State Consumer Disputes Redressal Commission
Smt.Varsha Vyas Ben Kesharwani vs Manager D.H.F.L. Pramerica Life ... on 27 August, 2019
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vukosnd dz-1 dh vksj ls ?ku';ke HkkbZ ds'kjkuh dk LokLF; laca/kh tkap dj fy;s Fks] mlds mijkar gh chek ikWfylh nsus ds fy, jkth gq, FksA ifjokfnuh ds ifr Lo- Jh ?ku';ke HkkbZ ds'kjkuh dh e`R;q fnukad&20-01-2018 dks g`n;k?kkr gksus ls gks xbZA ikWfylh ds fu;e o 'krksZa ds rgr chek /kkjd dh e`R;q gksus ij dOgjst jkf'k&25]68]497@&¼iPphl yk[k vM+lB gtkj pkj lkS larkucs :Ik;s½ vukosnd dz-1 ls ifjokfnuh izkIr djus dh vf/kdkfj.kh gSA ifjokfnuh us vukosnd dz-1 ds dk;kZy; esa chek nkok izLrqr dh gS] fdUrq vkt fnukad rd ifjokfnuh dks chek jkf'k dk Hkqxrku vukosnd dz-1 }kjk ugha fd;k x;k gS vkSj uk gh dksbZ tokc fn;k x;k gSA ifjokfnuh us dbZ ckj O;fDrxr :i ls eqykdkr dj chek nkok Hkqxrku djus dk fuosnu fd;k mlds mijkar Hkh dksbZ dk;Zokgh ugha dh xbZ tks fd vukosndx.k dh lsok esa fuEurk dh Js.kh esa vkrk gSA ifjokfnuh us vius vf/koDrk ds ek/;e ls vukosndx.k dks uksfVl izsf"kr fd;k] mlds mijkar Hkh vukosndx.k dh vksj ls jkf'k Hkqxrku djus dk dksbZ iz;kl ugha fd;k x;k gS vkSj uk gh dksbZ tokc fn;k x;k gS ftlds dkj.k // 4 // ifjokfnuh dks ;g ifjokn ykus dh vko';drk iM+h gSA vr% ifjokfnuh dks ifjokn&i= esa of.kZr vuqlkj vuqrks"k fnykbZ tkosA 03- fojks/kh i{k dzekad&1 dh vksj ls fyf[kr dFku izLrqr djrs gq, ;g vfHkopu fd;k x;k gS fd ifjokfnuh ds ifr Lo- ?ku';ke HkkbZ ds'kjkuh us vukosnd dz-1 ls Mh- ,p- ,Q- ,y- izesfjdk dzsfMV ykbZQ Iyl ba';ksjsal ds rgr ikWfylh dzekad&lh- th- 000027 ¼Iyku ,½ izkIr fd;k Fkk tks fd 04 o"kZ ds fy, Fkk ftldk chfer ewY;&25]68]497@&¼iPphl yk[k vM+lB gtkj pkj lkS larkucs :Ik;s½ Fkk vkSj bldk ,deq'r izhfe;e 68]496-68 ¼vM+lB gtkj pkj lkS fN;kucs :Ik;s vM+lB iSls½ FkkA mDr ikWfylh fnukad&26-10-2017 dks tkjh fd;k x;k FkkA ifjokfnuh us e`rd ?ku';ke HkkbZ ds'kjkuh dh e`R;q dh lwpuk ds lkFk nkok izi= izLrqr dh Fkh vkSj pwafd ikWfylh ysus ds 'kh?kz ckn e`R;q gqbZ Fkh blfy, vukosnd dz-1 }kjk tkap djk;s tkus ij ;g ik;k x;k fd e`rd us izLrko&i= esa viuh chekjh ds laaca/k esa dksbZ mYys[k ugha fd;k Fkk] tcfd chek /kkjd Lo- ?ku';ke HkkbZ ds'kjkuh fiNys 04 lky ls MkbZfcfVd VkbZi&II ls ihfM+r Fkk ftldk mipkj gsjhVst gkWfLiVy esa MkW- vkj- ds iVsy ls djk;k tk jgk FkkA e`rd ?ku';ke HkkbZ ds'kjkuh chek ikWfylh ysus ds iwoZ gh dksjksujh vkVZjh fMlhl] MkbZfcfVd VkbZ& II ,oa gkbZijVsa'ku ls ihfM+r Fkk