Haryana

Karnal

570/2009

Shallej Singh S/o Surjat Singh - Complainant(s)

Versus

Tata AIG Life Insurance Co., 2Tata AIG Life Insurance Co.,3 Tata AIG Life Insurance Co.,4Tata AIG Li - Opp.Party(s)

Pardeep Kapor

01 Sep 2014

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                           Complaint No.570 of 2009

                                                           Date of Instt. 19.08.2009

                                                           Date of decision: 10.03.2015

 

Shallej Singh son of Surat Singh  resident of House No.1278, Sector 7, Urban Estate, Kurukshetra tehsil Thanesar District Kurukshetra.

                                                                     ……..Complainant.

                                                Vs.

1. Tata AIG Life Insurance company Ltd.Unit 302, Building No.4, Infinity IT Park Film City Road Dindoshi Malad- East Mumbai 400097 through its Managing Director.

 

2.Tata AIG Life   Insurance Ltd. Registered and corporate office 6^th Floor, Peninsula Towers, Peninsula Corporate Park, Ganpatrao Kadam Marg, Lower Parel (W) Mumbai through its Manager.

 

3.Tata AIG Life Insurance Company Ltd. 789, Lotus Tower, New Friends colony, Community Centre, New Delhi through its Manager.

 

4. Tata AIG Life Insurance Company Ltd.SCO No.151-152, Sector 8-C, Chandigarh near Axis Bank, Chandigarh now new address SCO No.107-108, 2^nd Floor Sector 43-B, Chandigarh through its Manager.

 

5.Tata AIG Life Insurance Company Ltd. SCO No.244, 245.246, Second Floor Sector 12, Karnal through its Manager.

 

6.Gaurav Kumar Agent Tata AIG Life Insurance Company Ltd. House no.345, Ward No.2, Pundri district Kaithal.

.

                                                                   …..Opposite Parties.

 

                                      Complaint u/s 12 of the Consumer

                                      Protection Act.

 

Before           Sh.Subhash Goyal……..President.

                    Sh.Subhash Chander Sharma       ……Member.

 

Argued by:-  Sh.Pardeep  Kapoor   Advocate for the complainant.

                   Sh. A.K.Vohra   Advocate for the OPs.

 ORDER

           

                        In brief the complainant has filed the present complaint against the OP u/s 12 of the Consumer Protection Act alleging deficiency in services on the part of the Ops  on the allegations that the complainant was insured by the Ops vide insurance policy No. 0017662402 on 28.7.2008  for a sum of Rs.1,50,000/-.It has been alleged that prior to issuing of policy, the Ops got the complainant medically examined from their own doctor and the complainant was having no disease of any kind. After issuance of the policy, the complainant suffered liver problem and liver plantation of the complainant has been done and the complainant also suffered stomach problem  and the complainant has spent Rs.four lakhs. The complainant submitted all the bills to the OP but the Ops failed to make the payment of the claim amount. Thus, alleging deficiency in services on the part of the Ops, the complainant has filed the present complaint against the Ops and has prayed for payment of the claim amount alongwith compensation for the harassment caused to him and the litigation expenses. The complainant has also tendered his affidavit in support of the contents of the complaint alongwith some other documents.

 

2.                 On notice the Ops appeared and filed written statement raising the preliminary objections that  the complainant has suppressed the true and material facts while filing the present complaint; that the complaint was not legally maintainable; that the insurance contract is based on the principle of “Uberrima fide i.e. utmost good faith whereby a legal obligation is cast upon the party  seeking insurance.

 

                    On merits, it was contended that the life assured was suffering from alcoholic liver diseases, cirrhosis of liver, porial hypertension and esophageal  various diseases prior to obtaining of the insurance cover and the complainant was hospitalized in the year 2006 and factum of pre existing disease was not disclosed at the time of application dated 18.7.2008 for obtaining of the policy and has not replied the questionnaire correctly and as such on account of suppression of facts the said claim has been repudiated.  Thus, it was contended that there was no deficiency in  services on the part of the Ops and dismissal of the complaint  has been sought. Sh.Rajesh Sharkar Dhane authorized signatory of the Ops has also tendered his affidavit in support of the contentions made in the written statement alongwith certain other documents will be discussed at the relevant stages.

