Charanjit Singh, President

1        The complainant has filed the present complaint by invoking the provisions of Section 34, 35, 36 and 38 of the Consumer Protection Act against the opposite parties on the allegations that as the opposite parties No.1 & 2 is dealing in the life insurance policies and for that purpose, they had spread out number of agents in the field for covering the life risks of common man and opposite parties No.1 & 2 in order to secure the business and for having monetary gains, usually allures and gives attractive offers to the common man at the time of giving policies and further assures the family members of the applicants that if any untoward incident occurred the opposite parties No.1 & 2 i.e the company will give all the benefits and the sum assured at the doorstep as the family will have to go nowhere and the services will be availed while sitting at home and the agents of the opposite parties i.e. the company as well as its officials as per the directions issued by the higher officials, use to give lucrative offers to common people, just in order to secure their business. The company's officials and agent i.e. opposite parties No.3 Shriram Fortune Solutions limited having office in the area of Tarn Taran as such the O.P No.1 & 2 is doing its business in the area of Tarn Taran through its agents. The O.P No.3, its officials approached the complainant & his family and gave lucrative offers for having a life insurance policy i.e. SHRIRAM NEW SHRI VIDYA policy and had told about the above policy to the family members of the complainant and they were attracted to the offers made by the opposite parties/its agents. The family members of the complainant had proposed to assure the life of Davinder Kaur w/o Gurbinder Singh, vide application vide the life insurance policy of the company that is "SHRIRAM NEW SHRI VIDYA Plan" and the company has issued the policy in favour of the deceased/ applicant Davinder Kaur vide policy No.NP011908197507 and the said policy was issued in the year 2019 and the basic premium half yearly was fixed of Rs.24,911/- and the complainant has paid the first premium of the policy vide receipt bearing No.0120190819790 dated 1.9.2019. The basic sum assured was fixed of Rs. 3,19,000/- and the death claim was fixed as Rs. 7,71,000/-  and the premium paying term was fixed up to 28.2.2029 complainant is nominee of the policy. Afterwards unluckily, the applicant Baljit Kaur died a natural death on 13.11.2019 at her residence at Village Mari Megha, District Tarn Taran. The complainant had given the required information to the company regarding the death of the applicant Davinder Kaur for obtaining the amount of sum assured on death under the policy. All the requisite details, that is death certificate, forms and information were produced to the officials of the opposite parties i.e. the company and the officials of the opposite parties i.e. the company kept mum for several months since the death of the applicant Davinder Kaur and thereafter just in order to save their skin & money and above all to decline the genuine claim of the complainant, repudiated the claim in a highly arbitrary manner vide it's correspondence dated 20.10.2020 on the basis of alleged incomplete, false and self-interpreted medical record and others alleged documents/ submissions, which had never seen the light of day & were never within the knowledge of the complainant as well as of the deceased and without showing any of the alleged documents to the complainant. All the alleged facts mentioned by the company i.e. opposite party in the above said correspondence regarding the deceased life assured are false and based upon the baseless & frivolous documents, if any would produce by the company later on. The deceased life assured had given all the correct facts before purchasing of the policy but the agents of the company have got the signature of the applicant on all the documents without dictating the contents of the clauses to the applicant/deceased as such there is no fault on part of the applicant in this respect. The alleged disease as mentioned by the insurance company is not such a fatal disease, which can cause death of a human being and moreover the applicant/deceased was not suffered with any of the alleged disease. The authorized doctor of the insurance assessed company had examined the insured, the fitness and after complete satisfaction, then the policy was being issued and if the deceased life insured could have been suffered with such kind of serious disease, then it must come to the knowledge of the insurance company at that time. At the time of issuing of the policy, no alleged terms and conditions have been ever dictated/ explained to the applicant/her representatives. The  complainant has prayed that the opposite parties No. 1 and 2 may be directed to pay the total minimum Death benefit under the policy i.e. sum of Rs. 7,71,000/- on account of loss and compensation with interest to the complainant. The opposite parties may be directed to pay Rs. 20,000/- as compensation and Rs. 10,000/- as litigation expenses.  Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, Self attested copy of forwarding order Ex. C-2, Self attested copy of  policy schedule Ex. C-3, Self attested copy of premium receipt Ex. C-4, Self attested copy of application form Ex. C-5, Self attested copy of coy of claim repudiation letter Ex. C-6, Self attested copy of death certificate Ex. C-7, Self attested copy of Adhar Card of Davinder Kaur Ex. C-8, Self attested copy of Adhar Card of Gurinder Singh Ex. C-9.

