State Consumer Disputes Redressal Commission
Pnb Met Life India Insurance Co. Ltd. vs Manjit Kaur on 20 May, 2024
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No.605 of 2022
Date of Institution : 19.07.2022
Reserved on : 07.05.2024
Date of Decision : 20.05.2024
PNB MetLife Insurance Company having its registered office at Unit
No.701, 702, 703, 7th Floor, West Wing 26/27, Mahatma Gandhi
Road, Bengaluru - 560001 being represented through its Managing
Director.
.....Appellant/Opposite Party
Versus
Manjit Kaur widow of Balwinder Singh Rai, resident of 14, VPO
Boparai, Tehsil Patti, District Tarn Taran (Pujnjab).
.....Respondent/Complainant
Appeal under Section 41 of Consumer
Protection Act, 2019 to challenge the
order dated 31.12.2021 passed by the
District Consumer Disputes Redressal
Commission, Tarn Taran in C.C. No.71 of
2017.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Present:-
For the Appellant : Ms. Komal Preet Kaur, Advocate for Sh. Deepak Arora, Advocate For Respondent : Sh. H.S. Oberoi, Advocate
1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported in the Digest? Yes/No 2 First Appeal No.605 of 2022 JUSTICE DAYA CHAUDHARY, PRESIDENT:-
The Appellant/OP i.e. PNB MetLife Insurance Co.
through its Managing Director has filed the present Appeal under Section 41 of the Consumer Protection Act, 2019 (in short the "Act") being aggrieved by the impugned order dated 31.12.2021 passed by District Consumer Disputes Redressal Commission, Tarn Taran (in short the "District Commission") in C.C. No.71 of 2017 vide which the Complaint filed by the Complainant had been allowed.
2. The case of the Complainant before the District Commission was that she was the widow of Balwinder Singh Rai who had purchased one life insurance policy by paying premium regularly towards the policy No.21388311. The insured was to be paid an amount of Rs.12,00,000/- as insurance claim in case of natural death. However, said amount was subject to regular payment of the premium. Further it has been mentioned that the deceased life assured (DLA) had been paying the insurance premium regularly since the purchase of the policy from the year 2014. The husband of the Complainant had nominated the Complainant as nominee in the said policy. All formalities were completed including the medical test of the insured before issuance of the policy. However, the husband of the Complainant namely Balwinder Singh Rai had expired on 24.11.2016 and the cause of his death was stated to be natural as he was not ill. However he was quite healthy before his death. The Complainant lodged the claim to the OP of Rs.12,00,000/- but only 3 First Appeal No.605 of 2022 the assurance was given by the OP but after some time the Complainant received a letter from OP dated 04.05.2017 whereby the claim was repudiated. Thereafter, the Complainant had approached the Chairman Claim Committee of PNB Met Life Insurance Company Limited. However, the Committee also did not grant any relief and the order of repudiation passed by the Insurance Company was upheld. The Complaint was filed before the District Commission with the prayer to pay an amount of Rs.12,00,000/- and also to pay Rs.50,000/- as compensation and Rs.20,000/- as litigation expenses.
3. Upon issuing notice in the Complaint, OP had appeared through Counsel and filed its written version contesting the Complaint. Certain preliminary objections were raised stating that the Complaint was liable to be dismissed being frivolous and the same was filed with malafide intention just to have wrongful gain. Certain material facts were concealed. Further it was mentioned that it was not a case of any 'deficiency in service' and there were no allegations of 'unfair trade practice' at the instance of OP. Other averments made in the Complaint were denied.
4. By considering the averments made in the Complaint and reply thereof filed by OP and also on hearing the oral arguments raised from both the sides, the Complaint filed by the Complainant was allowed. The relevant portion of the impugned order as mentioned in para No.9 is reproduced as under:-
4First Appeal No.605 of 2022
"9. In the light of the above discussion, the Complaint succeeds and the same is hereby allowed with costs in favour of the Complainant. The Opposite Party is directed to make the insurance claim to the Complainant. The Complainant has been harassed by the Opposite Party unnecessarily for a long time. The Complainant is also entitled to Rs.15,000/- (Rs.Fifteen Thousand only) as compensation on account of harassment and mental agony and Rs.10,000/- (Rs.Ten Thousand only) as litigation expenses. Opposite Party, is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the Complainant is entitled to interest @9% per annum, on the awarded amount, from the date of Complaint till its realization. Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room."
5. Being aggrieved by the order dated 31.12.2021 passed by the District Commission, the Appellant/OP Insurance Company has filed the present Appeal.
