2019

Raj Kumar - Complainant(s)

Versus

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

Devender Kumar Gupta

15 Nov 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 198 of 2019

                                                          Date of instt.11.04.2019

                                                          Date of Decision 15.11.2019

 

Raj Kumar Gupta, age 62 years son of late Shri Sandhu Ram, resident of VPO Gheer, Tehsil and District Karnal.

                                                 …….Complainant.

                                              Versus

 

1.SBI Life Insurance Co. Ltd. SCO 144, 2^nd floor, near OPS Vidya Mandir School, Urban Estate, Karnal.

2. Regional Director, SBI Life Insurance Co. Ltd. SCO no.109-110, 1^st floor, Sector 17-B, Chandigarh-160017.

                                                                         …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present Shri Devender Kumar Advocate for complainant.

                Shri N.K.Zak Advocate for opposite parties.

 

                    (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased policy no.56029463603 named as SBI Life Flexi Smart Insurance, Mode: Annually, Date of commencement: December 21, 2012, sum assured: Rs.2,50,000/-, Installment premium: Rs.25,000/-. The 1^st installment of premium was paid by the complainant at the time of purchasing the policy with next date of payment of premium as December 21,2013. At the time of purchase of the policy the complainant was hale and healthy and he was not suffering with any disease. Thereafter, the complainant has been making payment of all the premiums by way of yearly installment for the year 2012-2013, 2013-14, 2014-2015, 2015-2016, 2016-2017. After issuance of the abovesaid policy, the complainant suffered coronary artv. Disease and he had undergone treatment of the same on 13.11.2013. The payment of the yearly premium due on 21.12.2017 could not be made by the complainant due to heavy rush of work. The complainant in the month of July, 2018 approached the OP no.1 with a request to accept the premium due on 21.12.2017 with penalty, if any.  The complainant was advised to deposit the pending installment of premium and accordingly the complainant deposited Rs.25,000/- on account of said premium on 16.07.2018, which was accepted by the OPs without any objection. Thereafter, the complainant vide letter dated 19.07.2018 was asked to undergo a Medical examination from its Diagnosis Center Chaudhary Medical and Maternity Hospital, Karnal on payment of medical charges to be borne by the complainant. Complainant got conducted his medical test from the abvoesiad Diagnosis Centre of the OP on payment of requisite fee and report complete in all respect alongwith form of identity proof was sent by the diagnoses center to the Manager, Policy Servicing Department of OPs, vide letter dated 19.07.2018 addressed to Chaudhary Medical and Maternity Hospital, Karnal. The complainant approached the OPs so many times for revival of the policy. The OP sent a “Revival Quotation” dated 31.07.2018 for deposit of two installments of premiums i.e. Rs.25,000/- +Rs.25,000/-. Though the complainant had already deposited Rs.25,000/- on 16.07.2018 on account of pending premium due on 21.12.2017, yet the complainant complied with the requirement of OPs and further deposited another amount of Rs.50,000/- with the OPs. Thereafter, complainant received a letter dated 28.08.2018 from OP no.1 to the effect that the revival request of the complainant has been declined i.v.o Hearth Disease and Diabetes.”  The said letter is illegal, arbitrary, against the principle of natural justice, unfair trade practice and deficiency in service. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to jurisdiction; maintainability and concealment of true and material facts. On merits, it is pleaded that complainant had submitted a proposal for SBI Flexi Smart Plan vide proposal no.56QD230793 dated 13.12.2012, opting for annual mode for payment of premium during the terms of the policy alongwith the initial premium of Rs.25,000/-. On receipt of the proposal of the complainant, the OPs had called for the requirement of Medical examination vide a letter dated 13.12.2012. On receipt of his medical report, a requirement for the consent for extra premium in view of diabetes was raised and after receipt of the consent and based on the information provided in the proposal documents, the policy no.56029463603 having date of commencement as 21.12.2012 for term of policy as 10 years and basic sum assured of Rs.2,50,000/- was issued containing the Terms and Conditions of the Policy. It is further pleaded that the premium was payable on 21^st December of every year during the term of the policy. The complainant paid the premiums upto the due date 21.12.2016. Thereafter, he did not pay any premium. The policy lapsed due to non-payment of premium since the due date 21.12.2017. The OPs sent renewal premium intimation, lapse intimation and lapse cum revival intimation to the complainant through normal post. It is further pleaded that complainant’s policy lapsed due to non-payment of premium dues since 21.12.2017. The policy holder submitted his Declaration of Good Health dated 09.07.2018 declaring himself in sound health, alongwith Rs.25000/- towards revival amount. The OPs raised the requirement of medical examination with fresh declaration of good health. The complainant had undergone medical examination on 01.08.2018. The fresh declaration of good health dated 03.08.2018 and medical examination report dated 01.08.2018 were received on 03.08.2018. The complainant at the time of medical examination in reply to the question no.B(1) Do you have any evidence of abnormality or surgery of (a) Cardiovascular system-High BP/Palpitation/chest pain/ raised cholesterol, heart attack or any other disorder of heart/blood vessel, the complainant stated that he had undergone CABG (Coronary Artery Bypass Grafting) in 2013. The revival request of the complainant could not be accepted due to his adverse medical report. The complainant was informed, vide letter dated 28.08.2018 that his policy cannot be revived in view of Heart Disease and Diabetes. Hence, there is no deficiency in service on the part of the OPs in revival of the policy. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C12 and closed the evidence on 13.09.2019.

