State Consumer Disputes Redressal Commission
Jaswinder Kaur vs Pnb Met Life India Insurance Co. Ltd. on 2 February, 2016
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 1086 of 2015
Date of institution: 1.10.2015
Date of Decision: 2.2.2016
Jaswinder Kaur wife of Late Sarabjit Singh, resident of Village Bholeke,
Tehsil Dera Baba Nanak, District Gurdaspur.
Appellant/Complainant
Versus
1. PNB Met Life India Insurance Co. Ltd., Regd. Office Brigade
Seshmahal, 5, Vani Vilas Road, Basavanagudi, Bangalore - 560004
through its Senior Manager/Office in Charge Claims.
2. Punjab National Bank, Fatehgarh Churrian for PNB Met Life India
Insurance Co. Ltd., Tehsil Dera Baba Nanak, District Gurdaspur
through its Branch Manager/Office in Charge.
Respondents/Ops
First Appeal against the order dated 19.8.2015
passed by the District Consumer Disputes
Redressal Forum, Gurdaspur.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Jasbir Singh Gill, Member
Mrs. Surinder Pal Kaur, Member
Present:-
For the appellant : Sh. Deepak Arora, Advocate
First Appeal No. 1086 of 2015 2
Gurcharan Singh Saran, Presiding Judicial Member
ORDER
The appellant/complainant(hereinafter referred as complainant) has filed the present appeal against the order dated 19.8.2015 passed by the District Consumer Disputes Redressal Forum, Gurdaspur(hereinafter referred as the District Forum) in consumer complaint No. 22 dated 12.1.2015 vide which the complaint filed by complainant was partly accepted with the direction to Ops to pay the NEFT unused amount of Rs. 62,182.64p to the complainant with saving bank interest w.e.f. the date of unsent NEFT besides Rs. 2,000/- as cost of litigation. Order was ordered to be complied with within 30 days otherwise it will carry interest @ 9% p.a. from the date of order.
2. Complaint was filed by the complainant under the Consumer Protection Act, 1986 (in short 'the Act') against the respondents/opposite parties (hereinafter referred as OPs) on the averments that husband of the complainant Sarbjit Singh had taken life insurance cover policy No. 21032756 of OP issued on 1.3.2013 with insurance cover of Rs. 3,50,000/- after paying premium amount of Rs.62,182.64p. He suffered chest infection and was admitted on 22.3.2014 in EMC Super Speciality Hospital, Amritsar and died on 25.3.2014. Under that policy, Ops were to pay sum assured of Rs. 3,50,000/-. Complainant alongwith all requisite documents lodged the claim. However, Ops instead of making the payment of the claim amount started to put off the matter with one excuse or the other. However, vide letter dated 2.7.2014, they repudiated the claim on the First Appeal No. 1086 of 2015 3 ground of non-disclosure of material facts. The act of repudiation of the claim on flimsy grounds is deficiency in service. Hence, the complaint with the direction to Ops to pay sum assured alongwith interest @ 18% per annum from 25.3.2014 and pay Rs. 30,000/- as compensation for harassment.
3. The complaint was contested by Ops. Op No. 1 in its written reply/version took the preliminary objections that the complaint was false, malicious and malafide, which was nothing but an abuse of process of the Forum, therefore, liable to be dismissed under Section 26 of the Act; complaint was vague and baseless; as there was no deficiency in service on the part of Op; the matter in dispute was not a consumer dispute; husband of the complainant(hereinafter referred as DLI) had taken the policy of OP No. 1 Met Smart Platinum Plan on the basis of application form bearing No. 201710407 on 1.3.2013 wherein he was required to pay premium for 10 years and sum assured was Rs. 3,50,000/-. DLI in the declaration declared that he had made true and accurate disclosure of all the facts and had not withheld any information, on the basis of which policy No. 21032756 was issued in favour of the DLI. On the basis of declaration, the DLI had understood the terms and conditions of the policy and agreed that if any untrue statement be contained in the application form, the policy contract shall be null and void. On 19.5.2014, OP received a death claim intimation from the complainant intimating Op that DLI died on 25.3.2014. Vide letter dated 20.5.2013, complainant was requested to furnish few documents for processing the claim and it was disclosed that before taking the policy, the DLI was a heart First Appeal No. 1086 of 2015 4 patient and was being treated at Army Hospital and Fortis Hospital. Medical record from EMC Hospital, Amritsar showed that DLI was a known case of Coronary Artery Disease (CAD), Dilated Cardiomyopathy (DCMP) for which he had undergone CABG, Type 2 DM and eventually died on 25.3.2014. Therefore, DLI had suppressed the material fact with regard to the treatment already taken by him and mis-represented to OP. Therefore, Op had rightly repudiated the claim. Further a sum of Rs. 62,182.64p being the fund value of the policy was refunded vide UTR CITIN14449595987 through NEFT towards the final settlement of the policy. The claim was also refunded by the Claims Committee and after perusal of the facts and circumstances they concluded that the claim was rightly repudiated. Contract of insurance was of utmost good faith and non- disclosure of material facts vitiate the policy, therefore, there was no deficiency in service on the part of OP. Therefore, the complaint was liable to be dismissed. On merits, issuance of policy in favour of the DLI was admitted. However, the claim was repudiated in view of the reasons stated above in the preliminary objections on the ground of concealment of material facts, therefore, the claim was not payable. No deficiency in service on the part of the Op. Complaint was liable to 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 her affidavit Ex. C-1, repudiation letter Ex. C- 2, statement of a/c Ex. C-3, death certificate Ex. C-4, death summary First Appeal No. 1086 of 2015 5 Ex. C-5, decline notice Ex. C-6, complaint Ex. C-7, postal receipt Ex. C-8, legal notice Ex. C-9, postal receipts Exs. C-10 & 11, email Ex. C- 12, bank passbook copy Ex. C-13, Aadhar card copy Ex. C-14. On the other hand, Ops had tendered into evidence affidavit of Urmila Mekalki Ex. Op-1/1, application form Ex. Op-1/2, claim intimation form Ex. Op-1/3, policy details Ex. Op-1/4, repudiation letter Ex. Op-1/5, grievance letter Ex. Op-1/6, reply of notice Ex. Op-1/7. OP No. 2 had tendered into evidence affidavit of Karamjit Singh, Manager Ex. Op- 2/1.
