Orissa

Cuttak

CC/131/2023

Vysyaraju Pruthvi Raj - Complainant(s)

Versus

The Authorised Person,Claims Support Unit,Max Life Insurance Co Ltd - Opp.Party(s)

D Mishra & associates

20 Dec 2023

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C.No.131/2023

 

Vysyaraju Pruthvi Raj,

S/o: Lae V.Dharma Raju

Jamal Colony,1^st line,

Maa Majhigouri Nilayam,

Jeypore,Koraput,Odisha-764001.                                            ... Complainant.

 

          Vrs.

 

1.       The Authorised Person,

Claims Support Unit,

Max Life Insurance Co. Ltd.,

Plot No.90A,Sector-18,Gurugram,

                  Haryana,Pin-122015

 

2.       The Authorised Person,

Max Life Insurance Co. Ltd.,

Regd. Office-419,Bhai Mohan Singh Nagar,

Railmajra,Tehsil Balachaur,

                  Dist: Nawanshahr,Punjab-144533.

 

3.       The Executive Vice President (Operations centre),

Max Life Insurance Co. Ltd.,5^th Floor,

Udyog Nagar,Plot No.90-C,Sector-18,

                  Gurugram,Haryana,Pin-122015.

 

4.       Branch Manager,

Max Life Insurance Co. Ltd.,

Link Road Square,Madhupatna,

M/s. Royal Tower,

                   Cuttack-753010,Odisha

 

5.      Authorised Advisor,

M/s. Policy Bazar Insurance B Pvt. Ltd.,

TB(869196),Plot No.119,Sector-44,

Gurgaon,New Delhi.                                                   ...Opp. Parties.

 

   Present:      Sri Debasish Nayak,President.

          Sri Sibananda Mohanty,Member.

 

  Date of filing:    28.04.2023

  Date of Order:  20.12.2023

 

  For the complainant:            Mr. D.Mishra,Adv. & Associates.

     For the O.Ps.             :            Mr. R.C.Panigrahi,Adv. & Associates.

.

     Sri Debasish Nayak,President.                                                    

The case of the complainant bereft unnecessary details as made out from the complaint petition in nutshell is that his deceased father V.Dharmaraju had obtained a life insurance policy from the O.Ps through online Policy Bazar.Com for an assured value of Rs.50,00,000/- and was paying the premiums regularly till he breath his last on 16.4.2022.  He died due to health complicacies like sudden rise of blood sugar and blood pressure which led to failure of other organs of his body.  After his death, the complainant being the nominee and son of the deceased assured had approached the O.Ps claiming for the insurance amount(death claim) of his father but such claim of the complainant was repudiated through their letter dated 27.8.2022 on the grounds that the insured was suffering from diabetes with hypertension, chronic kidney disease, prior to executing the proposal form with the O.Ps.  When the claim was repudiated, the complainant had issued a legal notice to the O.Ps on 19.11.2022 stating that his father was never suffering from any chronic disease while he had entered into or obtained the insurance policy from the O.Ps.  Thus, the complainant has come up with this case claiming the assured sum of Rs.50,00,000/- from the O.Ps together with another sum of Rs.3,00,000/- towards his mental agony and harassment.  He has also claimed an amount of Rs.2,00,000/- from the O.Ps towards giving false promises while obtaining the insurance policy  alongwith compensation of Rs.10,10,000/- from the O.Ps together with his litigation cost of Rs.20,000/-.  He has further prayed for any other order as deemed fit and proper.

          The complainant has annexed copies of several documents alongwith his complaint petition in order to prove his case.

2.       The O.Ps have contested this case and have filed their written version jointly.  As per the written version of the O.Ps, the policy-holder V.Dharmaraju was suffering from kidney problem and was under treatment which he had not disclosed while executing the policy  proposal form with the O.Ps.  The said deceased/assured had made the present complainant as his nominee as because he is his son and the assured sum in the said Insurance policy was of Rs.50,00,000/-.  The O.Ps could know  about all the previous ailments of the policy-holder deceased from the medical records of the deceased life-assured which they had  obtained from the AIIMS Hospital at Bhubaneswar from 23.5.2021 to 16.6.2022.  The life-assured was diagnosed with recurrent bilateral nephrolithiasis post multiple surgeries, bilateral multiple infundibular stenoses with isolated calyectasis, left pyelonephritis, Urosepsis, renal candidates, CKD(Chronic kidney disease) with ESRD(End-stage renal disease) with metabolic acidosis with hyperkalemia,Anemia,diabetes mellitus, Hypertension which he had not disclosed for which the death claim as made by the complainant for the life-assured was repudiated by the O.Ps through their letter dated 27.8.2022.  The life-assured had obtained the policy on 15.2.2022 and had died on 16.4.2022.  Due to such early death of the life-assured, the matter was investigated into by the O.Ps wherefrom they could know that the life-assured was suffering from previous ailments for which he was under treatment but he had suppressed those without disclosing the same while entering into and obtaining the policy from the O.Ps.  In this connection, the O.Ps have relied upon a pertinent decision of the Hon’ble Supreme Court in the case of Branch Manager,Bajaj Allianz Life Insurance Company Ltd. & Ors. Vrs Dalbir Kaur in Civil Appeal No.3397 of 2020 wherein their lordships have held that “A contract of insurance is one of utmost good faith.  A proposer who seeks to obtain a policy of life insurance is duty bound to disclose all material facts bearing upon the issue as to whether the insurer would consider it appropriate to assume the risk which is proposed.   It is with this principle in view that the proposal form requires a specific disclosure of pre-existing ailments, so as to enable the insurer to arrive at a consideration decision based on the actual risk.  In the present case, the proposer failed to disclose the vomiting of blood which had taken place barely a month prior to the issuance of policy of insurance and of the hospitalization which had been occasioned as a consequence.  The investigation by the insurer indicated that the assured was suffering from a pre-existing ailment, consequent upon alcohol abuse and that the facts which were in the knowledge of the proposer had not been disclosed.  This brings the ground for repudiation squarely within the principles which have been formulated by this Court.