6. There was delay of 155 days in filing of the Appeal. M.A. No.462 of 2022 was filed for condonation of delay which was supported by an affidavit. Said Application was allowed and delay of 155 days in filing the Appeal was condoned vide order dated 22.07.2022 and said MA was disposed off accordingly.
7. Ms. Komal Preet Kaur Advocate, appearing on behalf Mr. Deepak Arora Advocate, the counsel for the Appellant has submitted that the findings recorded by the District Commission while allowing the Complaint are not based on proper appreciation of material facts and documents as placed on record. However, without 5 First Appeal No.605 of 2022 considering the reply as well as the oral arguments, the order has been passed which is contrary to the facts and law. Learned Counsel has further submitted that the terms and conditions of the policy were explained to the insured at the time of taking of the policy and DLA had given declaration stating that he was healthy but certain necessary information was withheld. Further it has been submitted that in the Proposal Form, the DLA had not mentioned the relevant facts and as such the certain material facts were concealed. Learned Counsel has further submitted that the DLA was suffering from disease and was taking the treatment. The policy was issued by believing the insured and his physical health but he expired on 24.11.2016. Learned Counsel has further submitted that an investigation was carried out by the OP and it was noticed that the DLA had undertaken right leg surgery with blood transfusion prior to issuance of the policy. Apart from this, the insured was having medical history but nothing was informed about his medical history and it was a case of total misrepresentation. Learned Counsel has further submitted that the OP had placed on record certain documents to show that the insured had suffered various ailments relating to spine problem. The OP had also annexed certified copy certificate of Sh. Guru Ram Dass Charitable Hospital, Amritsar dated 09.01.2017 wherein it was specifically mentioned that DLA had been diagnosed as a case of Hepatitis C virus (+) with Alcoholic Liver Disease with Liver Cirrhosis with portal hypertension with hepatic Encephalopathy with Hepatocellular Carcinoma and thereafter the 6 First Appeal No.605 of 2022 DLA had expired on 24.11.2016 due to said ailments. Learned Counsel has relied upon judgments i.e. "Reliance Life Insurance Co. Ltd. Vs. Rekhaben Nareshbhai Rahtore" 2019 (2) CPJ-53, "LIC Vs. Manish Gupta" CA No.3944 of 2019 arising out of SLP © No.5001 of 2019, decided on 15.04.2019, "LIC of India Vs. Rukma" 2012(II) CPJ 44 (NC) and so on in support of her arguments.
8. Mr. H.S. Oberoi Advocate, learned counsel for the Respondent/Complainant has submitted that the order passed by the District Commission is based on proper appreciation of evidence and law. Detailed findings have been recorded by the District Commission by considering the stand taken by the Respondent/Complainant. The order passed by the District Commission is well reasoned which is based on proper appreciation of facts and evidence. Detailed findings have been recorded and no interference is required. Learned Counsel for the Respondent/Complainant has submitted that the policy was issued by covering the risk with the commencement date i.e. 12.09.2014. DLA had expired on 24.11.2016. The claim became due only after the period of two years and one month. As per the Provisions of Section 45 of the Insurance Act, 1938, the insurer could not have repudiated the claim after the expiry of period of two years from the date of issuance of the policy on the ground that the statement made in the proposal or any document was false or inaccurate. Learned Counsel has further submitted that admittedly the Appellant/OP had got conducted the complete medical checkup 7 First Appeal No.605 of 2022 of DLA and was satisfied with the result of medical test conducted at the time of issuance of the policy. It was wrongly rejected on the ground on non-disclosure of certain facts. Learned Counsel has further submitted that it was wrongly mentioned by the insurer that insured was suffering from various health problems and was in a critical stage prior to issuance of the policy. Learned Counsel has further submitted that there was no conclusive proof on record to show that the deceased had undergone any surgery prior to taking of the policy or he was examined by any expert to prove that the patient was operated by him. Learned Counsel has also relied upon judgments i.e. "Sulbha Prakash Motegaonkar Vs. Life Insurance Corporation of India, CA No.8245/2015, decided on 05.10.2015, "Bajaj Allianz Life Insurance Co. Versus Raj Kumar" III(2014) CPJ 221 (NC) and "National Insurance Company Limited & another Vs. Balwinder Singh" 2012(1) CLT 34 in support of his arguments.
9. We have heard the arguments raised by learned Counsel for both the parties. We have also perused the impugned order passed by the District Commission and other documents as available on the file.
