Complaints filed on: 04-09-2021
Disposed on:25-04-2023
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 25th DAY OF APRIL 2023
:P R E S E N T:
SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT
SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER
SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER
CC.No. 125/2022
Ramya C.J. C/o T.P.Divakar
Kotte Beedi, Gubbi, Tumakuru
Karnataka-572 216.
……….Complainant
(By Sri.Dr.P.Ravishankar ., Advocate)
V/s
1. The Chief Executive Officer
(Represented by Authorised Officer)
HDFC Life Insurance Company Ltd.,
Lotha Excelus, 13th Floor, Apollo
Mills Compound, N.M.Joshi Marg,
Mahalaxmi, Mumbai-400 011.
2. HDFC, Claims Review Committee
HDFC Life Insurance Company Limited,
11th Floor, Lodha Excelus, Apollo Mills Compound,
N.M.Joshi Road, Mahalaxmi, Mumbai-400 011.
3. Authorised Signatory,
Regd. Office, Ramon House,
169, Backhay Reclamation,
Churchgate, Mumbai-400 020.
……….Opposite Parties
(By Sri.Himanand D.C. ., Advocate)
:O R D E R:
SMT.G.T.VIJAYALAKSHMI - PRESIDENT
This complaint is filed by the complainant against the OPs with a prayer to direct the OPs to pay the sum assured of Rs.16,00,000/- along with 12% interest from the date of death till the date of realization and also prays to direct the OPs to pay Rs.10,000/- towards cost of the litigation and Rs.25,000/- towards mental agony and such other reliefs as this Hon’ble Commission deems fit to grant.
2. The brief facts of the complaint is as under:-
The husband of complainant was a member of a Group Credit Protect Plus Insurance Policy bearing Certificate No.PP0002880289K00 for the housing loan of Rs.15,46,686/- with single premium of Rs.39,534.23/- and the membership commenced on 30.11.2020 and over is to expire on 29.11.2030. The master policy number is PP000288 and the Loan account number is 1100599. It is further submitted that the complainant is the wife of deceased policy holder T.Divakar and also nominee to the said policy. Unfortunately, the husband of the complainant died at Hassan on 12.01.2022 and in that regard a complaint was registered under section 174 and after formalities, the body was handed over to the family and last rites was performed at Tumkur. Thereafter, being the nominee of the policy, the complainant preferred a claim before the OP, but the OP rejected the claim without any valid reasons and on false grounds. Being aggrieved by the rejection of the claim by OP No.1, the complainant approached by filing an application before the OP No.2 and the OP No.2 also rejected the claim without applying the mind.
The complainant further contended that the rejected the claim of the complainant without any basis, the death was under mysterious circumstances and there is no suppression of facts as alleged by the OP. Further it is submitted that the policy was subscribed as a group policy to cover the loan extended by the housing wing and under the said policy there is no individual request of health is made.
The complainant further submitted that the OPs have extended the loan facility to pay the premium of Rs.46,686/-. It is further submitted that this Hon’ble Commission has both pecuniary and territorial jurisdiction to try the complaint as life assured died in the state of Karnataka near Hassan and cremation and last rites were performed at Tumkur and premium collected by the OP at Tumkur. But the OP just to escape from the clutches of jurisdiction of the judicial authorities, they have not given any local address and correspondence is made to Bombay, which unfair trade practice by the OPs. The cause of action arose when the OP rejected the claim of the complainant on 31.03.2022. It is further submitted that the OPs have decided to take rejection of claim without any documents or evidence and just to escape from their liability, they have taken flimsy and untenable reasons for rejection of claim which is clear deficiency in service on the part of OPs. Hence, the complaint.
3. After service of notice, the OPs appeared through their counsel and filed the version, wherein the OPs have contended that the complainant’s husband namely Divakar T.P. was a member of a Group Credit Protect Plus Insurance Policy bearing certificate No.PP00028880289K00 for availing housing loan bearing policy No.PP000228 from the OP for a sum assured of Rs.15,46,686/- towards the death benefits commencing from 26.11.2020 and the policy was issued on the basis of an application by the life assured to OP/company and the nominee under the policy is the wife of deceased life assured i.e. the complainant. It is further contended that after the death of the life assured, the complainant being nominee made a claim for death benefits. After the claim, they made investigation and it was established that the deceased life assured was suffering from Diabetes mellitus and hypertension which is prior to issuance of the policy and the said facts was not disclosed by the deceased life assured at the time of application/member enrollment form. Therefore, it is clear that the deceased life assured suppressed the material facts and obtained the policy. There is no any illegality has been committed by the OP in repudiating the death claim submitted by the complainant as the medical records submitted are self-explanatory indicating non-discloser on the part of complainant. It is further contended that it is a settled principle of law that a contract of insurance is one of utmost good faith on the part of the assured. Thus, it needs little emphasis that when a piece of information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full discloser of the information on the subject which is within his knowledge, but the deceased life assured was not disclosed the same and not acted fairly. The OP denied the other allegations made by the complainant in the complaint and contended that they have repudiated the claim as per the terms and conditions of the policy and hence there is no deficiency of service on their side. On these among other grounds, it is prayed by the OP to dismiss the complaint with cost.
