State Consumer Disputes Redressal Commission
Kotak Mahindra Life Insurance Company ... vs Anu Lamba & Anr. on 19 December, 2024
FA/673/2023 D.O.D.: 19.12.2024
KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
IN THE DELHI STATE CONSUMER DISPUTES
REDRESSAL COMMISSION
Date of Institution: 16.12.2023
Date of Hearing: 08.10.2024
Date of Decision: 19.12.2024
FIRST APPEAL 673/2023
IN THE MATTER OF:
KOTAK MAHINDRA LIFE INSURAANCE CO. LTD.,
HAVING REGISTERED OFFICE AT:
8TH FLOOR, PLOT C-12, BLOCK-G-BKC,
BANDRA (E), MUMBAI - 400051.
ALSO, AT:
UNIT NO. 901 (A-WING) & (B-WING),
9TH FLOOR, INTELLION SQUARE (BUILDING NO.4),
INFINITY PARK, OFF. W.E. HIGHWAY,
GENERAL A.K. VAIDYA MARG, MALAD (EAST),
MUMBAI - 400097.
(Through: BSK LEGAL)
.... Appellant
VERSUS
1. MS. ANU LAMBA,
W/O LATE MR. JITENDER LAMBA,
R/O 4677, GALI NO.3, AJIT NAGAR,
GANDHI NAGAR, DELHI - 110031.
(Through: Mr. Dishant Sharma, Advocate)
.... Respondent no.1
DISMISSED Page 1 of 17
FA/673/2023 D.O.D.: 19.12.2024
KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
2. SHUBHAM HOUSING FINANCE,
THROUGH ITS DIRECTOR/AUTHRORIZED PERSON,
2ND FLOOR, PLOT NO.5, ANAND HOUSE,
LOCAL SHOPPING CENTRE,
KARAN PURA, DELHI - 110015.
(Through: Mr. Tarun Kumar, Advocate)
.... Respondent no.2
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)
HON'BLE PINKI MEMBER (JUDICIAL)
Present: Mr. Jaspreet Singh Sandhu, proxy counsel for Mr. Sanjay Kumar
Chadha, counsel for the appellant.
Respondent no.1 in person.
Mr. Dishant Sharma along with Mr. Vikas Mehan, counsel for
respondent no.1.
Mr. Tarun Kumar, counsel for respondent no.2 on VC.
PER: HON'BLE JUSTICE SANGITA DHINGRA SEHGAL
(PRESIDENT)
JUDGMENT
1. The facts of the case as per the District Commission record are under:
"The Complainant has alleged deficiency in service on the part of OPs in not settling the insurance claim for the Insurance Policy taken by her husband late Sh. Jitender Lamba at the time of availing Housing Loan.
1. The facts as narrated in the complaint are that the husband of the Complainant Sh. Jitender Lamba availed a Housing Loan DISMISSED Page 2 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
from OP1 (Account No.0KRM2011000005031846). At the time of sanction of the said Housing Loan, OP1 also got issued one Life Insurance Policy of the husband of the Complainant through OP2 and the premium amount of Rs.87094/- was also deducted from the Loan Account and Policy No.GA000172 was issued by OP2. This Insurance Policy was for the period of 60 months i.e. from 30.11.2020 to 29.11.2025 and the sum assured was Rs. 19,80,000/-. As per the Insurance Policy, in case of death of the insured, the Insurance Company shall be liable to pay the full sum assured either to the Nominee of the insured which is the Complainant or directly to the OP1.
2. Unfortunately, the husband of the Complainant, Sh. Jitender Lamba expired on 18.09.2021 and intimation to this effect was sent by the Complainant to both the Ops. Relevant documents with regard to the claim settlement were submitted by the Complainant to OP2 and a claim No.AA173408 was assigned. However, despite this OP1 insisted the Complainant to deposit the EMI of the loan amount whereas she had already submitted her claim papers to OP2.
3. Subsequently, on 05.01.2022, OP2 repudiated the claim for the reason that the husband of the Complainant late Sh. Jitender Lamba at the time of insurance being taken had claimed himself of good health whereas upon their investigation and assessment the husband of Complainant was found suffering from Diabetes Mellitus, Hypertension and Chronic Obstructive Pulmonary Diseases and OP2 refunded the premium amount of Rs. 73809/- to the Complainant stating that their liability was limited to refund of the premium amount only. The Husband of the DISMISSED Page 3 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
Complainant had relied upon his medical test reports dated 03.11.2020 of Sri Anandpur Trust Charitable Diagnostic Centre which were done before taking the loan and issuance of the Insurance Policy and has stated that there was no serious ailment detected in the said report.
