Order by:

Sh.Amrinder Singh Sidhu, President

1.           The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the agent of Opposite Parties approached to the life assured and allured her with the policy of opposite parties and gave assurance that if any problem arises in duration of the policy period than the company pay amount for the same as assured. On such allurement the Life Assured agree to purchase the said insurance policy of the opposite parties and paid requisite premium before issuing the policy. The opposite parties issued the policy bearing No.03895522 of plan Exide Life Sanjeevni with policy term of 25 years and she was assured for Rs. 25,00,000/- and date of issue is 14.12.2017. On 14.08.2019 complainant was going to Delhi for attending the marriage ceremony of her relatives, when she reached to Meham in Haryana she felt sudden chest pain radiating to left shoulder. She was taken to Deepanjali Multi Specialty Hospital, Meham District Rohtak in Haryana. After carrying out the tests doctor declared she was suffering with severe heart attack, she is lucky to be admitted within short time otherwise it was difficult to save her life. She remained in the hospital for three days and was discharged on 16.03.2019. As the complainant was assured for cardio vascular (Heart attack), she sent all the treatment records along with original copy of policy to the insurance company for the authorized compensation because her illness. severe heart attack comes under the 100% categories as per the Policy Sr. No.05. The assured received a letter from the insurance company dated 20^th Nov. 2019 stating that company has reviewed all the documents and come to know that Ranjit Kaur was suffering pre-existing health problems prior to applying for the policy with us and she has not disclosed, on the basis of this pre-existing illness the claim is repudiated and policy is cancelled. Complainant received call from insurance company for taking the health policy though she was having some hearth problems and it was disclosed to company, their answer was that the paneling doctor will carry out medical check up and if she is declared medically fit than only policy can be taken. Her medical was carried out in Mittal Hospital, Moga and was medically fit thereafter policy was issued. The aforesaid repudiated letter for claim compensation is illegal, null and against the law and same is not binding on the complainant. At the time of selling the policy respondents allured her telling that insurance company is service Oriented to the customer/ insurer persons but Opposite Parties started taking unwarranted defence hide and seek method for repudiating the claim. The complainant also approached the Insurance Ombudsman at Chandigarh on 04.02.2020 she also followed the same guidelines of Insurance Company and decided not to interfere with the decision of the insurance company. On 18.12.2020 complainant served a legal notice to the Opposite Parties through her counsel by registered post to insurance company, but till date reply of the legal notice is not received. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Parties may be directed to pay Rs.25,00,000/- according to the terms and conditions as mentioned in the policy alongwith all the benefits and interest @ 9% from the date of admission of the complainant in the hospital.

b)      To pay Rs.50,000/- compensation on account of deficiency in service.

c)       To pay Rs.11,000/- as litigation expenses.

d)      And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.      

2.       Opposite Parties  appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the present complaint filed by the Complainant in its entirety is vague, false, vexatious and frivolous and is required to be dismissed in limine. The present complaint has been filed by the Complainant only to injure the goodwill and reputation of Opposite Parties. Complainant had with malafide and dishonest intention not only concealed the material facts but had also twisted and distorted the same to suit his convenience and to mislead this Commission. The Complaint therefore deserves outright dismissal. The present complaint is not legally maintainable as the same is barred by the principal of res-judicata as the complainant has earlier filed a complaint before Insurance Ombudsman Chandigarh vide reference No. CHD-L-025-1920-1685 and the same was dismissed vide order dated 05.08.2020. The complainant did not challenge the said order before the Higher Authorities; therefore the order passed by the Insurance Ombudsman Chandigarh became final. Therefore the complainant cannot seek his remedy before this Commission as the matter has already been finally decided by Insurance Ombudsman. Therefore the present complaint is liable to be dismissed. The policy holder Mrs. Ranjit Kaur has submitted proposal form on 26.11.2018 for policy bearing No. 03895522 under "Exide Life Sanjeevani Option-A" product offered by opposite parties approved by Insurance Regulatory and Development Authority of India (IRDAI). The said policy was issued on the answers, statements, documents submitted, coverage opted, premium amount, premium paying term and declaration made by her in the proposal form. As per the process of the opposite party the claim was investigated under section 45 of the Insurance Act, 1956 to verify the veracity of the claim. During investigation it was found that the complainant was suffering from Cardiac Distress, CAD from 14.03.2018 which is prior to the proposal date and the said fact was not disclosed by the complainant before proposing the policy. Further from the medical record, it found that the life assured was getting treatment from Deepanjali Hospital and remained admitted in the Hospital from 14.03.2018 to 17.03.2018 for cardiac distress, CAD and was treated by Dr. Deepak Kumar. Therefore, the complainant was suffering from the aforesaid disease much prior to the taking of policy. However the relevant question in the proposal application dated 26.11.2018 seeking insurance cover under this policy was answered as "NO" by Policy holder/complainant., the relevant part of the same are reproduced as under:-

Section VII, Health Details of the life to be Assured.

