By : ASISH DEB, PRESIDENT,
1. The case of the complainant in short is that the complainant is the wife and nominee of late Shah Nagib Akhtar. Her husband Nagib Akhtar, since deceased, purchased a Life Insurance Policy being No.19791792 from the OP Company and its yearly premium was Rs. 99,999/-. Husband of the complainant nominee i.e the insured died on 06.12.2018 at Binodinee Matri Seba Sadan Nursing Home. Nominee of the insured demanded the sum assured of Rs. 6,99,993/- from the Opposite party, but the OP paid only Rs. 75,807,46 in the A/c of the complainant on 01.02.2019 and the OP has repudiated the insurance claim of the complainant by a letter dated 31.01.2019. Being dissatisfied with the action of the Opposite party the complainant herein has filed this complaint case with a prayer for a direction upon the OP to pay the complainant a sum of Rs. 5,99,993/- along with other consequential reliefs.
2. Summons was issued upon the Op and the Op appeared and contested the case by filing a written version and prayed for dismissal of the complaint on the grounds inter alia that the complaint is vexatious , speculative and harassing. The specific defense of this OP is that the insured purchased a HDFC Sl. Pro growth Flexi Policy being policy No. 19791792 in November, 22, 2017 where total sum assured was Rs. 6,99,993,00 and the tenure of the policy was for 10 years with annual Premium of Rs. 99,999/-. Upon verification of the documents produced by the insured the policy documents were sent to the insured by courier. It is the contention of the OP that the insured did not pay the 2nd premium of the policy. Before issuing the policy the OP examined the insured by putting various medical questionnaires regarding any medical treatment, symptoms of any pre-existing disease etc. Subsequently in December,06, 2018 i.e within one year and thirteen days of the policy the insured expired and thereafter the complainant raised the claim of death benefit. On receipt of such claim the OP investigated upon the death case of the insured and came to know that there was suppression of pre-existing disease of the life assured. The life assured was suffering from diabetes mellitus and hypertension prior to issuance of the policy ,and he was under medical treatment which is established from the medical prescriptions of the insured. On the above grounds, the Op has repudiated the claim of the complainant.
3. Under the above circumstances, the OP prays for dismissal of the complaint case with cost
.
4. Contentions of the Ld Advocates
A. Ld Advocate for the Complainant has submitted that the op should not have repudiated the claim ; repudiation of claim is not backed by any justified or acceptable reason. Even If a person was suffering from hypertension ,the insurance claim of the legal heir of such a person can not be repudiated on the ground that the life assured had suppressed this information from the insurance company. According to him hypertension is not a material disease. So far as diabetes is concerned same parameter will apply. Disease of diabetes is so common in our country men, at least in this part of the country that almost every third person is suffering from it. A person suffering from diabetes can live even for 20 to 30 years if he takes proper medicines. Therefore, non-disclosure of above diseases by the life assured does not entitle Insurance Company to repudiate the insurance Claim Settlement of claim partially by the op also substantiate the genuineness of the claim of the complainant. He added that the insurance company insure a person, take premium and when it comes to making the insurance claim settlement find out flimsy grounds or sketchy evidence or take one or other grounds to reject the claim. The op did not exercise the right of repudiation judicially and on sound principle. The act of the op certainly amounts to deficiency in service. The complaint case should be allowed as prayed for.
B. Per Contra: Ld. Counsel for the op has vehemently contented that alleged deficiency in service is baseless The life assured was suffering from diabetes mellitus and hypertension prior to issuance of the policy ,and he was under medical treatment which is established from the medical prescriptions of the insured. There is direct nexus of the said diseases with the death of the life assured. The life assured had violated the terms and condition of the insurance contract. According to him the op was justified in repudiating the claim in full in view of the exclusion clause which excludes suppression of material facts about pre-existing disease. The life assured also did not pay the 2nd premium due before his death on time ie before due date. As there was no deficiency in service, the instant case is liable to be dismissed.
