State Consumer Disputes Redressal Commission
Dlf Permerica Life Insurance Pvt. Ltd. vs Baljinder Bansal on 12 May, 2015
1
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR-37A, CHANDIGARH
FIRST APPEAL No.298 of 2014
Date of Institution: 24.03.2014
Date of Decision : 12.05.2015
DHFL Pramerica Life Insurance Co. Ltd., 2nd Floor, Bhai Jarnail Singh
Complex, Above Vijay Bank, Near Income Tax Office, G.T. Road,
Moga, Punjab.
.....Appellant/Opposite Party
VERSUS
Baljinder Bansal S/o Dharampal Bansal r/o New Sodhi Nagar, Zira
Road, Moga, Punjab now R/o Nihal Singh Wala, District Moga, Punjab.
.....Respondent/Complainant
First Appeal against the order dated
05.02.2014 passed by the District
Consumer Disputes Redressal Forum,
Moga.
Quorum:
Hon'ble Mr.Justice Gurdev Singh, President
Sh. Baldev Singh Sekhon, Member
Present:
For the appellant : Sh. Gurvinder Singh, Advocate For the respondent : None BALDEV SINGH SEKHON, MEMBER This appeal has been filed by the appellant-insurance company against the order dated 05.02.2014 passed by the District Consumer Disputes Redressal Forum, Moga (in short "District Forum"), vide which the complaint filed by the respondent/complainant was allowed and appellant/Opposite Party (in short 'the OP') was directed to pay to the 2 F.A.No. 298 of 2014 legal heirs of Dharam Pal Bansal, a sum of Rs. 3,63,000/-; being the insurance claim amount, within 30 days from the date of receipt of copy of the order, failing which, the awarded amount was to carry interest @ 6% per annum from the date of filing of the complaint till realization. It was further directed to pay Rs. 1,000/- on account of litigation expenses.
2. Briefly stated, the facts of the case are that Sh. Dharampal Bansal, son of Jagan Nath (father of the complainant) purchased an insurance policy, bearing No.00113682, from OP. It was pleaded that after filling of the proposal form for insurance, the OP got conducted the medical examination of Sh.Dharam Pal at Jalandhar from its own doctor and it accepted the proposal form and issued the policy in question, only after receiving the medical report. Unfortunately, Dharam Pal died on 20.5.2012, during the subsistence of the policy. The complainant lodged the insurance claim with the OP and completed all the relevant formalities. However, OP repudiated his claim on 23.1.2013 on the ground that at the time of purchasing the policy, Dharam Pal Bansal, deceased life insured (in short 'DLI') had concealed the facts regarding his pre-existing ailment i.e. Chronic Renal Failure, Diabetes, Hypertension, Hepatitis C Virus and closed communicated fracture of both legs and that the claim was not payable as per terms and conditions of the policy. It was pleaded that the plea of the OP was false and baseless as the policy was accepted after conducting medical tests. He also got served a legal notice upon OP on 1.8.2013 but still it failed to release the claim. Hence he filed the complaint before District Forum seeking directions to the OP to release him the amount of the 3 F.A.No. 298 of 2014 claim alongwith interest @ 2% per month from the date of death of DLI till realization. A compensation of Rs.50,000/- on account of mental and physical harassment, besides Rs. 20,000/- as legal expenses, was also prayed.
3. Upon notice, OP contested the complaint and filed written reply taking preliminary objections that the complaint was false, malicious and an abuse of the process of law. The complainant had mislead the District Forum by stating wrong facts and suppressing the actual material facts. His claim was repudiated by it on the ground of mis- representation of material facts by DLI. In the proposal form, a set of questionnaire was given to DLI with regard to his medical history, but all those questions were answered in negative by him. Based on the information, given in the proposal form and the declaration contained therein, it issued the insurance policy, in question. In the death claim received from the complainant, it was intimated that DLI suddenly expired on 20.5.2012 due to heart attack, whereupon an investigation was got conducted and it was found that DLI was, infact, suffering from Chronic Renal Failure (CRF), Diabetes, Hypertension, Hepatitis C Virus and closed Communicated Fracture of both legs since 2009. It was also found that DLI remained admitted in Rajiv Hospital, Moga from 17.8.2009 to 22.8.2009, but, he did not disclose the facts at the time of submitting the proposal form for insurance. It was pleaded that contract of insurance, being of utmost good faith, DLI was under an obligation to disclose the said material medical information in the proposal form, which was necessary for determining the risk under the said policy. Thus, he violated the terms and conditions of the policy and his claim 4 F.A.No. 298 of 2014 was rightly repudiated. The complainant was duly intimated about the repudiation, vide letter dated 31.10.2012. Denying all other allegations, dismissal of the complaint was prayed.
4. Parties led their evidence by way of affidavits and documents before the District Forum, which after going through the same, allowed the complaint, in aforesaid terms.
5. Aggrieved by this order, the OP has come up in appeal on the ground that the learned District Forum erred in not appreciating the fact that during the investigation, it was revealed that the DLI was suffering from Diabetes, Hypertension Chronic Renal Failure, Hepatitis C Virus and Closed Communicated Fracture of both legs prior to inception of the policy and that he was also taking treatment for the same. The cause of death of DLI is not relevant to the suppression of the facts about his pre-existing disease. It was wrong to assume that the DLI, who was patient himself, would not be aware of what was noted in the OPD card and would be ignorant about what the doctor had diagnosed and recorded in the OPD Card. District Forum has further failed to appreciate that the complainant had not challenged any document relied upon by the OPs and therefore, the medical record produced by it cannot be ignored. Acceptance of the appeal and setting aside of the impugned order was prayed.
