National Consumer Disputes Redressal
Pnb Metlife Insurance Company Ltd. vs Vinita Devi on 24 September, 2018
Author: R.K. Agrawal
Bench: R.K. Agrawal
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 1045 OF 2017 (Against the Order dated 28/03/2017 in Complaint No. 32/2015 of the State Commission Bihar) 1. PNB METLIFE INSURANCE COMPANY LTD. THROUGH RAJEEV SHARMA,UNIT NO. 701,-703 FLOOR,WEST WING,RAHEJA TOWERS,26/27,M.G ROAD, BANGALORE-560001 ...........Appellant(s) Versus 1. VINITA DEVI W/O LATE SANJAYA SHARMA,VILL.PUPRI,PO-RATAN LAXMI,PS.PUPRI, CHANDIGARGH ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE R.K. AGRAWAL,PRESIDENT HON'BLE MRS. M. SHREESHA,MEMBER For the Appellant : Mr. Ritesh Khare, Mr. Akhilesh Gossain, Mr. Raj Dev Singh & Ms. Shrusti, Advocates. For the Respondent : Mr. Pulkit Tare & Mr. Anup Jain, Advocates.
Dated : 24 Sep 2018 ORDER Aggrieved by the order dated 28.03.2017 in CC No. 32/2015 passed by the Bihar State Consumer Disputes Redressal Commission at Patna (for short "the State Commission") PNB MetLife India Insurance Company Ltd. (for short "the Insurance Company") preferred this First Appeal under Section 19 of the Consumer Protection Act, 1986 (for short "the Act). By the impugned order, the State Commission has allowed the Complaint preferred by Smt. Vinita Devi (hereinafter referred to as "Complainant") and directed the Opposite Party (hereinafter referred to as "the Insurance Company") to pay to the Complainant the assured amount of ₹20,00,000/- along with interest @ 6% from the date of filing of the Complaint i.e. 13.07.2015 till final payment; ₹30,000/- towards compensation and ₹10,000/- towards litigation costs within one month from the date of receipt of the said order failing which the decretal amount would carry interest @ 10% p.a.
2. Briefly put, the facts of the case are that Late Sh. Sanjay Sharma, the Complainant's husband, was insured with the Insurance Company for a sum of ₹20,00,000/- vide Insurance Policy No. 21209054 for the period from 20.11.2013 to 20.11.2028. It was stated that the Insured was physically fit and on 28.12.2013 he fell from a bed/chowki at his residence at Village Pupri, Sitamarhi and was immediately taken to the clinic of Dr. Mihir Chandra at Darbhanga. The said doctor after examining the Insured recommended his hospitalization. However, the insured died on the way to the hospital. The Complainant preferred a claim which was repudiated by the Insurance Company vide letter dated 29.12.2014 on the ground of suppression of material facts regarding the health condition of the Insured. The Complainant on receipt of the repudiation letter immediately got issued a legal notice dated 13.02.2015 denying the version of the Insurance Company, but it was of no avail. Thereafter, the Complainant filed a Complaint before the State Commission seeking directions to the Insurance Company to pay to the Complainant a sum of ₹20,00,000/- towards insurance amount along with ₹2,00,000/- towards compensation for mental agony and physical harassment and ₹30,000/- towards costs. Interest @ 12% on the said amount was also prayed for from the date of death of the insured till the date of final payment.
3. The Insurance Company filed their Written Statement denying all the allegations in the Complaint. It was stated therein that in the proposal form there was a column wherein the Life Assured was required to provide answers with respect to his medical history to which he replied that he was not suffering from any disease and that he did not take any medical treatment. Believing the information provided by the Insured to be true and correct, the Insurance Company issued the Insurance Policy. It was pleaded that the Insured had paid just one premium under the Policy and thereafter the Insurance Company received the Death Claim Intimation dated 10.11.2014 from the Complainant intimating them that the Insured died on 28.12.2013 due to heart attack. As the claim was an early claim because the Insured died within a short span of only 3 months, the Insurance Company as per the procedure, carried out an investigation to settle the claim of the Complainant. During the course of investigation, it was revealed that the Insured did not provide true and correct information in the proposal form with respect to his medical history; that the Insured was diagnosed with liver cirrhosis, prior to the issuance of Policy and was a known case of Alcoholic Kidney Disease; the treatment records of Dr. Y.K. Thakur, MD dated 20.06.2013 clearly stated that the Insured was suffering from liver cirrhosis; the Haematology report of the Insured also revealed an abnormal reading for SGOT, SGPT, Alkaline Phosphate and Creatinine level; all these reports dated 20.06.2013 are prior to the proposal form was submitted on 19.11.2013, meaning thereby that the Insured was suffering from liver cirrhosis at the time of submitting of the proposal form and despite that he intentionally concealed this material fact despite answering a specific question with respect to the same and thus played fraud upon the Insurance Company. It was pleaded that the Insurance Company rightly repudiated the claim of the Complainant.
