State Consumer Disputes Redressal Commission
Dlf Pramerica Life Insurance Company ... vs Kuldeep Kaur on 13 May, 2014
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.1433 of 2012
Date of institution : 22.10.2012
Date of decision : 13.05.2014
1. DLF Pramerica Life Insurance Company Limited, Registered
Office at DLF Centre, Sansad Marg, New Delhi-110 001
through its Regional Manager.
2. DLF Pramerica Life Insurance Company Limited, Ist Floor,
Vidya Tower, Mall Road, Near Udham Singh Chowk,
Ferozepur City through its Branch Manager.
.......Appellants- Opposite Parties Nos.1 & 2
Versus
Kuldeep Kaur, resident of Village Bhure Kala, Post Office Khai
Pheme Ke, Tehsil and District Ferozepur.
......Respondent-Complainant
First Appeal against the order dated
24.08.2012 of the District Consumer
Disputes Redressal Forum, Ferozepur.
Quorum :-
Hon'ble Mr. Justice Gurdev Singh, President.
Mr. Vinod Kumar Gupta, Member
Mrs. Surinder Pal Kaur, Member.
Present:-
For the appellants : Shri Gurvinder Singh, Advocate. For the respondent: Shri Piyush Sharma, Advocate. JUSTICE GURDEV SINGH, PRESIDENT :
This appeal has been preferred by the appellants/opposite parties Nos.1 and 2-Insurance Company against the order dated 24.8.2012 passed by District Consumer Disputes Redressal Forum, Ferozepur (in short, "District Forum"), vide which the complaint filed First Appeal No.1433 of 2012. 2 by the respondent/complainant under Section 12 of the Consumer Protection Act, 1986, was allowed and these opposite parties were directed to pay the sum insured within 30 days of the date of receipt of copy of the order and failing that to pay interest at the rate of 9% per annum from the date of filing of the complaint till the payment of that amount.
2. As per the allegations made by the complainant, in her complaint, she is the wife of Virsa Singh, who during his life-time got himself insured with the Insurance Company, vide Policy No.000038805 and paid Rs.25,000/- twice as premium. At the time of the issuance of the policy he was medically examined by opposite parties No.3 and 4; namely, Raman, Life Associate and Yogesh Jain, Sales Manager and it was after complete investigation that he was not suffering from any disease and was fit to be insured that the premium amount was accepted and the policy was issued. In the month of July 2011 he fell ill for which he was treated in DMC Hospital, Ludhiana, but could not survive and died on 7.7.2011. Intimation of his death was given to the Insurance Company. Initially, it assured her to make the payment of the insurance claim and all the formalities were got completed from her at that time. Some documents were got filled and her signatures were obtained on blank forms also. Later on, it started putting her off on one pretext or the other and the insurance claim was not paid to her, though she was the nominee of her husband. Ultimately, her claim was repudiated, vide letter dated 27.1.2012, on vague allegations First Appeal No.1433 of 2012. 3 and the sum of Rs.19,330/- was refunded to her. She approached the Insurance Company for the withdrawal of that letter and made a request for the payment of the insurance claim but it refused to do so. No sufficient opportunity of hearing was afforded to her before repudiating her legal, valid and genuine claim. It adopted unfair trade practice by not releasing the legally payable amount, which caused unnecessary harassment, mental agony and torture to her. She prayed for the issuance of following directions to the Insurance Company:-
i) to pay Rs.5,00,000/-, as the amount of insurance claim along with interest at the rate of 18% per annum;
ii) to pay Rs.50,000/-, as damages and compensation for causing mental agony, unnecessary harassment and financial loss etc. to her; and
iii) to pay Rs.5,500/-, as litigation expenses.
3. The complaint was contested by the Insurance Company and detailed reply was filed. It admitted therein that Virsa Singh had obtained the insurance policy for Rs.5,00,000/- in respect of which annual premium of Rs.25,000/- was payable and that after his death the complainant, as his nominee, filed the claim which was repudiated. It also admitted that before his death the assured remained admitted in Dayanand Medical College and Hospital, Ludhiana, for his treatment. While denying the other allegations made in the complaint, it pleaded that the insurance plan obtained by the assured was "DLF Pramerica Ezee Wealth" after duly First Appeal No.1433 of 2012. 4 deliberating upon and understanding all the terms and conditions thereof by submitting a duly filled and signed proposal form No.000285702 dated 30.9.2010 containing all the details and information. It was confirmed by him that he understood all the terms and conditions and that the correct information was being supplied by him. Regarding the medical details he mentioned in the proposal form that he had never any signs or symptoms nor received any treatment for any disease mentioned therein. The death claim intimation was received just after 10 months of the commencement of the policy and investigation was conducted and during investigation, it was established that before his death he was suffering from hypertension, renal failure, CVA etc. and had suffered attack in the year 2008. While in the Hospital, he was diagnosed with HTN, nephropathy (obstructive) with renal failure, old CVA etc. He was known case of HTN for the last 5 years and had suffered cardio arrest (Cardio Pulmonary Infract) in the year 2008. He by misrepresenting and concealing all these material facts obtained the policy. It was wrongly mentioned by him in the proposal form that he was completely fit and was not suffering from any disease or ailment, though he was very well aware that he was suffering from hypertension, renal failure CVA etc. and had suffered attack in the year 2008. The claim made by the complainant was repudiated on the ground that he was suffering from those diseases and made a false declaration in the proposal form and concealed the material facts. By repudiating the claim on those grounds, it did not commit First Appeal No.1433 of 2012. 5 any deficiency in service nor adopted any unfair trade practice. The contracts of insurance are contracts of uberrima fides and the insured was required to observe utmost good faith and was required to disclose all the above said material facts relating to his health. The complainant has no cause of action to file this complaint and is trying to deceive and mislead the Consumer Forum by stating wrong facts and submissions.