ftldk mipkj fiNys dbZ o"kZ ls fofHkUu gkWfLiVy esa djk;k tk jgk Fkk] tcfd ifjokfnuh ds ifr }kjk iziksty QkeZ fnukad&26-10-2017 esa ;g ?kks"k.kk // 5 // dh xbZ Fkh fd og iw.kZr% LoLFk gS rFkk esfMdy iz'uksRrj ds tokc esa ifjokfnuh ds ifr }kjk NO vafdr fd;k x;k gS ftlesa MkbZfcfVd] gkbZijVsa'ku rFkk vU; 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vukosnd dz-1 dh vksj ls Lo- ?ku';ke HkkbZ ds'kjkuh dk LokLF; laca/kh tkap fd;k x;k Fkk vkSj fpfdRlh; ijh{k.k ls larq"V gksus ds ckn gh chek ikWfylh tkjh dh xbZ Fkh vkSj ml le; rd ifjokfnuh ds ifr dksbZ dksbZ tfVy ;k ?kkrd chekjh ugha FkhA vpkud 12 tuojh 2018 dks ifjokfnuh ds ifr Lo- ?ku';ke HkkbZ ds'kjkuh dks vLoLFk gksus ds dkj.k mUgsa jked`".k ds;j gkWfLiVy esa HkrhZ djk;k x;k Fkk vkSj bZykt ds nkSjku fnukad&20-01-2018 dks ifjokfnuh ds ifr dh e`R;q g`n;k?kkr gksus ls gks xbZ Fkh vkSj bl ij ifjokfnuh }kjk nkok izLrqr fd;k x;k Fkk] ijUrq vukosnd dz-1 chek daiuh us mDr nkos dk fujkdj.k ugha fd;k] rc ifjokfnuh }kjk vukosnd dz-1 chek daiuh dks uksfVl izsf"kr fd;k x;k Fkk ftldk dksbZ tokc chek daiuh }kjk ugha fn;k x;kA chek daiuh ds fyf[kr dFku ls ;g irk pyk fd vukosnd dz-1 chek daiuh }kjk nkok egRoiw.kZ rF; fNikus ds vk/kkj ij fujLr fd;k x;k gSA ifjokfnuh ds ifr }kjk fdlh izdkj ds egRoiw.kZ rF;ksa dks fNik;k ugha x;k gSA vukosnd dz-1 chek daiuh }kjk tkap ls larq"V gksus // 7 // ds mijkar gh chek fd;k x;k FkkA ifjokfnuh ds ifr Lo- ?ku';ke HkkbZ ds'kjkuh tc gkWfLiVy esa HkrhZ gq, rHkh mUgsa Hkh chekfj;ksa ds ckjs esa irk pyk Fkk mlds ckn Hkh vukosnd dz-1 chek daiuh }kjk ifjokfnuh ds nkos dks vLohdkj dj fn;k x;k tks fd lsok esa deh ,oa O;kolkf;d dnkpj.k dks nf'kZr djrk gSA blfy, ifjokfnuh dk ifjokn Lohdkj fd;k tkos vkSj ifjokfnuh dks ifjokn&i= esa of.kZr vuqrks"k iznku dh tkosA 08- fojks/kh i{k dzekad&1 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh lkSjHk feJk dk rdZ gS fd e`rd ?ku';ke HkkbZ ds'kjkuh us Mh- ,p- ,y- ,Q- izesfjdk xzqi dzsfMV ykbZQ Iyl ds rgr ikWfylh vukosnd dz-1 us izkIr fd;k Fkk tks fd 04 o"kZ ds fy, Fkk vkSj ftldh izhfe;e dh jkf'k ek= 68]496-68 ¼vM+lB gtkj pkj lkS fN;kucs :Ik;s vM+lB iSls½ FkhA mDr ikWfylh fnukad&26-10-2017 dks tkjh dh xbZ Fkh ftldk chfer ewY;&25]68]497@&¼iPphl yk[k vM+lB gtkj pkj lkS larkucs :Ik;s½ FkkA ifjokfnuh ds }kjk fpfdRlh; nLrkostksa ds lkFk nkok izi= izLrqr fd;k x;k rc bldh izkjafHkd tkap djkbZ xbZ rks ;g ik;k x;k fd e`rd chek /kkjd iwoZ ls chekfj;ksa ls xzflr Fkk ftls mlus