4. Alleging deficiency in service on the part of OP1 & OP2, the Complainant has made following prayers in her complaint:
i. To pay the full claim amount i.e. Rs.19,80,000/- alongwith interest @18% p.a. to the Complainant.
ii. To adjust the claim amount with the pending loan amount of the husband of the Complainant and pay the balance amount alongwith interest @18% p.a. to the Complainant. and iii. To pay a sum of Rs. 1,00,000/- as damages/ compensation towards the mental pain, agony & harassment and loss of physical and mental comforts suffered by the Complainant due to negligence and deficiency in service on the part of the OPs. iv. Award the costs of the proceedings in favour of the Complainant v. Pass any other relief/s in favour of the Complainant and against the OPs, which this Forum may deem fit and proper under the facts and circumstances of the case as well as in the interest of justice, equity and fair play."
2. The District Commission after taking into consideration the material available on record passed the order dated 19.09.2023, whereby it held as under:
"The case of the Complainant is that her husband late Sh. Jitender Lamba, was holding valid Insurance Policy (Exhibit DISMISSED Page 4 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
CW-1/2) issued by OP2 for the period 30.11.2020 to 29.11.2025 for total sum assured of Rs. 19,80,000/- for which premium of Rs. 87,094/- was also deducted by OP1 while granting the Housing Loan to her husband.
9. The husband of the Complainant expired on 18.09.2021 due to heart attack and at Max Hospital it was observed as 'brought dead'. Thereafter the Complainant submitted all relevant documents to settle the claim in terms of the Insurance Policy no. GA000172 issued by OP2. In the said Policy the Complainant was the nominee. This Insurance Policy was specially designed for the members of Shubham Housing Development Finance Co. Ltd. by OP2. As per Clause 7 Annexure 1 of the policy all claim must be notified to the insurer by the policy holder/ nominee in writing within three months of the date of the death along with the death certificate and documents as specified in the policy documents. This was done by the Complainant.
10. It is undisputed that the husband of the Complainant expired on 18.09.2021 due to sudden cardiac arrest and when he was taken to the Hospital, he was declared 'brought dead'. The Complainant has enclosed previous medical treatment documents along with the complaint which establishes that the husband of the Complainant was suffering from Morbid Obesity and was undergoing treatment for other ailments also including Diabetes, Hypertension. Further, at the time of issuance of the Insurance Policy OPs had relied upon 'Good Health Declaration' given by the husband of the Complainant and thereafter the Policy was issued to the husband of the Complainant.
11. The reason given by OP2, while rejecting the claim, by way DISMISSED Page 5 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
of letter dated 05.01.2022 written by them to the Complainant is that the husband of the Complainant was suffering from Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Diseases prior to signing of declaration of good health which were not disclosed in reply to the specific question asked in the Proposal Form and therefore the claim was not maintainable and OP2 refunded Rs. 73808.86 to the Complainant by way to NEFT.
12. From the facts of this case, it is observed that OP2 acted differently at the time of issuing the Insurance Policy and no such medical problem of the husband of the Complainant was noticed by them nor any medical test of the husband of the Complainant was done and when the claim was submitted by the Complainant as nominee w.r.t. that policy then upon their investigation objections have been taken taken viz. Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Diseases to repudiate the claim and for this purpose OP2 scutinised previous Medical record of the husband of the Complainant of 7 years i.e. from 2015.
13. Hon'ble NCDRC has held in the case of Neelam Chopra Vs LIC & Anr (Revision Petition no.4461 Of 2012 decided on 08.10.2018) that non-disclosure of common life-style diseases like Diabetes and Hypertension are not the grounds to deny insurance claim. Hon'ble Supreme Court in Gurmel Singh Vs National Insurance Co Ltd 2022 SCC Online SC 666 has held that insurance companies become too technical at the time of settling the claim in order to reject the same. Similar are the facts of the present case where the claim of the Complainant has been rejected on the ground of life-style diseases which cannot be a DISMISSED Page 6 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
termed as a valid ground for repudiation of the claim.
14. Age of the insured Sri Jitender Lamba was 57 years at the time taking Insurance Policy from OP2. His age profile was such that OP2 should have got done his Medical Tests done rather than relying only upon his 'good health declaration'. However the same was not done and after the death of the insured when the claim arose then OP2 did its internal investigation and relied upon reports and treatment taken by the insured from the year 2015. This speaks volumes about the pre and post conduct of OP2 for issuing the Policy and thereafter rejecting the claim.
