State Consumer Disputes Redressal Commission
Birpal vs Icici Pru.Life Insurance Co. on 6 September, 2017
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA First Appeal No : 921 of 2016 Date of Institution: 04.10.2016 Date of Decision : 06.09.2017 Birpal son of late Ramphal Nagar, Resident of Village and Post Tigaon, Faridabad. Appellant-Complainant Versus ICICI Prudential Life Insurance Company Limited, through its Manager, S.C.O. No.100-101, Second Floor, Main HUDA Market, Sector-16, Faridabad-121002. Also at its registered office at: ICICI Prulife Towers, 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025. Respondent-Opposite Party CORAM: Hon'ble Mr. Justice Nawab Singh, President. Mr. Balbir Singh, Judicial Member.
Argued by: Shri B.S. Walia, Advocate for appellant.
Shri Hitender Kansal, Advocate proxy on behalf of Shri Chetan Gupta, counsel for respondent.
O R D E R BALBIR SINGH, JUDICIAL MEMBER This complainant's appeal is directed against the order dated August 30th, 2016 passed by District Consumer Disputes Redressal Forum, Faridabad (for short 'the District Forum') whereby complaint was dismissed.
2. Partap Singh (hereinafter referred to as 'the Life Assured')-brother of complainant Birpal, was provided a Life Guard Insurance Policy bearing No.10248060 by ICICI Prudential Life Insurance Company Limited (for short the 'Insurance Company')-Opposite Party for a period of 25 years commencing from November 11th, 2008, mentioning Sum Assured as Rs.15.00 lacs. The Life Assured died on January 23rd, 2009. After death of the life assured, complainant being real brother and nominee of the life assured, submitted insurance claim along with relevant documents before the Insurance Company-Opposite Party. The opposite party repudiated claim of the complainant vide letter dated January 04th, 2010 (Annexure R-6) on the ground that the life assured had concealed material facts from the Insurance Company. It was stated that the life assured did not disclose his ailments in the proposal form and also did not disclose regarding issuance of another insurance policy in his name. Ultimately, when the opposite party did not make payment of the amount despite service of the legal notice dated March 31st, 2010, the complainant filed the present complaint under Section 12 of the Consumer Protection Act, 1986 with a prayer to direct the opposite party/insurance company to pay an amount of Rs.15.00 lacs being sum assured with interest at the rate of 12% per annum w.e.f. March 23rd, 2009; an amount of Rs.1,00,000/- as compensation on account of un-necessary harassment and mental agony and an amount of Rs.11,000/- as litigation expenses.
3. The Opposite Party/Insurance Company in its written version has taken plea that the complaint is not maintainable in the present form and that the insured had concealed material facts at the time of providing insurance policy. As per version of the opposite party, the insurance policy was provided to the life assured-Partap Singh during his life time on the basis of undertaking given by him at the time of submitting his proposal form. The life assured concealed material facts from the insurance company regarding his existing disease. During investigation by the investigator of the insurance company, it was revealed that the life assured was suffering from Asthma for the last about five years and he was also suffering from Paralysis. It was also found that the life assured had already applied for insurance policy from another insurance company for a sum of Rs.50.00 lacs. In this way, the answer to question No.35 of the proposal form was found fake and due to this reason claim of the complainant was repudiated. It is admitted fact that the insurance policy, as mentioned in the complaint, was provided for a period of 25 years w.e.f. November 11th, 2008 mentioning total sum assured as Rs.15.00 lacs. The life assured Partap Singh died within three months from the date of commencement of the insurance policy. The opposite party prayed that the complaint filed by the complainant be dismissed with cost.
4. Both the parties adduced evidence in support of their respective claims.
5. After hearing arguments, vide impugned order dated August 30th, 2016, complaint filed by the complainant was dismissed holding that the life assured had concealed material facts from the insurance company at the time of submitting the proposal form.
6. Aggrieved with the impugned order dated August 30th, 2016, the present appeal bearing No.921 of 2016 has been filed by the complainant with a prayer to set aside the impugned order and to grant relief as prayed in his complaint.
7. We have heard learned counsel for the parties and have perused the case file.
8. During the course of arguments, there was no controversy of any type that the life assured-Partap Singh (since deceased) brother of the complainant purchased a Life Guard Insurance Policy bearing No.10248060 from the opposite party for a period of 25 years commencing from November 11th, 2008, mentioning total Sum Assured as Rs.15.00 lacs. It is evident from the insurance policy and documents Annexure R-1 and R-2. It is also admitted fact that the life assured died on January 23rd, 2009. Copy of the Death Certificate issued from Health Department is placed on the file, although the same has not been tendered in evidence, wherein the date of death of Partap Singh is mentioned as January 23rd, 2009. The insurance claim of the complainant has been repudiated on the ground that the life assured had earlier applied for another life insurance policy from another insurance company and that the life assured did not disclose his pre-existing disease as Partap Singh was suffering from Paralysis at the time of his death and he was also suffering from Asthma for a period of last five years. It will be pertinent to mention here that the opposite party also in its written version has not taken plea that the life assured during his life time was provided another insurance policy by another insurance company. Only it is pleaded that the life assured had applied for providing another life insurance policy before another insurance company. Neither the name of that insurance company has been mentioned in the written version nor full particulars have been supplied by the opposite party to presume that the life assured earlier had submitted a proposal form before another insurance company providing him another insurance policy for total sum assured as Rs.15.00 lacs. Plea of the opposite party is not specific and is not supported by any convincing documentary evidence. So, on this ground, insurance claim of the complainant cannot be declined.