4. The State Commission allowed the Complaint after observing thus:-
".....the claim of the complainant was repudiated vide Company's letter dated 27.11.2014 on the ground of suppression of material facts regarding health. In support of the allegation, the photo copy of the doctor Mr. Y.K. Thakur of Hazipur is on the record with Lakshmi Janc Ghar, Vaishali. Test report copy as well as the prescription of Dr. Mihir Chandra of DMCH, who treated the life assured on 28.12.2013. We find it very peculiar, how, a copy of prescription of Dr. Y.K. Thakur of Hazipur has been produced by the OPs in support that the life assured was under treatment of Dr. Thakur and the patient was suffering from Liver Cirrhosis, an Alcohlic disease. Whereas Dr. Mihir Chandra of D.M.C.H. in whose treatment the life assured was before death has mentioned in his prescription that the patient is suffering from 'Breathlessness.' It appears that the life assured was never treated by so called doctor Y.K. Thakur at Hazipur in the District of Vaishali and test reports also seems not genuine of Hazipur. The life assured was a resident of Pupri, Sitamarhi which is about 50 Kms. From Darbhanga. The Doctor's prescription and test reports are of Hazipur, almost 100 kms. away from Pupri the native place of life assured. How, he was brought to Hazipur from Pupri for treatment in place of Darbhanga only 50 kms from Pupri. No Carbon Copy is kept by any Doctor generally. If it was kept, the Doctor should had to be examined and cross-examined. The Doctor Mr. Thakur has not himself produced evidence on affidavit. At that situation, we cannot consider it and rely on such document and as such on that basis the Insurance Company cannot deny payment of the assured amount to the complainant. Consequently, the repudiation of the insurance claim is not correct and justified. It is deficiency on the part of the Insurance Company and the Company is liable to pay the assured amount to the claimant."
5. The State Commission directed the Insurance Company to pay to the Complainant through her operational Post Office Account the assured amount of ₹20,00,000/- along with interest @ 6% from the date of filing of the Complaint i.e. from 13.07.2015 till final payment. Apart from that, a sum of ₹30,000/- towards compensation and ₹10,000/- towards costs were also awarded. The Insurance Company was directed to comply the order within one month from the date of receipt of the order, failing which it would carry interest @ 10% p.a.
6. Ld. Counsel for the Appellant vehemently argued that there was clear suppression of his health condition by the Insured as he was diagnosed with liver cirrhosis prior to the issuance of the policy and was a known case of alcoholism and kidney disease; that the treatment record of Dr. Y.K. Thakur dated 20.06.2013 clearly shows that the deceased life assured was suffering from liver cirrhosis; that the Haematology report revealed abnormal reading for SGOT, SGPT, Alkaline Phosphate and Creatinine level and that the life assured was duty-bound to answer the questions in the proposal form in utmost good faith, but he had intentionally suppressed that he was suffering from liver and kidney diseases and therefore, the repudiation was justified.
7. As the issuance of the policy and the period of coverage including the sum assured is not in dispute, we address ourselves to the point as to whether there was any suppression of material fact by the insured prior to the taking of the policy. Ld. Counsel for the Appellant drew our attention to the certificate dated 20.06.2013 issued by Dr. Thakur. Ld. Counsel appearing for the Respondent vehemently denied that the life assured had ever taken treatment from the said doctor. In this prescription it is noted that the patient had liver problem and history of alcoholism and kidney disease. The State Commission has observed that the insured was a resident of Pupri, Sitamarhi which is about 50 kms from Darbhanga whereas Dr. Y.S. Thakur and the test reports filed by the Appellant are of Hazipur which is almost 100 kms away from Pupri, the native place of the Insured.
8. We rely on the judgement of this Commission titled Sushil Kumar Jain Vs. United India Insurance Co. Ltd. I (2012) CPJ 204 (NC) which has attained finality, wherein it is observed that the doctor's prescriptions have to be substantiated by an Affidavit of the said doctor, specially in the light of the fact that it is being disputed by the Complainant. In the instant case the Insurance Company has not produced the affidavit of the concerned doctor nor did the said doctor answer any interrogatory by way of evidence before the Fora below. At the cost of repetition, it is reiterated that the burden to prove that the life assured was suffering from any pre-existing disease lies with the Insurance Company and the Insurance Company had not filed any documentary evidence or Affidavit of the treating doctor in support of their contention. Hence we find force in the contention of the Counsel of the Complainant that the insured was never treated by the said doctor Y.K. Thakur of Hazipur as the reports are not substantiated by any affidavit of evidence. In the light of this observation, we are of the considered view that the aspect of nexus between the kidney disease and heart attack is of no relevance in the instant case. The State Commission has rightly placed reliance on the prescription given by Dr. Mihir Chandra, in whose treatment the Insured was before his death and in the said prescription it is only stated that the insured had breathlessness and lost consciousness and thereafter died. There is absolutely nothing in the patient's history record or in the prescription which even remotely suggests either liver cirrhosis or alcoholism or any kidney disease. The Supreme Court in a catena of judgements held that the onus to prove whether there was any suppression of material fact prior to the issuance of the policy is on the Insurance Company, which in the instant case, they have failed to discharge. At the cost of repetition, in the absence of any documentary evidence to substantiate the contention of the Appellant that there was material suppression regarding the health condition of the Insured, we find no reason to interfere with the well-considered order of the State Commission as far as deficiency of service is concerned. However, we are of the considered view that having awarded interest @ 6% p.a., awarding of further compensation of ₹30,000/- is excessive and the same is being set aside. In the result, this Appeal is allowed in part and the order of the State Commission is modified to the extent of deleting of compensation of ₹30,000/- and also the default interest @ 10% p.a. confirming the rest of the order. To clarify the rest of the order of the State Commission with respect of the payment of the sum insured along with interest @ 6% p.a. is hereby confirmed. There is no order as to costs. The statutory deposits shall stand refunded to the Insurance Company.
9. Vide order dated 25.08.2017 this Commission while granting interim stay had directed the Appellant to deposit 50% of the principal amount of the compensation awarded by the State Commission. Needless to add, the said amount with accrued interest, if any, shall stand released to the Complainant and the balance shall be adjusted from the decretal amount.
......................J R.K. AGRAWAL PRESIDENT ...................... M. SHREESHA MEMBER