15. Otherwise also Reply of OP1 and OP2 cannot be considered in their defense in terms of the Order dated 03.11.2022 of this Commission, which has attained finality as no Appeal was filed by them, and therefore the complaint filed by the Complainant goes un-rebutted and for the reasons stated above and Complainant is able to establish deficiency on the part of OP2. Since OP1 was only instrumental in issuance of the Insurance Policy no. GA000172 from OP2 and deducting the premium amount, no adverse order is passed against OP1 as there is no deficiency in service on their part. For the reasons stated supra, this Commission orders as follows:
- OP2 to pay Rs. 19,06,191/- alongwith interest @9% p.a. with effect from 05.01.2022 to the OP1 in the Loan Account no. OKRM2011000005031846 in the name of late Sri Jitender Lamba and any balance amount left after adjusting the outstanding liability in the said account is to be paid by OP2 to theComplainant ;
- OP2 to pay Rs.50,000/- to the Complainant towards mental DISMISSED Page 7 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
pain and agony;
- OP2 to pay Rs.25,000/- to the Complainant towards legal cost."
3. Aggrieved by the aforesaid order of the District Commission, the Appellant/Opposite Party has preferred the present appeal, contending that the District Commission failed to appreciate that the Respondent no.1 concealed the fact that the policyholder was suffering from diabetes mellitus, hypertension, and obstructive pulmonary disease prior to obtaining the policy. Therefore, the repudiation of the claim was justified as per the terms and conditions of the said policy regarding pre-existing diseases. The counsel for the Appellant further submitted that the District Commission failed to consider Section 45 of the Insurance Act, 1938, which emphasizes that the relationship between the insured and insurer is based on utmost good faith (uberrima fides). Therefore, the concealment of material facts by the Respondent no.1 about pre-existing diseases at the time of obtaining the policy violated said principle.
4. The counsel for the Appellant also submitted that the District Commission erred in considering that only a summons dated 19.05.2022 was issued to the Appellant for appearance, which did not direct the filing of a written statement/reply to the complaint. Consequently, the summons was improper, invalid, and not in accordance with the law. Moreover, there was no delay on the Appellant's part in filing the written statement. The counsel for the Appellant further submitted that the plan/policy issued to Respondent No. 1 was a reducing cover policy, with the commencement of risk under the policy dated 30.11.2020. Since the insured person passed away on 19.09.2021, as per the reducing cover plan and life cover schedule, Respondent No. 1 is entitled to Rs. 18,04,194/- and not Rs. 19,06,191/- as awarded by the District Commission. Pressing the aforesaid contentions, the Appellant prayed for setting aside the impugned judgment.
DISMISSED Page 8 of 17FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
5. The Respondent no.1, on the other hand, denied all the allegations of the Appellant and submitted that there is no error in the impugned order dated 19.09.2023.
6. The Respondent No. 2 also filed reply to the present appeal and refuted all the claims made by the Appellant and asserted that the impugned order dated 19.09.2023 is without any infirmity or error.
7. We have perused the material available on record.
8. The first question for consideration before us is whether the District Commission erred by not taking the written statement filed by the appellant on record under Consumer Protection Act'2019?
9. We deem also it appropriate to refer to Section 38(2)(a) r/w Section 49(1) of the Consumer Protection Act, 2019 which provides as under:
"Section 38(2): Where the complaint relates to any goods, the District Commission shall, -
2(a) refer a copy of the admitted complaint, within twenty-one days from the date of its admission to the opposite party mentioned in the complaint directing him to give his version of the case within a period of thirty days or such extended period not exceeding fifteen days as may be granted by it;"
Section 49 (1): The provisions relating to complaints under sections 35, 36, 37, 38 and 39 shall, with such modifications as may be necessary, be applicable to the disposal of complaints by the State Commission."
10. Perusal of the aforesaid statutory position reflects that the written version/written statement against the consumer complaint should be preferred within a period of thirty days or extended period of fifteen days DISMISSED Page 9 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
as granted by it, from the date of receipt of the copy of the Complaint along with notice.
11. It is admitted fact that the notice was issued to the Appellant and the said notice long with copy of the compliant duly served upon the respondent. Therefore, it is clear that the appellant should have filed with 30 days from the date receiving of copy of the complaint. However, the Appellant failed to file the same with stipulated period of 30 days. Moreover, the appellant filed the same after 45 days from the date of receipt of the notice along with the copy of the complaint.
