Delhi

East Delhi

CC/209/2016

SH.A.M TEWARI - Complainant(s)

Versus

TATA AIG INS. - Opp.Party(s)

02 Mar 2020

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. NO. 209/16

Shri A.M. Tewari

Husband of the Deceased Policy Holder

R/o 5-B, SFS Flats,

Highway Apartment,

Ghazipur, Delhi- 110096

•  

Vs

 

1. TATA AIG Life Insurance Co. Ltd.

Unit-302, Building No. 4,

Infinity IT Park,

Film City Road,

Dindoshi Malad East,

Mumbai- 400097

 

2. CEO, Managing Director

TATA AIG Life Insurance Co. Ltd.

Delphi-B wing,

2.  

Hiranandani Business Park,

Pawai, Mumbai- 400076

 

….Opponents

Date of Institution: 29.04.2016

Judgment Reserved on: 02.03.2020

Judgment Passed on: 02.03.2020

CORUM:

Sh. SUKHDEV SINGH                  (PRESIDENT)

Dr. P.N. TIWARI                           (MEMBER)

Ms. HARPREET KAUR CHARYA (MEMBER)

 

ORDER BY: HARPREET KAUR CHARYA (MEMBER)

JUDGEMENT

The present complaint has been filed by Shri AM Tewari, the complainant, against, TATA AIG Life Insurance Co. Ltd (OP-1) and CEO, MANAGIND DIRECTOR, TATA AIG   Life Insurance Co. Ltd., (OP-2) under Section 12 of the Consumer Protection Act, 1986.

Briefly stated the facts necessary for the disposal of present complaint are in the month of February, 2009, the authorized agent of TATA AIG life insurance approached the deceased wife of the complainant, Smt. Raj Laxmi Tewari and convinced her to purchase an insurance policy by misleading and playing fraud on the pretext that medical test would be conducted before the issuance of policy. Payment of Rs. 50,000/- was made towards the premium, however, no medieal test was conducted despite reminders.

The policy was issued by OP and the second premium was paid vide cheque no. 452525 dated 19.03.2010. The reminder for the annual third premium of Rs. 50,000/- was received by the complainant which was due in the month of March, 2011 but unfortunately the insured expired on 15.02.2011.

Claim was filed with OP alongwith original policy and other documents. On 28.04.2011, the complainant received a cheque of Rs. 65,105.38 from OP as full and final settlement without any reason. The complainant was shocked to received the said amount as the sum insured was                              Rs. 10,00,000/-, for which the premium was being paid.

The complainant visited the office of OP and requested for the copy of the insurance application and proposal form, where he came to know that part II of the policy document had not been signed by the deceased policy holder. On 09.02.2012., the complainant requested the OP to settle the claim which is duly replied. In another letter dated 06.08.2012 addressed to the customer care cell of OP, the complainant requested for the medical certificate pertaining to the medical done before the issuance of policy. Despite, several reminders the complainant’s grievance remained                        un-addressed. Claim before insurance ombudsman was also filed on 24.12.2013, whereby the same was dismissed vide order dated 23.02.2015.

On 16.12.2014, again a cheque of Rs. 65,105.385 was sent to the complainant, which has not been encashed by him. Feeling aggrieved by the act/ omission on the part of OP, the complainant has prayed for directions to OP to pay Rs. 10,00,000/- as claim alongwith interest @18% per annum.

The complainant has annexed the application form, general amendment form, sales benefit illustration, letter dated 04.09.2009, endorsement, first premium receipt, policy information, death claim, letters dated 09.02.2012, 07.06.2012, 05.07.2012, 06.08.2012, 09.11.2012 and 15.03.2013, copy of the complaint to ombudsman, claim payment letter, award of ombudsman have been annexed with the complaint.

OP have filed Written Statement upon service of summons. They have taken several pleas in their defence such as; there was no deficiency in services as the claim of the complainant had been repudiated vide letter dated 03.05.2011 on the ground that the life assured had suppressed material facts regarding the condition of  her health. The deceased life assured was suffering from intestinal lung disease, sensory motor polynuropathy, osteoporosis and obstructive sleep apnoea and was hospitalized on earlier occasions.

It was submitted that at the time of filing the application form the life assured was explained the terms and conditions and the declaration was signed after reading and understanding the same.  The contract of insurance is based on the doctrine of Ubrrema fide i.e. utmost good faith. It was further submitted that the application form, which formed the part of the policy contract the life assured had declared that:

“I/We have made no statement to the agent, medical examiner or any other person associated with TATA AIG life insurance co. ltd. which in any way modifies the answers and statement on this application.”

“I/We understand and agree that TATA AIG life insurance co. ltd. must be notified of any changes in my health and circumstances between the date of this application and prior to the acceptance of the risk.”

Since, the life insured had answered in negative to the question no.5, a,el,k 7&8 of step 10, the policy was issued. As the complainant had concealed the material facts regarding the health the policy issued was void ab initio. Rest of the contents has been denied.