5. The points that arise for Determination are as follows:
I. Is the Complaint case maintainable in its present form?
II. Is the Complainant entitled to get the reliefs as prayed for?
6. DECISION WITH REASONS
7. In Re:- Points No. I & II
8. As both the points are inter related we are inclined to address the points simultaneously in order to avoid repetition of facts and evidence.
9. We have given thoughtful consideration to the rival contentions of the Ld Counsel for both parties.
10. Having regards had to the contents of complaint ,written version ,evidence and other materials on record, it appears that complainant is a consumer and the op Insurance Co. acted as service provider,as such the instant case is maintainable in its present form in law.
11. It is evident that indisputably complainant,s husband had purchased a HDFC Sl. Pro growth Flexi Policy being policy No. 19791792 in November, 22, 2017 where total sum assured was Rs. 6,99,993,00 and the tenure of the policy was for 10 years with annual Premium of Rs. 99,999/-..One annual Premium of Rs. 99,999/-.was paid. The Complainant is the legal representative and nominee of the deceased life assured. In December,06, 2018 i.e within one year and thirteen days of the policy the insured expired, before payment of 2nd premium and ,thereafter the complainant raised the claim of death benefit. Nominee of the insured demanded the sum assured of Rs. 6,99,993/- from the Opposite party, but the OP paid only Rs. 75,807,46 in the A/c of the complainant on 01.02.2019 and the OP has repudiated the insurance claim of the complainant by a letter dated 31.01.2019. But the crux of the dispute is the repudiation of the claim by the mainly on threefold grounds viz, the life assured was suffering from diabetes mellitus and hypertension prior to issuance of the policy ,and he was under medical treatment. The life assured also did not pay the 2nd premium due before his death on time ie before due date.
12. It is the trite law that admitted facts need not be proved. Coming to the threefold grounds of the repudiation raised by the op are not backed by any just and proper reason. In this context, this Commission find that there is substance in the contentions propounded by the Ld Counsel for the complainant . Hypertension is not a material disease. So far as diabetes is concerned same parameter will apply. Disease of diabetes is so common in our country men, at least in this part of the country that almost every third person is suffering from it. A person suffering from diabetes can live even for 20 to 30 years or more if he takes proper medicines. Therefore, non-disclosure of above diseases by the life assured does not entitle Insurance Company to repudiate the insurance Claim. In some cases,the insurance company insure a person, take premium and when it comes to making the insurance claim settlement find out flimsy grounds or sketchy evidence or take one or other grounds to reject the claim. Then, the allegation of the op that life assured did not pay the premium due before his death on time ie before due date has got no leg to stand upon the death of the life assured occurred within the grace period allowed for premium payment.Moreover,the op has failed to prove by cogent evidence that there was at all any nexus of diabetes mellitus and hypertension with the death of the life assured. On total appreciation of the materials on record, it is clear that the facts as averred by the complainant, have been duly proved. Therefore, the contentions of the Ld Advocate for the op have got no leg to stand upon.
13. The op did not exercise the right of repudiation judicially and on sound principle. The act of the op certainly amounts to deficiency in service. Thus, there is element of deficiency of service or negligence on the part of the op. The op should pay Rs. 5,99,993/- as towards insurance claim, Rs.5000/- as towards compensation for harassment and Rs.2000/- as litigation costs to the Complainant. In addition to that Complainant will get simple interest @ 7% per annum on said amount from the date of filing of this case till realization from the OP.
14. Both the points are answered accordingly.
15. In the result, the complaint case succeeds.
16. Hence, it is
O R D E R E D
17 . That the Consumer Case No. 246 of 2019 be and the same is allowed on contest against the OP.
18. The OP is directed to pay Rs. 5,99,993/- as towards insurance claim, Rs.5000/- as towards compensation for harassment and Rs.2000/- as litigation costs to the Complainant. In addition to that Complainant will get simple interest @ 7% per annum on the said amount from the date of filing of this case till realization from the OP.
- The OP is directed to issue a bank draft /bankers’ cheque for the said amount within 45 days from date of this order in default the Complainant would be at liberty to put the order into execution.
- Let a copy of this judgment be supplied to the parties , each free of cost.
