View 984 Cases Against Aviva Life Insurance
View 32692 Cases Against Life Insurance
View 32692 Cases Against Life Insurance
Shri. Chandrashekar Shinde filed a consumer case on 18 Jan 2018 against The Manager AVIVA Life Insurance and Others in the Bangalore 4th Additional Consumer Court. The case no is CC/14/1551 and the judgment uploaded on 23 Jan 2018.
Complaint filed on: 02.09.2014
Disposed on: 18.01.2018
BEFORE THE IV ADDL DISTRICT
CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU
1ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027
CC.No.1551/2014
DATED THIS THE 18TH JANUARY OF 2018
SRI.S.L.PATIL, PRESIDENT
SRI.D.SURESH, MEMBER
SMT.N.R.ROOPA, MEMBER
Complainant/s: -
Sri.Chandrashekar Shinde,
S/o Sri.Vejendra Rao Shinde, Aged about 55 years,
R/at no.225, 1st A cross,
HMT, C/o Mathikere, Near Chowdeshwari Temple, Bengaluru-54.
By Adv.Sri.A.Nagaraja
V/s
Opposite party/s
Respondent/s:-
Aviva Life Insurance,
Claims Management Group, Aviva Life Insurance co., India Ltd., 2nd floor, Prakash Deep Building, 7, Tolstoy Marg,
New Delhi – 110001.
Aviva Life Insurance co.,
India ltd., Aviva Tower,
Sector Road, Opp.DLF
Golf course, DLF phase V,
Sector 43,
Gurgaon–122003,
Haryana.
Ex-parte
Ashirwad Towers, plot no.2,
old no.182, 3rd floor, Kodamakkam High road, Nungambakkam,
Chennai-600034.
By Adv.Smt.Vedashree.A
PRESIDENT: SRI.S.L.PATIL
This complaint is filed by the Complainant against the Opposite party no.1, 2 & 3 (herein after referred as Op.no.1, 2 & 3 or Ops) seeking issuance of direction to pay the hospital medical bills amount of Rs.1,50,000/- and damages and other losses of Rs.5 lakhs sustained by the Complainant for the wrong doings of the Ops. Further direct the Ops to continue the health policy by collecting the quarterly premium in future.
2. The brief facts of the case of the Complainant are that one of the agent of Ops have approached the Complainant and requested to have a Medical claim health insurance policy. Owing to their agent’s request the Complainant has agreed to take a policy of their insurance company. Accordingly the agent of the Ops instructed the Complainant to do some formalities and procedures before taking the policy as the Complainant is aged about more than 50 years and the agent of Ops have completed the formalities and procedures as required by the Op’s company. The Complainant further submitted that after following the formalities and procedures the agent of the Ops have given a prescribed form for taking the policy and collected all the details which is prescribed under the application and filled up all the columns in the said application form and collected the same from the Complainant. The Complainant has taken a policy for a sum of Rs.2,50,000/- and the agent of the Ops instructed him to pay a quarterly premium of Rs.6,250/-. Accordingly, the Complainant has paid first quarterly premium of Rs.6,250/- through a cheque in the name of Ops health insurance company. After acceptance the above mentioned premium amount by the Ops have issued a policy bond bearing policy no.AFP2974903, dtd.30.05.10 (herein after referred as mediclaim policy) to the Complainant which covers the risk from the said date. Thereafter the Complainant was regularly paying the quarterly premium without committing any default to the Ops. At the time of taking the policy the Complainant was not suffering from any ailments and he was quite hail and healthy. The Complainant further submitted that he was admitted in M.S.Ramaiah Memorial hospital on 09.08.13 with a diagnosis of hypertensive 3rd vertical bleed EVD (POD) type II DM, hypertension and he was hospitalised and took treatment as an inpatient for the said ailment. In order to claim insurance from the Ops, the Complainant has informed through his son-in-law through a letter to pay the hospital expenses by furnishing the relevant hospital records and medical bills through his son-in-law one Karan Honnavar. After receipt of the said letter the Ops have declined to give the benefits to the Complainant which was assured in the policy, by giving evasive replies and taking wrong conclusions. The Complainant has spent medical expenses by borrowing loan from his relatives and friends hoping that the Ops will pay the policy amount assured by them, due to noncompliance of the policy amount by the Ops, the Complainant has suffered huge loss which leads to mental agony to the Complainant, due to fault on the part of the Ops. It shows deliberate and mala-fide intention of the Ops that has to how the Ops are avoiding to pay the benefits assured under the policy to the Complainant. The Complainant further submitted that subsequently in another letter, dtd.15.11.13 has been sent by the Ops to the Complainant for declining and cancellation of the policy of the Complainant by giving untenable reason, which is far away from truth. It is also the case of the Complainant that before issuing the policy the Ops had completed all the requisite formalities and procedures to issue the policy. But reasons assigned in the letter, dtd.15.11.13 for declining and cancellation of the policy on different grounds that the Complainant had diabetes prior to the issue of policy. After receipt of the said letter