State Consumer Disputes Redressal Commission
Sbi Life Insurance Co. Ltd. vs Nirmal Singh on 11 August, 2015
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 1139 of 2014
Date of institution: 12.8.2014
Date of Decision: 11.8.2015
1. SBI Life Insurance Co. Ltd. Navi Mumbai, Pin 400 614 through its
Managing Director/Authorized Signatory.
2. SBI Life Insurance Co. Ltd., Fountain Chowk, Ludhiana through its
Divisional Manager.
(Through M/s Neelam Singh w/o Shri S.P. Singh, Aged 50 years,
having office at SBI Life Insurance Company, 1st Floor, Kapas
Bhawan, Central Processing Unit (CPC), CBD, Belapur, Navi
Mumbai-400 614)
Appellants/OP Nos. 1 & 2
Versus
Mr. Nirmal Singh S/o Sh. Ghukar Singh R/o H. No. 204/B/4, Sunder Nagar
Kacha Malak Road, Jagraon, Distt. Ludhiana Pin Code-142026
Respondent/Complainant
First Appeal against the order dated 24.6.2014
passed by the District Consumer Disputes
Redressal Forum, Ludhiana.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Jasbir Singh Gill, Member
Mrs. Surinder Pal Kaur, Member
Present:-
For the appellants : Sh. Rajneesh Malhotra, Advocate
For the respondent : Sh. Hitesh Sood, Advocate
First Appeal No. 1139 of 2014 2
Gurcharan Singh Saran, Presiding Judicial Member
ORDER
The appellants/OPs(hereinafter referred as "OPs") have filed the present appeal against the order dated 24.6.2014 passed by the District Consumer Disputes Redressal Forum, Ludhiana (hereinafter referred as the District Forum) in consumer complaint No. 461dated 1.7.2013 vide which the complaint filed by the respondent/complainant(hereinafter referred as the complainant) was allowed with a direction to the Ops to settle and pay the claim of the complainant as per the terms and conditions of the policy and also pay Rs. 15,000/- as compensation and Rs. 2,000/- as litigation expenses. Order be complied within 30 days, failing which the Ops shall be liable to pay interest @ 9% p.a. from the date of filing of the complaint till realization.
2. A consumer complaint was filed by the complainant under the Consumer Protection Act, 1986 (in short 'the Act') against the OPs on the averments that Smt. Kamaljit Kaur(hereinafter referred as 'DLA') wife of the complainant was holder of insurance policy No. 93000000105 under SBI Dhan Raksha Plus LPPT Loan Scheme bearing No. 31464176067 issued on 27.10.2010 valid upto 26.11.2026. The DLA was having the said death claim policy since long and it was got renewed from time to time. At the time of issuing the said policy, the DLA was got medically examined by the Ops. However, in the month of November, 2011, the DLA suffered severe heart attack and was got admitted in Pruthi Hospital, 301-Lajpat Nagar, Near Nakodar Chowk, Jalandhar and she unfortunately died. First Appeal No. 1139 of 2014 3 The complainant lodged a claim with the Ops vide letter dated 19.4.2012. As demanded by the Ops, the complainant submitted all requisite documents to the Ops and they assured that they will settle the claim within a short period. However, the complainant was astonished to receive the letter dated 15.12.2011 vide which the claim filed by the complainant was refused. The complainant thereafter several times approached the Ops with a request to settle the claim but they postponed the matter on one excuse or the other. The complainant had spent a sum of Rs. 3 lacs on the treatment of his wife out of which a sum of Rs. 2 lacs was paid to the hospital authorities. The repudiation of the claim by the Ops, amounted to deficiency in services on the part of the Ops. Hence, the complaint with a direction to the Ops to release the claim amount and to pay Rs. 2 lacs as medical expenses and Rs. 55,000/- as litigation expenses.
3. The complaint was contested by the Ops, who filed their joint written reply taking preliminary objections that the complaint was filed by the complainant before Insurance Ombudsman, which was a quasi-judicial body, therefore, the present complaint was hit by Section 11 of the CPC under the principle of res-judicata; the complaint before the District Forum was not maintainable as the matter was already pending before the Insurance Ombudsman; the insurance contract was a contract of utmost faith and the DLA while taking the policy breached this principle as she was suffering from and was under treatment of diabetes mellitus Type II and hypertension, whereas he had submitted a declaration of good health alongwith other details in the membership form. Otherwise the DLA First Appeal No. 1139 of 2014 4 was bound to disclose every factual declaration of good health; there was no deficiency in services on the part of the Ops. The DLA had taken the policy by suppressing the history of pre-existing disease, which was very well within her knowledge and fraud is an act of deliberate deception, therefore, the complaint was liable to be dismissed. On facts, the policy was admitted. It was submitted that DLA had availed housing loan from the Ops and applied for Dhanraksha Plus LPPT cover group insurance scheme under Master Policy No. 93000000105 and her Membership No. was 932291932 dated 13.10.2010. Under the policy in the event of deaths of insured, the sum assured will be payable, outstanding amount on date of death of DLA was Rs. 5,35,250/-. The objection taken in the preliminary objections were reiterated. It was submitted that DLA had obtained the policy by suppressing the material facts with regard to her health and the disease to which she was suffering before taking the policy. The claim was rightly repudiated by the Ops. The complaint was without any merit and it be dismissed.
