Complainant Gurpreet Kaur through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the necessary directions may kindly be issued to the opposite parties to take necessary action and to release the amount of Rs.10,00,000/- as death claim of deceased Harjit Singh her husband alongwith interest @ 12% P.A. and opposite parties be also directed to pay Rs.50,000/- as damages and compensation for causing mental and physical agony to him, in the interest of justice.
2. The case of the complainant in brief is that she was got married with Harjit Singh son of Tarsem Singh in the year 2010. One female child namely Navleen Kaur was born from this wedlock who is presently about 4 years old. At the time of marriage, Harjit Singh was settled in Doha Qatar as a driver and he was quite hale and healthy. On 20.1.2013 her husband got one Life Insurance Policy bearing No.473556430 dated 20.01.2013 for Rs.10,00,000/- from the opposite parties through the agent for a period of 20 years with a half yearly premium amount of Rs.23,534/-, later on increased to Rs.24,534/-.Deceased Harjit Singh paid 1st installment of Rs.23,534/- on 07.02.2013, 2nd installment of Rs.24,922/- on 05/09/2013, 3rd installment of Rs.24,534/- on 31/01/2014, 4th installment of Rs.24,534/- on 14/07/2014 and 5th installment of Rs.24,534/- on 20/01/2015 and thereafter Harjit Singh died on 24/03/2015. She has next pleaded that after the death of Harjit Singh, she applied for death claim against the policy in question from the opposite parties but the opposite parties repudiate her death claim vide letter 30/09/2015 on the ground that deceased Harjit Singh was not having good health prior to the date of proposal and he suffering from severe headache C visual disturbance and seizures as per his treatment chart and therefore deceased has suppressed about his diseases and not given correct information in the proposal form for assurance dated 15.2.2013, therefore opposite parties are not liable to pay any claim to her under the policy stated above. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.
3. Notice of the complaint was served upon the opposite parties who appeared through their counsel and filed their joint written reply taking the preliminary objections that the present complaint is not maintainable and it was revealed during the course of investigation that the deceased life assured was not keeping good health prior to date of proposal and suffering from ailment/pre existing disease at the time of obtaining the policy with intention to play fraud with the LIC and to grab the public money by giving false statement and wrong declaration in his proposal form at the time of obtaining insurance policy; the claim has been repudiated after considering all the aspects. The date of first premium receipt is 15.2.2013 and the risk under the policy commenced on 15.2.2013. As per Josan Holistic Hospital, Amritsar, deceased/life assured was admitted on 11.2.2013 and was discharged on 21.2.2013. It is clearly shows that the insurance was taken with malafide intention. He was diagnosed as a case of Severe Headache C. Vertigo C. Visual disturbances. Again the deceased life assured was admitted for some problem at Oxford Hospital Jalandhar from 10.8.2013 to 19.8.2013 as per hospital record. Deceased life assured had history of Seizures. It clearly shows that the abovementioned disease was well in knowledge of DLA and he was not keeping good health prior to acceptance of commencement of risk under the policy. It has been next pleaded that the contract of insurance is contract based on doctrine of UTMOST GOOD FAITH. According to this doctrine the proposer who is one of the parties to the contract is presumed to have means of knowledge of facts which are not accessible to the opposite parties, who is other party to the contract. In all the contract of life insurance, the proposer is bound to make full disclosure of all the material information and facts not merely those which he thinks material. Non disclosure or fraud in any manner and documents leading to acceptance of the risk automatically discharges the corporation from all liabilities under the contract. It is next pleaded that the deceased life assured had deliberately suppressed material facts to obtain the insurance fraudulently and by doing so he violated the principle of UTMOST GOOD FAITH, which is the basis of insurance contract and here in terms of policy contract (Condition 5 forfeiture in certain events of conditions of privileges of policy bond) the claim has been repudiated. Had the life assured been alive, still the claim would have been rejected in terms of policy contract. It is repudiated after the death of the life assured because the LIC come to know about incorrect submissions made by the deceased life assured at the time of proposal after his demised. On merits, it was stated that Smt.Gurpreet Kaur (wife) is the nominee under the policy bearing No.473556430 in the name of deceased Harjit Singh with date of commencement 20.01.2013 on the principle of UTMOST GOOD FAITH. Date of first premium receipt was 15.2.2013 for sum assured Rs.10,00,000/- under plan and germ 14-21 with half yearly mode of payment. The policy was dated back from 20.1.2013 but date of risk under the policy was accepted from 15.2.2013. The claim under the policy in question has been repudiated as per repudiation letter dated 30.9.2015 on the basis of concealment of material and actual facts regarding health by deceased life assured. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.