the Complainant and his family members were shocked and surprised have under gone a mental agony. The Complainant further submitted that the Complainant had policy from 25.05.10 after a lapse of 3½ years without availing the medical facility to the Complainant, the ops have declined the policy and returned the cheque of Rs.18,793/- dtd.12.11.13, which shows the mala-fide and deliberate intention of Ops to escape from the liability of paying the medical bills. The Complainant further submitted that the Director-operations of the Op’s company issued a letter dtd.21.08.13 regretting the loss of Complainant’s life, even though he is alive, also establishes of sending wrong and painful and agony message by doing wrong investigations by the Ops company officials. Both the letters sent by the Op contrary to each other and clearly establishes the intention of the Op to escape from the liabilities of paying the benefits in favour of the Complainant as assured in the policy. The Complainant further submitted that at last the Complainant has issued legal notice to the Ops on 04.01.14 through his counsel and till to day they have not come forward to give their reply to the said notices. The Complainant further submitted that without any alternative the Complainant is filing the present complaint against the Ops for suitable redress. Hence this complaint.
3. On receipt of the notice, Op.no.1 & 2 did not appear before this forum. Hence Op.no.1 & 2 placed exparte. Though filed Vakalath for Op.no.3, version not filed by the learned counsel for the Op.no.3.
4. The Complainant to substantiate his case filed affidavit evidence and further affidavit evidence and got marked the documents Ex-A1 to A9 and closed his side. Inspite of appearance, Op.no.3 did not chosen to file affidavit evidence, hence it was taken as affidavit evidence has not filed. The Complainant filed written arguments. The Ops neither filed written arguments nor address oral arguments. Heard learned counsel for the Complainant.
5. The points that arise for our consideration are:
6. Our answers to the above points are as under:
Point no.1: In the Affirmative.
Point no.2: As per the final order for the following
REASONS
7. Point no.1: We have briefly stated the facts of the case of the Complainant. Inspite of the notice duly served on Op.no.1 & 2, they did not appear. Op.no.3 did appear through its counsel, but not filed version much less the affidavit evidence. When the Ops did not appear to oppose the claim of the Complainant, at this stage it should be presumed that the contention taken by the Complainant premia-facie appears to be true and correct. Anyhow, we place reliance on the available materials on record.
8. It is surprise to note that, in response to the claim application, the Ops sent a regretting letter stating that the Complainant is dead though alive. This itself goes to show that, how the Ops are dereliction on their duty in response to the claim of the Complainant.
9. At this stage, it is not in dispute that the Complainant has availed the mediclaim insurance policy from the Op’s agents. Accordingly the agent of the Ops instructed the Complainant to do some formalities and procedures before taking the policy as the Complainant is aged about more than 50 years. In this context, the formalities and procedures have been complied and the necessary applications have been furnished to Ops. The Complainant has taken a policy for a sum of Rs.2,50,000/- and the agent of the Ops instructed him to pay a quarterly premium of Rs.6,250/-. Accordingly the Complainant has paid the said amount. After acceptance of the premium amount, the Ops have issued a policy bond bearing policy no.AFP2974903, dtd.30.05.10 (herein after referred as insurance policy) to the Complainant which covers the risk from the said date. The said policy is marked as Ex-A1. Thereafter the Complainant was regularly paid the quarterly premium without committing any default to the Ops. The Complainant also made it clear that at the time of taking the policy he was not suffering from any ailments and he was quite hail and healthy. To deny this fact, Op did not filed its version. That on 09.08.13, the Complainant was admitted in M.S.Ramaiah Memorial hospital with a diagnosis of hypertensive 3rd vertical bleed EVD (POD) type II DM, hypertension, wherein he was taken treatment as inpatient. In order to claim insurance from the Ops, he has informed through his son-in-law through a letter to pay the hospital expenses by furnishing the relevant hospital records and medical bills. After receipt of the said letter the Ops have declined to give the benefits to the Complainant which was assured in the policy, by giving evasive replies and taking wrong conclusions. Now we will have to culled out, whether the Complainant has got any pre-existing disease, so as to repudiate the medical claims. In this context we place reliance on the contents of Ex-A4 which is with regard to the repudiation letter denying the claim of the Complainant, wherein the relevant portion reads thus:
We would also like to inform you that it has been found that you had failed to disclose existing medical condition at the time of submission of proposal form.
