Haryana

Fatehabad

CC/69/2019

Raj bala - Complainant(s)

Versus

The Life Insurance Corporation - Opp.Party(s)

Anil Saini

08 Jan 2024

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                      Sh.Rajbir Singh, President.                                                         Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                               Complaint Case No.: 69 of 2019.

                                              Date of Institution:    25.01.2019

                                                        Date of order:            08.01.2024.      

 

Smt.Rajwala wd/o Bhoop Singh son of Kirpal Singh resident of near Kali Mata Mandir Tohana District Fatehabad.

                                                                          ….. Complainant.

 

                                         

                                                     Versus   

 

 

1.The Life Insurance Corporation of India,near Biswas School Urban Estate Hisar District Hisar through its Branch Manager.

2.Life Insurance Corporation of India Rohtak Division SCO 3,4,5 Sector-1 Rohtak-124001 through its Branch Manager.

3.The Life Insurance Corporation of India Branch Office New Gupta Colony, Tohana Tehsil Tohana District Fatehabad through its Branch Manager.

 

….Opposite parties.

 

Complaint U/s 12 of the Consumer Protection Act

                                                                                

Present:          Shri Anil Saini, Advocate for the complainant.

                  Shri Naresh Sachdeva, Advocate for the opposite parties.

 

ORDER

SH.RAJBIR SINGH, PRESIDENT

                   Brief facts of the present complaint are that husband of the complainant namely Bhoop Singh took an insurance policy Jiwan Anand bearing No.179789001; that the complainant was nominee under the said policy; that the life assured died on 05.01.2017 and the complainant lodged the claim with the OPs besides submitting all the requisite documents  to release the claim but to no avail, therefore, the complainant got served legal notice served upon the Ops.  The act and conduct of the Ops clearly amounts to deficiency in service on their part. 

2.                Averments of the complaint have been strongly opposed in the joint written statement filed on behalf of Ops wherein several preliminary objections such as maintainability, concealment of material facts, locus standi and estoppal etc. have been taken. It has been further submitted that the death claim liability was repudiated on genuine grounds and intimation was sent to the complainant vide letter dated 15.03.2018; that an amount of Rs.23,000/- was paid to the complainant through NEFT on 16.03.2018 as full and final settlement, therefore, there is no deficiency in service on the part of Ops;  that in the proposal form dated 06.02.2015,  the life assured had answered the following questions:-

During the last five years, did you consult a medical practitioner for any ailment requiring treatment for more than a week?	No
Have you ever been admitted to any Hospital or nursing home for general check-up, treatment or operation?	No
Have you remained absent from place of work on grounds of health during last five years?	No
Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, high blood pressure, low blood pressure, cancer, epilepsy, Hernia, Leprosy, or any other disease?	No
Are you suffering from or have you ever suffered from ailment pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or nervous system?	No

 

It has been further submitted that the life assured has violated the terms and conditions of the policy in question, therefore, the ops have rightly repudiated the claim of the complainant as the policy in question was purchased with malafide intention. Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint.

4.                The parties then led their respective evidence by way of affidavits and documents. The complainant has tendered in evidence his affidavit as Annexure CW1/A and documents Annexure C1 to Annexure C6. On the other hand, the Ops have tendered into evidence affidavit Annexure R1 and documents Annexure R2 to Annexure R10.

5.                We have heard learned counsel for the parties and with their kind assistance, the material available on the case file, have been perused and examined.

6.                Learned counsel for the complainant argued that claim of the complainant regarding death of her husband, who was insured with OPs has been wrongly & illegally rejected by the OPs on the ground that the deceased (life assured) had made incorrect statement and withheld correct information regarding his health at the time of effecting insurance. He has further contended that life assured was not suffering from disease before he proposed for the policy. It has been further argued that before issuance of the policy to the deceased, he was thoroughly examined by the empanelled doctors of the Ops and after declaring him hale and healthy, the Ops had issued the policy in question to the deceased (life assured).    

7.                On the other hand, learned counsel for Ops has argued that at the time of filling of proposal form the life assured did not disclose true facts about his pre-existing disease intentionally and made false answers to the questions mentioned in the proposal form regarding his health. It has been further argued that had the life assured disclosed the true status qua his health in the proposal form, the OPs would not have issued the policy in question to the life assured. Since, the life assured had violated the terms and conditions of the policy, therefore, the claim was rightly repudiated. However, an amount of Rs.23,000/- has already been paid to the complainant as full and final settlement.  Lastly, prayer for dismissal of the complaint has been made.

8.                          The Ops in their reply have specifically taken the plea that the life assured was the patient of shortness of breath and he had not disclosed this fact in the proposal form.          Now, point for consideration before this Commission is as to whether the deceased (life assured) had concealed his health status from the Ops before issuance of the said policy or not?

9.                          In order to prove the fact of concealment of pre-existing disease at the time of purchasing the policy in question by the deceased (life assured), learned counsel for the Ops has placed on record medical history of the deceased (life assured) as Annexure R8 but he has failed to prove on the case file that the disease (Shortness of breath and palpitation) mentioned in medical record have any nexus with the death of deceased (life assured).  Perusal of the case file reveals that the Ops have not produced any medical record of the life assured and the documents on which the Ops are relying upon are the part of enquiry conducted by the Ops after receiving the claim application.  Moreover, all these documents are photo stat copies and even the Ops have not brought the affidavit of the concerned doctor on the case file who has affixed  his signatures on the papers/certificate Annexure R7 and Annexure R8. So, merely on the basis of assumption and presumption, it cannot be assumed that father of the complainant was treated in hospital at Tohana for shortness of breath. In the present case, the opposite parties have failed to prove on record that life assured was suffering from any disease at the time of taking the insurance policy in question rather the complainant has been fully able to prove his case by leading cogent and reliable evidence. Therefore, the opposite parties have wrongly repudiated the claim of the complainant and same is not justified.  

10.                        Further, The burden of proof was upon the OPs to prove that the insured was suffering from pre-existing diseases prior to taking the policy, but they have miserably failed to discharge this onus, by not leading any cogent and convincing evidence to prove this fact. On this point, reliance can be taken from the case law titled as Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC),  wherein it was held by the Hon'ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus, the repudiation of the claim on the ground of pre-existing disease was held to be invalid. After considering all the facts and going through the material available on the case file, we have no hitch to reach at a conclusion that the Ops are only trying to back out from the contract and it is a general observation that in a number of cases, the insurance companies are issuing policies basing on the statements made by the proposer in utmost good faith but when it comes to settlement of claims, they start examining the matter under the microscope.  The present case is squarely covered by the case law relied upon by learned counsel for the complainant.

10.                        Thus, as a sequel to our above discussion, we accept the present complaint and direct the Ops to pay the amount of Rs.1,01,000/-            (Rs.23,000/- has already been paid out of total sum assured of Rs.1,30,000/- sum assured) to the complainant alongwith interest @ 6% per annum from the date of filing of present complaint till actual realization. We also direct the Ops to further pay a sum of Rs.11,000/- for mental agony and harassment including litigation expenses to the complainant.  The order be complied within a period of 45 days from today.

11.                        In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                            Dated: 08.01.2024

 

 

                                                                                                        

          (K.S.Nirania)                       (Harisha Mehta)                (Rajbir Singh)                              Member                               Member                                           President