4. Both the parties produced evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel on their behalf allowed the complaint, vide aforesaid order.
5. We have heard learned counsel for both the sides and have carefully gone through the records of the case.
6. It was submitted by the learned counsel for the opposite parties-Insurance Company that the District Forum committed an illegality by ignoring the evidence produced by the Insurance Company in the form of the report of the Investigator and the discharge summary etc. of the Hospital, from which it stands proved that at the time the insured obtained the insurance policy he was suffering from the number of diseases, as mentioned in those documents. By concealing the material facts and by making false declaration, he obtained the insurance policy and the claim made by the complainant, after his death, was correctly repudiated. In these circumstances the order passed by the District Forum cannot be sustained and is liable to be set aside.
First Appeal No.1433 of 2012. 6
7. On the other hand, it was submitted by the learned counsel for the complainant that after properly appreciating the averments of the parties and recording the reasons for discarding the evidence produced by the Insurance Company that the insured was suffering from pre-existing disease, the District Forum correctly recorded the findings in favour of the complainant and there is no ground for upsetting those well reasoned findings.
8. The letter of repudiation was proved on the record as Ex.C-4. The claim made by the complainant after the death of the insured was repudiated on the ground that he had withheld material information regarding hypertension, Cerebro Vascular Accident along with Cardio Pulmonary Arrest at the time of affecting the assurance and that he was taking treatment for the same prior to the proposal signing date and had not disclosed that fact in the proposal form and that such a non-disclosure makes the contracts of insurance void. The proposal which was filled up by the insured at the time of obtaining the insurance policy was proved on the record as Ex.R-3. There was Column No.46 under the head "Health Details of the Life to be insured" and the same contained the following four queries:-
"1. I have never had any signs or symptoms, or been told that I have any heart condition, hypertension, stroke, disability, paralysis, cancer, tumor or abnormal growth, diabetes, kidney problem, liver First Appeal No.1433 of 2012. 7 disease, lung diseases, gastrointestinal disease, mental illness, HIF infections or AIDS.
2. I do not currently have nor am I receiving treatment for any symptoms, apart from minor ailments, such as cold and flu or any medical conditions or disabilities. I have not been hospitalized due to illness or injury for a continuous period of more than 2 days or received medical treatment for a continuous period of more than 6 days during the last five years period.
3. I have not undergone and am not awaiting to undergo any surgical procedure, any investigative or diagnostic tests or medical examinations (other than for routine health screen)
4. I have never been declined, postponed, rated up, or in any way issued with a Policy on special terms for any type of benefit or ever made a claim for life, disability, accident, health or critical illness."
All these queries were answered in the affirmative by the insured. He also put his signature on the declaration to the effect that the answers given by him were correct and that he had not withheld any information.
First Appeal No.1433 of 2012. 8
9. The Insurance Company proved on record the investigation report Ex.R-7. As per this report, the Investigator on the basis of the investigation conducted by him came to the conclusion that the insured was suffering from hypertension, renal failure, CVA etc. The affidavit of that Investigator was not proved on the record and in the absence of any such affidavit no reliance can be placed on this report.
10. The Insurance Company has also relied upon the Death Summary Ex.R-6, for proving that the deceased was suffering from pre-existing diseases at the time of obtaining the insurance policy. There is no column in this Death Summary as to the history of previous illness. There is one column of final diagnosis and it is in that column that it is recorded that he had old CVA and had hypertension for the last 5 years and had pulmonary arrest in the year 2008. The Insurance Company neither examined the doctor, who prepared that Death Summary nor proved on record the original treatment file of the deceased on the basis of which that Death Summary was prepared. In the absence of that evidence, it is not possible for us to record a finding that the insured had knowledge of the fact that he was suffering from such like diseases at the time he filled up the proposal form. We do not find any illegality or infirmity in the findings recorded by the District Forum and the same is hereby upheld.
11. There is no merit in the appeal and the same is dismissed accordingly.
First Appeal No.1433 of 2012. 9
12. The appellants/opposite parties Nos.1 and 2 deposited the sum of Rs.25,000/- at the time of filing of the appeal on 22.10.2012. They deposited another sum of Rs.50,000/- on 21.12.2012 in compliance of the order dated 6.12.2012. Both these sums along with interest which has accrued thereon, if any, shall be remitted by the registry to the respondent/complainant by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the District Forum and the appellants/opposite parties No.1 and 2.
13. The arguments in this case were heard on 7.5.2014 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 court cases.
(JUSTICE GURDEV SINGH) PRESIDENT (VINOD KUMAR GUPTA) MEMBER (MRS. SURINDER PAL KAUR) MEMBER May 13, 2014.
Bansal