As per the medical documents and the statement provided by Mr.Chandrashekar Shinde during claim evaluation, it has been found that your are suffering from Diabetes and was also having loss of vision in (LT) eye since 2009 and treatment for the same prior to signing of the proposal.
However, in the proposal form dtd.25.05.10, under the ‘Health & Activity section” part you had answered ‘No’ to specific question related in respect to your medical condition.
6.2 B. Have you ever had any medical or surgical treatment, including investigations, tests, scans or x-ray for any of the following illnesses or medical conditions?
iv: Diabetes, kidney or liver problem ? – ‘NO’
Insurance being a contract of ‘uberrimae fidae (utmost good faith), the policy holder is duty bound to reveal all relevant facts to the insurer in order for the insurer to determine the policy holder’s eligibility for availing the insurance. In light of the above, we regret to inform you that no claim is admitted against the company and your claim stands declined and policy stands cancelled.
However, as a good will gesture amounting Rs.18,793/- was refunded towards Surrender Value of your policy via cheque numbering 179898 dtd.12.11.13 drawn on Axis bank ltd., Please also note that in making this offer we do not admit that any amount is legally due and payable to you under the policy. Hence, your policy is terminated.
Referring to the said alleged pre-existing medical condition, Ops have denied the claim. To falsify the contention of Ops, learned counsel for the Complainant has draw our attention to the contents of Ex-A9 which is the discharge summary of the Complainant which goes to show that
‘Patient was admitted with complaints of giddiness and weakness of all limbs was evaluated. In background of his co-morbidities Type 2 DM, Hypertension, dyslipidemia and high BP (220/110mmHg) at presentation, immediate CT brain plain done showed leftmid brain bleed extending to 3rd ventricle. Patient was immediately shifted to ICU started on Labetolol and Mannitol injections, steroids and diuretics added and symptomatic treatment continued. Prophylactic antiepileptic added to treatment. Slowly dose of Labetalol tapered and patient kept on oral antihypertensive CCB, L2-against (alpha 2 agonist) Intubation and EVL done on 10.08.13 in view of obstructive hydrocephalus. EVD was removed after 5 days. 2D ECHO is normal. USG abdomen shoed B/L Gr. I Nephropathy, Nephro opinion taken advised to stop nephrotoxic drug and conservative management. Patient’s general condition and neurological condition improved. He had fever spikes on two consecutive days in his recovery phase, all infectious work up done and antibiotics escalated to Meropenem. Fever spikes subsided. At present patient improved and is being discharged with the medical advice.
10. Referring to the above contents of Ex-A9, submits that the health condition of the Complainant was not so serious at the time of discharging from the hospital and he was improved. We placed reliance on the contents of the discharge summary. Oral observation with regard to the ailing was due to diabetes and hypertensive. The diabetes is not considered as disease, it is only a disorder. Hypertensive may occur on account of some kind of stress. The Ops have not denied the contents of the complaint as well as the affidavit evidence filed by him. Further the Ops have not examined any of the competent doctors to falsify the contents of discharge summary marked as Ex-A9 placed before this forum. If the claim of the Complainant is repudiated on these grounds is totally illegal, in the light of the following decisions:
Held: We have carefully considered the material placed on record. We find that the appreciation of the evidence by the State commission is reasonable and calls for no interference. There is no convincing and reliable material placed on the record by the Op to substantiate the allegations that the Complainant had suppressed material information while submitted the proposal form. In view of the stand taken by the Complainant that the material placed on record by the insurance company related to his son, it was incumbent upon the insurance company to examine the doctors concerned to fix up the identity of the Complainant. No steps were taken by the Op to that direction and they simply relied upon a certificate issued by the doctor. The only evidence led by the insurance company was by way of an affidavit of Sanadkumar, an employee of the Insurance company.
In these circumstances, the State Commission was justified in holding that the insurance company failed to prove that the statement made by the Complainant was fraudulently made by him with the knowledge of the falsity of the statement or that the suppression was of material facts which had not been disclosed.
The order of the State Commission is based on cogent reasons and does not suffer from any legal infirmity. We have no hesitation in confirming the order of the State Commission. In the result, the appeal fails and it is dismissed with costs which are quantified at Rs.2,000/-.
