Karnataka

Chitradurga

CC/97/2014

Dildar Begum W/o. Syed Haris - Complainant(s)

Versus

The Branch Manager, ICICI Prudential Life Insurance - Opp.Party(s)

Shri. Abdul Jaleel Zulfquar

15 Dec 2015

ORDER

 

COMPLAINT FILED ON : 04/12/2014

     DISPOSED ON: 15/12/2015

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHITRADURGA

 

CC. NO. 97/2014 DATED:  15th December 2015

 

PRESENT :-     SRI. T.N. SREENIVASAIAH      PRESIDENT                                      B.A., LL.B.,

                        SRI.H.RAMASWAMY,               MEMBER

                                         B.Com., LL.B.,(Spl.)

SMT.G.E.SOWBHAGYALAKSHMI,       

                                         B.A., LL.B.,                   MEMBER

 

COMPLAINANT	Dildar Begum, W/o Syed Haris, R/o 1st Cross, Maruthi Nagar, Near Railway Track, Chitradurga-577501.   (Rep by Sri. Abdul Jaleel Zulfquar, Advocate)
OPPOSITE PARTIES	1. The Branch Manager,      ICICI Prudential Life Insurance,      OPP. SBM Bank, Chitradurga.   2.  Gayatri Nathan,      Vice President-Claims,      ICICI Prudential Life Insurance      Co. Ltd., Vinoda Silk Mills      Compound, Chakravarthy      Ashok Nagar, Ashoka Road,      Kandavali East,      Mumbai-400101.      (Rep by Sri. O. Chinnappa,  Advocate)

SRI. T.N. SREENIVASAIAH. PRESIDENT.

ORDER

The complainant has filed a complaint U/s 12 of C.P. Act 1986 against the OPs for a direction to the OPs to pay Rs.12,25,000/- with interest, compensation and cost etc.

2.     The brief facts of the case of the complainant are that, being attracted by the advertisement given by the OPs, the son of complainant Syed Noushad S/o Syed Harris had taken life insurance policy bearing No.168551844 on 23.07.2012 by making online payment of Rs.3,258/- as first year premium in the office of OP No.1 by submitting information with documents.  After verification of the document, OP No.1 has issued policy for a sum of Rs.12,25,000/-.  OP No.1 has issued the policy with a condition that, the policy holder must pay yearly premium till 23.07.2041 or the death whichever is earlier.  It is further stated that, OP No.1 has given assurance to the life assured for a sum of Rs.12,25,000/- with other benefits.   The son of complainant at the time of purchasing the policy he made his mother Dildar Begum, the complainant has made as a nominee under the said policy.  Unfortunately the life assured died on 23.09.2012 due to Gastric Ailments.  Complainant is an illiterate woman, she is not in a position to approach the OPs for settlement of the claim.  At the time of cleaning her house, her relations have got the policy copy and told her about the policy which was purchased by her son.  It is further stated that, on 09.10.2013, the complainant approached the OP No.1 for settlement of the claim with necessary documents and the OPs promised her that, they will settle the claim but, drag on the matter for one or the other reasons.  Finally on 20.02.2014, OP No.2 issued a letter repudiating the claim of the complainant on the ground of suppression of material facts stating that, the life assured was suffering from Chronic kidney disease and he was hospitalized on 02.07.2012 for dialysis.  The family of the complainant is entirely depending on the deceased life assured and her family is facing very difficult to eke out their life.  The conduct of the OPs amounts to deficiency of service so, she sustained financial loss and mental agony and etc., and prayed for allow the complaint.

