Jharkhand

Bokaro

CC/22/2020

Sundari Devi - Complainant(s)

Versus

The Branch manager, SBI Life Insurance - Opp.Party(s)

Pushpanjali Kumari

13 Oct 2022

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-21-03-2020

Date of final hearing-13-10-2022

 Date of Order-13-10-2022

Case No. 22/2020

Sundari Devi, W/o Late Mithilesh Kumar Kewat,

R/o Jaridih Bazar, Bich Bazar, Jaridih, Gandhinagar, Bokaro

Vs.

1. The Branch manager, SBI Life Insurance

 Phusro Branch, District Bokaro

 2. The Manager, SBI Life Insurance

 Regd. Office at Natraj, M.V. Road and Western Express Highway Junction, Andheri (E) Mumbai- 400069 

 

                             Present:-

                             Shri Jai Prakash Narayan Pandey, President

          Smt. Baby Kumari, Member

 

PER- J.P.N Pandey, President

-Judgement-

1. Complainant has filed this case with prayer for direction to O.Ps. to pay Rs. 10,00,000/- with interest @ 12% from 30.12.2018 till its realization as rest of the insurance claim and to pay Rs. 50,000/-  as compensation, Rs. 10,000/- as litigation cost respectively to the complainant.

2.  Complainant’s case in brief is that her husband late Mithilesh Kumar Kewat took SBI Life Smart Wealth Builder Policy on 19.06.2017 vide Policy No. 1K790438904 on yearly premium of Rs. 2,00,000/- and sum assured was Rs. 14,00,000/- only, in which complainant has been nominated as nominee. After full satisfaction with the good health condition of the insured said policy has been issued by the O.Ps. and premium for 2 years first on 19.06.2017 and second on  23.10.2018 (total Rs. 4,00,000/-) was paid by the husband of the complainant but unfortunately he died on 30.12.2018 at his residence under normal death. After death of the husband of the complainant she visited the office of the O.Ps. for death claim and provided all required and demanded documents to the O.Ps. but instead of payment of Rs. 14,00,000/- total Rs. 4,00,000/- only has been paid to the complainant and rest of the claim amount Rs. 10,00,000/- has not been paid on the ground that prior to the commencement of the policy i.e. in the month of April and May 2017 deceased was suffering with diabetes Mellitus, hypertension and heart disease which was suppressed but said statement is totally incorrect because policy was issued after proper verification and medical examination of the policy holder, after full satisfaction related to sound health of the deceased. Inspite of issuance of legal notice matter was not solved hence this case has been filed with above mentioned prayer.

3. O.Ps. have filed W.S. mentioning therein that the grant of insurance cover is on the basis of principle of utmost good faith and insured is duty bond to disclose everything concerning his health habit etc. which are within his knowledge at the time of proposal of the policy failing which insurer is having right to repudiate the claim and in this case deceased insured has suppressed the material fact that he was suffering from Diabetes Mellitus, Hypertension and heart disease prior to the proposal of the policy.  Further reply is that on the basis of the statement of proposal form insurance cover is being granted and in this case there is no negligence or deficiency on the part of O.Ps. rather deceased insured himself has suppressed material facts regarding pre-existing disease to which he has suppressed. As per declaration of the deceased insured in case of any miss-statement or suppression of material information said contract shall be treated as per provision of section 45 of the Insurance Act 1938. Further reply is that at the time of submission of form insured has answered all questions negatively in respect to his health. Further reply is that these O.Ps. have also conducted a medical examination in this case in which answering O.Ps.( as mentioned at para 4 at page No. 4 of W.S.)  replied in the negative to all the specific questions and based on the details furnished in the proposal form and medical examination report and the declaration given by the deceased concerned policy was issued. Deceased died on 30.12.2018 but claim intimation was received on 15.05.2019 with considerable delay and as per investigation report deceased was suffering with above mentioned disease who was admitted in Bhagwan Mahavir Medica Hospital on 26.04.2017 and discharged on 03.05.2017 with history of NIDDN, HTN, DCM, LBBB, Severe L.V. Dysfunction EF-30% (i.e. non insulin dependant diabetes mellitus, Hypertension, Dialated Cardiomyopathy, Left Bundle Branch Block, Severe left Ventricle dysfunction). On 13.06.2017 Medical history of the DLA noted by the same hospital as HTN, DM2, DCMP, FRACTURE RIGHT LEG, ACIDITY. In this way deceased has suppressed material facts hence as per terms of the policy O.Ps. were having right to repudiate the claim or cancel the policy or forfeit the premiums and not to entertain any claim. In this way claim has been rightly repudiated. Further reply is that the premium amount of Rs. 4,00,000/- received under the policy was refunded on 11.06.2019 in the account of the complainant. Hence repudiation of claim is justified and in accordance with terms of the policy. Contents  of para 1,2,6 & 7 of the complaint petition have not been controverted. Contents of para 4 (1) of the complaint petition have been admitted and rest of the contents of the complaint petition have been denied by the O.Ps. From page 12 to 16 of the W.S. principles laid down in so many cases have been mentioned by the O.Ps. but no such decisions have been provided for perusal.