12. Furthermore, it is to be noted that the Hon'ble Apex Court has left no room for confusion and has already settled the legal position in this regard in New India Assurance Company Ltd vs Hilii Multipurpose Cold Storage Pvt.Ltd. (2020) SCC 75. The Hon'ble Apex Court has categorically held that the Consumer Commission cannot condone the delay beyond the statutory limit of 45 days from the date of service. Thus, we opine that District Commission has only exercised the jurisdiction vested in it by not taking the written statement of the Appellant on record.
13. The next question for consideration before us is whether the insured i.e., Respondent has deliberately concealed the fact of pre-existing disease i.e., Diabetes and Hypertension at the time of obtaining the policy?
14. Insurance documents are invariably on standard form contracts and usually the insured person signs on the be extremely tenuous to expect a layman to read each and every clause of an insurance document before signing occasions, a person who intends to obtain insurance has no choice to say NO to a clause in an insurance policy insurance is primarily obtained for the purpose of unforeseen medical conditions which may affect a person has been no fraud, concealment or suppression, at the time of obtaining insurance, policies ought to be honoured claimants running from pillar to DISMISSED Page 10 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
post in order to get medical reimbursement from insurance companies. The insurance policy issued to the complainant was only after medical examination. This obviously means clause was applied by the Insurance Company mechanically and not on the basis of a specific test.
15. Furthermore, the insurance company is responsible for conducting a medical examination of the policyholder in advance. This examination is essential to determine whether the policyholder has any pre-existing medical conditions. By performing this assessment, the insurance company ensures that any existing health issues are identified and appropriately addressed before the policy is finalized. Moreso, the Doctrine of good faith is two-way traffic and not a one-way traffic. If the Insurance benefit of doctrine of good faith, then they have to accept whatever the insured declares and should not subject medical test and get certificate from the doctor on the panel that the insured possesses sound and good health mediclaim insurance policy. Such a certificate will be meaningless and of no relevance as to the state of health.
16. The next issue of pre-existing disease of diabetes, hypertension, we deem it appropriate refer to Revision Petition No. 3557 of 2013 titled as "Sunil Kumar Sharma vs. TATA AIG Life Insurance Company and Ors"
decided on 01.03.2021, wherein the Hon'ble National Commission has dealt the issue of pre-existing disease and held as follows:
"14. Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No. 656 of 2007, decided on 17.09.2007 held as under:
"Insurance-Mediclaim-Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse expenses incurred by him for his medical treatment, in DISMISSED Page 11 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
accordance with policy of insurance-Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension-Petitioner was advised to undergo ECG, which he did-Insurer accepted proposal and issued cover note-It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors-That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension-It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless-Policy would be reduced to a contract with no content, in event of happening of contingency-Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability-Main purpose rule would have to be pressed into service-Insurer renewed policy after petitioner underwent CABG procedure-Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable-As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency-Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."
15. In RP No. 4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), it was held that:
"11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.
14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the DISMISSED Page 12 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."
16. Based on the above discussion, I am of the opinion that the Insurance Company had not been able to prove beyond doubt that the Complainant was suffering from diabetes before filing of the proposal form. It is also to be noted that the Insurance Company had given Insurance to a person of 66 years of age without any preliminary medical examination which could have definitely revealed whether the proposer was suffering from diabetes or not. It is commonly known that a person of 66 years of age has a high probability of suffering from common lifestyle diseases like diabetes and hypertension. If the company is ready to take the risk at this age of the proposer, without any preliminary medical examination, then the company should be ready to honour the claim also because the chances of death of such persons are more during the currency of the Policy."
17. We further deem it appropriate to refer to Revision Petition No. 4461 of 2012 titled Neelam Chopra Vs. Life Insurance Corporation of India & Ors. dated 08.10.2018, wherein the Hon'ble NCDRC has held as under:
"So far as the life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi has taken the following view in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007:
"Insurance- Mediclaim-Reimbursement- Present Petition filed for appropriate directions to respondent to reimburse expenses incurred by him for his medical treatment, in accordance with policy of insurance- Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension-Petitioner was advised to undergo ECG, which he did- Insurer accepted proposal and issued cover note- It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors- That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without DISMISSED Page 13 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
hypertension- It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless- Policy would be reduced to a contract with no content, in event of happening of contingency- Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability- Main purpose rule would have to be pressed into service- Insurer renewed policy after petitioner underwent CABG procedure- Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable- As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency- Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."
11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common."
18. The aforesaid dicta make it amply clear that the repudiation of the claim cannot be made on the ground that the existence of common life style disease like diabetes and Hypertension etc.
