Haryana

Karnal

CC/239/2018

Suman Devi - Complainant(s)

Versus

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

Deepak Tuteja

27 May 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 239 of 2018

                                                          Date of instt. 18.09.2018

                                                          Date of Decision 27.05.2019

 

Suman Devi wife of Shri Satish Kumar son of Shri Raghubir Singh resident of House no.4473, Gali no.1, Shastri Nagar, Karnal.

 

                                                                        …….Complainant

                                        Versus

 

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

2. SBI Life Insurance Co. Ltd. Natraj, M.V. Road & Western Express Highway Junction, Andheri (East) Mumbai through its authorized officer.

                                                                                                                                                                             …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

            

 

 Present:  Shri Tarun Sharma 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 the husband of complainant has taken an insurance policy naming SBI Life-Smart Money Back Gold, vide policy no.IN637099204 UIN no.111NO96V02 from the OPs in which sum assured was Rs.14,00,000/- commencing from 3.11.2017 as per policy in case of death, some assured is Rs.14,00,000/- plus other benefits and complainant’s husband has also paid Rs.39,377/- semi annual as premium for the abovesaid policy which was accepted by the OPs. The said policy was issued for the twenty five years i.e. upto 03.11.2042. The husband of complainant died on 27.12.2017 due to cardiac arrest. Complainant being nominee in the abovesaid policy, a claim has been lodged by her at office of the OPs and in this regard complainant completed all the formalities as required by the OPs. Complainant visited the office of OPs several times and requested for the claim amount but surprisingly on 6.4.2018 complainant received a latter form the OPs in which the claim of the complainant rejected by the OPs on the false ground that husband of complainant was suffering from Cancer. Then complainant sent a legal notice to the OPs vide which he demanded the death claim of her husband but it also did not yield any result. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version stating therein that the Deceased Life Assured Mr. Satish Kumar had applied for SBI Life-Smart Wealth Builder policy, vide proposal no.1NQW631316 dated 02.11.2017 for a sum assured of Rs.14,00,000/-. On the basis of the information furnished in the proposal fork and replying on the information to be true and accurate, the proposal form was accepted and SBI Life-Smart Money Back gold policy bearing no.IN637099204 was issued with date of commencement 03.11.2017 for a Basic Sum Assured of Rs.14,00,000/- with a semi yearly premium paying terms of 25 years. It is further stated that the Deceased Life Assured (DLA) is reported to have died on 27.12.2017. The policy resulted in claim in just 1 month 24 days from the date of commencement of the policy. Therefore, the company investigated into the matter and it was revealed that the DLA was suffering from Cancer prior to the date of commencement of the policy, which he did not disclose in the proposal form while applying for insurance cover. As per FNAC Report of Postgraduate Institute of Medical Education and Research, (PGIMER) Chandigarh date 07.05.2016 having CR no.201602832569 diagnosis is mentioned as “Lymph node, cervical level II (right), Carcinoma Squamous cell, Metastatic.” Further, in remarks it is noted that “Patient is a known case of carcinoma base of tongue.”

 3.            It is further stated that as per the Biopsy Report of PGIMER, Chandigarh dated 14.05.2016 Medical Diagnosis is noted as Ca BOT and further diagnosis is noted as Tongue (base): Carcinoma, Squamous cell, moderately differentiated. In the C.T. scan Report dated 17.05.2016 of the PGIMER, Chandigarh, clinical history and findings is mentioned as Ca BOT and impression is noted as “Enhancing soft tissue thickening involving the BOT with extension as described and metallic necrotic cervical lymphadenopathy.” As per the outpatient card of PGIMER dated 25.06.2016 having CR no.201602832569 it is clear that the DLA was taking treatment of Radiotherapy. Hence, in view of the documentary evidence provided by SBI Life which clearly prove the pre-existing diseases of the DLA prior to the date of commencement of cover and thus, SBI Life has lawfully repudiated the claim and is in accordance with the terms and conditions of the policy. If the DLA had disclosed in the proposal form that he was suffering from Cancer and was under treatment for the same, the company would have declined the proposal and would not have issued the policy. The DLA committed a fraud with an intention to obtain the insurance cover by suppressing the fact that she was suffering from Cancer and Hypertension which was very well within her knowledge. Thus, there was no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Complainant tendered into evidence her affidavit his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C14 and closed the evidence on 7.3.2019.