2        Notice of this complaint issued to the opposite parties and opposite parties No.1  and 2 appeared through counsel and filed written version by interalia pleadings that on 28.8.2019 deceased life assured namely Davinder Kaur wife of Sh. Gurbinder Singh took life insurance policy bearing no. NP011908197507 from OP No. 1 and 2. A bare perusal of policy schedule attached with the complaint shows that column "Declaration By The Insurer which reads as Shriram life insurance company Ltd having received a proposal and declaration and the first premium from the proposer life assured named in the schedule and the said proposal and declaration with the statements contained) referred therein having been agreed by the proposer and the company on the basis of this assurance do this policy agreed in consideration of and subject to due respect of the subsequent installments of premiums, if any as set out in this schedule, to pay the benefits to the lawfully entitled person or persons subject to the terms and conditions, on submission of proof to the satisfaction of the company". The deceased life assured paid 1^st half yearly premium of 24,911/- including GST and policy commenced from 28.8.2019, in which the risk commence from 31.8.2019, the duration of policy was for 10 years and premium payment term was 10 years payable half yearly and last premium due date was 28^th February 2029. The sum assured under the policy is Rs.3,19,000/- The Proposal Form clearly mentioned the guidelines for filling the Proposal Form wherein it is mentioned that insurance is a contract of utmost good faith which requires the insurer, proposer and the life assured to disclose all material facts and not to suppress any material facts in response to the questions in the Proposal Form. Before filling the form, the proposer is supposed to read the product brochure so that he/she fully understand the benefits of the product as well as the terms and conditions.  As per column No. 14/15 in the said proposal form it is mentioned about the proposal medical history of the life to be assured, to which deceased life assured has not given any details. It is further submitted that have you ever suffered from any ailment as mentioned below and all those columns she has mentioned as NO. Life assured died on 13.11.2019. Being an early death claim, the opposite parties No. 1 and 2 got the death claim investigated from their investigator namely Sakshi Investigation & Detective Agency, from which it came to light that deceased life assured had died of cancer and she has been old patient of cancer, having taking treatment in several hospitals such as Dhawan Hospital, Gurunanak Hospital etc. which was not disclosed by deceased life assure date the time of submitting the proposal form.  The claim of complainant/ nominee under the policy on account of death of deceased life assured was repudiated by OP No. 1 and 2 vide repudiation letter dated 20.10.2020 on the ground that in the proposal form life assured had replied in the negative to following questions

The OP No. 1 and 2 had covered the risk for the above said policy on the basis of facts mentioned in the Proposal Form. On receiving the death claim intimation for the above said policy, various investigations were done, which revealed that deceased life assured was unknown case of Cancer and that she was on a regular treatment prior to date of proposal dated 20.8.2019, which is deliberate concealment of material fact with malafide intention. The life assured had given false and misleading information to OP No. 1 and 2, had she replied to the above questions truthfully and correctly in the proposal form, the company's underwriting decision would have been different. The company has been led to issue the policy by suppression of material facts regarding her medical history. Further by referring to the principle of "uberrima fide" and section 45 of Insurance Act and facts and circumstances claim of complainant was rightly and legally repudiated. The present complaint is not maintainable as the complainant has not approached this Commission with clean hands and concealed the true facts that deceased life assured was unknown case of cancer and was taking treatment for the same before opting to purchase the present policy and false declaration has been made in the proposal from and this material fact has been concealed when there is a particular query to this effect in the Proposal Form. This commission has no territorial jurisdiction to entertain and adjudicate the present complaint. No cause of action has arisen in favour of complainant to file the present complaint is there is no unfair trade practice or deficiency in service on the part of OP. The contract of insurance are based on the principle of "Uberrimei Fidei" i.e. utmost good faith and insurance companies are under no obligation to get medical conducted of proposed life assured in each and every case before issuance of policy. It is the duty of proposed life assured to disclose the true material information which could affect the decision of the insurer as to whether it would like to issue the policy to such proposed life assured or not.  The opposite parties No. 1 and 2 have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party No. 1 and 2 have placed on record  affidavit of Mr. E. Shridhar Ex. OPs/1 alongwith documents Ex. OPs/2 to OPs/8.

3        Notice of this complaint was sent to the opposite party No. 3 but no one appeared on behalf of opposite party No. 3 and consequently, the opposite party No. 3 was proceeded against exparte.

4        We have heard the Ld. counsel for the complainant and opposite parties No.1  and 2 and have carefully gone through the record placed on the file.

5        From the combined and harmonious reading of the documents and pleadings on record is going to prove that Davinder Kaur has obtained an insurance policy i.e. "SHRIRAM NEW SHRI VIDYA Plan" vide policy No.NP011908197507 and the basic premium half yearly was fixed of Rs.24,911/-. The complainant has paid the first premium of the policy vide receipt bearing No.0120190819790 dated 1.9.2019. In the present matter the insurance policy is not in dispute, death of Davinder Kaur is also not disputed. As per the complainant, after the death of Davinder Kaur,  the requisite documents along with the claim form have been supplied to the opposite parties but the said claim was repudiated by the opposite parties vide repudiation letter Ex. C-6 in which it has been mentioned that DLA Davinder Kaur was a known case of Cancer prior to the date of proposal dated 20.8.2019, which is a deliberate concealment of material facts with malafide intention and finally no claim was payable under this policy and this matter was closed.

