Punjab

Moga

CC/16/164

Meeta Singh - Complainant(s)

Versus

The Regional Manager, Bharti AXA Life Insurance Co. Ltd. - Opp.Party(s)

Sh.Amit Goyal

02 Aug 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 164 of 2016

                                                                                      Instituted on: 23.11.2016

                                                                                      Decided on: 02.08.2017 

 

Meeta Singh     s/o Bhaga Singh, resident of House no.432, Raunta, Tehsil Nihal Singh Wala, Near Gurudwara Moga, District Moga.

 

                                                                                ……… Complainant

 

Versus

1.       The Regional Manager, Bharti AXA Life Insurance Company Limited having its Regd. Office: Unit 601 & 602, 6^th Floor, Raheja Titanium, off Western Express Highway, Goregaon (E), Mumbai.

 

2.       The Manager, Bharti AXA Life Insurance Company Limited, Branch Moga, G.T. Road, Moga.  

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Amit Goyal, Advocate Cl. for complainant.

                   Sh. Gurmeet Singh Dhaliwal, Advocate Cl. for opposite parties.

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against The Regional Manager, Bharti AXA Life Insurance Company Limited having its Regd. Office: Unit 601 & 602, 6^th Floor, Raheja Titanium, off Western Express Highway, Goregaon (E), Mumbai and others (hereinafter referred to as the opposite parties) directing them to continue the policy bearing no.501-3938211 as per terms and conditions of the insurance policy and to receive/accept the next premium/installment as settled between the complainant and opposite parties at the time of making the insurance policy. Further opposite parties may be directed to pay Rs.50,000/- on account of mental tension and harassment and Rs.15,000/- as litigation expenses to the complainant on any other relief which this Forum may deem fit and proper be granted.

2.                Briefly stated the facts of the case are that in the month of January, 2016, complainant took a insurance policy i.e. Triple Health Insurance Plan for a sum assured of Rs.20 lacs for a period of 15 years from the opposite parties, through its agent and he paid Rs.51,085/- as policy premium to opposite parties. As per terms and conditions and in order to fulfil the necessary requirements for the said insurance policy, on the directions of the officials of the opposite parties, the complainant got medically examined and also conducted various health tests and after conducting proper health requirement, policy was issued to complainant on 18.01.2016. However, to the utter surprise, in the month of October, 2016 the opposite parties terminated the abvoesaid policy of the complainant on his own without any valid reason and also refund the premium amount to complainant via NEFT through bank transaction on 3^rd October 2016 without informing the complainant and issued a letter regarding termination of policy due to the reason 'non disclosure of material facts' but there is no such fact, which the complainant concealed from opposite parties. The policy was issued by opposite parties after getting fully satisfied and after conducting all medical tests as per terms and conditions of the policy and after fulfilling all other requirements, so the question of non disclosure of material facts does not arise. The complainant approached opposite parties and requested them to continue his policy as he is still ready and willing to fulfil the requirements, if any left and also ready to deposit the amount with them as per terms and conditions, but they refused to do the same without any reason or cause. The complainant never concealed any material facts from opposite parties for which the opposite parties have terminated his insurance policy. Due to the act and conduct of opposite parties, the complainant ahs suffered mental tension, harassment as well as financial loss. Hence this complaint.

3.                Upon notice, opposite parties appeared through counsel and filed written reply submitting that the after understanding the key features of the policy, the complainant had signed and submitted the proposal form for insurance. Based on the information provided by the complainant in the documents furnished at the proposal stage including Online Proposal form, Customer Declaration, benefit Illustrations and others, the opposite parties had issued the policy on the life of the insured bearing no.501-3938211. The policy documents alongwith copies of all the supporting documents were dispatched to the Life Assured. In the proposal form Column no.7 (Health Records of Life to be Insured) information was sought in respect of past medical history, consultation with doctor, medication, medical advice, disease/disorder etc. and hospitalization within the preceding five years of the life insured and he answered in the negative to all the said questions and based on the said response, the opposite parties was persuaded to issue the policy. It was stated in bold under the Column no.7 that non-disclosure as to any of the above health questions may lead to repudiation of the claim. In Column no.9 (Declaration and Authorization) it was stated that the details in the proposal form have been filed in accordance with the information provided, the same is true and correct and has been duly checked and verified and that there was no misstatement. It was also lastly stated that 'I declare that should any statement including health declaration be incomplete, false, wrong or inaccurate or should there be any omission(s) or withholding of information on my/our part, the company shall have the right to cancel the policy. The policy was issued on 09.02.2016 and the policy was identified as high potential risk and due to which risk score was run post issuance in said. Hence, the investigation and authentication was initiated on the profile check basis on the details and documents available in the record of the policyholder. During the investigation and site visit, it was revealed by the wife (Gurpreet Kaur) of the policyholder that LA is suffering from TB past 2 years and got treatment from many hospitals of Moga, Ludhiana and Barnala, but his health condition is still very poor & right now he is in a hospital. Even the nearby neighbor's Satnam Singh, Harnam Singh and Jarnel Singh told that LA is TB patient & his health condition is not well. During investigation it was found that the life insured was suffering from TB and he intentionally did not mention about the same in the proposal form. Moreover, the policy was rescinded based on the above and refund of the premium was processed via NEFT for Rs.49,235/- on 3^rd October, 2016. This medical history, hospitalization were prior to the life insured filing the proposal form for the policy and the answers furnished by him were thus false and he had given false and misleading information to opposite parties. Had the life insured replied correctly and truthfully, while signing the proposal and had informed the opposite parties of his health status/hospitalization and report, the opposite parties under no circumstances would have enrolled her under the subject policy.

