Punjab

Patiala

CC/19/281

Chamkaur Singh - Complainant(s)

Versus

The Max Life Insurance Company - Opp.Party(s)

Sh Preetinder Sharma

10 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

 

Consumer Complaint No.	:	CC/ 281/2019
Date of Institution	:	1.8.2019
Date of Decision	:	10.2.2023

 

 

Chamkaur Singh aged about 31 years son of Late Sh.Nirmal Singh, R/o village Ladha Heri, Tehsil Nabha, District Patiala.

 

 

                                                                   …………...Complainant

                                      Versus

 

1. The Max Life Insurance Company, Leela Bhawan, Patiala.
2. The Max Life Insurance Company, 3^rd Floor, Axis House Bombay Dying Mill Compound, Pandurang, Budhkar Marg Warli, Maharashtra-400025.
3. Axis Bank Ltd., Nabha District Patiala.

                                                                   …………Opposite Parties

 

Complaint under the Consumer Protection Act

 

 

QUORUM

                                      Hon’ble Mr.S.K.Aggarwal, President

                                      Hon’ble Mr.G.S.Nagi,Member         

 

 

PRESENT:                   Sh.Preetinder Sharma, counsel for the complainant.

                             Sh.S.P.Singh, counsel for OPs No.1&2

                             Sh.Y.R.Mangla, counsel for OP No.3.                          

 

                                     

 ORDER                                          

1. The instant complaint is filed by Chamkaur Singh  (hereinafter referred to as the complainant) against The Max Life Insurance Company (hereinafter referred to as the OP/s) under the Consumer Protection Act ( for short the Act).
2. The averments of the complainant are as follows:

That father of the complainant namely Nirmal Singh since deceased took Max Life insurance Policy bearing No.124058835 on 28.9.2016. Nirmal Singh, father of the complainant died on 9.12.2018 at PGI, Chandigarh. After his death benefits of the policy were disbursed in the family members of the complainant.

Nirmal Singh also got loan of Rs.9.54.099/- from OP No.3 who also issued policy bearing No.35003239 on 7.7.2018 having assured the loan amount of Rs.9,54,099/-to be expired on 19.7.2023. Nirmal Singh paid single premium of Rs.72,098/- of the said policy during his life time. After the death of Nirmal Singh, complainant approached OP No.1 to release the sum assured but the OP refused to do so. Complainant served legal notice dated 16.7.2019 upon the OPs but of no avail. Thus, there is deficiency in service on the part of the OPs. Consequently, prayer has been made for acceptance of the complaint.

