State Consumer Disputes Redressal Commission
Dhfl Premerica Lic vs Surinder Kumari on 11 February, 2016
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.1595 of 2014
Date of institution : 10.12.2014
Date of decision : 11.02.2016
1. DHFL Pramerica Life Insurance Co. Ltd. (Erstwhile known as
DLF Pramerica Life Insurance Co. Ltd.), 4th Floor, Building
No.9, Tower-B, Cyber City, DLF City, Phase-III, Gurgaon-
122002.
2. DHFL Pramerica Life Insurance Co. Ltd. (Erstwhile known as
DLF Pramerica Life Insurance Co. Ltd.), office at above
Easyday, opposite Surinder Di Hatti, Sunami Gate, Sangrur,
Punjab.
....Appellants/Opposite Parties
Versus
1. Surinder Kumari W/o Late Sh. Puran Chand;
2. Vikas Ahuja S/o Late Sh. Puran Chand;
Both R/o H.No.103, Pratap Nagar, Sangrur, Punjab.
....Respondents/Complainants
First Appeal against the order dated
04.11.2014 of the District Consumer
Disputes Redressal Forum, Sangrur.
Quorum:-
Hon'ble Mr. Justice Gurdev Singh, President
Mr. Vinod Kumar Gupta, Member
Mr. Upjeet Singh Brar, Member Present:-
For the appellants : Shri U.K. Kanwar, Advocate
For the respondents : Shri Sanjeev Goyal, Advocate.
JUSTICE GURDEV SINGH, PRESIDENT :
This appeal has been preferred by the
appellants/opposite parties against the order dated 04.11.2014 passed by District Consumer Disputes Redressal Forum, Sangrur (in First Appeal No.1595 of 2014 2 short, "District Forum"), vide which the complaint filed by the respondents/complainants, under Section 12 of the Consumer Protection Act, 1986 (in short, "the Act"), was allowed and the opposite parties were directed to pay Rs.3,82,000/- to them, along with interest at the rate of 9% per annum from the date of filing of the complaint till the realization of that amount; Rs.10,000/-, as compensation, for mental tension, agony and harassment; and Rs.10,000/-, as litigation expenses.
2. The complainants alleged, in their complaint, that complainant No.1 is the widow and complainant No.2 is the son of Puran Chand; who got himself insured with the opposite parties for a sum of Rs.1,91,000/-, vide Policy No.000126189. The annual premium payable was Rs.19,225/- and in case of the death of the life assured, the nominee was to get double the assured amount. The first premium was paid at the time of issuance of the Policy and the second premium was paid on 11.03.2013. In the month of September, 2013, the life assured suddenly fell ill and was immediately taken to Dayanand Medical College & Hospital, Ludhiana and was admitted at that place on 20.09.2013. He was discharged on 22.09.2013 and on the same day, he died in the house. Immediately after his death, complainant No.2, being the nominee, lodged the claim with the opposite parties, by submitting all the relevant documents and was assured that the claim would be released within 15 days. However, the same was not released, though that complainant approached opposite party No.2 repeatedly and every time he was told that the case had been referred to First Appeal No.1595 of 2014 3 opposite party No.1. They (complainants) were shocked to receive the letter dated 31.03.2014, vide which their claim was illegally and arbitrarily repudiated, on the ground that the life assured was undergoing treatment of kidney and was diabetic before getting the Policy. In fact, he was hale and hearty before the inception of the Policy and was not suffering from any such disease. He was already having one Medical Policy from Life Insurance Corporation of India, which was obtained on 17.07.2008 and no claim was ever lodged by him under that Policy for the reimbursement of the medical expenses. Even after the repudiation of the claim, they had approached opposite party No.2 with the request to release the claim amount, who asked them to give confirmation of Life Insurance Corporation of India that no amount had been claimed by the life assured under the Medical Policy. Thereafter, the complainants approached Life Insurance Corporation for getting that confirmation and that fact was confirmed by it, vide e-mail dated 30.04.2014. After that confirmation, he again approached opposite party No.2 with the said e-mail, but that opposite party flatly refused to entertain his request. This act of the opposite parties in repudiating their claim on false and wrong grounds amounts to negligence and deficiency in service and as a result thereof, they suffered a lot of mental agony and harassment. They prayed for the issuance of following directions to the opposite parties:-
i) to pay the claim amount of Rs.3,82,000/-, along with interest at the rate of 18% per annum from the date of death of the life assured till realization;First Appeal No.1595 of 2014 4
ii) to pay Rs.50,000/-, as compensation for the mental agony and harassment suffered by them; and
iii) to pay Rs.11,000/-, as litigation expenses.