19. We also deem it appropriate to refer to the dicta of the Hon'ble National Commission in Life Insurance Corporation of India Vs. Sunita & Others reported at 2020 SCC OnLine NCDRC 710, wherein it has been held as under:
"7. We have heard the learned counsel of both the parties and perused the material on record.
8. As per the death summary, the death was due to a sudden cardiac arrest and inspite of best resuscitative measures, the patient could not be revived. We note both the fora have arrived at concurrent findings and allowed the complainant.
9. In the present case, the deceased assured was suffering from diabetes mellitus and chronic liver disease when bought to the hospital. But, the death was due to cardiac arrest. In our view the cause of death is nowhere connected to his pre-existing disease. Our view dovetails from the decision of Hon'ble Supreme Court in the Civil Appeal No. 8245 of 2015 titled Sulbha Prakash Motegaoneker v. Life Insurance Corporation DISMISSED Page 14 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
of India, decided on 05.10.2015, wherein it was observed that suppression of information regarding any pre-existing disease, if it has not resulted in death or has no connection to cause of death, would not disentitle the claimant for the claim.
10. We find the Orders of the District Forum and the State Commission to be well appraised and well-reasoned. The State Commission concurred with the findings of the District Forum. We note in particular the extracts of the respective observations made by the two fora, quoted in paras 4 and 5 above. Within the meaning and scope of section 21(b), we find no grave error in appreciating the evidence by the two for a below, as may necessitate re-appreciation of the evidence in revision. We find the award made by the District Forum (quoted in para 4 above), and as affirmed by the State Commission, to be just and appropriate. We find no jurisdictional error, or a legal principle ignored, or miscarriage of justice, as may necessitate interference in the exercise of the revisional jurisdiction of this Commission.
11. The revision petition, being misconceived and devoid of merit, is dismissed."
20. From the aforesaid dicta of the Hon'ble National Commission, it flows that only the existence of a pre-existing disease is not sufficient to repudiate the claim and the death of the Insured should actually occur due to the pre- existing disease.
21. From the aforesaid two dicta of the Hon'ble National Commission, it is abundantly clear that firstly, the Insurance Company cannot repudiate the claim if the death of the deceased is not caused due to the pre-existing disease, secondly, we do not find any document which shows us that the cause of death of the insured due to Hypertension, Diabetes or obstructive pulmonary disease. More so, it is clear from the record, that the insured person was expired on 18.09.2021 due to sudden cardiac arrest. Therefore, there is no justification provided by the Appellant, which is in consonance with the well-established law, to repudiate the claim of the Respondent no.1.
22. We are in agreement with the District Commission that the insured, Sri DISMISSED Page 15 of 17 FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
Jitender Lamba, was 57 years old at the time of purchasing the insurance policy from the Appellant. In light of his age, the Appellant should have conducted a medical examination rather than relying solely on the insured's declaration of 'good health.' However, the Appellant failed to conduct a proper medical examination, and it was only after the insured's death that the Appellant began investigating the deceased's medical history. This clearly indicates that at the time of issuing the policy, the Appellant was merely focused on issuing the policy, despite being aware that the insured was 57 years old and potentially suffering from lifestyle-related diseases.
23. The counsel for the Appellant further submitted that the plan/policy issued to Respondent No. 1 was a reducing cover policy. According to the reducing cover plan and life cover schedule, Respondent No. 1 is entitled to Rs. 18,04,194/- and not Rs. 19,06,191/-. However, we have found no evidence, term or condition in the said policy that indicates Respondent No. 1 is not entitled to the total sum insured in the event of the policyholder's death. Therefore, the Appellant's submission that the Respondent is only entitled to a claim from 11.09.2019 to 20.09.2019 holds no merit.
24. Accordingly, we do not find any infirmity in the judgment of the District Commission and agree with the reasons given by the District Commission. Consequently, we uphold the judgment dated 19.09.2023 passed by the District Consumer Disputes Redressal Commission-V, North West District, Shalimar Bhag, Delhi-110088 and the present appeal is dismissed.
25. No order as to costs.
26. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
27. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
DISMISSED Page 16 of 17FA/673/2023 D.O.D.: 19.12.2024 KOTAK MAHINDRA LIFE INSURANCE CO. LTD. VS MS. ANU LAMBA AND ANR.
28. A copy of this Judgment is to be sent to the concerned District Commission.
29. File be consigned to the record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) MEMBER (JUDICIAL) Pronounced On:
19.12.2024 LR-ZA DISMISSED Page 17 of 17