State Consumer Disputes Redressal Commission
Ms. Kundan Palmoo Negi. vs Pnb Metlife India Insurance Co. Ltd. & ... on 1 September, 2022
H. P. STATE CONSUMER DISPUTES REDRESSAL
COMMISSION SHIMLA
Consumer Complaint No.: 11/2018
Date of Presentation: 27.07.2018
Order Reserved on : 26.08.2022
Date of Order : 01.09.2022
......
Ms. Kundan Palmoo Negi D/O Sh. K.M.Negi R/O Village, PO
and Tehsil Pooh, District Kinnaur, HP
...... Complainant
Versus
1. PNB Met Life Insurance Company Ltd., through
its Managing Director Unit No.701, 702 and 703 Severn Floor,
West Wings, Rahaja Towers, 26/27 MG Road, Banglore-
580001
2. National Bank for Agriculture and Rural
Development(NABARD) through its Managing Director, Plot
No.2-24, G Block Bandra Kurla Complex, Bandra (E),
Maharashtra-400051
3. National Bank for Agriculture and Rural
Development (NABARD) through its Chief General Manager,
Block-34 SDA Complex, Shimla-9
.....Opposite Parties.
Coram
Hon'ble Justice Inder Singh Mehta, President
Hon'ble Ms. Sunita Sharma, Member.
Hon'ble Mr. R.K. Verma, Member
Whether approved for reporting?1 Yes
For Complainant: Mr. Sunil Kumar, Advocate
For Opposite Party No.1: Mr. Naveen Pathania, Advocate
1 Whether reporters of the local papers may be allowed to see the order?
Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018)
For Opposite Parties No.2&3: Ms. Jyoti Chauhan, Advocate
Vice Mr. Sanjay Dalmia,
Advocate
Justice Inder Singh Mehta, President
ORDER
The complainant has filed the instant complaint seeking directions to the opposite parties to pay the balance personal claim amount of Rs.50.00 lacs due under the policy along with interest @12% per annum from the date of death of late Mr. Thakur Singh, till its realization, to pay Rs.1.00 lac as damages on account of mental agony & harassment, besides litigation charges to the tune of Rs.30,000/-. Brief facts of Case:
2. Briefly, the case of the complainant is that her brother late Sh. Thakur Singh was employee of opposite parties No.2 and
3. Late Sh. Thakur Singh was insured under Group Insurance Policy No.0003390 purchased by opposite parties No.2 & 3 for their employees. The complainant was mentioned as nominee in the policy since late Sh. Thakur Singh was un-married.
According to the complainant, during the subsistence of the insurance policy, Mr. Thakur Singh, her brother died on 08.08.2016. As per post mortem report, the life assured died due to emphysema. The cause of death was natural. Neither the 2 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) deceased nor she (complainant) was aware about the said disease and the same was not detected till his death.
Per the complainant, the deceased-life assured was insured for a sum of Rs.1 Crore. However, opposite party No.1 only paid Rs.50.00 lacs. Rest of the policy amount was declined vide letter dated 02.6.2017 on the ground of concealment of material fact by the deceased-life assured, who was suffering from diabetes prior to obtaining the insurance policy. As per the complainant, the deceased had not died on account of diabetes. At the time of taking insurance policy, the deceased life assured was medically checked up by the penal of doctors of PNB MetLife India Insurance Company Ltd., and thereafter policy has been issued. There is no concealment of any material fact. Non- settlement of the claim for the entire sum assured amounts to deficiency in service and unfair trade practice on the part of opposite party No.1. Hence, this complaint.
3. The complaint is contested by the opposite parties by filing separate replies.
Opposite party No.1 in its reply has not disputed issuance of group insurance policy No.00003390 purchased by opposite parties No.2 and 3, in which the deceased Mr. Thakur Singh was also covered for Rs.50.00 lacs. It is also not disputed that the deceased life assured had opted for additional cover of 3 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) Rs.50.00 lacs. It is submitted that taking into consideration the replies given to the questions regarding health and lifestyle and depending upon the age, no extensive medical examination was triggered by the company. The result of the medical test was within the normal range. Even diabetes test also came within the normal range. As such, company had not done any further detailed medical investigation and the said additional cover of Rs.50.00 lacs was extended in favour of the deceased life assured, by believing the information provided by him in the proposal form as truthful.
According to opposite party No.1, the deceased life assured had suppressed the material fact qua his previous ailment, as he was suffering from diabetes mellitus since 15 years and was taking insulin through injections as is evident from discharge summary of Max Healthcare Hospital (Annexure R-4).
The contract of insurance is a contract based on "uberrimaefidei" i.e., utmost good faith. Since the deceased has suppressed past history of his ailment of diabetes mellitus, therefore, his claim has rightly been repudiated vide letter dated 2nd June, 2017(Annexure-5). There is no deficiency in service or unfair trade practice, as alleged.