Therefore from the stated circumstances, it is evident that the complainant had given wrong information and suppressed material facts about her health in order to wrongfully obtain the subject policy from the Opposite Party. The complainant herself admitted the fact of having heart problem in Para No. 7 of the complaint. However the complainant never disclosed the said fact at the time of proposing the policy. Therefore the present complaint is liable to be dismissed. Further alleges that insurance contracts are contracts based on "Utmost Good Faith" and that the Life Assured/Proposer being a party to the contract is bound to disclose all material facts known to him at the time of proposal. The Proposer/Life Assured is under a legal and solemn obligation to disclose all material facts correctly, honestly and truthfully to the insurance company at the time of obtaining the policy, failing which the contract is rendered void. The contract of insurance is based on the Doctrine of "Uberrimae Fidei" and even if any due diligence is done by the insurance company, it does not change the basic element of an insurance contract. The insured is obliged to give full and correct information on all matters, which would influence the judgment of a prudent insurer in determining whether he will accept the risk, and if he would, at what rate of premium and subject to what conditions. The material facts, as having a bearing on the risk in the life insurance contracts, include the state of health and illness (present or past) occupation and habits, particulars of previous insurance etc., which are only within the knowledge of the proposer/life assured. The insurer, therefore, has to rely entirely on the information, which the Proposer / Life Assured gives at the time of proposal. If a material fact is suppressed, the insurer will be misled about the risk covered, and hence the same will vitiate the contract. The insurer will then be well within its right to treat the contract as void as per the terms & conditions of the policy document.  In written reply, opposite parties put reliance of certain judgements of Hon'ble Supreme Court of India and National Commission. Further alleges that non disclosure amounts to fraud and nobody cannot take the benefit of its own wrong U/S. 19, of The Contract Act (9 of 1872). Further alleges that the answering opposite party had taken into consideration the provisions of Section 2 (d) of the Protection of Policy holders' Interests Regulations, 2002, at the time of issuing the policy to the life assured.          Further alleges that the complainant has tried to challenge the veracity of the decision of the answering opposite party to repudiate the claim. The complainant should approach the Civil Courts in order to challenge the veracity of the decision of the answering opposite party to repudiate the claim. The complainant has filed the captioned complaint with the sole motive to gain illegally at the cost of answering opposite party. The present complaint is not maintainable for want of cause of action as from a simple perusal of the whole complaint it is clear that there no cause of action has arisen in favour of complainant & against the answering opposite party. On merits, it is submitted that the policy in question was purchased by the complainant in a pre-planned manner in order to play fraud with the opposite parties. On the basis of information and declarations provided in proposal application  No.MB-763600 dated 26.11.2018 the opposite issued the following policy.

The aforesaid policy was issued by the opposite parties in "utmost good faith" on the basis of information & declaration given in the proposal form. However from the investigation it is proved that the policy in question have been taken only to play fraud with the opposite parties. The policy was issued subject to its terms & conditions. Further more the opposite party canceled the policy and refunded her premium of Rs.6993/- through NEFT on 15.11.2019. Further submitted that the complainant in para no. 7 of the complaint herself admitted that she was having some heart problem and it was disclosed to the company. However the complainant with malafide intention did not place on record the treatment taken by her in March, 2018 from the Deepanjali Hospital. From the stated circumstances, it is clear that the policy in question was taken in a preplanned manner in order to play fraud with the opposite parties. Further submits that even otherwise the disease of the complainant is not covered under the policy because the complainant opted option-A (Cardio Vascular condition) and the claim is strictly payable as per part-C of the policy, the payment of claim under Option-A (Cardio Vascular condition) is payable as per C.1. The following are the conditions for the payment of claim.

C.1.1. Benefits payable on Diagnosis of Option A (Cardiovascular Conditions)

The Benefit under the Policy will be paid, depending upon the category of Cardiovascular Conditions diagnosed. The covered conditions under Cardiovascular are specified in Annexure I. The categories under which the covered cardiovascular conditions are classified are as under:

CARDIOVASCULAR

As per the terms & conditions of the policy, 25% of claim, in case of mild category, 50% in case of moderate category and 100% in case of severe category, but in the present case, there is evidence on the file that the complainant got treated under any of the category, because as per the medical record produced by the complainant it has been mentioned on the daily progress chart as under:

So PT came to this hospital and after all investigations, reveals IWMI Cardiac makers were +ve (Positive). So Pt. got admitted here for further treatment and management. Pt. was thrombolised by INJ STK 100 ML NS/45 Minutes.

          Therefore the complainant was given injection for thrombolised. No surgery was ever conducted upon the complainant. IWMI refers to "Inferior Wall Myocardial Infarction" and Thrombolysis, also known as thrombolytic therapy, is a treatment to dissolve dangerous clots in blood vessels, improve blood flow, and prevent damage to tissues and organs. Therefore the complainant was treated with medical management and as such the claim of the complainant does not fall any of the category as mentioned in the policy terms & conditions. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint was made.

3.       In order to  prove  her  case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C6.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties also tendered  into evidence the  affidavit of Sh.Chidanand, Deputy General Manager- Legal Ex.OPs/1 alongwith copies of documents Ex.OPs/2 to Ex.OPs/6.

