National Consumer Disputes Redressal
Reliance Life Insurance Co. Ltd. & Anr. vs Tarun Kumar Sudhir Halder on 31 May, 2019
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 2097 OF 2017 (Against the Order dated 23/02/2017 in Appeal No. 213/2016 of the State Commission Maharashtra) 1. RELIANCE LIFE INSURANCE CO. LTD. & ANR. REGISTERED NO. 121) 9TH FLOOR, R-TECH PARK, NIRLON COMPOUND NEAR HUB MALL, GOREGAON(E) MUMBAI-400063 MAHARAHSTRA 2. MANAGER, RELIANCE LIFE INSURANCE CO. LTD., BRANCH CHALISGAON, SAHARA PLAZA EAST MUMBAI MAHARAHSTRA ...........Petitioner(s) Versus 1. TARUN KUMAR SUDHIR HALDER R/O. A.P. SHIRASGAON TAL. CHALISGAON, DISTRICT-JALGAON MAHARAHSTRA ...........Respondent(s)
BEFORE: HON'BLE MR. PREM NARAIN,PRESIDING MEMBER
For the Petitioner : Mr. B.S. Banthia , Advocate For the Respondent :
Dated : 31 May 2019 ORDER
This revision petition has been filed by the petitioner Reliance Life Insurance Co. Ltd. against the order dated 23.2.2017 of the State Consumer Disputes Redressal Commission, Maharashtra, (in short 'the State Commission') passed in First Appeal no.FA/16/213.
2. Brief facts of the case are that on 12.07.2010 Life Assured Smt. Rekha Halder submitted a proposal Form for obtaining policy plan of RLIC- Traditional Super Invest Assure Plan and on the same date the proposal was accepted and the policy bearing Policy No.17418432 was issued. On 24.06.2011 Life Assured died due to diabetic Ketoacidosis. Insurance Company repudiated the claim on the ground of non-disclosure of material information.
3. Aggrieved, the complainant preferred complaint bearing No.76 of 2012 before the District Consumer Complaint Redressal Forum, Jalgaon, (in short 'the District Forum'). The District Forum vide its order dated 14.10.2015 passed the following order:-
"1. The complaint of the complainant has been approved partially.
2. The order is given to the Respondent Reliance Life Insurance Company Ltd., that they should pay the amount of Rs.1,12,500/- to the complainant. The said amount should be paid to the complainant within 30 days of the order and if the payment is not made the complainant would be liable to get the interest of 9 percent per annum till the complete payment is made.
3. The order is given to the respondent Reliance Life Insurance Company Ltd., that they should pay Rs.5,000/- towards physical and mental trauma and Rs.3000/- towards complaint expenses to the complainant."
4. Heard the learned counsel for the petitioner at the admission stage. Learned counsel for the petitioner stated that the matter was not listed for taking up the application for condonation of delay and the State Commission has wrongly considered the application for condonation of delay on 23.02.2017 when the counsel for the petitioner was not present. Learned counsel for the petitioner stated that from the record, it appears that the case was fixed for 25.02.2016 and was adjourned for 23.02.2017 and the case was fixed for passing suitable order on 23.02.2017 and the case was not fixed for hearing on that date therefore, the State Commission cannot dismiss the case in default.
5. Learned counsel for the petitioner argued that the State Commission has illegally dismissed the application for condonation of delay in default as it was not fixed for hearing therefore the State Commission could not have dismissed the appeal in default.
6. Learned counsel further stated that the District Forum has failed to appreciate that in the proposal form the Life Assured suppressed material facts and gave wrong answers with an intention to deceive the Insurance Company.
7. Learned counsel for the petitioner stated that the sum assured under the policy was of INR. 1,12,500/- and the policy came into effect from 12 July, 2010. In the said proposal form, Life Assured knowingly and intentionally answered in negative, when the following specific questions were asked to the Life Assured with respect to her Personal Medical History including as to whether she had diabetes or not:
"29. Are you currently taking any medication or drugs, other than minor conditions (e.g. cold and flu) either prescribed or not prescribed by a doctor, or have you suffered from any illness, disorder, disability or injury during past 5 years which has required any form of medical or specialized examination (including chest x-ray, gynaecological investigations, pap smear, or blood tests) consultation, hospitalization or surgery?