4. The complainant has filed her affidavit evidence and marked the documents at Ex.C1 to 5. The OP Nos. 1 & 2 have filed their affidavit evidence and produced some copies of documents.
5. We have heard the arguments from both side counsels. The complainant and OPs also filed the written arguments.
6. The Points that would arise for our consideration are:
1) Whether there is any deficiency in service on the part of OPs?
2) Whether complainant has entitled for reliefs sought for?
7. Our findings to the aforesaid points are as under:
Point No.1: Partly in the affirmative
Point No.2: As per the final order
:R E A S O N S:
8. On perusal of pleadings, evidence and documents placed by the parties, it is an admitted fact that husband of complainant namely Divakar was a member of Group Credit protect plus insurance policy for the housing loan sum assured of Rs.15,46,686/-. The membership commenced on 30.11.2020 to 29.11.2030. The nominee under the policy is the wife of the husband of the complainant (Divakar) died @ Hassan on 12.01.2022 and a complaint was registered. Thereafter, the complainant being a nominee made a claim for death benefits, but OPs rejected the claim without any valid reasons.
9. Now the main allegation of the complainant is that, without any documents/evidence, the OP has rejected the claim of the complainant. For these allegation, the OPs have contended that after receiving the claim for death benefits from the complainant, OPs made investigation and it was established that the deceased life assured was suffering from diabetes mellitus and hypertension prior to issuance of the policy. The diabetes and hypertension was not disclosed by the deceased life assured in the member enrolment form. From the above said facts, it is clear that the deceased life assured suppressed the material facts and obtained the policy. Therefore, the OPs have repudiated the death claim submitted by the complainant as per the terms and conditions of the policy and there is no deficiency of service.
10. To prove the case of complainant, the complainant has produced Ex.C1/copy of policy and wherein it is clearly mentioned the death benefit under the policy was Rs.15,46,686/-. Ex.C2/copy of death summary issued by Hassan Institute of Medical Sciences disclose the cause of death as “due to complications of alcoholic liver diseases”. Ex.C3/copy of Repudiation letter dated:31.03.2022, wherein it is stated that “Our investigations have established that the Life Assured was suffering from Diabetes Mellitus and Hypertension prior to issuance of policy”. On the contrary, the OP produced the document of Dasegowda Health Centre. But it is not legible and the OP also not stated anything about the said document. The OP has not asked any specific questions regarding diabetic and hypertension in the group enrolment form.
11. The counsel for complainant submitted that the deceased life assured has not suppressed any material information with regard to his health. Moreover, hypertension and diabetes is not a disease. Except Dasegowda Health Centre document, the OPs have not produced any evidence. Further, the OPs have not produced any documents to prove that from the diabetes/hypertension only, the complainant’s husband dies. The Ex.C2/copy of death summary issued by Hassan Institute of Medical Sciences it is clearly mentioned that “cause of death “due to complications of alcoholic liver diseases”
12. If the complainant’s husband died due to hypertension/diabetes, then it is pre-existing disease, as a nominee, the complainant is not entitled to claim death benefits. Only existing of pre-existing disease is not sufficient to repudiate the claim, but the death of the deceased life assured should actually occur due to such pre-existing disease. In the present case, the OPs have not produced any evidence to prove that the complainant’s husband was taken treatment for diabetes/hypertension prior to taking the policy. Moreover, hypertension is a lifestyle disease and it can be easily controlled with the conservative medication. Therefore, concealment of diabetes and hypertension cannot be termed as non-disclosure of pre-existing disease. We have perused all the material available on record, facts and circumstances of the case and in the light of observation made by the Hon’ble Apex Court and Hon’ble National Commission in catena of judgments, we found there is a deficiency of service on the part of OPs and thereby caused mental agony to the complainant.
13. The complainant claimed for Rs.16,00,000/- as sum assured along with 12% interest from the date of death of the complainant’s husband. But as per policy, the sum assured is Rs.15,46,686/- (death benefits). Hence, OPs are liable to settle the claim of the complainant i.e. sum assured of Rs.15,46,686-00 with interest @ 8% P.A. from the date of repudiation to till realization. For the act of OPs, the complainant is compelled to approach this Commission. Therefore, the complainant is entitled for Rs.10,000/- as compensation for mental agony and Rs.10,000/- as litigation expenses. Accordingly, we pass the following:-
:O R D E R:
The complaint is allowed in part with costs
The OPs are jointly and severally directed to pay Rs.15,46,686/- along with interest @ 8% PA from the date of repudiation i.e. 31.03.2022 to till realization.
The OPs are further jointly and severally directed to pay Rs.10,000/- towards compensation for mental agony and Rs.10,000/- towards litigation expenses.
Further, the OPs are jointly and severally directed to comply the above order within 45 days from the date of receipt/acknowledge this order.
Supply copy of this order to both parties with free of costs immediately.