3. The opposite parties filed joint written reply before the District Forum, in which they admitted that the Insurance Policy, in question, was obtained by Puran Chand, life assured; under which the sum assured was Rs.1,91,405/- and the annual premium payable was Rs.19,313/- and that two premiums had already been paid under that Policy. They also admitted that death claim was received by them on 05.11.2013 and that the same was repudiated, on the ground, mentioned in the repudiation letter. While denying the other allegations made in the complaint, they averred that the life assured, after completely understanding the terms and conditions of the product "DLF Pramerica Assure Money + Plan", duly submitted the signed Proposal Form bearing No.AF 000586637 on 29.02.2012 and offered a sum of Rs.19,313/-, as the initial annual premium. The contents of the Proposal Form were duly explained to him and he had given a declaration, stating that the contents of the application were so read over and explained to him and that he had furnished the information therein after fully understanding the contents thereof as well as the terms and conditions of the Plan. It was on the basis of that Proposal Form that the Policy was issued to him and was despatched at his address and was duly delivered to him. On receipt of the claim made by the complainants, after the death of the life assured, the investigation was got conducted through an investigating agency; named "The Third Eye", as it was an early First Appeal No.1595 of 2014 5 claim and the life assured had died after 1½ year of the date of issuance of the Policy. It was during that investigation that it was revealed that the life assured was a known case of Diabetes Mellitus from the last five years; for which he was taking the treatment and that he was suffering from Morbid Obese with Type-2 DM with D Triopathy with CKD stage-5 with Right Lower Limb Cellulites with Sepsis with Shock. Being a known case of that disease, it is implied that he was aware of his health conditions before filling up the Proposal Form and still he did not reveal that information therein. In- spite of the fact that he was aware that he was suffering from dreadful disease, he applied for the Policy to get undue advantage, by suppressing that fact. The questions, in answer to which he was to disclose that information, were included in the questionnaire, contained in the Proposal Form. He had declared in that Proposal Form regarding the complete, true and accurate disclosure of the facts. The disease, from which he was suffering, cannot be termed as a normal disease. He was bound to give correct answers to the questions regarding his health and regarding which he had the personal knowledge. Even if he had undergone medical examination by the doctors appointed by them, even then it was not possible for those doctors to detect that disease, unless he had disclosed the details thereof or the symptoms thereof. On account of the non- disclosure of the material facts, the contract of insurance had become void and the claim made by the complainants was rightly repudiated. Had the true and full disclosures been made by the life assured, they would not have issued the Policy in his favour. First Appeal No.1595 of 2014 6 On account of the non-disclosure of the material facts, the Policy is vitiated. The complainants have no locus standi to file this complaint, as there was no deficiency in service on their part. The complaint is based on mere surmises and conjectures and lacks cause of action. The complainants have suppressed the material facts from it. They prayed for the dismissal of the complaint, under Section 26 of the Act; being false, malicious and having been filed with mala fide intention.
4. Both the sides produced evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel on their behalf, allowed the complaint, vide aforesaid order.
5. We have heard learned counsel for both the sides and have carefully gone through the records of the case.
6. In the appeal, the opposite parties filed an application for producing additional evidence, which was allowed and thereafter, they tendered in evidence the Discharge Summary Ex.OP-7 and in rebuttal to that evidence, the complainants proved on record affidavit of Surinder Kumari, complainant No.1, Ex.C-7. At the time of arguments, learned counsel for the opposite parties placed reliance on that Discharge Summary, Ex.OP-7, and submitted that from that Discharge Summary, it stands proved that the life assured was admitted in Dayanand Medical College & Hospital, Ludhiana on 01.06.2010 and was diagnosed as suffering from "DM 2 with Nephropathy with Acute on CRF with UTI with Hypertension with HCV related Cirrhosis with Portal HTN with Morbid Obesity". For First Appeal No.1595 of 2014 7 obtaining the Policy, in question, the life assured filled up the Proposal Form dated 29.02.2012, Ex.OP-1; which contained the questionnaire regarding the diseases etc., if any, from which he was suffering. He answered all those questions in the negative and, as such, concealed the fact that he was suffering from above said diseases. The contracts of insurance are based on the doctrine of Uberrima fides and the life assured was required to disclose the diseases, from which he was suffering and about which he had the knowledge. By concealing that material information, he obtained the Policy and, as such, the opposite parties were justified in repudiating the claim made by the complainants after his death under the Policy. On account of the non-disclosure of the material information, the contract of Insurance became void and no such claim was permissible under such a void contract. The District Forum committed an illegality, while recording findings to the contrary and those findings are liable to be set aside.