Answer: No.
31. Have you ever in the past suffered or presently suffering from any medical ailments such as disorder of the heart, chest pain, high blood pressure, stroke, asthma, any respiratory problems, cancer or tumour, lump of any kind, diabetes, hepatitis, disorder or stones in urinary tract or kidneys, blood disorder (including anaemia) mental or psychiatric conditions, tuberculosis, disease or brain or nervous system, fits, eplilepsy, AIDS or tested positive for HIV?
Answer: No."
8. I have given a thoughtful consideration to the arguments advanced by the learned counsel for the petitioner Insurance Company and examined the material on record. First of all, it is seen that it is not correct to say that the matter was adjourned to 23.2.2017 from 25.02.2016 straightway. In fact, there were many dates in between and the learned counsel for the Insurance Company has filed those orders passed by the State Commission. On 25.02.2016 the matter was adjourned to 2.4.2016. Even on 22.8.2016 none was present before the State Commission and therefore, the matter was adjourned to 24.10.2016. The matter was again taken up on 20.2.2017, wherein it has been stated by the State Commission that none was present for applicant and the matter was adjourned to 23.2.2017. The State Commission has also recorded that the applicant is not at all diligent in pursing the proceedings. Finally on 23.2.2017, the matter was again taken up by the State Commission and when none was present on behalf of the applicant the State Commission dismissed the application for condonation of delay and consequently the appeal filed by the petitioners. Thus, it is clear that on many dates, the petitioners were not present before the State Commission to pursue the appeal and to argue on the application for condonation of delay. In these circumstances, there was no alternative before the State Commission but to consider the application for condonation of delay and to decide the same.
9. It is very surprising that the petitioner has not filed the copy of the application for condonation of delay moved before the State Commission along with the present revision petition and the State Commission has also not mentioned the period of delay in filing the appeal by the petitioners. In the revision petition also, the delay in filing the appeal has not been mentioned, therefore, this Commission is unable to consider whether the delay in filing the appeal deserves condonation because there is no paper on the file to give any indication of delay in filing the appeal before the State Commission.
10. Moreover, on merits it is seen that on merits the case of the petitioner is that the Deceased Life Assured (DLA) suppressed the material information in respect of pre-existing disease of diabetes, which was existing for about four years and the insured died due to diabetic Ketoacidosis. It is seen from the Claim Form B- Medical Attendant Certificate, that the following is mentioned:-
6. What was the cause of death Diabetic Ketoacidosis (not readable)
7. Date when diagnosed first:
22.06.2011
11. Even the allegation of the petitioner that the DLA was suffering from the disease of diabetes for about four years is not corroborated by the Medical Attendant Certificate where the following is mentioned:-
9. When did he/she first complain of illness?
Since (not readable with cutting)
12. From the above entry, it seems that either the doctor filling up this form has not clearly given the date or somebody has made cutting after the word 'since'. Thus, no conclusion can be drawn in respect of the period since when the DLA was suffering from diabetes. From the entries in the Medical Attendant Certificate it is clear that the DLA first complained about illness only on '22.06.2011'. This entry clearly denies pre-existing disease of Diabetic Ketoacidosis. The Insurance Company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2011, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion. Moreover, in case of diabetes of late, this Commission has been taking a view that diabetes is a life style disease and is so common in India that the whole insurance claim cannot be rejected on this ground. In this regard, 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 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."
13. In RP No.4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC) it has been 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 complainant for indemnification of the claim in the light of the judgement of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."
14. Based on the above discussion, first of all the order of the State Commission rejecting the application for condonation of delay in default seems to be perfectly justified as none appeared on behalf of the applicant Insurance Company before the State Commission on many consecutive dates. Moreover, even on merits, the case of the petitioner is not justified and is against the record filed by the petitioner. Thus, I do not find any merit in the revision petition and accordingly, revision petition No.2097 of 2017 is dismissed at the admission stage.
...................... PREM NARAIN PRESIDING MEMBER