 

3. On service of notice OPs appeared through Advocate and filed version stating that, the deceased life assured had taken life insurance policy bearing No.16851844 titled ICICI Pru iCare RP Option I T31 on 23.07.2012 for a term of 30 years for an assured sum of Rs.12,25,000/-.  The annual premium payable by the deceased life assured was Rs.3,258/-.  On receiving duly completed Online proposal form, the OPs have issued Policy No.16851844 and the date of commencement as 23.07.2012 and the complainant is the nominee under the said policy.  The OPs duly verified the online proposal form of the deceased life assured for issuance of the policy by believing the information given therein and the deceased life assured did not disclosed any medical infirmities and hence, the policy was issued without subjecting the medical tests.  It is further stated by the OPs that, the important guidelines mentioned at the top of the proposal form that, insurance is a contract of utmost good faith requiring of the proposer and the life to be assured not only to disclose all material facts but also not to suppress any material facts in response to the questions in the proposal form.  It is further stated that, right from proposal stage it was always made abundantly clear to life assured that, truthful answers to question in proposal form are of immense importance for accepting life insurance proposal of life assured and obligation of disclosing true facts continue even after signing of the proposal of insurance and continues even subsequent to signing of proposal form and before acceptance of risk by the OPs.  Further it was clearly stated in the proposal form that in event of question in proposal form turning out to be false or mis-leading contract of insurance is liable to declared null and void under Section 45 of Insurance Act and claim under policy will be repudiated in such conditions.  It is further stated that, the policy documents along with Welcome Kit was duly dispatched by insurance company to life assured and the same was duly received.  It is further stated that, in accordance to Clause 6(2) of the insurance regulatory and development authority (Protection of Policyholder's Interests) Regulations, 2002 every policy document sent by it is accompanied by a forwarding letter which clearly mentions that in case policyholder is not satisfied with the features or the terms and conditions of the policy he can withdraw/return the policy within 15 days under the Free Look Period provision but, the life assured retained the policy document and did not approach the OP with any discrepancies regarding details mentioned in the proposal form and terms and conditions of the policy.  It is further stated that, by believing the information given by the life assured to be true and correct in all aspects, the said proposal was accepted at standard rates of premium.  It is further stated that the life assured died on 23.09.2012 and death claim intimation was received on 09.10.2013.  It is further stated that, the claim was filed by the complainant and the cause of death was stated as nil as no cause of death stated therein and further mentioned nil hospitalization of deceased life assured in last 5 years and now submitted complainant stating cause of death as "Heart and Gastric ailments".  The present claim is an early claim as deceased life assured died within two months from the date of issuance of policy due to kidney problem, which shows clear intention to defraud OP company by taking policy on ailing life and at the time of taking proposal no adverse medical facts were cited by the life assured.  It is stated that, at the time of applying for policy the life assured had not disclosed any adverse regarding his health in the proposal form and the same is evidenced by fact that life assured had replied negative to question No.13.  It is evident from the records that, the deceased life assured was hospitalized on 27.06.2012 for kidney dialysis and the same was reconfirmed by Dr. T.S. Shivananda, Professor and HOD of Bapuji Educational Association, Davanagere in the treatment summary which categorically states that, the deceased life assured was diagnosed to have chronic kidney disease and he had taken treatment in the hospital on earlier also for his chronic kidney disease.  On careful investigation conducted by the OPs on receipt of the claim it was revealed that, the cause of death was "Chronic Kidney Disease" which was so admitted by the complainant and the deceased life assured had also undergone various medical procedure before the date of proposal form for cure of his kidney disease.  It is further stated that, under Section 45 of the Insurance Act postulate repudiation of such policy within a period of two years, the policy is fully capable of being called in question, inter-alia on the ground that, certain facts have been suppressed which were material to disclose or that it was fraudulently been made by the policy holder or that the policy holder knew at the time of making it that statement was false, statute, therefore, itself provides for limitation for valid repudiation of an insurance policy and in the present case, the life assured was died within two months from the date of taking policy and on investigation the information provided by the life assured were found to incorrect and false and thus the decision of the OPs to declare policy as null and void is fully justified and same cannot be termed as deficiency in service by the OPs and the present complaint deserves to be dismissed.  It is further submitted that, the claim has been repudiated bonafide and on the basis of documentary evidence of suppression of material facts by the life assured in his proposal for insurance and the same cannot be considered as deficiency in service and hence, prayed for dismissal of the complaint.     