5.             On the other hand, OPs tendered into evidence affidavit of Neelam Singh Ex.RW1/A, affidavit of Mr. R.K. Garg Ex.RW2/A and documents Ex.R1 to Ex.R8 and closed the evidence on 11.04.2019.

6.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.             The case of the complainant is that her husband had purchased a life insurance policy naming SBI Life-Smart Money Back Gold, vide policy no.IN637099204 UIN no.111NO96V02 from the OPs in which sum assured was Rs.14,00,000/- commencing from 3.11.2017. The policyholder was expired on 27.12.2017 due to cardiac arrest. Complainant being nominee intimated the OPs and lodged the death claim with the OPs. But OPs have repudiated the claim of the complainant, vide letter dated 06.04.2018 in illegal manner. The complainant is legally entitled for the insured amount as per policy.

8.             On the other hand, the case of the OPs is that after receiving the information of death of policyholder, the matter was investigated, upon internal investigation it was found that the Deceased Life Assured has suppressed and concealed the material facts and provided false information in the proposal form, which were material with respect to the issuance of the policy. The DLA failed to provide the requisite documents and resultantly, the OPs declared the policy as void ab-initio. There is no deficiency in service on the part of the OPs.

9.             Admittedly, the DLA had purchased a life insurance plan policy on 3.11.2017. It is also admitted the DLA has expired during the subsistence of the policy. As per version of the complainant her husband expired due to heart attack. But there is no document on the file to prove that DLA expired due to heart attack. Complainant failed to prove that cause of death of the DLA. The policy in question was issued on 3.11.2017 and DLA was died on 27.12.2017 just after  1 month 24 days from the date of commencement of the policy.

10.            The claim of the complainant was repudiated by the OPs on the ground that during the investigation, it was found that the DLA has suppressed and concealed the material facts and provided false information in the proposal form. In this regard OP relied upon the investigation report Ex.R3, FNAC Report dated 7.5.2016 Ex.R4, CT scan report dated 17.05.2017 Ex.R5 and outdoor patient card Ex.R6. As per FNAC report it is mentioned that “FNA smears from right level II cervical lymph node show tumour cells arranged in sheets, clusters and singly scattered Tumour cells show squamoid differentiation. Features are of metastatic squamous cell carcinoma.”  As per C.T. scan Report dated 17.05.2016 of the PGIMER, Chandigarh, clinical history and findings is mentioned as Ca BOT and impression is noted as “Enhancing soft tissue thickening involving the BOT with extension as described and metallic necrotic cervical lymphadenopathy.”  And as per the outpatient card of PGIMER dated 25.06.2016  it is clear that the DLA was taking treatment of Radiotherapy. Hence, in view of those documents it is proved that DLA was suffering from pre-existing disease. Thus, there is no deficiency in service on the part of the OPs while repudiating the claim of the complainant.

11.            It is settled principle of insurance law that contract of insurance is a contract uberrima fides and utmost faith must be observed by the contracting parties. Every material fact must be disclosed, otherwise there is good ground for rescission of contract. If, there are misstatements or suppression of material facts, the policy can be called into question. In this regard reference may be made to the judgment of the Hon’ble Supreme Court in case titled Satwant Kaur Sandhu Versus New India Assurance Co. IV( 2009) CPJ 8 (SC) and judgment of Hon’ble National Commission in case Life Insurance Corporation of India and another Versus Bimla Devi Revision Petition no.3806 of 2009 decided on 12.8.2015.

12.            Thus, as a sequel to abovesaid discussion and in view of law cited above, we do not find any merits in the complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:27.05.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

 

                (Vineet Kaushik) 

                 Member