6. After going through the allegations in the complaint, written version filed by Ops, evidence and documents brought on the record, the complaint was partly allowed as referred above.
7. It has been argued by the counsel for the appellant/complainant that the claim was wrongly repudiated by the Op as well as the complaint was wrongly dismissed by the District Forum as the deceased was perfectly hale and hearty at the time of obtaining the policy. He suddenly fell sick on 22.3.2014. He was admitted in EMC Super Speciality Hospital, Amritsar and died on 25.3.2014. However, no medical record was tagged by the investigating agency regarding his illness nor there was any evidence that he was suffering from any serious ailment. The record collected from Fortis Hospital, Amritsar that the deceased was admitted in that hospital on 29.12.2009 and was discharged on 1.1.2010 i.e. two days and had undergone investigation for two days does not mean that he was suffering from any ailment and relied upon the judgment "Oriental Insurance Company Limited versus Baby Simran Kaur", First Appeal No. 1086 of 2015 6 2014(2) CLT 361-362. In this case, the claim was repudiated on the ground of concealment of pre-existing disease. In that case, the insured was suffering from heart valve since birth, due to internal congenital disease, therefore, there was no material fact of mis- representation. In an other judgment, relied upon on "Life Insurance Corporation of India vs. Santosh Rani" 1998(2) CLT 471. In that case, there was no opinion of the Doctor about the treatment, if any taken by the insured for evidence. In those circumstances, the insurance company was asked to pay the amount. However, in the present case, Ops had appointed Probe India to investigate the matter and his report is Ex. Op-1/4. He in his report stated that ailment was suspected as per the investigations LA was a heart patient and that they took a record and placed on the record of Fortis Hospital, Department of Cardiology, Discharge summary according to which patient Sarabjit Singh was admitted in that hospital on 29.12.2009 and was discharged on 1.1.2010 and in the diagnosis Coronary Artery Disease(CAD), Triple Vessel Disease, Severe OY Dysfunction Hypertension DM Type-II were found. Coronary Angiography was done on 30.12.2009, therefore, DLI was aware about the coronary artery disease (CAD) on that day. Whereas in the proposal form Ex. Op-1/2 in which there was specific columns about the medical status of the applicant and Column No. 13 reads as under;-
13. During the past five years, Yes No
(a) Have you Consulted any doctor or health √ practitioner for illness lasting for more than 4 days except for fever, common cold or cough?
First Appeal No. 1086 of 2015 7
(b) Have you Undergone ECG, X-rays, blood test √
or other tests?
(c) Have been admitted/advised to be admitted to √
any hospital or any other medical facility?
and applicant stated 'No', therefore, he had concealed the material fact with regard to his heart problem. A reference has been given to 2013(1) CPJ 606 "Komal Sharma Deepak Kumar Sharma and Ors. versus Life Insurance Corporation of India and Ors.". In that case, Doctor certificate showed that insured was suffering from Auto Immune Hepatits and pneumonia for the last 10 years due to cardio respiratory arrest. It was observed that he was under a solemn obligation to make true and full disclosure of information on subject which was within his knowledge. Similar observations were made in 2015 DNJ 3 "Life Insurance Corporation of India versus Santosh Devi" in which judgment of "Satwant Kaur Sandhu Vs. New India Assurance Company Ltd." (2009) 10 SCR 560 and "P.C. Chacko V. Chairman, L.I.C. of India", AIR 2008 SC 425 were relied up. Against these judgments, the counsel for the appellant was not having any contradictory judgment that in case he has suppressed the material facts even then he was entitled to the claim. Whereas judgment referred by the complainant is not directly dealing with suppression of material facts at the time of taking policy. We are of the opinion that the District Forum properly appreciated the evidence and documents on the record and had rightly came to the conclusion that Op was justified to repudiate the claim.
First Appeal No. 1086 of 2015 8
8. We are of the opinion that no point is made out in favour of the appellant/complainant to admit the appeal, the same is hereby dismissed in limine.
9. The arguments in this appeal were heard on 22.1.2016 and the order was reserved. Now the order be communicated to the parties as per rules.
(Gurcharan Singh Saran) Presiding Judicial Member (Jasbir Singh Gill) Member February 2, 2016. (Surinder Pal Kaur) as Member