                   Opposite parties have taken certain preliminary objections that complaint of the complainant is baseless, devoid of any merits and without any cause of action whatsoever; that the complainant has not come before this Forum with clean hands and has suppressed material information, is guilty of suppression-veri and suggestion-falsi, the application does not disclose true and correct facts. The life insured had filed in the proposal form and answered the questionnaire therein in respect to medical history/hospitalization. Additionally, the life insured made a declaration that he had read and understood the contents of the document and accepted the same. Furthermore, the complainant has also put his signatures on the customer declaration form on the declaration and authorization para where it is stated that he has understood the nature and contents of questions asked in the proposal form. That Insurance being a contract between the policyholder and the answering opposite party and both are government by the terms and conditions mentioned in the policy document and all the benefits are payable strictly as per the policy terms and conditions. The life insured had enrolled in the policy and the statements of the Life insured have been called into question by the opposite party within the period of two years being inaccurate and false in terms of section 45 of the Insurance Act. Even otherwise, the suppression/non disclosure was in respect of material facts, the same was fraudulently done by the Life insured so as to mislead the opposite party and the opposite party was infact misled into issuing the policy by the said non-disclosure/suppression and would under no circumstances have been issued the subject policy had the true and correct facts been in the knowledge of the opposite party. A contract of insurance is governed by the principle uberima fides i.e. it is a contract of utmost good faith, but the Life Insured failed to follow the said principle while seeking the said policy and made false statement in the proposal form and the policy was thus vitiated and accordingly the rescinded and the premium amount was returned. The policy has been assailed and challenged within the period of two years of the policy since the statements made in the proposal form was false and he suppressed material facts fraudulently as to his hospitalization, tests and medical position, the said statements were in respect of material matters and had the opposite party been aware of the said position it would have never issued the policy in favour of the life insured; that complaint of the complainant is without any cause of action whatsoever and there has been no deficiency/unfair trade practices whatsoever on the part of opposite party. The life insured has voluntarily entered into insurance contract with the opposite party and the said contract has proceeded on the basis of information furnished by the life insured in the proposal form. Since there was deliberate suppression and misrepresentation/fraud by the life insured hence the said contract was vitiated. That this Forum has no jurisdiction to entertain the present complaint since the contract of insurance is vitiated by misrepresentation and fraud which require a proper trial by a civil/criminal court and evidence has to be taken which is not possible in a summary trail; that there was no deficiency in service or negligence on the part of opposite parties. The complainant has failed to show that there was any deficiency in service or negligence on the part of opposite parties; that the opposite parties has put in place an elaborate grievance redressal Mechanism and in case of any grievance the policyholder can approach the Grievance Redressal Cell and in case not satisfied he can approach the Grievance Redressal Officer and thereafter Senior Grievance Redressal Officer. In case the policyholder is still not satisfied by the resolution by the answering opposite parties, he can approach the Insurance Ombudsman; that the complainant has sought relief on the basis of allegation which are not supported by any documentary evidence to substantiate the same. Therefore, the complaint does not deserve any consideration by this Forum; that the complaint of the complainant is without any just or reasonable basis of cause, an abuse of process of law, misuse of machinery provided for redressal of genuine grievances of consumers. In parawise reply, all other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with exemplary cost has been made.

4.                In order to prove the case, complainant tendered in evidence his duly sworn affidavit Ex. C-1 alongwith copies of documents Ex.C-2 to Ex.C-12 and closed the evidence. 

5.                On the other hand, opposite parties tendered in evidence affidavit of Sh.Sachin Kalra, Associate Vice President Legal Ex.OPs-1 alongwith copies of documents Ex.OPs-2 & Ex.OPs-3 and closed the evidence.