3. Upon notice, OPs appeared through counsel and filed written statements having contested the complaint of the complainant.
4. In the written statement filed by OPs No.1&2 various preliminary objections have been raised.
5. On merits, it is alleged that Late Nirmal Singh had purchased a policy from the OPs bearing No.35003239, the premium amount of which was Rs.72098.59/-, under which the payment mode was single and the sum assured was Rs.9,54,099/-. The said policy was issued on 20.7.2018.It is also alleged that under the said policy early death claim of the life assured was received. The LA was covered under the Group Credit Life Policy.LA had one more individual policy No.124058835, which was paid. As per claim statement life assured died natural death within 4 months 20 days from the issuance of policy while as per medical certificate, cause of death (PGI Chandigarh) he died due to Refractory septic shock, Sepsis -Community acquired pneumonia. Acute Chronic Liver Failure alcoholic related cirrhosis, Ascites and as per medical record life assured presented in the hospital in the year 2011 with complaint of altered sensorium and abdominal. He was also suffering from ethanol related decompansated cirrhosis, ascite-grade-III. As per the OPD slip of Nehru Hospital, life assured was a case of alcoholic liver disease and was taking treatment from Chandigarh . His condition deteriorated and died at PGI Chandigarh during treatment. Nominee has provided the medical cause of death certificate of PGI Chandigarh. The claim was repudiated under the said given circumstances and the same was communicated to the complainant. The complainant is not entitled for any alleged amount or interest nor he is entitled for any compensation as he claimed. There is no deficiency in service on the part of OPs. After denying all other averments of the complainant, OPs No.1&2 have prayed for the dismissal of the complaint.
6. In the written statement filed by OP No.3, it is denied that the complainant is consumer of OP No.3.It is admitted that Late Nirmal Singh, father of the complainant obtained a vehicle loan from OP No.3 and an insurance policy was also obtained by him from OPs No.1&2, the expiry date of which was 19.7.2023 and also he paid single premium of Rs.72,098/- of the said policy during his life time. The loan account of complainant’s father has been categorized in NPA category as the complainant has not been paying installments in the loan account after the death of his father. The complainant has also concealed the fact about the disease of his father. The complainant has filed a false case against OP No.3 in Civil Courts at Nabha. After denying all other averments, OP No.3 has also prayed for the dismissal of the complaint.
7. In support of the complaint, ld. counsel for the complainant has furnished affidavit, Ex.CA of the complainant,Ex.C1 copy of insurance policy, Ex.C2 copy of premium receipt, Ex.C3 copy of legal notice, Ex.C4 & Ex.C5 postal receipts, Ex.C6 reply to legal notice dated 10.5.2019 and closed the evidence.
8. In rebuttal, ld. counsel for OPs No.1&2 has tendered in evidence Ex.OPA affidavit of Sh. Radhakrishna Das Adhikari, Deputy Manager , alongwith documents,  Ex.OP1 to Ex.OP16  and closed the evidence.
9. The ld. counsel for OP No.3 has tendered in evidence Ex.OPB, affidavit of Hardeep Singh Oberoi, Branch Manager, Axis Bank, Branch Nabha alongwith document,Ex.OP17 copy of letter dated 11.3.2019 and closed the evidence.
10. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
11. Admittedly Nirmal Singh, father of the complainant was holder of an insurance policy No.124058835, Ex.C2, issued on 28.9.2016.The deceased had also taken vehicle loan from OP No.3 for Rs.9,54,099/- and had got insured his life for the said amount from OP No.3 through OPs No.1&2 vide policy bearing No.35003239, Ex.C1/Ex.OP2.The said policy was valid for a period of five years and maturity was due on 19.7.2023. A premium of Rs.72098/- was to be paid against the said policy. The father of the complainant died on 9.12.2018.Death certificate in this regard is Ex.OP3. Thereafter, complainant lodged claim with the OPs vide Ex.OP4. The claim against policy No. 124058835 was settled. This fact is admitted by the complainant in his complaint. However, the claim against policy No.35003239 was repudiated by the OPs. Legal notice was also served by the complainant, copy of which is Ex.C3.However, no fruitful purpose was served.
12. The OPs vide letter dated 10.1.2019, Ex.OP5 demanded various documents from the complainant for the settlement of the claim. Vide letter dated 11.4.2019,Ex.OP9, the OPs repudiated the claim on the ground that father of the complainant was suffering from Alcoholic Liver Disease & in the year 2011 he was suffering from Altered Sensorium attributed to Hepatic Encephalopathy, prior to signing the health declaration form. However, premium paid by the deceased amounting to Rs.61,100/-( exclusive of service taxes) was refunded to the complainant in Axis bank  account No.245010633007 by way of NEFT, being master policyholder under the policy. At the request of the complainant, the case was reviewed by the OP and was again declined on the same grounds mentioned above vide documents Exs.OP10 to Ex.OP15.
13. Claim has been repudiated vide letter dated 11.4.2019,Ex.OP9 on the ground that as per medical reports dated 8.3.2018, it has been confirmed that father of complainant was suffering from alcoholic liver disease & in year 2011 he was suffering from Altered Sensorium attributed to Hepatic Encephalopathy, prior to signing the Health Declaration Form.
14. In the light of above information,  death claim was declined due to  non-disclosure of medical history. Further OPs have refunded amount of Rs.61,100/-by treating the above statement as misstatement and not a fraud. OPs have also relied upon the medical certificate of cause of death , Ex.OP3, issued by the PGI Chandigarh, wherein cause of death has been shown as ‘Refractory Septic Shock’. OPs have also prepared general verification report,Ex.OP6, as per which enquiries were made by them from the family members of the complainant. As per Para No.11  of the report, they have stated that LA was not having any critical illness before and he was not having any medical record whatsoever. They have also stated that no previous medical history in the case of LA was found in PGI, Chandigarh and their contention that LA was alcoholic for last 30 years and was a chronic bidi smoker, has not been proved by cogent and reliable evidence. To know about the medical history of LA OPs have also visited various hospitals i.e. Patiala Heart Institute, Patiala and Rajindra Hospital, Patiala but they failed to find any medical record against the LA.
15. In view of the aforesaid discussion, we are of the opinion that LA i.e. father of complainant namely Nirmal Singh was not having any previous medical history and since he was not having any previous medical history, no such disclosure was made by the LA at the time of taking of policy. Moreover, OPs have failed to prove that LA was having any previous medical history even after visiting various hospitals and trying to discover medical history, which was not there. Furthermore, it has been held in number of cases that repudiation of claims under Section 45 of the Insurance Act, 1938 ,  three conditions must be satisfied i.e.

1. The statement must be on a material matter or must suppress fact which it was material to disclose;
2. The suppression must be fraudulently made by the policy holder;   and
3. The policy holder must have known at the time of making statement that it was false or that it suppressed facts which it was material to disclose.

16. In the present case none of these three conditions applied to the LA as there was no suppression of the facts by the LA as the disease was not known to the LA at the time of taking the policy. Moreover, it was incumbent upon the OPs to prove that the complainant was suffering from liver disease and had concealed these material facts at the time of taking policy. In fact the OPs had tried their best to discover previous medical history of the complainant after visiting various hospitals but failed to prove the same.
17. As such  the denial of  claim against policy No.35003239, on the ground that the deceased was suffering from Altered Sensorium attributed to Hepatic Encephalopathy, prior to signing the health declaration form, is not justified and amounts to deficiency in service, on the part of OPs. We therefore, partly allowed the complaint and OPs No.1&2 jointly and severally are directed;
    1.  
    11.  
18.           The instant complaint could not be disposed of within stipulated period due to heavy rush of work, Covid protocol and for want of Quorum from long time.
85109252238716.  
85109252238717.  

 

                                              G.S.Nagi                           S.K.AGGARWAL

                                              Member                          President