4. The parties were allowed by the learned District Forum to lead their evidence.
5. In support of his allegations, the complainant had tendered into evidence his affidavit Ex. CA, policy details Exs. C-1 to C-3, death certificate Exs. C-4 & 5, certificate Ex. C-6, letter dt. 27.3.2012 Ex. C-7, letters Exs. C-8, 9 & 10, Insurance Ombudsman letters Exs. C-11 to 14. On the other hand, Ops had tendered into evidence affidavit V. Srinivas Ex. RA, master policy Ex. R-1, membership form Ex. R-2, member details Ex. R-3, claims First Appeal No. 1139 of 2014 5 investigation report Ex. R-4, hospital record and reports Ex. R-5 to 14, letter of SBI Ex. R-15 & 16.
6. After going through the allegations as alleged in the complaint, written reply filed by the OPs, evidence and documents brought on the record, the complaint was allowed by the District Forum as referred above.
7. Aggrieved with the order passed by the learned District Forum, the appellants/OPs have filed the present appeal.
8. We have heard the learned counsel for the parties.
9. It is an admitted fact that DLA Kamaljit Kaur was member of SBI Dhan Raksha Plus LPPT Loan Scheme taken by the Ops vide master policy No. 31464176067. The membership form of DLA is 932291932 dated 13.10.2010. The risk commence from 27.10.2010 for the sum assured Rs. 5,35,350/- whereas the DLA died on 17.11.2011 and when investigation was conducted, it was found that the DLA was suffering from diabetes mellitus Type II and hypertension prior to the enrolment of insurance cover, therefore, he had taken the policy after concealing the material facts whereas while signing the declaration form, she had signed the declaration that she was presently in sound mental and physical health and that she did not suffer from any physical defect/infirmity. She had never suffered currently from diabetes, hyper tension or other disease as mentioned in the declaration during the last 12 months. However, the Ops have placed on the record certain documents that would show that before taking the policy, she was suffering from various ailments i.e. hyper tension and diabetes mellitus II.
First Appeal No. 1139 of 2014 6
10. He has placed on the record Ex. R-5 of Kalyani Hospital, Jagraon, Ex. R-6 from Om Clinical Laboratory, Exs. R-7 to 9 from Public Clinical Laboratory, Ex. R-10 Sidharth Scan and Diagnostic Centre, Ex. R-11 BBC Heart Care report Ex. R-12 Ludhiana Scan Centre, Ex. R-13 certificate of Hospital Treatment. However, the counsel for the respondent/complainant claimed that as per the proposal form, the date of birth of the complainant is 5.10.1962, therefore, in the year when she died in November, 2011, she was 49 years of age. He has further contended that the documents placed on the record does not pertain to the DLA. He has referred to the first document Ex. R-5 and its perusal will reveal that it is in the name of Kamaljit Kaur, female 47 years, Jagraon but its address/husband name has not been given. Whereas this slip was issued in the year 2006 and at that time she was aged about 45 years. Ex. R-6 is the document issued in March, 2006. Here also only name Kamaljeet Kaur is mentioned further details and address are missing. Similarly in Exs. R-7 to 9 only name Kamaljit Kaur mentioned. In Ex. R-10 it was mentioned that Kamaljit Kaur wife of Nirmal Singh but it is not mentioned to when CT Scan was belonging wherein it was mentioned that she needs the surgery of Gall Bladder. In Ex. R-12 also, name of Kamaljit Kaur is mentioned but again her husband name and address is not given. Therefore, without complete particulars, we cannot connect these documents with that of the deceased Kamaljit Kaur wife of Nirmal Singh of Jagraon. The material point for consideration is whether before taking the policy, the DLA had concealed the particulars of the treatment taken by her or the disease to which she First Appeal No. 1139 of 2014 7 was suffering and only on that ground the claim was repudiated. However, as stated above, the documents/treatment record which the Ops had submitted on the record cannot be connected with that of the DLA. No other document has been referred, therefore, on the basis of above referred documents, we are of the opinion that the counsel for the OP was unable to connect the documents to prove on the record that DLA was taking treatment or was suffering from the disease referred above. Moreover, the complainant in his complaint as well as in the affidavit has stated that before taking the policy, she was subject to medical examination. But that record has not been placed on the record, perhaps it was withheld by the Ops as it may not support to the complainant. He has also referred to the various clauses of the insurance policy and clause No. 3 'Eligibility Criteria' has been fixed as under:-
"3. ELIGIBILITY CRITERIA: The Member who, at the time of his/her admission to the Scheme, • Has a minimum outstanding loan/sanctioned loan(excluding interest) as specified in Annexure 1 for the relevant Loan Category.
