Haryana

Fatehabad

CC/163/2019

Chameli - Complainant(s)

Versus

SBI Life Insurance - Opp.Party(s)

Jitender Thakar

14 Nov 2023

ORDER

BEFORE THE  DISTRICT CONSUMER DISPTUES REDRESSAL COMMISSION, FATEHABAD.

Complaint No.163 of 2019.

Date of instt.24.04.2019. 

                                                          Date of Decision: 14.11.2023.

 

Smt.Chameli widow of Ram Niwas son of Prithvi Singh resident of village Matana Tehsil & District Fatehabad.

 

                                                                             ..Complainant.

                                      Versus

1. SBI Life Insurance Company Limited, Registered & Corporate Office: Natraj, M.V.Road & Western Express Highway Junction, Andheri (East), Mumbai 400059, through its Chairman-cum-Managing Director.
2. SBI Life Insurance Company Limited, Branch Office, Fatehabad through its Branch Manager.

..Opposite parties.

     

      Complaint under Section 12 of Consumer Protection Act, 1986.          

 

Before              Sh.Rajbir Singh, President.

                        Smt.Harisha Mehta, Member.

     Dr.K.S.Nirania, Member.

Present :          Sh. Jitender Thakker, Advocate for complainant.

                       Sh. Rohtash Bishnoi, Advocate for OPs.

 

ORDER

SH.RAJBIR SINGH, PRESIDENT

 

                         The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant against the Opposite Parties (hereinafter to be referred as OPs) with the averments that her husband late Shri Ram Niwas got his life insured with the OPs on 30.12.2014 vide policy No.1K010613802 by making the payment of Rs.1 lac as premium; that the complainant was nominated as nominee in the above said insurance policy; that life assured expired on 21.06.2017 and regarding this the complainant intimated the Ops besides submitting all the requisite documents with them; that instead of making the claim amount, the Ops repudiated  the claim of the complainant wrongly and illegally.  The repudiation of insurance claim of the complainant by the OPs amounts to deficiency in rendering service to the OPs.  Hence, this complaint.

2.                          On being served, OPs appeared through counsel and resisted the complaint by filing a joint written statement wherein various preliminary objections with regard to maintainability, territorial jurisdiction, cause of action, concealment of true and correct facts and locus standi etc; have been raised. On merits, it is submitted that there is a positive duty on the part of the proposer to disclose all material facts accurately and fully to the insurance company.  In the instant case the life assured was suffering from Diabetes Mellitus, End stage Renal Disease, Hypertension, Heart disease, CVA  and also underwent PTCA prior to the date of proposal which he did not disclose in the proposal form and procured the insurance policy fraudulently.  It is further submitted that suppression of material information is fatal to the contract of insurance which is based on the principle of utmost good faith.  In the present case, the life assured committed a fraud with the OPs with intention to obtain the insurance cover by suppressing the history of pre-existing disease which was very well within his knowledge because as per the record of Fortis Hospital, the DLA was case of DM (Diabetes Mellitus) more than 10 years HTN (Hypertension) CAD (Coronary Artery Disease), Post PTCA + (S) ISR LAD (03.02.2016), PTCA + (S) to LAD (06.10.2014), Old CVA + ® Hemiparisis (2014), Alcoholic, case of regular follow up. It is further submitted that the repudiation of the insurance claim of the complainant by the OPs is perfectly in accordance with the terms and conditions of the insurance policy and the same is sustainable in the eyes of law.  The OPs have further prayed for dismissal of the present complaint being devoid of merits.

3.                          The learned counsel for the complainant tendered in evidence affidavit of the complainant as Ex. C1 along-with documents Annexure C1 to Annexure C4.  On the other hand, the learned counsel for the OPs tendered in evidence affidavit of Neelam Singh as Ex. RW1/A along-with the documents as Annexure A to Annexure I and closed the evidence of the OPs.