7. On the other hand, it was submitted by the learned counsel for the complainants that there is no evidence on the record for connecting the above said Discharge Summary, Ex.OP-7, with the life assured. It becomes very much clear from the deposition contained in the affidavit of Surinder Kumari, Ex.C-7, that this medical record does not belong to Puran Chand, life assured. Therefore, no such finding can be recorded that he was suffering from the diseases mentioned in the Discharge Summary and that he concealed that fact, while giving answers to the questions contained in the Proposal Form. Correct findings were recorded by the District First Appeal No.1595 of 2014 8 Forum and there is no ground for upsetting those well reasoned findings.
8. In the Discharge Summary, Ex.OP-7, the name of the patient is recorded as "Puran Chand" and age as "57 years". There is no column regarding the parentage or the address of the patient. However, counsel for the opposite parties has drawn our attention towards the endorsement made at the end of that Discharge Summary, which is as under:-
"Partap Nagar, outside Sunami Gate, Sangrur."
By referring to that endorsement, he has tried to assert that this Discharge Summary relates to Puran Chand, life assured.
9. While deciding the question, whether this Discharge Summary relates to the life assured or not, the deposition made by complainant No.1 in her affidavit Ex.C-7 that this record does not relate to the life assured is to be kept in mind.
10. The Discharge Summary, regarding the admission of one Puran Chand in this very hospital from 31.08.2013 to 05.09.2013, forms part of the document Ex.OP-7 itself. In that Discharge Summary also, there is no column regarding the parentage or address of the patient and like Discharge Summary pertaining to the admission of the patient from 01.06.2010 to 12.06.2010, the same address of the patient is recorded at the end. Another Discharge Summary forms part of the document Ex.OP-7 and as per that Discharge Summary, patient Puran Chand remained admitted in that hospital from 16.03.2010 to 24.03.2010 and was found suffering First Appeal No.1595 of 2014 9 from the same diseases. In that Discharge Summary, it has been added that as per the record, the address of the patient is "H.No.103, Partap Nagar, Sangrur". It is pertinent to note that in the Death Certificate of the life assured, proved on the record as Ex.C-5, the same address is mentioned. That very address was mentioned in the Insurance Policy Ex.C-6. The position becomes crystal clear from one document, which is DAMA (Discharge Against Medical Advice) issued by the said Hospital and it is at Page-107 of the record of the District Forum. In that document, which is the "Last Medical Attendant's Report", the patient Puran Chand is recorded to be the resident of H.No.103, Partap Nagar, Sangrur. From all these, it becomes very much clear that the Discharge Summary, Ex.OP-7, relates to the life assured itself. He remained admitted in the hospital from 01.06.2010 to 12.06.2010 for the treatment of above said diseases and, as such, it cannot be said that he had no knowledge about these diseases, when he filled up the Proposal Form in the year 2012. By giving wrong answers to the questionnaire contained in the Proposal Form, he concealed the material information; which was likely to affect the mind of the opposite parties in accepting/non-accepting the proposal, so submitted by him. The suppression of that material information makes the contract of insurance void and the opposite parties were justified in repudiating the claim of the complainants. The District Forum committed an illegality, by recording findings to the contrary. First Appeal No.1595 of 2014 10
11. In the result, the appeal is allowed, the order passed by the District Forum is set aside and the complaint filed by the complainants is dismissed.
12. The appellants had deposited a sum of Rs.25,000/- at the time of filing of the appeal. They deposited another sum of Rs.3,98,852.49P, vide receipt dated 20.02.2015, in compliance of the order dated 23.12.2014. Both these sums, along with interest which has accrued thereon, if any, be remitted by the registry to the appellants/opposite parties, by way of a crossed cheque/demand draft after the expiry of 45 days of the sending of certified copy of the order to them.
13. The arguments in this case were heard on 09.02.2016 and the order was reserved. Now, the order be communicated to the parties.
14. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE GURDEV SINGH) PRESIDENT (VINOD KUMAR GUPTA) MEMBER (UPJEET SINGH BRAR) MEMBER February 11, 2016.
(Gurmeet S)