4. The opposite parties No.2 and 3 in their joint reply have admitted that the deceased life assured was their employee 4 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) and was covered under Group Insurance Policy issued by opposite party No.1 and he had also opted for Optional Group Term Insurance Plan. Opposite parties No.2&3 are not liable to indemnify the complainant. There is no deficiency in service or unfair trade practice, as alleged.
5. Separate rejoinders denying the contents of the replies filed by the opposite parties and reiterating those of the complaint have been filed.
6. Thereafter the parties were called upon to produce the evidence. The complainant tendered in evidence her affidavit Ex. CW-1. The opposite party No.1 tendered in evidence affidavit Ex. OP1-1 of Mr. Rajeev Sharma, its Senior Manager (Legal), whereas opposite parties No.2 and 3 tendered in evidence affidavit Ex. OPW2&3-1 of Mr. Sanjeev Sharma.
7. We have heard the learned counsel for the parties and have gone through the case file carefully.
8. Learned counsel of the complainant has submitted that deceased/insured had availed Life Insurance Policy from the opposite party No.1 and the complainant is the nominee of the deceased/insured. He further submitted that deceased died on 08.08.2016. He further submitted that deceased/insured had also taken another Life Insurance policy from the opposite party No.1 for a sum assured of Rs.50.00 lacs and the amount of said policy 5 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) has been released in favour of the complainant. Learned counsel of the complainant has further submitted that in the instant case claim of the complainant has been wrongly repudiated on the alleged non-disclosure of pre-existing disease i.e. Diabetes Mellitus. He further submitted that the complainant is entitled to the insured amount of Rs.50.00 lacs and relied upon order of the Hon'ble National Commission in case titled Neelam Chopra Vs. Life Insurance Corporation of India, decided on 08.10.2018.
9. On the other hand, learned counsel of the opposite party No.1 has submitted that the complainant is not entitled to the relief as sought in the complaint due to the fact that insured had suppressed material fact of his pre-existing disease i.e. Diabetes, which he was suffering from last 15 years and as such claim of the complainant has been rightly repudiated and prayed that complaint be dismissed and relied upon order of Hon'ble National Commission in Revision petition No.884 of 2015 titled Kotak Mahindra Old Mutual Life Insurance ltd. Vs. Aditya Kardam, dated 06.01.2017 and order of Hon'ble Supreme Court of India in petitions No.13664-13667/2017 in Aditya Kardam Vs. Kotak Mahindra Old Mutual Life Insurance ltd. 6 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018)
10. Learned counsel(s) of the opposite parties No.2 and 3 have submitted that she adopts the arguments advanced on behalf of the opposite party No.1.
FINDING
11. Admitted facts which emerged out of the pleadings of the parties are that deceased brother of the complainant, who was employee of opposite parties No.2 & 3 was insured under "MetLife Complete Care Plus Under Employer-Employee group scheme" for a basic sum of Rs.50.00 lacs as is evident from Annexure-1. The death of the life assured due to emphysema is also not in dispute. The same is also proved by the final opinion given by Dr. S.Valliappah(PG JR), Department of Forensic Medicine & Toxicology, Government Medical College & Hospital, Sector-32, Chandigarh, appearing at page 74 of the record of this Commission. It is also not in dispute that a basic sum assured of Rs.50.00 lacs was reimbursed to the complainant on the same terms and conditions of the insurance policy.
12. The only dispute is regarding payment of additional cover of equivalent amount of Rs.50.00 lacs.
13. The opposite party No.1 repudiated this claim of the complainant vide repudiation letter dated 02.06.2017(Annexure-
5) on the ground that "Late Mr. Thakur Singh was suffering from Diabetes Mellitus prior to policy issuance. However, the 7 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) concerned question in the application form dated 06 Jan 2015, seeking insurance cover under this policy was answered as "No" by Late Mr. Thakur Singh".
14. Once the basic sum insured of Rs.50.00 lacs was reimbursed by the opposite party No.1 on the same terms and conditions of the policy, the opposite party No.1 was not justified in withholding the rest of the additional amount of Rs.50.00 lacs by taking the plea of suppression of material facts.
15. Moreover, it is admitted by opposite party No.1 in para No.23 of the reply that medical tests of the deceased life- assured were conducted. The result of the medical test was within the normal range. Even diabetes test was also within the normal range.
16. The opposite party No.1 itself has also placed on record photo copy of check list for Met Life dated 31.12.2015. Its perusal depicts that several medical tests including Glycosylated Hemoglobin(HbA1C) & FBS (Faster Blood Sugar) were prescribed, which were conducted upon the person of life assured, as is evident from report dated 31.12.2015 issued by Jain Clinic, Shimla appearing at page No.43 of the record of this Commission. Its perusal indicates that the result of all the medical tests was within the normal range. Even diabetes (FBS & 8 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) HbA1C) tests conducted upon the deceased-life assured were within normal range.