- Smt.Gurpreet Kaur, complainant tendered into evidence her own affidavit Ex.C1 along with other documents Ex.C2 to Ex.C9 and closed the evidence.
- Counsel for the opposite parties tendered into evidence affidavit of Sh.Yogender Singh Sisodia Manager (Legal) Ex.OP-1 along with other documents Ex.OP-2 to Ex.OP-13 and closed the evidence.
6. We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contestants. We find that the present dispute has arisen on account of the impugned ‘repudiation’ (Ex.C7/Ex.OP13) of 30.09.2015 of the insurance-claim (by the opposite party insurers, hereinafter for short ‘the OP’) as filed by the present complainant pertaining to the ‘death-claim’ of her late (demised) husband Harjit Singh, the DLA (deceased life assured). We observe that the one and the only prime eventful aspersion founding/ supporting the repudiation of the impugned 'death claim' in question has been the intentional non-disclosure/concealment (by the DLA) of his alleged ill health and continuing (pre-existing) multiple diseases in his ‘personal signed-statement’ in the related ‘proposal for assurance’ dated 15.02.2013. Somehow, we are inclined to examine the validity & legality of the impugned repudiation (of the related insurance claim) in the back-drop of proceeding and also the succeeding acts & events in the light of the facts on records and current law on insurance vis-à-vis consumer subject matter, in issue.
7. We find that the related insurance policy cover (Ex.C2/Ex.OP12) indicates 20.01.2013 as the date of commencement of the Policy # 473556430 with Proposal No: 9756 of date: 06.02.2013 and thus it is not understood as to how another unnumbered proposal of 15.02.2013 creeps in to incubate the impugned repudiation. Further, incidentally though interestingly, the OP insurers have produced none of the above two (DLA signed-proposals) on the records of the present proceedings. The other documentary evidence (Ex.OP2 to Ex.OP11) as produced by the OP insurers undoubtedly proves the DLA’s post-insurance ‘hospitalization’ on two occasions in February’ 2013 & August’ 2013 in two different Hospitals and subsequent death on 24.03.2015 but it surely stands apart as ‘not proved’ that the DLA had the knowledge of his ‘existing’ ailments that he concealed at the time of purchase of the Policy in question. There has been no evidence on records of prior-insurance ‘medical-treatment’ of the DLA for any of disease/ ailment, of whatsoever. We find that the OP insurers here have arbitrarily repudiated the present claim merely on the ‘presumption’ that the DLA had the knowledge of his ‘ailments’ at the time of purchase of ‘insurance’ since he was hospitalized soon after said ‘purchase’ and he intentionally concealed the material information that was material to disclose. To remove all ambiguity, it may be clarified here that an ‘insurance claim’ and for that matter any ‘issue’ can be neither legally ‘favored’ nor legally ‘ousted’ on the basis of mere ‘presumption’ how strong it might appear to be. We further find that the present policy in question was purchased through the services of Partap Singh LIC Agent code # 232451081 carrying his name/ signatures on policy and confidential report etc; hence it is understood that all the DLA’s information in totality was fully available in the hands of the OP/LIC insurers’ Representative/Agent to secure business etc.
8. Under the circumstances, what reliability can be placed on the personal statement of the DLA on proposal Forms upon which the very repudiation of the Claim has been based by the OP LIC insurers. And, above all why the complainant (beneficiary) be made to suffer for of the unholy nexus (if any), that existed between the DLA and the LIC Agent/representative. Moreover, section 45(3) of the Insurance Act, 1938 (as amended up to date) bars repudiation of Policy on account of mis-statement(s) and/or suppression of fact(s) that are within the knowledge of the insurers. The OP must realize that their administrative decisions in settling insurance claims are open to judicial reviews and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law.
9. In the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s repudiation letter # 1762/1081 dated 30.09.2015 of the impugned death claim being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’. Thus, we ORDER the OP insurers to pay the impugned ‘insurance claim’ pertaining to the Policy in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA from the date of filing of the complaint till actually paid.
10. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President
Announced: (Jagdeep Kaur)
June,17 2016 Member
*MK*