4. On the basis of the pleadings of the parties following points are being framed for decision of this case:-

A. Whether repudiation of the claim by the O.Ps. is justified and based on material facts ?

B. Whether complainant is entitled to get relief as claimed ?

5. On careful perusal of the pleadings of the parties it appears that following facts either have been admitted or have not been controverted by the parties.

a. That insured Mithilesh Kumar Kewat was the husband of the complainant Sundari Devi.

b. That Insured Mithilesh Kumar Kewat obtained SBI Life Smart Wealth Builder Policy from the O.Ps.

c. That date of commencement of that very policy was 19.06.2017.

d. That total insured amount was Rs. 14,00,000/-.

e. That deceased insured was medically examined by the Doctor of the Insurance company.

f. That date of birth of the deceased insured was 24.04.1957 who was retired CCL employee and pensioner of that very company.

g. That after observing all formalities O.Ps. have received first premium of Rs. 2,00,000/- from the husband of the complainant on 19.06.2017 and thereafter, Rs. 2,00,000/- on 23.10.2018.

h. That deceased died on 30.12.2018 at his residence under normal death.

i. That insurance claim of the deceased was submitted before the O.Ps. and part of the claim for Rs. 4,00,000/- only has been considered and paid to the complainant.

j. That the competency of the complainant towards receipt of the claim amount under life insurance policy is also not in dispute because it is admitted fact that the O.Ps. have remitted Rs. 4,00,000/- in the bank account of the complainant through electronic mode.

6. Point No. A & B:- Since decision on both points is interlinked with each other hence both the points are being taken up together for decision.

7. In view of above mentioned admitted or not controverted facts we have to discuss the matter in respect to evidence and pleadings of the parties. It is apparent from Annexure-A of the O.Ps. that it is photo copy of the proposal form submitted by the husband of the complainant on 06.06.2017 in office of the O.Ps. with due receipt. This form has been signed by the husband of the complainant on 06.06.2017. Therefore, we have to see whether the papers Annexure-E & F (medical papers of deceased insured related to Medica Hospital, Ranchi) are only papers on which basis it is alleged that husband of the complainant has suppressed material facts in the proposal form. The paper related to treatment of the husband of the complainant procured and filed by the O.Ps. show that Annexure-F  is the Out Patient Paper dt. 13.06.2017 by which the husband of the complainant was examined for treatment as OPD patient on 13.06.2017 who again visited the said hospital on 23.06.2017 & 15.07.2017 but in our opinion said treatment was done after submission of the proposal form on 06.06.2017 before the O.Ps. with their due acknowledgement. Hence Annexure-F is not helpful for the O.Ps. and on this basis they cannot repudiate the claim of complainant. In this way it appears that amongst two papers on which basis claim has been repudiated one is related to post policy period hence repudiation on this basis is not justified.

8.  So far, Annexure-E is concerned it shows that it is photo copy of discharge summary of the husband of the complainant and accordingly he was admitted in the Medica Hospital, Ranchi on 26.04.2017 for the complain related to Spiral Fracture Right Distal Tibia and Fibula which was caused on 20.04.2017 due to fall from bike caused pain and swelling right leg with inability to walk. In this paper past history has been mentioned as known case of NIDDM, HTN, DCM, LBBB, Severe LV Dysfunction EF-30%. This paper shows that after treatment, husband of the complainant was discharged on 03.05.2017. It is important to note here that this paper is related to the period prior to issuance of the insurance policy but here in this case said patient was admitted in the hospital for the treatment of fracture. It is quite possible that patient would have not able to understand the medical terminology or he has not noticed it as material facts to be disclosed before the Insurance Agent. However, it is apparent from Annexure-A/1 that it is medical examination form and medical examination of the deceased insured has been done by a competent doctor of the insurance co. who has noted all details including the blood pressure etc. and he has certified that “ he has personally interviewed and examined the husband of the complainant and he has recorded in his own hand the true and correct findings as above and in his presence husband of the complainant has singed”. Therefore, apart from disclosure by the husband of the complainant the O.Ps. have got examined the husband of the complainant by their own doctor and after full satisfaction insurance policy has been issued. In this way on careful perusal of Annexure-E read with Annexure-A/1 it appears that in the present case there is no justification of repudiation of the claim.