izLrko&i= esa mYysf[kr ugha fd;k Fkk vkSj izLrko&i= esa lgh fooj.k ugha fn;k Fkk] tcfd ifjokfnuh ds ifr Mk;fcfVd VkbZi&II] gkbZijVsa'ku rFkk dksjksujh vkVZjh fMlhl ls xzflr Fkk vkSj e`rd iwoZ esa Hkh fofHkUu vLirkyksa esa bZykt pyk Fkk vkSj ;g egRoiw.kZ rF; chek /kkjd }kjk // 8 // fNik;k x;k Fkk vkSj blfy, ifjokfnuh ikWfylh ds rgr fdlh izdkj dh jkf'k ikus dh vf/kdkfj.kh ugha gSA vukosnd dz-1 chek daiuh us nkok vLohdkj djds fdlh Hkh izdkj ls lsok esa dksbZ deh ugha fd;k x;k gSA vr% ifjokfnuh dk ifjokn lO;; fujLr fd;k tkosA vukosnd dz-1 chek daiuh dh vksj ls vius rdZ ds leFkZu esa Satwant Kaur Sandhu Vs. New India Assurance Company Limited (2009) 8 Supreme Court Cases 316, United India Insurance Co. Ltd. Vs. M. K. J. Corporation with M. K. J. Corporation Vs. United India Insurance Co. Ltd. (1996) 6 Supreme Court Cases 428, Modern Insulators Ltd. Vs. Oriental Insurance Co. Ltd. (2000) 2 Supreme Court Cases 734, Life Insurance Corporation of India Vs. Smt. G. M. Channabasamma (1991) 1 Supreme Court Cases 357, Mithoolal Nayak Vs. Life Insurance Corporation of India 1962 AIR 814 dk voyacu fy;k gSA 09- fojks/kh i{k dzzekad&2 dh vksj ls dksbZ milatkr ugha gq, gSa blfy, fojks/kh i{k dzekad&2 ds fo:} ,di{kh; dk;Zokgh dh xbZ gSA 10- geus mHk;i{k ds fo}ku vf/koDrkx.k dk rdZ Jo.k fd;k rFkk vfHkys[k dk ifj'khyu fd;k x;kA 11- ;g vfookfnr gS fd ifjokfnuh ds ifr Lo- ?ku';ke HkkbZ ds'kjkuh us Mh- ,p- ,y- ,Q- izesfjdk xzqi dzsfMV ykbZQ Iyl ds rgr chek ikWfylh izkIr fd;k Fkk ftldk chfer ewY; 25]68]497@&¼iPphl yk[k vM+lB gtkj pkj lkS larkucs :Ik;s½ FkkA // 9 // 12- ifjokfnuh dh vksj ls ;g crkus dk iz;kl fd;k x;k gS fd vukosnd dz-1 chek daiuh ds fpfdRld }kjk ikWfylh tkjh djus ds iwoZ ifjokfnuh ds ifr Lo- ?ku';ke HkkbZ ds'kjkuh dk fpfdRlh; ijh{k.k fd;k x;k Fkk ftlesa dksbZ tfVy ,oa ?kkrd chekjh gha ik;k x;k FkkA ifjokfnuh dh vksj ls ikWfylh 'ksM~;wy ¼,usD'pj lh&2½ izLrqr fd;k x;k gS rFkk ,usD'pj lh&6 vukosndx.k dks izsf"kr uksfVl izLrqr fd;k x;k gSA ifjokfnuh vkxs ;g crkuk pkgrh gS fd vukosnd dz-1 }kjk ifjokfnuh ds chek nkos dh jf'k ds Hkqxrku ds laca/k esa dksbZ iz;kl ugha fd;k x;k Fkk vkSj uk gh uksfVl dk tokc fn;k x;k FkkA ifjokfnuh dks vukosnd dz-1 ds fyf[kr dFku ls gh chek nkok fujLr gksus dh tkudkjh gqbZ vkSj nkok fujLr djus dk vk/kkj ;g crk;k x;k gS fd ifjokfnuh ds ifr }kjk iz'ukoyh tks iwNk x;k Fkk mldk lgh mRrj ugha fn;k x;k FkkA ifjokfnuh ds ifr }kjk LokLF; laca/kh rF;ksa dks izdV ugha fd;k