Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 675.
Instituted on : 02.12.2019
Decided on : 09.01.2024
Smt. Neelam age 42 years, w/o Late Sh. Ajit Singh s/o Sh.Dheera Singh r/o H.No.1490/19, Chinyot Colony, Rohtak..
………..Complainant.
Vs.
SBI Life Insurance Company Limited having its one of the branch situated at 2nd Floor, Shop No.85, Ward No.17, Opposite party Surya Hotel, HUDA Complex, Rohtak through its Manager.
…….Respondent/Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR.VIJENDER SINGH, MEMBER
Present: Sh.Hawa Singh, Advocate for complainant.
Sh.Gulshan Chawla, Advocate for opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that the husband of the complainant has purchased an insurance policy from the respondentand paid the insurance premium of Rs.28164/- on dated 25 July 2018. The respondent issued the policy No.IN692410210. The husband of the complainant was quite healthy and was living a comfortable life. The insurance application form was filled up by the agent of the insurance company and the signatures of the husband of complainant was obtained by him on the application form. The husband of the complainant died due to the heart attack on 12.03.2019 whereas he was not having any history of heart problem.The complainant applied for the claim with the opposite party but the death claim of Ajit Singh was not considered by the respondent and the respondenthad only transferred an amount of Rs.26949.36 to the complainant’s bank account. The respondent has served a letter dated 02.08.2019 upon the complainant, vide which the she was informed that if she is not satisfied with the decision of the respondent company she may sent her representation for re-consideration of her claim to the Claim Review Committee of the respondent. In reply to the same, the complainant made a representation to the competent authority and dispatched the same through registered post on 03.10.2019. But till date neither the respondent settled the death claim of the deceased Ajit Singh nor paid any compensation to the complainant. The act and conduct of the respondent is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that respondent/opposite party may kindly be directed to pay the death claim of the deceased Ajit Singh alongwith interest @ 12% p.a. and also to pay an amount of Rs.200000/- on account of physical and mental harassment suffered by the complainant and Rs.15000/- as litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the respondent/opposite party. Opposite party in its reply has submitted that DLA Late Sh. Ajit Singh had applied for the SBISmart Money back policy and based on the duly filled and signed proposal form submitted by him and relying on the information to be true and accurate, the proposal form was accepted and the policy bearing no.IN692410210 was issued to him with date of commencement 31.08.2018 for a basic sum assured and accidental death benefit rider of Rs.600000/- each with yearly premium paying term of 15 years. It is further submitted that on receipt of claim intimation, as it was an earlyclaim within 6 months 12 days from the date of issuance of policy, the opposite party conducted investigation and it was revealed that the DLA was suffering and under treatment for Heart disease prior to the issuance of the policy, which he did not disclose in the proposal form while applying insurance cover. As per the Discharge Card issued by the City Maternity & Nursing Home Rohtak, the DLA Mr. Ajit Singh was hospitalized from 05.03.2018 to 13.03.2018 and Final Diagnosis mentioned as “Ischemic Heart Disease(IHD)with congestion Heart Failure, Bilateral(B/L) Pleural Effusion”. As per the Emergency Certificate issued by doctor from City Maternity & Nursing Home dated 15.11.2018 the DLA was admitted in the hospital in emergency condition with ‘LVSF(Left Ventricular Systolic function) with 35% with anteriolateral wall hypothesism on Echo and UGSS(Ultrasound Sonography) shows mild nephromegaly with B/L Pleural Effusion & ECG…..”. As per the USG Whole Abdomen report dated 25.09.2011 of DLA issued by City Diagnostic Centre, the impression is mentioned as “Choleithiasis” (Cholelithiasis is the medical term for gallstone disease. It refers to the presence of one or more gallstones in the common bile duct). As per the Laboratory report for Lipid Profile issued by Immuno Diagnostics Pvt. Ltd. dated 26.09.2011, the Triglycerides of the DLA noted as 257 mg/dl, however the normal range is between 30-150 & VLDL Cholesterol noted as 51 however, normal range of the same is between 15-40 mg/dl. The DLA in his proposal form has clearly stated that he was not suffering from any disease while the documentary evidence placed on record amply proves that he suffered from and was under treatment for heart disease. Hence the claim under the policy was repudiated and an amount of Rs.26949.36 has been transferred to the bank account of complainant held with State Bank of India, Rohtak through direct credit on 31.07.2019 towards refund of premiums as per the amended insurance laws. The decision to repudiate the claim was communicated with the payment details to the complainant vide claim repudiationletter dated 02.08.2019. Further a representation for the said case was received and it was put up before the Claim Review Committee(CRD). The Claim Review Committee reviewed the claim and found it not possible to pay the claim, as the claim was not admissible due to “Suppression of material facts” by the DLA at the time of applying for insurance. The same has been intimated to the complainant vide letter dated 01.01.2020. The complainant is not entitled to get any death claim benefits or compensation, as the decision to repudiate the claim is as per the terms and conditions of the policy. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.PW1/A, documents Ex.P1 to Ex.P6 and closed his evidence on 16.08.2021. On the other hand, Ld. counsel for opposite parties has tendered affidavit Ex. RW1/A, documents Ex.R1 to Ex.R10 and closed his evidence on 20.01.2022.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. We have perused the documents placed on record by both the parties. As per respondent the deceased LA committed a fraud with an intention to obtain an insurance cover by suppressing the history of pre-existing disease i.e. heart disease in his proposal form. We have minutely perused the documents placed on record by both the parties. The respondent has submitted that the proposal form has been submitted by the deceased LA with the insurance company on dated 27.07.2018 which is placed on record as Ex.R1. The date of commencement of policy is 31.08.2018 and the next premium was due on February 2019. The respondent insurance company has placed on record proposal form Ex.R1, premium receipt dated 31.08.2018 as Ex.R2, claim form Ex.R3, Investigation report Ex.R4 and discharged card issued by City Maternity and Nursing home of deceased LA as Ex.R5. Ex.R7 and Ex.R8 are laboratory reports. Ex.R9 and Ex.R10 are no claim letters. The perusal of documents itself shows that the deceased LA was admitted in City Maternity& Nursing Home on dated 05.03.2018 and discharged on 13.03.2018. As per investigation report Ex.R4, LA was suffering from heart disease and before death he was admitted at Dr.Marwa Clinic. As per the emergency certificate Ex.R6 issued by City Maternity and Nursing Home dated 15.11.2018, it has been mentioned in this report that : “He was admitted in this hospitalin emergency condition 
LVSF with 35% with anteriolateral wall hypothesism on Echo and UGSS(Ultrasound Sonography) shows mild nephromegaly with B/L Pleural Effusion & ECG….. ….”. From the bare perusal of this report and documents it is well established that deceased was suffering from heart disease on the date of commencement of policy. Hence the claim of the complainant has been rightly repudiated by the insurance company vide letter Ex.R9 and ex.R10. As such present complaint stands dismissed with no order as to costs.
6. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
09.01.2024.
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Nagender Singh Kadian, President
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TriptiPannu, Member.
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Vijender Singh, Member.