9.  It has to be noted here that the plan under which insurance cover has been provided is the plan of SBI LIFE –SMART WEALTH BUILDER (A UNIT –LINKED, NON- PARTICIPATING PLAN). Therefore, this plan cannot be treated as pure life insurance plan. Rather it is an insurance cum investment solution plan.

10. Taking the matter with another angle it is apparent from Annexure-A (the proposal form)  that the husband of the complainant has also obtained two SBI Life Insurance Policies with sum assured Rs. 3,50,000/- for each and in respect to all those policies payment has already been made by the O.Ps. to the complainant and this fact is not in dispute nor it has been controverted by the O.Ps. Contrary to it inspite of making payment  in respect two other policies the part payment of policy under question has been refused by the O.Ps. which is showing no parity in the claim settlement process of the O.Ps.

11. As per terms and conditions of the policies in case of suppression of material facts by the insured the insurance company was having liberty to either cancel the policy and to forfeit the premium already paid and in case of death of the insured, premium was to be forfeited. But here in this case it has not been done by the Insurance company. It is admitted fact that the claim was for payment of Rs. 14,00,000/- but only Rs. 4,00,000/- has been paid by the O.Ps. to the complainant without disclosing the terms and conditions of the policy under which said part payment is permissible.  On careful perusal of the terms and conditions of the insurance policy it appears that there is no such provision to make part payment. However, here in this case part of the claim of the complainant has been allowed by the insurance co. (O.Ps.) for which there is no such provision. Therefore, in this circumstance O.Ps. shall be stopped to make any other statement by denial of part of the benefit of the policy specially when its part payment has already been made.

12. On perusal of the case record it appears that except the statement made in para 4 of the complaint petition and photo copy of the death certificate (Annexure-2) there is no any other evidence on  record to show that death of the deceased was due to the ailments as alleged by the O.Ps. rather it is disclosing the fact that the deceased died on 30.12.2018 at his residence under normal circumstance. Therefore, it is apparent that there is no evidence to establish relation of alleged disease  with the death of the insured.

13. Learned Counsel for the O.Ps. has placed reliance on the principles laid down by the Hon’ble Supreme Court in the case of Reliance Life Insurance Co. Ltd. & Anr. Vrs. Rekhaben Naresh Bhai Rathor decided on 24.04.2019 and in the case of Oriental Insurance Co. Ltd. Vrs. Mahendra Construction decided on 01.04.2019. It appears that the facts and circumstance of this case and the facts and circumstance of above noted cases are different hence those principles are not helpful for the O.Ps. O.Ps. have also placed reliance on the principles laid down by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No. 4486/2010 decided on 09.02.2011 and Revision Petition No. 4107/ 2009 decided on 22.05.2015 but the facts and circumstance of this case are different from above noted cases hence it is not helpful for the O.Ps.

13. Learned Counsel for the complainant has placed reliance on the decision dt. 12.03.2018 passed by the Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh in connection with First Appeal No. 102/2018 Life Insurance corporation of India Vrs. Smt. Reena Nanda.  Attention of this Commission has been down on para 10, 11 & 12 of that very decision in which it has been observed that :-

 

10. “In this regard, we rely upon a judgment reported in IV (2008) CPJ 89 titled as “Life Insurance Corporation of India & Ors.V. Kunari Devi” wherein it has been observed that the history recorded in the hospital is not to be taken as an evidence. Further, the Hon’ble National Commission in another judgment reported in III (2014) CPJ 340 titled as “National India Assurance Company Ltd. V. Rakesh Kumar” wherein it has been observed that the people can live for months, rather years, without having any knowledge that they have any disease it’s often discovered accidentally after routine checkups, it cannot be stated to be the concealment and the repudiation is not justified. In para No.4 of the complaint, it has been mentioned that DLA died on account of Cardiac arrest, which has not been rebutted by the opposite party in their written reply. In another judgment reported in 2016(1) CPR 566 titled as “LIC of India & Anr. Vs. Kolla Santhi & Anr.” wherein, it has been observed that the cardiac respiratory arrest cannot be said to be a pre-existing disease and can occur suddenly.