        4. Complainant himself examined as PW-1 by filing affidavit evidence and documents are marked at Ex.A-1 to Ex.A-6. 

5.     On behalf of OP No.2 one Sri. Ranjita Das, the Manager Legal of OPs examined as DW-1 by filing affidavit evidence and no documents have been produced.   

 

        6. Arguments heard.

 

7. Now the Points that arise for our consideration for the decision of the complaint are that:

 

Point No.1:- Whether the complaint proves that, OPs have committed deficiency of service and he is entitled for compensation as stated in her complaint?

 

Point No.2:- What order?

 

        8. Our findings on the above points are as follows:

 

        Point No.1:- Affirmative.

        Point No.2:- As per the final order.

 

                                        ::REASONS::

 

9. Point No. 1:- It is not in dispute that, being attracted by the advertisement given by the OPs, the son of complainant Syed Noushad S/o Syed Harris had taken life insurance policy bearing No.168551844 on 23.07.2012 by making online payment of Rs.3,258/- as first year premium from OP No.1.   After verification of the documents, OP No.1 has issued policy for a sum of Rs.12,25,000/- with other benefits with a condition that, the policy holder must pay yearly premium till 23.07.2041 or the death whichever is earlier.  Complainant is the nominee under the said policy and her son died on 23.09.2012 due to Gastric Ailments.   On 09.10.2013, the complainant approached the OP No.1 for settlement of the claim with necessary documents and on 20.02.2014, OP No.2 issued a letter repudiating the claim of the complainant on the ground of suppression of material facts stating that, the life assured was suffering from Chronic kidney disease.  The conduct of the OPs amounts to deficiency of service so, she sustained financial loss and mental agony and etc., and prayed for allow the complaint.

 

10.  So, as on the date of accident, insurance policy was in force.  It is the main contention of the complainant that she made a claim to the OPs by producing all the relevant documents and in spite of policy was in force, OPs have not settled the claim on the ground that, the deceased life assured has obtained the policy by suppressing the material facts and thereby the OPs have committed deficiency of service and the complainant has sustained financial loss and mental agony and so, this complaint has been filed. 

 

       11.  In support of her contentions,  complainant has relied on his affidavit evidence in which she has reiterated the contents of complaint.  Complainant has also relied on documents like copy of acknowledgement slip dated 19.10.2013 marked as Ex.A-1, Copy of Insurance legal notice dated 09.10.2013 issued to OP No.2 marked as Ex.A-2, Copy of letter written by OPs to the complainant marked as Ex.A-3, Copy of Postal receipts marked as Ex.A-4, Copy of legal notice dated 11.07.2014 marked as Ex.A-5, Copy of letter dated 16.07.2014 issued by the office of the insurance ombudsman marked as Ex.A-5. 

 

12.  On the other hand, it is argued by the Advocate for OPs that, the son of the complainant i.e., deceased life assured had taken life insurance policy bearing No.16851844 titled ICICI Pru iCare RP Option I T31 on 23.07.2012 for a term of 30 years for an assured sum of Rs.12,25,000/- by making annual premium of Rs.3,258/-.  The date of commencement as 23.07.2012 and the complainant is the nominee under the said policy.  The OPs duly verified the online proposal form of the deceased life assured for issuance of the policy.  It is further argued that, right from proposal stage it was always made abundantly clear to life assured that, truthful answers to question in proposal form are of immense importance for accepting life insurance and obligation of disclosing true facts continue even after signing of the proposal of insurance and continues even subsequent to signing of proposal form and before acceptance of risk by the OPs.  It is further argued that, in accordance to Clause 6(2) of the insurance regulatory and development authority (Protection of Policyholder's Interests) Regulations, 2002 every policy document sent by it is accompanied by a forwarding letter which clearly mentions that in case policyholder is not satisfied with the features or the terms and conditions of the policy he can withdraw/return the policy within 15 days under the Free Look Period provision but, the life assured retained the policy document and did not approach the OPs with any discrepancies regarding details mentioned in the proposal form and terms and conditions of the policy.  It is further argued that, the life assured died on 23.09.2012 and death claim intimation was received on 09.10.2013.  It is further argued that, the cause of death of the life assured as "Heart and Gastric ailments".  The present claim is an early claim as deceased life assured died within two months from the date of issuance of policy due to kidney problem, which shows clear intention to defraud OPs company by taking policy to gain benefits.    It is evident from the records that, the deceased life assured was hospitalized on 27.06.2012 for kidney dialysis and in the treatment summary which categorically states that, the deceased life assured was diagnosed to have chronic kidney disease and he had taken treatment in the hospital on earlier also for his chronic kidney disease.   On investigation the information provided by the life assured were found incorrect and false and thus on the basis of documentary evidence of suppression of material facts by the life assured in his proposal for insurance and the same cannot be considered as deficiency in service and hence, prayed for dismissal of the complaint.     