6        However, being an early death claim the opposite parties No. 1 and 2 got the death case investigated from their investigator namely Sakshi investigation and detective agency, from which it came to light that DLA had died of cancer and she has been a old patient of cancer, having treatment in several hospitals such as Dhawan Hospital, Guru Nanak Hospital etc., which was not disclosed by DLA at the time of submitting the proposal from. Copy of the investigation report dated 23.7.2020 is Annexure R-3.   The claim of complainant/ nominee under the policy on account of death of deceased life assured was repudiated by OP No. 1 and 2 vide repudiation letter dated 20.10.2020 on the ground that in the proposal form life assured had replied in the negative to following questions

The OP No. 1 and 2 had covered the risk for the above said policy on the basis of facts mentioned in the Proposal Form. On receiving the death claim intimation for the above said policy, various investigations were done, which revealed that deceased life assured was unknown case of Cancer and that she was on a regular treatment prior to date of proposal dated 20.8.2019, which is deliberate concealment of material fact with malafide intention. The life assured had given false and misleading information to OP No. 1 and 2, had she replied to the above questions truthfully and correctly in the proposal form, the company's underwriting decision would have been different. The company has been led to issue the policy by suppression of material facts regarding her medical history. Further by referring to the principle of "uberrima fide" and section 45 of Insurance Act and facts and circumstances claim of complainant was rightly and legally repudiated.

7        The case of the opposite parties revolves and depends upon the investigation report that the DLA was suffering from Cancer.  As per the investigator, this fact came in to the knowledge of the investigator from the hospital such as Dhawan Hospital, Guru Nanak Hospital  that the DLA is suffering and she has been known case of cancer and taking the treatment from the above said hospitals. But the opposite parties have filed to produce any of the record which pertains to the above said hospitals that the DLA was under the treatment of said disease i.e. Cancer. However, the investigation report itself suggests that cause of death is a sudden cardiac arrest. The investigator in his investigation report has mentioned that he found that this LA had cancer and took treatment from Dhawan Hospital in Bhikhiwind City and also from Guru Nanak Multiplicity Hospital in City Tarn Taran. Further in this report investigator further mentioned that as per the vicinity this lady was undergone an abdominal surgery in Dhawan Hospital Bhikhiwind about one-two years back, where she found the malignancy and after this, DLA was taking treatment from some hospital in this area. But the investigator as well as the opposite parties has not placed on record any cogent evidence which support the version of the investigator that the DLA was suffering from cancer. Time and again, it has been mentioned about two hospitals i.e. Dhawan Hospital and Guru Nanak Multiplicity Hospital Tarn Taran but there is no record found on record that the DLA was treated in the above said hospitals for cancer. If the DLA was admitted and taking the treatment from the said hospitals then what prevented the opposite parties to place on record the documents regarding the treatment of DLA.  However, the opposite parties have placed on record one certificate which pertains to Deep Hospital which suggests that the DLA was brought to his hospital which was clinically dead. The opposite parties have themselves placed on record statements of Sarpanch, Amandeep Singh and Gurwinder Singh in which they have clearly stated that the death of the DLA was due to sudden cardiac arrest. It is beyond imagination that how the opposite parties are stating that the DLA was suffering from Cancer prior to the date of inception of the policy. Merely, the investigator in his report mentioned that the DLA was suffering from Cancer i.e. to on the hearsay statements. The report of the investigator is not supported by the treatment record of the above said hospitals. As such, the report of the investigation cannot be relied upon. The opposite parties have also failed to prove the nexus between cardiac arrest and cancer. Moreover the investigation report is not supported by the affidavit of investigator/ surveyor. In the absence of which no evidentiary value can be made on the report submitted by the surveyor. Reliance in this connection has been placed upon Manikant Vs. New India Assurance Co.Ltd. 1(2012) CPJ 88 (NC) of the Hon’ble National Commission wherein it has been held that the surveyor did not appear in court and subject himself to cross examination nor was any affidavit filed by him to prove his report . Producing a document in court does not by itself constitute proving the document. It has to be backed by credible evidence. In the instant case, no evidence was led to prove the surveyor’s report in the absence of which the surveyor’s report has little evidentiary value.   Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.        The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

8        Now we have to see how much amount is payable to the complainant under the death claim. The complainant in his complaint in Para No. 4 pleaded that the basic sum assured was Rs. 3,19,000/- and the death claim was fixed as Rs. 7,71,000/- The perusal of Policy schedule Ex. C-3 shows that sum assured is Rs. 3,19,000/- and as per terms and conditions of the policy and as per Annexure III of the policy, the complainant is entitled to the additional benefit as detailed in the same under death claim. Moreover, Para No. 4 of the complaint is not specifically denied by the opposite parties in their written version. As such, the complainant is entitled to Rs. 7,71,000/- as prayed for in the complaint.

9        In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant and against the Opposite Parties. The opposite Parties are directed to make the payment of Rs. 7,71,000/- to the complainant. The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to Rs.20,000/- as compensation on account of harassment and mental agony and Rs 11,000/- as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission.

Announced in Open Commission

23.08.2023