 

3.                We have heard the learned counsel for the parties and have gone through the case file very carefully.

 

 

4.       Therefore, after going through the facts and circumstances of the case, evidence on the file and the arguments advanced by the learned counsel for the parties, it emerges that the complainant has filed the present complaint alleging deficiency in services on the part of the OP that the complainant was insured with the OP as is evident from Ex.C1  and Ex.C2 and at the time of obtaining the policy, the complainant was medically examined vide medical report Ex.C3. It has come in evidence that during the continuation of the policy, the complainant suffered liver problem and liver  plantation was done.  The complainant suffered stomach problem and he submitted all the bills but the claim of the complainant was repudiated vide letter Ex.C4 on the ground that after investigation it was revealed that life assured/complainant was suffering from alcoholic liver diseases, cirrhosis of liver, porial hypertension and esophageal  various diseases prior to obtaining of the insurance cover and the complainant was hospitalized in the year 2006 and factum of pre existing disease was not disclosed at the time of application dated 18.7.2008 for obtaining of the policy and has not replied the questionnaire correctly and as such on account of suppression of facts the said claim has been repudiated.

 

5.                 However, as per contention of the OP as contained in the written statement, it emerges that the claim has rightly been repudiated since insurance is a contract of “Uberrima fides”  i.e. utmost good faith and suppression of material facts would be breach of said contract and insurer was entitled to repudiate the claim as held in  Satwant Kaur Sandhu  Vs.New India Assurance Company Limited (2009)8 SCC 316.  Reliance has also been placed on Mithoolal Nayak Vs.LIC of India AIR 1962 SC 814 Maya Devi Vs.LIC , RP No.2091 of 2007.

 

                    It was also argued that in view of the medical record of the complainant from Fortis Hospital, Mohalli, the photo copy of which has been placed as Ex.O4, it emerges that the complainant was suffering from liver as well as stomach problem and he was having alcoholic hypertension in the year 2006 i.e. prior to obtaining the said insurance policy and as such the suppression of facts itself was a valid and legal ground to repudiate the claim.

 

6.                 However, the argument advanced on behalf of the OPs is not sustainable in the eyes of law because the Ops have submitted declaration form Ex.O2 which was filled in by the complainant/insured prior to obtaining of the insurance policy and in the said Ex.O2, the complainant – policy holder has specifically tick marked at point “G” of clause 4 regarding the medical problems. Therefore, since the complainant in the declaration form Ex.O2 has specifically disclosed about the problems in liver disorder, gall bladder, disorder ulcer bleeding from stomach, hemorrhoids  or any disease of the digestic track, therefore, it cannot be said that the complainant had suppressed the factum of pre existing diseases  so as to come to the conclusion that the complainant was responsible for   breaching utmost good faith so as to come to the ground for repudiating the medical claim. Therefore, in view of Ex.O2 itself we are inclined   to hold that repudiation of the claim by the Ops was not sustainable in the eyes of law and as such we hold that there was deficiency in services on the part of the Ops.

 

6.                So far as quantum of compensation to be granted to the complainant is concerned from Ex.C7 to Ex.C19,amount of Rs.3,92,784/- comes out but the sum insured in the present case is to the tune of Rs.2,50,000/- vide insurance policy Ex.C1, therefore, the complainant is entitled to the sum insured.

 

7.                Therefore, as a sequel to our above discussion, we accept the present complaint and direct the OP no.1 to  OP No.5 to  make the payment of the sum insured to the complainant alongwith the interest @ 9% per annum from the date of filing of the present complaint i.e. 19.08.2009 till its actual realization. The complainant shall also be entitled for a sum of Rs. 10000/- for the harassment caused to him and a sum of Rs.2200/- towards legal fee and legal expenses. The OP no.1 to 5 shall make the compliance of this order within a period of thirty days from the date of receipt of the copy of this order. However, the OP no. 6 is exonerated from its liability being merely an agent.  The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced
dated: 10.03.2015                                                                           

                                                              (Subhash Goyal)

                                                             President,

                                                         District Consumer Disputes

                                                          Redressal Forum, Karnal.

                   (Smt.Shashi Sharma)

                             Member.

 

 

 

 

Argued by:-  Sh.Pardeep  Kapoor   Advocate for the complainant.

                   Sh. A.K.Vohra   Advocate for the OPs.

 

                   Arguments heard. Vide our separate order of the even date, the present complaint has been accepted. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

 

Announced
dated: 10.03.2015                                                                           

                                                              (Subhash Goyal)

                                                             President,

                                                         District Consumer Disputes

                                                          Redressal Forum, Karnal.

                   (Smt.Shashi Sharma)

                             Member.