FkkA 13- ,usD'pj lh&5 jked`".k ds;j gkWfLiVy jk;iqj dk MsFk lejh gS ftlesa e`rd ?ku';ke HkkbZ ds'kjkuh dks fnukad&12-01-2018 dks HkrhZ fd;k x;k Fkk vkSj ftlesa Hypertension, Diabetic Mellitus type-II, Coronary Artery Disease chekjh ls xzflr gksuk crk;k x;k gS vkSj blh vk/kkj ij ifjokfnuh }kjk ;g crkus dk iz;kl fd;k x;k gS fd ifjofknuh ds ifr dks tuojh 2018 esa gh mDr chekjh ds ckjs esa tkudkjh gqvk gS tcfd blds [k.Mu esa vukosnd dz-1 dh vksj ls // 10 // gsfjVst gkWfLiVy }kjk tkjh fd;k x;k izek.k&i= ¼,usD'pj vks-ih- 6½ izLrqr fd;k x;k gS ftlesa ;g mYysf[kr gS fd e`rd fiNys 04 o"kksZa ls Diabetic Mellitus type-II dk bZykt gsfjVst gkWfLiVy esa djok jgk FkkA vukosnd dz-1 dh vksj ls ,usD'pj vks- ih- 1] 2&¼2½ izLrqr fd;k x;k gS tks fd iziksty QkeZ gS vkSj mlesa LokLF; laca/kh iz'uksRrjh ds mRrj esa e`rd chek /kkjd }kjk fuEu izfof"V;ka dh xbZ gSa%& Medical History of the Life to be assured Proposed Insured Joint Life 1 Have you ever suffered or are currently suffering from
a)Chest pain or heart attack or any other heart disease Yes No Yes No
b) Cancer, Tumor, growth or cyst of any kind Yes No Yes No
c) -----
d) ---- e) ----- f) ------ g) Diabetic Yes No Yes No h) High Blood Presure Yes No Yes No i) --- 2 During the last 5 years have you undergone any major Yes No Yes No
surgery or been hospitalized for more than one week 3 Do you take part in any adventorous sports or hobbies Yes No Yes No 14- vukosnd dz-1 dh vksj ls izLrqr ,usD'pj vks- ih-&1] 2 ¼1½ ,oa vks- ih- 1] 2 ¼2½ iziksty QkeZ gS ftlesa ifjokfnuh ds ifr Lo- ?ku';ke HkkbZ ds'kjkuh ds }kjk LokLF; laca/kh iz'uksRrjh ds mRrj esa Diabetic, // 11 // Hypertension ,oa fdlh Hkh g`n; laca/kh chekjh ds laca/k esa No fy[kk x;k gS rFkk ;g ?kks"k.kk dh xbZ gS fd ifjokfnuh ds ifr iw.kZr% LoLFk Fks ftlesa mudk gLrk{kj vafdr gSA vr% mDr nLrkost ls Li"V gksrk gS fd ifjokfnuh ds ifr ds }kjk iziksty QkeZ esa fdlh Hkh izeq[k chekjh ls xzflr gksuk ugha crk;k x;k gSA 15- Gurmeet Kaur @ Meeto & Anr. vs. Life Insurance Corporation of India, III (2015) CPJ 246 (NC), esa ekuuh; jk"Vªh; vk;ksx }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "Deceased had been suffering from diabetes for the last 14-15 years and suffered from chronic renal failure for last 4-5 years. No evidence on record to prove that information given by Doctor regarding health status of insured was incorrect. Violation of conditions of policy established. Repudiation justified."