 

11.   It is pertinent to mention here that the complainant has referred in the complaint that before getting the policy he was medically examined by the doctor on the panel of LIC and the report is positive and there is no specific column with regard to HTN/DM which was wrongly replied by the DLA before the medical examiner of the opposite party. Otherwise tests of hypertension and DM are routine tests normally conducted in any medical examination. The tests may be normal, therefore, it was not mentioned in the report. Counsel for the opposite party has referred to the judgment of the Hon’ble National Commission titled as Phoola Devi V. Life Insurance Corporation of India in Revision Petition No.2271 of 2011 delivered on 9.08.2016, wherein it was observed that the medical check-up was usually conducted by the Medical Officer of the LIC, base on the information given by the insurer. In this case, no wrong information was supplied by the DLA with regard to the hypertension/DM2 in the prescribed form given by the medical examiner to the insured. Therefore, there is no misrepresentation before the medical examiner of the LIC, then in that situation, the report of the medical examiner of the LIC cannot be ignored. In this regard, we rely upon the judgment of the Hon’ble National Commission reported in III (2014) CPJ 221 titled as “Bajaj Allianz Life Insurance Co. Ltd. Vs. Raj Kumar”. In that case also, the claim was rejected on the ground of suppression by pre-existing disease. In that case, the doctor of the authorized insurance company examined the insured, assessed fitness and after complete satisfaction issued the policy. It cannot be said that he deliberately concealed the previous illness. The order in favour of the complainant and was upheld and revision petition of the insurance company was dismissed. A reference can be made to another judgment reported in 2014 (1) CLT 220 titled as ICICI Lombard General Insurance Company Ltd. Vs. Jasbir Singh. In that case, the Hon’ble State Commission after relying upon the judgment of Hon’ble National Commission reported in IV (2012) CPJ 839 titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Valsa Jose”, wherein it was observed that the hypertension is a life style disease, thus repudiation on the ground that suppression of facts is not justified. A reference can be made to another judgment reported in II (2013) CPJ 103 titled as “Kotak Mahindra Old Mutual Life Insurance Ltd. Vs. Chander Isarsingh Dhansinghani & Anr.” In that case also, no evidence was brought on the record that previous treatment of the deceased life insured, there was no deliberate concealment and it was held that the repudiation is not justified. In that judgment of Hon’ble National Commission reported in II (2005) CPJ 32 titled as “Surinder Kaur & Ors. Vs. LIC of India & Ors.” Has been referred, wherein it was observed that doctor’s opinion based on hospital history is not sufficient to prove suppression of material facts on the part of the insured. A reference has also been made to another judgment reported in “I (2004) CPJ 91, titled as “LIC of India V. Smt. Promila Malhotra” wherein it has been referred that in case there are allegations that insured made false representation and suppressed the material facts then the burden to prove that insured made false representation on the Corporation.

 

12. There is a disparity in passing of the order passed by the opposite party as four policies were taken by the DLA. Only policy No.473547502 has been repudiated, whereas other three policies were allowed by the opposite party. No reason has been given why those policies were allowed and why this policy was not allowed. Therefore, the opposite party cannot take two stands of one person with regard to pre-existing disease. In case, the claim of this policy has been repudiated on the basis of DM-2 with the DLA for the last 19 years then no reason is there why other three policies were allowed, therefore, this policy is required to be allowed on the basis of parity”.

  14. In light of above discussion and principles laid down by the Hon’ble National Commission and State Commission as mentioned above we are of the view that there is no evidence to show that the death of the deceased was due to the alleged pre-existing diseases and it cannot be said that deceased has suppressed material facts in obtaining the policy specially when the insured aged about more than 60 years  was medically examined by the Doctor of the O.Ps. There is no parity in settlement of claims of the complainant in respect to same insured, these O.Ps. have settled the claim of two other insurance policies but they have repudiated the part claim of policy under this case. There is no any case regarding forfeiture of the premium by the O.Ps. on the ground related to suppression of material facts. It is admitted fact that out of Rs. 14,00,000/- Rs. 4,00,000/- has already been paid by the O.Ps. to the complainant in this way there is part acceptance of the claim by the O.Ps. hence they cannot be permitted to deny part of the claim related to rest of the amount of Rs. 10,00,000/-. Thus in light of above discussion both the points are being decided in favour of the complainant.

15.    Accordingly prayer is allowed in the following manner:-

O.Ps. are directed to pay rest of the claim of Rs. 10,00,000/- to the complainant within 45 days from the date of receipt/production of the copy of this order, failing which they shall pay interest @ 10% per annum from 21.03.2020 (the date on which complaint was filed). Further O.Ps. are directed to pay Rs. 15,000/- as compensation in respect to various type of physical and mental harassment caused to the complainant and to pay Rs. 7000/- as litigation cost within above mentioned period. Office to provide free copy of this Judgment to both the parties.

 

(J.P.N. Pandey)

                                                                                      President

 

                                                                                     

                                                                                       (Baby Kumari)

                                                                                          Member