• Has a minimum loan term of 3 years and a loan term not exceeding the maximum Loan term specified in Annexure 1 for the relevant Loan Category.
• Has a minimum age* of 18 years and does not exceed a maximum age applicable for the relevant Loan Category as stated in Annexure 1 • is in good health.First Appeal No. 1139 of 2014 8
• Has completed and submitted a membership form along with required documents.
• Has satisfactorily completed a good health declaration in the format prescribed by the Company (for members falling within the Free cover limit** only), and • Has undergone a medical examination as per the medical underwriting process of the Company, if applicable, and fulfils the underwriting criteria to the complete satisfaction of the Company; and • is otherwise insurable."
which included a medical examination as per the medical underwriting process of the Company, therefore, for the eligible criteria, the DLA was required to undergo the medical examination because the loan was for a period of more than three years and minimum premium was more than Rs. 500/- and age was between 18 to 65 years, therefore, in the category of which the loan was sanctioned to the DLA, medical examination was required and it has been stated by the complainant that DLA was subject to medical examination before sanction of the loan. For the reasons best known to the Ops they have not placed on the record the said medical examination of the DLA rather they have pleaded that they have not gone for any medical examination of the DLA. Therefore, in case they have not gone for medical examination then they themselves have violated the eligibility criteria before issuance of the policy.
11. He has further contended that from the medical record of the DLA, it is clear that she was suffering from hyper tension and First Appeal No. 1139 of 2014 9 diabetes mellitus for the last 6-7 years, therefore, these observations given by the treating Doctor co-relate to the record produced by the Ops. However, we have observed earlier that proper address on those prescription slips was not mentioned, it cannot state that those were pertaining to the DLA.
12. No doubt the treating doctor of the DLA has mentioned that disease referred by the Ops in their written reply. However, mere certificate given by the Doctor is not sufficient till some corroborating evidence is made available on the record. A reference can be made from the judgment of the Hon'ble National Commission in Revision Petition No. 200 of 2007 "Mr. Satinder Singh versus National Insurance Co. Ltd." decided on 24.1.2011 wherein it has been observed that "recording of history of patient in the above stated manner does not become a substantiate piece of evidence and convincing evidence be brought on record that complainant was aware of pre-existing disease for which he had taken the treatment of disease." Therefore, mere reference by the Doctor is not sufficient to say that DLA was suffering from diabetes mellitus II and hyper tension form the last 6-7 years before her death. The DLA had died due to heart attack then it is to be also established by the Ops that the diabetic mellitus and hyper tension had the nexus to cause heart attack to the DLA. It was held by the Hon'ble National Commission in III (2012) CPJ 208 (NC) "Life Insurance Corporation of India & Anr. Versus Naseem Bano", that bed head ticket cannot be the conclusive proof. There was no piece of evidence which may prove that prior to filling up of proposal form, record of any hospital, slips of doctors, any First Appeal No. 1139 of 2014 10 prescriptions showing the name of medicines which deceased must be taking, saw the light of the day. Heart attack has no nexus with ailments like Diabetic Mellitus and Hypertension. Repudiation was not justified." In another judgment "Life Insurance Corporation Ltd. Vs. Shitla Devi" I (2011) CPJ 128. In that case, deceased died due to heart failure which had no nexus with the previous disease, which has been alleged to be suppressed. It was observed that there is no material fact/fraud on the part of the policy holder.
13. Here also there is no medical record connecting the nexus of diabetic mellitus and hypertension, which have caused the heart attack to the DLA, as such, the Ops have failed to prove on the record that the DLA had suppressed the material information at the time of taking the insurance policy.
14. No other point has been argued.
15. In view of the above discussion, we do not find any merit in the appeal and the same is dismissed with no order as to costs.
16. As the insurance policy was taken to secure the loan sanctioned by Op No.3 to the DLA, as such, first lien is of OP No. 3 to receive this amount.
17. The appellants had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal and Rs. 3,00,000/- in compliance with the order dated 22.8.2014. A sum of Rs. 17,000/- alongwith interest, if any, be paid to the respondent/complainant whereas the remaining amount, alonwith interest, be paid to OP No. 3 by way of a crossed cheque/demand draft after the expiry of 45 days, from the despatch of the order to the First Appeal No. 1139 of 2014 11 parties; subject to stay, if any, by the higher Fora/Court. Remaining amount also be paid by OP Nos. 1 & 2 to OP No. 3 to settle the house loan amount of the DLA.
18. The arguments in this appeal were heard on 29.7.2015 and the order was reserved. Now the order be communicated to the parties as per rules.
19. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Gurcharan Singh Saran) Presiding Judicial Member (Jasbir Singh Gill) Member August 11, 2015. (Surinder Pal Kaur) as Member