13.  We have carefully gone through the records submitted by complainant it is seen that, the OPs herein have accepted the policy bearing No.168551844 on 23.07.2012 for a sum of Rs.12,25,000/- by receiving premium through online without subjecting the life assured to a medical examination.  Now the contention taken by the OPs is that, the deceased life assured has taken insurance policy by suppressing the material facts of his health condition, which cannot be accepted.  It is the bounden duty of the OP/Insurance Company to conduct medical test of the life assured before accepting the policy.  Whenever the insurance company accepted the insurance policy and the policy was in force at the time of death of life assured, its duty is to settle the claim.  Herein, the OP/insurance company failed to do so.  After issuing the insurance policy in the name of the complainant, the repudiation of the claim made by the complainant herein cannot be reasonable and justifiable.   Therefore, we cannot accept the contention taken by the OPs that, the deceased life assured has purchased the policy by suppressing the material facts, without disclosing his correct health condition.    So, in our considered opinion, when once the insurance company issued the policy by accepting the information given by the life assured and denied to settle the death claim on the ground that, suppression of material facts does not arise.   Therefore, we come to the conclusion that, there is a deficiency of service on the part of OPs/insurance company in settling the claim of the complainant.  Hence, the complainant is entitled for compensation as claimed.  Accordingly, this Point No.1 is held as Affirmative to the complainant.

 

14.  Point No.2:- For the foregoing reasons, we pass the following.

ORDER

        It is ordered that the complaint filed by the complainant U/s 12 of CP Act 1986 is hereby allowed.

 

The OPs are directed to pay a sum of Rs.12,25,000/-, the sum assured under the policy along with interest at the rate of 6% p.a from the date of complaint till realization. 

 

It is further ordered that, the OPs are directed to pay a sum of  Rs.10,000/- towards mental agony and Rs.5,000/- towards costs of the proceedings. 

 

It is further ordered that, the OPs are directed to pay the above amount to the complainant within 60 days from the date of this order. 

 

 

        (This order is made with the consent of Members after the correction of the draft on 15/12/2015 and it is pronounced in the open Court after our signatures.)

 

 

 

MEMBER                   MEMBER                      PRESIDENT

 

-:ANNEXURES:-

Complainant by filing affidavit evidence taken as PW-1

Witness examined on behalf of Complainant:

                                                -Nil-

On behalf of OPs one Sri. Ranjita Das, Manager Legal by filing affidavit evidence taken as DW-1

 

Witnesses examined on behalf of OPs:

 -Nil-

Documents marked on behalf of Complainant:

01	Ex-A-1:-	Copy of acknowledgement slip dated 19.10.2013.
02	Ex-A-2:-	Copy of legal notice dated 09.10.2013 issued to OP No.2.
03	Ex-A-3:-	Copy of letter written by OPs to the complainant
04	Ex-A-4:-	Copy of Postal receipts
05	Ex-A-5:-	Copy of legal notice dated 11.07.2014
06	Ex-A-6:-	Copy of letter dated 16.07.2014 issued by the office of the insurance ombudsman

 

Documents marked on behalf of Opponent:

-Nil-

 

 

 

MEMBER                   MEMBER                      PRESIDENT

Rhr.