Haryana

StateCommission

A/1055/2016

BIRLA SUN LIFE INSURANCE CO. LTD. - Complainant(s)

Versus

SHAKUNTLA - Opp.Party(s)

S.C.THATAI

30 Mar 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    1055 of 2016

Date of Institution:      04.11.2016

Date of Decision :       30.03.2018

1.     Birla Sun Life Insurance Company Limited, Branch at Kaithal through Ms. Aakriti Manocha, Deputy Manager-Legal.

2.     Branch Manager, Birla Sun Life Insurance Company Limited, 314 Wadhva Complex, near Metro Station, Vikas Marg, Laxmi Nagar, Delhi-110093.

3.     Managing Directors/Assistant Manager (Claims) Birla Sun Life Insurance Company Limited 1, India Bulls Centre, Tower-1, 16^th Floor, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400013.

                                      Appellants-Opposite Parties

Versus

 

Shakuntla w/o Sh. Sheru, Resident of House No.61/3, Village Palade Siwan Tehsil and District Kaithal, Haryana.

                                      Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Balbir Singh, Judicial Member.

                                                                                                         

Argued by:          Shri S.C. Thatai, Advocate for appellants.

                             Shri Pardeep Solath, Advocate for respondent.

 

                                                   O R D E R

 

BALBIR SINGH, JUDICIAL MEMBER

 

        This appeal has been preferred against the order dated August 18^th, 2016 passed by District Consumer Disputes Redressal Forum, Kaithal (for short ‘the District Forum’).

2.                Sheru (since deceased) –husband of Shakuntla (respondent herein) during his life time was provided a life insurance policy No.006287211 (Exhibit OP-1) by Birla Sun Life Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Parties, under BSLI Vision Life Secure Plan mentioning October 29^th, 2013 as date of commencement and Rs.8,00,000/- as sum assured. Unfortunately, Sheru (hereinafter referred to as the ‘Life Insured’) died on November 24^th, 2013.  Information regarding death of the life insured was given to the Insurance Company along with Death Certificate (Mark C-10) and all other relevant documents immediately. The insurance claim of the complainant was not accepted by the Insurance Company despite time and again requests and even after service of legal notice (Mark C-8) dated September 09^th, 2014. The complainant had to face un-necessary harassment and mental agony due to faults of the Insurance Company-Opposite Parties.

3.                The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 with a prayer to direct the opposite parties to pay the total insured amount of Rs.8.00 lacs to the complainant with interest at the rate of 24% per annum from the date of death of the life insured; to pay an amount of Rs.1,50,000/- on account of un-necessary harassment and mental agony.

4.                The Opposite Parties in their written version have taken plea that the complaint filed by the complainant is not maintainable; that the complainant has no locus standi and cause of action to file the present complaint and that the life insured concealed true and material facts at the time of obtaining the insurance policy and also the complainant concealed true and material facts from the District Forum. As per version of the opposite parties, the life insured was suffering from serious stomach ailment called “Acute Pancreatitis” for the last about 5-6 months prior to the date of insurance policy on October 29^th, 2013.  The life insured took treatment from Dev Nursing Home, Karnal Road, Kaithal w.e.f. October 23^rd, 2013 from where he was referred for further treatment to Government Medical College & Hospital, Sector-32, Chandigarh. The life insured died exactly after one month from the date of obtaining the insurance policy, on November 24^th, 2013.  The life insured concealed regarding his existing disease and obtaining treatment from Dev Nursing Home, Karnal Road, Kaithal and few other hospitals. Moreover, the driving licence provided by the life insured regarding proof of his age was also found fake as per report of the surveyor. Keeping in mind all these circumstances, the insurance claim of the complainant was rightly repudiated vide letter dated June 30^th, 2014. The complainant is not entitled to receive any amount as claimed in the complaint. It is prayed that the complaint filed by the complainant be dismissed with costs.

 5.               Parties led evidence in support of their respective claims before the District Forum.

6.                After hearing arguments, vide impugned order dated August 18^th, 2016, the complaint filed by the complainant was allowed by the learned District Forum directing the opposite parties to pay the total sum assured to the complainant with interest at the rate of 8% per annum from the date of order and to pay Rs.3,000/- as compensation on account of un-necessary harassment and mental agony.

7.                Aggrieved with the impugned order dated August 18^th, 2016 passed by the learned District Forum, the opposite parties filed the present First Appeal No.1055 of 2016 with a prayer to set aside the impugned order and to dismiss the complaint filed by the complainant holding that the complainant is not entitled to receive any amount as prayed in the complaint.

8.                We have heard learned counsel for the parties and perused the case file.

9.                It is admitted fact that the life insured-Sheru (husband of the complainant) was provided life insurance policy (Exhibit OP-1) by Opposite Parties under BSLI Vision Life Secure Plan with effect from October 29^th, 2013 mentioning sum assured as Rs.8,00,000/-. The life insured was required to pay an amount of Rs.35,360/- annually as premium.  Last installment of the premium was to be paid on April 29^th, 2042. During the course of arguments there was no controversy of any type that the life insured died on November 24^th, 2013.  After death of the life insured the complainant being nominee of the life insured submitted insurance claim with the Opposite Parties. Death Claim intimation Form is Exhibit OP-2. Plea has been taken in the written version that the driving licence produced by the life insured as proof of his age was found fake but no convincing evidence has been adduced in this regard and regarding age of the deceased there appears to be no controversy in this case. As per version of the opposite parties  the life assured was suffering from  serious stomach ailment called “Acute Pancreatitis” for the last about 5-6 months prior to the date of insurance policy on October 29^th, 2013.The life insured concealed this material fact regarding his existing disease at the time of submitting his Proposal Form Exhibit OP-8.  As per version of the opposite parties, the insurance claim of the complainant has been rightly repudiated as the life insured and the complainant concealed material facts regarding existing disease.