Rejoinder to the Written Statement of OP was filed on behalf of complainant, where the averments made in the complaint have been                     re-affirmed and those of the Written Statement have been denied. It has been stated that since the life insured was over 60 years of age, the requirement of medical tests was mandatory, which was overlooked by OP.

Evidence by way of affidavit was filed by the complainant, where he has narrated averments made in the complaint. He has got exhibited the copy of application form, general amendment forms, sales benefit illustrations, letter of Managing Director to Customer, letter dated 09.04.2009, endorsement policy information dated 16.03.2009, first life insurance premium receipt dated 16.03.2009 are Ex. CW1/1 (Colly.); death claim intimation cum claimants statement dated 30.03.2011 is Ex. CW1/2. Copy of the letter written to Manager TATA AIG, which is of date 09.02.2012 and letter dated 07.06.2012 to customer care cell, TATA AIG are Ex. CW1/3 and Ex. CW1/4 respectively. Reply from Manager TATA AIG, which is date 05.07.2012 is Ex. CW1/5, copy of letter written to customer care cell, TATA AIG dated 06.08.2012 is Ex. CW1/6, copy of letter written to TATA AIG dated 09.11.2012 and 15.03.2013 are Ex. CW1/7 (Colly.), copy of complaint filed before the insurance ombudsman is Ex. CW1/8,  copy of letter dated 09.03.2015 issued by the officer of the insurance ombudsman is Ex. CW1/9, copy  of award dated 23.02.2015 is Ex. CW1/10, copy of cheque dated 16.12.2014 is Ex. CW1/11 (Colly.), copy of cheque dated 08.01.2018 alongwith its covering letter is Ex. CW1/12 (Colly.)

Sh. Anmol Khishore, Manager Legal, TATA AIA Life Insurance Company Limited (Previously known as TATA AIG Life Insurance Co. Ltd.) has been examined on behalf of OP. He has deposed on oath the contents of their Written Statement.

 He has also got exhibited the copy of the application form as Ex.R1/A, copy of the discharge cummary as taken from the records of the treating hospital as Ex.R1/B (Colly.), copy of the repudiation letter as Ex.R1/C.

We have heard the submission made by Ld. Counsel for Complainant and have perused the written arguments filed by OP, since no one appeared on their behalf to argue. The complainant is aggrieved by non-payment of the insured amount of Rs. 10,00,000/- on the ground given in Ex.CW1/5 (Colly.), where the life insured has answer questions in Negative.

Step 10		Health Details of Life Insured	Reply
Q5	a	Stroke epilepsy fits recurrent headache paralysis faints or any another disorder of the brain, spinal cord or nerves?	No
	e	Asthma, pneumonia, tuberculosis, emphysema, coughing up blood persistent cough, or any other disorder of the chest or lungs?	No
	k	Back or neck complaint arthritis, gout, physical disability or other disorder of the bones joints or muscles?	No
	l	Any illness that has caused you to be absent from work for a continuous period of 7 days or more?	No
Q7		In the last 5 years, have you attended any doctor or any other medical facility for investigation, or diagnostic tests (such as X-ray, ultrasound, CT scan, biopsy ECG, blood or urine, etc)?	No
Q8		Have you any other illness, injury, operations or abnormality not mentioned under any question above which is recurrent or has symptoms persisting for more than 7 days	No

 

In support of their contention OP have placed on record the discharge summary which is Ex.RW1/B, which is discharge summary of Metro Centre for Respiratory Diseases, with date of admission as 20.10.2008 and date of discharge as 21.10.2008. The complainant was diagnosed with “ILD with chest infection with acute on chronic respiratory failure, OSAHS, Osteoporosis and Sensory Motor Polyneuropathy”. Another discharge summary dated 28.01.2009, where date of admission is 27.12.2008, the deceased life insured was diagnosed with “acute infective exacerbation of ILD with acute on chronic respiratory failure, Sepsis, Osteopania, Essential Hyper Tension and Sensory Motor Polyneuropathy”. The proposal form is of date 08.03.2009, which is approximately within a period of 6 weeks from the date of discharge from Metro Centre for Respiratory Diseases. Thus, the OP has successfully discharged their onus that the complainant had concealed the material facts. It is settled principle of law that contract of insurance is based on principle of utmost good faith, but in the instant case the deceased life assured failed to disclose the material facts pertaining to her health. At the same time, the complainant has also placed on record letter dated 09.01.2018, where a cheque of Rs. 72,699/- has been enclosed towards the settlement of the premium refund. The same is Ex. CW1/12 (Colly.).

Thus, in the facts and circumstance of the present case, we hold that OP is not deficient in rendering services, but at the same time, since, OP has offered an amount towards the settlement of the claim, we direct them to issue a fresh cheque of Rs. 72,699/- within 30 days from the date of receipt of order. For the reasons discussed above the complaint is disposed of accordingly.

 The order be complied within 30 days from the date of receipt of order. Copy of this order be sent to the parties as per law.

 

 

(DR. P.N. TIWARI)                                    (HARPREET KAUR CHARYA)     Member                                                 Member

 

 

(SUKHDEV SINGH)

          President