5.       During the course of arguments, ld.counsel for the Complainant as well as Opposite Parties have mainly reiterated the facts as narrated in the complaint as well as in written reply respectively. We have perused the rival contentions of the parties and also gone through the record on file. The main contention of the complainant she purchased a policy bearing no.03895522 namely Exide Life Sanjeevani with policy term of 25 years from opposite parties. On 14.08.2019 complainant was going to Delhi for attending the marriage ceremony of her relatives, when she reached to Meham in Haryana she felt sudden chest pain radiating to left shoulder. She was taken to Deepanjali Multi Specialty Hospital, Meham District Rohtak in Haryana. After carrying out the tests doctor declared she was suffering with severe heart attack. After discharge from the hospital she lodged the claim with opposite parties, but they repudiated the claim of the complainant on the ground that company has reviewed all the documents and come to know that Ranjit Kaur was suffering from pre-existing health problems prior to applying for the policy with us and she has not disclosed, on the basis of this pre-existing illness the claim is repudiated and policy is cancelled. On the other hand, ld.counsel for the Opposite Party has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that The policy holder Mrs. Ranjit Kaur has submitted proposal form on 26.11.2018 for policy bearing No. 03895522 under "Exide Life Sanjeevani Option-A". The said policy was issued on the answers, statements, documents submitted, coverage opted, premium amount, premium paying term and declaration made by her in the proposal form. As per the process of the opposite party the claim was investigated under section 45 of the Insurance Act, 1956 to verify the veracity of the claim. During investigation it was found that the complainant was suffering from Cardiac Distress, CAD from 14.03.2018 which is prior to the proposal date and the said fact was not disclosed by the complainant before proposing the policy. Further from the medical record, it found that the life assured was getting treatment from Deepanjali Hospital and remained admit in the Hospital from 14.03.2018 to 17.03.2018 for cardiac distress, CAD and was treated by Dr. Deepak Kumar. Therefore, the complainant was suffering from the aforesaid disease much prior to the taking of policy. To prove this contention, ld. counsel for the opposite parties have produced on record copies of medical record of the complainant w.e.f 14.03.2018 to 17.03.2018 Ex.OPs/6. However the relevant question in the proposal application dated 26.11.2018 seeking insurance cover under this policy was answered as "NO" by Policy holder/complainant, the relevant part of the same are reproduced as under:-

Section VII, Health Details of the life to be Assured.

Since the complainant made a false statement in the proposal application, whereby she did not disclose the past history of herself. Since the complainant intentionally and willfully did not disclose in the application about  her past history. Had this information been provided to the Opposite Parties at the time of applying for the insurance policy, hence, the Opposite Parties repudiated the claim of the complainant.  However, the Opposite Parties cancelled the policy and paid an amount of Rs.6993/- through NEFT on 15.11.2019 to complainant, hence the claim of the complainant was rightly repudiated. In this regard, Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No. 434 of 2017 titled as Shriram Life Insruance Company Limited Vs. K.Viraja  decided on 15^th January, 2020 has  held that the Insurance contracts are governed by the Principle of ‘UBERRIMA FIDE” and the proposer applying for insurance is expected to correctly furnish all the material information regarding his health, family history, personal medical history, income etc. Policyholder failed to disclose his pre-proposal health ailment of hypertension. According, the State Commission Order was set aside and the complaint dismissed.   Furthermore, Hon’ble Supreme Court of India in Civil Appeal No.8701 of 1997 decided on 02.11.1999 titled as Ravneet Singh Bagga Vs. M/s.KLM Royal Dutch Airlines has held that a Bonafide decision in good faith and a bona fide dispute is not covered within the term of ‘deficiency in service and only inefficiency, lack of due c are, absence of bona fide, rashness, haste or omission like acts on the part of the agency rendering services under a contract may be held guilty of deficiency in rendering service.  Further Section 45 of the Insurance Act permits an insurer to cancel a life insurance policy in case a material concealment is made even if it does not amount to fraud. In view of the aforesaid facts it is evident complainant has did not disclosed her past history in the proposal application, so the opposite parties rightly repudiated the claim of the complainant.  Moreover, the Opposite Parties have already refunded the Rs.6993/- to the complainant and at this stage, the complainant has no insurable interest with regard to the policy in question.  

6.       Keeping in view the aforesaid facts and circumstances and replying upon the judgements of Hon’ble Supreme Court of India as well as Hon’ble National Commission, New Delhi (supra), we are of the view that the complainant has failed to prove any deficiency in service on the part of the Opposite Parties.

7.       In view of the above discussions, there is no merit in the complaint and the same stands dismissed. Keeping in view the aforesaid facts and circumstances, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.

8.       Reason for delay in deciding the complaint.

          This complaint could not be decided within the prescribed period because the State Government has not appointed any of the Whole Time Members in this Commission for about 3 years i.e. w.e.f. 15.09.2018 till 27.08.2021 as well as due to pandemic of COVID-19.

Announced in Open Commission.