10. Facts relating to issuance of the policy in favour of the DLA and death of DLA during the currency of the policy, refusal of claim by OP and thereafter filing of Complaint by the wife of the DLA before the District Commission and allowing the Complaint vide order 8 First Appeal No.605 of 2022 dated 31.12.2021 and thereafter filing of Appeal by the Appellant Insurance Company before this Commission are not in dispute. It is also not in dispute that the DLA had been paying premium regularly as per the terms and conditions of the policy. The DLA or his nominee was entitled for an amount of Rs.12,00,000/- in case of natural death. There was a condition that the said amount was to be paid only on paying regular premium. The husband of the Complainant had expired on 24.11.2016 and cause of death was natural as per the version of the Complainant as he was quite healthy before his death and was not suffering from any ailment. However, as per the version of the OPs, the ground taken in the order of rejection, the insured had undergone right leg surgery with blood transfusion. This material fact was concealed from the OPs at the time of issuance of the policy.
11. Although, a ground was taken that the insured had taken treatment of right leg surgery with blood transfusion but the OP had not produced any document of any hospital alongwith the affidavit of the concerned doctor to authenticate the same that the DLA had undergone any surgery. The District Commission had categorically mentioned in its order that there was no conclusive proof on record to show that the DLA was ever undergone any surgery prior to taking of the policy. No concerned Doctor had ever been examined to prove that the DLA was operated upon by him.
9First Appeal No.605 of 2022
12. As far as concealment of any disease or material information, no evidence has been produced by the Appellant/OP alongwith the concerned Doctor's affidavit to prove that before purchase of the policy, the DLA had been taking the treatment of any ailment/problem from any Hospital or Doctor and the DLA had the knowledge that he was suffering from the heart disease. However, in absence of any such evidence, the claim was wrongly repudiated by the Insurance Company. The District Commission had considered this aspect and had also given a categoric finding that the claim was wrongly repudiated. The Hon'ble National Commission in case titled as "PNB Metlife Insurance Company Limited Vs. Vinita Devi"
2019(1) C.P.J. 441 (NC) had held that "burden to prove that the life assured was suffering from any pre-existing disease lies with the Insurance Company". In the present case, the Appellant has failed to produce on record any authentic medical documents/treatment record alongwith any affidavit of concerned doctor or hospital to prove that the life assured had suffered such ailment at the time of taking the policy neither before the District Commission nor before this Commission. Moreover, the death of the insured did not relate to any injury or any reason otherwise and as such the death cannot be related to any other factor. The Hon'ble Supreme Court of India in case "Sulbha Prakash Motegaonkar" (Supra) has held that "that there was no nexus between the cause of death and non-disclosure of the diseases". In the present case, the Appellant has failed to 10 First Appeal No.605 of 2022 prove on record any nexus between the cause of death and non- disclosure of the ailment suffered by the DLA.
13. It is pertinent to mention here that the before taking the policy, the medical checkup of the insured was conducted and after his full satisfaction with the result of medical tests of the DLA, the policy was issued. The Hon'ble National Commission in case "Baja Allianz Life Insurace" (Supra) has held that "when the insurer is satisfied by the result of medical tests at the time of issuing policy, it cannot reject the claim later on the ground of non-disclosure."
14. The risk of the policy was commenced w.e.f. 12.09.2014 and the DLA had expired on 24.11.2016. As per the Provisions of Section 45 of the Insurance Act, 1938, the Insurance Company could have raised the objection of concealment, false information or document within a period of two years but in the present case even after elapse of two years the OP had raised objection of concealment and false information. The Insurance Company could not prove the concealment on the part of the DLA by way of producing cogent evidence and as such the judgment relied upon by the Appellant/OP are not applicable in the present case.
15. For the facts and reasons as mentioned above and also as per ratio of judgments in a number of cases as mentioned above, we find no reason to interfere with the order passed by the District Commission and the Appeal filed by the Appellant/OP being devoid of any merit is hereby dismissed.
11First Appeal No.605 of 2022
16. The Appellant had deposited an amount of Rs.25,000/- at the time of filing of the Appeal with this Commission. Said amount, alongwith interest which has accrued thereon, if any, shall be remitted by the Registry to the District Commission forthwith. The Respondent/Complainant may approach the District Commission for the release of the same and the District Commission may pass an appropriate order in this regard in accordance with law.
17. Since the main case is decided, the pending applications, if any, are also disposed of.
18. The appeal could not be decided within the stipulated period due to heavy pendency of Court cases and due to pandemic of Covid-19.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER May 20, 2024 (MM)