16- L.I.C. of India v. MU Jakia, IV (2013) CPJ 129 (NC), esa ekuuh; jk"Vªh; vk;ksx }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "15. It is an undisputed fact that Shri Akhil Khan the deceased had taken LIC policy from the respondent for a sum of Rs.51,000/- on 1.1.2004. It is also an admitted fact that as per the bed head ticket of Maharana Bhopal Hospital, Udaipur the deceased was admitted to the hospital on 3.6.2003 for the treatment of chronic renal failure, hypertension, septicaemia, nephritis and was discharged from the hospital on 6.6.2003. While the State Commission has correctly come to the conclusion that the petitioner were justified in repudiating the claim of the respondents on the ground of suppression of material fact regarding health and that the finding of the District Forum rejecting the claim of the respondents were based on correct appreciation of entire material evidence available on record and they // 12 // do not suffer from any basic infirmity or illegality or perversity and hence, no interference is called for with the same and appeal was dismissed."
17. L.I.C. of India v. Pratima Mishra, IV (2013) CPJ 161 (Chha.), esa bl vk;ksx }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "9. Documents in respect of treatment of deceased insured, which have been brought on record by the appellant before the District Forum are photocopies of the treatment of the deceased insured in Ramkrishna Care Hospital, Raipur as well as Chandulal Chandrakar Memorial Hospital, Bhilai. From these documents, it appears that as per noting of Ramkrishna Care Hospital, Raiapur on C.T. Scan, it was found that there was no bony injury and all four limbs could be raised by him. Pupil of both eyes were normal. Thus, nothing substantial was noted by the Hospital for which it can be said that it was a circumstance which had adversely affected the health of the insured and was required to be notified by him to the Insurance Corporation. Later on he was treated with Chandulal Chandrakar Memorial Hospital, Bhilai from 15.03.2008, where ultimately he died on 16.03.2008. Thus, from record of the treatment given in Ramkrishna Care Hospital, it appears that it is not containing any such information which can be said to be relating to circumstance adversely affected the health of the deceased insured and was required to be notified by him to the Insurance Corporation."
18- Branch Manager, LIC Of India Vs. Jyothi Sudhir 2016 (4) CPR 471 (NC), esa ekuuh; jk"Vªh; vk;ksx }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "Consuer Protection Act, 1986-Sections 15,17,19 and 21-Insurance Act, 1938-Section 45- Insurance- Repudiation of death claim on ground of suppression of pre-existing disease-Any fact which goes to root of contract of insurance and has a bearing on risk involved would be material. Had assured disclosed that he was suffering from // 13 // Hypertension and Diabetes Mellitus, Corporation would have asked for special medical reports which would have been placed before a medical referee and based upon report of medical referee, decision would have been taken whether to accept proposal or not- False or inaccurate statement by assured was on a material aspect which influenced decision of insurer on whether to accept proposal or not. Insurer was justified in repudiating claim on account of false statement made by assured in proposal form."
19- Sunita Goyal Vs. Bajaj Allianz Life Insurance Co. Ltd. & anr. 2018 (1) CLT 63 (NC) esa ekuuh; jk"Vªh; vk;ksx }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "13. It is clear from the facts and circumstances of the case that suffering from diabetes, hypertension etc. and getting treatment for ARF was a material fact which must be within the knowledge of the deceased policy holder. It was, therefore, the bound duty of the deceased to have disclosed these facts and for his failure to do so, he cannot take advantage of section 45 of Insurance Act, on the ground that the death took place after two years of obtaining the policy in question. Even after the lapse of two years of taking the policy, it was necessary to disclose information about the material facts before the Insurance Company.
14. It is a settled legal preposition that a contract of insurance is a contract of good faith 'uberrima fides'. As stated by the Hon'ble Supreme Court in "Life Insurance Corporation of India & Ors. vs. Asha Goel(Smt.) & Anr."(supra), every material fact must be disclosed otherwise, there is a good ground for rescission of the contract."