10.              It is evident from the hospital record/prescription slip Exhibit OP-5 that Shamsher Singh was admitted in Dev Nursing Home, Karnal Road, Kaithal on October 23^rd, 2013 from where he was referred to Government Medical College & Hospital, Sector-32, Chandigarh for further treatment. Report from New Gupta Lab, dated 23^rd October, 2013 is placed on the file regarding tests examination and obtaining blood samples etc. of Shamsher Singh-life insured. The complainant in her application Exhibit OP-3 written to the opposite parties has mentioned that her husband died on 24^th November, 2013. He was suffering stomach pain and was admitted in Dev Nursing Home, Karnal Road, Kaithal on October 23^rd, 2013 from where he was referred for further treatment to Government Medical College & Hospital, Sector-32, Chandigarh. She stated that her husband died when he was being taken to Chandigarh for treatment. From the above mentioned documents it is evident that before issuance of the insurance policy, the life insured (husband of the complainant) was not having good health as he was suffering from serious stomach ailment called “Acute Pancreatitis” but the life insured did not disclose this fact at the time of submitting the proposal form intentionally. The treatment record issued from Dev Nursing Home, Karnal Road, Kaithal shows that the life insured got treatment from that hospital and even other hospitals also. In this way, it is a clear case of concealment regarding disease suffered by the life insured prior to the date of obtaining the insurance policy which is certainly against the terms and conditions of the insurance policy. In this way, the life insured violated the terms and conditions of the insurance policy and the complainant is not entitled to receive the insurance claim.

11.              Learned counsel for the complainant has argued that the name of the life assured (complainant’s husband) was Sheru and no document has been produced regarding medical treatment given to life insured Sheru before providing the insurnace policy. Our attention was drawn towards the prescription slip Exhibit OP-5Dev Nursing Home as well as copy of the test report issued from New Gupta Lab, wherein name of the patient was mentioned as Shamsher and not Sheru. Surveyor appointed by the Insurance Company in his report has also mentioned in clear words that as per his verification, the life insured-husband of the complainant got treatment from Dev Nursing Home as well as in Deep Shikha Nursing Home under Dr. Pradeep Singla and he was referred to Post Graduate Institute of Medical Sciences and Research, Chandigarh (PGIMER) for further treatment on October 24^th, 2013 and the life insured died on October 24^th, 2013 on his way to PGIMER, Chandigarh. In this case, it will be pertinent to mention here that in the insurance policy (Exhibit OP-1), Proposal Form (Exhibit OP-8) and all other documents concerned with the life insured, the name of the life insured has been mentioned as Sheru. In the prescription slip issued from Dev Nursing Home and in the slip issued from New Gupta Lab name of the patient is mentioned as Shamsher. Learned counsel for the complainant further argued that name of complainant’s husband was Sheru and not Shamsher and this medical record appears to be of some other person. In this case, the opposite parties have tendered in evidence photo copy of a duly attested affidavit of complainant Shakuntla (Exhibit OP-6) wherein she made it clear that name of her husband is Shamsher Singh @ Sheru. She further clarified that her husband was known as Shamsher Singh as well as Sheru.

12.              Apart from it, at the time of arguments learned counsel for the opposite parties placed on the file the Municipality wise beneficiaries list (Annexure A-10) of the persons receiving family pension etc. In this document at Sr.No.92 in one column name of husband of Shakuntala is mentioned as Sheru and in the second but last column name of husband of the complainant is mentioned as Shamsher Singh.

13.              From the above mentioned documents, it clearly appears that the life insured Sheru was known as Shamsher Singh also and the medical prescription slip (Exhibit OP-5) and other medical record in the name of Shamsher Singh is concerned with the treatment given to the life insured.  Moreover, the complainant also could not adduce any positive and convincing evidence to prove that any other person having the same name and father’s name is living in the village and he actually got treatment on 23^rd October, 2013 from Dev Nursing Home, Kaithal. 

14.              In case law Satwant Kaur Sandhu vs. New India Assurance Company Ltd. (2009) 8 SCC 316, it has been observed by the Hon’ble Supreme Court that the expression “material fact” is to be understood in general terms to mean as any fact which would influence the judgment of a prudent Insurer, in deciding whether to accept the risk or not.  If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form.  Any inaccurate answer will entitle the Insurer to repudiate their liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance, which is based on the principle of utmost faith – uberrima fides.  Good faith forbids either party from non-disclosure of the facts which the party privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary.

15.              As a result as per discussions above in detail, we have no hesitation in holding that the life insured concealed this material fact that he was suffering from serious stomach ailment called “Acute Pancreatitis” for the last about 5-6 months prior to the date of insurance policy on October 29^th, 2013 for which he took treatment from Dev Nursing Home and few other hospitals prior to the date of issuance of the insurance policy. It is a clear case of violation of the terms and conditions of the insurance policy. So, the complainant is not entitled to receive any amount as insurance claim from the opposite parties regarding insurance policy provided to her husband.

16.              As per discussions above in detail, it is held that the learned District Forum fell in error while passing the impugned order dated August 18^th, 2016. Hence, the impugned order is held illegal and invalid and is hereby set aside. Resultantly, the appeal filed by the appellants-opposite parties is allowed and the complaint filed by the complainant stands dismissed.

17.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellants against proper receipt and identification in accordance with rules, after expiry of period of appeal/revision, if any.

 

Announced: 30.03.2018

(Balbir Singh) Judicial Member

(Nawab Singh) President

 

CL