In the light of the decision cited supra, we come to the conclusion that the claim repudiated by Op is totally illegal. Hence the Complainant is entitled for the medical claims.
11. Turning to the cancellation of Complainant’s mediclaim policy by the Ops is just and proper ? our answer is no, in the light of the unreported decision of the Hon’ble Supreme Court in the Appeal (civil) 2296/2000 dtd.02.08.2001 in the case of Biman Krishna Bose Vs. United India Insurance co., ltd., & Anr. The relevant portion reads thus:
The appellant, Biman Krishna Bose, has appeared in person. He argued that the High court even after setting aside the order refusing to renew the policy, was not justified in directing the appellant to take fresh mediclaim policy. According to the appellant by the said order of the High court he has been placed at a great disadvantageous position. The appellant referred to the exclusion clause of the policy taken out by them. Relevant clauses 2.1 and 2.1.14 of the mediclaim policy run as under:
2.1: The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connect with or in respect of:
2.1.14: All diseases/injuries which are pre-existing when the cover incepts for the first time.
On the strength of the exclusion clause, the appellant urged that in case the appellant is required to take fresh mediclaim policy, all the diseases which have surfaced during the period the policy was not renewed shall be treated as pre-existing diseases and the same would neither be covered by the fresh policy nor he will be paid the money which he has incurred for treatment of the said diseases during the relevant time and therefore, the order of the High court be set aside. We find substance in the argument.
Under Section 9 of the General Insurance Business (Nationalization) Act, 1972 (hereinafter referred to as the act), General Insurance Corporation of India (in short GIC) was set up as a Government company for the purpose of superintendence, control and carrying out the business of general insurance in the country. Under Section 24 of the act, the acquiring companies were given the exclusive privilege to carry on general insurance business in India. Under section 3(a) of the Act, an acquiring company has been defined to mean any Indian Insurance company in which any other company has been merged in pursuance to the amalgamation scheme formulated under the Act. The respondent insurance company is one of such acquiring company. A perusal of the provisions of the Act makes it evident that it is only the acquiring companies which have exclusive privilege of carrying on the general insurance business in India, under the supervision and control of General Insurance Corporation of India. Excepting the acquiring companies no other company in private sector has a right and privilege to carry on general insurance business in India and to that extent the acquiring companies have a monopoly over such business. In such a situation, acquiring companies have the trapping of the State being other authorities under Article 12 of the Constitution of India. The acquiring companies thus being the State under Article 12 of the Constitution are expected to act fairly and reasonably. In the present case, what we find is that the respondent insurance company refused to renew the insurance policy of the appellant on the ground of his past conduct. The past conduct attributed is that the appellant had gone in litigation for payment of his claim lodged by him with the respondent insurance company. If an insured lodges a claim with the company and the company does not honor the claim, the insured is left with no alternative but to knock the doors of court of law. Merely because the appellant had approached the consumer forum and this court for redressal of his grievance, can such an act be attributed as bad record as to dis-entitle the appellant to get his policy renewed. The answer is no. Where an insurance company under the provisions of the act having assumed monopoly in the business of general insurance in the country and thus acquired the trappings of the State being other authorities under Article 12 of the constitution, it requires to satisfy the requirement of reasonableness and fairness while dealing with the customers. Even, in an area of contractual relations, the State and its instrumentalities are enjoined with the obligations to act with fairness and in doing so, can take in to consideration only the relevant materials. They must not take any irrelevant and extraneous consideration while arriving to a decision. Arbitrariness should not appear in their actions or decisions. In the present case, what we find is that arbitrariness is writ large in the actions of the respondent company when it refused to renew the mediclaim policy of the insured on the ground of his past conduct i.e. having gone into litigation for payment of his claim against the respondent company. We are, therefore, in agreement with the view taken by the High court that the order of the respondent company refusing to renew the mediclaim policy of the appellant was unfair and arbitrary.
Coming to the next question whether the appellants policy was required to be renewed with effect from the date when it fell due for renewal. The view taken by the High court is that an insurance policy cannot be renewed for the period which has already expired. It is not disputed that original mediclaim policy taken out by the appellant provided for its renewal. It is also not disputed that the appellant applied for renewal of the insurance policy well in time and sent a cheque towards its premium. The respondent company has not challenged the order of the High court setting aside the order refusing to renew the mediclaim policy of the insured. Under such facts and circumstances of the case, whether the appellant can be directed to take a fresh mediclaim policy on the premise that no renewal of the policy can be ordered for the expired period.