4.                          In his arguments, the learned counsel for the complainant contended that nothing was concealed by the life assured regarding his state of health while filing the proposal form for getting the insurance claim.  The entire information regarding his health was provided by the life assured to OPs.  Therefore, it cannot be said that the particular of life assured were not disclosed by him at the time of signing of the contract of insurance.  It is further contended by the learned counsel that the documents relied upon by the OPs regarding the medical treatment record of Fortis Hospital, Mohali are only photo copies and the same cannot be read in evidence. Moreover, the OPs have not filed the affidavit of the doctor who gave treatment to the life assured.  Nor any employee of the above-said hospital has been examined by the OPs to prove the above-said documents.  It is also contended by the learned counsel that a genuine claim of the complainant has been repudiated by the OPs on false and flimsy grounds.  Learned counsel for the complainant further argued that once a policy has completed three year period, any claim arising out of it will have to be passed. In support of its case, the learned counsel for the complainant placed reliance on Section 45 of Insurance Act and the judgment rendered by Hon’ble High Court of Punjab & Haryana, Chandigarh in case tilted as Religare Health Insurance Company Ltd. Vs. The Chairman, Permanent Lok Adalat and another decided on 07.01.2020 in CWP No.107 of 2020 and another judgment rendered by Hon’ble National Commission in case titled as Life Insurance Corporation of India Vs. Omvati Devi 2018 (2) CPJ 455.

5.                          On the other hand, the learned counsel for the OPs vehemently controverted the arguments advanced by learned counsel for the complainant and further contended that since the life assured had concealed the pre-existing disease while submitting the proposal form for obtaining life insurance and as such the insurance claim of the complainant has been rightly repudiated by the OPs vide letter dated 01.11.2017.  It is further contended by the learned counsel that repudiation of the insurance claim of the complainant by the OPs is perfectly in accordance with the terms and conditions of the insurance policy and the same is sustainable in the eyes of law.  In support of its case, the learned counsel for the OPs relied upon the judgment cited as 2016 (4) CLT Page 497, 2016 (4) CLT Page 290, 2015 (4) CLT Page 518 and 2013 (4) CPJ Page 370.

6.                          We have duly considered the arguments advanced by learned counsel for the parties and have also perused the entire material placed on record.  It is not disputed that life of Ram Niwas husband of the complainant was insured by the OPs vide policy no. 1K010613802 on 30.12.2014 for an amount of Rs. 4 lakh.  It is also not disputed that the life assured died on 21.06.17 i.e. during the subsistence of the insurance policy.  It is also admitted fact that the complainant being wife of the life assured was nominated as nominee in the policy in dispute.  The OPs in the present case has repudiated the insurance claim of the complainant on the ground that the deceased life assured had not disclosed the true and material fact with respect to state of his health in the proposal form filed by him for taking the insurance policy.

7.                          After hearing arguments and examining the material placed on record, we find force in the contention raised by learned counsel for the OPs.  From perusal of the record, it is revealed that in the proposal form there were specific questions regarding medical details and state of health of the life assured under Para No. 13 of the Proposal Form signed by the life assured.  All the questions were replied by the life assured in negative. The aforesaid questions and reply thereto is reproduced as under:-

Medical and other Details:-

13 (iv)During the last ten years, have you undergone or advised to undergo hospitalization or an operation or any investigation or tests or medical treatment?

13 (xiv)Do you have diabetes or have ever suffered or treated or have you been advised to undergo investigation for diabetes?

13(xv) Are you suffering from or did you suffer or undergo investigation in the pat from or have you been advised to undergo investigation or treatment for (d) Heart disease (Chest pain, vascular disease etc.)?