9. As per version of the opposite party, the life assured-Partap Singh, was a patient of Asthma for the last about five years when he died. At that time he was also a paralysis patient. The opposite party could not produce any convincing documentary evidence to prove that the life assured during his life time got treatment regarding ailment of Asthma or that he was suffering from Paralysis. It makes no difference if the Death Certificate was issued from Public Health Centre, Tigaon or not because the insurance company itself has admitted in paragraph No.5 of the written version regarding facts of the case. In this way, the situation is clear that the date of commencement of the insurance policy was November 11th, 2008 and the life assured Partap Singh breathed his last on January 23rd, 2009.
10. The opposite party-Insurance Company has repudiated the claim of the complainant mainly on the basis of the report of the surveyor Sai Associate & Innogative Private Limited (Annexure R-4) and Inquiry Report of Shri Sanjay Bhatt, The Claim Consultant.
11. From the surveyor report, Annexure R-4, as well as Inquiry Report of Shri Sanjay Bhatt, it is clear that they could not collect any evidence to prove that the life assured Partap Singh ever remained admitted in any hospital and he got treatment of Asthma as well as Paralysis. Sanjay Bhatt as well as Sai Associate & Innogative Private Limited surveyor agency have only stated that they made inquiries from the Public Health Centre, Tigaon regarding issuance of Death Certificate and from other villagers and stated that other villagers told that Partap Singh was suffering from Asthma and Paralysis. The surveyor did not record statement of any other person/resident of the same village. Moreover, even if public persons would have recorded their statements, those statements would have been of no help to the opposite party in this case because on the basis of oral statements alone, findings cannot be given that it is a case of pre-existing disease.
12. To rebut the insurance claim of the complainant, the opposite party was required to prove that the life assured prior to submitting the proposal form (Annexure R-1) got his treatment regarding Asthma and Paralysis. Shri Sanjay Bhatt in his report has mentioned that he visited Public Health Centre, Tigaon and checked the entry regarding death of Partap Singh. It was found that the rubber seal was put on the original but the signature of doctor were not there. However, he was told that entries regarding death are genuine. Sanjay Bhatt also met Dr. Vikas Sharma, who told that as and when information was received regarding death of a person in Public Health Centre, Anganwadi worker is asked to verify regarding death and thereafter death certificate is issued. Sanjay Bhatt, met Dr. Vijay Chauhan, Dr. Rastogi and Dr. Dharamveer who used to give treatment to the family members of the deceased. Shri Sanjay Bhatt has mentioned that he has doubt regarding date of death of Partap Singh as one of Partap's neighbours and relative told Anganwadi worker in his presence that Partap died three days before Diwali i.e. three days before October 28th, 2008.
13. The surveyor as well as Sanjay Bhatt, Consultant, did not record statement of any person mentioned in their repots. Moreover, none of these persons appeared in the witness box to support the version of the opposite party. In these circumstances, on the basis of the inquiry report of Shri Sanjay Bhatt dated August 12th, 2009 as well as report of the surveyor-Sai Associate & Innogative Private Limited, findings cannot be given that Partap Singh died on any day other than January 23rd, 2009 and that Partap Singh during his life time ever got treatment or remained admitted in hospital for his treatment in connection with Asthma as well as Paralysis. Moreover, Doctor on the panel of the insurance company-opposite party, who examined the insured before providing the insurance policy, was also in a position to make observation after check up without any treatment/diagnostic test that the insured was suffering from paralysis. It makes no difference if Partap Singh died in his farmhouse or in his village or at any other place because regarding death of Partap Singh, there is no controversy in between the complainant and the opposite party.
14. As per discussions above in detail, we feel no hesitation in holding that the opposite party-Insurance Company miserably has failed to prove that the life assured-Partap Singh was suffering from Asthma or paralysis diseases before he was provided insurance policy. So, it is not a case of pre-existing disease of the insured. In these circumstances, findings can be safely given that the act of the opposite party to repudiate the insurance claim of the complainant was illegal and unjustified. It appears that the insurance company through its surveyor and investigator made all possible efforts not to provide payment of the sum assured to the complainant perhaps because Partap Singh died just after three months from the date of commencement of the insurance policy. Such type of negative attitude/role played by the insurance company cannot be appreciated. Moreover, the disease of paralysis allegedly suffered by the life assured-Partap Singh, could have been easily detected by the doctor on the panel of the insurance company also by whom the insured was examined before providing him life insurance policy. The opposite party tried to create more and more confusion un-necessarily. The District Forum has committed an error while dismissing the complaint and as such the impugned order passed by the learned District Forum cannot be allowed to sustain.
15. Admittedly, the total sum assured as per insurance policy (Annexure R-2) is Rs.15.00 lacs. Resultantly, it is held that the complainant being brother and nominee of the life assured-Partap Singh is entitled to receive the total sum assured Rs.15.00 lacs from the opposite party with interest at the rate of 9% per annum from the date of filing of the complaint till its realisation. The complainant had to face un-necessary harassment and had to spent lot of money in this litigation due to negative attitude of the opposite party. In these circumstances, it will be justified to award to the complainant an amount of Rs.11,000/- as litigation expenses.
16. Resultantly, the present appeal filed by the complainant is allowed, the impugned order dated August 30th, 2016 passed by the District Forum is set aside and consequently the complaint filed by the complainant stands allowed. The opposite party-Insurance Company is directed to pay an amount of Rs.15.00 lacs to the complainant along with interest at the rate of 9% per annum from the date of filing of the complaint till its realisation and Rs.11,000/- as litigation expenses.
Announced:
06.09.2017 (Balbir Singh) Judicial Member (Nawab Singh) President CL