17. Therefore, the arguments of the learned counsel for the opposite party No.1 that the deceased-life assured was suffering from diabetes mellitus prior to taking the policy and that questions were wrongly answered in "negative" in Individual Underwriting Form (Annexure -2), in presence of check list for Met Life (Annexure-3) and medical test report dated 31.12.2015 of the life assured (appearing at page No.43 of the record of this Commission) relied upon by opposite party No.1 itself, loses its significance.
18. It is the assertion of the opposite party No.1 in its pleadings that it had received claim intimation form along with medical documents of Max Healthcare Hospital and during careful evaluation of the record it revealed that the deceased life assured was suffering from diabetes mellitus prior to taking of the insurance policy. The complainant has specifically denied to have supplied these documents in her rejoinder. Therefore, it was incumbent upon the opposite party No.1 to have produced the claim intimation form to prove this fact but this material document has been withheld by the opposite party No.1 for the reasons best known to it. Therefore, an adverse inference is to be drawn against the case set up by the opposite party No.1. 9 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018)
19. Opposite party No.1 in order to prove that the deceased life assured was having pre-disease of diabetes mellitus has placed much reliance upon photo copy of discharge summary (Annexure 4) alleged to have been issued by Max Super Specialty Hospital, Mohali (Pb). Its perusal depicts that it does not bear any stamp & signatures of the issuing authority. Therefore, we are not inclined to attach credence to the alleged discharge summary which is of no help to the case of opposite party No.1 for want of affidavit of the doctor/authority concerned, who alleged to have issued the said discharge summary. Moreover, the instant case, the cause of death as per final opinion (appearing at page No.74 of the record of this Commission), given by Dr. S.Valliappah (PG JR), Department of Forensic Medicine & Toxicology, Government Medical College & Hospital, Sector 32, Chandigarh was emphysema, a natural cause.
20. Further, we are of the opinion that diseases like diabetes mellitus and hypertension are life style diseases and there is probability of such ailments arising in non-diabetics or non-hypertensive persons.
21. The case laws cited above by the learned counsel for the opposite party No.1 are not applicable in the facts and circumstances of the instant complaint, because in the present 10 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) case, the deceased-life assured was subjected to medical tests by the opposite party No.1 prior to taking of the insurance policy and his all medical tests including were found in normal range. The relevant portion of the report of Jain Clinic, New Shimla (appearing at page No.43 of the record of this commission) is re-produced as under:-
GULCOSE MEMORY TEST Glycosylated 5.2 % Below 6.0% (Normal) Hemoglobin(HbA1C) -7.0(Good Control)
-8.0(Fair Control) 8.0-10.0% (Unsatisfactory Control) B. Sugar(Fasting) 90.4 mg (80-120) This fact has been asserted by the opposite party No.1 in para No.23 of its reply, which is reproduced as under:-
"That the Company submits that taking into consideration the replies given to the questions regarding health and lifestyle and depending on the age, proposed sum assured and premium amount payable; no extensive medical examinations were triggered by the Company. The result of the medical test was within the normal range. Even diabetes test also came within the normal range. Hence, company had not done any further detailed medical investigation. However, if LA would have disclosed his 11 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) medical history of diabetes, Respondent Company can collaborate the finding of medical report with medical history to rightly decide on giving additional cover. The copy of medical report at the time of proposal is annexed as Annexure-3".
22. The aforesaid factum appearing on record is ipso fact clear that the deceased/life assured at the time of obtaining the insurance policy has complied with its terms and conditions and nothing remained to be done on his part.
23. Therefore, the subsequent repudiation letter smells nothing else than the harassment caused to the complainant.
24. We are of the opinion "that once the basic sum assured was paid to the complainant on the similar terms and conditions, the opposite party No.1 was not justified in withholding the additional cover of Rs.50.00 lacs on the ground of concealment of material facts". The repudiation of the claim of the complainant qua additional cover of Rs.50.00 lacs in our considered opinion amounts to deficiency in service on the part of opposite party No.1.
25. So far as opposite parties No.2 and 3 are concerned, they are the employers of the deceased-life assured. They had only purchased the policy in question from opposite party No.1 for 12 Kundan Palmo Negi versus PNB Met Life Insurance & ors.
(CC No.11/2018) their employees. Therefore, no deficiency in service can be attributed on their part.
26. Accordingly, the complaint is partly allowed. The opposite party No.1 is directed to pay additional cover due under the policy i.e. Rs.50.00 lacs to the complainant along with interest @ 9% per annum from the date of institution of this complaint, till its realization. The opposite party No.1 is also directed to pay Rs.75,000/- as compensation for mental harassment etc., besides litigation charges to the tune of Rs.25,000/-.
27. Certified copy of this order be sent to the parties and their counsel(s) strictly as per rules. Pending applications, if any, also disposed of. File after due completion be consigned to the record-room.
Justice Inder Singh Mehta President Sunita Sharma Member R.K. Verma Member 01.09.2022 Pkw 13