 

8.                          A perusal of the above details reveals that the life assured had answered in negative to all the questions put to him.  However, from perusal of the medical treatment taken by the complainant from Fortis Hospital, Mohali, (Annexure RH), it is revealed that the life assured was the DM (Diabetes Mellitus) more than 10 years HTN (Hypertension) CAD (Coronary Artery Disease), Post PTCA + (S) ISR LAD (03.02.2016), PTCA + (S) to LAD (06.10.2014), Old CVA + ® Hemiparisis (2014), Alcoholic, case of regular follow up prior to the filing of proposal form, which the life assured had not disclosed in the proposal form.  Therefore, we are of the considered opinion that the DLA had concealed the material fact regarding his state of health and the previous disease intentionally for obtaining the insurance policy. It is a well settled principle of law that the contract of insurance is a contract of aberrima fides and there must be complete good faith on the part of the assured and thus the assured is under a solemn obligation to make full disclosure of material fact, which may be relevant for the insurer to take into account while deciding whether the proposal should be accepted or not. The declaration in the proposal form and the statement given by the life assured were the basis of contract of mutual trust between the insurer and the assured and any false statement given with respect to state of health or disclosing the false information would make the contract vitiate as has been done in the present  case. Reliance is placed on the case law titled Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. reported in IV(2009)8 SCC Page 316 and P.C.Chacko and anr. Vs. Chairman L.I.C. India 2008 (1) SCC 321.

9.                The Contention of the learned counsel for the complainant to the extent that original record of the treatment of DLA has not been produced by the OPs and the photo copies of the same cannot be read in evidence and cannot be relied upon, is not tenable as the provisions of Indian Evidence Act are not strictly applicable in the Consumer Protection Act, 2019. Therefore a photo copy of the document which is clear and legible can be relied upon provided that otherwise or contrary is not proved on the file. The complainant could have summoned the officials of the concerned hospital to prove that the document of medical treatment of DLA has not been issued by the said hospital. Moreover the functionaries of hospital do not have any interest in the OPs nor they are inimical to the complaint nor did they have motive to issue a false certificate. Therefore in case the medical treatment record is not supported by the affidavit of the concerned doctor, does not take away the beneficiary value of the document. It is also pertinent to mention here that the complainant at no stage had pleaded that life assured was not treated from Fortis Hospital, Mohali. Therefore, we are of the considered opinion that it is a valid piece of evidence. It is not the case of the complainant that the life assured had not affixed his signature on the proposal form.  It is a presumption of law that a person signs a document after reading and understanding the contents of the document.

10.              A perusal of medical treatment record reveals that prior to filing of proposal the DLA was suffering from Heart Disease (6.10.2014). The said disease is a progressive disease and gets worsen with the lapse of time and is susceptible to life threatening complications and concealment of the same amounts to suppression of a material fact. Perusal of the case file further reveals that the premium amount of Rs.3 lacs received by the Ops has already been refunded to the complainant in saving account No.917010028402756 maintained in Andhra Bank, Fatehabad on 29.10.2017 (Annexure RI) before filing of the present complaint which was filed on 24.04.2019, therefore, provisions of Section 45 of Insurance Act are not attracted  in the case in hand and the case law relied upon by learned counsel for the complainant is hereby distinguished being not applicable to the case in hand. In view of the aforesaid discussions, we are of the considered opinion that the repudiation of insurance claim of the complainant by the Ops is in order and sustainable in the eyes of law.

11.                        On the basis of above mentioned discussion, we are of the considered opinion that there was no deficiency in service at all or any unfair trade practice, on the part of any of the Ops, as alleged, so as to make any of them liable to any extent in this matter. Hence, the complaint is dismissed in view of the facts and circumstances stated above.  All the parties are left to bear their own costs. A copy of this order be supplied to both the parties free of cost as per rules.  This order be uploaded, forthwith, on the website of this Commission as per rules for the perusal of the parties. File be consigned to record room, as per rules, after due compliance.

 

Announced in open Commission.                                                            Dated: 14.11.2023

 

 

                                                                                                        

(K.S.Nirania)                       (Harisha Mehta)                (Rajbir Singh)                         

Member                                     Member                                     President