6. We have thoroughly gone through the pleadings of the parties and have carefully perused the evidence brought on record of the District Forum.
7. Admittedly, the DLI Sh. Dharampal Bansal purchased insurance policy, bearing No.00113682, from OP and during its subsistence, 5 F.A.No. 298 of 2014 thereof DLI died on 20.5.2012. Thereafter, the complainant filed the death claim with the OP which was got investigated by OP and same was repudiated by it, vide its letter dated 23.1.2012 (Ex.C-4), on the following grounds :
"With reference to your query against policy number 113682, we would like to bring to your notice that on the basis of medical documents procured during Claim evaluation, late Mr. DHARAMPAL BANSAL was undergoing treatment for Chronic Renal Failure, Diabetes, Hypertension, Hepatitis C Virus & Closed Comminuted Fracture of Both Legs prior to proposal signing date. These facts were not disclosed to us at the time of affecting the assurance with us.
We, therefore, hereby inform you that as a result of policyholder's failure to disclose the correct information in question, the policy 113682 has, in terms of the declaration made by the policy holder in the proposal form and the policy contract, become void. Therefore, we stand by our decision to repudiate claim under policy number 113682 due to non- disclosure of Chronic Renal Failure, Diabetes, Hypertension, Hepatitis C Virus & Closed Comminuted Fracture of Both Legs at the time of signing the proposal form."
8. OP has proved on record the proposal form filled by the DLI on 12.1.2012 as Ex. OP-2, in which the DLI replied the questions regarding his medical health, mentioned in column 46, in negative confirming that he was not suffering and did not suffer from any diseases mentioned therein. He declared his general health as 'good'. The OP has further proved on record the medical record pertaining to DLI obtained by it from Rajiv Hospital, Moga, as Ex.OP-4, where he remained admitted from 17.8.2009 to 22.8.2009 and during which he was operated upon on 18.8.2009 for closed communicated fracture of both bones of left leg 6 F.A.No. 298 of 2014 and interlocking nailing of fracture was done. It was mentioned in bold letters on the first page of admission file that he was 'HCV+ve'. Under the column Diagnosis, it is mentioned that the complainant was suffering from CRF with HTN. Dr. Rajiv Gupta, who operated the DLI, also submitted a certificate to the effect that DLI was admitted in his hospital on 17.8.2009 and he had closed communicated fracture both bones (L) leg and was operated on 18.8.2009 and interlock nailing of fracture was done. He was discharged from the hospital on 22.8.2009 in a stable condition. It was further certified that he was a known case of Diabetes and HTN. In the Bio-Chemistry Report dated 17.8.2009, the DLI was found positive for HCV (1&2). It is, thus, confirmed that the DLI was suffering from Hepatitis C Virus as well. Thus it is evident from the medical record and the certificate of the treating doctor that the DLI was suffering from a number of diseases and even remained admitted in the hospital where he was operated upon. But, he willfully suppressed these facts while filling the proposal for insurance. The contract of insurance being of utmost good faith, DLI was under
obligation to disclose the said material facts in proposal form for the purpose of determining the risk under the policy. DLI signed declaration and authorization with regard to true, accurate disclosure of all facts and his 'deliberate concealment' of material facts about his heath has rendered the contract void abinitio.
9. The learned District Forum has wrongly concluded that the medical record cannot be taken into consideration because the same is not supported by the affidavit of the doctor; whereas it is a settled law that the medical record and the certificate of the doctor is to be relied 7 F.A.No. 298 of 2014 upon even if same is not supported by his affidavit. Moreover, the complainant has not denied that the DLI remained admitted in Rajiv Hospital, Moga and that he was operated upon 18.8.2009 nor he challenged the veracity the medical record proved by OP.
10. Hon'ble Supreme Court in case "Satwant Kaur Sandhu Vs. New India Assurance Company Ltd.", 2009 CTJ 956 (Supreme Court) (CP) has held as under :
"Judged from any angle, we have no hesitation in coming to the conclusion that the statement made by the insured in the proposal form as to the state of his health was palpably untrue to his knowledge. There was clear suppression of material facts in regard to the health of the insured and, therefore, the respondent
- insurer was fully justified in repudiating the insurance contract. We do not find any substance in the contention of learned counsel for the appellant that reliance could not be placed on the certificate obtained by the respondent from the hospital, where the insured was treated. Apart from the fact that at no stage the appellant had pleaded that the insured was not treated at Vijaya Health Centre at Chennai, where he ultimately died. It is more than clear from the said certificate that information about the medical history of the deceased must have been supplied by his family members at the time of admission in the hospital, a normal practice in any hospital. Significantly, even the declaration in the proposal form by the proposer authorises the insurer to seek information from any hospital he had attended or may attend concerning any decease or illness which may affect his health." 8 F.A.No. 298 of 2014
11. In view of the above said findings and the law laid down by the Hon'ble Supreme Court, the appeal of the OP is allowed and the impugned order of the District Forum is set aside. Consequently, the complaint filed by the complainant is dismissed. No order as to costs.
12. A sum of Rs.25,000/- was deposited by the appellant at the time of filing of the appeal before this Commission. Another amount of Rs.3,78,560/- was deposited by them vide receipt No.137872 dated 28.07.2014 as per directions of this Commission. Both these amounts, alongwith interest which has accrued thereon, if any, shall be remitted by the registry to the appellant/OP 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 appeal were heard on 29.04.2015 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 the court cases.
(JUSTICE GURDEV SINGH) PRESIDENT (BALDEV SINGH SEKHON) MEMBER May 12, 2015 KK 9 F.A.No. 298 of 2014