20- mijksDr U;k; n`"Vkarksa esa Hkh ekuuh; jk"Vªh; vk;ksx }kjk ;gh vfHkfu/kkZfjr fd;k x;k gS fd ;fn izLrkod iwoZorhZ xaHkhj chekfj;ksa dks izLrko&i= esa ugha n'kkZrk gS rks ;gh ekuk tkosxk fd chek izLrkod us // 14 // izLrko&i= esa ,sls rkfRod rF;ksa dks fNik;k gS ftldk izHkko vxj mu chekfj;ksa dk mYys[k fd;k tkrk rks chekadu ij iM+rkA ,slh n'kk esa ;fn chek daiuh us e`R;q nkos dks fujLr dj fn;k gS rks mls lsok esa fuEurk ugha ekuk tkosxkA 21- vukosnd dz-2 b.Mlb.M cSad gS ftlds }kjk O;kolkf;d _.k iznku fd;k x;k Fkk vkSj _.k dh lqj{kk ds fy, thou chek ikWfylh dk izhfe;e vukosnd dz-1 dks Hkqxrku fd;k x;k FkkA vukosnd dz-2 }kjk izhfe;e dh jkf'k dk Hkqxrku djds vius nkf;Ro dk fuokZg fd;k x;k gSA ,sls esa chek nkos ds Hkqxrku ds laca/k esa vukosnd dz-2 dk dksbZ Hkh nkf;Ro mRiUu ugha gksrk gSA vr% ge vukosnd dz-2 dks bl izdj.k ls mUeksfpr djrs gSaA 22- mijksDr foospuk ds ifjizs{; esa ge bl fu"d"kZ ij igaqps gSa fd e`rd /ku';ke HkkbZ ds'kjkuh gkbZijVsa'ku] 'kqxj vkSj dksjksujh vkVZjh fMlhl ls xzflr Fkk] ijUrq vukosnd dz-1 us tks izLrko&i= izLrqr fd;k gS mlesa bu rF;ksa dk mYys[k ugha fd;k x;k gS vkSj iz'uksa dk mRrj **ugha** esa fn;k x;k gSA ifjokfnuh ds vuqlkj mlds ifr Lo- ?ku';ke HkkbZ ds'kjkuh us fnukad&26-10-2017 esa ikWfylh izkIr fd;k gS vkSj tuojh 2018 esa jked`".k ds;j gkWfLiVy esa HkrhZ fd;k x;k gS] vFkkZr~ ikWfylh ysus ds djhcu 03 eghus ds Hkhrj gh chekjh ls xzflr gqvk gS vkSj jked`".k ds;j gkWfLiVy }kjk mUgsa Coronary Artery Disease gksuk crk;k x;k vkSj Coronary Artery Disease dk vFkZ ;g gksrk gS fd yacs le; ls // 15 // pyk vk jgk th.kZ ;k iqjkuk jksxA blls Li"V gS fd e`rd ?ku';ke HkkbZ ds'kjkuh ikWfylh izkIr djus ds iwoZ ls Coronary Artery Disease ls xzflr Fkk] tcfd esfMdy gsYFk laca/kh tks iz'u iwNs x, Fks mu lHkh iz'uksa dk mRrj uk esa fn;k x;k FkkA blls Li"V gS fd iziksty QkeZ Hkjrs le; Lo- ?ku';ke HkkbZ ds'kjkuh us vius iwoZ chekjh ds laca/k esa mYys[k ugha fd;k Fkk vkSj Coronary Artery Disease dk irk 1&2 fnu esa pyuk laHko ugha gS vkSj vkVZjh laca/kh chekjh iwoZ esa gksuk LokHkkfod gS vkSj bu rF;ksa dks fNikrs gq, chek/kkjd Lo- ?ku';ke HkkbZ ds'kjkuh us izLrko&i= esa Hypertension, Diabetic Mellitus Type-II rFkk Coronary Artery Disease dk mYys[k ugha fd;k gS tks fd egRoiw.kZ rF;ksa dks fNikus dh ifjf/k esa vkrk gSA bl izdkj bl izdj.k esa Suppression of Material Facts fo|eku gS vkSj bl izdkj vuksondx.k us ifjokfnuh ds nkos dks vLohdkj dj fdlh izdkj dh lsok esa deh ugha fd;k gSA vr% ifjokfnuh chek ikWfylh ds rgr fdlh Hkh izdkj dk vuqrks"k izkIr djus dh vf/kdkfj.kh ugha gSA 23- vr% ifjokfnuh dh vksj ls izLrqr ifjokn fujLr fd;k tkrk gSA izdj.k dh ifjfLFkfr dks ns[krs gq, i{kdkj viuk&viuk O;; ogu djsaxsA ¼ U;k;ewfrZ lh- ch- cktis;h ½ ¼ Jherh :fp xks;y ½ v/;{k lnL;
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