6.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

7.                Ld. counsel for complainant argued that in the month of January,  2016 complainant took a insurance policy for a sum assured of Rs.20 lacs for a period of 15 years from the opposite parties and duly paid Rs.51,085/- as policy premium. He argued that at the time of issuance of policy, the complainant got medically examined and after conducting proper health requirement policy was issued to complainant. However in the month of October, 2016 the opposite parties terminated the abvoesaid policy of the complainant on his own without any valid reason and also refund the premium amount to complainant and issued a letter regarding termination of policy due to the reason 'non disclosure of material facts', but the complainant has not concealed any fact from opposite parties. The policy was issued by opposite parties after getting fully satisfied and fulfilling all other requirements, so the question of non disclosure of material facts does not arise. The complainant approached opposite parties and requested them to continue his policy as he is still ready and willing to fulfil the requirements, if any left and also ready to deposit the amount with them as per terms and conditions, but they refused to do the same.

8.                On the other hand, opposite parties admitted that the complainant purchased insurance policy from them. They submitted that the policy was identified as high potential risk and due to which risk score was run post issuance in said. Hence, the investigation and authentication was initiated on the profile check basis on the details and documents available in the record of the policyholder. During the investigation and site visit, it was revealed by the wife (Gurpreet Kaur) of the policyholder that LA is suffering from TB past 2 years and got treatment from many hospitals of Moga, Ludhiana and Barnala, but his health condition is still very poor & right now he is in a hospital. Even the nearby neighbor's Satnam Singh, Harnam Singh and Jarnel Singh told that LA is TB patient & his health condition is not well. During investigation it was found that the life insured was suffering from TB and he intentionally did not mention about the same in the proposal form. Moreover, the policy was rescinded and refund of the premium was processed via NEFT for Rs.49,235/-. The insurance being a contract between the policyholder and the answering opposite party and both are governed by the terms and conditions mentioned in the policy document and all the benefits are payable strictly as per the policy terms and conditions. The suppression/non disclosure was in respect of material facts, the same was fraudulently done by the Life insured so as to mislead the opposite party. A contract of insurance is governed by the principle uberima fides i.e. it is a contract of utmost good faith, but the Life Insured failed to follow the said principle while seeking the said policy and made false statement in the proposal form and the policy was thus vitiated and accordingly the rescinded and the premium amount was returned. The policy has been assailed and challenged within the period of two years of the policy since the statements made in the proposal form was false and he suppressed material facts fraudulently as to his hospitalization, tests and medical position, the said statements were in respect of material matters and had the opposite party been aware of the said position it would have never issued the policy in favour of the life insured.

9.                We have thoroughly gone through the file, evidence and arguments lead by ld. counsel for the parties. The case of the complainant is that he purchased insurance policy from the opposite parties. However, after few months of its purchase, the opposite parties terminated his policy due to the reason 'Non disclosure of material facts'. In reply, opposite parties submitted that the policy was identified as high potential risk and due to which risk score was run post issuance in said. So, the investigation and authentication was initiated on the profile check basis on the details and documents available in the record of the policyholder. During the investigation, it was found that the complainant was suffering from TB. As it was found that the life insured was suffering from TB, so the policy was terminated. The plea of opposite parties for terminating the claim of the complainant is that as the complainant has not disclosed the true fact about his health at the time of purchase of policy, so they terminated his policy. Now, the main question for determination is that whether the complainant was suffering from TB or any other disease of not? In order to consider this, it is to mention that at the stage of evidence, opposite parties had moved an application for medical examination of complainant to determine that he is suffering from TB or not from a duly constituted panel/hospital. The said application was allowed by this Forum and Civil Surgeon, Moga was directed to constitute the panel of expert and specialized doctors to get the medical examination of complainant thoroughly and to determine whether he was suffering from TB or any other disease or not and to submit their report with the Forum. Thereafter, the complainant was duly examined by the expert and specialized doctors constituted by the Civil Surgeon and they submitted their report dated 09.05.2017 with this Forum, vide its report they stated that complainant has not been suffering from TB or any other disease. From this report, it is clear that complainant has not suffered from TB or any other disease. We are of the considered opinion that opposite parties failed to prove that complainant was suffering from TB or any other disease and they terminated the policy of the complainant wrongly and illegally.

10.              In view of the above, the present complaint is hereby allowed and opposite parties are directed to re-continue the policy of the complainant and to receive the premium from the date of re-continuation of the policy as per terms and conditions of the policy. Further opposite parties are directed to pay Rs.12,000/-(Twelve thousand only) as compensation for mental tension, agony and harassment suffered by the complainant and Rs.3000/-(Three thousand only) as litigation expenses to the complainant. Compliance of the order be made within 30 days from the receipt of the copy of the order, failing which, the complainant shall be entitled to initiate proceedings under section 25 & 27 of the Consumer Protection Act. Copy of the order be supplied to the parties free of costs. File be consigned to record room.

Announced in open Forum

Dated: 02.08.2017

                                                (Bhupinder Kaur)                    (Ajit Aggarwal)

                                                        Member                                President