A renewal of an insurance policy means repetition of the original policy. When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes in to force. In common parlance, by renewal, the old policy is revived and it is sort of a substitution of obligations under the old policy unless such policy provides otherwise. It may be that on renewal, a new contract comes in to being, but the said contract is on the same terms and conditions as that of the original policy. Where an insurance company which has exclusive privilege to carry on insurance business has refused to renew the mediclaim policy of an insured on extraneous and irrelevant consideration, any disease which an insured had contacted during the period when the policy was not renewed, such decease cannot be covered under a fresh insurance policy in view of the exclusion clause. The exclusion clause provides that the preexisting diseases would not be covered under the fresh insurance policy. If we take the view that the mediclaim policy cannot be renewed with retrospective effect, it would give handle to the insurance company to refuse the renewal of the policy on extraneous consideration thereby deprive the claim of insured for treatment of diseases which have appeared during the relevant time and further deprive the insured for all time to come to cover those diseases under an insurance policy by virtue of the exclusion clause. This being the disastrous effect of wrongful refusal of renewal of the insurance policy, the mischief and harm done to the insured must be remedied. We are, therefore, of the view that once it is found that the act of an insurance company was arbitrary in refusing to renew the policy, the policy is required to be renewed with effect from the date when it fell due for its renewal.
12. In the instant case the Op by its letter marked as Ex-A4 dtd.15.11.13 informed to the Complainant stating that
‘Insurance being a contract of ‘uberrimae fidae (utmost good faith), the policy holder is duty bound to reveal all relevant facts to the insurer in order for the insurer to determine the policy holder’s eligibility for availing the insurance. In light of the above, we regret to inform you that no claim is admitted against the company and your claim stands declined and policy stands cancelled.
However, as a good will gesture amounting Rs.18,793/- was refunded towards Surrender Value of your policy via cheque numbering 179898 dtd.12.11.13 drawn on Axis bank ltd., Please also note that in making this offer we do not admit that any amount is legally due and payable to you under the policy. Hence, your policy is terminated.’
13. In the light of the unreported decision of Hon’ble Supreme court cited supra, the reasons assigned by the Ops in terminating the policy of the Complainant holds not good. Hence we have no other go except to direct the Ops to continue the mediclaim policy of the Complainant by collecting the regular quarterly dues from the due dates. Accordingly we come to the conclusion that there is deficiency of service on the part of Ops in settling medical bills so also in continuing the policy of the Complainant. Accordingly we answered the point no.1 in the affirmative.
14. Point no.2: In the result, we passed the following:
ORDER
The complaint filed by the Complainant is hereby allowed in part.
2. The Ops are directed to pay medical bills of Rs.1,50,000/- to the Complainant within six weeks from the date of this order, failing which the said amount will carry interest at 6% p.a. till realization.
3. We also direct the Ops to continue the said mediclaim policy of the Complainant by collecting regular quarterly dues from the due dates.
4. With regard to the damages and other losses are concerned, the same is negativated. We fix Rs.2,000/- towards cost of litigation.
Supply free copy of this order to both the parties.
(Dictated to the Stenographer, got it transcribed, typed by her/him and corrected by me, then pronounced in the Open Forum on 18th January 2018).
(SURESH.D)MEMBER | (ROOPA.N.R)MEMBER
|
(S.L.PATIL) PRESIDENT |
1. Witness examined on behalf of the complainant/s by way of affidavit:
Sri.Chandrashekar Shindhe, who being the complainant was examined.
Copies of Documents produced on behalf of Complainant/s:
Ex-A1 | Policy |
Ex-A2 | Letter of condolence sent to Complainant’s wife |
Ex-A3 | Medical bills |
Ex-A4 | Letter dtd.15.11.13 |
Ex-A5 | Cheque bearing no.179898 dtd.12.11.13 |
Ex-A6 | Legal notice dtd.04.01.14 |
Ex-A7 | Original Postal receipts |
Ex-A8 | Original Postal acknowledgements |
Ex-A9 | Original Discharge summary |
(SURESH.D)MEMBER | (ROOPA.N.R)MEMBER
|
(S.L.PATIL) PRESIDENT |
Consumer Court | Cheque Bounce | Civil Cases | Criminal Cases | Matrimonial Disputes
Dedicated team of best lawyers for all your legal queries. Our lawyers can help you for you Consumer Court related cases at very affordable fee.