4.             On the other hand, OPs tendered into evidence Neelam Singh Ex.OW1/A and documents Ex.O1 to Ex.O16 and closed the evidence on 14.10.2019.

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

6.             The case of the complainant, in brief, is that he purchased a SBI Life Flexi Smart Insurance policy from the OPs and mode of payment was annually. The complainant firstly paid the premium at the time of commencement of the policy i.e.21.12.2012 and thereafter complainant paid the premium regularly till 2016 but he could not pay the premium due on 21.12.2017.  In the month of July, 2018 complainant approached the OPs for revival of the policy but OPs refused to revive the policy on the ground that complainant has been suffering from Heart Disease and Diabetes.

7.             The case of the OPs is that complainant’s policy lapsed due to non-payment of premium dues since 21.12.2017. The policy holder submitted his Declaration of Good Health dated 09.07.2018 declaring himself in sound health, alongwith Rs.25000/- towards revival amount. The OPs raised the requirement of medical examination with fresh declaration of good health. The complainant had undergone medical examination on 01.08.2018. The fresh declaration of good health dated 03.08.2018 and medical examination report dated 01.08.2018 were received on 03.08.2018. The complainant at the time of medical examination in reply to the question no.B(1) Do you have any evidence of abnormality or surgery of (a) Cardiovascular system-High BP/Palpitation/chest pain/ raised cholesterol, heart attack or any other disorder of heart/blood vessel, the complainant stated that he had undergone CABG (Coronary Artery Bypass Grafting) in 2013. The revival request of the complainant could not be accepted due to his adverse medical report. The complainant was informed, vide letter dated 28.08.2018 that his policy cannot be revived in view of Heart Disease and Diabetes.

8.             Admittedly, the complainant had purchased Flexi Smart Plan on 13.12.2012 with the premium of Rs.25000/- for the term of the ten years with sum assured of Rs.25,000/-. It is also admitted that the premium was payable on 21^st December of every year. It is also admitted that the complainant paid the premiums upto the due date 21.12.2016 without delay. As per OPs, the policy lapsed due to non-payment of premium since the due date 21.12.2017.

9.             In the month of July, 2018 the complainant approached the OP no.1 with request to accept the premium due on 21.12.2017 and the same was accepted by the OPs on 19.07.2018. On the request (Ex.C4) of the OP, the complainant went undergo a medical examination on 31.07.2018, OP sent a revival quotation dated 31.07.2018 as Ex.C7 with request to deposit the due premium which was deposited by the complainant as Rs.50,000/-, due premium was also received by OPs, vide receipt Ex.C8 by the OP. All these facts admitted by the OPs.

10.            As per clause no.8, Revival, Policy holder can revive his policy during its revival period of 12 months from the date of the earliest premium not paid. In the present case, the premium was due on December,2017 and complainant approached the OPs for revival the policy in the month of August, 2018 within the period mentioned in the said clause.

11.            The revival request was rejected by the OPs on the medical grounds, as per version of the OPs the complainant had undergone CABG in 2013 and he only deposited premium since December, 2016. Second grounds of the OPs for not revival of the policy is that the complainant was Diabetic and the policy of the complainant cannot be revived in view of Heart Disease and Diabetes. Learned counsel for the OP relied upon the authority of Hon’ble National Commission in case M/s Aviva Life Insurance Co. Ltd. Versus Bimla Nainwal and Ors. 2019(2) CPR 287 in which Hon’ble National Commission held that Policy lapsed and hence surrender value sent to the complainant. In the said case the insured had deposited the three premiums and thereafter policy had lapsed for non-deposition of the premium and the OP has refund the surrender value, but in the present case OPs did not refund the surrender value till date thus the authority cited by the OPs is not applicable to the case in hand.

12.                    We can rely upon the authority of Hon’ble State Commission, New Delhi case titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, has drawn conclusion in para 9 of the order and the relevant clause is 9(iii), which is reproduced as under:-

        “9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment. Form the Tax Invoice dated 23.11.2017 of Jurong Health Services Pvt. LTd. Singapore, it is evident that the complainant had incurred 13720.03 Singapore Dollars on his treatment, therefore, the OPs are liable to pay the medical expenses of 13720.03 Singapore Dollars to the complainant. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by him alongwith litigation expenses. Further, in case of Religare Health Insurance Co. Ltd. Versus Swarn Kanta Jain 2018 (30 CLT-441), the Hon’ble State Commission Punjab observed that the history recorded in the discharge summary cannot be taken as an evidence. Mere averments in the discharge summary is not sufficient to conclude that insured was in the knowledge that she was suffering from the disease of sacroidosis with unveitis-It is also matter of concern that in India number of people continued to live for number of years without notice of any disease for which they are the suffered and it comes to light only during investigation or at the time of treatment-Claim was wrongly rejected.

13.            Keeping in view that the ratio of the law laid down in the aforesaid judgments, facts and circumstances of the present case, we are of the considered view that the act of the OPs amount to deficiency in service and unfair trade practice while repudiating the claim of the complainant..

14.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.1 to revive the policy in question subject to deposit of due premium amount without any interest or penalty. We further direct the OPs to pay Rs.15,000/- to the complainant on account of mental agony and harassment suffered by him and Rs.5500/- for the litigation expense. This order shall be complied within 30 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:15.11.2019                                                                       

                                                                          President,

                                                                District Consumer Disputes

                                                                Redressal Forum, Karnal.

               

  (Vineet Kaushik)         Dr. Rekha Chaudhary)

      Member                      Member