Delhi

North East

CC/127/2021

Ramesh Sharma - Complainant(s)

Versus

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

21 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.127/21

 

 

In the matter of:

 

	Sh. Ramesh Sharma S/o Lt. Shri R.N Sharma R/o G-18C, Dilshad Colony, Delhi 110095	Complainant
	Versus
	SBI Life Insurance Company Ltd., Through Branch Manager New Delhi 10, SBI Life Insurance Company Ltd., 1st Floor, 1/235, Ram Nagar, G.T Road, Shahdara, New Delhi 110032   Head Office at: New Delhi 4, SBI Life Insurance Co. Ltd., 112 1st Floor ABO, Dayanand Road, Opposite to Golcha Cinema, Delhi 110002	Opposite Party

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

16.09.2021 12.07.2023 21.08.2023

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Adarsh Nain, Member

The Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant’s wife, Madhu Sharma (now deceased) purchased a Life insurance policy bearing policy no. 35006094107 from the Opposite Party Company. The term period of the policy was ten years and sum assured was RS. 2,52,000/-. Complainant stated that the maturity amount that the policy bearer was supposed to receive at the end of ten years was Rs. 5,00,000/-. The first premium amount of Rs. 29,959/- was paid on 24.11.2010 and thereafter further premium amount was paid on 13.01.2012, 06.11.2012, 08.07.2015, 24.11.2016, 21.01.2019 and finally the last payment of Rs. 31,938/- was paid on 10.08.2020. Complainant further stated that the last payment was supposed to be done on 23.11.2019 but due to unavoidable circumstances Complainant’s wife could not make the payment on time due to which the policy got lapsed. Opposite Party made the wife of the Complainant sign/fill a revival form wherein there was an option that “Whether the person is in a good health?” and the wife of the Complainant wrote “Yes” and only after that the Complainant’s wife paid the last premium on 10.08.2020. It is further submitted that since the Complainant’s wife was not feeling well and complaining of pain in abdomen and vomiting since 10 days, she was referred to Metro Hospital on 23.07.2020. Complainant stated that after certain tests and evaluation on 28.07.2020, it was found that she was a patient of cancer and referred for chemotherapy and on 04.10.2020, Complainant’s wife (policy bearer) died. On 16.10.2020, Complainant approached to Opposite Party for claiming the maturity amount and submitted all the documents and copy of death certificate. But Opposite Party did not give any reply to the application of the Complainant rather without giving any reason it returned the last premium payment made by the wife of the Complainant on 10.08.2020 and the rest of the amount which was assured along with bonus was repudiated by the Opposite Party. The Complainant wrote letters on 27.01.2021, 02.02.2021 for seeking claim of insurance policy taken by the deceased wife of the Complainant but Opposite Party did not give the maturity amount nor the assured amount. Hence, the Opposite Party failed to discharge its duty/service and has performed unfair trade practices. Complainant further stated that the Ombudsman vide letter dated 27.04.2021 rejected the complaint of the Complainant made under Rule 13 read with Rule 17 of the Insurance Ombudsman Rules, 2017 and observed that the deceased wife of the Complainant had falsely declared about her “good health” in the revival form however, the hospital records and other death claim documents clearly show that she was already under the treatment for cancer of liver after being diabetic. Complainant has prayed to direct the Opposite Party to pay an amount of Rs. 5,00,000/- along with 12 % interest p.a. from the due date of the policy, Rs. 1,00,000/- on account of mental harassment and Rs. 1,00,000/- on account of litigation expenses.

Case of the Opposite Party

2. Opposite Party contested the case and filed its written statement. The Opposite Party took the preliminary objection that the life insurance contract is a contract of utmost good faith and the life assured late Ms Madhu Sharma committee a breach of the principle of utmost good faith by suppressing the material fact that she was suffering from cancer and was under treatment for the same prior to the date of revival of policy. On merits, it is contended that deceased life assured applied for revival of subject policy and submitted declaration of good health declaring herself in sound health and replied in negative to the medical questionnaire that whether the applicant suffered from any illness requiring treatment for more than three days. It is further submitted that the Declaration of Good health is very important document and the sole basis of revival of insurance contract. The Opposite Party has contended that claim is not payable because deceased life assured suppressed material facts regarding illness and replied the specific questions in negative and thus revived the policy fraudulently, hence, the claim have been rightly repudiated as revival was void due to above reason. Thus the complaint needs to be dismissed.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his case filed his affidavit wherein he has supported the assertions made in the complaint.

Evidence of the Opposite Party

5. To support its case Opposite Party has filed affidavit of Smt. Neelam Singh, wherein, she has supported the case of the Opposite Party as mentioned in the written statement.

Arguments & Conclusion

6. We have heard the Ld. Counsel for the Complainant and Ld. Counsel for the Opposite Party.  We have also perused the file and written arguments filed by the Complainant and Opposite Party. The case of the Complainant is that the complainant’s wife (life assured) purchased a policy.  Since the policy lapsed due to non-payment of last installment, it was revived after the Complainant’s had filled the revival form and also submitted the Declaration of Good Health and paid the installment on 10.08.2020. It is also the case of the Complainant that the deceased life assured was referred to Metro Hospital on 23.07.2020 due to abdominal pain and vomiting for the past 10 days after certain tests and evaluation on 28.07.2020, it was found that she was a patient of cancer and referred for chemotherapy and on 04.10.2020, the life assured died. It is alleged that the Opposite Party neither paid the maturity amount nor the assured amount. It is alleged that the Opposite Party returned the last paid premium and repudiated the rest of the amount which was assured along with bonus.
7. On the other hand, the case of the Opposite Party is that claim was not payable because deceased life assured suppressed material facts regarding illness and replied the specific questions in negative and thus revived the policy fraudulently, hence, the claim have been rightly repudiated as revival was void due to above reason.
8. While perusing the material on record, we observed that the Complainant has himself stated in the Para 4 of the complaint as follows-

‘’… after certain tests and evaluation on 28.07.2020, it was found that she was a patient of cancer and referred for chemotherapy”.

9. It is further evident from the record available more particularly the medical record including the death summary of the Deceased life assured that the deceased life assured was suffering from several health complications before the date of declaration of Good health. The death summary clearly mentions that the patient had been under treatment and tests conducted on 28.07.2020 were suggestive of Liver malignant disease. It is further evident that though the biopsy report was issued on 11.8.2020, but the specimen for Liver biopsy was sent much earlier as the registration date is 31.07.2020.
10. The above observations clearly indicate that the life assured was not at all maintaining good health on 10.08.2020 when the declaration of good health was submitted for reviving of the subject policy. The life assured had also replied in negative to certain specific questions related to illness. This shows that the life assured had suppressed the material information with regard to her state of health which vitiated the contract of insurance.
11.  The perusal of the material of record reveals that the complainant also initiated the proceedings of the Insurance Ombudsman, Delhi raising against the Opposite Party wherein Ombudsman rejected the complaint and held that insurers were justified in repudiating the claim on account of non-disclosure of material facts.
12.  In view of above facts and discussion, as the policy in question was revived by the deceased life assured by concealment of the material fact with regard to state of her health, we are of the considered view that the Opposite Party Insurance company was right in repudiating the claim of the Complainant.
13. Thus, we dismiss the present complaint accordingly with no order as to costs.
14. Order announced on 21.08.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)	(Adarsh Nain)	(Surinder Kumar Sharma)
(Member)	(Member)	(President)