          The O.Ps have also relied upon another pertinent decision oof the Hon’ble Apex Court in the case of Reliance Life Insurance Co. Ltd. & Anr. Vs. Rekhaben Nareshbhai Rathodhas published in AIR 2019 SC 2039 wherein their lordships have held that “In a contract of insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not accept the risk is a material fact.  If the proposer has knowledge of such fact, she or he is obliged to disclose it particularly while answering question in the proposal form.  An inaccurate answer will entitle the insurer to repudiate because there is a presumption that information sought in the proposal form is material for the purpose of entering into a contract of insurance.”  Accordingly, the O.P through their written version have urged to dismiss the complaint petition with cost.

          The O.Ps have also filed copies of several documents alongwith their written version in order to support their stand.

          The O.Ps have filed their evidence affidavit through one Ajay Chanchal working as Asst. Manager,MAX Life Insurance Company Ltd. but the contents of the said evidence affidavit when perused, it is noticed that the same happens to be a reiteration of the averments as made in the written version.

3.        Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a proper conclusion here in this case.

                      i.          Whether the case of the complainant is maintainable?

          ii.         Whether there was any deficiency in service on the part of                                               the O.Ps and if they have practised any unfair trade ?

         iii.         Whether the complainant is entitled to the reliefs as claimed by him?

Issue no.ii.

               Out of the three issues, issue no.ii  being the pertinent issue in this case, is taken up  first for consideration here.

          Perused the contents of the complaint petition, that of the written version, the written notes of submissions as filed from either sides, the evidence affidavit as filed by the O.Ps as well as copies of the documents as available in the case record, it is noticed that in fact the deceased father of the complainant was the policy-holder in the Policy bearing no.351220074-WAH76 which was obtained from the O.Ps wherein the sum assured was of Rs.50,00,000/-.  The said policy was obtained by the policy-holder on 15.2.2022 but he had died on 16.4.2022.  While perusing the proposal form of the said policy-holder, it is noticed that he has not mentioned about his previous ailments while filling-up the said proposal form rather, had suppressed those without disclosing.  The relationship between the insurer and the insured is definitely one of good faith and the policy-holder is duty bound to disclose all the material facts in the life insurance policy while executing the proposal form; thereby leaving option to the insurer to think about covering the risk as proposed. 

In this context, it would be proper to reiterate the findings of the Hon’ble Supreme Court in the case of Branch Manager,Bajaj Allianz Life Insurance Company Ltd. & Ors. Vrs Dalbir Kaur in Civil Appeal No.3397 of 2020 wherein their lordships have held that “A contract of insurance is one of utmost good faith _ A proposer who seeks to obtain a policy of life insurance is duty-bound to disclose all material facts bearing upon issue as to whether insurer would consider it appropriate to assume risk which is proposed. It is with this principle in view that proposal form requires a specific disclosure of pre-existing ailments, so as to enable insurer to arrive at a considered decision based on actuarial risk”.  Here as it appears that the policy-holder could know that due to the seriousness of his illness, perhaps he would not survive for a long period for which he had preferred to obtain a policy from the O.Ps for a huge sum assured of Rs.50,00,000/- on 15.2.2022 and subsequently he had died on 16.4.2022.  The act of the deceased/assured here in this case tilts our eyebrows which signifies the mens-rea of the said deceased/assured.  Thus, when the deceased assured obtained the policy without disclosing about his previous ailments which he was suffering, but the documents from the All India Institute of Medical Sciences, Bhubaneswar, Department of Eurology were obtained by the O.Ps clearly signifies that the deceased life-assured had intentionally suppressed his material facts of his illness without disclosing those in the proposal form while executing the same.  Quite strangely the complainant even has categorically mentioned that his deceased father who is the deceased life-assured here in this case, was not suffering from any previous ailments as alleged by the O.Ps. When the O.Ps through cogent documentary  evidence could amply establish about the previous ailments of the deceased life-assured, it can never be said here that the O.Ps were deficient in their service when they had repudiated the death claim of the complainant since when the death of the deceased assured was due to failure of health complicacies leading to failure of organs in his body.  It can also be concluded that by repudiating the death claim as made by the complainant, the O.Ps cannot be said to  have practised any unfair trade.  Accordingly, this issue goes against the complainant.

Issues no.i & iii.

From the discussions as made above, the case of the complainant is not maintainable and the complainant is thus not entitled to the reliefs as claimed by him.  Hence it is so ordered;

                                              ORDER

Case is dismissed on contest against the O.Ps and as regards to the facts and circumstances of the case without any cost.

Order pronounced in the open court on the 20^th day of December,2023 under the seal and signature of this Commission.            

               

                                                                                  Sri Debasish Nayak

                                                                                           President

                                                                                                         

                                                                                       Sri Sibananda Mohanty

                                                                                                   Member